Chronic urticaria Management of chronic urticaria Classification (based on trigger) Classify urticaria as spontaneous (no definite eliciting factor involved) or inducible (specific definite factor involved). A Initial evaluation Obtain limited investigations as part of the initial evaluation of patients with chronic spontaneous urticaria, including a CBC, CRP and/or ESR, and in specialized care total IgE and IgG-anti-TPO, and more biomarkers as appropriate. A Clinical assessment Q Does the patient have chronic inducible urticaria? Yes Use provocation threshold measurements and the urticaria control test to measure disease activity and control in patients with chronic inducible urticaria, respectively. A No Obtain further diagnostic measures in patients with chronic spontaneous urticaria based on clinical history and physical examination, especially in patients with long-standing and/or uncontrolled disease. A Clinical assessment Use the urticaria activity score 7 and/or angioedema activity score to assess disease activity in patients with chronic spontaneous urticaria. A Use the chronic urticaria quality of life questionnaire and angioedema quality of life questionnaire to assess quality of life impairment in patients with chronic spontaneous urticaria. A Use the urticaria control test and/or angioedema control test to assess disease control in patients with chronic spontaneous urticaria. A Avoidance of inciting agents Advise patients with chronic spontaneous urticaria to discontinue medications suspected to worsen the disease, such as NSAIDs. A Systemic corticosteroids EAACI Q Does the patient have an acute exacerbation of chronic urticaria? Yes Consider offering a short course of rescue systemic corticosteroids in patients with an acute exacerbation of chronic urticaria. C Do not use systemic corticosteroids for long-term in patients with chronic urticaria. D No Histamine-1 receptor antagonists Offer a second generation H1RA as first-line therapy in patients with all types of urticaria. A Offer updosing of a second generation H1RA up to 4-fold in patients with chronic urticaria unresponsive to a standard-dosed second generation H1RA as second-line therapy before considering other treatments. A Consider advising patients to take second generation H1RAs regularly for the treatment of chronic urticaria. C Avoid using different H1RAs at the same time. D Do not use higher than 4-fold standard-dosed H1RAs in patients with chronic urticaria. D Omalizumab Offer add-on omalizumab for the treatment of patients with chronic urticatia unresponsive to high-dose second generation H1RAs. A Pediatric patients Q Is the patient a child? No Target complete symptom control in patients with urticaria, considering as much as possible the safety and the quality of life of each individual patient. A Serial clinical assessment Assess disease activity, impact and control at every follow-up visit in patients with chronic urticaria. A Cyclosporin Consider offering cyclosporin for the treatment of patients with chronic urticaria unresponsive to high-dose of second generation H1RAs and omalizumab. C Yes Consider using the same treatment algorithm with caution (weight-adjusted dosage) in pediatric patients with chronic urticaria. C Pregnant patients EAACI Q Is the patient a pregnant woman? Yes Consider using the same treatment algorithm with caution both in pregnant and lactating patients after risk-benefit assessment. Do not use drugs contraindicated or not suitable in pregnancy. C No Goals of treatment Target complete symptom control in patients with urticaria, considering as much as possible the safety and the quality of life of each individual patient. A Serial clinical assessment Assess disease activity, impact and control at every follow-up visit in patients with chronic urticaria. A Cyclosporin Consider offering cyclosporin for the treatment of patients with chronic urticaria unresponsive to high-dose of second generation H1RAs and omalizumab. C