The treatment of
chronic spontaneous urticaria begins with
antihistamines; however, the dose required typically exceeds that recommended for
allergic rhinitis. Second-generation, relatively non-sedating H₁-receptor blockers are typically employed up to 4 times a day. First-generation
antihistamines, such as
hydroxyzine or
diphenhydramine (
Atarax or
Benadryl), were employed similarly in the past. Should high-dose
antihistamines fail to control symptoms (at least 50%),
omalizumab at 300 mg/month is the next step. This is effective in 70% of
antihistamine-refractory patients. H₂-receptor blockers and
leukotriene antagonists are no longer recommended; they add little and the literature does not support significant efficacy. For those patients who are unresponsive to both
antihistamines and
omalizumab,
cyclosporine is recommended next. This is similarly effective in 65%-70% of patients; however, care is needed regarding possible side-effects on blood pressure and renal function.
Corticosteroids should not be employed chronically due to cumulative toxicity that is dose and time dependent. Brief courses of
steroid e.g., 3-10 days can be employed for severe exacerbations, but should be an infrequent occurrence. Finally, other agents, such as
dapsone or
sulfasalazine, can be tried for those patients unresponsive to
antihistamines,
omalizumab, and
cyclosporine.