Approach to therapy in chronic urticaria: when benadryl is not enough

Chronic urticaria is a relatively common disorder in which its management often presents a difficult clinical challenge. Histamine antagonists are the mainstays of therapy, and the second-generation antihistamines offer an attractive combination of efficacy, convenience, and lack of side effects. For patients whose symptoms are not controlled by once daily second-generation antihistamines, adjunct therapy with first generation H1-antihistamines, H2-antihistamines, doxepin, or leukotriene modifiers may be effective. Short-term systemic corticosteroids are useful for acute symptom flares but should not be used chronically. For chronically unremitting disease, immunomodulatory agents such as low-dose oral cyclosporine often are useful.