The maddening itch: an approach to chronic urticaria

Chronic spontaneous urticaria (CSU) is defined as the presence of urticaria with daily or almost daily symptoms for 6 weeks or more. CSU affects 0.1%-0.8% of the population. Its pathogenesis involves autoimmunity, abnormalities in signal transduction, and the action of histamine on H1 receptors. Investigation of CSU should be guided by a thorough history and physical examination. A concise laboratory evaluation, including the CU index, is recommended. This index can provide useful data on severity and response to therapy. Initial treatment should involve increasing doses of nonsedating antihistamines until the intended effect is achieved. Only when a patient is unresponsive to high-dose nonsedating antihistamines (or sedating antihistamines) can we consider CSU refractory and consider immunomodulatory therapy. The most promising drugs are cyclosporine and, more recently, omalizumab.