New Urticaria Guidelines Stress Simplicity

Selected by Pietro Cazzola

AADNew guidelines for the diagnosis and treatment of urticaria have been endorsed by 15 professional organizations so far and are now being prepared for publication, according to a consensus meeting participant who summarized key points at the American Academy of Dermatology summer meeting.
The guidelines, developed at an earlier conference held in Berlin attended by experts from 39 countries, are straightforward, relatively simple, “and truly developed for global application,” according to Dr. Kiran Godse of Patil Medical College and Hospital, Navi Mumbai, India. The guidelines represent a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA2LEN), the European Dermatology Forum (EDF), the American Academy of Allergy, Asthma and Immunology (AAAAI), and the World Allergy Organization (WAO).
The simplicity of the guidelines starts with the definition of urticaria. It consists of three characteristics: “wheals, angioedema, or both.” While the definition goes on to specify that these conditions should be differentiated from autoinflammatory syndromes, hereditary angioedema, and other diseases that produce hives or swelling, the new guidelines abandon the term “idiopathic.”
“Our understanding of the etiology and pathogenesis has advanced to the point that we can identify the causes in most cases,” said Dr. Godse, indicating that classifying cases as “idiopathic” without further investigation is unhelpful when the goal is to find and avoid triggers.
A number of subclassifications, such as spontaneous urticaria, inducible urticaria, acute urticaria, and chronic urticaria, are defined and employed to guide clinical management. In patients with acute urticaria, diagnostic testing beyond a careful history is not recommended, except when avoidance strategies fail and recurrences are common.
Even in chronic urticaria, which is defined as symptoms persisting for at least 6 months, Dr. Godse said that the guidelines recommend “limited” initial diagnostic studies.
By relying on careful patient history rather than clinical tests to differentiate the major forms of this disease, such as cold urticaria, heat urticaria, delayed pressure urticaria, solar urticaria, and symptomatic dermographism, the guidelines in effect propose that underlying etiologies do not usually require an extensive workup. However, the guidelines do advise more extensive tests in individuals with persistent and significant disease, which can be measured with the Chronic Urticaria Quality of Life (CU-QoL) and the Angioedema Quality of Life (Ae-QoL) instruments. Both are strongly recommended for baseline assessment of symptom burden.
The treatment goal of the stepwise management is clear: complete absence of symptoms. “Treat the disease until it is gone,” said Dr. Godse, summarizing this recommendation.
If symptoms cannot be eliminated simply by avoiding causes and aggravating factors, the guidelines identify second-generation, nonsedating H1 antihistamines as the first-line pharmacotherapy. Dr. Godse said that the guidelines specifically recommend continuous rather than on-demand regimens at the lowest effective dose. However, if symptoms persist after 1-4 weeks of therapy, the dosing frequency should be increased before moving to adjunctive use of additional therapies. Adjunctive therapies listed in the guidelines include omalizumab, cyclosporine A, and montelukast. The first two of these options received strong recommendations on the basis of a high level of evidence, but the third was given a weak recommendation on the basis of a low level of evidence.
In those who fail these therapies, the list of alternatives is lengthy and includes a short course of corticosteroids, immunomodulating therapies such as methotrexate, and intravenous immunoglobulins. While any one of these may be useful in an individual patient, the overall evidence of benefit was considered to be of relatively low quality.
Ultimately, the guidelines attempt to define an approach that is uniformly applicable across diverse populations, a full range of possible etiologies, and within different systems of medical care, according to Dr. Godse.
Asked for their opinion after hearing the guidelines explained at the meeting, Dr. Paul Schneiderman and Dr. Aaron Warshawsky said they were favorably impressed. Both thought the guidelines were clear, reasonable, and potentially helpful in clinical practice. Dr. Schneiderman, an associate clinical professor of dermatology at Yale University, New Haven, Conn., who maintains a private practice in Syosset, N.Y., reported that he will be able to better judge the clinical applicability of the new guidelines when he sees the full publication, but both he and Dr. Warshawsky, a dermatologist in private practice in Poughkeepsie, N.Y., agreed that advances in urticaria justify updated guidelines.
Dr. Godse reported no financial disclosures relevant to his presentation.

Bosworth T.