Current and future therapies for treating chronic spontaneous urticaria

Introduction: Chronic spontaneous urticaria (CSU) is a disabling condition that causes deterioration of quality of life. Areas covered: The international EAACI/GA(2)LEN/EDF/WAO guidelines have provided a stepwise treatment algorithm for CSU management. Second-generation H-1-antihistamines are the first-line treatment, and the second step is the up-dosing of the same drugs. In refractory patients, the guidelines recommend the addition of omalizumab, ciclosporin A or montelukast. Systemic corticosteroids can be used as a short course during acute exacerbations. A plethora of alternative treatments has been evaluated, although the overall level of evidence for such treatments is low. Future treatment options may include inhibitors of skin mast cells and antagonists to mast cell-activating signals that are relevant for the induction of CSU signs and symptoms. Expert opinion: The only licensed options included in the guidelines algorithm are standard-dosed second-generation H1-antihistamines and omalizumab. High-quality evidence has documented a rapid and strong symptomatic effect of omalizumab in CSU, although the optimal long-term regimens should be further investigated. The role of alternative drugs deserves additional studies. The potential of the existing treatments for inducing remission of CSU is unknown, and this is an important area of research, as is the evaluation of predictors of response, prognostic factors, and pathomechanisms.