Table 3 Summary of clinical guidelines for the treatment of urticaria in adults and children^a

Step I

Monotherapy with second-generation, non-sedating H₁-antihistamines^b

Monotherapy with second-generation H₁-antihistamines^b

Avoidance of triggers and physical stimuli

Avoidance of triggers and physical stimuli

Non-sedative second-generation H₁-antihistamine

• As appropriate, change to another drug, increase the dose up to 2 times, or combine the two types

Step II

Up-dosing of non-sedating H₁-antihistamines^c

(up to 4 times approved dose; weight adapted)

One or more of the following:

• Up-dosing of second-generation H₁-antihistamines^c

• Add another second-generation H₁-antihistamine

• Add H₂-antagonist

• Add leukotriene receptor antagonist

• Add first generation H₁-antihistamine

Monotherapy with second-generation, non-sedating H₁-antihistamines

H₁-antihistamines:

• First generation

• Non-sedating second-generation

H₂-antihistamines

Add an alternative agent:

• H₂–antihistamine

• Anti-leukotriene

Step III

Add an alternative agent:

Omalizumab

Up-dosing of potent antihistamine^c

Up-dosing of non-sedating H₁-antihistamines^c

(up to 4 times approved dose; weight adapted)

• Corticosteroids

• Doxepin

• Narrowband ultraviolet B light

Add an alternative agent:

• Oral corticosteroid

• Omalizumab

• Cyclosporine

Step IV

Add an alternative agent:

• Cyclosporine A

Add an alternative agent:

• Omalizumab or cyclosporine

• Other anti-inflammatory agents

• Immunosuppressants

• Biologics

Change to:

• Different non-sedating H₁-antihistamines, or

• First generation sedating antihistamine

Add an alternative agent:

• Leukotriene antagonist

• Cyclosporine

• Trial treatment

Step V

–

–

Add an alternative agent:

• Cyclosporine A

• Second-generation, non-sedating H₂-antihistamine

• Dapsone

• Omalizumab

• Dapsone,

• Intravenous immunoglobulin

• Methotrexate

–