Chronic urticaria
Wheals and/or angioedema persisting for more than 6 weeks. A cause is identified in fewer than half of cases. First-line treatment is second-generation antihistamines.
ICD-10 L50.110 drugs
Also known as: Chronic spontaneous urticaria, CSU
Drugs used for this condition
- ABilastineFirst line · Second-generation antihistamineFirst-line for chronic spontaneous urticaria under EAACI/GA²LEN/EDF/WAO 2022 at standard 20 mg. With insufficient response, up-titration to 80 mg/day is acceptable (off-label, EAACI consensus). When symptoms persist at quadruple-dose, add omalizumab.
- ACetirizineFirst line · Second-generation antihistaminesFirst-line for chronic spontaneous urticaria. If the standard 10 mg dose fails to control symptoms, EAACI/GA2LEN guidelines allow up-dosing to 4-fold (40 mg daily) before stepping up to omalizumab. Tolerability of higher doses is generally good.
- ADesloratadineFirst line · Second-generation antihistamineFirst-line for chronic spontaneous urticaria under EAACI/GA²LEN/EDF/WAO 2022 at 5 mg once daily. With insufficient response, up-dosing to 20 mg/day is acceptable (off-label, EAACI consensus). When symptoms persist at quadruple dose, add omalizumab.
- AEbastineFirst line · Second-generation antihistamineFirst-line for chronic spontaneous urticaria. Per EAACI 2022, up-dosing to 40 mg/day is acceptable when the standard dose is insufficient.
- AFexofenadineFirst line · Second-generation antihistamineFirst-line for chronic spontaneous urticaria at 180 mg once daily. Per EAACI 2022, up-titration to 720 mg/day is acceptable before adding omalizumab.
- ALevocetirizineFirst line · Second-generation antihistamineFirst-line for chronic spontaneous urticaria under EAACI/GA²LEN/EDF/WAO 2022 at standard dose 5 mg once daily. With insufficient response, up-dosing to 20 mg/day is acceptable (off-label, EAACI consensus). When symptoms persist at quadruple dose, add omalizumab.
- ALoratadineFirst line · Second-generation antihistaminesFirst-line treatment for chronic urticaria. If the standard dose is insufficient, EAACI/GA2LEN permit up-dosing second-generation antihistamines up to 4-fold as a class-level recommendation; loratadine-specific up-dosing data are limited. Higher doses are usually tolerated acceptably.
- ARupatadineFirst line · Second-generation antihistamine with additional PAF antagonismFirst-line for chronic spontaneous urticaria under EAACI/GA²LEN/EDF/WAO 2022: second-generation antihistamines at standard dose. With insufficient response, up-dosing rupatadine to 40 mg/day is acceptable (off-label, EAACI consensus). When symptoms persist at quadruple dose, add omalizumab.
- DDexchlorpheniramineSecond line · First-generation sedating antihistamineIn chronic spontaneous urticaria, EAACI/GA²LEN 2022 lists second-generation antihistamines (bilastine, rupatadine, ebastine, levocetirizine) as first-line. Sedating first-generation H1 antihistamines are not preferred. Dexchlorpheniramine is used sparingly and short-term for severe itching with sleep disruption.
- DHydroxyzineSecond line · First-generation antihistamine with anxiolytic activityPreviously considered standard for urticaria with marked itching and accompanying anxiety. Current EAACI/GA²LEN 2022 guidance does not recommend first-generation antihistamines as preferred agents due to sedation and anticholinergic effects. Use is uncommon – reserved for urticaria with severe sleep disruption where sedation is welcomed, in short courses.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit