Therapeutic Challenges in Chronic Spontaneous Urticaria

Abstract

Chronic spontaneous urticaria (CSU) involves cutaneous symptoms of swelling, redness, and itching that persist for longer than 6 weeks. These episodes can continue for months or years, with a disease duration of 1 to 5 years on average. The prevalence of CSU is estimated to be 0.5% to 1%. Frequent recurring episodes of generalized urticaria and angioedema reduce the quality of life for those patients with CSU. Treatment with second-generation antihistamines is insufficient in 36.8% of patients, even at high doses. Although omalizumab (humanized anti-immunoglobulin IgE) is also indicated for the treatment of this condition and has been used to treat patients who are unresponsive to high-dose second-generation antihistamines, omalizumab therapy is ineffective in one-third of those cases. Therefore, the current conventional treatments, including omalizumab, still do not provide adequate relief for some patients with CSU. This review discusses the therapeutic challenges, off-label drug use, and combined drug therapies in CSU patients who do not respond to the current conventional drug therapy. Cyclosporine and methotrexate may be beneficial in the management of CSU which is unresponsive to conventional treatments. The combined use of these drugs with conventional therapies may increase the effectiveness of the treatment in difficult-to-manage cases. Methotrexate may be an effective alternative to cyclosporine for those CSU patients who cannot tolerate cyclosporine due to its high incidence of adverse effects.