title: Current challenges and controversies in the management of chronic spontaneous urticaria.
abstract: Chronic spontaneous urticaria (CSU) is characterized by the recurrence of itchy wheals for at least 6 weeks, affects up to 1% of the general population and may severely impair quality of life. H1-antihistamines are the cornerstones of treatment, but in about 10% of cases they fail to control the disease even at higher than licensed doses. In these patients, short courses of oral steroids may induce a remission in about 50% of cases. Omalizumab, a monoclonal anti-IgE, is effective in antihistamine-unresponsive patients although optimal treatment duration needs to be defined. Immunosuppressive treatment with cyclosporine is also effective in the majority of antihistamine-resistant chronic spontaneous urticaria (CSU) patients, but its use is limited by potential side effects. In refractory patients, other approaches include intravenous immunoglobulin, rituximab, dapsone and anticoagulants. The present review looks with particular interest at the prevalence of treatment failures with the main third-level treatments (corticosteroids, omalizumab and cyclosporine) and discusses them in light of the possible different pathogenic mechanisms underlying chronic spontaneous urticaria.
authors.affiliation: a 1 Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano (MI), Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Asero
authors.affiliation: b 2 UOC Immunologia Clinica A, Policlinico Umberto I, Roma, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Pinter
authors.affiliation: b 2 UOC Immunologia Clinica A, Policlinico Umberto I, Roma, Italy.
authors.forename: Alessandro Maria
authors.initials: AM
authors.lastname: Marra
authors.affiliation: c 3 Unità Operativa di Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Tedeschi
authors.affiliation: d 4 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Medicina Interna, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Cugno
authors.affiliation: e 5 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Unità Operativa di Dermatologia, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy.
authors.forename: Angelo Valerio
authors.initials: AV
authors.lastname: Marzano
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000818:Animals; D002908:Chronic Disease; D016572:Cyclosporine / Q000627:therapeutic use*; D006801:Humans; D000069444:Omalizumab / Q000627:therapeutic use*; D015995:Prevalence; D012008:Recurrence; D017211:Treatment Failure; D014581:Urticaria / Q000188:drug therapy* / Q000453:epidemiology
chemical_list: D000305:Adrenal Cortex Hormones; D000069444:Omalizumab; D016572:Cyclosporine
keywords: chronic spontaneous urticaria; corticosteroids; cyclosporine; omalizumab