Chronic idiopathic urticaria (CIU), defined as wheals and/or angioedema lasting for ≥6 weeks without an identifiable cause, is a burdensome condition. This review provides recommendations regarding the efficient recognition and differential diagnosis of CIU from other chronic urticaria forms and discusses the importance of evaluating CIU’s impact on patients’ quality of life and assessing unmet treatment needs.
The goal of treatment is achieving complete resolution of symptoms through a systematic approach and close patient cooperation, thereby improving quality of life. The U.S. Practice Parameter describes a step-care approach to CIU management, with second-generation H1-antihistamines at approved doses as the first-line treatment. For patients with inadequately controlled symptoms, dose advancement or add-on therapies, followed by use of potent antihistamines, may be considered. Of the alternative agents available for the treatment of patients with refractory CIU, omalizumab, an anti-immunoglobulin E monoclonal antibody, is the only treatment approved by the Food and Drug Administration for use in adults and adolescents (≥12 years old) with CIU who remain symptomatic despite H1-antihistamine therapy. Ultimately, treatment decisions should weigh the potential clinical benefit versus harm for each agent and consider the patient’s preference. By discussing available treatment options and providing evidence-based recommendations, this review aims to support aspects of decision making when managing this complex condition.