Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the British Association of Dermatologists.

Management of People with Chronic Urticaria

British Association of Dermatologists

Publication Date: Jan 27, 2022

Page Last Updated: May 5, 2026

First‐line treatment options for people with chronic spontaneous urticaria

R12 (↑↑) Offer a second‐generation H1‐antihistamine, using a regular daily licensed dose (Table 4).
R13 (↓↓) Do not offer first‐generation H1‐antihistamines routinely, unless there is no alternative, due to concerns about their short‐ and long‐term effects on the central nervous system.
R14 (↑↑) Offer updosing (i.e. increasing the dose above the licensed dose) of a single second‐generation H1‐antihistamine, by up to fourfold the licensed dose, to people whose symptoms are inadequately controlled by the standard licensed dose, provided it is tolerated and there is no caution or contraindication (see section 7.2 and Appendix C – LETR narratives). Attempt stepwise dose reduction following complete symptom control. There is no evidence to guide the optimum duration of updosing or speed of dose reduction.
R15 (↓↓) Do not updose mizolastine (see section 7.2).
R16 (GPP) Consider switching from one second‐generation H1‐antihistamine to another in people whose symptoms do not respond adequately to, or who do not tolerate, the first drug at standard or increased doses.
Θ3 There is insufficient evidence to make a recommendation on using two different second‐generation H1‐antihistamines at the same time.
R17 (↓↓) Do not updose first‐generation H1‐antihistamines (see R13).
R18 (↑) Consider montelukast, in addition to a second‐generation H1‐antihistamine, in people whose symptoms are inadequately controlled by standard and increased doses of second‐generation H1‐antihistamines.
R19 (↑↑) Offer* progression of therapy, through first‐line treatment options (see R12–R18) every 2–4 weeks (every 2 weeks in severe treatment‐resistant disease).
R20 (↑) Consider oral prednisolone (e.g. 0·5 mg kg−1) for short, infrequent courses of a few days as rescue treatment to control severe exacerbations, in addition to continued use of a second‐generation H1‐antihistamine.
R21 (↓↓) Do not offer* long‐term systemic corticosteroids unless there is no other option. Use the lowest effective dose for the shortest possible period.10

Treatment options for inducible urticarias

There is much less evidence available than for CSU, but for people with all types of inducible urticaria the following are recommended (based mainly on small case series and anecdotal evidence).

First‐line treatment options for people with all types of inducible urticaria

R29 (↑↑) Offer* a second‐generation H1‐antihistamine, using a regular daily licensed dose (Table 4).
R30 (↓↓) Do not offer* first‐generation H1‐antihistamines routinely, unless there is no alternative, due to concerns about their short‐ and long‐term effects on the central nervous system.
R31 (↑↑) Offer* updosing of a single second‐generation H1‐antihistamine by up to fourfold the licensed dose to people whose symptoms are inadequately controlled by the standard licensed dose, provided it is tolerated and there is no caution or contraindication (section 7.2 and Appendix C – LETR narratives). Attempt stepwise dose reduction following complete symptom control. There is no evidence to guide the optimum duration of updosing or speed of dose reduction.
R32 (↓↓) Do not updose mizolastine (see section 7.2).
R33 (GPP) Consider switching from one second‐generation H1‐antihistamine to another in people whose symptoms do not respond adequately to, or who do not tolerate, the first drug at the standard or increased dose.
R34 (↓↓) Do not updose first‐generation H1‐antihistamines (see R30).

Second‐line treatment options for people with all types of inducible urticaria

R35 (↑) Consider omalizumab, in addition to a second‐generation H1‐antihistamine, in people whose symptoms are inadequately controlled by first‐line options, subject to licensing and funding.
R36 (GPP) Offer self‐injectable adrenaline, if appropriate, for those at risk of anaphylaxis, for example in association with cold or cholinergic urticaria.

Third‐line treatment options for people with all types of inducible urticaria

Consider the following options, in addition to second‐generation H1‐antihistamines, in people with specific types of inducible urticaria, whose symptoms are inadequately responsive to first‐ and second‐line treatment options, or where the latter are contraindicated or inappropriate.

Document Overview

Document Title: Management of People with Chronic Urticaria

Authoring Society: British Association of Dermatologists

Document Publication Date: Jan 27, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United Kingdom

Full Text Freely Available: Yes

Full Text Guideline: academic.oup.com/bjd/article/186/3/398/6705777?login=false

Source Citation: Sabroe RA, Lawlor F, Grattan CEH, Ardern-Jones MR, Bewley A, Campbell L, Flohr C, Leslie TA, Marsland AM, Ogg G, Sewell WAC, Hashme M, Exton LS, Mohd Mustapa MF, Ezejimofor MC; British Association of Dermatologists’ Clinical Standards Unit. British Association of Dermatologists guidelines for the management of people with chronic urticaria 2021. Br J Dermatol. 2022 Mar;186(3):398-413. doi: 10.1111/bjd.20892. Epub 2022 Jan 27. PMID: 34773650.

Document Scope, Criteria, and Use Cases

Document Objectives: Provide up‐to‐date, evidence‐based recommendations for the management of urticaria, offering an appraisal of all relevant literature up to March 2020, while addressing important, practical clinical questions relating to chronic urticaria.

Scope: Management, Treatment

Diseases/Conditions (MeSH)

D000080223 - Chronic Urticaria

D014581 - Urticaria

D000080223 - Chronic Urticaria

D014581 - Urticaria

Keywords: chronic urticaria, urticaria

Target Provider Population: Allergist, immunologist, dermatologist, primary care physician, internist, rheumatologist

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Management of People with Chronic Urticaria

Summary of Recommendations

General management for people with all types of chronic urticaria

General management for people with chronic spontaneous urticaria

First‐line treatment options for people with chronic spontaneous urticaria

Second‐line treatment options for people with chronic spontaneous urticaria

Third‐line treatment options for people with chronic spontaneous urticaria

Treatment options for inducible urticarias

Cholinergic urticaria

Cold urticaria

Delayed pressure urticaria

Solar urticaria

Symptomatic dermographism

Considerations

Document Overview

Document Scope, Criteria, and Use Cases