Centre of Evidence of Dermatology Best practice guidelines

Guidelines chronic spontaneous urticaria Updated on december 2019


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Chronic spontaneous urticaria resistant to a quadruple dose of anti-H1 antihistamines

Back to decision-making tree Print last updated on 18/09/2020

Patient picture


Previous treatments

Initially took anti-H1 antihistamines at conventional doses (MA dose) – 3 different molecules – then, for 2 years at multiple doses: 2 tablets of desloratadine 5 mg in the morning, 2 in the evening. She takes homeopathy as well. She is very reluctant to undergo new therapies.

Other elements

What do you suggest?

See proposition




  • Explain that a gluten-free diet is not effective in CSU in the absence of associated celiac disease.
  • Explain that she can continue with homeopathy if she wishes, but that there is no evidence of effectiveness.
  • Explain that there may be an association between being overweight and CSU.


  • Assess the impact of CSU on her quality of life before proposing a third-line treatment (after anti-H1 antihistamines at conventional dose, and then quadruple dose). The assessment can be made using the DLQI or CU-QoL scores. It is also preferable to assess CSU activity at this stage, using the UCT and UAS7 scores.


  • In case of major discomfort, the preferred option is the addition of omalizumab to anti-H1 antihistamines. The patient is overweight and therefore more at risk of developing high blood pressure. The patient should be referred to a hospital for initiation of treatment. Omalizumab is prescribed at a dose of 300 mg for 4 weeks subcutaneously. *Some experts suggest other treatments before introducing omalizumab, in particular montelukast, 1 tablet per day, in addition to anti-H1 antihistamines, for about 2 months. The WG does not recommend this course, as there is no established benefit in the literature for montelukast in CSU; the level of this recommendation is low, however.
  • If she is opposed to omalizumab because she finds the drug too new or because it is administered by injection, suggest cyclosporine as an alternative, in the absence of high blood pressure. In this young, overweight patient, monitoring the renal function is particularly important.
    The prescription details are:
    cyclosporine 3 mg/kg/day, twice daily for 6 months, with weekly blood pressure monitoring and biological monitoring (CBC, ionogramme, creatinine, urea) once weekly for one month, then monthly.

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