Chronic urticaria in children: what to do when antihistamine updosing has not worked
This protocol addresses the management of chronic urticaria in patients under 18 years of age whose symptoms remain uncontrolled after a trial of high-dose second-generation antihistamines. It describes the next step when first-line escalation has not achieved complete symptom control.
Patient population
Children and adolescents under 18 years of age with chronic urticaria. Treatment decisions in this age group require particular attention to licensing status, available paediatric experience, and weight- and age-adjusted dosing at every step of the algorithm.
Previous line — reason for escalation
Updosing of the 2nd-generation H1-antihistamine (up to 4-fold, weight- and age-adjusted) did not achieve the treatment targets: a continuous urticaria activity score (UAS) of 0 and a urticaria control test (UCT) score of 16. Failure to reach these targets is the indication for moving to the next treatment step described here.
Treatment goals
The aim is complete, sustained symptom control — defined as a continuous UAS of 0 and UCT of 16 — alongside normalisation of quality of life.
Next-line approach (partial overview)
When antihistamine updosing fails in this paediatric population, the protocol involves add-on therapy with a biologic agent — the only approved biologic for antihistamine-refractory disease in patients above a certain age threshold. Specific eligibility criteria, dosing, and the full structured regimen are in the protocol.
Full regimen, sequencing, and monitoring details available via the link below.
References
DOI: 10.1111/all.70210
We suggest using the same treatment algorithm with caution (e.g., according to licensing status, experience for use in children, weight-and age-adjusted dosage) in children with chronic urticaria.
Currently, omalizumab is the only approved biologic for anti-histamine refractory CSU in patients aged older than 12 years, while dupilumab is undergoing trials in children ≥ 2 years with uncontrolled CSU.
The goal of treatment is to treat the disease until it is gone, as efficiently and as safely as possible, aiming at a continuous complete control (consistently UAS = 0/UCT = 16) and a normalization of quality of life.
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