@article {Kaplan:2018:1088-5412:184,
title = "Diagnosis, pathogenesis, and treatment of chronic spontaneous urticaria",
journal = "Allergy and Asthma Proceedings",
parent_itemid = "infobike://ocean/aap",
publishercode ="ocean",
year = "2018",
volume = "39",
number = "3",
publication date ="2018-05-01T00:00:00",
pages = "184-190",
itemtype = "ARTICLE",
issn = "1088-5412",
eissn = "1539-6304",
url = "https://www.ingentaconnect.com/content/ocean/aap/2018/00000039/00000003/art00007",
doi = "doi:10.2500/aap.2018.39.4121",
keyword = "urticaria, histamine, Angioedema, auto-antibodies, cyclosporine, antihistamine, omalizumab",
author = "Kaplan, Allen P.",
abstract = "
Background:
Chronic Spontaneous Urticaria (CSU) is an endogenous disorder that is strongly associated with autoimmunity, particularly with immunoglobulin G (IgG) antibody to the alpha subunit of the IgE receptor seen in 3540% of patients. Basophils and cutaneous mast
cells can be activated and lead to a late-phase-like perivascular infiltration about small venules and hive formation. 
Methods:
Review of current literature. 
Results:
Antibody to thyroid antigens are seen in 25% of patients; a small fraction of these
may be clinically hypothyroid (Hashimoto's Thyroiditis). Forty percent of patients have angioedema, but not laryngeal edema. Therapy typically begins with second-generation antihistamines (H1 receptor blockers) up to four times a day. The failure rate is substantial, and estimates
vary from 25% to 50%. The drug of choice for antihistamine resistant cases is omalizumab, at 300 mg/month, which is effective in 70% of patients. H-2-antagonists and leucotriene antagonists are no longer recommended because the literature does not support additional efficacy beyond blockage
of H-1 receptors. For patients unresponsive to antihistamines and omalizumab, cyclosporine is recommended next. This is similarly effective in 6570% of patients; however, assessment of blood pressure and renal function need to be followed every 46 weeks. Corticosteroid should
not be employed chronically; however, a brief course of 310 days can be used acutely for severe exacerbations. Other agents, such as dapsone, sulfasalazine, or hydroxychloroquin, can be tried when the aforementioned medications fail, but the results are unpredictable because they have
not been shown to have efficacy beyond the placebo effect (2530%), and have not been studied in patients for whom the aforementioned approach i.e. antihistamines, omalizumab, and cyclosporine has failed. 
Conclusion:
High dose antihistamines, omalizumab and cyclosporine
(in that order) are effective and recommended for therapy of CUS, an inflammatory skin disorder associated with autoimmunity in 45% of patients.",
}