THERAPEUTIC ESCALATION IN PEDIATRIC CHRONIC URTICARIA: CLINICAL EFFICACY, DISEASE CONTROL, AND SAFETY
Keywords:
Chronic urticaria; Chronic spontaneous urticaria; Child; Adolescent; Histamine H1 antagonists; Omalizumab; CyclosporineAbstract
DOI: https://doi.org/10.46296/yc.v10i18.0856
Abstract
Chronic urticaria in pediatric patients (defined by pruritic wheals and/or angioedema lasting 6 weeks) is a challenging dermatologic and immunologic condition that can significantly impair quality of life and school performance. This article critically reviews the efficacy and safety of the recommended stepwise management approach in current guidelines, which begins with second-generation H1 antihistamines (non-sedating) at standard doses, followed by updosing (increasing the dose up to 4-fold) in cases of insufficient disease control, and introduction of second-line therapies such as omalizumab (anti-IgE monoclonal antibody) and third-line therapies like cyclosporine (immunomodulator) as needed based on clinical response. We synthesize evidence published in the last decade regarding key outcomes: urticaria activity and disease control (e.g. UAS7, UCT), quality of life improvements (CDLQI or other pediatric indices), and safety/tolerability (e.g. sedation, serious adverse events, infections, hypersensitivity reactions). Results: Current evidence supports the use of second-generation H1 antihistamines as first-line in children, even at higher-than-standard doses, with a favorable safety profile (3,4); likewise, omalizumab has shown high efficacy in older children (12 years) with antihistamine-refractory chronic urticaria, and emerging data suggest benefits in younger (<12 years) patients (5). Cyclosporine can be effective in refractory pediatric chronic urticaria, though its use is reserved due to potential toxicities (6). Conclusions: We discuss knowledge gaps, including the scarcity of pediatric trials, extrapolation from adult data, and the need for future research to optimize the risk–benefit balance at each step of therapy escalation.
Keywords: Chronic urticaria; Chronic spontaneous urticaria; Child; Adolescent; Histamine H1 antagonists; Omalizumab; Cyclosporine.
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References
Tondury B, Mühleisen B, Ballmer-Weber BK, et al. The pictorial representation of illness and self measure (PRISM) instrument reveals a high burden of suffering in patients with chronic urticaria. J Investig Allergol Clin Immunol. 2011;21(2):93–100.
Ferrer M. Epidemiology, healthcare resources use and clinical features of different types of urticaria. Alergológica 2005. J Investig Allergol Clin Immunol. 2009;19(Suppl 2):21–26.
Simons FE, Simons KJ. Histamine and H1-antihistamines: celebrating a century of progress. J Allergy Clin Immunol. 2011;128(6):1139–1150.e4.
Novak Z, Yáñez A, Kiss I, et al. Safety and tolerability of bilastine 10 mg administered for 12 weeks in children with allergic diseases. Pediatr Allergy Immunol. 2016;27(5):493–498.
Alomari O, Ozceker D, Mokresh ME, et al. Omalizumab in pediatric chronic spontaneous urticaria: A systematic review and meta-analysis of efficacy and safety. Pediatr Allergy Immunol. 2025;36(6):e70132.
Kulthanan K, Chaweekulrat P, Komoltri C, et al. Cyclosporine for chronic spontaneous urticaria: a meta-analysis and systematic review. J Allergy Clin Immunol Pract. 2018;6(2):586–599.e6.
Bernstein JA, Lang DM, Khan DA, et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014;133(5):1270–1277.
Zuberbier T, Aberer W, Asero R, et al. The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria (2017 update). Allergy. 2018;73(7):1393–1414.
Balp MM, Weller K, Carboni V, et al. Prevalence and clinical characteristics of chronic spontaneous urticaria in pediatric patients. Pediatr Allergy Immunol. 2018;29(6):630–636.
Brunetti L, Francavilla R, Miniello VL, et al. High prevalence of autoimmune urticaria in children with chronic urticaria. J Allergy Clin Immunol. 2004;114(4):922–927.
Iriarte Sotés P, Armisén M, Usero-Bárcena T, et al. Efficacy and safety of up-dosing antihistamines in chronic spontaneous urticaria: a systematic review of the literature. J Investig Allergol Clin Immunol. 2021;31(4):282–291.
Maurer M, Rosén K, Hsieh HJ, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013;368(10):924–935.
Agache I, Akdis CA, Akdis M, et al. EAACI Biologicals Guidelines – Omalizumab for the treatment of chronic spontaneous urticaria in adults and in the paediatric population 12–17 years old. Allergy. 2022;77(1):17–38.
Caffarelli C, Paravati F, El Hachem M, et al. Management of chronic urticaria in children: A clinical guideline. Ital J Pediatr. 2019;45:101.
Potter PC, Mitha E, Barkai L, et al. Rupatadine is effective in the treatment of chronic spontaneous urticaria in children aged 2–11 years. Pediatr Allergy Immunol. 2016;27(1):55–61.
Nelson HS, Reynolds R, Mason J. Fexofenadine HCl is safe and effective for treatment of chronic idiopathic urticaria. Ann Allergy Asthma Immunol. 2000;84(5):517–522.
Doshi DR, Weinberger MM. Experience with cyclosporine in children with chronic idiopathic urticaria. Pediatr Dermatol. 2009;26(4):409–413.
Neverman L, Weinberger M. Treatment of chronic urticaria in children with antihistamines and cyclosporine. J Allergy Clin Immunol Pract. 2014;2(4):434–438.
Madurga S. Antihistamínicos de primera generación sedantes: Australia publica riesgos graves de daños en los niños. Panorama Actual Med. 2022;46(459).
Laboratorio Rontag. El manejo de la urticaria: consejos clínicos. Rontag.com (sitio web); 2019 [citado 07 Ene 2026]. Disponible en: https://www.rontag.com.
Maurer M, Houghton K, Costa C, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report. Allergy. 2011;66(3):317–330.
Konstantinou GN, Asero R, Maurer M, et al. EAACI/GA²LEN task force consensus report: the autologous serum skin test in urticaria. Allergy. 2009;64(9):1256–1268.
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