Diagnostic tests for chronic urticaria
The practice parameter reinforces that there is no role for food or inhalant testing for chronic urticaria, unless there is contact urticaria.
There is little value in ordering ANA for chronic urticaria without clinical suspicion of systemic autoimmunity.
Thyroid antibodies are a marker for autoimmune urticaria (IgG to IgE receptor). This does not imply that thyroid hormone replacement will treat the hives.
The 1st line therapy for chronic urticaria is nonsedating antihistamines. High doses may be needed (up to 4 times the normal dose).
If your urticaria patients complains of sedation, consider fexofenadine (Allegra), now available OTC. Fexofenadine is non-sedating even at high doses. Cetirizine (Zyrtec) is sedating at 2x or 4x normal dose.
Current 2nd generation antihistamines (even at high dose) do not appear to cause Q-T prolongation.
Histamine 4 receptor has a profound effect on itch. Need to develop new drugs for ocular and other pruritic conditions
Montelukast has varied results in treating chronic urticaria. Montelukast offers only minor benefit as an adjunct in therapy of urticaria. But it is very safe.
Comment from @Stolib: the interesting thing is that montelukast offers only minor benefit as an adjunct in the treatment of almost anything.
Cyclosporine significantly decreases both urticaria wheals and itching, but requires monitoring and dose reduction for side effects. Approximately 80% of chronic urticaria patients on cyclosporine responded, but side effects are common, and may limit therapy.
Hydroxychloroquine is shown to be useful as well, but it takes 3 months to reach effect.
Many other options exist, including tacrolimus and omalizumab (Xolair).
When allergists are asked for CIU: "Do you find __(medication) can be useful?", the answer is "Yes, sometimes." There are lots of options out there, but no overwhelming data for benefit.
In skin biopsy, ask pathologist to comment on neutrophils vs. mononuclear cells. Dapsone works well for neutrophilic urticaria. Consider biopsy with more than 50% neutrophilic infiltrate to be neutrophilic predominant urticaria. Dapsone and/or colchicine can be more useful in neutrophilic urticaria.
New practice parameter for urticaria is coming soon.
Evidence for Methotrexate as a Useful Treatment for Steroid-dependent Chronic Urticaria http://goo.gl/tnFFd
Image source: Urticaria, Wikipedia, public domain.