Management of Pediatric Chronic Spontaneous Urticaria: A Review of Current Evidence and Guidelines

Abstract

Chronic urticaria (CU) is associated with debilitating symptoms such as pruritic wheals and/or angioedema, which can significantly affect patients’ sleep, productivity and quality of life. Chronic spontaneous urticaria (CSU) is defined in cases in which no triggering factor is identified. Various guidelines directing the optimal management of CU in the adult population were published and updated over the recent years with the most accepted and widely used being the EAACI/GA 2 LEN/EDF/WAO 2017 guidelines. Meanwhile, guidelines specific to the pediatric population are scarce, mainly due to the fact that high quality evidence is lacking for many treatment options in this age group. The objective of this article is to review and synthesize the existing literature regarding the management of pediatric CSU. Our review highlights evidence supporting the EAACI/GA 2 LEN/EDF/WAO 2017 treatment guidelines with non-sedating second-generation antihistamines (sgAHs) as the mainstay of treatment for pediatric CSU, considering their demonstrated efficacy and reassuring safety profile. Additionally, the use of omalizumab in adolescents is well supported by the current literature. There is limited data available regarding the updosing of sgAHs, omalizumab in children with CSU under 12 years of age and the treatment with cyclosporine and leukotriene receptor antagonists (LTRAs) in pediatric patients of all ages. However, the results from currently available case series and case reports are promising for omalizumab and cyclosporine use in children with CSU, although large and well-designed randomized control trials (RCTs) assessing these treatment options are needed in order to formulate strong recommendations for their use. First-generation antihistamines (fgAHs) remain commonly used in pediatric CSU treatment despite a lack of studies assessing their efficacy and safety in the pediatric population and their widely known inferior safety profile compared to sgAHs.

Long term treatment with omalizumab in adolescent with refractory solar urticaria

“…The 2017 EAACI/GA2LEN/EDF/WAO international guidelines recommend the use of omalizumab as third–line of treatment for the management of CSU in adults and adolescents aged ≥12 years with inadequate response to H 1 -antihistamines [ 15 ]. Omalizumab use in patients younger than 12 years is still off-label for CSU despite emerging data suggesting safety and efficacy in this population [ 16 ].…”

Overview on chronic spontaneous urticaria in the pediatric age groups

“…Cetrizine is approved for use in CSU from 6 months 44 The use of Leukotriene receptor anatagonist (LTRA), was tried as add on therapy with antihistamines in non responders for 2 or 4 weeks. 9, 46 However, the EAACI/GA²LEN/EDF/WAO guidelines did not recommened the use of montelukast in antihistamines resistant CSU cases. 8 Their use remains off-label in CSU management.…”

In silico Identification of Immune Cell-Types and Pathways Involved in Chronic Spontaneous Urticaria

“…CSU is associated with significant morbidity due to intractable pruritus that decreases quality of life by disrupting sleep and work/school productivity ( 2 ). Up to 55% of CSU cases are refractory to first- and second-line therapies consisting of second generation H1-antihistamines at standard and up to fourfold doses, respectively ( 1 , 3 , 4 ). In addition, up to 30% of patients requiring the third-line therapy, omalizumab, do not exhibit a complete response ( 5 ).…”