The evidence-based consensus statement for the management of urticaria was released by the Skin Allergy Research Society (SARS) of India in the year 2017. The guidelines includes the updated definition, causes, classification, and management of urticaria as per the Indian context.

The following are the important aspects of urticaria management as per the evidenced-based consensus statement of 2017:

Updated classification of urticaria

The consensus statement strongly recommends the use of the updated classification that differentiates urticaria based on the nature of episodes and the eliciting factors or stimuli.

• Acute urticaria is defined as the appearance of urticaria for less than 6 weeks.
• Chronic urticaria is defined as a condition in which the individual has urticaria episodes daily for more than 6 weeks. It can be further divided into:
  • Chronic spontaneous urticaria (CSU): In CSU, the episodes of urticaria occur without any external stimuli for more than 6 weeks.
  • Chronic inducible urticaria (CINDU): In CINDU, urticaria is caused by external stimuli such as changes in temperature, pressure etc.

Urticaria Activity Score 7 (UAS7)

The UAS7 tool that helps provide information about severity as well as the treatment efficacy. The guidelines suggest that weekly UAS7 should be used for assessing the severity of urticaria. The weekly UAS7 score is the sum of score of each day of the week and can vary between 0 and 4 The daily UAS7 score is calculated based on the intensity of itching and number of wheals.

Treatment of urticaria as per the new approach

The guidelines recommend the following therapeutic options for Urticaria management.

• Preference of 2nd generation anti-histamines: This guideline recommends the use of second-generation H1 anti-histamines over the first-generation H1 anti-histamines. It also suggests assessing the efficacy of the second- generation H1 anti-histamines using the UAS7 criteria. If second-generation H1 anti-histamines are not sufficiently effective, then it is recommended to increase the dose by 4-fold. The dose should be increased only in case of levocetirizine, fexofenadine, and desloratadine of all the available second-generation H1 anti-histamines in India.
• Corticosteroids for short-term management: This guideline also suggests using short-term corticosteroid therapy for the treatment of underlying inflammation. Long-term use of corticosteroids is not recommended.
• Cyclosporine vs. Omalizumab: If symptoms are not controlled effectively, even with 4-times increased dose of second-generation antihistamines, then either omalizumab or cyclosporine should be used. The guideline proposes the use of cyclosporine over omalizumab as it is more suitable in India. However, it is recommended to monitor the patients continuously for serious side effects.
• Other Alternatives: It is recommended to use hydroxyzine (first generation anti histamine), methotrexate, autologous serum therapy and doxepin when Omalizumab or cyclosporine are unavailable or contraindicated. The first-generation antihistamines are losing importance globally, but hydroxyzine is recommended as it was found to be effective in few Indian cases.

Urticaria is a highly prevalent condition known to be two times more common in women than in men. Though the prevalence rate of urticaria in India is not yet determined, the guideline aims to help specialists by providing evidence-based and therapeutic approaches to Urticaria in the Indian perspective.

This article was originally published on August 24, 2018.