Chronic Urticaria — SCE Dermatology MCQ

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ModerateInflammatory DermatosesChronic UrticariaSCE Dermatology

A 48-year-old woman with chronic urticaria has daily wheals lasting less than 24 hours with no residual bruising. She has been on maximum-dose Cetirizine (20 mg daily) for 6 weeks without adequate control. According to NICE/BAD guidelines, what is the next step?

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Correct answer: D — Add Omalizumab

For chronic spontaneous urticaria not controlled by up-dosed second-generation H1-antihistamines (up to fourfold the licensed dose, i.e., Cetirizine 40 mg/day has already been tried in this case at 20 mg), the next step per NICE/EAACI guidelines is Omalizumab (anti-IgE monoclonal antibody). The guideline pathway is: standard-dose antihistamine → up-dose antihistamine (up to 4× standard) → Omalizumab → Ciclosporin. Montelukast may be tried as an add-on but evidence is limited. Short courses of Prednisolone are for acute exacerbations only.

Reference: NICE TA339 2015 Omalizumab; EAACI/GA²LEN 2022 Urticaria Guideline