Refractory Urticaria — SCE Dermatology MCQ

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ModerateInflammatory DermatosesRefractory UrticariaSCE Dermatology

A 45-year-old woman has chronic urticaria and angioedema. She has been on maximum-dose antihistamines and Omalizumab without adequate control. What is the next-line treatment option according to EAACI guidelines?

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Correct answer: E — Ciclosporin (calcineurin inhibitor — used as fourth-line for refractory CSU)

EAACI/GA²LEN urticaria guidelines stepwise approach: Step 1 — standard-dose second-generation H1-antihistamine; Step 2 — up-dose to fourfold; Step 3 — Omalizumab (anti-IgE); Step 4 — Ciclosporin. Ciclosporin (3-5 mg/kg/day) is effective for severe refractory CSU through inhibition of T-cell activation and mast cell mediator release. It requires monitoring (BP, renal function, lipids). Short courses of oral corticosteroids may be used for severe exacerbations but are not appropriate for long-term management. Other options under investigation include Ligelizumab (next-generation anti-IgE), Fenebrutinib (BTK inhibitor), and Remibrutinib.

Reference: EAACI/GA²LEN 2022; BAD; NICE