Use of non-biologic treatments in antihistamine-refractory chronic urticaria: a review of published evidence
The Journal of Dermatological Treatment. 2017;:1-38
BACKGROUND Knowledge of effectiveness and safety of the non-biologic, non-antihistamine treatments used for chronic urticaria is important as in some cases the principal guideline-recommended drug; omalizumab, has limited effect, side effects, or is too expensive or unavailable. Herein we systematically review the evidence for the use of the non-biologic treatments in antihistamine-refractory chronic urticaria. METHODS We performed a systematic review of the literature using PubMed and Webofscience and identified studies that reported use of one or more of the non-biological, non-antihistamine treatment options for chronic urticaria. The studies were evaluated based on study design, number of patients, effect of treatment and safety. RESULTS We identified 118 studies or case-series with 13 different treatments (azathioprine, chloroquine, colchicine, cyclosporine, dapsone, intravenous immunoglobulin (IVIG), methotrexate, montelukast, mycophenolate mofetil, plasmapheresis, sulfasalazine, tranexamic acid and ultraviolet light (UV) A, UVB) totaling 1682 patients. There was a paucity of controlled trials for most of the treatments reviewed albeit the strongest evidence in favour of a beneficial effect in chronic urticaria was, apart from montelukast and cyclosporine, seen for UV-therapy and dapsone followed by IVIG. CONCLUSION The treatment options reviewed should be seen as potential alternatives in treatment-resistant chronic urticaria where guideline-based selections have failed. However, larger controlled trials are warranted to advance the level of evidence, possibly supporting some treatments' future recommendation in selected patients.