Effectiveness and Safety of Pharmacological Treatments for Chronic Inducible Urticaria: A Narrative Synthesis.

Background

Several treatments for chronic inducible urticaria (CIndU) have been studied, but reviews covering all subtypes are limited.

Objectives

Our goal is to synthesize the effectiveness and safety of available therapies across all CIndU subtypes.

Methods

We performed a review of PubMed and Scopus databases to identify studies reporting treatment data on cold urticaria, symptomatic dermographism, solar urticaria, delayed-pressure urticaria, exercise-induced urticaria, cholinergic urticaria and mixed subtypes. No studies were identified that specifically focused on heat, aquagenic, or contact urticaria; however, these subtypes are encompassed within certain studies examining mixed subtypes.

Results

Our search yielded 36 studies. Second-generation H1-antihistamines as first-line treatment provided significant symptom control in most CIndU subtypes, with updosing to four times the standard dose showing greater effectiveness than standard doses. Omalizumab was highly effective as second-line treatment for antihistamine-refractory patients, although relapse after discontinuation was common. In delayed-pressure urticaria dapsone and high-dose intravenous immunoglobulin yielded good responses. Narrowband UVB benefited symptomatic dermographism and solar urticaria but with high relapse rates. Emerging mast cell-depleting therapies (barzolvolimab, lirentelimab) showed promising effectiveness, while the interleukin-1 inhibitor rilonacept failed to demonstrate clinical benefit. Across the 36 studies, adverse events were generally low for most treatments, with higher incidence reported with barzolvolimab.

Conclusions

Updosed antihistamines are more effective than standard doses in controlling CIndU symptoms without a significant increase in adverse events. Omalizumab at 150-300 mg every 4 weeks is effective for antihistamine-refractory CIndU, though it is off-label. Relapse after treatment cessation is frequent, highlighting the need for personalized long-term strategies. Novel endotype-specific treatments require dedicated CIndU trials, as current evidence is largely extrapolated from chronic spontaneous urticaria.