Immunomodulatory approaches to the management of chronic urticaria: an immune-mediated inflammatory disease.

Although commonly encountered in clinical practice, chronic urticaria (CU) remains difficult to treat. In contrast to acute urticaria, neither exogenous triggers nor specific immunoglobulin E are identified in most chronic cases. A body of evidence suggests that CU is represented within the spectrum of immune-mediated inflammatory diseases (IMID). Our understanding of the CU disease pathogenesis now recognizes a role for T cells, B cells, and autoantibodies, and intrinsic abnormalities of histamine-releasing effector cells, thus providing new targets of intervention beyond the current mainstay of often inadequate symptomatic treatment directed against histamine receptors and steroids, with their attendant morbidities. Agents previously used to treat other autoimmune and inflammatory diseases have demonstrated efficacy in CU. Newer biologic and nonbiologic immunomodulatory agents approved for other indications and in clinical development provide potential options for this often severe disease.