Chronic spontaneous urticaria - a management pathway for patients with chronic spontaneous urticaria.

Chronic spontaneous urticaria (CSU) is a common and challenging disease, especially with respect to healthcare provision in the context of the German statutory health insurance system. If treatment with second-generation antihistamines is unsuccessful, current guidelines recommend further therapeutic options. However, most of these are off-label. This discrepancy between treatment according to guidelines and the ability to prescribe drugs at the expense of the statutory health insurance (reimbursability) often leads to uncertainties in everyday clinical practice. In addition, physicians prescribing certain drugs are faced with the difficulty of measuring and documenting therapeutic success/outcome. Respective outcome measurement methods have not yet been established in daily practice. Using a consensus process, a working group composed of dermatologists in private practice and specialized urticaria centers has defined a practical pathway for the implementation of current treatment recommendations based on the 2013 S3 guidelines for urticaria. Here, we present a diagnostic and therapeutic management pathway for CSU. Further, we discuss prescription issues in daily practice, including updosing of antihistamines, with regard to cost-effectiveness and drug approval on the basis of published studies and current legislation. Constituting the highest treatment level, the use of cyclosporine A, montelukast, and omalizumab, which has recently become available as therapeutic option, is reviewed. The urticaria control test (UCT) is presented as a valid outcome measure in routine practice. Our objective was to provide physicians in private practice with a practical guideline-based therapeutic decision tool, taking into account the requirements imposed by the statutory health insurance system. It is not meant to replace individualized history taking or treatment of this heterogeneous disease. Rather, we would like to suggest reference points for clinical diagnosis and treatment of CSU.