Exploring treatment options for pediatric refractory chronic urticaria

Abstract

Introduction: Urticaria is an inflammatory skin condition characterized by pruritic wheals, angioedema, or both. The global lifetime prevalence of chronic urticaria (CU) is estimated at 1.4%, with a slightly higher prevalence in children than adults. Although CU is not life-threatening, it significantly affects children’s quality of life, affecting sleep, daily activities, and emotional well-being. Areas covered: While many cases remit over time, a subset of children experiences refractory CU, which does not respond to standard or high-dose antihistamines. Treatment follows a stepwise approach, with second-generation H1-antihistamines, including dose escalation, as the first-line therapy. Omalizumab, a monoclonal anti-IgE antibody, is recommended for antihistamine-refractory cases. Other options include cyclosporine A and short-term corticosteroids for severe exacerbations. Emerging therapies, including dupilumab, Bruton’s tyrosine kinase inhibitors, and barzolvolimab, show promise for refractory cases but require further research in pediatric populations. Expert opinion: A stepwise treatment approach for pediatric refractory CU is presented in this review. Given its chronic nature and treatment challenges, ongoing research is crucial to optimize management strategies and improve patient outcomes. © 2025 Elsevier B.V., All rights reserved.