EAACI Report Explores Pediatric Chronic Urticaria Diagnosis and Treatment Patterns

The European Academy of Allergy and Clinical Immunology (EAACI) Task Force has released a report titled “Improving Chronic Urticaria Management in Pediatrics.”¹ The literature explores diagnostic and management practices in patients between the ages of 0 and 18 with chronic urticaria.

Methods & Materials

To develop this report, an online survey consisting of 41 multiple-choice questions was sent out to EAACI’s email lists and social media channels (LinkedIn, Facebook, and Twitter). The questionnaire was developed by an 18-member task force of urticaria experts. About 161 participants from 55 countries answered the entire survey. Over 75% were based in Europe, along with South America (10%) and Asia (7.4%). Nearly 75% were pediatric allergists. Adult allergists, pediatricians, immunologists, and pediatric immunologists were also represented. Most worked at a public or university hospital but some did work in private practice.

Most of the respondents expressed that they used published guidelines in chronic urticaria treatment but 10.6% said that they do not refer to any guidelines at all. Furthermore, most international guidelines, including those from EAACI, recommend a diagnostic workup that consists of patient history, a physical examination, disease activity, and control.

Results on Diagnosis and Testing

The most commonly used routine tests for diagnosing patients were full blood counts (83.3%), thyroid profile (64.6%), IgE (62.7%), thyroid antibodies (62.1%), C-reactive protein (59%), and antinuclear or another antibodies (50.9%). Basophil activation test and basophil histamine release assay were rarely used (6.2% and 2.5%, respectively).

Less than 20% of clinicians test their patients routinely for chronic urticaria when clinically suspected and only 25% test their pediatric patients for cholinergic urticaria. The reasons for not testing include a lack of equipment and/or time, as well as a lack of knowledge on how to perform the test. Other methods, such as the ice cube test (84.1%) and a dermographometer (71%), are typically used when chronic inducible urticaria is suspected. Furthermore, approximately 80% of pediatric patients suffer from chronic spontaneous urticaria, in which there is no identifiable trigger.²

Results on Management and Treatment

Regarding treatment with second-generation antihistamines, which are considered to be the first-line treatment in EAACI guidelines, providers increase the dosage 2 to 4 times if the standard dose gives no response, regardless of the patient’s age. After initial dosage, about half of the respondents wait 2 weeks for up-dosing, while 25% wait 1 week, and 20% wait 4 weeks. 

The recommended second-line treatment is omalizumab, according to the EAACI. For children 12 and over, half of the providers prescribed omalizumab for 6 months, and 25% extended to 12 months. The most common dosage in this age group is 300 mg every 4 weeks, as indicated by more than half of the respondents. Those between the ages of 0 and 5 had a shorter duration. However, in this clinician population, omalizumab was typically not prescribed in patients aged <5 years (77.6%), 6-11 years (45%), and adolescents (24.7%). It was found that the longer the duration of therapy with omalizumab, the less often relapse occurred after stopping the drug (p = 0.034). When patients do not respond to omalizumab, over half of respondents prefer oral ciclosporin-A while 20% utilize oral corticosteroids. It is worth noting that guidelines do not recommend this for long-term use in pediatric patients due to side effects.

Limitations and Next Steps

One study limitation may be the limited population utilized, as the survey was only given to providers with EAACI membership. This made it so that most of the clinicians were based in Europe. Additionally, these survey answers were retrospective and self-reported.

Despite these, it is clear that challenges and unmet needs still remain in the diagnostic workup and pharmacologic treatment of pediatric patients with chronic urticaria. Further education and research, along with more access to certain testing tools, are needed to improve outcomes of chronic urticaria in this patient population.

References

1. Arasi S, Pite H, Beken B, et al. An overview on current practices regarding the diagnosis and management of chronic urticaria in pediatrics: An EAACI Task Force report. Pediatr Allergy Immunol. 2025;36(8):e70174. doi:10.1111/pai.70174

2. Zuberbier T, Aberer W, Asero R, et al. The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria. Allergy. 2018;73(7):1393-1414. doi:10.1111/all.13397