Guidelines for the management of chronic spontaneous urticaria: recommendations supported by the Centre of Evidence of the French Society of Dermatology

Abstract

Dear Editor, Chronic spontaneous urticaria (CSU) is an inflammatory disease characterized by spontaneous weals or angio-oedema for more than 6 weeks. The natural history of the disease is resolution within several months or years, and treatment is necessary to limit flares, reduce pruritus and improve quality of life (QoL). Numerous medical drugs are available, all having suspensive effects on CSU. International guidelines from the EAACI/GA2LEN/EDF/UNEV were published in 2018,1 but practice remains heterogeneous, especially for CSU refractory to H1 antihistamines and regarding states’ official drug approval and reimbursement policies. The Centre of Evidence of the French Society of Dermatology formulated recommendations on treatments for CSU based on evidence from the literature and on consensus expert opinion.2 Firstly, a multidisciplinary working group, composed of eight health professionals including a biostatistician, with no conflicts of interest regarding the pharmaceutical industry, performed systematic reviews of all interventions, except for alternative treatments. The French National Health Authority performed the research of articles, including any therapeutic prospective study published between 2000 and 2017 found on MEDLINE, Embase, CENTRAL, LILACS and PsycINFO. Articles on diets and paediatric populations were included from 1995 because they were much fewer in number. Articles on H1 and H2 antihistamines were included after the inclusion periods of the systematic reviews from the Cochrane Collaboration, which were thus updated.3, 4 The working group analysed the studies (two persons independently for each intervention) by describing the effect estimates, biases and harms, then graded the level of evidence (from D – no direct research evidence, to A – several multicentric double-blinded studies with concordant positive results and acceptable risks) after reaching unanimous consensus.5 The comments from the eight experts who were secondarily interviewed were incorporated into the recommendations, then the synthesis was submitted to a multidisciplinary panel of 28 reviewers, including health providers and patients, who scored each recommendation from 1 to 9. In conclusion, several drugs are considered effective for CSU. The impact on QoL should guide any therapeutic escalation. There is a need for randomized controlled trials (i) comparing omalizumab to immunosuppressive drugs, (ii) in paediatric individuals with CSU, and (iii) evaluating the usefulness of systemic steroids. On behalf of the French Center of Evidence, these data led to a practical decision-making algorithm (Figure 1) and are included on a dedicated website to provide an easy-to-use tool with a fast step-by-step navigation according to clinical situations (https://reco.sfdermato.org/en/guidelines-chronic-spontaneous-urticaria). Further methodological information is available upon direct request. we thank the experts and reviewers for their helpful involvement, and Mr Laurent Elgard for the website. Florence Hacard: Writing-original draft (equal). Bruno Giraudeau: Writing-original draft (equal). Gwenaelle d'Acremont: Writing-original draft (equal). Marie-Hélène Jegou-Penouil: Writing-original draft (equal). Annie-Pierre Jonville-Bera: Writing-original draft (equal). Stephane Munck: Writing-original draft (equal). Bach-Nge Pham: Writing-original draft (equal). Sandra Mavoungou: Writing-original draft (equal). Hélène Cornillier: Writing-original draft (equal). Bernard Guillot: Project administration (supporting); Validation (supporting); Writing-review & editing (supporting). Marie Beylot-Barry: Validation (equal). Olivier Chosidow: Validation (equal). Annabel Maruani: Supervision (lead).

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