Gaps and challenges in diagnosis and treatment: all the recommendations

Chronic spontaneous urticaria (CSU) is a condition that has a significant impact on quality of life and is characterised by the appearance of itchy wheals and angioedema lasting for more than 6 weeks. The prevalence of CSU in Italia is 0.1–1.5 cases per 1,000 inhabitants per year, whilst the global prevalence is 0.1–1.4 per cent of the general population. Although international guidelines, updated this year, provide detailed guidance on the clinical classification and therapeutic management of this chronic inflammatory skin condition, their application in ‘real-life’ practice remains inconsistent, leading to diagnostic delays, incorrect diagnoses and sub-optimal use of currently available treatments. Clinicians dealing with this condition often rely on personal experience, which may be influenced by national regulatory policies. To bridge this gap, an Italian panel of specialists conducted a consensus exercise using the Delphi method, with the aim of identifying the main areas where approaches to the condition are inconsistent and of producing clear, unambiguous recommendations tailored to the Italian context.

To this end, a panel of 10 clinicians – mainly dermatologists and allergists with extensive expertise in the management of CSU – drew up 27 statements (15 on the diagnostic work-up and 12 on treatment timelines and parameters). These statements were then submitted to a panel of 37 specialists (28 dermatologists and 9 allergists) to establish consensus, which was deemed to have been reached when supported by at least 70 per cent of the panel. Consensus was defined as ‘strong’ when supported by more than 90 per cent of the panel. Statements that did not achieve consensus in the first round were reworded by the panel and put to a vote again in a second round.

The majority of the statements achieved consensus as early as the first round; only two statements, relating to the need to determine the levels of VES and anti-TPO IgG, failed to achieve consensus even after the relevant statements had been reworded.

As regards diagnosis, there is strong consensus that it remains essentially clinical, based on medical history and direct physical examination, and cannot be replaced by photographic documentation alone (which is useful only as a supplementary tool). A differential diagnosis with vasculitic urticaria is necessary when the wheals last for more than 24 hours, are painful or burning, or leave post-inflammatory hyperpigmentation, particularly in the presence of systemic symptoms such as arthralgia and fever. Among laboratory tests, a complete blood count, CRP and total IgE are considered essential; further blood chemistry tests should only be carried out when strictly necessary and only where the patient’s medical history warrants such investigations. However, there is no consensus on whether erythrocyte sedimentation rate (ESR) and anti-thyroid peroxidase (anti-TPO) IgG should be performed in all patients; the authors of the publication find this outcome surprising, given the role of anti-TPO IgG in identifying the type IIb autoimmune endotype of CSU for the purpose of selecting an appropriate treatment. It is worth noting the panel’s strong consensus against carrying out diagnostic tests that lack scientific validation.

With regard to diet, low-histamine diets are not generally recommended, as there is a lack of adequate scientific evidence; diets that exclude certain specific foods should be reserved for individual cases caused by specific, identified dietary triggers, as food is a rare cause of CSU.