What treatments do you consider for cholinergic urticaria refractory to high dose H1 blockers and omalizumab?

Generally, my initial approach to cholinergic urticaria (CholU) is the same for chronic spontaneous urticaria and other forms of chronic inducible urticaria [1]. Most patients with antihistamine-refractory cholinergic urticaria (CholU) will respond to omalizumab 300 mg monthly. Those individuals with Chol who achieve a complete response to omalizumab, usually do so within 6 weeks [2]. However, it can take up to 6 months to see an improvement with omalizumab.

If the patient’s situation precludes waiting 6 months, then omalizumab can be increased to 300 mg every 2 weeks (off-label dosing) per international EAACI/GA²LEN/EuroGuiDerm/APAAAC guidelines for chronic urticaria [1]. Alternatively, cyclosporine (3.5–5 mg/kg per day in divided doses) ca...