Based on the understanding of the aetiology of hive development, this publication provides the suggested therapy for persistent spontaneous urticaria. As a result, in addition to a discussion of clinical utility, the mechanism of action of each medication is described. Antihistamines, omalizumab, and cyclosporine are the most often used medications, with success rates of 40–55, 65–80, and 70–80 percent, respectively. When used sequentially, about 90% of patients can be successfully treated. Because of its efficacy, ease of use, and acceptable side-effect profile, the addition of omalizumab constitutes a significant advancement. The contact with IgE eliminates any reactivity to antigens to which it may be directed, down regulates IgE receptors on mast cells and basophils, and leads to down-regulation of mast cell activities, resulting in hives relief.

In nearly half of CSU patients, high-dose antihistamines are beneficial. Because of its efficacy and low side-effect profile, the use of omalizumab for antihistamine resistance has revolutionised antihistamine-resistant treatment. If the response is inadequate, cyclosporine is the next option. Patients should be closely watched for any changes in blood pressure or renal function. All of these are significantly safer than long-term corticosteroid use.

Reference: https://journals.lww.com/co-allergy/Abstract/2019/08000/Treatment_of_urticaria__a_clinical_and_mechanistic.18.aspx