Table 3 General considerations for specialist referral

A referral should be considered in any of the following situations:

 1. Failure of or difficulty tolerating first-line treatments. If the patient's CU persists despite the use of second-generation antihistamines at standard or four-times standard dosing, or if the patient is unable to tolerate high-dose second-generation antihistamines

 2. Need for specialized treatments. Specialists can recommend and have access to a wider range of treatment options for CU, including immunomodulatory therapies, in cases where standard treatments have been ineffective

 3. Severe symptoms: If the patient experiences severe symptoms of urticaria and angioedema, or if the condition significantly affects QOL

 4. Atypical features: If the presentation of CU is atypical or there are additional symptoms that raise concerns, such as systemic symptoms (e.g., fever, arthritis), a specialist can recommend a more comprehensive evaluation and appropriate diagnostic work-up