We would firstly like to commend the authors on the recent BSACI guidelines on chronic urticaria and angio-oedema [1]. We would also like to mention the use of doxepin for consideration if high-dose anti-histamine therapy is not effective. Doxepin is an old-fashioned tri-cyclic anti-depressant, which nowadays is little used for depression, especially with the advent of the SSRI class of drugs. It has combined H1, H2 and muscarinic blocking activities, which may contribute towards its efficacy in chronic urticaria [2]. We feel that it represents an alternative agent before immunomodulatory therapy is indicated. There is a reasonable literature on its use in chronic urticaria, which dates back to the 1980s. The use of doxepin is mentioned in the 2014 AAAAI and ACAAI update: the diagnosis and management of acute and chronic urticaria.
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