Management of chronic urticaria: Current status and future prospect

Abstract

Chronic urticaria is a mast cell-driven inflammatory disease characterized by recurrent wheals, angioedema or both for more than 6 weeks, with substantial effects on sleep, quality of life, mental health and daily functioning. Type I autoallergic and type IIb autoimmune mechanisms represent major endotypes, but many patients show overlapping or mixed features, contributing to heterogeneous clinical courses and variable treatment responses. Current management relies on confirming the diagnosis, excluding differential diagnoses, identifying aggravating factors and comorbidities and monitoring disease activity and control using validated patient-reported outcome measures. A limited, clinically guided diagnostic workup is preferred, with extended investigations reserved for selected cases based on history, examination, red flags or isolated angioedema. Second-generation H1-antihistamines remain the first-line therapy, with up-dosing recommended in insufficient responders. Omalizumab has transformed the treatment of antihistamine-refractory disease, while newer options such as dupilumab and remibrutinib further expand the therapeutic landscape. Ciclosporin remains an effective option in selected patients, particularly those with severe or difficult-to-treat disease, but requires careful safety monitoring. In chronic inducible urticaria, provocation testing, threshold assessment, trigger counselling and individualized treatment are central to care. Despite recent advances, important unmet needs remain, including reliable biomarkers for endotyping, evidence-based selection among emerging therapies, better data in children and other special populations, standardized definitions of remission and relapse and disease-modifying strategies. Future management is expected to move towards biomarker-driven, personalized care, enabling more precise treatment selection and sustained disease control.