Management of Chronic Spontaneous Urticaria Made Practical: What Every Clinician Should Know

Abstract

Despite its significant impact on quality of life, optimal management of chronic spontaneous urticaria remains challenging because of knowledge gaps regarding triggers, treatment response variability, and limited data for special populations. Second-generation H1-antihistamines are the first-line treatment and effective in approximately 50% of patients. For those who remain symptomatic, up-dosing up to fourfold is safe and recommended. However, prolonged ineffective antihistamine therapy should be avoided to prevent delayed disease control. In such cases, timely escalation to biologics, particularly omalizumab, is essential. Omalizumab remains the cornerstone of biologic therapy, offering rapid and sustained efficacy with an excellent safety profile. Personalized approaches involving dose escalation or interval adjustments further optimize outcomes. Cyclosporine A serves as an effective third-line option, particularly for autoimmune chronic spontaneous urticaria, but requires close monitoring because of dose-related adverse effects. Special considerations for children, pregnant individuals, and elderly people are discussed, reflecting the need for tailored approaches. Trigger avoidance, particularly nonsteroidal anti-inflammatory drugs, may aid management, although evidence is limited for many suspected exacerbating factors. Regular assessment of disease activity and control using validated tools such as the Urticaria Activity Score and Urticaria Control Test is essential for guiding treatment decisions and monitoring response. Updated international guidelines are anticipated to address emerging therapies and current knowledge gaps. © 2025 Elsevier B.V., All rights reserved.