Updated International Urticaria Guidelines: Diagnosis, Assessment, and New Treatment Recommendations

Conclusions

• The updated international chronic urticaria guideline emphasizes a structured, evidence-based process for diagnosis, classification, and treatment.
• Routine workup in chronic spontaneous urticaria should be limited, with further testing guided by history, physical examination, and disease features.
• Clinicians should actively look for rare alternative diagnoses and comorbid syndromes when the presentation is atypical or long-standing.
• Disease activity, quality of life, and control should be monitored regularly, and patient-reported tools such as UAS7 and UCT are central to management.
• Digital self-monitoring tools like the CRUSE app can make guideline-based tracking of urticaria easier for patients and clinicians.
• Second-generation H1 antihistamines remain the recommended first-line therapy, with up-dosing to four times the standard dose when needed.
• Using multiple different antihistamines or exceeding fourfold dosing is not recommended because there is insufficient evidence of benefit.
• For antihistamine-refractory disease, omalizumab remains a key second-line treatment, while dupilumab and remibrutinib are now additional second-line options.
• Treatment choice among second-line options may be influenced by comorbidities, prior biologic exposure, and other patient-specific factors.
• Long-term systemic corticosteroids are discouraged, although brief rescue courses may be used for acute flares.
• Newer therapies such as dupilumab and remibrutinib show meaningful efficacy in phase 3 trials, including in subgroups such as omalizumab-refractory or low-IgE patients.
• The overall goal of care is to keep escalating or adjusting therapy until patients have no signs and symptoms and the disease is fully controlled.