Dr. Dareen Siri discusses highlights of her lecture Management & Future of CSU in Dermatology at the 6th Annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

Dr. Siri stresses that with new FDA-approved therapies making CSU "all over the place these days," clinicians still have to nail the diagnosis first. Even seeing this multiple times a day, she says she has "almost got tricked too," so she always asks about the individual lesions rather than trusting the photos patients bring in. True urticaria is itchy, evanescent, and resolves in less than 24 hours leaving normal-looking skin — persistence in the same spot, hyperpigmentation, livedo reticularis, bruising, or burning-over-itching points toward mimickers like the urticarial phase of bullous pemphigoid or urticarial vasculitis. She also asks about systemic symptoms — fever, preceding illness, joint pain, lethargy — and unusual triggers like cold or vibration, keeping rare zebras like cryopyrin-associated periodic fever syndrome in mind while remembering that "common is common."

On treatment, she reserves the chronic urticaria index panel for resistant or atypical cases rather than ordering "the kitchen sink" up front, and starts with maximized second-generation, non-sedating H1 antihistamines (up to four times daily, or two agents twice daily) with the focus on H1 rather than H2 blockade. For patients who fail — and many do — she moves to omalizumab, and now has dupilumab and the oral BTK inhibitor remibrutinib (Rapcido) as options. She notes early thinking that BTK inhibition may help patients who failed anti-IgE or IL-4/IL-13 therapy or who skew toward an autoimmune subtype with lower IgE, and points to a pipeline of mast-cell–targeted monoclonals and small molecules — "there's more."

  • Always ask about the individual lesion, not just the photos — true urticaria is itchy, evanescent, resolves in under 24 hours, and leaves normal skin; fixed lesions, burning over itching, bruising, or post-inflammatory pigment suggest urticarial vasculitis or other mimickers.
  • Screen for systemic clues (fever, preceding illness, joint pain, lethargy) and unusual triggers like cold or vibration; keep rare entities such as cryopyrin-associated periodic fever syndrome on the radar without over-working up common cases.
  • Skip the full lab panel up front — get the recommended basic labs and start treatment; reserve the chronic urticaria index for patients resistant to first-line therapy or with autoimmune features.
  • Maximize second-generation, non-sedating H1 antihistamines (up to four times daily) and focus on H1 blockade — H2 blockers and antileukotrienes are unvalidated adjuncts.
  • After antihistamine failure, options include omalizumab, dupilumab, and the oral BTK inhibitor remibrutinib; BTK inhibition may suit autoimmune-subtype or lower-IgE patients, with mast-cell–targeted agents still ahead in the pipeline.