How to Approach Chronic Urticaria from Allergist and Dermatologist Perspectives

At the SDPA 2026 Annual Summer Dermatology Conference, Mark Eliason, MD, and Mili Shum, MD, presented a joint dermatology-allergy perspective on chronic urticaria, emphasizing collaborative care, accurate diagnosis, and updated treatment algorithms.1

Eliason is a general dermatologist and professor at the University of Utah Department of Dermatology, with a fellowship in melanoma research and an emphasis on familial melanoma. Shum is known for her role as an allergist and immunologist, also serving as an assistant professor of medicine at the University of Utah. Both provided several notable insights to attendees of their session on addressing hives in patients.

Understanding the Mechanism

During their session, Eliason opened with the pathophysiology behind hives, noting the driving by mast cells of most urticarial reactions through both immune-mediated pathways and non-immune mechanisms, including direct activation by medications such as aspirin, opioids, and NSAIDs. Additionally, Eliason highlighted the emerging role played by basophils and the MRGPRX2 receptor as future therapeutic targets for chronic urticaria.

During the talk, Eliason pointed to prevalence data, noting chronic spontaneous urticaria (CSU) and its impact on roughly 0.1% of people in North America. He added CSU rises to 1.4% to 1.5% in its prevalence within parts of Latin America and Asia. Additionally, women can be impacted roughly twice as often as men in adulthood, Eliason noted. He also discussed common comorbidities, including thyroid autoantibodies, anxiety and depression, systemic lupus erythematosus (SLE), and atopic dermatitis.

When to Suspect Something Other Than Hives

One significant theme of the talk was differential diagnosis. Eliason walked through several look-alike conditions, including arthropod bites, tinea, subacute cutaneous lupus erythematosus, urticarial vasculitis, cutaneous mastocytosis, urticarial pemphigoid, and early-stage herpes zoster. Eliason further emphasized key distinguishing features of chronic urticaria, highlighting lesion duration beyond 24 hours, residual pigmentation or bruising, the presence of pain rather than pruritus, and vesiculation. He further commented that presentation can differ in patients with darker skin tones.

Shum addressed when allergy testing is appropriate, stressing that it should be reserved for patients with a clear, reproducible temporal relationship between exposure and symptoms. Reactions occurring within 2 hours suggest food or drug allergy, while reactions within 6 hours may indicate alpha-gal or NSAID-related triggers. She cautioned against routine food allergy testing due to its high false-positive rate and noted that random testing can lead to unnecessary dietary restriction. Shum also distinguished histaminergic angioedema, which responds to antihistamines and often accompanies hives, from bradykinin-mediated angioedema, which does not.

Updated Treatment Algorithm

Shum spoke on the latest international urticaria guidelines, noting the recommendation of second-generation antihistamines as first-line therapy, with up-dosing to 4 times the standard dose if needed. For individuals who without a response, US Food and Drug Administration (FDA)-approved biologics, dupilumab, omalizumab, and remibrutinib, can provide targeted options with distinct onset times and safety considerations.

Eliason later noted alternative immunomodulatory and immunosuppressive options for refractory cases, including hydroxychloroquine, tacrolimus, cyclosporine, and mycophenolate. The speaker noted cyclosporine’s rapid onset and potential disease-modifying impacts, though mycophenolate’s favorable safety profile was also highlighted. Both of the presenters underscored the value of treating urticaria holistically, noting hives’ substantial effects on patient sleep, mental health, and general quality of life.

References

1. Elliason M, Shum M. CSU & Allergist. Presented at SDPA Summer 2026. Jun 10-14, 2026.