Updated Urticaria Guidelines Clarify Diagnosis, Biomarkers, Treatment Pathways

An updated international guideline for , finalized at a global consensus conference in December 2024, reinforces a streamlined diagnostic approach while incorporating new evidence on emerging therapies, biomarkers, and disease mechanisms in chronic urticaria.1

Developed using Cochrane and GRADE methodology, the revision reflects the work of >200 experts from 59 countries and represents the first major update since 2022.2 For clinicians, the update clarifies where evidence has matured meaningfully, particularly regarding the use of biomarkers, the role of provocation testing in chronic inducible urticaria, treating pediatric patients, and evaluating next-generation therapies for refractory disease.1

Updated Definitions and Treatment Goals

The guideline continues to define urticaria as “a condition characterized by the development of wheals (hives), angioedema, or both.”

Wheals are characterized by 3 features: a clearly defined, superficial swelling that varies in size and shape and is usually surrounded by redness; itching or sometimes a burning sensation; and a short duration, with the skin returning to normal within 30 minutes to 24 hours. Angioedema is defined by a sudden, marked deep swelling of the lower dermis, subcutaneous tissue, or mucous membranes that is skin colored or erythematous; sensations of tingling, burning, tightness, and sometimes pain rather than itching; and a slower resolution than wheals, with symptoms that may last up to 72 hours.

Therapeutic goals emphasized in the guideline include, when possible, complete symptom control, avoidance of known eliciting factors, induction of tolerance in select chronic inducible urticaria subtypes, and pharmacologic prevention of mast cell mediator release.

What Changed Since the 2022 Guideline?

Updated evidence

Experts conducted a systematic review of randomized controlled trials across 3 databases through February 9, 2024. Of 1946 records identified, 12 trials met inclusion criteria. The update incorporates 12 new or revised GRADE evidence profiles and evidence-to-decision frameworks.

Clearer positioning of biomarkers

Although disease duration, activity, and treatment response, as well as laboratory markers, are commonly assessed in chronic spontaneous urticaria (CSU), the guideline states that no biomarker has sufficient predictive accuracy for routine clinical use. The document also highlights growing recognition that some urticaria therapies may beneficially affect comorbid conditions, including omalizumab and dupilumab in asthma, dupilumab in atopic dermatitis, and omalizumab in food allergy and chronic rhinosinusitis with nasal polyps.

Stronger consensus on provocation testing

The guidelines recommend provocation testing to diagnose chronic inducible urticaria. It also recommends the use of provocation thresholds and validated patient-reported outcome tools to assess disease activity and control.

Expanded pediatric guidance

New recommendations support the use of the same treatment algorithm in children as adults, with caution regarding age, weight, and regulatory approvals. Recent evidence suggests disease characteristics and treatment responses in pediatric patients largely mirror those seen in adults. To date, only UAS7 and UCT have been validated in children.

Questions the Guidelines Answer

The following questions and responses are drawn directly from the international urticaria guideline recommendations, verbatim.

How should urticaria be classified?

The guideline recommends classifying urticaria by duration as acute (≤ 6 weeks) or chronic (> 6 weeks), and by etiology as spontaneous (no identifiable trigger) or inducible (a specific, reproducible trigger).

Should the current classification of chronic urticaria be maintained?

Yes. The guideline recommends maintaining the existing classification system.

Should routine diagnostic testing be performed in acute urticaria?

The guideline recommends against routine diagnostic testing in acute spontaneous urticaria.

What diagnostic measures are recommended in chronic spontaneous urticaria?

Limited investigations are recommended. Basic testing includes a differential blood count and CRP and/or ESR. In specialized care settings, total IgE and IgG anti–thyroid peroxidase antibodies may be considered, with further testing guided by clinical history and disease severity.

How should chronic inducible urticaria be evaluated?

Provocation testing is recommended for diagnosis. Provocation threshold measurements and the Urticaria Control Test (UCT) are recommended to assess disease activity and control.

Which tools should be used to monitor disease activity and control?

For disease activity, the guideline recommends UAS7 and/or the Angioedema Activity Score (AAS). For disease control, UCT and/or the Angioedema Control Test (AECT) are recommended.

What is the recommended first-line treatment?

Second-generation H1-antihistamines are recommended as first-line therapy for all forms of urticaria.

Is antihistamine updosing recommended?

For patients with chronic urticaria unresponsive to standard dosing, updosing second-generation H1-antihistamines up to fourfold is recommended before advancing to other therapies. Doses above fourfold are not recommended.

What add-on therapies are recommended for antihistamine-refractory disease?

Omalizumab is recommended as add-on therapy for patients unresponsive to high-dose antihistamines. Dupilumab and remibrutinib may be considered as add-on options, although use may be off-label. Ciclosporin is suggested when licensed options are ineffective or unavailable.

What is the role of corticosteroids?

The guideline strongly recommends against long-term systemic corticosteroid use. A short rescue course may be considered for acute exacerbations.

Should the same treatment algorithm be used in children, pregnancy, and lactation?

The guideline suggests using the same algorithm with caution in children and in pregnant or lactating women, following individualized risk–benefit assessment and avoiding contraindicated therapies.

References

1. Zuberbier T, Hameed Ansari Z, Abdul Latiff AH, et al. The International Guideline for the Definition, Classification, Diagnosis and Management of Urticaria. Allergy. 2026. https://doi.org/10.1111/all.7021

2. Zuberbier T, Abdul Latiff AH, Abuzakouk M, et al. The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. 2022;77(3):734-766. doi:10.1111/all.15090