Updates in Management of CSU, With Jason Hawkes, MD, MS

In this video series, Jason Hawkes, MD, MS, a board-certified dermatologist and associate professor of Dermatology at the University of California Davis, reviews significant therapeutic advancements in CSU management over the past five years. Hawkes describes a shift from initial discomfort with novel biologics, such as dupilumab and remibrutinib, toward greater comfort and routine use among dermatologists. He notes that the approval of remibrutinib and increased clinical trial activity have expanded treatment options, allowing dermatologists to offer targeted therapies that align with standard dermatological practice and mitigate earlier concerns, such as the anaphylaxis risk associated with omalizumab.

Hawkes details the recommended stepwise approach to antihistamine therapy, emphasizing that current guidelines support dose escalation up to fourfold as tolerated by the patient. He explains that, when patients exhibit nonresponsiveness at this level, clinicians should promptly consider biologics like omalizumab, dupilumab, or remibrutinib. About half of patients may not respond to maximal antihistamine doses, and further escalation beyond this, including combinations of antihistamines, is rarely effective. The "responsive versus nonresponsive" paradigm guides the decision to advance therapy.

Addressing the role of standardized disease activity metrics, Hawkes observes that tools such as ISS7, HSS7, UAS7, and the urticaria control test, while valuable in clinical trials, are not widely adopted in routine practice, particularly within dermatology. Instead, he recommends pragmatic patient-centered questions regarding the persistence of hives, itch, and the impact on daily activities, sleep, and quality of life. He underscores the importance of regular, direct assessments of symptom control to guide individualized treatment decisions for patients with CSU.