Urticaria Management in North America: What We Know and What We Do Not Know

This paper aims to provide a comprehensive overview of urticaria, with particular attention to chronic spontaneous urticaria (CSU). The review addresses critical questions related to the classification, pathophysiology, diagnosis, and treatment of urticaria while highlighting significant knowledge gaps. These gaps present exciting opportunities for future research, potentially revolutionizing our understanding and management of this condition.

Recent research on urticaria has advanced our understanding of its pathophysiology, particularly the role of dermal mast cells and their degranulation in releasing inflammatory mediators such as histamine, prostaglandins, leukotrienes, proteases, and cytokines. This process is central to the development of wheals and pruritus in urticaria. Treatment primarily aims to manage symptoms, with antihistamines as the first-line therapy, followed by omalizumab and cyclosporine, depending on severity and treatment response. Emerging treatments, such as Bruton’s tyrosine kinase inhibitors (BTK inhibitors) and leukotriene receptor antagonists, are currently under investigation.

Urticaria, commonly known as hives, is characterized by the appearance of pruritic wheals surrounded by surrounding erythema; it may co-exist with angioedema. Emerging treatments such as BTK inhibitors could significantly impact clinical practice, particularly for patients who fail treatment with antihistamines, omalizumab, and cyclosporine. Despite these advancements, significant knowledge gaps remain, particularly in understanding the pathogenesis of CSU, long-term disease management, and the impact of environmental and socioeconomic factors on urticaria. Addressing these gaps through further research is crucial for improving the management and outcomes of patients with urticaria.