Clinical perspective
Why Treatment Escalation Remains a Challenge in CSU
Despite established treatment recommendations, many patients with chronic spontaneous urticaria (CSU) continue to experience persistent symptoms and inadequate disease control. A 2026 analysis from the international Chronic Urticaria Registry (CURE), published in Allergy, examined real-world treatment patterns to better understand how clinicians escalate therapy and why some patients remain symptomatic. The findings highlight important gaps between recommended management strategies and treatment decisions in routine clinical practice.
Researchers analyzed baseline information from 3,995 adults with CSU, including 1,288 patients with evaluable Urticaria Control Test (UCT) data at six-month follow-up. Treatment response was assessed according to changes in disease control, with complete response defined as a UCT score of 16 and an improvement of at least three points. The study evaluated treatment escalation involving second-generation H1 antihistamines and omalizumab, providing insight into outcomes associated with different management approaches.
Complete response rates varied considerably depending on the treatment escalation pathway. Among patients who moved from no treatment to standard-dose antihistamines, 5.3% achieved complete response. The corresponding rate was 6.0% among those escalated from standard-dose to higher-dose antihistamines and 28.4% among patients escalated from antihistamines to omalizumab. These findings illustrate the challenges of achieving complete disease control, even when treatment is intensified.
The analysis also identified a substantial gap in treatment escalation among patients with poorly controlled CSU. Of those clinically eligible for escalation at baseline, 28.6% did not receive intensified treatment or underwent treatment reduction, despite continuing to experience inadequate control at follow-up. Patient characteristics, disease duration, symptom presentation, and existing treatment patterns were associated with differences in escalation decisions. The observational study design and incomplete follow-up data limit conclusions about the causes of these decisions.
The findings underscore the importance of routinely evaluating disease control and reassessing treatment when patients remain symptomatic. For clinicians, validated assessment tools and individualized treatment discussions may help identify patients whose current management is insufficient. The registry also highlights the continuing need for additional therapeutic approaches and further research into barriers that prevent patients from achieving sustained CSU control.
Original research: Kolkhir P, et al. Unmet Needs in Treatment Escalation for Chronic Spontaneous Urticaria: Findings From the CURE Registry. Allergy. 2026.