Experts Spotlight Chronic Spontaneous Urticaria: Symptoms, Diagnosis, and Treatment
Interview with Dr. Ruaa Alharithy, MD, MScCH, FRCPC, Dermatology Consultant, Assistant Professor, Vice President, Saudi Society of Dermatology and Dermatologic Surgery (SSDDS):
Chronic Spontaneous Urticaria (CSU) is an autoimmune disease characterized by the unpredictable appearance of wheals and/or angioedema. Wheals are itchy, superficial skin swellings, and angioedema is pronounced swelling of the lower dermis and subcutis or mucous membranes. Symptoms recur spontaneously, on a near-daily basis, over >6 weeks; many patients experience flare-ups over several years and, consequently, reduced quality of life.
Symptoms arise independently of external causes, although circumstances such as infection or high levels of stress may exacerbate disease activity. The clinical manifestations of urticaria are consistent across age, sex, race, and ethnicity groups, with wheals and angioedema appearing in similar anatomical distributions. Among patients with Chronic Spontaneous Urticaria, angioedema affects children less frequently than adults (5%-15% vs 30%-50%), and female predominance may be less common in children with urticaria compared with adults.
The burden of CSU on patients, their family and friends, the health care system, and society is substantial. Its debilitating symptoms, disruption of daily activities, sleep, and emotional well-being can create a cycle of frustration and decreased quality of life (QoL) often worsened by comorbidities such as anxiety and depression. A detailed medical history is essential in the diagnosis of urticaria and is the first step in the diagnostic workup.
The second step is the physical examination of the patient. Since wheals and angioedema are transient and may not be present at the time of physical examination, it is important to review prior documentation, including patient-provided photographs of wheals and/or angioedema. The third step involves a basic diagnostic workup which includes a limited set of recommended diagnostic tests such as differential blood count.
Although CSU pathogenesis is not yet fully understood, it is well-established that its signs and symptoms are due to the activation of skin mast cells and the subsequent release and effects of their mediators. Clinical predictors of longer course of CSU and suboptimal response to treatment include presence of chronic inducible urticaria (CIndU), high disease activity, elevated CRP and/or the presence of angioedema. The approved therapies for the treatment of CSU recommended by the guidelines include second generation H1-Antihistamines, biological treatments and other novel therapies .
Following an overview of the key aspects of Chronic Spontaneous Urticaria (CSU) and its impact on patients’ lives, it becomes clear that regularly tracking symptoms and treatment response is essential for physicians to make timely, informed decisions. In this context, Dr. Ruaa Alharithy, MD, MScCH, FRCPC, Dermatology Consultant, Assistant Professor, Vice President, SSDDS, emphasized that real-world studies show differences in the assessment of CSU symptoms between physicians and patients. These differences may arise from intermittent CSU symptoms and unpredictable flare-ups making it difficult for patients to communicate the full impact of symptoms during appointments .In a study of physician-patient communication in CSU: Over 25% of patients reported symptoms as more severe than their physician; 5% of patients report symptoms less severe than their physician; and 68% patient-HCP agreement.
Speaking about the importance of timely physician action and the need to avoid persisting with ineffective treatment strategies, Dr. Ruaa stressed that delays in achieving adequate disease control may lead to ongoing symptoms, patient frustration, and disengagement from care . Evidence shows that therapeutic inertia has real consequences: in an observational study, a proportion of CSU patients received no active treatment, potentially reflecting treatment discontinuation due to lack of efficacy . In a separate CSU patient survey, switching physicians was frequently driven by the need for more effective symptom control and improved disease management . These findings highlight the importance of early assessment of response and timely escalation of therapy in accordance with international CSU guidelines, rather than prolonged reliance on ineffective strategies. Proactive, guideline-based treatment optimization can improve symptom control, patient satisfaction, and long-term adherence.
Dr. Ruaa concluded by offering advice to patients with Chronic Spontaneous Urticaria (CSU) who have started treatment, saying: “I encourage every patient to assess their condition shortly after beginning treatment by asking themselves two simple questions: Is the itch negatively impacting your sleep? Is the itch affecting daily activities? Like exercise, childcare, studying or work. Promptly identifying patients who need more can help optimize management of CSU.”
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