Navigating Second-Line Treatments in 2026 CSU Guidelines, With Adam Friedman, MD

The 2026 international guidelines for chronic spontaneous urticaria (CSU) formalize 3 second-line treatment options: remibrutinib (Rhapsido), omalizumab (Xolair), and dupilumab (Dupixent).

Adam Friedman, MD, FAAD, professor and chair of dermatology, residency program director, Department of Dermatology, George Washington University School of Medicine and Health Sciences, discussed the update at the 2026 Dermatology Education Foundation (DEF) DERM2026 conference in Las Vegas.

The guidelines also reinforce rapid escalation of second-generation, non-sedating H1 antihistamines, moving from standard to quadruple dosing within 3 to 4 weeks of diagnosis. Friedman noted European guidance has moved faster on this timeline than the 2014 US Joint Task Force parameters. These updates build on prior HCPLive coverage of the same guideline revision.

"We've got 3 on-label options for the management of a disease that affects 1% of the global population that is uniquely burdensome because it comes out of nowhere, no matter what you're doing, and there's no underlying cause based on the definition. It's more about which one makes the most sense for your patient," Friedman said.

Omalizumab carries roughly a decade of real-world and trial experience, but the guidelines list all 3 second-line options without ranking preference. Friedman said the expanded menu lets clinicians match therapy to patient preference, injection versus oral dosing, comorbidity profile, and prior response.

Third-line options remain cyclosporine and off-label immunosuppressants, including mycophenolate mofetil, azathioprine, and methotrexate. Friedman cited a George Washington University resident survey showing many trainees feel comfortable managing CSU but are unaware the guidelines exist, pointing to a gap in guideline dissemination rather than clinical readiness.

References

1. Dermatology Education Foundation. DERM2026 agenda. https://dermnppa.org/derm2026-agenda/. Accessed August 5, 2026.

2. HCPLive. Updated guidelines and the current CSU treatment landscape. https://www.hcplive.com/view/updated-guidelines-and-the-current-csu-treatment-landscape. Published July 8, 2026. Accessed August 5, 2026.