The Role of Dermatologists and APPs in Diagnosing CSU

In this episode titled “The Role of Dermatologists and APPs in Diagnosing CSU,” the moderator and panelist turn to the formal workup for inducible urticaria and the broader question of who should be diagnosing CSU. The panelist describes the textbook dermatographometer, a small card with multiple pressure-calibrated tines used to elicit a line of hives, though a simple stroke test with the thumb is used instead in practice. The formal ice-cube test for cold urticaria is also described, placing an ice cube on the skin for several minutes and observing for delayed hives, though history alone is usually sufficient and physical challenge testing is rarely necessary.

Asked about the respective roles of dermatologists and advanced practice providers in diagnosing CSU, the panel argues there is no meaningful distinction, noting that what matters most is the clinician’s attentiveness rather than their specific title, and that APPs, who often have longer appointment times, may be especially well positioned to catch the diagnosis. Both speakers stress the importance of keeping CSU on the differential whenever a patient describes recurring, unpredictable hives, since the condition is frequently misdiagnosed as an acute allergic reaction in urgent care or emergency settings, and diagnostic delays of up to two years, with symptoms sometimes persisting past five years, are common.

A case is shared of a psoriasis patient whose undiagnosed CSU led to repeated, unnecessary courses of systemic corticosteroids before being correctly identified and started on an effective targeted therapy. The episode closes with reassurance that most patients are forthcoming, rather than minimizing, about how significantly CSU affects their daily lives, underscoring the importance of timely recognition and treatment. In the next episode, “Updated Guidelines and the Current CSU Treatment Landscape,” the panel reviews the newly updated international guideline and walks through how shared decision-making is used to match patients to one of three advanced therapy options.