Updated Urticaria Guidelines and Emerging Mechanisms in CIndU

"Updated Urticaria Guidelines and Emerging Mechanisms in CIndU" features the panel connecting current guideline recommendations to the therapies still in development.

Dr. Cotter asks Dr. Finklea how the updated international urticaria guidelines position systemic agents. She explains that the February 2026 update placed omalizumab, dupilumab, and remibrutinib on equal footing after failure of up-titrated second-generation antihistamines. She values that flexibility because it supports shared decision-making based on comorbidities, preference, and needle phobia. Omalizumab received the highest level of evidence given its decade of CSU data. She expects further updates soon as CIndU-specific data accumulate.

Dr. Cotter agrees that the new approval in symptomatic dermographism may prompt repositioning. Dr. Trotter describes choosing among agents by subtype, comorbidities such as asthma, and preference for oral versus injectable therapy. She notes that patients are often in the driver's seat.

Dr. Cotter then asks what excites the panel most for patients who have not achieved control. Dr. Trotter highlights mast cell depletion. She uses a plumbing analogy: antihistamines mop up water after a pipe bursts, BTK inhibitors stop the burst, and depletion replaces the pipes. She wants to see how depletion affects efficacy, safety, and immune function. She is also interested in MRGPRX2 antagonism for patients whose disease is not IgE mediated.

Asked about off-target effects of KIT-directed depletion, Dr. Finklea describes neutropenia, hair lightening, hypopigmentation, and taste changes, which were reversible in her trial patients. She is excited about potential applications in other mast cell disorders. Dr. Cotter notes that patients with mast cell activation syndrome are often underserved.

Dr. Trotter adds interest in the gut microbiome and the skin-gut connection across inflammatory diseases. She notes that the guidelines even mention low-histamine diets for some patients.

Our next episode, "Monitoring Advanced Therapies for CIndU in Clinical Practice," turns to the practical monitoring each advanced therapy requires.