International urticaria guideline published
The 2026 update to the international urticaria guideline represents a significant evolution in the management of chronic urticaria, refining treatment paradigms while maintaining the stability of the core stepwise algorithm familiar to clinicians.
Published in Allergy following a consensus conference in December 2024, this iteration incorporates an updated systematic review up to February 2024 and introduces 12 new GRADE profiles to strengthen the evidence base.
For the practising physician, the guideline reinforces the central role of second-generation H1-antihistamines as first-line therapy, with prompt updosing up to fourfold recommended for patients who do not achieve symptom control at standard doses.
The treatment algorithm beyond antihistamines remains hierarchical, positioning omalizumab as the preferred third-line add-on therapy, followed by ciclosporin for refractory disease, thereby preserving a clear and practical escalation pathway.
A notable development in the 2026 document is its pragmatic stance on biomarkers, acknowledging that while the identification of endotypes such as Type IIb autoimmune urticaria holds promise for personalised medicine, no single biomarker currently possesses sufficient accuracy for routine clinical decision-making.
However, in specialised care settings, measuring total IgE and IgG-anti-TPO antibodies may be considered to hint at autoimmune endotypes and predict treatment response, particularly as low total IgE combined with high IgG-anti-TPO is associated with poor response to conventional therapies.
The guideline also strengthens recommendations for provocation testing in chronic inducible urticaria, emphasising threshold measurement to standardise diagnosis and improve management of physical urticarias.
The therapeutic landscape is cautiously expanded, with emerging evidence supporting the potential role of dupilumab and the BTK inhibitor remibrutinib as add-on options for antihistamine-refractory patients, though physicians should remain mindful of licensing status and off-label considerations.
The 2026 update provides robust guidance for special populations, validating the use of the Urticaria Activity Score (UAS7) in and Urticaria Control Test (UCT) available in CRUSE application in children and recommending the same treatment algorithm as for adults, with appropriate adjustments for age and weight. For pregnant or lactating women, second-generation antihistamines with favourable safety profiles, such as cetirizine, are preferred.
The guideline strongly reiterates the recommendation against long-term systemic corticosteroids, restricting their use to short rescue courses of three to five days for severe flares, thereby reinforcing the importance of steroid-sparing strategies in chronic disease management.
View the guideline here.