Mind, Mucosa, and Skin: The Triad of Urticaria, Allergic Rhinitis, and Psychological Disorders

Chronic spontaneous urticaria (CSU) is frequently associated with psychiatric comorbidities that impairs quality of life, increase overall disease burden, and may influence both disease course and treatment response. However, while several database-based studies exist, data focusing on DSM-5-based psychiatric diagnoses established through formal psychiatric assessment in omalizumab-treated antihistamine-refractory CSU patients are scarce. Allergic rhinitis frequently coexists with CSU and may further contribute to psychological burden through sleep disturbance, chronic nasal symptoms, and shared type 2 inflammatory pathways.

To determine the prevalence and distribution of psychiatric comorbidities according to DSM-5 criteria in patients with CSU treated with omalizumab and to explore their relationship with clinical and laboratory parameters.

This retrospective study included 72 adult patients with antihistamine-refractory CSU who received omalizumab treatment and underwent psychiatric evaluation between 2015 and 2025 at a tertiary allergy center. Psychiatric diagnoses were retrospectively extracted from medical records, without standardized pre- or post-treatment psychiatric assessments. Demographic, clinical, and laboratory data, including total IgE, eosinophil and basophil counts, thyroid autoantibodies, and complement levels, were recorded. Psychiatric diagnoses were classified according to DSM-5 categories. Statistical analyses were performed using the Fisher-Halton-Freeman and Friedman tests, with P <0.05 considered significant.

Among the 72 patients (70.8% female; median age, 45 y), psychiatric disorders were identified in 90.3% (n=65). The most frequent diagnostic groups were anxiety disorders (53.8%; 35/65), particularly generalized anxiety disorder (49.2%; 32/65), followed by mood disorders (29.2%; 19/65) and sleep-wake disorders (10.8%; 7/65). Under omalizumab treatment, median UAS7 scores significantly decreased from 42.0 (35.0-42.0) before treatment to 7.0 (1.7-28.0) at 24 months ( P <0.001), while UCT scores significantly increased from 0.0 (0.0-3.0) to 14.0 (5.5-15.2) ( P <0.001).

Psychiatric comorbidities, especially anxiety and depressive disorders, are highly prevalent among patients with CSU receiving omalizumab. Given the strong psychodermatological interaction, routine psychiatric assessment and stress-management interventions should be integrated into the management of CSU to improve overall outcomes and quality of life.