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Treatment Approaches for Omalizumab-Refractory Chronic Spontaneous Urticaria
Luis Felipe Ensina1,2, Marta Ferrer3, Mona Al-Ahmad4,5
1Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil.
Journal of Inflammation Research
|June 25, 2026
Summary
Omalizumab is key for chronic spontaneous urticaria (CSU), but some patients don't respond fully. Precision medicine, using biomarkers and validated scores, is improving management for refractory CSU.
Area of Science:
- Immunology
- Dermatology
- Pharmacology
Background:
- Chronic spontaneous urticaria (CSU) significantly impacts quality of life.
- Omalizumab is a primary treatment for CSU unresponsive to antihistamines.
- A subset of patients exhibit partial or complete refractoriness to omalizumab therapy.
Purpose of the Study:
- To review current strategies for defining, predicting, and managing omalizumab-refractory CSU.
- To highlight the role of validated patient-reported outcome measures in assessing treatment response.
- To explore the utility of emerging biomarkers in guiding personalized CSU management.
Main Methods:
- Narrative review of existing literature on omalizumab-refractory CSU.
- Analysis of validated outcome measures like Urticaria Activity Score (UAS7) and Urticaria Control Test (UCT).
- Examination of biomarker data, including total IgE levels and basophil activation tests, for endotyping CSU.
Main Results:
- Accurate response assessment requires validated tools to differentiate true non-response from pseudo-resistance.
- Biomarker profiles suggest distinct CSU endotypes (e.g., type I vs. type IIb autoallergic) influencing omalizumab efficacy.
- Cyclosporine A is an established option for refractory cases, with novel therapies like dupilumab and BTK inhibitors emerging.
Conclusions:
- Management of refractory CSU is evolving towards precision medicine.
- Integrating outcome measures, endotyping, and patient factors is crucial for optimizing care.
- Further research is needed for standardized treatment algorithms and predictive biomarkers.
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