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Biologic therapies for adult chronic urticaria: what works, what doesn't, and why
Ragıp Ertaş1, Muhammed Burak Yücel2, Zenon Brzoza3,4
1Department of Dermatology, Kayseri Faculty of Medicine, Kayseri City Education and Research Hospital, University of Health Sciences, Kayseri, Türkiye.
Introduction:
Chronic spontaneous urticaria (CSU) remains uncontrolled in many adults despite antihistamines and anti-immunoglobulin E (IgE) therapy. The expanding therapeutic landscape includes validated biologic options, promising investigational mechanisms, and unsuccessful therapeutic programs.
Areas Covered:
This narrative review integrates guidelines, randomized trials, regulatory information, systematic reviews, and cohort studies identified through PubMed/MEDLINE and ClinicalTrials.gov searches through 20 July 2026, with targeted updates during revision. It evaluates anti-IgE therapies, interleukin-4/interleukin-13 blockade, KIT receptor-directed mast-cell depletion, other biologic pathways, and non-biologic small molecules for context. Biomarkers, safety, negative trials, and disease modification are examined.
Expert Opinion:
Omalizumab remains the benchmark therapeutic agent. Dupilumab inhibits interleukin-4/interleukin-13 signaling and is approved for CSU and several type 2 and other inflammatory conditions. Remibrutinib is an oral Bruton tyrosine kinase inhibitor with efficacy across IgE-defined subgroups, supporting its relevance beyond a single proposed autoimmune endotype. Anti-KIT therapy is a leading investigational biologic strategy. Biomarkers should inform response probabilities rather than rigid prescribing decisions. Definitive disease modification remains unproven.
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