CSU in Practice: From Persistent Symptoms to Stepwise Care

David Seiter, FNP-C, and Daniel Butler, MD, follow CSU care from the first visit forward, beginning with the details that establish the diagnosis and the tests that often do not add much to it. From there, they work through second-generation H1-antihistamines, including why consistent rather than reactive dosing matters, how to approach updosing, and when it is time to stop waiting for a response that is unlikely to come.

Along the way, they unpack what has changed in current guidance, including the move away from routinely adding H2-antihistamines or montelukast, before turning to the broader systemic treatment landscape. With omalizumab, dupilumab, and remibrutinib now offering different paths forward, the conversation becomes less about finding a single “next” therapy and more about matching an appropriate option to the patient in front of you through shared decision-making.