The CSU Shuffle: Getting Patients to Treatment Sooner

Patients with chronic spontaneous urticaria (CSU) can spend months searching for an explanation, moving between urgent care, primary care, and allergy appointments without getting much closer to relief. By the time they reach dermatology, they may not have a single hive to show for it. In this episode of The Spot Check, Jamie Restivo, PA-C, talks with David Seiter, FNP-C, about breaking what Restivo calls the “CSU shuffle” and the role dermatology clinicians can play in getting patients treated sooner.

Much of that begins with a careful history rather than another round of testing. Seiter explains how he distinguishes CSU from inducible urticaria, the history-based clues that point to something other than CSU, such as urticarial vasculitis or angioedema without hives, and why an exhaustive search for triggers can sometimes delay care. Once the diagnosis is established, the conversation turns to treatment, including what the updated urticaria guidelines recommend for second-generation H1-antihistamines, how quickly doses can be increased, how long to wait before considering escalation, and why moving to advanced therapy means adding on rather than replacing antihistamines.

With three targeted therapies now available, clinicians have more to consider than efficacy alone. Restivo and Seiter discuss omalizumab, dupilumab, and the oral BTK inhibitor remibrutinib, comparing their mechanisms, expected response times, and safety considerations. They also look at the practical side of treatment selection, from needle preferences and twice-daily dosing to travel, storage, and the routines patients can realistically maintain.

Follow-up is just as important. Seiter describes how he sets expectations for improvement, checks on patients after starting systemic therapy, and approaches tapering antihistamines once symptoms are consistently controlled. His larger point is that dermatology clinicians are well positioned to manage CSU, and for many patients, another referral or another test is not what they need.