Advances in Urticaria Care with Jason Hawkes, MD, MS

Dermatology Times recently spoke with Jason Hawkes, MD, MS, a medical dermatologist and principal investigator at the Oregon Medical Research Center in Portland, Oregon, to discuss the latest approaches to managing urticaria. Hawkes shared insights on distinguishing acute from chronic urticaria, following treatment guidelines, and exploring emerging therapies that promise to transform patient care.

Hawkes began by clarifying the distinction between acute and chronic urticaria, 2 subtypes with vastly different management approaches. He says acute urticaria is most common in children under 5 and typically resolves within 1 to 2 weeks, often triggered by factors such as medications, immunizations, infections, or insect stings. Chronic urticaria, however, persists beyond 6weeks and presents more of a clinical challenge. While spontaneous remission occurs in some cases, approximately 10 to 40% of patients with urticaria experience a more prolonged and complex disease course.

When managing chronic urticaria, clinicians rely on established treatment guidelines to guide decision-making. Hawkes highlighted 2 major resources: the American Academy of Allergy, Asthma, and Immunology (AAAAI/Quad AI) guidelines, last revised in 2014, and the International guidelines, updated in 2021 and currently undergoing further revisions. Both guidelines emphasize the importance of identifying and eliminating potential triggers, such as NSAIDs, opioids, allergens, and physical stimuli, as the first step. Following this, second-generation antihistamines are recommended for their efficacy and lack of sedative adverse events.

For patients who continue to experience symptoms, antihistamine doses may be increased up to 4 times the standard amount. “Within about 1 and a half to 2 weeks, we can usually get up to that 4-fold dosing,” Hawkes said. “In my experience, they're either going to respond that 4-fold dosing or antihistamines in general, or they're not.” In cases where antihistamines fail to provide adequate relief, clinicians must escalate treatment to systemic therapies.

Omalizumab, a monoclonal antibody targeting IgE, is often the first-line systemic therapy for chronic urticaria after antihistamine failure. According to Hawkes, most patients respond well to omalizumab, with a typical starting dose of 300 mg administered monthly. Although omalizumab carries a black box warning for anaphylaxis, this risk is primarily associated in patients with asthma. “We don't really see that occur in our urticaria patients, so a lot of that is just some reassurance and talking through it with patients,” he added.

Hawkes expressed enthusiasm for several emerging therapies that offer new hope for patients with treatment-resistant chronic urticaria. One such therapy is dupilumab, a monoclonal antibody widely used for atopic dermatitis and other inflammatory conditions. Late-stage clinical trials have demonstrated that approximately one-third of patients with chronic spontaneous urticaria achieve complete symptom resolution with dupilumab, while a much higher percentage experience significant improvement. Dupilumab is particularly appealing for patients with coexisting conditions, such as asthma or atopic dermatitis, due to its broad range of indications and established safety profile.

Another promising option is remibrutinib, an oral Bruton's tyrosine kinase inhibitor that targets intracellular signaling pathways in mast cells. Phase III trials have shown that remibrutinib delivers rapid clinical responses, often within days to a week. “This is going to be a very fast therapy for those patients who are averse to injections, or may have some preference for an oral pill,” Hawkes explained. He also highlighted its efficacy in treating both wheals and angioedema, providing comprehensive relief for patients with these overlapping symptoms. Unlike corticosteroids, remibrutinib is well-tolerated, with petechiae being the most common adverse event in a small percentage of patients.

Hawkes emphasized that these new therapies, along with others currently in development, such as anti-cytokine agents and KIT inhibitors, represent a significant leap forward in urticaria management. He underscored the importance of early treatment escalation, particularly when antihistamines fail, to improve patient outcomes and quality of life.

“This is going to be very exciting,” Hawkes concluded. “I hope you'll embrace these patients in your clinic as we're going to have a lot more options we've had in the last decade.”