FLORA’S KISS BLOG  |  DEEP DIVE

Hives That Stay

Understanding chronic spontaneous urticaria: diagnosis, causes, treatment, prednisolone, and what daily life really looks like.

Most of us have had hives at some point. A new washing powder, a sting, a virus, and a few itchy welts appear and fade within a day or two. For some people, though, the hives keep coming back, week after week, with no obvious reason at all. They might appear on a forearm before breakfast, on the neck by lunch, and on the thighs by bedtime. That is chronic spontaneous urticaria, or CSU.

This topic is close to home for us at Flora’s Kiss. CSU sits right where our two passions meet: skin that reacts more than most, and the way a body’s sensitivity shapes every part of a day. It is also widely misunderstood. People with CSU are often told it must be something they ate, or that it is “just stress”, or that they simply need a stronger antihistamine. The reality is more interesting, and more validating.

In this deep dive we cover what CSU is, what the immune system is doing underneath, how it is diagnosed, the full treatment pathway in Australia (including a close look at prednisolone), why angioedema can appear without any surface hives and when swelling becomes an emergency, how anaphylaxis can kill and why every first-aid step matters, what histamine actually does in the brain, what living with it day to day actually involves, the long-term outlook, and where to find specialists and support here in South Australia.

What is chronic spontaneous urticaria?

Urticaria is the medical word for hives. Australia’s peak clinical immunology body, ASCIA, describes CSU as hives that are chronic (lasting six weeks or more, appearing several times a week) and spontaneous (with no identifiable outside trigger).¹ The international urticaria guideline, updated in 2026, uses the same split: acute versus chronic by duration, and spontaneous versus inducible by whether a specific, reproducible trigger exists.²

The two hallmark features are:

• Wheals (hives): raised, itchy, sometimes burning swellings that can be red, white or skin-coloured. They range from the size of a pinhead to a dinner plate, and each one usually fades within 24 hours, only for new ones to appear somewhere else.^1,2
• Angioedema: the same reaction happening deeper, in the lower dermis and the tissue beneath the skin, so it shows as swelling rather than raised welts. It most often affects the lips, eyelids, face, hands, feet or genitals, tends to tingle, burn or ache rather than itch, and can take up to three days to settle.^1,2

Angioedema: hives that sit deeper

This is one of the most misunderstood parts of CSU, so it is worth slowing down on. The international guideline defines urticaria as wheals, angioedema, or both.² In other words, angioedema is not a separate illness that happens to sit alongside CSU. In CSU it is part of the condition itself: the same mast cells releasing the same chemicals, but in the deeper layers of the skin rather than near the surface. You can think of it as deep hives.

Because the swelling happens deeper, it looks and feels different from the hives most people picture. There may be no raised red welts at all, just puffiness, tightness or a swollen lip or hand. Around 29% to 45% of people with CSU have angioedema, and an estimated 5% to 10% have angioedema without any surface wheals at all.²² Researchers have also noted that angioedema in CSU is underdiagnosed.²²

Researchers continue to study whether wheals and angioedema differ in the blood vessels and chemical messengers involved, but the mast cell is at the centre of both.²² That is why angioedema-only CSU can be confusing for clinicians who mainly picture urticaria as a visible rash. When swelling comes without hives, it is still worth considering CSU, while also ruling out the less common types of angioedema that are not driven by mast cells (see the urgent help box below).

Up to one in five people will have hives at some point in life, but chronic urticaria is far less common, affecting somewhere between 0.1% and 3% of people depending on the study, and CSU is by far its most common form.³ It is seen more often in women and frequently begins in adulthood.

Where CSU sits in the urticaria family

Many people have both CSU and an inducible type at once. Readers who enjoyed our earlier deep dive on cold urticaria will recognise that as a member of the inducible family.

What is happening under the skin?

The central player in CSU is the mast cell, an immune cell that sits just beneath the skin and in the linings of the body. Mast cells are packed with granules of histamine and other chemical messengers. When they are switched on, they release these chemicals, which make nerve endings itch and make small blood vessels widen and leak fluid. The result is redness, swelling and itch: a wheal.¹

In CSU the question is why the mast cells keep switching on with no outside threat. For many years the answer was “unknown”, which is why the condition used to be called chronic idiopathic urticaria. Research over the past decade has shown that, for a large share of people, the answer is autoimmunity: the immune system makes antibodies that activate the body’s own mast cells.^4,5

The two autoimmune patterns

These patterns can overlap in the same person, and genetic research suggests CSU has more in common with other autoimmune diseases than with classic allergies like hay fever.^4,5 That is also why CSU often appears alongside autoimmune thyroid disease, and why doctors may check thyroid antibodies.^2,4

Things that can make CSU worse

Because CSU is spontaneous, avoiding triggers will not make it go away. Many people notice that certain things turn the volume up during an active phase, though. Commonly reported aggravators include heat, hot showers and exercise; alcohol; aspirin and anti-inflammatory painkillers such as ibuprofen; tight clothing, waistbands and straps; viral infections; poor sleep; and emotional stress. Stress does not cause CSU, but it can amplify a flare.

Symptoms: more than a rash

On paper, the symptoms of CSU sound simple: itchy welts and sometimes swelling. In practice the experience is broader.

• Itch that dominates attention. CSU itch is often intense, worse in the evening and at night, and can feel prickling or burning rather than simply itchy.
• Moving, shape-shifting welts. Individual hives come and go within hours, so the pattern on the skin changes through the day. Many people learn to photograph them, because they have often vanished by the time of a doctor’s appointment.¹
• Swelling that changes how you look. Angioedema of the lips or eyelids can be confronting, especially on waking.
• Broken sleep from night-time itch, plus the drowsiness some people get from high-dose antihistamines, adds up. (More on why in the histamine section below.)
• Dermographism alongside. Many people with CSU also find that scratching or pressure leaves raised lines on the skin, a form of inducible urticaria.

When swelling reaches the mouth and throat

CSU is not an allergy, and on its own it is not linked to anaphylaxis.²⁷ That can sound reassuring, but it should not be mistaken for safety. Angioedema in CSU can sometimes affect the tongue, throat or voice box, and swelling there can be just as dangerous.

• How often it happens. Angioedema occurs in roughly 29% to 45% of people with CSU.²² In an Italian study of 34 people with CSU and angioedema, 15% had swelling of the throat or voice box.²⁸
• Why it is dangerous. Swelling of the tongue or throat can narrow the airway and make breathing difficult. ASCIA advises that severe throat swelling needs early medication and immediate transfer to hospital by ambulance, and an emergency medicine review warns that airway angioedema can be fatal.^29,30
• The signs to act on. Swelling of the tongue, swelling or tightness in the throat, difficulty talking or a hoarse voice, and difficult or noisy breathing all mean calling 000 straight away.^29,31
• Not all angioedema is the same. The swelling in CSU is driven by mast cells and histamine. Some angioedema is driven instead by a different chemical, bradykinin. This includes swelling caused by ACE inhibitor blood pressure medicines and hereditary angioedema, a rare genetic condition. ASCIA notes that ACE inhibitor swelling usually affects the face, tongue and throat, is not itchy, and is not an allergic reaction. Bradykinin-type swelling is unlikely to respond to antihistamines, steroids or adrenaline and needs specific treatments, so it is important to know which kind you have, especially if your swelling comes without hives.^29,30
• Have a plan. If you have ever had swelling of the tongue or throat, ask your specialist what to do if it happens again, and whether you should have a written action plan.

How anaphylaxis can kill, and why every first-aid step matters

CSU itself does not cause anaphylaxis,²⁷ but this matters to the CSU community for three reasons. In the moment, severe throat swelling and anaphylaxis can be hard to tell apart. People with CSU can have allergies too, like anyone else. And any of us may one day be the person helping someone else.

Throat swelling is the danger most people picture, but anaphylaxis can kill in other ways too, sometimes with no swelling, hives or rash at all. Understanding the reason behind each first-aid step can stop a well-meaning person from making a dangerous decision in the moment.

• Shock: when blood pressure collapses. Mast cell chemicals widen blood vessels throughout the body and make them leak. Fluid moves out of the bloodstream into the tissues, and the heart’s pumping can weaken too. Blood pressure can then fall so far that the heart and brain do not get enough blood, and the heart can stop.³²
• The lungs: when the airways close from below. The airways inside the chest can tighten and become blocked with thick mucus, starving the body of oxygen, much like a severe asthma attack. People who have both a food allergy and asthma are at particular risk: fatal and near-fatal reactions are strongly associated with that combination.³²
• The warning signs can be missing. Sudden collapse can sometimes happen before any skin signs appear. No rash does not mean no anaphylaxis.³²

Lying flat is not about preventing a fall. It keeps blood flowing back to the heart.

• Why lie the person flat. Many people assume this is to stop someone hurting themselves if they faint. The real reason is far more serious. When blood pressure has collapsed, sitting or standing upright reduces the blood returning to the heart, and this can bring on a cardiac arrest. An Australian review describes avoiding an upright position as one of the most important parts of treatment.³² That is why ASCIA says to lay the person flat and not let them stand or walk, and to hold young children flat, not upright.^33,34
• The one exception: breathing difficulty. If breathing is difficult, ASCIA advises letting the person sit with their legs stretched out in front of them, rather than lying down. Someone who is unconscious or pregnant should be placed in the recovery position, on their left side if pregnant.³³
• Even after they seem better. ASCIA advises that the person should not stand, walk or be held upright, even if they appear to have recovered. Do not help them up to walk to a car or an ambulance.³³
• Why adrenaline, and why straight away. In fatal reactions, the median time to respiratory or cardiac arrest has been about 30 minutes for foods, 15 minutes for insect venom and just 5 minutes for medicines given in hospital.³² Adrenaline works quickly to reduce throat swelling, open the airways, and support the heart and blood pressure, so it acts against every one of these dangers at once.³⁵ Delays can be fatal, which is why ASCIA’s rule is “if in doubt, give adrenaline”. Side effects such as a racing heart, shakiness and pale skin are common and wear off.³⁵
• Why call 000 even if adrenaline works. Symptoms can return hours later in a second wave, known as a biphasic reaction. Studies put this at between 2% and 20% of cases, and people should be observed in an emergency department for at least six hours after a reaction.³² Further adrenaline may be given if there is no response after five minutes.³⁴

Histamine and the brain: clearing up a common myth

A belief that sometimes surfaces, even among health professionals, is that “too much histamine makes you sleepy”. It is an easy mix-up to make, because the antihistamines many of us grew up with made us drowsy. But the science points the other way: in the brain, histamine is one of the main chemicals that keeps us awake.

How histamine works in the brain

• The brain makes its own histamine. Its only source of histamine-producing nerve cells is a small cluster in the hypothalamus called the tuberomammillary nucleus, which sends connections across the brain, from the cortex to the brainstem.²³
• These neurons fire fastest when we are awake and active, slow right down in non-REM sleep, and are essentially silent during REM (dreaming) sleep.²³
• Histamine promotes wakefulness mainly through the H1 receptor. When H1 signalling is blocked, sleep increases.²³
• A separate receptor, H3, acts as a brake on histamine release. A narcolepsy medicine called pitolisant blocks that brake, raising brain histamine to make people more alert, not less.²³

So why do some antihistamines cause drowsiness?

Because they block histamine in the brain. Older, first-generation antihistamines such as diphenhydramine, doxylamine and chlorpheniramine cross into the brain easily and block H1 receptors there, which switches off part of the brain’s wakefulness system. That is exactly why they are used in many over-the-counter sleep aids. Newer second-generation antihistamines like fexofenadine and loratadine are far less sedating because much less of them reaches the brain.²³ The drowsiness comes from blocking histamine, not from having too much of it.

Then why are people with CSU so tired?

The tiredness is real, but it has other explanations. Histamine released by mast cells in the skin acts locally and is largely kept out of the brain by the blood-brain barrier. The fatigue people with CSU describe is more likely to come from:

• broken sleep from night-time itch and swelling
• drowsiness from antihistamines, especially older types or high doses
• the ongoing physical and emotional load of a chronic condition, including the anxiety and low mood that research links to CSU⁹

How CSU is diagnosed

There is no single blood test for CSU. It is diagnosed mainly from the history: hives on most days for more than six weeks without an allergic cause.¹ Both ASCIA and the international guideline recommend a deliberately limited set of tests rather than broad screening.^1,2

• A careful history and examination. Your doctor will ask about the pattern, duration, swelling, medicines, possible physical triggers and family history.
• Photos and a symptom diary. ASCIA specifically suggests a photographic record, because hives so often disappear before appointments.¹
• Basic blood tests. A full blood count and an inflammation marker (CRP and/or ESR).²
• Specialist tests, where useful. Total IgE and thyroid peroxidase antibodies may be checked in specialist care, with further testing only if the history points to something else.²
• Allergy tests are usually not needed. Hives lasting more than a few days are rarely caused by an allergy, so skin-prick and food allergy testing are only done if there is a specific reason.¹

Measuring CSU: the UAS7 score

Because CSU fluctuates, specialists track it with scores rather than snapshots. The most widely used is the Urticaria Activity Score over 7 days (UAS7), recommended by the international guideline alongside the Urticaria Control Test (UCT) and, for swelling, the Angioedema Activity Score.² Each day you rate the number of hives and the itch from 0 to 3, then add up a week’s worth.

Keeping UAS7 scores matters for access as well as tracking. Australian eligibility for subsidised omalizumab requires a current UAS7 score as part of the application.¹¹

Treatment: the stepped pathway

The aim of treatment is complete control: no itch, no hives, and as few side effects as possible.^1,2 Treatment controls symptoms while the condition runs its course; it is not a cure. Treatment follows a stepped approach, moving up only when the previous step has not achieved control.

A note on the newer medicines

2025 and 2026 have been big years for CSU. Remibrutinib works inside the mast cell, blocking an enzyme called Bruton’s tyrosine kinase that the cell needs to release its chemicals. In the TGA’s summary, people taking it had greater reductions in itch and hives after 12 weeks than those on placebo.¹³ Novartis has said it is assessing whether to apply for PBS listing and is supporting access through private pathways in the meantime, so cost is currently a real barrier.¹⁴ Dupilumab works differently, blocking two inflammatory signals (IL-4 and IL-13), and is already familiar to many Australians from its use in eczema.¹⁵

A closer look at prednisolone

Prednisolone is one of the most widely prescribed medicines for flares of autoimmune and inflammatory conditions, and many people with CSU will be offered a course at some point. Understanding where it fits, and where it does not, helps you have better conversations with your doctor.

How it works

Prednisolone is a corticosteroid, a synthetic version of cortisol, the hormone your adrenal glands make. At treatment doses it broadly dampens the immune system and reduces inflammation. It does not target one specific pathway; it turns the whole system down. That is why it works across so many conditions, including lupus, rheumatoid arthritis, vasculitis and inflammatory bowel disease, and why it can calm a severe CSU flare, often within days.

Where it fits in CSU

• Short-term rescue only. Both the international guideline and ASCIA’s Australian pathway position oral corticosteroids as a brief rescue for acute flares, not a maintenance treatment.^2,6 ASCIA’s pathway describes courses of 25 to 50 mg daily for a maximum of 5 to 10 days.⁶
• Never long term. The international guideline strongly recommends against long-term systemic corticosteroids in chronic urticaria.^2,16
• It doesn’t change the course. Prednisolone can quieten a flare, but it does not cure CSU or shorten how long the condition lasts. Hives often return as the dose comes down.
• Repeated courses are a signal. If someone keeps needing prednisolone, that usually means their day-to-day treatment is not controlling the condition, and it is time to step up the pathway or seek specialist review.

Why doctors limit it

Even short courses can cause noticeable side effects, and the risks build with repeated or longer use. These include:

Tapering and practical points

• After more than a few weeks, prednisolone must be reduced gradually rather than stopped suddenly, because the body’s own cortisol production is suppressed and needs time to restart. Short rescue courses often don’t need a taper, but always follow the prescriber’s instructions.
• It is usually taken in the morning with food, which mirrors the body’s natural cortisol rhythm and can reduce sleep disruption and stomach upset.
• Keep a record of every course: dates, dose and how well it worked. Specialists use this history when deciding on next steps.
• People living with diabetes, high blood pressure, osteoporosis or a history of mood conditions should make sure the prescriber knows, as prednisolone can affect all of these.

Living with CSU day to day

From the outside, CSU can look like “just a rash”. From the inside, it can reshape a whole day. Research consistently shows a real burden: in a large European study, depression, anxiety and sleep difficulties were around twice as common among people being treated for chronic urticaria as among people without it.⁹ A study comparing it with psoriasis found people with chronic urticaria had greater quality-of-life impairment.¹⁰

Low mood, anxiety and CSU: what the research shows

The emotional side of CSU is not a footnote. It is one of the most consistent findings in urticaria research, and it deserves to be talked about as openly as the itch.

A 2019 systematic review and meta-analysis brought together 25 studies on mental health in chronic urticaria. It found that around one in three people with chronic urticaria had at least one psychiatric condition, compared with about one in twenty in healthy comparison groups.²⁴ The most common were:

These pooled figures come from studies of different sizes and designs, so they are best read as a clear signal rather than exact numbers.²⁴ Other research points the same way: a large European study found depression, anxiety and sleep problems around twice as common in people treated for chronic urticaria,⁹ and poor sleep in CSU is linked with a markedly higher risk of anxiety and depression.⁸

A two-way street

Researchers increasingly describe the relationship between CSU and mental health as running in both directions.²⁵

• CSU wears down mood. Relentless itch, broken sleep, visible swelling, unpredictability, and the effort of being believed all take a toll. Feeling low or anxious in response is an understandable reaction to a hard situation, not a weakness.
• Stress can turn up the volume on CSU. Stress activates the body’s stress-hormone system and releases chemical messengers from nerve endings in the skin, such as substance P and corticotropin-releasing hormone. Mast cells carry receptors for these messengers, so stress can help nudge already-sensitive mast cells into releasing histamine. Some of these receptors appear in greater numbers in the skin of people with chronic urticaria.²⁵
• The loop feeds itself. Itch disrupts sleep, poor sleep heightens stress and lowers mood, and stress can worsen flares. Poorer mental health has been linked to more severe disease and lower quality of life.²⁵

It is important to be clear about what this does not mean. CSU is not “all in your head”, and stress does not cause it. The underlying driver is immune, often autoimmune. Stress is one of several things that can amplify an immune process that is already there.

Good control helps the mind too

There is encouraging evidence that treating CSU properly also lifts its emotional burden. A 2024 meta-analysis of seven studies found that people treated with omalizumab had significant improvements in depression and anxiety scores, and better sleep quality.²⁶ In one randomised trial within that analysis, people on omalizumab were more likely than those on placebo to no longer meet the criteria for depression.²⁶ This is one more reason not to settle for partial control.

What helps

• Ask to be asked. The meta-analysis authors recommend that people with chronic urticaria are routinely checked for mental health concerns, ideally with skin and mental health specialists working together.²⁴ If no one has asked how you are coping, it is fine to raise it yourself.
• Use the Medicare pathway. Your GP can prepare a Mental Health Treatment Plan, which provides Medicare-subsidised sessions with a psychologist.
• Consider approaches that calm the stress response. Reviews support combining psychological support and stress-reduction strategies with standard medical treatment.²⁵ Approaches that help with itch, sleep and coping, such as cognitive behavioural therapy and relaxation techniques, can ease the loop from the mental health side.
• Protect sleep. Because sleep sits at the centre of the loop, tell your doctor if night-time itch is keeping you awake. Better control of night symptoms often helps mood as well.
• Don’t carry it alone. Peer support, family understanding and practical help on flare days all matter, for the person with CSU and for those who live alongside them.⁷

What a day can look like

• Mornings can start with new welts or swollen eyelids. Getting dressed becomes a decision about what will not rub, press or trap heat.
• Work and study are affected by distraction from itch, drowsiness from medication, and appointments. Unpredictability is often the hardest part: a person can feel completely fine one hour and be covered the next.
• Social life may shrink. Hot venues, alcohol, sport and swimming can all aggravate flares, and visible hives or facial swelling can make people want to stay home.
• Evenings and nights are often the worst, as itch tends to peak then. Poor sleep feeds into fatigue, low mood and lower tolerance for itch the next day. One study found poor sleep was linked to worse disease control and higher rates of anxiety and depression.⁸
• The mental load of tracking scores, photographing hives, juggling doses, chasing referrals and explaining the condition to others is constant and invisible.

CSU also touches the people a person lives with. A study of household members found that poorer disease control was linked with lower family quality of life and higher anxiety among those living alongside the person with CSU.⁷ Naming that openly can make it easier for everyone to support each other.

Gentle daily strategies

None of these replace medical treatment, but many people find they make flare days more bearable.

• Keep it cool. Lukewarm rather than hot showers, a cool room at night, and cool compresses on itchy patches.
• Choose soft, loose clothing. Breathable cotton or bamboo, and avoiding tight waistbands, straps and seams where pressure sits.
• Be kind to the skin barrier. Simple, fragrance-free moisturisers and gentle cleansers can comfort itchy, scratched skin. Scratching can make hives worse, so keeping nails short helps.
• Take daily medicine consistently. Antihistamines for CSU work best taken regularly as prescribed, not only once a flare has started.
• Track patterns. A simple diary of UAS7 scores, photos, sleep, alcohol, painkillers, illness and stress helps you and your specialist see what is happening.
• Plan around flares. Spare clothes, medicine in your bag, a cooling spray, and permission to leave early.
• Look after your mind as well as your skin. If low mood, anxiety or exhaustion are building, tell your GP early rather than waiting (see the mental health section above).

Outcomes and the long-term outlook

The most encouraging fact about CSU is that, for most people, it does eventually go away on its own. The timeline varies widely, though.

• A review of long-term studies found that between 21% and 47% of people were in remission within the first year, with cumulative remission estimates of roughly 29% to 71% by five years and higher again by twenty years.¹⁷
• One study found a median symptom duration of nearly four years, with about a third of people having a relapsing and remitting course: going quiet for a while, then coming back.¹⁸
• Having angioedema alongside hives has been associated with more severe and longer-lasting disease.¹⁸

In the meantime, the outlook for symptom control has never been better. With antihistamines, omalizumab and now newer targeted medicines, most people can reach good control, even if the underlying condition takes years to burn out. The key is not to accept “just live with it” while symptoms are still disrupting life.

When care crosses specialties

Conditions like CSU sit at the meeting point of several fields: immunology, allergy, dermatology, general practice, emergency medicine, and often endocrinology because of the link with thyroid autoimmunity. In our own experience, and in what we hear from our community, the gaps tend to appear at those borders. A swelling with no visible rash gets dismissed as “not hives”. Old pharmacology ideas, like histamine causing sleepiness, get repeated as fact. Newer treatments are not yet on everyone’s radar.

This is not about blame. Medicine moves quickly, and the urticaria field has changed a great deal in just the past few years, with an updated international guideline in 2026, a growing understanding of CSU as an autoimmune condition, and new medicines approved in 2025 and 2026.^2,13,15 But that pace is exactly why it matters.

If you feel unheard

• Bring printed information from a trusted source, such as the ASCIA CSU page, to appointments.¹
• Show photos of swelling as well as hives, with dates and how long each episode lasted.
• Ask directly: “Could this be angioedema from chronic spontaneous urticaria?”
• Ask for a referral to a clinical immunologist or allergist, who has the most experience with CSU.
• Remember that you are allowed to seek a second opinion.

Getting to the right specialist in South Australia

Your GP can start treatment and increase antihistamine doses. If symptoms are not controlled, are severe or are affecting quality of life, ASCIA recommends referral to a clinical immunology/allergy specialist.¹ Dermatologists also manage CSU.

Pathways

• Public: Royal Adelaide Hospital, Clinical Immunology and Allergy. Needs a GP referral, and referrals are triaged by clinical urgency. The service also runs an offsite clinic on Fridays at 85 Wellington Road, Mount Barker, which may suit people in the Adelaide Hills.¹⁹
• Public: Flinders Medical Centre, Allergy and Clinical Immunology Service (Southern Adelaide Local Health Network), which also reaches sites such as Marion GP Plus and Noarlunga Health Service.²⁰
• Private specialists. ASCIA’s “Locate a specialist” directory lists clinical immunologists and allergists across Adelaide and regional SA. A GP referral is needed for a Medicare rebate.²⁰
• Many specialists offer follow-up by video, which helps regional patients and reduces travel during flares.

Making the most of the appointment

• Bring dated photos of hives and any swelling.
• Bring at least one or two weeks of UAS7 scores.
• List every medicine tried, the doses and how well each worked, including every prednisolone course.
• Mention other conditions, especially thyroid or other autoimmune conditions, and any family history.
• Note what matters most to you, such as sleep, work or visible swelling, so treatment decisions reflect your priorities.

Supports and resources

A closing thought

CSU asks a lot of the people who live with it: patience with a condition that comes and goes on its own schedule, persistence through a stepped treatment pathway, and resilience in the face of a body that seems to react to nothing at all. If that is you, or someone you love, please know that the itch is real, the exhaustion is real, and the need for good care is real. Treatment options are better than they have ever been, and for most people CSU does eventually settle.

As always, we would love to hear from you. If you live with CSU, what has helped you through the hard days?

Sources

1. ASCIA. Chronic Spontaneous Urticaria (CSU): Frequently Asked Questions. 2024. allergy.org.au/patients/skin-allergy/urticaria-hives-chronic
2. Zuberbier T, et al. The International Guideline for the Definition, Classification, Diagnosis and Management of Urticaria. Allergy. 2026. Summarised in HCPLive, “Updated Urticaria Guidelines Clarify Diagnosis, Biomarkers, Treatment Pathways”, 6 February 2026.
3. ASCIA. Position Paper: Chronic Spontaneous Urticaria (CSU). 2020. allergy.org.au
4. Kolkhir P, et al. Autoimmune chronic spontaneous urticaria. Journal of Allergy and Clinical Immunology. 2022;149.
5. Clinical and molecular aspects of managing chronic spontaneous urticaria: identifying endotypes, phenotypes, and determinants of treatment response and resistance. 2026. PMC12834803.
6. ASCIA. Treatment guideline for chronic spontaneous urticaria (Australia). 2020. allergy.org.au
7. Sánchez-Díaz M, et al. The Burden on Cohabitants of Patients with Chronic Spontaneous Urticaria: A Cross-Sectional Study. 2022. PMC9181347.
8. Sleep Quality as a Predictor of Quality-of-Life and Emotional Status Impairment in Patients with Chronic Spontaneous Urticaria: A Cross-Sectional Study. PMC9964690.
9. Burden of chronic spontaneous urticaria in European patients (matched survey study). The Patient. 2015. doi:10.1007/s40271-015-0145-9.
10. Burden of chronic urticaria compared with psoriasis. PMC6084337.
11. Services Australia. Severe chronic spontaneous urticaria: omalizumab PBS authority. servicesaustralia.gov.au
12. Pharmaceutical Benefits Advisory Committee. Omalizumab for chronic spontaneous urticaria: predicted versus actual utilisation (DUSC review). 2020 and 2023. pbs.gov.au
13. Therapeutic Goods Administration. Rhapsido (remibrutinib): Australian Prescription Medicine Decision Summary. 2026. tga.gov.au
14. Pharmacy Daily. Rhapsido listed on ARTG for CSU. June 2026.
15. Medscape. Dupilumab Approved for Chronic Spontaneous Urticaria. 18 April 2025; and Contemporary Pediatrics, FDA approves dupilumab for CSU in children 2 years and older, April 2026.
16. American Academy of Dermatology. Key messages: Urticaria guidelines. aad.org
17. Clinical Remission of Chronic Spontaneous Urticaria (CSU): A Targeted Literature Review. Dermatology and Therapy. 2022. doi:10.1007/s13555-021-00641-6.
18. Natural history, prognostic factors and patient perceived response to treatment in chronic spontaneous urticaria. Allergy, Asthma & Clinical Immunology. 2020. doi:10.1186/s13223-020-00459-5.
19. Royal Adelaide Hospital. Clinical Immunology and Allergy. rah.sa.gov.au
20. ASCIA. Locate a specialist: South Australia; and SA Health, Southern Adelaide Local Health Network Allergy & Clinical Immunology Service.
21. Allergy & Anaphylaxis Australia. Contact us / National Allergy Helpline. allergyfacts.org.au
22. Trajkova V, et al. Clinical and autoimmune characteristics associated with angioedema in patients with chronic spontaneous urticaria. Exploration of Asthma & Allergy. 2025;3:1009101.
23. Scammell TE, Jackson AC, Franks NP, Wisden W, Dauvilliers Y. Histamine: neural circuits and new medications. Sleep. 2019;42(1):zsy183.
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