Chronic urticaria is a common dermatologic condition, yet according to a recent survey, one in five clinicians deviates from known management guidelines. Researchers at the George Washington University (GWU) School of Medicine and Health Sciences Department of Dermatology surmised that the lack of confidence in workup and management of chronic urticaria and lack of adherence to guidelines may stem from limited clinical exposure to chronic urticaria during dermatology residency.
A poster presented at the ODAC Dermatology conference titled A Cross-Sectional Evaluation of Chronic Urticaria Training in Dermatology Residency evaluated residents’ training, guideline awareness, and confidence and knowledge in the diagnosis and treatment of chronic urticaria. I interviewed authors Nikkia Zarabian, BS, and Mina Farah, BA, research fellows with GWU, as well as Adam Friedman, MD, FAAD, chair of the GWU Department of Dermatology.
What prompted this deep dive into chronic urticaria training during dermatology residency?
Chronic urticaria (CU) is commonly seen in dermatology, yet, despite comprehensive guidelines for chronic spontaneous urticaria (CSU), gaps between awareness and implementation persist. In a global survey, nearly all physicians (96%) reported awareness of at least one urticaria guideline and stated they follow guideline-based management, yet approximately one in five (22%) deviated from recommendations.¹ This disconnect suggests that deficiencies may originate during residency, a critical period for establishing evidence-based management habits. Limited exposure to CU or insufficient formal education during training may contribute to delayed diagnosis, excessive testing, and inappropriate treatment.
Your poster mentions a 2025 study that found chronic urticaria affects up to 20 percent of people during their lifetime. Did you find the incidence rate surprising?
The lifetime prevalence of CU, including both CSU and chronic inducible urticaria (CIndU), is high, underscoring that it is a common condition dermatologists should be prepared to manage routinely. This prevalence highlights the importance of consistent, guideline-based training, as gaps in knowledge or confidence can impact a large patient population. CU should therefore be regarded as a core competency in dermatology rather than a subspecialty concern.
You surveyed U.S. dermatology residents about their education and training on chronic urticaria. While nearly 75% of the respondents thought their chronic urticaria education was sufficient, half denied following any guidelines. What does this reveal about the state of chronic urticaria diagnosis and treatment?
Although most residents felt their chronic urticaria education was sufficient, the finding that half do not follow formal guidelines reveals a gap between perceived preparedness and evidence-based practice. Training may adequately cover disease recognition and first-line therapy but place less emphasis on standardized diagnostic evaluation and stepwise treatment escalation. Notably, residents reported seeing relatively few patients with CU, averaging 1-2 new and 1-2 follow-up visits per month. This limited clinical exposure may reflect patient misinformation or confusion regarding which specialties manage CU, underscoring an opportunity for residents to educate the public on this. Consequently, management beyond antihistamines may be variable and shaped more by local practice patterns than by established guidelines, highlighting the need to strengthen guideline-focused education within residency.
What other educational gaps did your research discover?
We identified several additional gaps, including limited confidence in both diagnostic evaluation and long-term management of CU. Many residents were unfamiliar with established U.S. and European guidelines and reported inconsistent and excessive use of laboratory workups. There was also minimal use of validated tools to assess disease activity or quality of life, suggesting that structured monitoring is not yet well integrated into training. Uncertainty was most evident when selecting and sequencing second-line and advanced therapies.
You also asked residents about treatment protocols. Was there any similarity in how residents approach chronic urticaria?
There was strong agreement on first-line therapy. Most residents appropriately reported using second-generation antihistamines and escalating doses, often up to four times the standard dose, when symptoms persisted. However, approaches diverged considerably after antihistamine failure.
The poster notes that more than 75% of respondents referred their chronic urticaria patients to allergy/immunology. Is this high rate of referral warranted?
Referral to allergy/immunology may be appropriate in select situations, however, many are not. Most cases of CSU should be effectively managed within dermatology, particularly with the current treatment paradigm. The high referral rate observed in our survey likely reflects gaps in confidence and guideline familiarity rather than clinical necessity in every case, suggesting an opportunity to strengthen dermatology-based management.
What does your poster tell residency program directors about the state of chronic urticaria education?
The field of CU has evolved rapidly, with recent FDA approvals of dupilumab and remibrutinib expanding treatment options. As these therapies become more widely used and studied, updated guidelines are anticipated, emphasizing the importance of keeping education aligned with emerging evidence. Our findings suggest that residents are gaining exposure to CU and initiating treatment, but opportunities exist to further reinforce guideline-directed management, escalation strategies, and use of standardized assessment tools. Working with service line leaders to ensure resident involvement in the care of patients with CU may further strengthen experiential learning. Structured teaching focused on treatment algorithms, advanced therapies, and disease monitoring can enhance resident confidence, support consistent, evidence-based care, and optimize patient outcomes. Intentional patient outreach should also be prioritized, leveraging social media and other digital platforms to clearly identify CU as a dermatologic disease and guide patients to appropriate care.
References
-
- Kolkhir P, Pogorelov D, Darlenski R, et al. Management of chronic spontaneous urticaria: a worldwide perspective. World Allergy Organ J. 2018;11(1):14. Published 2018 Jul 4. doi:10.1186/s40413-018-0193-4
Additional authors of the poster include:
Savanna I. Vidal, BS, GWU Department of Dermatology
Nikita Menta, BA, GWU Department of Dermatology
