Dermatology

Chronic spontaneous urticaria (CSU) treatment: What to expect after a CSU diagnosis

Article contributed by Dr. Phoon Yee Wei

If you have recently been diagnosed with chronic spontaneous urticaria (CSU), one of your biggest questions may be: What happens next?

According to Dr Phoon Yee Wei, the goal of CSU treatment is clear — to achieve complete or as close to complete, control of symptoms as possible. Treatment is not simply about making itching, hives or swelling slightly less bothersome.

What does chronic spontaneous urticaria (CSU) treatment involve?

Once CSU has been diagnosed, treatment is typically initiated with antihistamines, which help control symptoms such as hives or itching by blocking the effects of histamine in the body¹.

Your doctor will then monitor how well your symptoms respond. In many cases, the response to a particular antihistamine dose can be assessed within the first one to two weeks. If symptoms remain poorly controlled, your doctor may increase the antihistamine dose in accordance with international CSU treatment guidelines or consider the next stage of treatment¹.

Dr Phoon views CSU treatment as a stepwise approach, with each decision guided by how well symptoms are being controlled.

Why do antihistamines work for some people with CSU but not others?

Your response to antihistamines may differ from someone else’s. Antihistamines may control your symptoms well, but you may also continue to experience hives, itching or swelling.¹

In Dr Phoon’s experience, this difference in response does not necessarily mean your treatment has failed. Instead, it helps your doctor decide whether your current treatment is sufficient or whether the next step in the CSU treatment pathway should be considered.

How do doctors know if CSU treatment is working?

For Dr Phoon, the answer is simple: Zero hives, zero itch. Good CSU symptom control means more than just having fewer flare-ups¹.

Over time, you may become accustomed to living with persistent itch or recurrent hives and assume this is something you need to tolerate. However, Dr Phoon emphasises that your treatment goals should aim for complete or near-complete symptom control whenever possible¹. If your hives or itch continue frequently, your treatment may need to be adjusted or escalated rather than remaining on the same approach indefinitely¹.

This is why it is important to tell your doctor if:

• Your hives continue to return;
• Your itch remains bothersome;
• Symptoms are affecting sleep or daily activities²;
• Your current treatment does not feel sufficient.

These details help your doctor assess whether your CSU is genuinely well-controlled.

Zero hives, zero itch.

Good CSU sypmtom control means more than just having fewer flare-ups.

– Dr Phoon

What happens if antihistamines do not control CSU?

If your symptoms remain inadequately controlled after your antihistamine treatment has been adjusted in accordance with treatment guidelines, your doctor may discuss the next stage of treatment with you¹.

Needing treatment escalation does not necessarily mean that your CSU is getting worse. It may simply mean that your current treatment is not sufficient to achieve the level of symptom control being targeted¹.

Can CSU go into remission?

Yes. Your CSU can improve over time, although the duration of the condition varies from person to person³.

You may experience CSU for a relatively short period, or your symptoms may continue for several years³.

Dr Phoon describes remission as reaching a point where your symptoms remain controlled after treatment has been stopped, rather than simply being symptom-free while treatment continues. If you are taking antihistamines, this may involve gradually reducing your dose over time and observing whether your hives or itch return¹.

The important point is that you should not automatically accept persistent hives and itch as the best possible outcome². If you are still experiencing frequent symptoms despite taking your treatment as advised, speak to your doctor about whether your chronic spontaneous urticaria is adequately controlled.

Dr Phoon Yee Wei is a Senior Consultant Dermatologist and Dermatologic Surgeon and Medical Director at Ascensus Skin – Ascensus Health Specialist Centre, Novena. Dr Phoon graduated with a Bachelor of Medicine and Bachelor of Surgery (MBBS) from the National University of Singapore Yong Loo Lin School of Medicine in 2009. Specialist training in Dermatology was subsequently completed, with residency at the National Skin Centre and Singapore General Hospital. Following his specialist training, Dr Phoon has practised as a dermatologist since January 2018. He also holds teaching appointments as Senior Clinical Lecturer at the National University of Singapore and Lee Kong Chian School of Medicine, and as Clinical Assistant Professor at Duke-NUS Medical School.

Sources

1. Zuberbier T, Ansari ZAH, Abdul Latiff AH, et al. The international guideline for the definition, classification, diagnosis and management of urticaria. Allergy. 2026;1-51. doi: 10.1111/all.70210
2. Weller K, Winders T, McCarthy J, Raftery T, Saraswat P, Constantinescu C, Balp MM, Bernstein JA. Urticaria Voices: Real-World Experience of Patients Living with Chronic Spontaneous Urticaria. Dermatol Ther (Heidelb). 2025 Mar;15(3):747-761. doi: 10.1007/s13555-025-01348-8. Epub 2025 Feb 28. PMID: 40019716; PMCID: PMC11909366.
3. Friedman A, Kwatra SG, Yosipovitch G. A practical approach to diagnosing and managing chronic spontaneous urticaria. Dermatol Ther (Heidelb). 2024 Jun;14(6):1371-1387. doi: 10.1007/s13555-024-01173-5

FA-11788559 | 16 Sept 2026

This article is written in collaboration with #ISEEU, an informational and educational website about Chronic Spontaneous Urticaria (CSU).