Chronic spontaneous urticaria: update on pathogenesis and therapeutic implications

BACKGROUND: The understanding of chronic spontaneous urticaria pathogenesis has been increasing recently. The central role of mast cells is being reinforced, but multiple cells, pathways, and mediators are involved in a complex interrelationship. Modern therapies for its management reflect the need to encompass different mechanisms and promise to alter the course of urticaria and the long journey of those with refractory disease. Continuous updating of these aspects is necessary to optimize patient care. OBJECTIVES: To review concepts and advances in the pathogenesis of chronic spontaneous urticaria, in addition to contextualizing promising drug options for its management. METHOD: A narrative review was conducted between 1977 and 2024, including relevant articles published in the scientific literature, indexed in the PubMed system. RESULTS: A total of 25,732 articles were found. Inclusion criteria were determined by the authors' decision regarding their level of importance for furthering knowledge in the areas of pathogenesis and treatment of chronic spontaneous urticaria, with preference given to meta-analyses, systematic reviews, and randomized trials. Regarding therapeutics, 138 articles from the last 15 years were prioritized, in addition to records on ClinicalTrials.gov, and the drugs could be in the clinical trial phase. Immunobiologicals and small molecules hold promise for future treatment regimens for chronic spontaneous urticaria. STUDY LIMITATIONS: Narrative reviews do not provide statistical value to the results and outcomes studied. CONCLUSION: A review of the pathogenesis of chronic spontaneous urticaria was conducted, contextualizing these aspects with promising drug options for its treatment, particularly immunobiologicals and small molecules.