Gaps and Challenges in the Diagnosis and Management of Chronic Spontaneous Urticaria: An Italian Delphi Consensus

Chronic spontaneous urticaria (CSU) is a burdensome condition characterized by recurrent wheals and/or angioedema lasting more than 6 weeks. Despite comprehensive international guidelines, their application remains limited, leading to delayed diagnosis, suboptimal treatment, and inconsistent disease monitoring. To enhance guideline understanding and standardized application, a Delphi study was conducted involving a steering committee composed of 10 Italian CSU experts (dermatologists, allergologists, and one internist). A total of 27 statements were formulated, covering key aspects of CSU diagnosis and management; most statements reached consensus in the first round. Experts strongly supported a thorough clinical history and physical examination, emphasizing the need for differential diagnosis in the presence of specific symptoms (e.g., prolonged wheal duration and systemic symptoms). Full blood count (FBC), C-reactive protein (CRP), and total immunoglobulin (Ig)E measurements were considered essential for the diagnostic workup, while statements on anti–thyroid peroxidase (TPO) IgG and erythrocyte sedimentation rate (ESR) did not reach consensus. The panel agreed on the use of second-generation antihistamines as first-line therapy, only the rescue use of corticosteroids, and the essential role of the urticaria activity score over 7 days (UAS7) and the urticaria control test (UCT) for long-term monitoring. They discouraged the widespread use of restrictive diets and nonscientifically validated tests and advocated for novel therapies to treat refractory cases. These consensus-based recommendations provide practical guidance for standardized CSU care in clinical practice. Uncertainty surrounding specific statements reinforces the importance of guidelines knowledge and adherence to ensure consistent CSU management.