From disease activity scores to precision medicine: biomarkers and composite models for risk stratification in chronic spontaneous urticaria

Chronic spontaneous urticaria is a common, mast cell driven condition that presents with wheals, angioedema, or both, and a substantial proportion of patients remain inadequately controlled despite guideline-directed antihistamine therapy. The 2026 guideline has expanded the advanced-treatment options to include omalizumab, dupilumab and remibrutinib, while ciclosporin remains an alternative later-line immunosuppressive option, yet it is organised around treatment response rather than prognosis, so patients with difficult-to-control disease are often recognised only after months of sequential escalation. This narrative review examines the scoring systems and biomarkers available in urticaria and angioedema and considers whether they can support early risk stratification and help identify patients at increased risk of difficult-to-control disease. The validated instruments in routine use, namely the Urticaria Activity Score, the Urticaria Control Test, the Chronic Urticaria Quality of Life Questionnaire, and their angioedema counterparts, measure current disease activity, control, and quality of life rather than long term outcome. A separate body of work has described biomarkers associated with the autoimmune type IIb endotype and with response to omalizumab, including low total IgE, a high ratio of IgG anti-thyroid peroxidase to total IgE, basopenia, and raised inflammatory markers, although most of this evidence is associative rather than prospectively predictive. The distinction between markers of current burden, markers of prognosis, and markers of treatment response is emphasised. Composite models integrating clinical characteristics, patient-reported outcomes, and biomarkers represent a promising approach toward precision management of CSU, although no validated prognostic tool is currently available for routine clinical use.