Chronic Urticaria Perceptions Vary Among Clinicians, Study Finds

Chronic urticaria (CU) is a mast cell–mediated inflammatory skin disorder defined by the presence of wheals, angioedema, or both for more than 6 weeks. It may occur spontaneously as chronic spontaneous urticaria (CSU), be inducible by specific triggers such as cold or pressure (chronic inducible urticaria, CIndU), or present as a combination of both phenotypes.¹ Although CU is widely recognized as a common and burdensome condition, much of the existing literature has focused on epidemiology and patient-reported outcomes. Less is known about how physicians perceive CU prevalence, disease onset, and clinical impact, and how these perceptions may differ by specialty, practice setting, or geographic region.

The CU-PAPER (Chronic Urticaria—Physician Estimation of Prevalence and Clinical Impact) study was designed to address this gap. This multicenter, cross-sectional survey assessed physicians’ estimates of CU prevalence and burden and compared them with published epidemiologic data. It also explored whether perceptions varied among different physician subgroups, including specialists affiliated with Urticaria Centers of Reference and Excellence (UCARE).²

Study Design and Physician Population

Between September 2024 and February 2025, 234 physicians from 46 countries completed an online questionnaire distributed through the UCARE network, direct email invitations, and an international urticaria meeting. Participants were predominantly allergists/clinical immunologists and dermatologists, with a median of 20 years of clinical experience. Nearly 70% reported treating both adult and pediatric patients with CU, and over two-thirds worked in university or training hospitals, most of which were affiliated with UCARE.

The survey assessed physicians’ estimates of CU age of onset, prevalence in adults and children, relative proportions of CSU and CIndU, and perceived impact on multiple domains of daily life, including sleep, mental health, work or school, and physical activity.

Perceived Prevalence and Age of Onset

Overall, physicians’ estimates of CU prevalence were generally consistent with published data, though some notable variation was observed. The median estimated prevalence of CU in adults was 2.5%, while the median estimate for children was 1.0%. Physicians estimated that CSU accounted for approximately 70% of adult CU cases and 60% of pediatric cases, with concomitant CIndU present in roughly one-third of patients with CSU.

Estimated age of onset also aligned broadly with existing literature, particularly for CIndU. Physicians reported a median onset age of 25 years for CIndU and 30 years for CSU. However, the perceived onset of CSU was somewhat younger than previously reported epidemiologic data, which typically place median onset in the early to mid-40s. Confidence in these estimates was moderate, highlighting persistent uncertainty even among experienced clinicians.

Geographic differences emerged, with physicians in Asia estimating a higher adult CU prevalence than those in Europe. These differences mirrored known regional variability reported in epidemiologic studies, suggesting that physician perceptions may reflect local disease patterns or healthcare system factors.

Perceived Burden of Disease

Across CU subtypes, physicians identified substantial impairment in patients’ daily lives. For CSU, sleep disturbance and mental health were most frequently reported as the most affected domains. In CIndU, limitations in physical activity predominated, followed by mental well-being and appearance. Patients with combined CSU and CIndU were perceived to experience a high burden across multiple domains, particularly sleep and mental health.

Physicians estimated that nearly half of patients with severe CSU experience significant disruption to sleep, daily activities, work, school, or leisure. Although perceived burden was lower for CIndU, a substantial proportion of patients were still thought to experience moderate to severe impairment.

Differences by Specialty and Practice Setting

Physicians affiliated with UCARE centers consistently reported lower and more literature-aligned estimates of CU prevalence than non-UCARE physicians, along with higher estimates of disease burden and greater confidence in their assessments. Specialists in dermatology and allergy/immunology also demonstrated higher confidence than non-specialists, such as general practitioners or internists.

Physicians treating both adult and pediatric patients reported greater confidence in estimating disease characteristics and burden, potentially reflecting broader clinical exposure. Importantly, non-specialists tended to estimate a lower proportion of patients experiencing severe disease impact, raising concern that CU burden may be underestimated in some clinical settings.

Clinical Implications

The CU-PAPER study highlights that, while physicians’ perceptions of CU prevalence and impact are largely aligned with existing evidence, meaningful gaps remain—particularly outside specialized urticaria centers. Underestimation of disease burden may influence treatment decisions, delay escalation of therapy, and negatively affect patient–physician communication.

These findings underscore the importance of continued education on CU for non-specialist physicians, wider dissemination of guideline-based management strategies, and routine use of patient-reported outcome measures. Improved recognition of CU burden may support earlier referral, optimized treatment, and shared decision-making—key steps toward achieving complete disease control, the central goal of CU management.

While this study reflects physician perceptions rather than direct epidemiologic measurement, its international scope provides valuable insight into how CU is viewed in real-world clinical practice and where opportunities for improvement remain.

References

1. Tbakhi B, Ware K, Park HS, Bernstein JS, Bernstein JA. An overview of chronic spontaneous urticaria: Diagnosis, management, and treatment. Allergy Asthma Immunol Res. 2025;17(5):531-546. doi:10.4168/aair.2025.17.5.531
2. Kern BM, Aulenbacher F, Cherrez-Ojeda I, et al. Physician estimation of the prevalence and clinical impact of chronic urticaria: results of the global, multicenter UCARE CU-PAPER study. Front Allergy. 2026;6:1732893. Published 2026 Jan 12. doi:10.3389/falgy.2025.1732893