Three Questions at the First Visit: Assessment, Prognosis, and Prediction in Chronic Spontaneous Urticaria

Chronic spontaneous urticaria is a common, mast cell-driven condition, and although the treatment ladder now extends to omalizumab, dupilumab, and remibrutinib, it is organised around treatment response rather than prognosis. This narrative review is built around the three questions a clinician faces at the first specialist visit: how active the disease is now, who will follow a persistent or severe course, and who will respond to which therapy. The validated instruments in routine use answer only the first question, since they measure current activity, control, and quality of life, and were not designed to forecast the future. Prognostic information about persistence and severity is scattered across clinical features such as disease duration, angioedema, and coexisting inducible urticaria, and across the autoimmune Type IIb endotype, but has not been assembled into a validated tool. Predictive biomarkers, including the baseline total IgE, the ratio of IgG anti-thyroid peroxidase to total IgE, basophil high-affinity IgE receptor expression, and functional autoreactivity, are associated with the response to omalizumab, yet most remain associative and may not transfer to newer agents. This review contends that answering the three questions will require composite, treatment-specific models that are validated prospectively, and it sets out the evidence, obstacles, and practical research agenda. No validated prognostic tool is currently available for routine use, although the components required to build one are becoming clear.