CSU More Burdensome in Female Patients, Especially in Midlife

Female patients with chronic spontaneous urticaria (CSU) experience more burdensome disease compared with men, a study published in the Journal of the European Academy of Dermatology & Venereology found.¹ The disease burden was especially significant in females aged 51 to 65 years, according to the research.

CSU, a dermatological condition characterized by persistent wheals and/or angioedema, disproportionately affects women,² but the new large-scale international study showed that sex-based differences in disease burden and treatment response are more pronounced than previously understood, especially in midlife.¹

The researchers used data from the Chronic Urticaria Registry (CURE) to examine sex differences among 4136 CSU patients from 58 participating sites across 29 countries. The findings showed strong female predominance, with women accounting for 72.4% of the patient population. While a noticeable female predominance was observed from childhood, a statistically significant difference emerged at age 31 (P < .001), and this trend continued to increase beyond age 50.

The study found that female patients consistently experienced a more severe and burdensome disease course compared with their male counterparts. Female patients showed a higher frequency of angioedema with or without wheals than males (65% vs 59.2%; P < .001) and wheals and angioedema (P < .001). Systemic symptoms like joint pain and malaise were also more common in females.

Food (14.1% vs 11.6%, P = .04) and stress (23.6% vs 18.3%, P < .001) were more commonly noted as symptom aggravators by females vs males, as well.

“Differences in triggering factors between females and males for CSU have not been previously reported,” the authors wrote. “The finding of stress and food as triggering factors could help female patients by informing them to try to manage or avoid stress if possible and make a food diary if they suspect any foods are exacerbating their symptoms.”

Quality of life was also worse among females, who reported more significant negative impacts to quality of life and sleep, as well as a higher rate of uncontrolled disease across treatment types.

Additionally, the disease became particularly burdensome and refractory for females in midlife, specifically between the ages of 51 and 65 years. In this age group, women had more comorbid conditions, including thyroid disease, autoimmune disease, obesity, and depression, as well as more frequent systemic symptoms and emergency visits. These pronounced sex differences largely diminished after age 65, however.

“Increases in disease severity and refractoriness in midlife may be attributed to the transition to menopause, due to changes in the immune system occurring at this time,” the authors wrote. “Changes may include increased production and response to pro-inflammatory cytokines and decreased secretion of anti-inflammatory cytokines. These changes, coupled with altered endocrine function, may explain the increased burden of CSU in women with age.” The higher rates of comorbidities in this subgroup could also cause a multifactorial effect, they added, noting that future research examining these and other aspects would be interesting.

The study was limited by a small sample size in the younger patient group and the absence of Urticaria Control Test values for some patients, both of which limit the study’s generalizability. Biomarker testing would also have been useful to determine whether CSU in females adopts more type 2b autoimmune patterns with age, the authors noted.

“Our findings show distinct disease patterns between female and male patients, which would encourage a patient-tailored approach, that is, considering the higher burden of CSU in middle-aged women (51-65 years) may help approach them more compassionately,” the authors concluded. “The 2 most important findings of our study, female predominance in CSU starts after age 30 and CSU gets more burdensome in midlife, suggest there is a complex interplay between factors such as immunological differences, hormones and comorbidities in the severity and manifestation of the disease.”

References

1. Kocatürk E, Salameh P, Asero R, et al. Sex matters in CSU: Women face greater burden and poorer urticaria control, especially in midlife-CURE insights. J Eur Acad Dermatol Venereol. Published online September 18, 2025. doi:10.1111/jdv.70027

2. Kolkhir P, Bonnekoh H, Metz M, Maurer M. Chronic spontaneous urticaria: a review. JAMA. 2024;332(17):1464-1477. doi:10.1001/jama.2024.15568