Del Rosso's What's New in the Medicine Chest 2026: CHE, CSU, and Vitiligo

In part 2 of his conversation with Dermatology Times, James Del Rosso, DO, reviewed several notable therapeutic advances that are reshaping management strategies across chronic spontaneous urticaria (CSU), chronic hand eczema (CHE), and vitiligo. His commentary highlighted how newer agents are filling long-standing gaps for patients who remain inadequately controlled on conventional approaches.

CSU remains a challenging condition, particularly for patients who fail high-dose H1 antihistamines. As Del Rosso noted, CSU is defined by persistent urticaria lasting at least 6 weeks despite standard therapy escalation. The treatment landscape has expanded beyond antihistamines with the availability of targeted biologic and small-molecule options.

Dupilumab, administered every 2 weeks as an injectable therapy, has demonstrated efficacy when used alongside antihistamines in adults with CSU. Del Rosso emphasized that onset may vary, with some patients responding quickly while others require several weeks before meaningful improvement is observed. This variability underscores the importance of counseling patients on realistic expectations early in treatment.

More recently, attention has shifted to remibrutinib, an oral Bruton tyrosine kinase (BTK) inhibitor studied in the REMIX trials at a dose of 25 mg twice daily. Del Rosso described its clinical performance as notable for speed of response, stating, “Most of the patients are going to see a very rapid, sometimes in a few days, significant reduction in the hives and the itching.” Such rapid onset may be particularly impactful for patients with severe symptoms and quality-of-life impairment.

Safety considerations with remibrutinib appear manageable. Mild petechiae have been reported, though Del Rosso characterized these findings as clinically inconsequential. A label warning advises caution around surgical procedures, similar to considerations with nonsteroidal anti-inflammatory drugs.

Beyond systemic therapy, Del Rosso also discussed meaningful progress in topical treatments. Delgocitinib, a topical pan-JAK inhibitor, has emerged as a new option for chronic hand eczema across etiologies, including atopic, allergic, and irritant disease. Clinical studies support both favorable efficacy and tolerability when used on the hands and wrists.

Topical ruxolitinib continues to play an important role in atopic dermatitis and vitiligo, though treatment parameters differ by indication. In vitiligo, use is limited to up to 10% body surface area, often prioritizing cosmetically sensitive sites such as the face, which Del Rosso noted tends to show the most consistent response. He also referenced emerging data combining topical ruxolitinib with home-based narrowband UVB therapy, an approach made more feasible by newer monitored phototherapy devices.

Collectively, these developments reflect a broader shift toward targeted, mechanism-driven therapy in dermatology, offering clinicians more flexibility to individualize care while improving outcomes for patients with historically difficult-to-treat disease.