Urticaria (Shara): A Narrative Review of Contemporary and Unani Perspectives

Background: Urticaria (Shara) is a common mast cell-mediated inflammatory skin disorder characterized by transient wheals, angioedema, or both, significantly affecting patients' quality of life. While contemporary management relies on second-generation antihistamines, biologics, and immunomodulatory agents, interest in complementary systems such as Unani medicine has increased because of their holistic therapeutic approach. Objective: To critically review the current evidence on the epidemiology, pathogenesis, clinical features, differential diagnosis, and management of urticaria, and to integrate contemporary scientific knowledge with Unani concepts and therapeutic principles. Methods: This narrative review integrates classical Unani literature with contemporary peer-reviewed evidence on urticaria, including international guidelines, systematic and narrative reviews, and clinical studies of Unani interventions. Priority was given to contemporary guideline recommendations and controlled clinical studies. No meta-analysis was performed, and the available evidence for Unani interventions was critically appraised with attention to study design, sample size, treatment duration, outcome measures, and limitations. Results: Current evidence identifies mast-cell activation, autoimmune mechanisms, and inflammatory mediators as central to chronic urticaria. The 2026 international guideline recommends a stepwise approach beginning with second-generation H1-antihistamines, followed by add-on targeted therapy for patients with inadequate control; omalizumab remains a key evidence-based option, while dupilumab and remibrutinib are incorporated into the evolving therapeutic landscape. Cyclosporine remains an off-label option for selected severe refractory disease. In Unani medicine, Shara is traditionally conceptualized in terms of Fasad-i-Dam and humoral imbalance, with management involving dietotherapy, pharmacotherapy, and regimental therapy. Preliminary controlled studies of selected Unani formulations report improvements in disease activity and quality of life; however, the evidence remains limited by small samples, short follow-up, and heterogeneous interventions. Conclusion: Contemporary guideline-directed therapy remains the evidence-based cornerstone of urticaria management. Selected Unani interventions show encouraging but preliminary efficacy signals that warrant rigorous, adequately powered evaluation before they can be recommended as adjuncts to standard care.