The FDA has approved omalizumab (Xolair) for the treatment of chronic hives. This is the first medication with a specific indication for [glossary slug=’chronic-idiopathic-urticaria’ /] (CIU). There are many patients with CIU that remain symptomatic, covered in hives and itchy despite multiple medications. The addition of Xolair may help these patients get their symptoms under control. The good: – Current treatment options are limited and often ineffective. – Convenience. Xolair is given as an injection on a monthly basis. Current medication regimens may include up to 20 pills per day. The bad: – Xolair is expensive and will require pre-approval. – Several clinical studies have demonstrated a high degree of safety. However, there are concerns that Xolair use may increase the risk of cardiac events and severe allergic reactions. The ugly: – Xolair, like other available medications, suppresses the hives but does not fix the underlying problem. Optimally, a cause can be identified and corrected or avoided.