<b><i>Background:</i></b> Ulcerative colitis (UC) is a chronic inflammatory bowel disease that is chronically present in patients throughout their lives. Hence, the chronic nature of the disease invariably requires continuous medical treatment. Advances in medical therapy over the last decades and current developments offer increasing options and are closely associated with a better life quality in patients. <b><i>Summary:</i></b> Recent developments in understanding the pathogenesis of UC are discussed. The current standard therapeutic regimens are outlined and recent developments and upcoming strategies introduced. <b><i>Key Points:</i></b> (1) Environmental factors that are yet to be defined contribute to the pathogenesis of UC. (2) An accelerated step-up therapy represents the current standard in UC. (3) Anti-integrins represent the most recently introduced pharmacological class in the therapy of UC. (4) Novel strategies including Janus kinase inhibitors are in the near future.