Medscape is available in 5 Language Editions – Choose your Edition here.


Cholinergic Urticaria Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
Updated: May 24, 2016

Approach Considerations

Traditional treatment options for cholinergic urticaria are antihistamines, leukotriene inhibitors, and immunosuppressives.[22, 23] However, cholinergic urticaria in some patients may be refractory.

Sometimes, an attack of cholinergic urticaria can be aborted by rapid cooling. Ultraviolet (UV) light has been beneficial in some patients with the condition, but one must be circumspect about contraindications to UV light.

Rapid desensitization with autologous sweat has been reported in patients resistant to conventional therapy who have sweat hypersensitivity.[24]

In evaluating any response to therapy, one must always consider that cholinergic urticaria can clear spontaneously.

Also see the clinical guideline summary from the British Association of Dermatologists, Guidelines for Evaluation and Management of Urticaria in Adults and Children.


Modifying one's diet may be helpful because cholinergic urticaria attacks can sometimes result from hot foods and beverages, highly spiced foods, and alcohol.


Patients with cholinergic urticaria should avoid the precipitating factors. These factors, in some persons, include exercise and any activity that causes sweating, such as elevated environmental temperature, hot food, sauna baths, immersion in hot water, gustatory stimuli, emotional stress, and hemodialysis.


Pharmacologic Therapy

Antihistamines, including cetirizine, are helpful for cholinergic urticaria. The response to cetirizine is important because some of the antihistaminic effect has been attributed to antimuscarinic activity. Some data suggest that a combination of H1 and H2 blockers is more effective than combining different H1 blockers.[25] The antimuscarinic cholinergic methanthelinium bromide has also been suggested as a therapeutic option.[26]

For patients with both cold urticaria and cholinergic urticaria, ketotifen (where available) may be helpful. About 62% of patients experience a reduction in wheals, and 68% of patients report reduced itching. Cardiorespiratory symptoms also reportedly respond to ketotifen.

Danazol is another agent that can be beneficial for patients with cholinergic urticaria, ostensibly because it elevates antichymotrypsin levels.

Beta-blockers, such as propranolol, have also been reported to be useful in treating the disease.[27]

Topically applied benzoyl scopolamine and oral scopolamine butylbromide, where available, may be helpful in blocking the appearance of cholinergic urticaria lesions after challenge.[28]

Contributor Information and Disclosures

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.


Jerri Hoskyn, MD Private Practice, River City Dermatology

Disclosure: Nothing to disclose.

Mark G Lebwohl, MD Chairman, Department of Dermatology, Mount Sinai School of Medicine

Mark G Lebwohl, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Amgen/Pfizer Honoraria Consulting; GlaxoSmithKline Honoraria Consulting; Novartis Honoraria Consulting; Ranbaxy Honoraria Lectures; Pfizer Honoraria Consulting; BioLineRX, Ltd. Honoraria Consulting; Celgene Corporation Consulting; Clinuvel None Investigator; Eli Lilly & Co. None Investigator; Genentech Honoraria Consulting

Christen M Mowad, MD Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

  1. Magerl M, Borzova E, Gimenez-Arnau A, et al. The definition and diagnostic testing of physical and cholinergic urticarias--EAACI/GA2LEN/EDF/UNEV consensus panel recommendations. Allergy. 2009 Dec. 64(12):1715-21. [Medline].

  2. Nakamizo S, Egawa G, Miyachi Y, Kabashima K. Cholinergic urticaria: pathogenesis-based categorization and its treatment options. J Eur Acad Dermatol Venereol. 2012 Jan. 26(1):114-6. [Medline].

  3. Soter NA, Wasserman SI. Physical urticaria/angioedema: an experimental model of mast cell activation in humans. J Allergy Clin Immunol. 1980 Nov. 66(5):358-65. [Medline].

  4. Montgomery SL. Cholinergic urticaria and exercise-induced anaphylaxis. Curr Sports Med Rep. 2015 Jan. 14(1):61-3. [Medline].

  5. Nakazato Y, Tamura N, Ohkuma A, Yoshimaru K, Shimazu K. Idiopathic pure sudomotor failure: anhidrosis due to deficits in cholinergic transmission. Neurology. 2004 Oct 26. 63(8):1476-80. [Medline].

  6. Takahagi S, Tanaka T, Ishii K, et al. Sweat antigen induces histamine release from basophils of patients with cholinergic urticaria associated with atopic diathesis. Br J Dermatol. 2009 Feb. 160(2):426-8. [Medline].

  7. Fukunaga A, Bito T, Tsuru K, et al. Responsiveness to autologous sweat and serum in cholinergic urticaria classifies its clinical subtypes. J Allergy Clin Immunol. 2005 Aug. 116(2):397-402. [Medline].

  8. Horikawa T, Fukunaga A, Nishigori C. New concepts of hive formation in cholinergic urticaria. Curr Allergy Asthma Rep. 2009 Jul. 9(4):273-9. [Medline].

  9. Hiragun M, Hiragun T, Ishii K, et al. Elevated serum IgE against MGL_1304 in patients with atopic dermatitis and cholinergic urticaria. Allergol Int. 2014 Mar. 63(1):83-93. [Medline].

  10. Ramam M, Pahwa P. Is cholinergic urticaria a seasonal disorder in some patients?. Indian J Dermatol Venereol Leprol. 2012 Mar. 78(2):190-1. [Medline].

  11. Kobayashi H, Aiba S, Yamagishi T, et al. Cholinergic urticaria, a new pathogenic concept: hypohidrosis due to interference with the delivery of sweat to the skin surface. Dermatology. 2002. 204(3):173-8. [Medline].

  12. Itakura E, Urabe K, Yasumoto S, Nakayama J, Furue M. Cholinergic urticaria associated with acquired generalized hypohidrosis: report of a case and review of the literature. Br J Dermatol. 2000 Nov. 143(5):1064-6. [Medline].

  13. Moore-Robinson M, Warin RP. Some clinical aspects of cholinergic urticaria. Br J Dermatol. 1968 Dec. 80(12):794-9. [Medline].

  14. Godse K, Farooqui S, Nadkarni N, Patil S. Prevalence of cholinergic urticaria in Indian adults. Indian Dermatol Online J. 2013 Jan. 4(1):62-3. [Medline]. [Full Text].

  15. Confino-Cohen R, Goldberg A, Magen E, Mekori YA. Hemodialysis-induced rash: a unique case of cholinergic urticaria. J Allergy Clin Immunol. 1995 Dec. 96(6 Pt 1):1002-4. [Medline].

  16. Sheraz A, Halpern S. Cholinergic Urticaria Responding to Botulinum Toxin injection for Axillary Hyperhidrosis. Br J Dermatol. 2013 Jan 10. [Medline].

  17. Silpa-Archa N, Kulthanan K, Pinkaew S. Physical urticaria: prevalence, type and natural course in a tropical country. J Eur Acad Dermatol Venereol. 2010 Dec 22. [Medline].

  18. Vadas P, Sinilaite A, Chaim M. Cholinergic Urticaria with Anaphylaxis: An Underrecognized Clinical Entity. J Allergy Clin Immunol Pract. 2016 Mar-Apr. 4 (2):284-91. [Medline].

  19. Torabi B, Ben-Shoshan M. The association of cholinergic and cold-induced urticaria: diagnosis and management. BMJ Case Rep. 2015 Feb 18. 2015:[Medline].

  20. Abajian M, Schoepke N, Altrichter S, Zuberbier HC, Maurer M. Physical urticarias and cholinergic urticaria. Immunol Allergy Clin North Am. 2014 Feb. 34(1):73-88. [Medline].

  21. Mihara S, Hide M. Adrenergic urticaria in a patient with cholinergic urticaria. Br J Dermatol. 2008 Mar. 158(3):629-31. [Medline].

  22. Otto HF, Calabria CW. A case of severe refractory chronic urticaria: a novel method for evaluation and treatment. Allergy Asthma Proc. 2009 May-Jun. 30(3):333-7. [Medline].

  23. Magerl M, Altrichter S, Borzova E, Giménez-Arnau A, Grattan CE, Lawlor F, et al. The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision. Allergy. 2016 Jun. 71 (6):780-802. [Medline].

  24. Kozaru T, Fukunaga A, Taguchi K, Ogura K, Nagano T, Oka M, et al. Rapid desensitization with autologous sweat in cholinergic urticaria. Allergol Int. 2011 Sep. 60(3):277-81. [Medline].

  25. Alsamarai AM, Hasan AA, Alobaidi AH. Evaluation of different combined regimens in the treatment of cholinergic urticaria. World Allergy Organ J. 2012 Aug. 5(8):88-93. [Medline]. [Full Text].

  26. Altrichter S, Wosny K, Maurer M. Successful treatment of cholinergic urticaria with methantheliniumbromide. J Dermatol. 2015 Jan 9. [Medline].

  27. Ammann P, Surber E, Bertel O. Beta blocker therapy in cholinergic urticaria. Am J Med. 1999 Aug. 107(2):191. [Medline].

  28. Tsunemi Y, Ihn H, Saeki H, Tamaki K. Cholinergic urticaria successfully treated with scopolamine butylbromide. Int J Dermatol. 2003 Oct. 42(10):850. [Medline].

  29. Feinberg JH, Toner CB. Successful treatment of disabling cholinergic urticaria. Mil Med. 2008 Feb. 173(2):217-20. [Medline].

  30. Metz M, Bergmann P, Zuberbier T, Maurer M. Successful treatment of cholinergic urticaria with anti-immunoglobulin E therapy. Allergy. 2008 Feb. 63(2):247-9. [Medline].

Close-up view shows small urticarial wheals within large erythematous flares.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.