eMedicine Specialties > Dermatology > Allergy & Immunology

Urticaria, Chronic: Differential Diagnoses & Workup

Author: Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), NOVA Southeastern University; Investigator, Hill Top Research, Florida Research Center
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Acute Febrile Neutrophilic Dermatosis
Mastocytosis
Atopic Dermatitis
Muckle-Wells syndrome
Bedbug Bites
Pruritic Urticarial Papules and Plaques of Pregnancy
Bullous Pemphigoid
Reticular erythematosus mucinosis
Chronic infantile neurologic cutaneous articular syndrome
Scabies
Contact Dermatitis, Allergic
Schnitzler Syndrome
Erythema Multiforme
Urticarial Vasculitis
Familial cold autoinflammatory syndrome
Wells Syndrome (Eosinophilic Cellulitis)
Fixed Drug Eruptions
Insect Bites
Lupus Erythematosus, Subacute Cutaneous

Other Problems to Be Considered

Melkersson-Rosenthal syndrome

Workup

Laboratory Studies

Elicit a history and perform a physical examination and challenge testing for physical causes in patients with chronic urticaria. Direct the selection of laboratory tests using the information elicited from the history and physical examination.

  • Complete blood cell count with differential: Patients with parasitic infections, especially in developing countries, or patients experiencing a drug reaction may have an elevated eosinophil count. The absence of blood eosinophilia may obviate the necessity for stool examination for ova.
  • Erythrocyte sedimentation rate: It may be elevated in persons with urticarial vasculitis.
  • Hepatitis B and C titers: Both hepatitis B and C may be associated with cryoglobulinemia, which is associated with some forms of cold-induced urticaria and urticarial vasculitis. In addition, an association has been reported between hepatitis C and chronic urticaria.14
  • Antinuclear antibody titers: These are indicated in patients in whom urticarial vasculitis is suggested.
  • Erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, and rheumatoid factor: Testing should be performed if an underlying rheumatologic disorder is suspected.
  • Stool ova and parasites: Consider this test in patients with GI tract symptoms, an elevated eosinophil count, or a positive travel history.
  • Serum cryoglobulins: Cryoglobulinemia is associated with some forms of cold-induced urticaria.
  • Complement studies: C3 (associated with pulmonary involvement in a subset of patients with urticarial vasculitis), C4 (may be low in hereditary angioedema), and C1-esterase inhibitor (hereditary angioedema) functional assays may be performed.
  • Thyroid function, antithyroid microsomal, and peroxidase antibody titers: Patients with urticaria unresponsive to antihistamines or steroids may have elevated titers, which may respond to thyroid hormone therapy.15 Patients may be euthyroid. Urticaria is also more common in patients with Hashimoto thyroiditis. If antithyroglobulin and antimicrosomal antibodies are present, this supports the diagnosis of chronic immunologic urticaria. The plasma level of thyrotropin helps screen for thyroid dysfunction.
  • CU Index (Chronic Urticaria Index) is available from a few reference laboratories. Patients with a chronic form of urticaria with a positive functional anti-FcεR test result likely have an autoimmune basis for their disease. A positive result does not indicate which autoantibody (anti-IgE, anti-FcεRI, or anti-FcεRII) is present. This test is usually combined with thyroid function, antithyroid microsomal titers, and peroxidase antibody titers.

Other Tests

  • Challenge testing: Challenge testing may be required to exclude a physical urticaria.
  • Skin biopsy: Histologic examination is not necessary for the diagnosis urticaria. A biopsy is necessary for the diagnosis of urticarial vasculitis or a neutrophil-predominant pattern of urticaria that may not respond well to antihistamines. A skin biopsy is indicated when individual urticarial lesions persist for more than 24 hours or have associated petechiae or purpura and in patients with systemic symptoms such as fever, arthralgia, or arthritis. Histological evidence of leukocytoclasia (neutrophilic infiltration with fragmentation of nuclei) is a characteristic feature of urticarial vasculitis. The presence of neutrophils may indicate potential benefit from treatment with dapsone or colchicine.
  • Prick or radioallergosorbent assay testing: This might be useful if contact urticaria is suggested.
  • Skin prick testing: Results may help identify a food allergy, which is a rare cause of chronic urticaria.

Histologic Findings

Dermal edema, blood vessel dilatation, and mild perivascular infiltrate predominantly consisting of monocytes and CD4+ lymphocytes are characteristic findings; some forms exist in which neutrophils predominate.

More on Urticaria, Chronic

Overview: Urticaria, Chronic
Differential Diagnoses & Workup: Urticaria, Chronic
Treatment & Medication: Urticaria, Chronic
Follow-up: Urticaria, Chronic
References
[ CLOSE WINDOW ]

References

  1. Tong LJ, Balakrishnan G, Kochan JP, Kinet JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol. Apr 1997;99(4):461-5. [Medline].

  2. Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. Jun 2009;39(6):777-87. [Medline].

  3. Mathelier-Fusade P. Drug-induced urticarias. Clin Rev Allergy Immunol. Feb 2006;30(1):19-23. [Medline].

  4. Yosipovitch G, Greaves M. Chronic idiopathic urticaria: a "Cinderella" disease with a negative impact on quality of life and health care costs. Arch Dermatol. Jan 2008;144(1):102-3. [Medline].

  5. O'Donnell BF, Lawlor F, Simpson J, Morgan M, Greaves MW. The impact of chronic urticaria on the quality of life. Br J Dermatol. Feb 1997;136(2):197-201. [Medline].

  6. Maurer M, Ortonne JP, Zuberbier T. Chronic urticaria: a patient survey on quality-of-life, treatment usage and doctor-patient relation. Allergy. Apr 2009;64(4):581-8. [Medline].

  7. Tebbe B, Geilen CC, Schulzke JD, Bojarski C, Radenhausen M, Orfanos CE. Helicobacter pylori infection and chronic urticaria. J Am Acad Dermatol. Apr 1996;34(4):685-6. [Medline].

  8. Valsecchi R, Pigatto P. Chronic urticaria and Helicobacter pylori. Acta Derm Venereol. Nov 1998;78(6):440-2. [Medline].

  9. Heymann WR. Chronic urticaria and angioedema associated with thyroid autoimmunity: review and therapeutic implications. J Am Acad Dermatol. Feb 1999;40(2 Pt 1):229-32. [Medline].

  10. Bansal AS, Hayman GR. Graves disease associated with chronic idiopathic urticaria: 2 case reports. J Investig Allergol Clin Immunol. 2009;19(1):54-6. [Medline].

  11. Baty V, Hoen B, Hudziak H, Aghassian C, Jeandel C, Canton P. Schnitzler's syndrome: two case reports and review of the literature. Mayo Clin Proc. Jun 1995;70(6):570-2. [Medline].

  12. Sigurgeirsson B. Skin disease and malignancy. An epidemiological study. Acta Derm Venereol Suppl (Stockh). 1992;178:1-110. [Medline].

  13. Torresani C, Bellafiore S, De Panfilis G. Chronic urticaria is usually associated with fibromyalgia syndrome. Acta Derm Venereol. 2009;89(4):389-92. [Medline].

  14. Kanazawa K, Yaoita H, Tsuda F, Okamoto H. Hepatitis C virus infection in patients with urticaria. J Am Acad Dermatol. Aug 1996;35(2 Pt 1):195-8. [Medline].

  15. Dreyfus DH, Schocket AL, Milgrom H. Steroid-resistant chronic urticaria associated with anti-thyroid microsomal antibodies in a nine-year-old boy. J Pediatr. Apr 1996;128(4):576-8. [Medline].

  16. Morgan M, Khan DA. Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1. Ann Allergy Asthma Immunol. May 2008;100(5):403-11; quiz 412-4, 468. [Medline].

  17. [Guideline] Powell RJ, Du Toit GL, Siddique N, et al. BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy. May 2007;37(5):631-50. [Medline].

  18. Zuberbier T, Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy. Acta Derm Venereol. 2007;87(3):196-205. [Medline].

  19. [Guideline] Grattan CE, Humphreys F. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol. Dec 2007;157(6):1116-23. [Medline].

  20. [Guideline] American Academy of Allergy, Asthma & Immunology. Consultation and referral guidelines citing the evidence: how the allergist-immunologist can help. J Allergy Clin Immunol. Feb 2006;117(2 Suppl Consultation):S495-523. [Medline].

  21. [Guideline] American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol. Mar 2006;96(3 Suppl 2):S1-68. [Medline].

  22. Egan CA, Rallis TM. Treatment of chronic urticaria with ketotifen. Arch Dermatol. Feb 1997;133(2):147-9. [Medline].

  23. Jauregui I, Ferrer M, Montoro J, et al. Antihistamines in the treatment of chronic urticaria. J Investig Allergol Clin Immunol. 2007;17 Suppl 2:41-52. [Medline].

  24. Grob JJ, Auquier P, Dreyfus I, Ortonne JP. How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily vs PRN and quality of life. Allergy. Apr 2009;64(4):605-12. [Medline].

  25. Ellis MH. Successful treatment of chronic urticaria with leukotriene antagonists. J Allergy Clin Immunol. Nov 1998;102(5):876-7. [Medline].

  26. Spector S, Tan RA. Antileukotrienes in chronic urticaria. J Allergy Clin Immunol. Apr 1998;101(4 Pt 1):572. [Medline].

  27. Papadopoulou N, Kalogeromitros D, Staurianeas NG, Tiblalexi D, Theoharides TC. Corticotropin-releasing hormone receptor-1 and histidine decarboxylase expression in chronic urticaria. J Invest Dermatol. Nov 2005;125(5):952-5. [Medline].

  28. Brodell LA, Beck LA. Differential diagnosis of chronic urticaria. Ann Allergy Asthma Immunol. Mar 2008;100(3):181-8; quiz 188-90, 215. [Medline].

  29. Charlesworth EN. Urticaria and angioedema: a clinical spectrum. Ann Allergy Asthma Immunol. Jun 1996;76(6):484-95; quiz 495-9. [Medline].

  30. Grattan CE, Francis DM, Slater NG, Barlow RJ, Greaves MW. Plasmapheresis for severe, unremitting, chronic urticaria. Lancet. May 2 1992;339(8801):1078-80. [Medline].

  31. Greaves M. Chronic urticaria. J Allergy Clin Immunol. Apr 2000;105(4):664-72. [Medline].

  32. Greaves MW, Tan KT. Chronic urticaria: recent advances. Clin Rev Allergy Immunol. Oct 2007;33(1-2):134-43. [Medline].

  33. Haas N, Toppe E, Henz BM. Microscopic morphology of different types of urticaria. Arch Dermatol. Jan 1998;134(1):41-6. [Medline].

  34. Jorizzo JL, Smith EB. The physical urticarias. An update and review. Arch Dermatol. Mar 1982;118(3):194-201. [Medline].

  35. Kaplan AP. Clinical practice. Chronic urticaria and angioedema. N Engl J Med. Jan 17 2002;346(3):175-9. [Medline].

  36. Kennedy MS. Evaluation of chronic eczema and urticaria and angioedema. Immunol Allergy Clin NA. 1999;19:19-33.

  37. Komarow HD, Metcalfe DD. Office-based management of urticaria. Am J Med. May 2008;121(5):379-84. [Medline].

  38. Mahmood T. Physical urticarias. Am Fam Physician. May 1 1994;49(6):1411-4. [Medline].

  39. Schocket AL. Chronic urticaria: pathophysiology and etiology, or the what and why. Allergy Asthma Proc. Mar-Apr 2006;27(2):90-5. [Medline].

  40. Tharp MD. Chronic urticaria: pathophysiology and treatment approaches. J Allergy Clin Immunol. Dec 1996;98(6 Pt 3):S325-30. [Medline].

  41. Weston WL, Badgett JT. Urticaria. Pediatr Rev. Jul 1998;19(7):240-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

chronic urticaria, hives, wheals, allergy, allergic reaction, anaphylaxis, anaphylactoid reaction, angioedema

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), NOVA Southeastern University; Investigator, Hill Top Research, Florida Research Center
Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association
Disclosure: Nothing to disclose.

Medical Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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.

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.