Chronic Urticaria Workup
- Author: Daniel J Hogan, MD; Chief Editor: William D James, MD more...
The information elicited from the history and physical examination is used to direct the selection of laboratory tests.
A complete blood count (CBC) with differential should be done. In patients with parasitic infections, especially in developing countries, or patients experiencing a drug reaction, the eosinophil count may be elevated.
Examination of the stool for ova and parasites should be considered in patients with gastrointestinal (GI) tract symptoms, an elevated eosinophil count, or a positive travel history. The absence of blood eosinophilia may render stool examination for ova unnecessary.
The erythrocyte sedimentation rate (ESR) may be elevated in persons with urticarial vasculitis. Antinuclear antibody (ANA) titers are indicated when urticarial vasculitis is suspected. ESR, C-reactive protein (CRP), ANA, and rheumatoid factor (RF) testing should be performed if an underlying rheumatologic disorder is suspected.
Hepatitis B and C titers may be helpful. 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.
Serum cryoglobulin and complement assays may be useful. Cryoglobulinemia is associated with some forms of cold-induced urticaria. C3 (associated with pulmonary involvement in a subset of patients with urticarial vasculitis), C4 (sometimes low in hereditary angioedema), and C1-esterase inhibitor (associated with hereditary angioedema) functional assays may be performed.
Thyroid function testing and antithyroid microsomal and peroxidase antibody titers may also be useful. Patients with urticaria unresponsive to antihistamines or steroids may have elevated titers, which may respond to thyroid hormone therapy. Patients may be euthyroid. Urticaria is also more common in patients with Hashimoto thyroiditis. The presence of antithyroglobulin and antimicrosomal antibodies supports the diagnosis of chronic immunologic urticaria. The plasma thyrotropin level helps screen for thyroid dysfunction.
The Chronic Urticaria (CU) Index is available from a few reference laboratories. Patients with a chronic form of urticaria who have a positive functional test result for autoantibody to the Fc receptor of immunoglobulin E (IgE)—that is, anti-FcεR—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 testing, antithyroid microsomal titers, and peroxidase antibody titers.
Other tests that may be required include challenge testing. Testing to cold, pressure, heat, ultraviolet light, and visible light may be required to exclude a physical urticaria.
Prick or radioallergosorbent assay testing may be useful if contact urticaria is suggested. Skin prick test results may help identify a food allergy, which is a rare cause of chronic urticaria.
Although histologic examination is not necessary for the diagnosis of urticaria, a skin 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 for patients in whom individual urticarial lesions persist for more than 24 hours or are associated with petechiae or purpura and for patients with systemic symptoms such as fever, arthralgia, or arthritis.
Characteristic histologic findings include dermal edema, blood vessel dilatation, and a mild perivascular infiltrate predominantly consisting of monocytes and CD4+ lymphocytes; some forms exist in which neutrophils predominate.
Histologic 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.
Dreyfus DH, Schocket AL, Milgrom H. Steroid-resistant chronic urticaria associated with anti-thyroid microsomal antibodies in a nine-year-old boy. J Pediatr. 1996 Apr. 128(4):576-8. [Medline].
Ellis MH. Successful treatment of chronic urticaria with leukotriene antagonists. J Allergy Clin Immunol. 1998 Nov. 102(5):876-7. [Medline].
Spector S, Tan RA. Antileukotrienes in chronic urticaria. J Allergy Clin Immunol. 1998 Apr. 101(4 Pt 1):572. [Medline].
[Guideline] Powell RJ, Du Toit GL, Siddique N, et al. BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy. 2007 May. 37(5):631-50. [Medline].
Morgan M, Khan DA. Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1. Ann Allergy Asthma Immunol. 2008 May. 100(5):403-11; quiz 412-4, 468. [Medline].
Tong LJ, Balakrishnan G, Kochan JP, Kinet JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol. 1997 Apr. 99(4):461-5. [Medline].
Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. 2009 Jun. 39(6):777-87. [Medline].
Bossi F, Frossi B, Radillo O, et al. Mast cells are critically involved in serum-mediated vascular leakage in chronic urticaria beyond high-affinity IgE receptor stimulation. Allergy. 2011 Dec. 66(12):1538-1545. [Medline].
Mathelier-Fusade P. Drug-induced urticarias. Clin Rev Allergy Immunol. 2006 Feb. 30(1):19-23. [Medline].
Ventura MT, Napolitano S, Menga R, Cecere R, Asero R. Anisakis simplex Hypersensitivity Is Associated with Chronic Urticaria in Endemic Areas. Int Arch Allergy Immunol. 2013. 160(3):297-300. [Medline].
Tebbe B, Geilen CC, Schulzke JD, Bojarski C, Radenhausen M, Orfanos CE. Helicobacter pylori infection and chronic urticaria. J Am Acad Dermatol. 1996 Apr. 34(4):685-6. [Medline].
Valsecchi R, Pigatto P. Chronic urticaria and Helicobacter pylori. Acta Derm Venereol. 1998 Nov. 78(6):440-2. [Medline].
Heymann WR. Chronic urticaria and angioedema associated with thyroid autoimmunity: review and therapeutic implications. J Am Acad Dermatol. 1999 Feb. 40(2 Pt 1):229-32. [Medline].
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].
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. 1995 Jun. 70(6):570-2. [Medline].
Sigurgeirsson B. Skin disease and malignancy. An epidemiological study. Acta Derm Venereol Suppl (Stockh). 1992. 178:1-110. [Medline].
Torresani C, Bellafiore S, De Panfilis G. Chronic urticaria is usually associated with fibromyalgia syndrome. Acta Derm Venereol. 2009. 89(4):389-92. [Medline].
Yosipovitch G, Greaves M. Chronic idiopathic urticaria: a "Cinderella" disease with a negative impact on quality of life and health care costs. Arch Dermatol. 2008 Jan. 144(1):102-3. [Medline].
O'Donnell BF, Lawlor F, Simpson J, Morgan M, Greaves MW. The impact of chronic urticaria on the quality of life. Br J Dermatol. 1997 Feb. 136(2):197-201. [Medline].
Maurer M, Ortonne JP, Zuberbier T. Chronic urticaria: a patient survey on quality-of-life, treatment usage and doctor-patient relation. Allergy. 2009 Apr. 64(4):581-8. [Medline].
Brodell LA, Beck LA. Differential diagnosis of chronic urticaria. Ann Allergy Asthma Immunol. 2008 Mar. 100(3):181-8; quiz 188-90, 215. [Medline].
Kanazawa K, Yaoita H, Tsuda F, Okamoto H. Hepatitis C virus infection in patients with urticaria. J Am Acad Dermatol. 1996 Aug. 35(2 Pt 1):195-8. [Medline].
Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau A, et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy. 2009 Oct. 64(10):1417-26. [Medline].
[Guideline] Powell RJ, Leech SC, Till S, Huber PA, Nasser SM, Clark AT. BSACI guideline for the management of chronic urticaria and angioedema. Clin Exp Allergy. 2015 Mar. 45(3):547-65. [Medline].
Egan CA, Rallis TM. Treatment of chronic urticaria with ketotifen. Arch Dermatol. 1997 Feb. 133(2):147-9. [Medline].
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].
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. 2009 Apr. 64(4):605-12. [Medline].
Staevska M, Popov TA, Kralimarkova T, Lazarova C, Kraeva S, Popova D, et al. The effectiveness of levocetirizine and desloratadine in up to 4 times conventional doses in difficult-to-treat urticaria. J Allergy Clin Immunol. 2010 Mar. 125(3):676-82. [Medline].
Maurer M, Rosén K, Hsieh HJ, Saini S, Grattan C, Gimenéz-Arnau A, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013 Mar 7. 368(10):924-35. [Medline].
Brooks M. FDA OKs Omalizumab (Xolair) for Chronic Hives. Medscape Medical News. Mar 21 2014. [Full Text].
Rorie A, Goldner WS, Lyden E, Poole JA. Beneficial role for supplemental vitamin D3 treatment in chronic urticaria: a randomized study. Ann Allergy Asthma Immunol. 2014 Feb 5. [Medline].
Janeczko LL. High-dose vitamin D supplements may benefit people with chronic urticaria. Reuters Health Information. February 24, 2014. [Full Text].