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Chronic Urticaria Workup

  • Author: Daniel J Hogan, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 02, 2015
 

Laboratory Studies

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.[22]

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.[1] 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.

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Other Tests

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.[23]

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.

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Histologic Findings

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.

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Contributor Information and Disclosures
Author

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; 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, Canadian Dermatology Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

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.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-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.

Dina D Strachan, MD Assistant Clinical Professor, Department of Dermatology, St Vincent's Medical Center

Dina Strachan, MD is a member of the following medical societies: American Academy of Dermatology

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.

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