Acute Urticaria Differential Diagnoses

  • Author: Henry K Wong, MD, PhD; Chief Editor: Michael A Kaliner, MD   more...
 
Updated: Jun 14, 2011
 
 

Diagnostic Considerations

In 50% of patients with acute urticaria, a specific etiology can be identified. Brief episodes of urticaria can be associated temporally with identifiable causes, and the method of exposure (ie, direct contact, oral or IV routes) is usually known.

Urticaria may be confused with a variety of other dermatologic diseases that are similar in appearance and are pruritic, including atopic dermatitis (eczema), maculopapular drug eruptions, contact dermatitis, insect bites, erythema multiforme, pityriasis rosea, and others. Usually, however, the experienced clinician is able to distinguish these conditions from urticaria because of the lesions' distinctive appearance, the fact that they are intensely pruritic, and because the lesions blanch completely with pressure (see Clinical Presentation).[1]

In chronic urticaria, which persists for longer than 6 weeks, a cause is difficult to identify, despite perhaps even exhaustive efforts. This is known as chronic idiopathic urticaria,[2] although most of these cases are chronic autoimmune urticaria, as defined by a positive RAST result.[8]

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Henry K Wong, MD, PhD  Associate Professor of Dermatology, Ohio State University College of Medicine

Henry K Wong, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, International Society for Cutaneous Lymphomas, and Society for Investigative Dermatology

Disclosure: EISAI Consulting fee Speaking and teaching; Amgen Consulting fee Speaking and teaching; Abbott Labs Honoraria Speaking and teaching; Centocor Honoraria Speaking and teaching; Celgene Grant/research funds None

Coauthor(s)

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Consulting fee Consulting; Celgene Honoraria Safety Monitoring Committee; GSK - Glaxo Smith Kline Consulting fee Consulting; TenXBioPharma Consulting fee Safety Monitoring Committee

Kevin P Connelly, DO  Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Steven A Conrad, MD, PhD  Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Shih-Wen Huang, MD  Professor Emeritus, Pulmonology and Allergy, Department of Pediatrics University of Florida College of Medicine

Shih-Wen Huang, MD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Nothing to disclose.

Harumi Jyonouchi, MD  Associate Professor, Division of Pulmonary Allergy/Immunology and Infectious Diseases, Department of Pediatrics, UMDNJ-New Jersey Medical School

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Mucosal Immunology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

M Scott Linscott, MD, FACEP  Professor, Division of Emergency Medicine, Professor of Surgery (Clinical), University of Utah School of Medicine

M Scott Linscott, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Utah Medical Association

Disclosure: Nothing to disclose.

Umer Najib, MD  Clinical Research Fellow, Department of Medicine, Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center

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.

Javed Sheikh, MD  Assistant Professor of Medicine, Harvard Medical School; Clinical Director, Division of Allergy and Inflammation, Clinical Director, Center for Eosinophilic Disorders, Beth Israel Deaconess Medical Center

Javed Sheikh, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American College of Allergy, Asthma and Immunology

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen C Dreskin, MD, PhD  Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, University of Colorado Health Sciences Center

Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology

Disclosure: Genentech Consulting fee Consulting; American Health Insurance Plans Consulting fee Consulting; Johns Hopkins School of Public Health Consulting fee Consulting; Array BioPharma Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Chief Editor

Michael A Kaliner, MD  Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy

Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians

Disclosure: Alcon Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering/Merck Consulting fee Consulting; Teva Consulting fee Consulting; Meda Honoraria Speaking and teaching; Ista Consulting

References

  1. Frigas E, Park MA. Acute urticaria and angioedema: diagnostic and treatment considerations. Am J Clin Dermatol. 2009;10(4):239-50. [Medline].

  2. Hide M, Francis DM, Grattan CE, Hakimi J, Kochan JP, Greaves MW. Autoantibodies against the high-affinity IgE receptor as a cause of histamine release in chronic urticaria. N Engl J Med. Jun 3 1993;328(22):1599-604. [Medline].

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

  4. Kaplan AP, Joseph K, Maykut RJ, Geba GP, Zeldin RK. Treatment of chronic autoimmune urticaria with omalizumab. J Allergy Clin Immunol. Sep 2008;122(3):569-73. [Medline].

  5. Viola M, Quaratino D, Gaeta F, Rumi G, Caruso C, Romano A. Cross-reactive reactions to nonsteroidal anti-inflammatory drugs. Curr Pharm Des. 2008;14(27):2826-32. [Medline].

  6. Kalogeromitros D, Kempuraj D, Katsarou-Katsari A, Gregoriou S, Makris M, Boucher W, et al. Theophylline as "add-on" therapy in patients with delayed pressure urticaria: a prospective self-controlled study. Int J Immunopathol Pharmacol. Jul-Sep 2005;18(3):595-602. [Medline].

  7. [Guideline] Magerl M, Borzova E, Giménez-Arnau A, Grattan CE, Lawlor F, Mathelier-Fusade P, et al. The definition and diagnostic testing of physical and cholinergic urticarias--EAACI/GA2LEN/EDF/UNEV consensus panel recommendations. Allergy. Dec 2009;64(12):1715-21. [Medline].

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

  9. Cardinale F, Mangini F, Berardi M, Sterpeta Loffredo M, Chinellato I, Dellino A, et al. [Intolerance to food additives: an update]. Minerva Pediatr. Dec 2008;60(6):1401-9. [Medline].

  10. Sheikh J. Advances in the treatment of chronic urticaria. Immunol Allergy Clin North Am. May 2004;24(2):317-34, vii-viii. [Medline].

  11. Schuller DE. Acute urticaria in children: causes and an aggressive diagnostic approach. Postgrad Med. Aug 1982;72(2):179-85. [Medline].

  12. Wedi B, Raap U, Wieczorek D, Kapp A. Urticaria and infections. Allergy Asthma Clin Immunol. Dec 1 2009;5(1):10. [Medline]. [Full Text].

  13. Kaplan AP. What the first 10,000 patients with chronic urticaria have taught me: a personal journey. J Allergy Clin Immunol. Mar 2009;123(3):713-7. [Medline].

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

  15. Ozkaya-Bayazit E, Demir K, Ozgüroglu E, Kaymakoglu S, Ozarmagan G. Helicobacter pylori eradication in patients with chronic urticaria. Arch Dermatol. Sep 1998;134(9):1165-6. [Medline].

  16. Di Campli C, Gasbarrini A, Nucera E, Franceschi F, Ojetti V, Sanz Torre E, et al. Beneficial effects of Helicobacter pylori eradication on idiopathic chronic urticaria. Dig Dis Sci. Jun 1998;43(6):1226-9. [Medline].

  17. Schnyder B, Helbling A, Pichler WJ. Chronic idiopathic urticaria: natural course and association with Helicobacter pylori infection. Int Arch Allergy Immunol. May 1999;119(1):60-3. [Medline].

  18. Leznoff A, Josse RG, Denburg J, Dolovich J. Association of chronic urticaria and angioedema with thyroid autoimmunity. Arch Dermatol. Aug 1983;119(8):636-40. [Medline].

  19. Rose RF, Bhushan M, King CM, Rhodes LE. Solar angioedema: an uncommonly recognized condition?. Photodermatol Photoimmunol Photomed. Oct 2005;21(5):226-8. [Medline].

  20. Botto NC, Warshaw EM. Solar urticaria. J Am Acad Dermatol. Dec 2008;59(6):909-20; quiz 921-2. [Medline].

  21. Kaplan AP. Urticaria angioedema. In: Adkinson NFY Jr, Busse WW, Bochner BS, Holgate ST, Simons FER, eds. Allergy: Principles and Practice. Philadelphia, Pa: Mosby; 2003:1537-58.

  22. Sackesen C, Sekerel BE, Orhan F, Kocabas CN, Tuncer A, Adalioglu G. The etiology of different forms of urticaria in childhood. Pediatr Dermatol. Mar-Apr 2004;21(2):102-8. [Medline].

  23. Kaplan AP. Chronic urticaria and angioedema. N Engl J Med. 2002;Vol. 346:175-9.

  24. Beltrani VS. Urticaria and angioedema. Dermatol Clin. Jan 1996;14(1):171-198. [Medline].

  25. Soter NA. Acute and chronic urticaria and angioedema. J Am Acad Dermatol. Jul 1991;25(1 Pt 2):146-54. [Medline].

  26. Varadarajulu S. Urticaria and angioedema. Controlling acute episodes, coping with chronic cases. Postgrad Med. May 2005;117(5):25-31. [Medline].

  27. 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].

  28. Zuberbier T, Iffländer J, Semmler C, Henz BM. Acute urticaria: clinical aspects and therapeutic responsiveness. Acta Derm Venereol. Jul 1996;76(4):295-7. [Medline].

  29. Davis MD, Brewer JD. Urticarial vasculitis and hypocomplementemic urticarial vasculitis syndrome. Immunol Allergy Clin North Am. May 2004;24(2):183-213, vi. [Medline].

  30. Kaplan AP. Urticaria and angioedema. In: Middleton E, Reed CE, Ellis EF, et al, eds. Allergy: Principles and Practices. St. Louis, Mo: Mosby-Year Book; 1998:1104-18.

  31. Sheila MA, Stephen CD. Urticaria. Prim Care Clin Office Pract. 2008;Vol. 35:141-57.

  32. Charlesworth EN. Urticaria and angioedema: a clinical spectrum. Ann Allergy Asthma Immunol Jun. 1996;76(6):484-95.

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

  34. Hirschmann JV, Lawlor F, English JS, Louback JB, Winkelmann RK, Greaves MW. Cholinergic urticaria. A clinical and histologic study. Arch Dermatol. Apr 1987;123(4):462-7. [Medline].

  35. Wong RC, Fairley JA, Ellis CN. Dermographism: a review. J Am Acad Dermatol. Oct 1984;11(4 Pt 1):643-52. [Medline].

  36. Dibbern DA Jr. Urticaria: selected highlights and recent advances. Med Clin North Am. Jan 2006;90(1):187-209. [Medline].

  37. Dibbern DA Jr, Dreskin SC. Urticaria and angioedema: an overview. Immunol Allergy Clin North Am. May 2004;24(2):141-62, v. [Medline].

  38. [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].

  39. Beltrani VS. Urticaria: reassessed. Allergy Asthma Proc. May-Jun 2004;25(3):143-9. [Medline].

  40. Mortureux P, Léauté-Labrèze C, Legrain-Lifermann V, Lamireau T, Sarlangue J, Taïeb A. Acute urticaria in infancy and early childhood: a prospective study. Arch Dermatol. Mar 1998;134(3):319-23. [Medline].

  41. Irinyi B, Széles G, Gyimesi E, Tumpek J, Herédi E, Dimitrios G, et al. Clinical and laboratory examinations in the subgroups of chronic urticaria. Int Arch Allergy Immunol. 2007;144(3):217-25. [Medline].

  42. [Guideline] 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. Oct 2009;64(10):1417-26. [Medline]. [Full Text].

  43. Brown NA, Carter JD. Urticarial vasculitis. Curr Rheumatol Rep. Aug 2007;9(4):312-9. [Medline].

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

  45. [Guideline] Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau AM, et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy. Oct 2009;64(10):1427-43. [Medline]. [Full Text].

  46. Slater JW, Zechnich AD, Haxby DG. Second-generation antihistamines: a comparative review. Drugs. Jan 1999;57(1):31-47. [Medline].

  47. Breneman DL. Cetirizine versus hydroxyzine and placebo in chronic idiopathic urticaria. Ann Pharmacother. Oct 1996;30(10):1075-9. [Medline].

  48. Bleehen SS, Thomas SE, Greaves MW, Newton J, Kennedy CT, Hindley F, et al. Cimetidine and chlorpheniramine in the treatment of chronic idiopathic urticaria: a multi-centre randomized double-blind study. Br J Dermatol. Jul 1987;117(1):81-8. [Medline].

  49. Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. Nov 2000;36(5):462-8. [Medline].

  50. Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med. Nov 1995;26(5):547-51. [Medline].

  51. Bluestein HM, Hoover TA, Banerji AS, Camargo CA Jr, Reshef A, Herscu P. Angiotensin-converting enzyme inhibitor-induced angioedema in a community hospital emergency department. Ann Allergy Asthma Immunol. Dec 2009;103(6):502-7. [Medline].

  52. Grattan CE, O'Donnell BF, Francis DM, Niimi N, Barlow RJ, Seed PT, et al. Randomized double-blind study of cyclosporin in chronic 'idiopathic' urticaria. Br J Dermatol. Aug 2000;143(2):365-72. [Medline].

  53. Vena GA, Cassano N, Colombo D, Peruzzi E, Pigatto P. Cyclosporine in chronic idiopathic urticaria: a double-blind, randomized, placebo-controlled trial. J Am Acad Dermatol. Oct 2006;55(4):705-9. [Medline].

  54. O'Donnell BF, Barr RM, Black AK, Francis DM, Kermani F, Niimi N, et al. Intravenous immunoglobulin in autoimmune chronic urticaria. Br J Dermatol. Jan 1998;138(1):101-6. [Medline].

  55. 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].

  56. Werni R, Schwarz T, Gschnait F. Colchicine treatment of urticarial vasculitis. Dermatologica. 1986;172(1):36-40. [Medline].

  57. Ruzicka T, Goerz G. Systemic lupus erythematosus and vasculitic urticaria. Effect of dapsone and complement levels. Dermatologica. 1981;162(3):203-5. [Medline].

  58. Nettis E, Dambra P, D'Oronzio L, Loria MP, Ferrannini A, Tursi A. Comparison of montelukast and fexofenadine for chronic idiopathic urticaria. Arch Dermatol. Jan 2001;137(1):99-100. [Medline].

  59. Asero R, Tedeschi A, Lorini M. Leukotriene receptor antagonists in chronic urticaria. Allergy. May 2001;56(5):456-7. [Medline].

  60. Gober LM, Sterba PM, Eckman JA, Saini SS. Effect of anti-IgE (omalizumab) in chronic idiopathic urticaria (CIU) patients. J Allergy Clin Immunol. 2008;121(2 supp 1):S147. [Full Text].

  61. Wong JT, Nagy CS, Krinzman SJ, Maclean JA, Bloch KJ. Rapid oral challenge-desensitization for patients with aspirin-related urticaria-angioedema. J Allergy Clin Immunol. May 2000;105(5):997-1001. [Medline].

  62. Grattan CE. Aspirin sensitivity and urticaria. Clin Exp Dermatol. Mar 2003;28(2):123-7. [Medline].

  63. Díaz Jara M, Pérez Montero A, Gracia Bara MT, Cabrerizo S, Zapatero L, Martínez Molero MI. Allergic reactions due to ibuprofen in children. Pediatr Dermatol. Jan-Feb 2001;18(1):66-7. [Medline].

  64. Lancey RA, Schaefer OP, McCormick MJ. Coronary artery bypass grafting and aortic valve replacement with cold cardioplegia in a patient with cold-induced urticaria. Ann Allergy Asthma Immunol. Feb 2004;92(2):273-5. [Medline].

  65. Simonart T, Askenasi R, Lheureux P. Particularities of urticaria seen in the emergency department. Eur J Emerg Med. Jun 1994;1(2):80-2. [Medline].

  66. Simons FE. Anaphylaxis. J Allergy Clin Immunol. Feb 2010;125(2 Suppl 2):S161-81. [Medline].

  67. Najib U, Sheikh J. An update on acute and chronic urticaria for the primary care provider. Postgrad Med. Jan 2009;121(1):141-51. [Medline].

  68. Poonawalla T, Kelly B. Urticaria : a review. Am J Clin Dermatol. 2009;10(1):9-21. [Medline].

  69. Simons FE. H1-Antihistamines: more relevant than ever in the treatment of allergic disorders. J Allergy Clin Immunol. Oct 2003;112(4 Suppl):S42-52. [Medline].

  70. Bains SN, Hsieh FH. Current approaches to the diagnosis and treatment of systemic mastocytosis. Ann Allergy Asthma Immunol. Jan 2010;104(1):1-10; quiz 10-2, 41. [Medline].

 
Previous
Next
 
Urticaria associated with a drug reaction.
Urticaria developed after bites from an imported fire ant.
Local urticaria on a patient with latex allergy who was touched with a latex glove.
Urticaria from drug reaction.
Photograph of dermographism.
Pressure urticaria (dermatographia) developed after strokes.
Acute urticaria associated with dermatographism.
Urticaria associated with acute group A beta-hemolytic streptococci infection.
Acute urticaria in a toddler affecting the face. Likely cause is postviral syndrome.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
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.