eMedicine Specialties > Pediatrics: General Medicine > Allergy & Immunology

Urticaria: Differential Diagnoses & Workup

Author: Shih-Wen Huang, MD, Medical Director of Allergy Service, Professor, Department of Pediatrics, Division of Immunology and Infectious Diseases, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Jun 15, 2009

Differential Diagnoses

Angioedema
Contact Dermatitis
Juvenile Rheumatoid Arthritis
Pityriasis Rosea
Serum Sickness
Vasculitis and Thrombophlebitis

Other Problems to Be Considered

Cellulitis and erysipelas
Erythema multiforme
Flushing
Guttate psoriasis
Idiopathic scrotal edema of children
Mastocytosis
Melkersson-Rosenthal syndrome
Reactive erythemas
Leukocytoclastic vasculitis: Persistent wheals that remain in the same anatomic place may represent an urticarial leukocytoclastic vasculitis.
Mastocytosis of skin in childhood

Workup

Laboratory Studies

In patients with acute urticaria, laboratory testing is not usually needed unless a particular medical condition is suspected.

  • Skin test or radioallergosorbent test (RAST) for IgE antibody: Perform these tests if the history is suggestive of a rash caused by foods, drugs, insect venom, or latex. This test may be needed to rule out an atopic component and label the urticaria as idiopathic.
  • Bacterial culture with sensitivity: Obtain if the patient has a history of fever and sore throat.
  • Thyroid profile, including antithyroid microsomal antibodies and antithyroglobulin antibody: Obtain if the patient has a strong family history of thyroid disorder or symptoms of hypothyroidism (more frequent in females). However, patients are often euthyroid.
  • C1 esterase inhibitor, C3, and C4 levels: Obtain if the patient has a family history of angioedema or if the child had concomitant history of swallowing or breathing problems with urticaria.
  • Stool for ova and parasites: Obtain if the patient reports ingestion of poorly cooked meats or travel in unsanitary areas.
  • Antinuclear antibody and urinalysis with microscopic examination: Perform these tests if the patient may have arthritis, photosensitivity, or other signs or symptoms of collagen vascular disease. Testing for autoantibody against Fc ε R1α is now available in a few commercial laboratories.
  • CBC count with differential, C-reactive protein, and erythrocyte sedimentation rate: Obtain if the patient's history indicates underlying vasculitis or inflammatory diseases.
  • Cold agglutinins and cryoproteins in patients with cold urticaria: The presence of a cryoglobulin suggests chronic hepatitis or malignancy.
  • Detection of H pylori with chronic idiopathic urticaria may be useful in selected patients.
  • One study reported that the prevalence of positive skin prick testing for food allergens and aeroallergens in patients with chronic urticaria was common but had little clinical relevance.9

Other Tests

  • Physical urticaria can be confirmed with physical challenge tests. These involve the application of the suspected stimuli (heat, pressure, light, vibration, scratching, cold [ice cube]) to the skin. Exercise testing can also be performed. Ice cube test findings are typically negative in patients with familial cold autoinflammatory syndrome.
  • Suspected food allergies can be confirmed or disproved with the use of food diaries. A food or symptom diary for a fixed duration (eg, 2-4 wk) may be helpful. Note all activities in which the patient was involved for 6-8 hours prior to the onset of urticaria. Cases have been reported in which a food or activity (such as jogging) by itself results in no symptoms but together (eg, eating a shrimp cocktail and then jogging) may result in urticaria with or without progression to anaphylaxis.

Procedures

The following guide may be useful:

  • If chronic urticaria (>6 wk) is present in a child who is not well or occurs in an infant, consider systemic disease (eg, systemic lupus erythematosus [SLE], Henoch-Schönlein purpura, dermatomyositis, serum sickness syndrome, occult infection, malignancy) 
  • If the condition is stable but the rash persists for more than 24 hours, consider urticarial vasculitis. Skin biopsy is recommended.
  • If the condition is stable and the rash is migratory for less than 24 hours, consider the associated symptoms, such as the following:
  • If no associated symptoms are noted, consider physical causes (eg, sun exposure, cold, heat, aquagenic, pressure, vibration). 
  • Treat the underlying or associated diseases. Otherwise, offer reassurance, antihistamine therapy, and follow-up.

Histologic Findings

  • Skin biopsy is not usually performed unless the diagnosis is in doubt.
  • Urticaria is associated with dermal edema without epidermal injury.
  • Erythema multiforme, a differential diagnosis, is associated with dermal perivascular mononuclear cell infiltrate and areas of epidermal necrosis.

Staging

The cutaneous biopsy of urticaria lesions may be divided into the following categories as the response to treatment could be different as a study indicated:

  • Class 1 - A mixture of perivascular dermal inflammatory infiltrates composed of lymphocytes, monocytes, and neutrophils, eosinophils, or both
  • Class 2 - Inflammatory infiltrate chiefly composed of neutrophils
  • Class 3 - Inflammatory infiltrate mainly composed of eosinophils

More on Urticaria

Overview: Urticaria
Differential Diagnoses & Workup: Urticaria
Treatment & Medication: Urticaria
Follow-up: Urticaria
Multimedia: Urticaria
References
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Further Reading

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Keywords

urticaria, hives,  anaphylactoid reaction, angioedema, pruritus, chronic urticaria, acute urticaria, papular urticaria, physical urticaria, histamine, transient urticaria, arthralgia, Henoch-Schönlein purpura, thyroid autoimmunity, celiac disease, hypothyroidism, hyperthyroidism, Hashimoto thyroiditis, collagen vascular diseases, rheumatoid arthritis, systemic lupus erythematosus, SLE, dermatomyositis, Behçet disease, inflammatory bowel disease, dental abscess, sinusitis, aphthous stomatitis, cholinergic urticaria, hereditary angioedema, edema

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Contributor Information and Disclosures

Author

Shih-Wen Huang, MD, Medical Director of Allergy Service, Professor, Department of Pediatrics, Division of Immunology and Infectious Diseases, 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.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; 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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing 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.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

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.

 
 
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