Chronic Urticaria Clinical Presentation

Updated: Oct 13, 2021
  • Author: Marla N Diakow, MD; Chief Editor: William D James, MD  more...
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An important historical characteristic of urticarial lesions is their transient nature. An individual wheal typically lasts for less than 24 hours. Pruritus is the most common associated symptom. If lesions last longer and are associated with pigmentary changes or symptoms (eg, pain or burning), consider performing a biopsy to exclude urticarial vasculitis.

In persons with physical urticaria, individual wheals last less than 1 hour. The exception to this rule is delayed pressure urticaria, in which individual wheals last at least 8-48 hours, especially on the palms and soles.


Physical Examination

The typical lesion of urticaria is a pale-to-red, well-demarcated papule or plaque. Lesions may be round, oval, annular, arcuate, serpiginous, or generalized. They resolve without postinflammatory pigmentary changes or scaling. Examination should focus on the following:

  • Characteristics of primary lesions: These are edematous, erythematous papules or plaques with a pale center (wheal) and surrounding erythema (flare)

  • Distribution of lesions: Lesions can be localized or generalized

  • Color of lesions: Depending on background skin color, lesions may be pale to red

  • Differentiation of urticaria types: Stroking the skin firmly tests for symptomatic dermatographism; exercise testing can confirm cholinergic urticaria; application of a melting ice cube in a plastic bag for 5 minutes may be used to test for cold urticaria (10 min after removal the ice cube wheal response is assessed)



Unlike angioedema, which may affect the airway, urticaria is not a life-threatening disease. As a rule, lesions of urticaria should resolve without complications; however, patients with severe pruritus may develop scratch purpura and excoriations that may become secondarily infected. Additionally, antihistamine use may cause somnolence and dry mouth. Finally, severe chronic urticaria has been shown to have a negative impact on the quality of life of affected patients. [27]

In a study by O’Donnell et al, the effects of chronic urticaria on the activities of daily living, social interactions, rest, and work were found to be similar to those experienced by patients with heart disease. [28] These findings were confirmed by a subsequent French-German study, which suggested that physicians should discuss the emotional aspect of chronic urticaria with patients if time allows. [29]