History

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)

Complications

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]

Differential Diagnoses

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Media Gallery

Urticaria developed after bites from an imported fire ant.
Urticaria associated with a drug reaction.

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Author

Marla N Diakow, MD Resident Physician, Department of Dermatology, State University of New York Downstate College of Medicine

Marla N Diakow, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jeannette Rachel Jakus, MD, MBA Clinical Assistant Professor, Director of Clinical Research, Assistant Program Director, Department of Dermatology, SUNY Downstate Medical Center; Dermatologist, Brody Dermatology

Jeannette Rachel Jakus, MD, MBA is a member of the following medical societies: American Academy of Dermatology, American Academy of Pediatrics, American Skin Association, Society for Pediatric Dermatology, Women's Dermatologic Society

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

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.

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.