Approach Considerations

Acute urticaria is generally diagnosed based on a detailed patient history and physical examination (see Clinical Presentation),^{[2, 3, 4]}and laboratory studies generally are not indicated. In pediatric cases, screening for streptococcal antigen may be indicated.^[18]The patient's history and physical examination should direct any diagnostic studies.^{[44, 2, 45]}

Imaging studies generally are not indicated unless a specific finding on clinical examination or history suggests an underlying etiology that may warrant further diagnostic studies.^[46]

The 2022 EAACI/GA2LEN/EDF/WAO diagnosis guideline recommends using the urticaria activity score (UAS) proposed in the previous version of the guideline to measure disease severity and monitor treatment results in daily practice. The UAS assigns a score from 0 (no disease activity) to 3 (intense activity) for each of the 2 key urticaria symptoms, wheals and pruritus. The sum of the scores represents disease severity on a scale from 0 (minimum) to 6 (maximum).^[5]

Skin Tests

Selected allergy tests can be performed if food allergy or stinging insect hypersensitivity is suspected. This process may be helpful for some cases of acute urticaria, but these studies are rarely helpful in the evaluation of chronic urticaria.^[20]However, they may be needed to rule out an atopic component and label the urticaria as idiopathic.

Skin tests or radioallergosorbent assay test (RAST) (specific IgE) can be performed to detect hypersensitivity to a limited number of antibiotics. Testing for pollen or other inhalants is generally not helpful, unless a severe allergy may be causing the urticaria, such as a severe allergy to pollens, cats, or latex (these may manifest as contact urticaria).

Routine allergy testing with a large battery of screening tests is not recommended. A few research centers perform an autologous serum skin test, but it is currently not a well-established procedure.

Physical Challenge Tests

Physical urticaria can be confirmed with physical challenge tests. These involve the application of the suspected stimuli (heat, pressure, light, vibration, scratching [dermographism], cold [ice cube]) to the skin. Exercise testing can also be performed to diagnose cholinergic urticaria. Ice cube test findings are typically negative in patients with familial cold autoinflammatory syndrome. With the exception of testing for dermographism, these tests are usually performed only by specialty centers.

Skin Biopsy

A diagnostic skin biopsy is not helpful but should be considered if lesions do not resolve in patients suspected of having urticarial vasculitis (eg, in patients who present with features such as fever, painful lesions, arthralgia, elevated erythroid segmentation rate, lesions that last 24 hours or longer, or lesions that resolve with residual petechiae or purpura).^{[35, 47]}

Histologic Findings

The histologic findings of acute urticaria are not dramatic. No epidermal change is present. Acute urticaria demonstrates intravascular margination of neutrophils. Later lesions demonstrate diapedesis of neutrophils through the vessel wall in the absence of karyorrhexis. Late lesions demonstrate intravascular, perivascular, and interstitial neutrophils with little to no karyorrhexis. A moderate number of eosinophils may be present.^[48]

Treatment & Management

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Media Gallery

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.

of 9

Author

Henry K Wong, MD, PhD Professor and Chairman, Department of Dermatology, University of Arkansas for Medical Sciences College of Medicine

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Seattle Genetics, Actillion, Celgene, Kyowa-Kirin<br/>Serve(d) as a speaker or a member of a speakers bureau for: Amgen<br/>Received income in an amount equal to or greater than $250 from: Celgene<br/>Received honoraria from Amgen for speaking and teaching; Received grant/ Received grant/research funds from Celgene for none; Received grant/research funds from Abbott Labs for independent contractor; Received grant/research funds from Amgen for none; Received honoraria from Seattle Genetics for consulting. for: Actelion-Advisory board, grants;Seattle Genetics - Advisory board.

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; 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, Association of American Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, American College of Allergy, Asthma and Immunology

Disclosure: Received grant/research funds from Genentech for other.

Acknowledgements

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