Sections

Urticaria

Workup

Approach Considerations

A thorough medical history, review of systems, and physical examination are warranted in order to exclude chronic autoimmune disease or underlying malignancy such as lymphoma.

Laboratory Studies

For acute urticaria, laboratory studies generally are not indicated. The patient's history and physical examination should direct any diagnostic studies.

For chronic or recurrent urticaria, basic laboratory studies should be prompted by signs and symptoms but may include a CBC count, erythrocyte sedimentation rate, thyroid-stimulating hormone value, and an antinuclear antibody level looking for possible causes of the urticaria.^[4]There may be benefit to radioallergosorbent, scratch, or patch testing.^[37]

Imaging Studies

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.^[4]

Procedures

Biopsy is generally not required for the diagnosis of classic urticaria (hives). However, if urticarial vasculitis is suspected (urticaria lasting >24 h with residual dyspigmentation; significant pain as well as pruritus), a punch biopsy of the lesion should be performed and sent to the pathology laboratory to look for leukocytoclastic vasculitis.^[9]

Treatment & Management

Frigas E, Park MA. Acute urticaria and angioedema: diagnostic and treatment considerations. Am J Clin Dermatol. 2009. 10(4):239-50. [Medline].
Poonawalla T, Kelly B. Urticaria : a review. Am J Clin Dermatol. 2009. 10(1):9-21. [Medline].
Ribeiro F, Sousa N, Carrapatoso I, Segorbe Luís A. Urticaria after ingestion of alcoholic beverages. J Investig Allergol Clin Immunol. 2014. 24(2):122-3. [Medline].
Irinyi B, Szeles G, Gyimesi E, Tumpek J, Heredi 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].
Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010 Feb. 125(2 Suppl 2):S161-81. [Medline].
[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. 2009 Oct. 64(10):1427-43. [Medline].
Sharma M, Bennett C, Carter B, Cohen SN. H1-antihistamines for chronic spontaneous urticaria: An abridged Cochrane Systematic Review. J Am Acad Dermatol. 2015 Aug 4. [Medline].
Bernstein JA, Lang DM, Khan DA, et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014 May. 133(5):1270-7. [Medline].
Brown NA, Carter JD. Urticarial vasculitis. Curr Rheumatol Rep. 2007 Aug. 9(4):312-9. [Medline].
Najib U, Sheikh J. An update on acute and chronic urticaria for the primary care provider. Postgrad Med. 2009 Jan. 121(1):141-51. [Medline].
Viegas LP, Ferreira MB, Kaplan AP. The maddening itch: an approach to chronic urticaria. J Investig Allergol Clin Immunol. 2014. 24(1):1-5. [Medline].
Darlenski R, Kazandjieva J, Zuberbier T, Tsankov N. Chronic urticaria as a systemic disease. Clin Dermatol. 2014 May-Jun. 32(3):420-3. [Medline].
Bolognia JL, Jorizzo JL, Shaffer JV. Dermatology. 3rd ed. Philadelphia, Pa: Elsevier Saunders; 2012.
Zuberbier T, Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy. Acta Derm Venereol. 2007. 87(3):196-205. [Medline].
Kaplan AP, Joseph K, Maykut RJ, Geba GP, Zeldin RK. Treatment of chronic autoimmune urticaria with omalizumab. J Allergy Clin Immunol. 2008 Sep. 122(3):569-73. [Medline].
Rather S, Keen A, Sajad P. Serum Levels of 25-hydroxyvitamin D in Chronic Urticaria and its Association with Disease Activity: A Case Control Study. Indian Dermatol Online J. 2018 May-Jun. 9 (3):170-174. [Medline].
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].
[Guideline] Magerl M, Borzova E, Gimrnez-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. 2009 Dec. 64(12):1715-21. [Medline].
Kasperska-Zajac A, Jasinska T, Grzanka A, Kowalik-Sztylc A. Markers of systemic inflammation in delayed pressure urticaria. Int J Dermatol. 2012 Nov 1. [Medline].
Tong LJ, Balakrishnan G, Kochan JP, Kinét JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol. 1997 Apr. 99(4):461-5. [Medline].
Konstantinou GN, Asero R, Maurer M, Sabroe RA, Schmid-Grendelmeier P, Grattan CE. EAACI/GA(2)LEN task force consensus report: the autologous serum skin test in urticaria. Allergy. 2009 Sep. 64(9):1256-68. [Medline].
Philpott H, Kette F, Hissaria P, Gillis D, Smith W. Chronic urticaria: the autoimmune paradigm. Intern Med J. 2008 Nov. 38(11):852-7. [Medline].
Konstantinou GN, Asero R, Ferrer M, Knol EF, Maurer M, Raap U, et al. EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria. Allergy. 2012 Nov 15. [Medline].
Hossler EW. Caterpillars and moths: Part I. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol. 2010 Jan. 62(1):1-10; quiz 11-2. [Medline].
Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. 2009 Jun. 39(6):777-87. [Medline].
Vonakis BM, Saini SS. New concepts in chronic urticaria. Curr Opin Immunol. 2008 Dec. 20(6):709-16. [Medline].
Guldbakke KK, Khachemoune A. Etiology, classification, and treatment of urticaria. Cutis. 2007 Jan. 79(1):41-9. [Medline].
Bains SN, Hsieh FH. Current approaches to the diagnosis and treatment of systemic mastocytosis. Ann Allergy Asthma Immunol. 2010 Jan. 104(1):1-10; quiz 10-2, 41. [Medline].
Goldfinger S. The inherited autoinflammatory syndrome: a decade of discovery. Trans Am Clin Climatol Assoc. 2009. 120:413-8. [Medline]. [Full Text].
Nichols KM, Cook-Bolden FE. Allergic skin disease: major highlights and recent advances. Med Clin North Am. 2009 Nov. 93(6):1211-24. [Medline].
Brodell LA, Beck LA. Differential diagnosis of chronic urticaria. Ann Allergy Asthma Immunol. 2008 Mar. 100(3):181-8; quiz 188-90, 215. [Medline].
Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, et al. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J. 2012 Nov. 5 (11):125-47. [Medline].
Sathishkumar D, Al-Abadi E, Nicklaus-Wollenteit I, Moss C, Hawkins PN, Gach JE. Early-onset urticaria: a marker of cryopyrin-associated periodic syndrome. Clin Exp Dermatol. 2017 May 17. [Medline].
Casale TB. Biologics and biomarkers for asthma, urticaria, and nasal polyposis. J Allergy Clin Immunol. 2017 May. 139 (5):1411-1421. [Medline].
Botto NC, Warshaw EM. Solar urticaria. J Am Acad Dermatol. 2008 Dec. 59(6):909-20; quiz 921-2. [Medline].
[Guideline] Powell RJ, Leech SC, Till S, Huber PA, Nasser SM, Clark AT. BSACI guideline for the management of chronic urticaria and angioedema. Clin Exp Allergy. 2015 Mar. 45 (3):547-65. [Medline].
Ozceker D, Dilek F, Yucel E, Tamay Z, Ozkaya E, Guler N. Can allergy patch tests with food additives help to diagnose the cause in childhood chronic spontaneous urticaria?. Postepy Dermatol Alergol. 2020 Jun. 37 (3):384-389. [Medline].
[Guideline] Powell RJ, Du Toit GL, Siddique N, Leech SC, Dixon TA, Clark AT, et al. BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy. 2007 May. 37 (5):631-50. [Medline].
Kaplan AP. Therapy of chronic urticaria: a simple, modern approach. Ann Allergy Asthma Immunol. 2014 May. 112(5):419-425. [Medline].
Shahzad Mustafa S, Sánchez-Borges M. Chronic Urticaria: Comparisons of US, European, and Asian Guidelines. Curr Allergy Asthma Rep. 2018 May 24. 18 (7):36. [Medline].
Zuberbier T, Bernstein JA. A Comparison of the United States and International Perspective on Chronic Urticaria Guidelines. J Allergy Clin Immunol Pract. 2018 May 18. [Medline].
Sype JW, Khan IA. Prolonged QT interval with markedly abnormal ventricular repolarization in diphenhydramine overdose. Int J Cardiol. 2005 Mar 18. 99(2):333-5. [Medline].
[Guideline] Fine LM, Bernstein JA. Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines. Curr Allergy Asthma Rep. 2015 Jun. 15 (6):30. [Medline].
Sil A, Tripathi SK, Chaudhuri A, Das NK, Hazra A, Bagchi C, et al. Olopatadine versus levocetirizine in chronic urticaria: an observer-blind, randomized, controlled trial of effectiveness and safety. J Dermatolog Treat. 2012 Nov 19. [Medline].
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. 2000 Nov. 36(5):462-8. [Medline].
Fedorowicz Z, van Zuuren EJ, Hu N. Histamine H2-receptor antagonists for urticaria. Cochrane Database Syst Rev. 2012 Mar 14. 3:CD008596. [Medline].
Smith PF, Corelli RL. Doxepin in the management of pruritus associated with allergic cutaneous reactions. Ann Pharmacother. 1997 May. 31(5):633-5. [Medline].
Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med. 1995 Nov. 26(5):547-51. [Medline].
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. 2009 Dec. 103(6):502-7. [Medline].
Mandel VD, Guanti MB, Liberati S, Demonte A, Pellacani G, Pepe P. Omalizumab in Chronic Spontaneous Urticaria Refractory to Conventional Therapy: An Italian Retrospective Clinical Analysis with Suggestions for Long-Term Maintenance Strategies. Dermatol Ther (Heidelb). 2018 May 16. [Medline].
Larenas-Linnemann DES, Parisi CAS, Ritchie C, Cardona-Villa R, Cherrez-Ojeda I, Cherrez A, et al. Update on Omalizumab for Urticaria: What's New in the Literature from Mechanisms to Clinic. Curr Allergy Asthma Rep. 2018 May 9. 18 (5):33. [Medline].
Ozbagcivan O, Akarsu S, Ilknur T, Fetil E. Urticaria and angioedema as possible reactions of omalizumab. An Bras Dermatol. 2018 Mar. 93 (2):304-305. [Medline].
Patil AD, Bingewar G, Goldust M. Efficacy of methotrexate as add on therapy to H1 antihistamine in difficult to treat chronic urticaria: A systematic review and meta-analysis of randomized clinical trials. Dermatol Ther. 2020 Jul 26. e14077. [Medline].
Su O, Bahali AG, Onsun N. The effect of at least 1-year use of omalizumab without interruption on relapse in patients with chronic spontaneous urticaria. Dermatol Ther. 2020 Aug 13. e14192. [Medline].
Maoz-Segal R, Levy T, Haj-Yahia S, Offengenden I, Iancovich-Kidon M, Agmon-Levin N. Combination therapy with omalizumab and an immune-suppressive agent for resistant chronic spontaneous rrticaria - A real-life experience. World Allergy Organ J. 2020 Aug. 13 (8):100448. [Medline].
Dabija D, Tadi P. Chronic Urticaria. StatPearls [Internet]. 2020 Jan. [Medline]. [Full Text].
Agache I, Rocha C, Pereira A, et al. Efficacy and safety of treatment with omalizumab for chronic spontaneous urticaria: A systematic review for the EAACI Biologicals Guidelines. Allergy. 2020 Aug 7. [Medline].
Sarti L, Barni S, Giovannini M, Liccioli G, Novembre E, Mori F. Efficacy and tolerability of the updosing of second-generation non-sedating H1 antihistamines in children with chronic spontaneous urticaria. Pediatr Allergy Immunol. 2020 Aug 3. [Medline].
Rajan JP, Simon RA, Bosso JV. Prevalence of sensitivity to food and drug additives in patients with chronic idiopathic urticaria. J Allergy Clin Immunol Pract. 2014 Mar-Apr. 2(2):168-71. [Medline].
Simons FE. H1-Antihistamines: more relevant than ever in the treatment of allergic disorders. J Allergy Clin Immunol. 2003 Oct. 112(4 Suppl):S42-52. [Medline].
Balaraman B, Bergstrom KG. Beyond antihistamines: treating chronic urticaria. J Drugs Dermatol. 2009 Nov. 8(11):1043-8. [Medline].
Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2009. J Allergy Clin Immunol. 2010 Jan. 125(1):85-97. [Medline].
Okubo Y, Shigoka Y, Yamazaki M, Tsuboi R. Double dose of cetirizine hydrochloride is effective for patients with urticaria resistant: a prospective, randomized, non-blinded, comparative clinical study and assessment of quality of life. J Dermatolog Treat. 2013 Apr. 24(2):153-60. [Medline].
Maurer M, Rosén K, Hsieh HJ, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013 Mar 7. 368(10):924-35. [Medline].
Kai AC, Flohr C, Grattan CE. Improvement in quality of life impairment followed by relapse with 6-monthly periodic administration of omalizumab for severe treatment-refractory chronic urticaria and urticarial vasculitis. Clin Exp Dermatol. 2014 Apr 23. [Medline].
Lang DM. Omalizumab is efficacious for management of recalcitrant, antihistamine-resistant chronic urticaria. Drugs Today (Barc). 2015 Jun. 51 (6):367-74. [Medline].
Wan KS. Efficacy of leukotriene receptor antagonist with an anti-H1 receptor antagonist for treatment of chronic idiopathic urticaria. J Dermatolog Treat. 2009. 20(4):194-7. [Medline].
Serhat Inaloz H, Ozturk S, Akcali C, Kirtak N, Tarakcioglu M. Low-dose and short-term cyclosporine treatment in patients with chronic idiopathic urticaria: a clinical and immunological evaluation. J Dermatol. 2008 May. 35(5):276-82. [Medline].
Kessel A, Toubi E. Low-dose cyclosporine is a good option for severe chronic urticaria. J Allergy Clin Immunol. 2009 Apr. 123(4):970; author reply 970-1. [Medline].
Holm JG, Ivyanskiy I, Thomsen SF. Use of nonbiologic treatments in antihistamine-refractory chronic urticaria: a review of published evidence. J Dermatolog Treat. 2017 May 31. 1-18. [Medline].
Akenroye AT, McEwan C, Saini SS. Montelukast reduces symptom severity and frequency in patients with angioedema-predominant chronic spontaneous urticaria. J Allergy Clin Immunol Pract. 2018 May 5. [Medline].

Media Gallery

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

of 2

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)

Mallory Shiver, MD Resident Physician, Department of Dermatology, University of Arkansas for Medical Sciences College of Medicine

Mallory Shiver, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Arkansas Foundation for Skin Cancer, Christian Medical and Dental Associations

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

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.

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