What is urticaria?
Urticaria is characterised by weals (hives) or angioedema (swellings, in 10%) or both (in 40%). There are several types of urticaria. The name urticaria is derived from the common European stinging nettle ‘Urtica dioica’.
A weal (or wheal) is a superficial skin-coloured or pale skin swelling, usually surrounded by erythema (redness) that lasts anything from a few minutes to 24 hours. Usually very itchy, it may have a burning sensation.
Angioedema is deeper swelling within the skin or mucous membranes, and can be skin-coloured or red. It resolves within 72 hours. Angioedema may be itchy or painful but is often asymptomatic.
Classification of urticaria
Urticaria is classified according to its duration.
- Acute urticaria(< 6 weeks duration, and often gone within hours to days)
- Chronic urticaria(> 6 weeks duration, with daily or episodic weals)
Chronic urticaria may be spontaneous or inducible. Both types may co-exist.
Inducible or physical urticaria includes:
- Symptomatic dermographism
- Cold urticaria
- Cholinergic urticaria
- Contact urticaria
- Delayed pressure urticaria
- Solar urticaria
- Heat urticaria
- Vibratory urticaria
- Aquagenic urticaria
Who gets urticaria?
One in five children or adults have an episode of acute urticaria during their lifetime. It is more common in atopics. It affects all races and both sexes.
Chronic spontaneous urticaria affects 0.5–2% of the population; in some series, two-thirds are women. Inducible urticaria is more common. There are genetic and autoimmune associations.
What are the clinical features of urticaria?
Urticarial weals can be a few millimetres or several centimetres in diameter, coloured white or red, with or without a red flare. Each weal may last a few minutes or several hours, and may change shape. Weals may be round, or form rings, a map-like pattern or giant patches.
Urticaria can affect any site of the body and tends to be distributed widely.
Angioedema is more often localised. It commonly affects the face (especially eyelids and perioral sites), hands, feet and genitalia. It may involve tongue, uvula, soft palate, or larynx.
Serum sickness due to blood transfusion, and serum sickness-like reactions due to certain drugs cause acute urticaria leaving bruises, fever, swollen lymph glands, joint pain and swelling.
In chronic inducible urticaria, weals appear about 5 minutes after the stimulus and last a few minutes or up to one hour. Characteristically, weals are:
- Linear in symptomatic dermographism
- Tiny in cholinergic urticaria
- Confined to contact areas in contact urticaria
- Diffuse in cold urticaria—if large areas of skin are affected, they can lead to fainting (potentially dangerous if swimming in cold water)
The weals are more persistent in chronic spontaneous urticaria, but each has gone or has altered in shape within 24 hours. They may occur at certain times of day.
What causes urticaria?
Weals are due to release of chemical mediators from tissue mast cells and circulating basophils. These chemical mediators include histamine, platelet-activating factor and cytokines. The mediators activate sensory nerves and cause dilation of blood vessels and leakage of fluid into surrounding tissues. Bradykinin release causes angioedema.
Several hypotheses have been proposed to explain urticaria. The immune, arachidonic acid and coagulation systems are involved, and genetic mutations are under investigation.
Acute urticaria
Acute urticaria can be induced by the following factors but the cause is not always identified.
- Acute viral infection—upper respiratory infection, viral hepatitis, infectious mononucleosis, mycoplasma
- Acute bacterial infection—dental abscess, sinusitis
- Food allergy(IgE mediated)—usually milk, egg, peanut, shellfish
- Drug allergy(IgE mediated)—often an antibiotic
- Drug pseudoallergy—aspirin, nonselective nonsteroidal anti-inflammatory drugs, opiates, radiocontrast media; these cause urticaria without immune activation
- Vaccination
- Bee or wasp stings
- Widespread reaction following localised contact urticaria—eg rubber latex
Severe allergic urticaria may lead to anaphylactic shock (bronchospasm, collapse).
Immune complexes due to blood transfusion cause serum sickness and certain drugs cause serum sickness-like reactions (urticaria leaving bruises, fever, swollen lymph glands, joint pain and swelling).
A single episode or recurrent episodes of angioedema without urticaria can be due to an angiotensin-converting enzyme (ACE) inhibitor drug.
Chronic urticaria
Chronic spontaneous urticaria is mainly idiopathic (cause unknown). An autoimmune cause is likely. About half of investigated patients carry functional IgG autoantibodies to immunoglobulin IgE or high-affinity receptor FcεRIα.
Chronic spontaneous urticaraia has also been associated with:
- Chronic underlying infection, eg Helicobacter pylori, bowel parasites
- Chronic autoimmune disease, eg systemic lupus erythematosus, thyroid disease, celiac disease, vitiligoand others
Weals in chronic spontaneous urticaria may be aggravated by:
- Heat
- Viral infection
- Tight clothing
- Drug pseudoallergy—aspirin, nonsteroidal anti-inflammatory drugs, opiates
- Food pseudoallergy—salicylates, azo dye food colouring agents such as tartrazine (102), benzoate preservatives (210-220) and other food additives
Inducible urticaria is a response to a physical stimulus.
| Type of inducible urticaria | Examples of stimuli inducing wealing |
| Symptomatic dermographism | · Stroking or scratching the skin
· Tight clothing · Towel drying after hot shower |
| Cold urticaria | · Cold air on exposed skin
· Cold water · Ice block · Cryotherapy |
| Cholinergic urticaria | · Sweat induced by exercise
· Sweat induced by emotional upset · Hot shower |
| Contact urticaria | · Eliciting substance absorbed through skin or mucous membrane
· Allergens (IgE-mediated): white flour, cosmetics, textiles, latex, saliva, meat, fish, vegetables · Pseudoallergens or irritants: stinging nettle, hairy caterpillar, medicines |
| Delayed pressure urticaria | · Pressure on affected skin several hours earlier
· Carrying heavy bag · Pressure from seat belt · Standing on ladder rung · Sitting on a horse |
| Solar urticaria | · Sun exposure to non-habituated body sites
· Often spares face, neck, hands · May involve long wavelength UV or visible light |
| Heat urticaria | · Hot water bottle
· Hot drink |
| Vibratory urticaria | · Jack hammer |
| Aquagenic urticaria | · Hot or cold water
· Fresh, salt or chlorinated water |
Recurrent angioedema without urticaria can be due to inherited or acquired complement C1 esterase deficiency.
How is urticaria diagnosed?
Urticaria is diagnosed in people with a history of weals that last less than 24 hours with or without angioedema. A family history should be elicited. A thorough physical examination should be undertaken.
Skin prick tests and radioallergosorbent tests (RAST) or CAP fluoroimmunoassay may be requested if a drug or food allergy is suspected in acute urticaria.
There are no routine diagnostic tests in chronic spontaneous urticaria apart from blood count and C-reactive protein (CBC, CRP), but investigations may be undertaken if an underlying disorder is suspected.
The autologous serum skin test is sometimes carried out in chronic spontaneous urtciaria, but its value is uncertain. It is positive if an injection of the patien’s serum under the skin causes a red weal.
Inducible urticaria is often confirmed by inducing the reaction, eg scratching the skin in dermographism or applying an ice cube in suspected cold urticaria.
Investigations for a systemic condition or autoinflammatory disease should be undertaken in urticaria patients with fever, joint or bone pain, and malaise. Patients with angioedema without weals should be asked if they take ACE inhibitor drugs and tested for complement C4; C1-INH levels, function and antibodies; and C1q.
Biopsy of urticaria can be non-specific and difficult to interpret. The pathology shows oedema in the dermis and dilated blood vessels, with variable mixed inflammatory infiltrate. Vessel-wall damage indicates urticarial vasculitis.
What is the treatment for urticaria?
The main treatment of all forms of urticaria in adults and in children is with an oral second-generation antihistaminechosen from the list below. If the standard dose (eg 10 mg for cetirizine) is not effective, the dose can be increased up to fourfold (eg 40 mg cetirizine daily). They are stopped when the acute urticaria has settled down. There is not thought to be any benefit from adding a second antihistamine.
- Cetirizine
- Loratidine
- Fexofenadine
- Desloratadine
- Levocetirizine
- Rupatadine
- Bilastine
Terfenadine and astemizole should not be used, as they are cardiotoxic in combination with ketoconazole orerythromycin. They are no longer available in New Zealand.
Although systemic treatment is best avoided during pregnancy and breastfeeding, there have been no reports that second-generation antihistamines cause birth defects. If treatment is required, loratidine and cetirizine are currently preferred.
Conventional first-generation antihistamines such as promethazine or chlorpheniramine are no longer recommended for urticaria:
- They are short-lasting.
- They have sedative and anticholinergic side effects.
- They impair sleep, learning and performance.
- They cause drowsiness in nursing infants if taken by the mother.
- They interact with alcohol and other medications.
- Lethal overdoses are reported.
Avoidance of trigger factors
In addition to antihistamines, the cause of urticaria should be eliminated if known (eg drug or food allergy). Avoidance of relevant type 1 (IgE-mediated) allergens clears urticaria within 48 hours.
- Treat identified chronic infections such as H pylori.
- Avoid aspirin, opiates and nonsteroidal anti-inflammatory drugs(paracetamol is generally safe).
- Minimise dietary pseudoallergens for a trial period of at least 3 weeks.
- Avoid known allergens that have been confirmed by positive specific IgE/skin prick tests if these have clinical relevance for urticaria.
- Cool the affected area with a fan, cold flannel, ice pack or soothing moisturising lotion.
The physical triggers for inducible urticaria should be minimised; see examples below. However, symptoms often persist.
- Symptomatic dermographism: reduce friction, eg avoid tight clothing.
- Cold urticaria: dress up carefully in cold or windy conditions and avoid swimming in cold water.
- Delayed pressure urticaria: broaden the contact area eg of a heavy bag.
- Solar urticaria: dress up and apply broad-spectrum sunscreens.
Some patients with inducible urticaria benefit from daily induction of symptoms to induce tolerance. Phototherapy may be helpful for symptomatic dermographism.
Treatment of refractory acute urticaria
If non-sedating antihistamines are not effective, a 4 to 5-day course of oral prednisone (prednisolone) may be warranted in severe acute urticaria.
Intramuscular injection of adrenaline (epinephrine) is reserved for life-threatening anaphylaxis or swelling of the throat.
Treatment of refractory chronic urticaria
Patients with chronic urticaria that has failed to respond to maximum-dose second generation oral antihistaminestaken for 4 weeks should be referred to a dermatologist, immunologist or medical allergy specialist.
There is good evidence to support treatment with omalizumab or ciclosporin, which each have a 65% response rate in antihistamine-resistant patients.
- Omalizumabis a monoclonal antibody directed against IgE, with low toxicity. Omalizumab is not funded by PHARMAC in New Zealand for urticaria (2015).
- Ciclosporinis a calcineurin inhibitor, with potential serious side effects (eg may increase blood pressure and reduce renal function).
Other treatments that are sometimes used off-label in chronic urticaria include:
- Leukotriene antagonist, montelukast
- Tricyclic antidepressants
- Methotrexate
- Dapsone
- Phototherapy
- Anti-TNF alpha agents, eg infliximab, adalimumab
- Intravenous immunoglobulins
Long-term systemic corticosteroids are not recommended, as high doses are required to reduce symptoms of urticaria and they have inevitable adverse effects that can be serious.
The effectiveness of treatment can be objectively monitored using urticaria control test. Patients are asked to score the physical symptoms of urticaria they have experienced in the previous four weeks, quality of life affected by urticaria, how often treatment was not enough to control symptoms, and overall control of urticaria.
Differential diagnosis of urticaria
Scombroid fish poisoning
Histamine release from decomposing scombroid fish causes erythema without weals, tachycardia, abdominal pain, diarrhoea and diaphoresis.
Papular urticaria
Insect bites are localised, often clustered in groups of 3–5 lesions, and they appear in crops. Bites persist for days. Close inspection reveals a central punctum. Chronic hypersensitivity to insect bites is often called papular urticaria.
Mastocytosis
The most common form of mastocytosis, maculopapular cutaneous mastocytosis is also called urticaria pigmentosa. Itchy brown patches or freckles on the skin are due to abnormal collections of mast cells.
Urticarial vasculitis
Urticarial vasculitis causes persistent urticaria-like plaques that last more than 24 hours and resolve with bruising.Biopsy reveals leukocytoclastic vasculitis.
Autoinflammatory syndromes
Urticarial rashes are rarely due to autoinflammatory syndromes, which are mediated by interleukin (IL) 1.
Urticarial rashes in autoinflammatory syndromes differ from urticaria:
- Patches are flat
- Lesions persist longer
- Distribution is symmetrical
- Systemic symptoms
- Elevated inflammatory markers such as C-reactive protein (CRP)
- Biopsy of skin lesion shows dense neutrophilic infiltrate
- Lack of response to antihistamines
What is the outlook for chronic urticaria?
Although chronic urticaria clears up in most cases, 15% continue to have wealing at least twice weekly after 2 years