Referral

Urticaria

Urticaria and angioedema are closely related, share many causes and treatments and can coexist. They are both manifestations of mast cell degranulation in superficial or deep skin layers respectively. They are not usually due to allergies.

Aetiology:

  • 50% of cases of spontaneous urticaria are idiopathic, the other 50% are autoimmune in nature and often have associated thyroid autoantibodies
  • Although spontaneous urticaria is not an allergy, symptoms can be exacerbated by a number of factors such as heat, stress, various medications such as aspirin and other NSAID, and in some cases pseudoallergens
Referral Criteria:
  • Diagnostic uncertainty (e.g. suspected drug rash or vasculitis)
  • Severe disease unresponsive to primary care management (secondary care treatments include cyclosporine, oral steroids and omalzumab)

Formulary, Chapter 13. Skin: Management of urticaria

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Signs and Symptoms

  • A slight female predominance
  • Can affect any age although 50% present between the ages of 20 and 40
  • 25% of patients have an atopic background
  • Symptoms
    • Although the condition may persist for several months, or in some cases years, individual lesions generally last between 30 minutes and 4 hours
    • Can have additional elements of physical urticaria such as dermographism or delayed pressure urticaria
  • Angioedema will affect some patients but is rarely life threatening
  • Natural history: 50% of patients with spontaneous urticaria can expect to be clear in six months, but some persist for years
  • Rapid appearance of raised erythematous very itchy skin swellings "wheals"

Differential Diagnoses

Individual lesions disappear within 24 hours and if not consider:

  • erythema multiforme
  • urticarial vasculitis (lesions can last for days and leave bruising)
  • erysipelas
  • if female of child bearing age - polymorphic eruption of pregnancy

Acute urticarial

  • Idiopathic
  • Viral infections
  • Physical – touch, pressure, hot, cold, solar, water, chemicals, cosmetics
  • Drugs – aspirin, opioids, NSAIDs, antibiotics, ACE inhibitors, statins, diuretics
  • Allergic – foods, infections

Chronic urticaria

  • Idiopathic most common
    • Chronic idiopathic urticaria is not an allergy but more because of irritable mast cells that degranulate with little or no provocation
    • Often in 20-40 year old females
    • Often a response to emotional stress or hormonal changes
    • Usually burns out after several months to a couple of years
  • Physical – touch, pressure, hot, cold, solar, water
  • Drugs – aspirin, opioids, NSAIDs, antibiotics, ACE inhibitors, statins, diuretics
  • Allergic – foods, infections Secondary to other disease – SLE, viral hepatitis, hyperthyroidism, lymphoma, infection
  • Auto-immune urticaria

Blood tests

  • Check TFT and autoantibodies - patients found to have significant titres of thyroid autoantibodies should have their TFT re-checked every six months as they are at increased risk of developing thyroid disease

H.pylori status

  • Check in patients with recalcitrant urticaria and who also have dyspepsia - urticaria may improve in some patients following H.pylori eradication

Other tests

  • In general, patients will not benefit from RAST or skin prick tests as an allergic cause is highly unlikely - a RAST test against a specific food may sometimes be used to disprove a theory, such that a negative result would make it very unlikely that any given food is responsible for the reaction

There is no place for patch testing

Referral criteria

  • Diagnostic uncertainty (e.g. suspected drug rash or vasculitis)
  • Severe disease unresponsive to primary care management (secondary care treatments include cyclosporine, oral steroids and omalzumab)

Patient Information

Evidence

North and East Devon - formulary - Skin

The Primary Care Dermatology Society

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: 30 January 2017