Urticaria, Angioedema and Mastocytosis in children

Scope

This guideline refers to children under 18 who may require further investigation and management of urticaria, angioedema or mastocytosis.

Chronic Urticaria occurs in 3% children, and acute urticaria occurs in 4.5-15% children.

Angioedema is much rarer occurring in 1/5000 patients.

Urticaria alone occurs in 50% of patients, angioedema with urticaria in 40% patients and angioedema alone in 10%.

The true incidence of mastocytosis is unknown

Out of scope

Anaphylaxis – see alternative referral pathway

​Assessment

History and Examination

History and examination of the child suggestive of urticaria or angioedema:

Urticaria is characterised by fluctuating weals and/or angio-oedema. A weal consists of three typical features:

  • a central swelling of variable size, almost invariably surrounded by a reflex erythema
  • associated itching or, sometimes, burning sensation
  • a fleeting nature, with the skin returning to its normal appearance, usually within 1–24 hours

Angio-oedema is characterised by:

  • a sudden, pronounced swelling of the lower dermis and subcutis, which is pale rather than pink and may be painful rather than itching
  • frequent involvement below mucous membranes
  • resolution that is slower than for weals and can take up to 72 hours

The history must rule any possible triggers such as food (see food guideline), latex, stings, and drugs.

Please ensure you check for infections:

  • childhood viral illnesses
  • ebstein Barr virus
  • viral hepatitides
  • parasites

Consider physical causes

  • cold, heat, pressure, vibration, exertion

Check the drug history including NSAIDs and opiates.

Red Flags

Consider underlying vasculitic process

  • Urticaria often painful and persists over 24 hours, initial weal fades away and leaves a "stain" or discolouration

Airway compromise with angioedema +/- urticaria

  • Treat as anaphylaxis

Rubbing freckles or macules causes an urticated lesion

​Investigations

Baseline investigations can include

  • Full blood count (FBC)
  • Erythrocyte sedimentation rate and C-reactive protein (ESR +/- CRP)
  • Liver and renal function
  • Thyroid function and thyroid antibodies

​Management

A non-sedating antihistamine should be started (syrup or tablet, as per BNFc doses)

Chapter 13 - Skin

If this is insufficient to control the symptoms after a month the dose can be doubled.

The BSACI management of chronic urticaria and angioedema algorithm may be helpful.

Referral

Referral Criteria

Please refer in to the paediatric allergy clinic if:

  • Urticaria last for more than 4 weeks
  • Urticaria does not respond to double doses of non-sedating antihistamine
  • Angioedema occurs alone
  • Wheals fade to leave pigmentary changes
  • Wheal occurs on rubbing freckles or macules

Referral Instructions

e-Referral Service Selection
  • Specialty: Children & Adolescent
  • Clinic Type: Allergy
  • Service: DRSS - Northern - Paediatrics (Medical) - NEW Devon CCG - 99P

Referral Forms

DRSS referral form

​Supporting Information

Patient Information

NHS Choices Angioedema

Evidence

NICE - Urticaria

NICE - Angio-oedema and anaphylaxis

BSACI Primary Care Guidelines

RCPCH - Care pathway for urticaria, angio-odema or mastocytosis

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: 6 July 2016

Review date: 5 July 2018

 

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