Acute and Chronic Urticaria: Evaluation and Treatment

 

Am Fam Physician. 2017 Jun 1;95(11):717-724.

  Patient information: See related handout on hives, written by the author of this article.

Author disclosure: No relevant financial affiliations.

Urticaria commonly presents with intensely pruritic wheals, sometimes with edema of the subcutaneous or interstitial tissue. It has a lifetime prevalence of about 20%. Although often self-limited and benign, it can cause significant discomfort, continue for months to years, and uncommonly represent a serious systemic disease or life-threatening allergic reaction. Urticaria is caused by immunoglobulin E- and non–immunoglobulin E-mediated release of histamine and other inflammatory mediators from mast cells and basophils. Diagnosis is made clinically; anaphylaxis must be ruled out. Chronic urticaria is idiopathic in 80% to 90% of cases. Only a limited nonspecific laboratory workup should be considered unless elements of the history or physical examination suggest specific underlying conditions. The mainstay of treatment is avoidance of triggers, if identified. The first-line pharmacotherapy is second-generation H1 antihistamines, which can be titrated to greater than standard doses. First-generation H1 antihistamines, H2 antihistamines, leukotriene receptor antagonists, high-potency antihistamines, and brief corticosteroid bursts may be used as adjunctive treatment. In refractory chronic urticaria, patients can be referred to subspecialists for additional treatments, such as omalizumab or cyclosporine. More than one-half of patients with chronic urticaria will have resolution or improvement of symptoms within a year.

Urticaria is a common dermatologic condition that typically presents with intensely pruritic, well-circumscribed, raised wheals ranging from several millimeters to several centimeters or larger in size. Urticaria can occur with angioedema, which is localized nonpitting edema of the subcutaneous or interstitial tissue that may be painful and warm. The intense pruritus can cause significant impairment in daily functioning and disrupt sleep.1 Typically otherwise benign and self-limited, urticaria can be a symptom of life-threatening anaphylaxis or, rarely, indicate significant underlying disease.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

It is important to rule out underlying anaphylaxis in patients presenting with urticaria.

C

2, 4, 9

Evaluate vital signs and symptoms involving other organ systems such as pulmonary, cardiovascular, neurologic, or gastrointestinal.

An extensive laboratory workup for urticaria is not generally recommended. Additional testing can be performed if the presentation suggests underlying causes requiring confirmation.

C

2, 4, 9, 16

Complete blood count with differential, erythrocyte sedimentation rate or C-reactive protein, thyroid-stimulating hormone, urinalysis, and liver function tests can be considered.

Second-generation H1 antihistamines are safe and effective symptomatic therapy for urticaria.

A

2, 4, 9, 19, 20

Second-generation H1 antihistamines are recommended over older antihistamines because of adverse effect profiles. All H1 antihistamines appear to be effective.

If needed to control symptoms of urticaria, second-generation H1 antihistamines can be titrated to two to four times the normal dose.

C

2, 4, 9

A higher risk of adverse effects is present with higher doses. Limited effectiveness data are available.

A short course of systemic corticosteroids may help control severe cases of urticaria.

C

2, 4, 9

Few clinical data support this recommendation, but it is widely practiced.

Other medications such as first-generation H1 antihistamines, H2 antihistamines, and leukotriene receptor antagonists may be added to control symptoms of chronic urticaria.

B

2, 4, 9

Several studies have produced varying results, but these are generally safe medications with some evidence of benefit.


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

It is important to rule out underlying anaphylaxis in patients presenting with urticaria.

C

2, 4, 9

Evaluate vital signs and symptoms involving other organ systems such as pulmonary, cardiovascular, neurologic, or gastrointestinal.

An extensive laboratory workup for urticaria is not generally recommended. Additional testing can be performed if the presentation suggests underlying causes requiring confirmation.

C

2, 4, 9, 16

Complete blood count with differential, erythrocyte sedimentation rate or C-reactive protein, thyroid-stimulating hormone, urinalysis, and liver function tests can be considered.

Second-generation H1 antihistamines are safe and effective symptomatic therapy for urticaria.

A

2, 4, 9, 19, 20

Second-generation H1 antihistamines are recommended over older antihistamines because

The Author

PAUL SCHAEFER, MD, PhD, is vice chair and associate professor in the Department of Family Medicine and assistant dean for student affairs at the University of Toledo (Ohio) College of Medicine and Life Sciences.

Address correspondence to Paul Schaefer, MD, PhD, University of Toledo Health Sciences Campus, MS 1179, 2240 Dowling Hall, 3000 Arlington Ave., Toledo, OH 43614 (e-mail: paul.schaefer@utoledo.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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