Acute Urticaria - DynaMed

Acute Urticaria - DynaMed 17/06/24, 1:00 p.m.
CONDITION • Updated 14 Jul 2023
Acute Urticaria
Overview and Recommendations
Background
● Urticaria is characterized by pruritic wheals (central edema surrounded by erythema and

associated with itching), that may vary in size, may occur singly or in multiples, and resolve
within 24 hours, without scarring.
● Acute urticaria is de!ned as symptoms or recurring symptoms that last ≤ 6 weeks. Acute
urticaria may be a symptom of many diseases and conditions.
● A common cause of acute urticaria in adults and children is infection, particularly infection
with rotavirus or rhinovirus, as well as common bacterial infections such as Mycoplasma
pneumoniae and group A streptococcal pharyngitis. Allergic and histaminergic causes are
also common, including reactions to medications (particularly, nonsteroidal anti-in"amma-
tory drugs [NSAID], angiotensin-converting enzyme [ACE] inhibitors, antibiotics), food aller-
gens (particularly cow’s milk), latex, inhalant allergens, and Hymenoptera stings.
● No underlying cause is found in 30%-50% of cases of acute urticaria.
● Angioedema, an acute painful swelling of the lower dermis, subcutis, or submucosal tissue
(including the mouth and bowel) that resolves within 72 hours, may occur in about 40% of
patients with urticaria.
Evaluation
● Diagnose urticaria based on the presence of erythematous well-de!ned wheals (duration <
24 hours), with or without angioedema.
● Obtain a detailed history unless a precipitating cause is obvious. Urticaria lasting < 6 weeks
is classi!ed as acute urticaria, while urticaria lasting ≥ 6 weeks is classi!ed as chronic ur-
ticaria. Routine diagnostic testing is not recommended for acute urticaria.
● Acute urticaria usually does not require diagnostic testing due to its self-limiting nature, ex-
cept in cases of suspected immunoglobulin E (IgE)-mediated food allergy or other eliciting
factors such as NSAIDs.
https://www-dynamed-com.pbidi.unam.mx:2443/condition/acute-urticaria Página 1 de 42
● Dermatographism can be elicited by stroking the patient’s back with a blunt tip and eliciting
a linear wheal.
● Consider further testing as needed based on the history for patients without an obvious
cause or those with severe symptoms unresponsive to antihistamine treatment.
● Consider other dermatological conditions with similar clinical presentations, such as ur-
ticarial vasculitis, auto-in"ammatory syndromes, drugs rashes, viral exanthems, mastocyto-
sis, or contact dermatitis.
Management
● Evaluate the need for emergency treatment, as urticaria with or without angioedema may
be an early sign of anaphylaxis. See Anaphylaxis for details of emergency treatment.
● The goal of treatment is to identify and eliminate any underlying cause or trigger of ur-
ticaria and to provide symptomatic relief.
● Use second-generation H1 antihistamines for symptomatic relief of acute urticaria (Strong
recommendation).
⚬ Oral second-generation H1 antihistamines are preferred over !rst-generation antihista-
mines, due to less risk of sedation or anticholinergic e#ects with second-generation H1
antihistamines. Second-generation H1 antihistamines have slower onset and are longer
lasting than !rst-generation antihistamines. Antihistamines should be taken regularly,
not just for symptoms.
⚬ In pregnant and lactating persons, consider loratadine or cetirizine for antihistamine
treatment.
⚬ In children, consider the same antihistamine treatment regimen as in adults, but ensure
weight-adjusted dosing and frequent monitoring.
● For severe symptoms or symptoms unresponsive to antihistamines, the 2 options are to
raise the dose of the antihistamine (up to 4x) or add a short course (< 10 days) of oral corti-
costeroids (for example, prednisone 20-50 mg/day) (Conditional recommendation).
● If there were initial signs of anaphylaxis, self-injectable epinephrine should be prescribed.
● Omalizumab is a humanized monoclonal anti-IgE antibody that may be e#ective to treat
chronic urticaria or prevent IgE-mediated food allergy (see also Chronic Urticaria and Im-
munoglobulin E (IgE)-mediated Food Allergy).
Related Topics
● Anaphylaxis
● Angioedema
● Chronic Urticaria
● Diagnosis and Evaluation of IgE-mediated Allergies
● Immunoglobulin E (IgE)-mediated Food Allergy
● Nonsteroidal Anti-in"ammatory Drug (NSAID)-related Urticaria and Angioedema
Background Information
Description
● urticaria are pruritic, transient (duration < 24 hours) wheals with or without
angioedema 1,2,3,4
⚬ acute urticaria de!ned as urticarial symptoms lasting < 6 weeks
⚬ common causes of acute urticaria include allergic response, infection, drug reaction, and
idiopathic causes
Also Called
● hives
● nettle rash
Types
● clinical classi!cation of urticaria 1,2,3,4

⚬ acute urticaria
– transient wheals (duration < 24 hours) with or without angioedema
– characterized by ≤ 6 weeks continuous activity
⚬ chronic urticaria
– chronic spontaneous urticaria
● transient wheals (duration < 24 hours), angioedema, or both
● characterized by ≥ 6 weeks continuous activity

– inducible urticaria tends to be chronic (continuous activity > 6 weeks), but may
present with symptoms of < 6 weeks duration, and includes any of the following
● symptomatic dermographism (also known as dermatographism, dermographia,
dermatographia, dermographic urticaria, or urticaria factitia), and most common
form of physical urticaria, a#ecting 1%-5% of general population
● cold urticaria (also known as cold contact urticaria)
● delayed pressure urticaria (also known as pressure urticaria)
● solar urticaria
● heat urticaria (also known as heat contact urticaria)
● vibratory urticaria
● cholinergic urticaria (associated with an increase in core body temperature and/or
hypersensitivity to sweat; may occur with exercise, stress, spicy foods, or passive
warming)
● contact urticaria (contact with allergens or chemicals)
● aquagenic urticaria (contact with water)
● adrenergic urticaria (very rare; reportedly due to stress-induced release of ep-
inephrine and norepinephrine)
Incidence/Prevalence
● peak onset of urticaria in adults between ages 20 and 40 years (Clin Exp Immunol 2008
Aug;153(2):151)
● lifetime prevalence approximately 9%-20% for acute urticaria, with or without
angioedema 1,2,3,4
STUDY
● SUMMARY
8.8% lifetime prevalence for any urticaria in Berlin, Germany
CROSS-SECTIONAL STUDY: Clin Exp Dermatol 2010 Dec;35(8):869
Details
⚬ based on cross-sectional study
⚬ 4,093 patients in Berlin, Germany responded to questionnaire survey
⚬ 767 had urticaria or angioedema
⚬ 8.8% lifetime prevalence for any urticaria
⚬ 1.8% lifetime prevalence for chronic urticaria
⚬ 70.3% of patients with chronic urticaria were women

⚬ Reference - Clin Exp Dermatol 2010 Dec;35(8):869
Associated Conditions
● angioedema, which may be characterized by acute swelling of lower dermis, subcutis, mu-
cous membranes, or submucosal tissue, is reported in about one-third of patients with ur-
ticaria 3
● diseases associated with urticaria or that present with urticaria and/or angioedema 1,4
⚬ Schnitzler syndrome (associated with multiple myeloma)
⚬ cryopyrin-associated periodic syndromes (CAPS)
⚬ maculopapular cutaneous mastocytosis
⚬ Gleich syndrome (episodic angioedema with eosinophilia)
⚬ Well syndrome (eosinophilic cellulitis)
⚬ Hashimoto thyroiditis
⚬ systemic lupus erythematosus
⚬ Sjogren syndrome
⚬ rheumatoid arthritis
⚬ vasculitis
⚬ celiac disease
⚬ lymphoma
Etiology and Pathogenesis
Causes
● most common triggers of acute urticaria include infection, foods and drug reactions, but
acute urticaria may be idiopathic in up to 50% of cases 3
● anaphylaxis as cause must be ruled out 3,4
● infection reported to be among the most commonly identi!ed cause of acute urticaria (rep-
resenting up to 40% of cases) 1,2,3,4
⚬ causative viral infections may include
– rhinovirus
– rotavirus
– hepatitis A virus (HAV) infection

– hepatitis B
– hepatitis C
– Epstein-Barr virus (EBV) infection
– herpes simplex
– parvovirus B19 infection
– HIV
⚬ potentially causative bacterial infections may include
– Mycoplasma pneumoniae
– group A streptococcal pharyngitis
– urinary tract infections (UTI) (pyelonephritis and cystitis)
– Helicobacter pylori infection
– Yersinia enterocolitica
⚬ infections from parasites may occur, such as due to Anisakis simplex, Giardia lamblia, or
Plasmodium falciparum
STUDY
⚬ SUMMARY
sensitization to , , fish, or common aeroallergens associated with
increased risk for relapsing acute urticaria in children and adolescents
CASE-CONTROL STUDY: J Epidemiol Community Health 2008 Jul;62(7):634
Details
– based on case-control study
– 200 patients aged 6-18 years with relapsing acute urticaria matched to 200 controls
and evaluated
– risk for relapsing acute urticaria increased with sensitization to
● A. simplex (odds ratio [OR] 3.86, 95% CI 2.04-7.29)
● Ascaris (OR 3.37, 95% CI 1.89-6.02)
● !sh (OR 4.62, 95% CI 1.85-11.52)
● common aeroallergens (OR 4.59, 95% CI 2.99-7.05)
– Reference - J Epidemiol Community Health 2008 Jul;62(7):634
● food allergens and pseudoallergens 2,3,4

⚬ food allergens and pseudoallergens are uncommon cause in adults, but may be more
common in children (Acta Derm Venereol 1996 Jul;76(4):295, )
⚬ IgE-mediated food allergies may cause acute urticaria

– common causes of acute urticaria, anaphylaxis, angioedema, and gastrointestinal
symptoms include cow's milk, egg, peanut, tree nut, !nned !sh (such as tuna, salmon,
cod), crustacean shell!sh (such as crab, lobster, and !sh), wheat, and soy
– see also Immunoglobulin E (IgE)-mediated Food Allergy and Diagnosis and Evaluation
of IgE-mediated Allergies
⚬ food pseudoallergens
– food pseudoallergens may contain histamine or salicylates, or cause direct release of
histamines
– ingestion of high levels of histamine in scombroid !sh (underprocessed tuna, macker-
el, anchovies, sardines, or sword!sh) may cause urticaria (CMAJ 2012 Apr
3;184(6):674, Ir Med J 2018 Jun 7;111(6):773)
– food pseudoallergens may be a cause of chronic urticaria
● medications, either via allergic reaction or direct mast cell degranulation, may cause acute
urticaria including 4
⚬ antibiotics
– most commonly beta-lactams
– vancomycin
⚬ opioids
⚬ nonsteroidal anti-in"ammatory drugs (NSAIDs), such as aspirin
⚬ aspirin
⚬ contrast media (Pneumologia 2013 Jan-Mar;62(1):47)
STUDY
⚬ SUMMARY
urticaria and morbilliform drug exanthem may be most common cutaneous reactions
to drugs
SYSTEMATIC REVIEW: Arch Dermatol 2001 Jun;137(6):765
Details
– based on systematic review of observational studies
– systematic review of 9 studies evaluating adverse skin reactions due to drugs
– many drugs did not have signi!cant rate of cutaneous reactions
– risk of cutaneous drug reaction
● 2.5%-3.5% for sulfonamides
● 1.1%-4.4% for penicillins

● 0.3%-0.69% for NSAIDs
– 5%-14% of rashes were urticaria and 73%-95% were morbilliform exanthems
– Reference - Arch Dermatol 2001 Jun;137(6):765
● inducible urticarias 1,2

⚬ inducible urticarias require reproducible stimulus that induces pruritic urticaria and/or
angioedema
⚬ inducible urticarias tend to be chronic (urticaria duration > 6 weeks)
⚬ physical inducible urticarias include all of the following
– symptomatic dermographism (also known as symptomatic dermatographism, dermo-
graphic urticaria, or urticaria factitia), which requires itchy whealing in response to
stroking or scratching of the skin (if itching or burning sensation is not present, then
response considered to be simple dermographism, a physiologic variant)
– cold urticaria (also known as cold contact urticaria)
– delayed pressure urticaria (also known as pressure urticaria)
– solar urticaria
– heat urticaria (also known as heat contact urticaria)
– vibratory urticaria
⚬ other inducible urticarias (stimulus is active and passive warming) include the following
– cholinergic urticaria (associated with an increase in core body temperature and/or hy-
persensitivity to sweat; may occur with exercise, stress, spicy foods, or passive warm-
ing)
– contact urticaria (contact with a trigger, such as allergens, chemicals, plants [stinging
nettle], or animals and animal products [jelly!sh])
– aquagenic urticaria (contact with water)
– adrenergic urticaria (very rare; reportedly due to stress-induced release of ep-
inephrine and norepinephrine)
⚬ rare variants of inducible urticaria include delayed dermographism, cholinergic dermo-
graphism, cold-dependent dermographism, and cold-induced cholinergic re"ex urticaria
(Allergy 2016 Jun;71(6):780)
Pathogenesis
● urticaria is characterized by dermal edema and perivascular and interstitial in"ammatory
cell in!ltration, with minimal change in the epidermis (Urticaria and Atopic Dermatitis Sep
2017 )
● initiation of mast cell activation/degranulation as a result of
⚬ immunologic (immunoglobulin E [IgE]-mediated) urticaria is most common, and may be
due to
– allergic reactions (for example, IgE-mediated type I hypersensitivity reactions)
– autoimmune reactions (for example, autoantibodies against IgE)
– complement-dependent (for example, C1 esterase inhibitor de!ciency)
⚬ nonimmunologic (IgE-independent) urticaria due to
– direct mast cell-releasing agents (for example, opiates, radiocontrast)
– production of vasoactive substances (for example, substance P, leukotrienes, and
prostaglandins)
– use of nonsteroidal anti-in"ammatory drug, such as aspirin
● may cause leukotriene formation and histamine release
● may interfere with arachidonic acid metabolism
⚬ use of angiotensin-converting enzyme inhibitors may cause angioedema (due to kinin
potentiation based on altered capacity for breakdown of bradykinin)
⚬ Reference - Am J Clin Dermatol 2009;10(4):239
● angioedema can involve deeper layers of dermis and submucosal or subcutaneous tissue
(Am J Clin Dermatol 2009;10(4):239)
History and Physical
History
Chief Concern (CC)
● eruption of transient wheals, which are typically characterized by all of the following 1,2,3,4
⚬ central swelling of variable size, almost always surrounded by re"ex erythema
⚬ itching and sometimes burning sensation
⚬ size may vary from few millimeters to centimeters
⚬ can occur with or without concurrent angioedema
⚬ "eeting nature; skin returns to normal within 1-24 hours, but new wheals may erupt ad-
jacent or distant to initial lesion

⚬ typically occurs within minutes to hours of medication or food allergen exposure if those
were triggers of reaction
● ask about symptoms of anaphylaxis, such as 2,3,4
⚬ wheezing
⚬ dyspnea
⚬ cough
⚬ dysphagia
⚬ dizziness
⚬ palpitations
⚬ syncope
⚬ gastrointestinal disturbance, such as vomiting or diarrhea
History of Present Illness (HPI)
● ask about timing of onset, frequency and duration of wheals, and any suspected provoking
factors 3
● ask about history of urticaria and angioedema, prior treatments, and response to treat-
ments 1,2
● ask about exposure to the most common triggers of acute urticaria, including 2,3
⚬ recent infections, contagious exposures, and travel history
⚬ food exposures and any observed correlation with foods
⚬ latex or other contact exposures
⚬ medication or drug ingestions
⚬ recent insect bites or stings
⚬ comorbid illnesses
● ask about other potential triggers, including triggers of inducible and physical urticaria,
such as
⚬ symptomatic dermographism (also known as dermatographism, dermographia, der-
matographia, dermographic urticaria, or urticaria factitia) which results in pruritic wheals
after rubbing or stroking of the skin
⚬ cold urticaria (also known as cold contact urticaria)
⚬ delayed pressure urticaria (also known as pressure urticaria)
⚬ solar urticaria
⚬ heat urticaria (also known as heat contact urticaria)

⚬ vibratory urticaria
⚬ cholinergic urticaria, where in an increase in core body temperature (such as may occur
with exercise) results in pruritic wheals
⚬ contact urticaria (contact with allergens or chemicals)
⚬ aquagenic urticaria (contact with water)
⚬ adrenergic urticaria (very rare; reportedly due to stress-induced released of epinephrine
and norepinephrine)
Medication History
● ask about use of angiotensin-converting enzyme (ACE) inhibitors, which is associated with
angioedema 2
● ask about use of potentially causative medications, vitamins, or supplements, such as 2,3
⚬ nonsteroidal anti-in"ammatory drugs (NSAIDs)
⚬ immunizations
⚬ hormones
⚬ laxative
⚬ opiates
⚬ ear and eye drops
Past Medical History (PMH)
● ask about 1,3

⚬ history of anaphylaxis
⚬ allergies, including food allergies
⚬ surgical implantations and events during surgery, such as after local anesthesia
⚬ psychosomatic and psychiatric diseases
⚬ autoimmune disease
⚬ gastrointestinal problems
⚬ occurrence of urticaria in relation to infections
Family History (FH)
● ask about family history of urticaria, angioedema, or atopy 1,3
Social History (SH)
● ask about 3
⚬ induction by physical contact or exercise
⚬ smoking habits (especially use of "avored or perfumed tobacco products)
⚬ stress
⚬ social and occupational history of exposures, such as contact to cold, heat, vibration, or
water
Physical
General Physical
● if any concern of angioedema or anaphylaxis, check blood pressure, heart rate, and pulse
oximetry 2
● check for fever 2
Skin
● assess for wheals, characterized by 1,2,3,4

⚬ central swelling and surrounding erythema
⚬ may appear in linear, circular, or arcuate formations
⚬ can occur anywhere on the body
⚬ may or may not be associated with angioedema
⚬ variations in size, ranging from few millimeters to centimeters, and several wheals may
form adjacent to each other or at di#erent locations of the body
⚬ central blanching with pressure, or clear, pale center
⚬ complete resolution without persistent purpura, pigmentation or scarring within 1-24
hours (if diagnosis unclear, consider marking border of lesion with pen and checking site
for resolution after 24 hours)
● check for evidence of symptomatic dermatographism (dermographism) if suspected by his-

tory of wheal formation within minutes of pressure applied to skin 2,4
⚬ dermatographic wheals may present as linear swellings that developed after leaning
against a !rm edge of furniture
⚬ consider testing for dermatographism by stroking skin with tongue blade
⚬ positive response if pruritic palpable wheal present within 10 minutes of testing
⚬ whealing of the skin (after !rm stroking) without itching or burning sensation is simple
dermatographism (a common physiological variant), not symptomatic dermatographism
● check for jaundice, suggesting any underlying hepatic disease 2
HEENT
● assess for swelling in face, lips, mouth, throat, and larynx suggestive of angioedema 4
Lungs
● if concern for angioedema or anaphylaxis, listen for wheezing and other signs of bron-
chospasm 4
Extremities
● check for synovitis if autoimmune disorder suggested by history 2
Diagnosis
Making the Diagnosis
● diagnosis of acute urticaria is made clinically based on patient history and physical exam
with identi!cation of typical itchy wheals anywhere on the skin (with or without angioede-
ma) 1,2
● suspect and treat for anaphylaxis if urticaria presents and/or angioedema present with
symptoms of other organ systems, such as 2
⚬ wheezing, dyspnea, cough, or other signs of pulmonary tract involvement
⚬ vomiting, diarrhea
⚬ dizziness and/or loss of consciousness
⚬ changes in blood pressure or heart rate
⚬ see also Anaphylaxis for evaluation and treatment
● medication-induced or allergic (immunoglobulin E [IgE]-mediated) acute urticaria can be
suspected in patients with
⚬ temporal relationship between trigger or drug administration and urticaria (typically de-
velops about 1 hour after drug administration)
⚬ medication in which urticaria is a recognized adverse e#ect
⚬ resolution or improvement of urticaria when trigger or medication is withdrawn
⚬ recurrent acute urticaria upon challenge or accidental reexposure to medication, or skin
prick testing to suspected allergen
Di!erential Diagnosis
● consider other conditions with similar clinical presentations, such as 2

⚬ viral exanthems (most common skin eruption in children)
⚬ arthropod bites
⚬ !xed-drug skin eruptions

⚬ photodermatitis
⚬ serum sickness-like reactions
⚬ contact dermatitis
⚬ anaphylaxis-associated reactions
⚬ drug hypersensitivity syndrome
⚬ Stevens-Johnson syndrome/toxic epidermal necrolysis
⚬ erythema multiforme
⚬ bullous pemphigoid (prebullous stage) and dermatitis herpetiformis
⚬ cryopyrin-associated periodic syndromes (CAPS)
– familial cold autoin"ammatory syndrome (FCAS)
– Muckle-Wells syndrome (MWS)
– chronic infantile neurologic cutaneous articular syndrome (CINCA)
⚬ Schnitzler syndrome
⚬ Gleich syndrome
⚬ phospholipase Cg2-associated antibody de!ciency
Testing Overview
● acute urticaria usually does not require diagnostic workup due to its self-limiting nature
except in cases of suspected immunoglobulin E (IgE)-mediated food allergy or eliciting fac-
tors such as nonsteroidal anti-in"ammatory drugs (NSAIDS) 1
● if necessary, testing may be guided by detailed patient history and exam assessment of
most common triggers of acute urticaria, including 3,4
⚬ recent infections, contagious exposures, and travel history
⚬ food exposures
⚬ latex or other contact exposures
⚬ medication or drug ingestions
⚬ recent insect bites or stings
⚬ comorbid illnesses
● if potential allergen reported by history, consider testing for allergic trigger, after initial
symptoms resolved, with serum speci!c IgE assays or skin prick test 2
⚬ consider also testing for common hidden allergens such as foods or latex
⚬ in patients with suspected food allergy, also consider
– patient-recorded food diary detailing timing and severity of symptoms for 1 week
– oral food challenge test
⚬ see also Immunoglobulin E (IgE)-mediated Food Allergy and Hymenoptera Sting Allergy
● if no identi!able cause detected by detailed history and physical exam
⚬ European Academy of Allergology and Clinical Immunology/Global Allergy and Asthma
European Network/European Dermatology Forum/World Allergy Organization
(EAACI/GA2LEN/EDF/WAO) 2018 guideline recommends against any routine diagnostic
testing for acute spontaneous urticaria 1
⚬ extensive evaluation without suspected comorbid illness not recommended, but Ameri-
can Academy of Allergy, Asthma & Immunology (AAAAI) and American College of Allergy,
Asthma & Immunology (ACAAI) 2014 guidelines suggest considering limited assessment
based on patient history, with select blood tests, such as complete blood count (CBC)
with di#erential, erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone
(TSH), and renal and liver pro!le 2
⚬ Australasian College of Dermatologists recommends against investigating episodes of
acute urticaria of < 6-week duration unless clinical history or examination reveals a likely
infective, in"ammatory, or neoplastic trigger or swelling and skin changes persist for >
24 hours (Choosing Wisely Australia 2016 Mar 1)
● consider skin biopsy only if clinical diagnosis unclear (AAAAI/ACAAI Grade C) 2
Management
Management Overview
● evaluate need for emergency treatment as urticaria may be early sign of anaphylaxis
● if anaphylaxis suspected, treat with epinephrine 0.3-0.5 mg (0.01 mg/kg in children up to
0.3 mg) intramuscularly in anterolateral thigh every 5-10 minutes as needed to control
symptoms and maintain blood pressure (see also Anaphylaxis)
● if signs of angioedema of the larynx or tongue, monitor airway patency
● mainstay of treatment of acute urticaria is identifying and eliminating any underlying cause
or trigger, which may require any of the following
⚬ discontinuing triggering drug
⚬ avoiding physical stimulus or exposures
⚬ eliminating infectious trigger

⚬ avoiding food allergens or other allergens
● use oral second-generation H1 antihistamines as !rst-line therapy for urticaria, including
spontaneous acute urticaria, triggered urticaria and inducible urticarias (including dermo-
graphism [dermatographism], cold, delayed pressure, heat, solar, vibratory, cholinergic,
contact, aquagenic, and adrenergic urticaria) (EAACI Strong recommendation, High-quality
evidence; AAAAI/ACAAI Grade B)
⚬ frequent monitoring and adjustment of antihistamine dosing often needed
⚬ options for second-generation H1 antihistamines and their standard FDA dosing include
– cetirizine (Zyrtec, available as oral formulations; Quzyttir, available as injection)
● adults:
⚬ oral: up to 10 mg orally once daily (5 mg orally once daily for adults ≥ 65 years
old)
⚬ injection: 10 mg IV over 1-2 minutes every 24 hours as needed
● children:
⚬ oral:
– aged 6-11 months: 2.5 mg orally once daily
– aged 12-23 months: 2.5 mg orally once daily; may increase dose to 2.5 mg
orally every 12 hours
– aged 2-5 years: 2.5 mg orally once daily; may increase dose to 5 mg orally
once daily or 2.5 mg orally every 12 hours
– aged 6-17 years: 5 or 10 mg (depending on symptom severity) orally once dai-
ly
⚬ injection:
– aged 6 months to 5 years: 2.5 mg IV over 1-2 minutes every 24 hours as need-
ed
– aged 6-11 years: 5 or 10 mg (depending on symptom severity) IV over 1-2
minutes every 24 hours as needed
– ≥ 12 years old: 10 mg IV over 1-2 minutes every 24 hours as needed
– desloratadine (Clarinex)
● adults: 5 mg orally once daily
● children:
⚬ aged 6-11 months: 1 mg orally once daily

⚬ aged 1-5 years: 1.25 mg orally once daily
⚬ aged 6-11 years: 2.5 mg orally once daily
⚬ ≥ 12 years old: 5 mg orally once daily
– levocetirizine (Xyzal)
● adults: 2.5 or 5 mg orally once daily in evening
● children:
⚬ aged 6 months to 5 years: 1.25 mg orally once daily in evening (do not exceed
recommended dose)
⚬ aged 6-11 years: 2.5 mg orally once daily in evening (do not exceed recommend-
ed dose)
⚬ ≥ 12 years old: 2.5 mg or 5 mg orally once daily in evening
– loratadine (Claritin)
● children:
⚬ aged 2-5 years: 5 mg orally once daily
– fexofenadine (Allegra)
● adults: 60 mg orally twice daily or 180 mg orally once daily
● children:
⚬ aged 6 months to < 2 years: 15 mg orally twice daily
⚬ aged 2-11 years: 30 mg orally twice daily
⚬ ≥ 12 years old: 60 mg orally twice daily or 180 mg orally once daily
– examples of oral second-generation H1 antihistamines available outside the of United
States include bilastine, ebastine, olopatadine, and rupatadine
● for patients unresponsive to second-generation H1 antihistamines in standard dosing, con-
sider up-dosing second-generation H1 antihistamines up to 4-fold standard dosing (EAACI
Conditional recommendation, High-quality evidence)
● in patients who do not achieve symptom control with higher-dose second-generation anti-
histamine, consider addition of !rst-generation H1 antihistamines at bedtime, after dis-
cussing adverse e#ects with patients 2,4
⚬ safety pro!le of !rst-generation antihistamines is lower than second-generation class
⚬ discuss adverse e#ects of these medications with patients, including sedation, dizziness,
confusion, and impaired motor control
⚬ use !rst-generation antihistamines with caution in older adults
● consider addition of short course (< 10 days) of oral corticosteroids (for example, pred-
nisone 20-50 mg/day) in patients with acute urticaria who are unresponsive to up-dosed
antihistamines (EAACI Conditional recommendation, Low-quality evidence; AAAAI/ACAAI
Grade C)
● in children, consider same treatment regimen, with weight-adjusted dosing, as in adults 1
● in pregnant and lactating persons, consider same treatment regimen, with preference for
loratadine or cetirizine (EEACI Weak recommendation, Clinical consensus)
● for patients suspected or known to have allergen-based urticaria and/or associated ana-
phylactic reaction, prescribe epinephrine autoinjector (such as EpiPen, Auvi-Q, Adrenaclick,
and Symjepi) for personal use 2
Diet
● in patients with immunoglobulin E (IgE)-mediated acute urticaria, elimination of causative

agent reported to improve symptoms within 24-28 hours
⚬ foods most commonly identi!ed as allergens in adults include
– seafood
– tree nuts
– peanuts
⚬ foods most commonly identi!ed as allergens in children include
– milk
– eggs
– wheat
– tree nuts
– peanuts
– seafood
Medications
Antihistamines
● second-generation H1 antihistamines are considered !rst-choice for treatment of urticaria

(EAACI Strong recommendation, High-quality evidence; AAAAI/ACAAI Grade B) 1,2
⚬ frequent monitoring, adjustment of dosing often needed
⚬ if symptoms unresponsive to antihistamine at standard dosing, consider up-dosing oral
second-generation H1 antihistamines that do not cause sedation up to 4-fold of ap-
proved dosing (EAACI Conditional recommendation, High-quality evidence)
⚬ do not increase dose higher than 4-fold standard dosed H1 antihistamime (EAACI Strong
recommendation, High-quality evidence
⚬ e#ective antihistamine regimens should be continued 4-6 weeks, then tapered o# (Am J
Clin Dermatol 2009;10(4):239)
● in children, consider same !rst-line treatment with second-generation H1 antihistamines
and up-dosing (with age- and weight-adjusted dosing) as adults 1
● options for second-generation H1 antihistamines and their standard FDA dosing include
1,2
⚬ cetirizine (Zyrtec, available oral formulations may include tablets, chewable tablets, oral-
ly disintegrating tablets, capsules, oral solution, or syrup; Quzyttir, available as injection)
– adults:
● oral: up to 10 mg orally once daily (5 mg orally once daily for adults ≥ 65 years old)
● injection: 10 mg IV over 1-2 minutes every 24 hours as needed
– children:
● oral:
⚬ aged 6-11 months: 2.5 mg orally once daily
⚬ aged 12-23 months: 2.5 mg orally once daily; may increase dose to 2.5 mg orally
every 12 hours
⚬ aged 2-5 years: 2.5 mg orally once daily; may increase dose to 5 mg orally once
daily or 2.5 mg orally every 12 hours
⚬ aged 6-17 years: 5 or 10 mg (depending on symptom severity) orally once daily
● injection:
⚬ aged 6 months to 5 years: 2.5 mg IV over 1-2 minutes every 24 hours as needed
⚬ aged 6-11 years: 5 or 10 mg (depending on symptom severity) IV over 1-2 min-
utes every 24 hours as needed
⚬ ≥ 12 years old: 10 mg IV over 1-2 minutes every 24 hours as needed

⚬ not recommended in children < 6 years old with renal or hepatic impairment
⚬ desloratadine (Clarinex, available formulations may include tablets and orally disinte-
grating tablets)
– adults: 5 mg orally once daily
– children (safety and e$cacy of orally disintegrating tablets not established in children
< 6 years old):
● aged 6-11 months: 1 mg orally once daily
● aged 1-5 years: 1.25 mg orally once daily
● aged 6-11 years: 2.5 mg orally once daily
● ≥ 12 years old: 5 mg orally once daily
– dose adjustments needed for renal or liver impairment in patients ≥ 12 years old: 5
mg orally every other day
⚬ levocetirizine (Xyzal, available formulations may include tablets or oral solution)
– adults: 2.5 or 5 mg orally once daily in evening
– children:
● aged 6 months to 5 years: 1.25 mg orally once daily in evening (do not exceed rec-
ommended dose)
● aged 6-11 years: 2.5 mg orally once daily in evening (do not exceed recommended
dose)
● ≥ 12 years old: 2.5 mg or 5 mg orally once daily in evening
– dose adjustments needed for renal impairment in patients ≥ 12 years old
● creatinine clearance (CrCl) 50-80 mL/min: 2.5 mg orally once daily
● CrCl 30-50 mL/min: 2.5 mg orally once every other day
● CrCl 10-30 mL/min: 2.5 mg orally twice weekly (once every 3-4 days)
● CrCl < 10 mL/min, end-stage renal disease, or patients undergoing hemodialysis:
use is contraindicated
– contraindicated in children aged 6 months to 11 years with renal impairment
⚬ loratadine (Claritin, available formulations may include tablets, capsules, chewable
tablets, orally disintegrating tablets, syrup, or oral suspension)
– adults: 10 mg orally once daily
– children:
● aged 2-5 years: 5 mg orally once daily

● ≥ 6 years old: 10 mg orally once daily
⚬ fexofenadine (Allegra, available formulations may include tablets, capsules, or oral sus-
pension)
– adults: 60 mg orally twice daily or 180 mg orally once daily
– children:
● aged 6 months to < 2 years: 15 mg orally twice daily
● aged 2-11 years: 30 mg orally twice daily
● ≥ 12 years old: 60 mg orally twice daily or 180 mg orally once daily
– dose adjustments needed for renal impairment:
● children:
⚬ aged 6 months to < 2 years: 15 mg orally once daily
⚬ aged 2-11 years: 30 mg orally once daily
⚬ examples of oral second-generation H1 antihistamines available outside of the United
States include bilastine, ebastine, olopatadine and rupatadine
● addition of !rst-generation antihistamine at bedtime may be considered in certain adults
who have not achieved symptom control with higher-dose second-generation antihista-
mines 2,4
⚬ however, the safety pro!le of !rst-generation antihistamines is lower than that of the
second-generation antihistamines
⚬ !rst-generation antihistamines have anticholinergic adverse e#ects, and should be used
with caution in older adults and children
⚬ discuss adverse e#ects with patients, including sedation, confusion, dizziness, and im-
paired motor control
⚬ examples of options include diphenhydramine (Benadryl), hydroxyzine (Vistaril), cypro-
heptadine (Periactin), and chlorpheniramine (Allerest)
● antihistamine use during pregnancy and lactation 1
⚬ consider using same treatment algorithm with caution both in pregnant and lactating
persons after risk-bene!t assessment; avoid drugs contraindicated in pregnancy (EAACI
Consensus recommendation)
⚬ prefer loratadine, with possible extrapolation to desloratadine, and cetirizine, with possi-
ble extrapolation to levocetirizine
⚬ !rst-generation H1 antihistamines should be avoided in pregnant persons
⚬ increased dosage of second-generation H1 antihistamines can only be carefully suggest-
ed in pregnancy, due to lack of safety studies
⚬ all antihistamines are transmitted in breast milk in low concentrations
– use of second-generation H1 antihistamines is advised
– avoid !rst-generation H1 antithistamines in lactating persons, as they may cause se-
dation in nursing infants
STUDY
● SUMMARY
IV cetirizine associated with similar reduction in pruritus severity compared to IV
diphenhydramine in adults presenting to emergency departments (EDs) and urgent care
centers with acute urticaria DynaMed Level 2
RANDOMIZED TRIAL: Ann Emerg Med 2020 Oct;76(4):489

Details
⚬ based on randomized noninferiority trial without per-protocol analysis
⚬ 262 adults (mean age 39 years, 63% women) presenting to EDs and urgent care centers
with acute urticaria were randomized to cetirizine 10 mg IV vs. diphenhydramine 50 mg
IV and followed for 28 days
⚬ all patients had patient-rated pruritus severity score ≥ 1 point (score range 0-3 points
with higher scores indicating greater severity)
⚬ mean patient-rated pruritus severity score at baseline was 2.2 in both groups
⚬ noninferiority of cetirizine de!ned as reduction in patient-rated pruritus score at 2 hours
< 0.5 points worse than with diphenhydramine at limit of 95% CI for di#erence
⚬ for patients discharged before 2-hour assessment (60%), patient-rated pruritus severity
score was based on last observation carried forward; all patients included in analysis
⚬ comparing cetirizine vs. diphenhydramine
– mean reduction in patient-rated pruritus severity score at 2 hours 1.6 points vs. 1.5
points (95% CI for di#erence 0.1 point worse to 0.3 points better, noninferiority met)
– need for rescue medication in 15% vs. 27.4% (p = 0.016, NNT 8)
– return to treatment center within 48 hours of discharge in 5.5% vs. 14.1% (p = 0.02,
NNT 12)
– mean time in treatment center 1.7 hours vs. 2.1 hours (p = 0.005)
– ≥ 1 adverse event in 3.9% vs. 13.3% (no p value reported)
⚬ cetirizine associated with less sedation compared to diphenhydramine

⚬ most common adverse events with diphenhydramine were dizziness and nausea
⚬ no deaths or adverse events leading to study withdrawal in either group
⚬ Reference - ETTAU-03 trial (Ann Emerg Med 2020 Oct;76(4):489)
H2 Blockers (H2 Antihistamines)
● for patients with suspected IgE or histaminergic-related urticaria and angioedema, in ur-
gent and emergency settings
⚬ consider combination diphenhydramine and H2 blocker (H2 antihistamine), which is re-
ported to be more e#ective than diphenhydramine alone for anaphylaxis; additionally
adding an H2 blocker to H1 antihistamine may help prevent hypotension and urticaria
associated with pruritus secondary to histamine (Acad Emerg Med 2014 Apr;21(4):469, J
Allergy Clin Immunol 2010 Sep;126(3):477-80.e1-42 )
⚬ dosing is same as dosing recommended for adjunctive use of antihistamines in anaphy-
laxis
– H1 antihistamine such as diphenhydramine
● adults: 25-50 mg IV over 10-15 minutes once
● children: 1 mg/kg (maximum dose 50 mg) IV over 10-15 minutes once
● identical oral doses may be su$cient for milder episodes
– H2 antihistamine such as
● famotidine 20 mg IV once in adults
● cimetidine 4 mg/kg IV once in adults
– References - Int J Emerg Med 2012 Nov 6;5(1):39, American Academy of Allergy, Asth-
ma, and Immunology/American College of Allergy, Asthma, and Immunology
(AAAAI/ACAAI) Joint Task Force: Anaphylaxis - a practice parameter update 2015 (Ann
Allergy Asthma Immunol 2015 Nov;115(5):341), Ann Allergy Asthma Immunol 2014
Dec;113(6):599, Ann Pharmacother 1992 Jun;26(6):782
⚬ ranitidine is discontinued in the United States and European Union due to presence of
N-Nitrosodimethylamine (NMDA), a probable human carcinogen (FDA Press Release
2020 Apr 1 , EMA Press Release 2020 Sep 18 )
⚬ see also Angioedema
● insu$cient evidence to recommend for or against H2 blockers in patients unresponsive to
up-dosed H1 antihistamines (EAACI Consensus recommendation) 1
STUDY
● SUMMARY
limited evidence to compare H2 blockers to diphenhydramine for acute urticaria, but
addition of H2 blocker to diphenhydramine may improve urgent symptoms in the emer-
gency department DynaMed Level 2
COCHRANE REVIEW: Cochrane Database Syst Rev 2012 Mar 14;(3):CD008596
Details
⚬ based on Cochrane review with limited evidence
⚬ systematic review of 4 randomized trials evaluating H2 blockers in 144 patients with
acute urticaria
⚬ 2 small trials compared H2 blocker vs. diphenhydramine
– no signi!cant di#erence in symptom improvement comparing
● famotidine vs. diphenhydramine in 1 trial with 25 patients
● cimetidine vs. diphenhydramine in 1 trial with 21 patients
⚬ 2 trials compared addition of H2 blocker to diphenhydramine vs. diphenhydramine
alone
– increased urticaria resolution with ranitidine plus diphenhydramine (compared to
diphenhydramine alone) in 1 trial with 91 patients (see summary below for details)
– reduced symptoms with cimetidine plus diphenhydramine (compared to diphenhy-
dramine alone) in 1 trial with 23 patients
⚬ Reference - Cochrane Database Syst Rev 2012 Mar 14;(3):CD008596
⚬ combination of IV ranitidine plus diphenhydramine is more e!ective than IV
diphenhydramine alone for resolution of mild acute urticaria DynaMed Level 1
– based on randomized trial
– 91 adults presenting to emergency department with mild acute allergic reactions
(mostly cutaneous manifestations, 12 with wheezing, 2 with hypotension) randomized
to ranitidine 50 mg IV vs. placebo
– all patients received diphenhydramine 50 mg IV
– comparing ranitidine vs. placebo
● urticaria at 2 hours in 8.3% vs. 26.2% (p = 0.02, NNT 6); among 53 patients with ur-
ticaria at baseline, resolution at 2 hours in 86% vs. 54% (NNT 4)
● angioedema or urticaria at 2 hours in 29.5% vs. 53.5% (p = 0.02, NNT 5); among 72
patients with angioedema or urticaria at baseline, resolution at 2 hours in 60% vs.
38% (NNT 5)
● additional diphenhydramine required in 4% vs. 23% (p < 0.05, NNT 6)

● no signi!cant di#erence in use of steroids, epinephrine, or hospitalization
– Reference - Ann Emerg Med 2000 Nov;36(5):462
Corticosteroids
● in severe cases, consider addition of oral corticosteroids such as prednisone or pred-

nisolone (0.5-1 mg/kg/day) for 3-10 days to control symptoms of acute urticaria 1,4
● for patients with acute urticaria who are unresponsive to up-dosed antihistamines, consid-
er addition of short course (< 10 days) of oral corticosteroids, such as prednisone 20-50
mg/day (AAAAI/ACAAI Grade C; EAACI Consensus recommendation, Low-quality
evidence) 1,2
● long-term use of oral corticosteroids for urticaria is not recommended (EAACI Strong rec-
ommendation, High-quality evidence) 1
● topical steroids are not e#ective in management of acute urticaria 1
STUDY
● SUMMARY
addition of corticosteroids in the emergency department or at home may not improve
symptoms in adults with acute urticaria DynaMed Level 2
RANDOMIZED TRIAL: Am J Emerg Med 2020 Feb 19 early online
Details
⚬ based on small randomized trial
⚬ 75 adults in the ED with acute urticaria and pruritus score > 5 by a 11- point visual ana-
logue score (VAS) randomized to 1 of the 3 following treatments
– chlorpheniramine 10 mg IV plus dexamethasone 5 mg IV once in the ED plus dis-
charge home with prednisolone 0.5 mg/kg/day orally for 5 days
– chlorpheniramine 10 mg IV plus dexamethasone 5 mg IV once in the ED
– chlorpheniramine 10 mg IV plus saline (placebo) IV once in the ED
⚬ all patients discharged with cetirizine 10 mg orally daily for 7 days
⚬ no signi!cant di#erence in pruritus by VAS at 60 minutes after treatment in the emer-
gency department comparing chlorpheniramine IV alone vs. chlorpheniramine IV plus
dexamethasone IV
⚬ urticaria activity score > 6 points (sum of daily itch and daily wheals on 4-point scale over
1 week; range 0-42 points; UAS7) at 1 week in

– 29.2% with chlorpheniramine plus dexamethasone plus prednisolone (no p values
reported)
– 0% with chlorpheniramine plus dexamethasone
– 4.2% with chlorpheniramine plus placebo
⚬ adverse e#ects including transient blurred vision, dry mouth, dyspepsia, dizziness,
headache, palpitations, perineal itching, and urinary retention in
– 4.2% with chlorpheniramine plus dexamethasone plus prednisolone
– 17.4% with chlorpheniramine plus dexamethasone
– 0% with chlorpheniramine plus placebo
⚬ Reference - Am J Emerg Med 2020 Feb 19 early online
STUDY
● SUMMARY
addition of prednisone to levocetirizine may not reduce itching in adults with acute ur-
ticaria DynaMed Level 2
RANDOMIZED TRIAL: Ann Emerg Med 2018 Jan;71(1):125
Details
⚬ based on randomized trial with low adherence
⚬ 100 adults presenting to emergency department with acute urticaria (≤ 24 hours) ran-
domized to levocetirizine (5 mg/day orally for 5 days) plus prednisone (40 mg/day orally
for 4 days) vs. levocetirizine alone
⚬ patients with angioedema, anaphylaxis, or fever were excluded
⚬ !rst dose of levocetirizine and prednisone (or placebo) was given during emergency de-
partment visit and patients were observed for 1 hour after treatment initiation
⚬ overall compliance 82% in levocetirizine plus prednisone group and 78% in levocetirizine
alone group; 3 patients crossed over from levocetirizine alone to levocetirizine plus
prednisone
⚬ itching relief assessed using numeric rating scale of 0 to 10, with score of 0 indicating
complete relief of itching
⚬ comparing levocetirizine plus prednisone vs. levocetirizine alone at 2-day follow-up
– itch score of 0 in 62% vs. 76% (not signi!cant)
– median itch score 0 vs. 0 (not signi!cant)
– self-reported rash resolution in 70% vs. 78% (not signi!cant)
– ≥ 1 relapse in 30% vs. 24% (not signi!cant)
⚬ no signi!cant di#erence between groups in adverse e#ects

⚬ Reference - Ann Emerg Med 2018 Jan;71(1):125
STUDY
● SUMMARY
prednisolone may reduce symptoms sooner than loratadine in patients with acute ur-
ticaria DynaMed Level 2
COHORT STUDY: Acta Derm Venereol 1996 Jul;76(4):295

Details
⚬ based on prospective cohort study
⚬ 109 patients (mean age 31 years) with acute urticaria (most with moderate-to-severe dis-
ease) seen between December 1992 and November 1994 at a dermatology clinic were
treated with loratadine or prednisolone
– 44 patients treated with loratadine 10 mg/day until remission
– 65 patients treated with prednisolone 50 mg/day for 3 days, then loratadine 10
mg/day until remission
⚬ all patients followed until complete remission
⚬ disease course was self-limiting in 100% of patients (longest duration was 3 weeks)
⚬ complete remission within 3 days occurred in 93.8% treated with prednisolone vs. 65.9%
with loratadine (p < 0.001, NNT 4)
⚬ Reference - Acta Derm Venereol 1996 Jul;76(4):295
Consultation and Referral

● consider referral to allergist or dermatologist for patients with any of the following
⚬ urticaria associated with anaphylaxis
⚬ suspected immunoglobulin E (IgE)-mediated cause of acute urticaria if symptoms persist
after elimination diet
⚬ acute urticaria with unidenti!ed cause and continued symptoms after 1-2 weeks of
treatment
⚬ acute urticaria not well controlled on antihistamine medication or symptoms or medica-
tion adverse e#ects that are interfering with participation in routine activities and im-
pairing quality of life
Follow-up
● follow-up patients in 2-6 weeks to assess symptoms and treatment response 2

● for patients with urticaria associated with anaphylactic reaction, provide patient with in-
jectable epinephrine (such as EpiPen, Auvi-Q, Adrenaclick, or Symjepi) and education for
2,4
self-administration
⚬ teach patients and caregivers of children how to use epinephrine and appropriate cir-
cumstances for administering it
⚬ epinephrine is never contraindicated in life-threatening situations such as anaphylaxis
⚬ prescribe 2-3 packs (each pack contains 2 pens) of self-injectable epinephrine autoinjec-
tors (available in 0.1 mg, 0.15 mg, and 0.3 mg doses)
⚬ patients should be instructed to carry 2 epinephrine autoinjectors (1 pack) in case of
biphasic reactions where a second dose is needed
⚬ in patients with relatively low risk of severe anaphylactic reaction, necessity of carrying
injectable epinephrine determined by patient and physician
⚬ References - Ann Allergy Asthma Immunol 2015 Nov;115(5):341, J Allergy Clin Immunol
2011 Apr;127(4):852
⚬ see also Anaphylaxis
● for patients with known allergic urticaria, epinephrine emergency action plan from Food
Allergy and Research and Education (FARE) can be found at FARE website
Complications and Prognosis
Complications
● potentially life-threatening and other complications associated with underlying cause or

urticaria (such as infection or allergic reaction) may include
⚬ anaphylaxis
⚬ syncope
⚬ bronchospasm
⚬ vomiting
⚬ diarrhea
Prognosis
● acute urticaria is typically self-limited and resolves with proper avoidance of triggers 4
● individual wheals typically resolve within 24 hours, although episode may persist for sever-
al days in which new wheals develop in di#erent areas 3
● most patients with urticaria do not have systemic reactions, but some allergic and inducible
urticarias (cold- or exercise-induced) may progress to anaphylaxis (Am J Clin Dermatol
2009;10(4):239)
● infection-induced acute urticaria usually lasts 1-3 weeks (Am J Clin Dermatol
2009;10(4):239)
STUDY
● SUMMARY
approximately 6% of patients with new-onset urticaria may develop chronic urticaria
COHORT STUDY: Allergol Int 2019 Jan;68(1):52
Details
⚬ based on prospective cohort study
⚬ 1,027,620 patients in South Korea with no history of urticaria were evaluated for diagno-
sis of new-onset urticaria (≥ 2 outpatient visits for urticaria and a prescription for ur-
ticaria medicine) between 2004 and 2013
⚬ 49,129 patients (4.8%) had diagnosis of new-onset urticaria over 10-year period, of
whom 2,980 (6.1%) developed chronic urticaria (based on continuous urticaria manage-
ment for ≥ 6 weeks)
⚬ children aged 0-9 years had lowest rate of chronic urticaria (1.2%) compared to patients
aged ≥ 10 years (7%-8.1%)
⚬ Reference - Allergol Int 2019 Jan;68(1):52
⚬ see Chronic Urticaria for additional information
STUDY
● SUMMARY
corticosteroid use for acute urticaria may be associated with laryngeal edema, food trig-
gers, and increased risk of relapse within 7 days after first episode of urticaria in adults
COHORT STUDY: J Dermatol 2019 May;46(5):383
Details
⚬ based on cohort study
⚬ 184 adults (mean aged 42 years, range 26-58 years) with a !rst episode of acute urticaria
(triggers identi!ed in 35%) were reviewed for treatment and outcomes with median fol-
low-up of 26 months
⚬ patients with anaphylaxis were excluded
⚬ treatments included antihistamines in 167 (91%) and corticosteroids in 102 (55%)

⚬ overall, relapse within 7 days in 85 (46%), relapse within 6 weeks in 168 (91%), and per-
sistence at median 26 months follow-up in 122 (66%)
⚬ compared to no corticosteroid use, corticosteroids associated with
– prevalence of food as trigger of acute urticaria (8% with corticosteroids vs. 5% without
corticosteroids, p = 0.03)
– laryngeal edema at presentation (12% with corticosteroids vs. 2% without corticos-
teroids, p = 0.01)
– increased risk of relapse within 7 days (odds ratio 1.93, 95% CI 1.06-3.57, p = 0.03)
⚬ Reference - J Dermatol 2019 May;46(5):383
Prevention and Screening

● not applicable
Quality Improvement
Choosing Wisely Italy
● Italian Society of Pediatric Allergy and Immunology (SIAIP) recommends to avoid perform-
ing routine allergy testing in children with acute urticaria (Choosing Wisely Italy 2014 Jun
, Choosing Wisely Italy 2014 Jun PDF [Italian])
Guidelines and Resources
Guidelines
International Guidelines
● European Academy of Allergy and Clinical Immunology/Global Allergy and Asthma Eu-
ropean Network/European Dermatology Forum/Asia Paci!c Association of Allergy, Asthma
and Clinical Immunology (EAACI/GA2LEN/EDF/APAAACI) guideline on de!nition, classi!ca-
tion, diagnosis, and management of urticaria can be found in Allergy 2021 Sep 18 early on-
line
● European Academy of Allergy and Clinical Immunology/Global Allergy and Asthma Eu-
ropean Network/European Dermatology Forum/World Allergy Organization

(EAACI/GA2LEN/EDF/WAO) guidelines on
⚬ de!nition, classi!cation, and diagnosis of urticaria can be found in Allergy 2009
Oct;64(10):1417
⚬ management of urticaria can be found in Allergy 2009 Oct;64(10):1427
⚬ summary of EAACI/GA2LEN/EDF/WAO guideline can be found in World Allergy Organ J
2012 Jan;5 Suppl 1:S1
● EAACI/GA2LEN/EDF/Urticaria Network (UNEV) consensus recommendation on de!nition
and diagnostic testing of physical and cholinergic urticarias can be found in Allergy 2009
Dec;64(12):1715
● EAACI/GA2LEN consensus report on autologous serum skin test in urticaria can be found in
Allergy 2009 Sep;64(9):1256
United States Guidelines
● American College of Allergy, Asthma, and Immunology/Society for Academic Emergency

Medicine (ACAAI/SAEM) consensus parameter on the evaluation and management of an-
gioedema in the emergency department can be found in Acad Emerg Med 2014
Apr;21(4):469
● American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma,
and Immunology (AAAAI/ACAAI) Joint Task Force on Practice Parameters (JTFPP) practice
parameter on diagnosis and management acute and chronic urticaria can be found in J Al-
lergy Clin Immunol 2014 May;133(5):1270
● American Academy of Allergy, Asthma, and Immunology/American College of Allergy, Asth-

ma, and Immunology/Joint Council of Allergy, Asthma, and Immunology
(AAAAI/ACAAI/JCAAI) 2010 practice parameter on drug allergy can be found in Ann Allergy
Asthma Immunol 2010 Oct;105(4):259 , update can be found in J Allergy Clin Immunol
2022 Dec;150(6):1333.
● National Comprehensive Cancer Network (NCCN) guideline on systemic mastocytosis can

be found at NCCN website (free registration required)
● American Academy of Allergy, Asthma, and Immunology (AAAAI) report on adverse reac-
tions to drugs and biologics in patients with clonal mast cell disorders can be found in J Al-
lergy Clin Immunol 2019 Mar;143(3):880
United Kingdom Guidelines
● National Institute for Health and Care Excellence (NICE) clinical guideline on diagnosis and
management of drug allergy can be found at NICE 2014 Sep 03:CG183 PDF , summary
can be found in BMJ 2014 Sep 3;349:g4852.
● British Occupational Health Research Foundation (BOHRF) guideline on occupational con-

tact dermatitis and urticaria can be found at BOHRF 2010 PDF or in Contact Dermatitis
2010 Oct;63(4):177, Br J Dermatol 2013 Jun;168(6):1167
● British Society for Allergy and Clinical Immunology (BSACI) guidelines on
⚬ management of chronic urticaria and angioedema can be found in Clin Exp Allergy 2015
Mar;45(3):547, commentary can be found in Clin Exp Allergy 2015 Aug;45(8):1370
⚬ management of drug allergy can be found in Clin Exp Allergy 2009 Jan;39(1):43, com-
mentary can be found in Clin Exp Allergy 2010 May;40(5):697
● Royal College of Paediatrics and Child Health (RCPCH) care pathway for children with ur-
ticaria, angioedema, or mastocytosis can be found in Arch Dis Child 2011 Nov;96 Suppl
2:i34
European Guidelines
● European Academy of Allergy and Clinical Immunology (EAACI) position paper on how to
classify cutaneous manifestations of drug hypersensitivity can be found in Allergy 2019
Jan;74(1):14
● European Academy of Allergy and Clinical Immunology (EAACI)

⚬ EAACI task force report on recognizing the potential of the primary care physician in the
diagnosis and management of drug hypersensitivity can be found in Clin Transl Allergy
2018;8:16
⚬ EAACI task force position paper on evidence for autoimmune urticaria and proposal for
de!ning diagnostic criteria can be found in Allergy 2013 Jan;68(1):27
● European Academy of Allergy and Clinical Immunology/European Network of Drug Allergy
(EAACI/ENDA) position paper on diagnosis and management of hypersensitivity reactions
to nonsteroidal anti-in"ammatory drugs (NSAIDs) in children and adolescents can be found
in Pediatr Allergy Immunol 2018 Aug;29(5):469
● Spanish Academy of Dermatology and Venereology (AEDV) consensus statement on clinical
pathway for patients with acute or chronic urticaria can be found in Actas Dermosi!liogr
2016 Jul-Aug;107(6):482 [English, Spanish]
Asian Guidelines
● Taiwanese Dermatological Association consensus for the de!nition, classi!cation, diagno-

sis, and management of urticaria can be found in J Formos Med Assoc 2016
Nov;115(11):968
● Japanese Dermatology Association (JDA) guideline on diagnosis and treatment of urticaria
can be found in Nihon Hifuka Gakkai Zasshi (Jpn J Dermatol) 2011;121:1339 [Japanese]
⚬ summary of JDA guideline can be found in Allergol Int 2012 Dec;61(4):517
● Asian expert guideline on diagnosis and management of urticaria can be found in Asian
Pac J Allergy Immunol 2016 Sep;34(3):190
Review Articles
● review of epidemiology, diagnosis, and work-up of urticaria can be found in J Am Acad Der-
matol 2018 Oct;79(4):599
● review of classi!cation and pathogenesis of urticaria and angioedema can be found in Clin
Rev Allergy Immunol 2018 Feb;54(1):88
● review of acute and chronic urticaria: evaluation and treatment can be found in Am Fam
Physician 2017 Jun 1;95(11):717
● review can be found in Immunol Allergy Clin North Am 2014 Feb;34(1):11
● review of annular urticarial lesions can be found in Clin Dermatol 2022 Sep;40(5):480
● review of di#erential diagnosis of urticarial lesions can be found in Front Allergy
2022;3:808543
● review of urticaria can be found in Nat Rev Dis Primers 2022 Sep 15;8(1):61
● review of pediatric urticaria can be found in Immunol Allergy Clin North Am 2014
Feb;34(1):117
● review of pediatric urticaria can be found in Acta Derm Venereol 2013 Sep 4;93(5):500
● review of physical urticaria can be found in Curr Allergy Asthma Rep 2017 Aug;17(8):51
MEDLINE Search
● to search MEDLINE for (Acute urticaria) with targeted search (Clinical Queries), click therapy
, diagnosis , or prognosis
Patient Information
● handout from Asthma and Allergy Foundation of America
● handout from American Academy of Pediatrics or in Spanish
● handout from TeensHealth or in Spanish
References
General References Used
The references listed below are used in this DynaMed topic primarily to support background infor-
mation and for guidance where evidence summaries are not felt to be necessary. Most references
are incorporated within the text along with the evidence summaries.
1. Zuberbier T, Aberer W, Asero R, et al. The EAACI/GA2LEN/EDF/WAO guideline for the de!ni-
tion, classi!cation, diagnosis and management of urticaria. Allergy. 2018 Jul;73(7):1393-
1414, commentary can be found in Allergy 2019 Feb;74(2):411.
2. 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.
3. Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. Urticaria: A comprehensive review:

Epidemiology, diagnosis, and work-up. J Am Acad Dermatol. 2018 Oct;79(4):599-614.
4. Schaefer P. Acute and chronic urticaria: evaluation and treatment. Am Fam Physician. 2017
Jun 1;95(11):717-24.
Recommendation Grading Systems Used
● American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asth-

ma and Immunology (AAAAI/ACAAI) Joint Task Force on Practice Parameters (JTFPP) grading
system for recommendations
⚬ strength of recommendation
– Grade A - directly based on category I evidence
– Grade B - directly based on category II evidence or extrapolated from category I evi-
dence
– Grade C - directly based on category III evidence or extrapolated from category I or II
evidence
– Grade D - directly based on category IV evidence or extrapolated from category I, II, or
III evidence
– Grade LB - laboratory based
⚬ categories of evidence
– Category Ia - evidence from meta-analysis of randomized controlled trials
– Category Ib - evidence from ≥ 1 randomized controlled trial
– Category IIa - evidence from ≥ 1 controlled study without randomization
– Category IIb - evidence from ≥ 1 other type of quasi-experimental study
– Category III - evidence from nonexperimental descriptive studies (such as compara-
tive studies)
– Category IV - evidence from expert committee reports, clinical experience or opinions
of respected authorities, or both
⚬ Reference - AAAAI/ACAAI JTFPP practice parameter on diagnosis and management acute
and chronic urticaria (J Allergy Clin Immunol 2014 May;133(5):1270)
● European Academy of Allergology and Clinical Immunology/Global Allergy and Asthma Eu-
ropean Network/European Dermatology Forum/World Allergy Organization
(EAACI/GA2LEN/EDF/WAO) uses Grading of Recommendations, Assessment, Development,
and Evaluation (GRADE) system
⚬ strength of recommendations
– Strong recommendation
● most individuals should receive intervention
● most well-informed individuals would want recommended course of action and
small proportion would not
● recommendation could be used for policy making or as quality indicator
– Weak recommendation
● majority of well-informed individuals would want suggested course of action, but
an appreciable proportion would not
● policy making or quality indicator development will require extensive debate
⚬ quality of evidence
– High-quality evidence - high-quality meta-analyses, systematic reviews of randomized

controlled trials (RCTs), or RCTs with very low risk of bias
– Moderate-quality evidence - well-conducted meta-analyses, systematic reviews of
RCTs, or RCTs with low risk of bias
– Low-quality evidence
● meta-analyses, systematic reviews of RCTs, or RCTs with high risk of bias
● high-quality systematic reviews of case-controlled or cohort studies; case-con-
trolled or cohort studies with a very low risk of confounding, bias, or chance and a
high probability that the relationship is causal
● well-conducted case-controlled or cohort studies with a low risk of confounding,
bias, or chance and a moderate probability that the relationship is causal
– Very low-quality evidence
● case-controlled or cohort studies with high risk of confounding, bias, or chance and
signi!cant risk that relationship is not causal
● nonanalytic studies (such as case reports or case series)
● expert opinion
⚬ Reference - EAACI/GA2LEN/EDF/WAO guideline on management of urticaria (Allergy 2014
Jul;69(7):868)
Synthesized Recommendation Grading System for DynaMed Content
● The DynaMed Team systematically monitors clinical evidence to continuously provide a

synthesis of the most valid relevant evidence to support clinical decision-making (see 7-
Step Evidence-Based Methodology ).
● Guideline recommendations summarized in the body of a DynaMed topic are provided
with the recommendation grading system used in the original guideline(s) and allow users
to quickly see where guidelines agree and where guidelines di#er from each other and
from the current evidence.
● In DynaMed content, we synthesize the current evidence, current guidelines from leading
authorities, and clinical expertise to provide recommendations to support clinical decision-
making in the Overview & Recommendations section.
● We use the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) approach to classify synthesized recommendations as Strong or Conditional.
⚬ Strong recommendations may be used when, based on the available evidence, clini-
cians (without con"icts of interest) consistently have a high degree of con!dence that
the desirable consequences (health bene!ts, decreased costs and burdens) outweigh
the undesirable consequences (harms, costs, burdens).
⚬ Conditional recommendations may be used when, based on the available evidence,
clinicians believe that desirable and undesirable consequences are !nely balanced, or
appreciable uncertainty exists about the magnitude of expected consequences (bene!ts
and harms).
⚬ Conditional recommendations may be used when clinicians disagree in judgments of
the relative bene!t and harm or have limited con!dence in their judgments.
⚬ Conditional recommendations may also be used when the range of patient values and
preferences suggests that informed patients are likely to make di#erent choices.
● DynaMed synthesized recommendations (in the Overview & Recommendations section)
are determined with a systematic methodology.
⚬ Recommendations are explicitly labeled as Strong recommendations or Conditional
recommendations when a quali!ed organization has explicitly deliberated on making
such a recommendation.
⚬ Recommendations are phrased to match the strength of recommendation.
– Strong recommendations use "should do" phrasing, or phrasing implying an expec-
tation to perform the recommended action for most patients.
– Conditional recommendations use "consider" or "suggested" phrasing.
⚬ Recommendations are veri!ed by ≥ 1 editor with methodological expertise, not involved
in recommendation drafting or development, with explicit con!rmation that Strong rec-
ommendations are adequately supported.
⚬ Recommendations are published only after consensus is established with agreement in
phrasing and strength of recommendation by all editors.
⚬ If recommendations are questioned during peer review or post publication by a quali-
!ed individual, or reevaluation is warranted based on new information detected through
systematic literature surveillance, the recommendation is subject to additional internal
review.
DynaMed Editorial Process

● DynaMed topics are created and maintained by the DynaMed Editorial Team and ad-
here to evidence-based methodology and inclusive language standards .
● All editorial team members and reviewers have declared that they have no !nancial or oth-
er competing interests related to this topic, unless otherwise indicated.
● DynaMed content includes Practice-Changing Updates, with support from our partner, Mc-
Master University.
Special Acknowledgements
On behalf of the American College of Physicians

● Barbara Turner, MD, MSEd, MACP, ACP Deputy Editor, Clinical Decision Resource, as
part of the ACP-EBSCO Health collaboration, managed the ACP peer review of the
Overview and Recommendations section and related clinical content in this topic.
● DynaMed topics are written and edited through the collaborative e#orts of the above indi-
viduals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic
medical practice. Recommendations Editors are actively involved in development and/or
evaluation of guidelines.
● Editorial Team role de"nitions
Topic Editors de!ne the scope and focus of each topic by formulating a set of clinical
questions and suggesting important guidelines, clinical trials, and other data to be
addressed within each topic. Topic Editors also serve as consultants for the internal
DynaMed Editorial Team during the writing and editing process, and review the !nal
topic drafts prior to publication.
Section Editors have similar responsibilities to Topic Editors but have a broader role
that includes the review of multiple topics, oversight of Topic Editors, and systematic
surveillance of the medical literature.
Recommendations Editors provide explicit review of Overview and Recommendations

sections to ensure that all recommendations are sound, supported, and evidence-
based. This process is described in "Synthesized Recommendation Grading."
Deputy Editors oversee DynaMed internal publishing groups. Each is responsible for all
content published within that group, including supervising topic development at all
stages of the writing and editing process, !nal review of all topics prior to publication,
and direction of an internal team.
Published by EBSCO Information Services. Copyright © 2024, EBSCO Information Services. All rights reserved. No part of this
may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or
by any information storage and retrieval system, without permission.
EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is
merely intended as a general informational overview of the subject for the healthcare professional.

Acute Urticaria - DynaMed

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Acute Urticaria - DynaMed

Uploaded by

Copyright:

Available Formats

Acute Urticaria - DynaMed 17/06/24, 1:00 p.m.

CONDITION • Updated 14 Jul 2023

● Urticaria is characterized by pruritic wheals (central edema surrounded by erythema and

● clinical classi!cation of urticaria 1,2,3,4

● characterized by ≥ 6 weeks continuous activity

⚬ 70.3% of patients with chronic urticaria were women

Etiology and Pathogenesis

– hepatitis A virus (HAV) infection

● food allergens and pseudoallergens 2,3,4

⚬ IgE-mediated food allergies may cause acute urticaria

● 1.1%-4.4% for penicillins

● inducible urticarias 1,2

● urticaria is characterized by dermal edema and perivascular and interstitial in"ammatory

History and Physical

Chief Concern (CC)

jacent or distant to initial lesion

History of Present Illness (HPI)

⚬ heat urticaria (also known as heat contact urticaria)

Past Medical History (PMH)

● ask about 1,3

Family History (FH)

● ask about family history of urticaria, angioedema, or atopy 1,3

Social History (SH)

● assess for wheals, characterized by 1,2,3,4

● check for evidence of symptomatic dermatographism (dermographism) if suspected by his-

● check for jaundice, suggesting any underlying hepatic disease 2

● check for synovitis if autoimmune disorder suggested by history 2

Making the Diagnosis

● consider other conditions with similar clinical presentations, such as 2

⚬ !xed-drug skin eruptions

⚬ eliminating infectious trigger

⚬ aged 6-11 months: 1 mg orally once daily

● in patients with immunoglobulin E (IgE)-mediated acute urticaria, elimination of causative

● second-generation H1 antihistamines are considered !rst-choice for treatment of urticaria

⚬ ≥ 12 years old: 10 mg IV over 1-2 minutes every 24 hours as needed

● aged 2-5 years: 5 mg orally once daily

RANDOMIZED TRIAL: Ann Emerg Med 2020 Oct;76(4):489

⚬ cetirizine associated with less sedation compared to diphenhydramine

H2 Blockers (H2 Antihistamines)

● additional diphenhydramine required in 4% vs. 23% (p < 0.05, NNT 6)

● in severe cases, consider addition of oral corticosteroids such as prednisone or pred-

1 week; range 0-42 points; UAS7) at 1 week in

⚬ no signi!cant di#erence between groups in adverse e#ects

COHORT STUDY: Acta Derm Venereol 1996 Jul;76(4):295

Consultation and Referral

● follow-up patients in 2-6 weeks to assess symptoms and treatment response 2

Complications and Prognosis

● potentially life-threatening and other complications associated with underlying cause or

⚬ treatments included antihistamines in 167 (91%) and corticosteroids in 102 (55%)

Prevention and Screening

Choosing Wisely Italy

Guidelines and Resources

ropean Network/European Dermatology Forum/World Allergy Organization

United States Guidelines

● American College of Allergy, Asthma, and Immunology/Society for Academic Emergency

● American Academy of Allergy, Asthma, and Immunology/American College of Allergy, Asth-

● National Comprehensive Cancer Network (NCCN) guideline on systemic mastocytosis can

United Kingdom Guidelines

● British Occupational Health Research Foundation (BOHRF) guideline on occupational con-

● European Academy of Allergy and Clinical Immunology (EAACI)

2016 Jul-Aug;107(6):482 [English, Spanish]

● Taiwanese Dermatological Association consensus for the de!nition, classi!cation, diagno-

General References Used

3. Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. Urticaria: A comprehensive review: