Urticaria & Angioedema

Key Features

Essentials of Diagnosis

• Eruptions of evanescent wheals or hives with or without angioedema

• Itching is intense, but very rarely, may be absent

• Urticaria is divided into acute and chronic forms

• Most incidents are acute and self-limited (1–2 weeks)

• Chronic urticaria (lasting > 6 weeks) may have an autoimmune basis

General Considerations

• Urticaria is defined as acute (< 6 weeks' duration) or chronic (> 6 weeks' duration)

• Chronic urticaria is further divided into chronic spontaneous urticaria and chronic inducible urticaria

• Chronic inducible urticaria is reproducibly triggered by specific exposures, such as

  • Cholinergic urticaria

  • Solar urticaria

  • Cold urticaria

  • Dermatographism

  • Delayed pressure urticaria

Clinical Findings

Symptoms and Signs

• Hives or angioedema or both

• Lesions are itchy red swellings of a few millimeters to many centimeters

• The morphology of the lesions may vary over a period of minutes to hours

• Individual lesions in true urticaria last < 24 h, and often only 2–4 h

• Angioedema is involvement of deeper vessels, with swelling of the lips, eyelids, palms, soles, and genitalia in association with more typical lesions

• Angioedema is no more likely than urticaria to be associated with systemic complications such as laryngeal edema or hypotension

• In cholinergic urticaria, triggered by a rise in core body temperature (hot showers, exercise), wheals are 2–3 mm in diameter with a large surrounding red flare

Differential Diagnosis

• True urticaria should be differentiated from diseases that present with similar lesions that are not true urticaria (eg, adult-onset Still disease, urticarial vasculitis, and cryopyrin associated periodic syndromes)

• Vasculitis

• Erythema multiforme

• Contact dermatitis (eg, poison oak or ivy)

• Cellulitis

Diagnosis

• In general, a careful history and physical examination are helpful but extensive costly workups are not indicated

Laboratory Tests

• Laboratory studies are generally not helpful in the evaluation of acute or chronic urticaria unless there are suggestive findings in the history and physical examination

• A complete blood count with differential, erythrocyte sedimentation rate or C-reactive protein, thyroid-stimulating hormone, and liver chemistries may be appropriate for some patients with chronic urticaria

• Functional ELISA test can detect patients with an autoimmune basis for their chronic urticaria

• Some patients with chronic spontaneous urticaria demonstrate autoantibodies directed against mast cell IgE receptors

Diagnostic Procedures

• In patients with individual lesions that persist past 24 h, a skin biopsy may confirm neutrophilic urticaria or urticarial vasculitis

Treatment

Medications

• H₁-antihistamines

  • Hydroxyzine, 10–25 mg orally two or three times daily or as a single nightly dose of 50–75 mg to reduce daytime sedation, is initial therapy

    ...