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Urticaria - Management
What assessment do I need to make for a first episode of urticaria?

  • Confirm the diagnosis and try to identify the underlying cause considering:
    • Timing of episodes (seasonal, perennial, nocturnal), geography (work, home, school), and environment (pets, smoking).
    • Drugs, including over-the-counter medicines.
    • Family history of urticaria or autoimmunity.
    • Recent travel, viral illness, or insect bites. For more information, see the CKS topic on Insect bites and stings.
    • Relationship to foods, occupation, and physical triggers.
    • Systematic enquiry, including ENT (ear, nose and throat) problems (e.g. rhinitis), gastrointestinal problems (diarrhoea, malabsorption), autoimmune disorders (diabetes, thyroid), atopy, and skin disorders.
  • Assess the severity of the episode:
    • Examine the ears, nose, and throat; listen to the person's chest; and measure blood pressure and pulse to exclude angio-oedema and anaphylaxis with systemic involvement, which needs urgent admission to hospital. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Investigations are not usually required.
Basis for recommendation
  • These recommendations are pragmatic advice based on expert opinion from the medical literature [Grattan et al, 2001; Kozel and Sabroe, 2005].
  • Investigations such as a radioallergosorbent test (RAST) or skin prick test are generally only undertaken by secondary care.
  • Depending on local policy, a RAST and/or a skin prick test should only be carried out where there is a clear link to a specific food or other agent (e.g. latex).
  • RAST is only useful for IgE-mediated reactions. These are more likely to be environmental triggers (e.g. latex, nuts). RAST is not useful for physical stimuli (cold, heat) or certain drug-reactions caused by a non-IgE-mediated mechanism.
  • Skin prick tests expose the person to an allergen extract and measure the size of the response (flare/weal) to help confirm or exclude an allergy to a specific allergen. However, the correlation between a positive skin prick test and the likelihood of developing a reaction on exposure to the allergen is not absolute [Berger, 2002].
  • Both tests can result in false-positive and -negative results.

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