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Urticaria - Management
What assessment do I need to make for recurrent or persistent urticaria?

  • Confirm the diagnosis of chronic urticaria (symptoms recur or persist for more than 6 weeks).
  • Although not always possible, try to identify the underlying cause using a detailed history and examination, 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.
  • Consider the following investigations:
    • Full blood count (FBC) looking for iron, B12 and folate deficiency, and eosinophilia of intestinal parasite infection and some drug-induced reactions.
    • Stool sample (if intestinal parasites suspected).
    • Erythrocyte sedimentation rate (ESR) — raised in vasculitic urticaria, chronic infection, and autoinflammatory syndromes.
    • Thyroid function tests (including autoantibodies).
    • Liver function tests and H. pylori screening if gastrointestinal symptoms are present.
  • Identify any ongoing trigger factors.
  • Assess the severity of symptoms and their impact on daily living and psychological well-being.
    • Itch in chronic urticaria is seen by most people as moderately or very troublesome. It may occur during the day and at night [Yosipovitch et al, 2002].
  • Consider referring people to an immunologist or dermatologist, depending on local policy.
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 are not usually helpful for identifying the underlying cause of chronic urticaria. However, there is some evidence to suggest that basic tests (e.g. FBC, stool sample, ESR, TFTs), in combination with a good history, are just as effective at identifying the cause as an extensive laboratory screen [Leznoff and Sussman, 1989; Kobza-Black and Champion, 1998; Kozel et al, 1998; Wanderer et al, 2000]. For example, a low haemoglobin concentration may suggest a chronic disorder as an underlying cause of chronic urticaria.
  • A radioallergosorbent test (RAST) is not usually needed, as allergy is only a rare cause of chronic urticaria [Wanderer et al, 2000].

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