• Scenario: First episode of urticaria: covers the management of a first episode of urticaria.
• Scenario: Recurrent or persistent urticaria: covers the management of urticaria that recurs or persists.

• Urticaria is a localised or generalised superficial swelling of the skin (epidermis and mucous membranes) that results in an itchy rash.

• Confirm the diagnosis and try to identify the underlying cause using a thorough history and examination.
• Exclude angio-oedema and anaphylaxis with systemic involvement (urgent admission needed) by examining the ears, nose, and throat; listening to the person's chest; measuring blood pressure and pulse. For more information see the CKS topic on Angio-oedema and anaphylaxis.
• Investigations are not usually required.

In depth

• Treatment is not needed if the episode is mild; acute urticaria is normally self-limiting, and is not serious or infectious.
• If symptomatic treatment is needed:
• Offer a non-sedating antihistamine to control daytime symptoms.
• Consider giving an additional sedative antihistamine at night if the itch is interfering with sleep.
• For severe symptoms:
• Give a short course of oral corticosteroids (e.g. prednisolone 40 mg daily for 3–5 days) in addition to the oral antihistamine.
• If rebound symptoms occur after a short course of corticosteroids seek specialist advice. Repeat courses of steroids are not recommended.

In depth

• First choice: cetirizine, fexofenadine, or loratadine.
• Additional sedating antihistamine to aid sleep: chlorphenamine or hydroxyzine.

In depth

• Admit a person with urticaria and angio-oedema involving the airway and/or anaphylaxis. Start initial treatment with intramuscular adrenaline, if available.
• Refer to an immunologist or dermatologist when there is:
• Urticaria with angio-oedema not involving the airway.
• Acute urticaria which is severe and thought to be due to a food or latex allergy.
• Chronic persistent urticaria (usually lasting beyond 6 weeks) which is troublesome despite the use of antihistamines and avoidance of known trigger factors.
• Vasculitic urticaria: suspect if lesions are painful and persistent.

In depth

• Recurrent or persistent urticaria that lasts for more than 6 weeks is called chronic urticaria.

• Assess the severity of symptoms and their impact on daily living and psychological well-being.
• Although it is not always possible, try to identify the underlying cause using a detailed history and examination.
• Consider the following investigations to determine a possible cause: full blood count (FBC), stool sample, erythrocyte sedimentation rate (ESR), thyroid function tests (TFTs, including autoantibodies), and liver function tests (LFTs) and Helicobacter pylori screening if gastrointestinal symptoms are present.
• Identify any ongoing trigger factors such as stress, alcohol, foods, and medication.
• Consider referring people to an immunologist or dermatologist, depending on local policy.

In depth

• Manage any underlying associated diseases (e.g. H. pylori infection, thyroid disease, connective tissue disorder), although there is limited evidence that correcting these conditions will improve the urticaria itself.
• Offer a non-sedating antihistamine to control daytime symptoms.
• Consider giving an additional sedating antihistamine at night if the itch is interfering with sleep.
• Topical menthol 1% cream can be used as an alternative to, or in addition to, an oral antihistamine.
• For a severe 'flare up', give a short course of oral corticosteroids (e.g. prednisolone 40 mg daily for 3–5 days) in addition to an oral antihistamine.
• If rebound symptoms occur after a short course of corticosteroids seek specialist advice. Repeat courses of steroids are not recommended.

In depth

• First choice: cetirizine, fexofenadine, or loratadine.
• Additional sedating antihistamine to aid sleep: chlorphenamine or hydroxyzine.

In depth

• Identify and avoid trigger factors such as stress, alcohol, caffeine, spices, certain foods, overheating, medications (e.g. angiotensin-converting enzymes, aspirin, codeine, nonsteroidal anti-inflammatory drugs).
• Try not to scratch — rub skin with palms of hands, keep nails short and clean.
• Choose clothing that does not irritate the skin (e.g. cotton).
• If skin creams or detergents worsen symptoms, use lubricating, alcohol-free, hypoallergenic products.
• Consider the use of calamine lotion to soothe itch.

In depth

• If urticaria recurs or persists (usually beyond 6 weeks) and is troublesome despite antihistamines and avoidance of known trigger factors, refer to an immunologist or dermatologist.
• Any suggestion of angio-oedema will require admission to hospital or daily review until symptoms resolve. For more information, see the CKS topic on Angio-oedema and anaphylaxis.

In depth

• Admit a person with urticaria and angio-oedema involving the airway and/or anaphylaxis. Start initial treatment with intramuscular adrenaline, if available.
• Refer to an immunologist or dermatologist when there is:
• Urticaria with angio-oedema not involving the airway.
• Acute urticaria which is severe and thought to be due to a food or latex allergy.
• Chronic persistent urticaria (usually lasting beyond 6 weeks) which is troublesome despite the use of antihistamines and avoidance of known trigger factors.
• Vasculitic urticaria: suspect if lesions are painful and persistent.

In depth