Chronic Urticaria

Last Updated: 2021-10-15

Author(s): Anzengruber F., Navarini A.

ICD11: EB00.1

Recurrent urticaria episodes that last longer than 6 weeks.

  • Prevalence: about 1% of the population.
  • Women: Men = 2: 1.

Chronic urticaria: Differentiation according to aetiology.

Chronic spontaneous urticaria (CSU):

  • Idiopathic
  • Autoimmune
  • Allergy
  • Pseudoallergy - Food additives, natural salicylates, amines, spices, green teas and alcohol
  • Infections and infestations

Chronically inducible urticaria:

  • Physical urticaria (pressure, vibration)
  • Cold urticaria
  • Heat urticaria
  • Light urticaria
  • Cholinergic urticaria
  • Aquagenic urticaria
  • Exercise-induced urticaria
  • Contact urticaria 
    • Allergic
    • Non-allergic

S. Urticaria.

Step 1

Medical history

Personal and family medical history for atopy, medication history (in particular: ASS, NSAIDS, β blockers, ACE inhibitors, histamine liberators).



Time of day?



Medical specialist: Atopy? Urticaria?

Nicotine or alcohol abuse?

Existence of angioedema?


Physical stimuli?



New implants?

Insect bites?

Association with menstrual cycle?

Previous therapies?


Wheals? Petechiae, hyperpigmentation?

Dermographism? Darier?

In the case of isolated urticaria factitia: no further clarification


Blood count-  differential leucocyte count, CRP, TSH, fT4

Thyroid autoantibodies (anti-TPO, anti-TG, TRAK), ANA

Tryptase, IgE total, possibly Fx5

Skin test

Atopy screening

Step 2: according to medical history

Angioedema without urticaria

C1 inhibitor concentration, function, C4

Vd. a. Food allergy (rare)

Allergological clarification:

Skin Test, CAP, Oral Provocation Test (OPT)

Increase in intake of histamine-rich food Low-histamine diet with nutritional advice, complaint diary

Anamnestically unclear connection with food intake

Rice-potato diet (ev stationary)

With improvement attempt low-additive diet

Especially physical urticaria:

Cold urticaria
Heat urticaria
Pressure urticaria

Cholinergic Urticaria
Light Urticaria

Aquagenic urticaria


Cold test

Heat test

Pressure test

Bicycle ergometers

UV threshold

Water test

Suspected autoreactive urticaria

Autologous serum test

Suspected Hepatitis

Hepatitis serology, ev Cryoglobulinemia

Reflux, stomach pain

H. pylori breath test

Systemic symptoms (fever, arthralgia, etc)

Suspected Schnitzler syndrome (rare)

Cryopyrin-associated periodic syndromes (rare)

Biopsy (neutrophil urticaria?)

Immune electrophoresis, immunofixation

 Ev. NLRP3 gene mutation search, measure IL-6 in thrust

Hives >24h/ Hyperpigmentation/Petechiae, therapy resistance

Biopsy, possibly DIF, C3, C4

Darier sign positive

Biopsy (mast cell staining)

ANAs increased

≤1:80 no further clarification

1:160 Follow-up

≥ 1:320 ANAs specificities (depending on clinic and binding pattern)

Depending on sexual history

HIV test

CRP↑ or leucocytosis

Focus search based on medical history

Eosinophilia or IgE↑

or stay in tropical regions

Stool analysis + serology

Suspected Early stage bullous


Biopsy with DIF, IIF in serum


  • The assessment of degree of suffering by PRISM and quality of life questionnaire (CU-QoL).
  • Determination of urticaria activity using UAS-7 diagnostics.
  • According to the guidelines, the exclusion of malignant diseases is obsolete.

Usually non‐specific histology , with vascular and lymphatic dilatation, oedema and a variable perivascular cellular dermal infiltrate consisting of lymphocytes, neutrophils and eosinophils.

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