Chronic urticaria (spontaneous / inducible)

Last Updated: 2023-07-07

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

ICD11: EB00.1

Recurrent urticaria episodes lasting longer than 6 weeks.

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

Chronic urticaria: differentiation according to aetiology.

  • Chronic spontaneous urticaria (CSU):
  • Chronic inducible urticaria:
    • Physical urticaria (pressure, vibration)
    • Cold urticaria
    • Heat urticaria
    • Light urticaria
    • Cholinergic urticaria
    • Autoimmune urticaria
    • Aquagenic urticaria
    • Exertional urticaria
    • Contact urticaria
      • Allergic
      • Non-allergic

S. Urticaria.

Stage 1

Medical history

Personal and family history for atopy, medication history (especially: ASA,

NSAIDS, β-blockers, ACE inhibitors, histamine ligators).



Dependent on time of day?



FA: Atopy? Urticaria?

Nicotine or alcohol abuse?

Is there angioedema?


Physical stimuli?



New implants?

Insect bites?

Association with menstrual cycle?

Previous therapies?


Quaddling?, petechiae, hyperpigmentation?

Dermographism?, Darier?

In isolated urticaria factitia: no further investigations

Blood count diff, CRP,TSH, fT4

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

Tryptase, IgE total, ev. Fx5
Skin testing Atopiescreening
Stage 2: according to history

Angioedema without urticaria
C1 inhibitor concentration, function, C4
Vd. a. Food allergy (rare)

allergological clarification:

skin testing, CAP, oral provocation testing (OPT)
Increase in intake of histamine-rich food low-histamine diet with nutritional counselling, complaints diary
Anamnestically unclear connection with food intake

Ev. Rice-potato diet (ev inpatient)

If improvement, try low additive diet

V.a. physical urticaria:

Cold urticaria Heat urticaria Pressure urticaria

Cholinergic urticaria Light urticaria

Aquagenic urticaria

Cold test

Heat test

Pressure test

Bicycle ergometer

UV threshold

Water test
V.a. autoreactive urticaria autologous serum test
V.a. Hepatitis Hepatitis serology, ev cryoglobulinaemia

Reflux, stomach pain

H. pylori breath test

Systemic symptoms (fever, arthral-gia, etc)

V.a. Schnitzler's syndrome (rare)

Cryopyrin-associated periodic

syndromes (rare)

Biopsy (neutrophilic urticaria?)

Immunelectrophoresis, immunofixation

Ev. NLRP3 gene mutation search, measure IL-6 in relapse
Quaddles >24h/ hyperpigmentation/petechiae, resistance to therapy Biopsy, ev. DIF, C3,C4
Darier's sign positive Biopsy (mast cell stain)
ANA increased

≤1:80 no further work-up

1:160 Follow-up

≥ 1:320 ANA specificities (depending on clinic and binding pattern)
Depending on sexual history HIV-Test
CRP↑ or leucocytosis Focus search according to history

Eosinophilia or IgE↑ or

tropical stay
Stool examination + serology
V.a. Early stage bullous

Biopsy with DIF, IIF in serum

  • Recording of suffering pressure by means of PRISM and quality of life questionnaire (CU-QoL).
  • Recording of urticaria activity by means of UAS-7 diagnostics.
  • According to guidelines, exclusion of malignant diseases is obsolete.

S. Urticaria.

  1. Zuberbier T, Henz BM. Acute and Chronic Urticaria.  Urticaria: Springer Science + Business Media; 1998:39-44.
  2. Heymann WR. Chronic urticaria and angioedema associated with thyroid autoimmunity: Review and therapeutic implications. Journal of the American Academy of Dermatology 1999;40:229-32.
  3. Sabroe RA, Poon E, Orchard GE, et al. Cutaneous inflammatory cell infiltrate in chronic idiopathic urticaria: Comparison of patients with and without anti-FcϵRI or anti-IgE autoantibodies. Journal of Allergy and Clinical Immunology 1999;103:484-93.
  4. Ring J. Desloratadine in the treatment of chronic idiopathic urticaria. Allergy 2001;56:28-32.
  5. Grattan CEH, Sabroe RA, Greaves MW. Chronic urticaria. Journal of the American Academy of Dermatology 2002;46:645-60.
  6. Kaplan AP. Chronic Urticaria and Angioedema. New England Journal of Medicine 2002;346:175-9.
  7. Yosipovitch G, Ansari N, Goon A, Chan YH, Goh CL. Clinical characteristics of pruritus in chronic idiopathic urticaria. Br J Dermatol 2002;147:32-6.
  8. Doeglas HMG. Reactions to aspirin and food additives in patients with chronic urticaria, including the physical urticarias*. British Journal of Dermatology 2006;93:135-44.
  9. Asero R, Tedeschi A, Coppola R, et al. Activation of the tissue factor pathway of blood coagulation in patients with chronic urticaria. Journal of Allergy and Clinical Immunology 2007;119:705-10.
  10. Powell RJ, Du Toit GL, Siddique N, et al. BSACI guidelines for the management of chronic urticaria and angio-oedema. Clinical & Experimental Allergy 2007;37:631-50.
  11. Engin B, Özdemir M. Prospective randomized non-blinded clinical trial on the use of dapsone plus antihistamine vs. antihistamine in patients with chronic idiopathic urticaria. Journal of the European Academy of Dermatology and Venereology 2008;22:481-6.
  12. Kaplan AP, Joseph K, Maykut RJ, Geba GP, Zeldin RK. Treatment of chronic autoimmune urticaria with omalizumab. Journal of Allergy and Clinical Immunology 2008;122:569-73.
  13. Bunselmeyer B, Laubach HJ, Schiller M, Stanke M, Luger TA, Brehler R. Incremental build-up food challenge - a new diagnostic approach to evaluate pseudoallergic reactions in chronic urticaria: a pilot study. Clinical & Experimental Allergy 2009;39:116-26.
  14. Godse K. Omalizumab in treatment-resistant chronic spontaneous urticaria. Indian Journal of Dermatology 2011;56:444.
  15. Maurer M, Altrichter S, Bieber T, et al. Efficacy and safety of omalizumab in patients with chronic urticaria who exhibit IgE against thyroperoxidase. Journal of Allergy and Clinical Immunology 2011;128:202-9.e5.
  16. Zuberbier, T. (2016). Klassifikation und Diagnostik der Urtikaria- deutschsprachige Version der internationalen S3-Leitlinie. Retrieved 30 May 2016, from
  17. Saini, S. (2016). Chronic urticaria: Clinical manifestations, diagnosis, pathogenesis, and natural history. Retrieved 30 May 2016, from