Chronic urticaria (spontaneous / inducible)
Last Updated: 2023-07-07
Author(s): Anzengruber F., Navarini A.
ICD11: EB00.1
Last Updated: 2023-07-07
Author(s): Anzengruber F., Navarini A.
ICD11: EB00.1
Recurrent urticaria episodes lasting longer than 6 weeks.
Chronic urticaria: differentiation according to aetiology.
S. Urticaria.
Stage 1 Medical history | Personal and family history for atopy, medication history (especially: ASA, NSAIDS, β-blockers, ACE inhibitors, histamine ligators). Frequency Duration Dependent on time of day? Localisation? Infections? FA: Atopy? Urticaria? Nicotine or alcohol abuse? Is there angioedema? Incompatibilities? Physical stimuli? Occupation? Hobbies? New implants? Insect bites? Association with menstrual cycle? Previous therapies? |
Status | Quaddling?, petechiae, hyperpigmentation? Dermographism?, Darier? In isolated urticaria factitia: no further investigations |
Laboratory | 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 pemphigoid | Biopsy with DIF, IIF in serum |
S. Urticaria.
First line: Non-sedating antihistamine (nsAH) of the 2nd generation (levocetirizine (Xyzal®) p.o. 5 mg 1x tgl, desloratadine (Aerius®) p.o. 5 mg 1x tgl, fexofenadine (Telfast®) p.o. 180 mg 1x tgl)
Second line if symptom persistence > 2-4 weeks: Dose increase of nsAH up to 4 times the dose
Third line in case of symptom resistance > 2-4 weeks under second line therapy: Omalizumab (Xolair®) s.c. 300mg 1x monthly.
Alternatives: ciclosporin A, others.
Self-recording of urticaria activity: UAS-7
A clinically meaningful improvement in urticarial activity is reflected by a 10-point reduction in the UAS-7. Score |
Quad count |
Pruritus |
0 |
none |
none |
1 |
mild (<20/24h) |
mild (no subjective impairment) |
2 |
moderate (20-50/24h) |
vacuous (but no interference with daily activity or sleep) |
3 |
pronounced (>50/24h) or large confluent areas of wheals |
Expressed (interference with daily activity or sleep) |
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