Urticaria

Basic Dermatology Curriculum

Last updated September 2015

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 Module Instructions
The following module contains a number of
blue, underlined terms which are
hyperlinked to the dermatology glossary, an
illustrated interactive guide to clinical
dermatology and dermatopathology.
We encourage the learner to read all the
hyperlinked information.

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 Goals and Objectives
The purpose of this module is to help participants
develop a clinical approach to the initial
evaluation and treatment of patients with urticaria.
After completing this module, the learner should
be able to:
Describe the morphology of urticaria
Distinguish between acute and chronic urticaria
Develop an initial treatment plan for a patient with
acute or chronic urticaria
Recognize the signs and symptoms of anaphylaxis

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 Urticaria: The Basics
Urticaria (hives) is a vascular reaction of
the skin characterized by wheals
surrounded by a red halo or flare (area of
erythema)
Cardinal symptom is PRURITUS (itch)
Urticaria is caused by swelling of the upper
dermis
Up to 20% of the population experience
urticaria at some point in their lives

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 Angioedema: The Basics
Angioedema can be caused by the same pathogenic
mechanisms as urticaria, but the pathology is in the
deep dermis and subcutaneous tissue and swelling is
the major manifestation
Angioedema commonly affects the face or a portion
of an extremity
Involvement of the lips, cheeks, and periorbital areas is
common, but angioedema also may affect the tongue,
pharynx, larynx and bowels
May be painful or burning, but usually not pruritic
May last several days

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Examples of Urticaria

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Example of Angioedema

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 Urticaria & Angioedema
Urticaria and angioedema may occur in any
location together or individually.
Angioedema and/or urticaria may be the
cutaneous presentation of anaphylaxis, so
assessment of the respiratory and
cardiovascular systems is vital.

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 Urticaria: Clinical Findings
Lesions typically appear over the course of
minutes, enlarge, and then disappear within
hours
Individual wheals rarely last >12hrs
Surrounding erythema will blanch with pressure
Urticaria may be acute or chronic
Acute = new onset urticaria < 6 weeks
Chronic = recurrent urticaria (most days) > 6 weeks
Most urticaria is acute and resolves

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 Common Causes of Acute Urticaria
Idiopathic
Infection
Upper respiratory, streptococcal infections,
helminths
Most common cause of urticaria in children is viral
illness
Food reactions
Shellfish, nuts, fruit, etc.
Drug reactions
IV administration
Blood products, contrast agents

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 Etiology of Chronic Urticaria
Idiopathic: over 50% of chronic urticaria
Physical urticarias: many patients with chronic urticaria
have physical factors that contribute to their urticaria
These factors include pressure, cold, heat, water
(aquagenic), sunlight (solar), vibration, and exercise
Cholinergic urticaria is triggered by heat and emotion
The diagnosis of pure physical urticaria is made when the
sole cause of a patients urticaria is a physical factor
Autoimmune Urticaria: possibly a third or more of patients
with chronic urticaria
Other: infections, ingestions, medications

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 Dermatographism
Most common form of
physical urticaria
Sharply localized edema or
wheal within seconds to
minutes after the skin has
been rubbed
Affects 2-5% of the
population

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 Urticaria Multiforme
A subset of pediatric urticaria
with larger polycyclic or annular
lesions with dusky and
ecchymotic centers along with
acral edema.
We can distinguish from
erythema multiforme (EM)
because in EM, individual
lesions are fixed for at least 7
days. Also, urticaria multiforme
improves with antihistamines.

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 Urticaria: Pathophysiology
The mast cell is the major effector cell in
urticaria
Immunologic Urticaria: antigen binds to IgE
on the mast cell surface causing
degranulation, which results in release of
histamine
Histamine binds to H1 and H2 receptors to cause
arteriolar dilatation, venous constriction and
increased capillary permeability, causing swelling
and itch.

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 Pathophysiology (cont.)
Non-Immunologic Urticaria: not dependent
on the binding of IgE receptors
For example, aspirin may induce histamine
release through a pharmacologic
mechanism where its effect on arachidonic
acid metabolism causes a release of
histamine from mast cells.
Physical stimuli may induce histamine
release through direct mast cell
degranulation.

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Case One
Mrs. Ila Cook

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 Case One: History
HPI: Mrs. Cook is a 46-year-old woman with a 3-day
history of a widespread pruritic rash. Individual lesions last
approximately 8hrs and then fully resolve.
PMH: hip replacement 6 weeks ago
Allergies: none
Medications: oxycodone (for pain, s/p hip replacement)
and aspirin
Family history: no history of atopic dermatitis or allergies
Social history: lives with her husband in the city
ROS: negative

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 Case One: Exam
Vital signs: afebrile, HR 74, BP 120/70, RR 16, O2
sat 98% on RA
Skin: diffuse erythematous papules coalescing
into plaques (wheals)
No associated bruising

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 Case One, Question 1
What other part(s) of the exam are essential?
a. Musculoskeletal
b. Neurologic
c. Psychiatric
d. Respiratory
e. Cognitive

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 Case One, Question 1
Answer: d
What other part(s) of the exam are essential?
a. Musculoskeletal
b. Neurologic
c. Psychiatric
d. Respiratory
e. Cognitive

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 Clinical Evaluation
Ask about symptoms of anaphylaxis, including: chest
tightness or difficulty breathing, hoarse voice or throat
tightness, nausea, vomiting, abdominal pain,
lightheadedness
In addition to the skin exam, the physician should obtain a
set of vital signs and evaluate for respiratory distress
(dyspnea, wheeze, bronchospasm, stridor) and
hypotension
For acute urticaria, no lab testing is required
Laboratory testing is generally driven by associated signs
and symptoms (e.g. C1 esterase deficiency only causes
angioedema, not hives)

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 Case One, Question 2
What important feature(s) are revealed in the
history?
a. The lesions fully resolve
b. She recently began new medications
c. The lesions last 8 hours
d. Three-day history of rash
e. All of the above

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 Case One, Question 2
Answer: e
What important feature(s) are revealed in the
history?
a. The lesions fully resolve (characteristic of
urticaria)
b. She recently began new medications (likely
etiology)
c. The lesions last 8hrs (individual wheals rarely
last over 12 hrs.)
d. Three-day history of rash (this is acute urticaria)
e. All of the above

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 Diagnosis: Medication-induced Urticaria

Medications are a common cause of urticaria and

angioedema
Penicillin and related antibiotics are common via the
IgE-mediated mechanism
Aspirin is a common cause via a non-IgE-mediated
mechanism
30% of chronic urticaria is exacerbated by
aspirin/NSAID use
Many patients ask about detergent use. However, it
generally causes irritant or allergic contact dermatitis,
not urticaria.

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Case Two
Ms. Sandra Jennings

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 Case Two: History
HPI: Ms. Jennings is a 55-year-old woman who presents to the
dermatology clinic with a 6-month history of periodic swelling
on her body. The swelling started with localized itching followed
by raised lesions that disappear within minutes to hours. She
finds these lesions embarrassing and would like treatment or a
cure.
PMH: no hospitalizations or major illnesses
Medications: occasional NSAID, daily fish oil, Vitamin D
Allergies: no known drug allergies
Family history: no history of skin disease
Social history: married, works as a nurse
Health-related behaviors: no tobacco or alcohol; has used
marijuana and cocaine in the past

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 Case Two Continued
Further questioning reveals that Ms. Jenningss
urticaria is worse with exercise, rubbing of the
skin, pressure (e.g. develops lesions at the site of
her purse strap on her shoulder), and
embarrassment.
She also describes that most of the time she
does not notice an association with any potential
triggers.
Her lesions appear 2-3x/week, often in public.
She is particularly embarrassed when lesions
appear on her face while taking care of patients.

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 Case Two: Skin Exam
Vital signs within normal limits
Full skin exam reveals:
No wheals or erythema
Multiple benign appearing nevi on the trunk

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 Case Two, Question 1
Which of the following medications may be
contributing to her urticaria?
a. Fish oil
b. Ibuprofen
c. Vitamin D
d. Marijuana
e. Cocaine

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 Case Two, Question 1
Answer: b
Which of the following medications may be
contributing to her urticaria?
a. Fish oil
b. Ibuprofen
c. Vitamin D
d. Marijuana
e. Cocaine

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 Clinical Evaluation
Urticaria is generally a clinical diagnosis
A detailed history and physical exam should be
performed
Many times patients will not present with urticaria
during their clinic visit
You can show patients photographs of urticaria and
ask if their lesions appear similar
Patients can take photos of their skin lesions and
bring them to their office visit

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 Clinical Evaluation
In most cases of chronic urticaria, no external
cause can be identified
If a physical urticaria is suspected, a challenge test
with the respective trigger may be performed
Patients will often ask about food allergies
IgE-mediated food allergy is far more likely to present
with acute urticaria
A detailed food diary or dietary modification may reveal
foods (or additives) that cause fluctuations in symptoms
of chronic urticaria

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 Allergy Testing
Allergy testing is not routinely performed in
patients with chronic urticaria.
Skin prick testing may reveal sensitivities to
a variety of allergens that may not be
relevant to the patients urticaria.
Laboratory tests may identify the 1/3 of
patients with chronic urticaria who have an
autoimmune pathogenesis. This adds
additional costs and may not change the
management.

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 Natural History and Prognosis
Symptoms of chronic urticaria can be severe and
impair the patients quality of life (QOL)
In most patients, chronic urticaria is an episodic
and self-limited disorder
Average duration of disease is two to five years
In patients with idiopathic chronic urticaria, there
is a rate of spontaneous remission at one year of
approximately 30 to 50 percent
However, symptoms extend beyond five years in
nearly one-fifth of patients

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 Back to Ms. Jennings
Ms. Jennings was recommended to avoid tight
clothing, stop ibuprofen, and start a first-
generation antihistamine (e.g. hydroxyzine).
During a follow-up visit, Ms. Jennings reports she
stopped the hydroxyzine because it made her too
sleepy and she worried it was beginning to affect
her work performance. She became teary-eyed
and shared her frustration with her skin condition
and fear that she would not be cured.

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 Case Two: Follow-up Visit
Patients with chronic urticaria are often frustrated and
fearful. Validation and reassurance are important
components of successful management.
Sharing the following information may help:
Chronic urticaria is rarely permanent. Approximately 50 %
of patients undergo remission within one year.
While acute urticaria and angioedema may be
manifestations of allergic reactions that can be life-
threatening, chronic urticaria is a different disorder that
rarely puts the patient at any acute risk.
The symptoms of chronic urticaria can be successfully
managed in the majority of patients.

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 Case Two, Question 2
Which of the following treatments would you
recommend for Ms. Jennings?
a. Daily oral 2nd generation H1 antihistamine
b. Daily topical retinoid to the face
c. No need to continue with an antihistamine;
stopping the NSAID should resolve the urticaria
d. Oral 2nd generation H1 antihistamine taken when
the itching begins
e. Mid-potency topical corticosteroid to the urticaria

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 Case Two, Question 2
Answer: a
Which of the following treatments would you recommend for
Ms. Jennings?
a. Daily oral 2nd generation H1 antihistamine
b. Daily topical retinoid to the face (not used for urticaria)
c. No need to continue with an antihistamine; stopping the
NSAID should resolve the urticaria (treatment should be
initiated in addition to removing potential triggers)
d. Oral 2nd generation H1 antihistamine taken when the itching
begins (less practical and will not help prevent the initial
lesions)
e. Mid-potency topical corticosteroid to the urticaria
(unhelpful for urticaria)

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 Treatment: Antihistamines
Oral H1 antihistamines are the first-line treatment for
acute and chronic urticaria
1st-generation H1 antihistamines are less well-tolerated
due to sedation, so are often taken at bedtime
e.g. 10-50 mg hydroxyzine 1-2 hours before bedtime
Can start with smaller doses (10 mg) to allow the patient to
manage the sedative effects
Remember to warn patient not to drive a car or operate other
dangerous machines within 4-6 hours of taking this medication
Do not take with other sedating medications

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 Treatment: Antihistamines
2nd-generation H1 antihistamines (e.g. Loratadine) are better
tolerated with fewer sedative and anticholinergic effects and
may be used in patients intolerant of or inadequately controlled
by 1st-generation agents
Certain populations, including children, the elderly, and patients
with renal or hepatic impairment may require dosage
calculation or adjustments when using H1 antihistamines
Also used with caution in patients with glaucoma, prostatic
hyperplasia, and respiratory disease
H2 antihistamines have mixed data on their efficacy for urticaria
and are generally not used as first-line therapy

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 Antihistamines
The following are examples of H1 antihistamines:
1st Generation
Diphenhydramine (OTC)
Hydroxyzine (Rx, generic)
Chlorpheniramine (OTC)
2nd Generation
Cetirizine (OTC)
Loratadine (OTC)
Fexofenadine (OTC)

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 Urticarial Lesions
Not all patients with urticarial eruptions have
urticaria. Which of the following patients has
ordinary urticaria?

D
C

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 Urticarial Lesions

Urticarial Ordinary Bullous

Vasculitis Urticaria Pemphigoid

D
C

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 Beyond Ordinary Urticaria
The appearance of the hives does not tell
you the underlying cause
The presence of systemic symptoms
should signal the possibility that an
urticarial rash is not ordinary urticaria but
rather a systemic syndrome with urticaria-
like skin lesions

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 Referral to Dermatology
Referral to a dermatologist and biopsy should be
performed in patients with one or more of the
following features:
Individual lesions that persist beyond 48 hours, are
painful or burning rather than pruritic, or have
accompanying petechial characteristics
Systemic symptoms
Lack of response to antihistamines
Lesions that leave pigmentation changes upon
resolution

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Case Three
Mrs. Julie Walker

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 Case Three: History
HPI: Mrs. Walker is a 25-year-old woman who was brought
to the emergency department by her husband after she
began feeling short of breath with a new and expanding
rash
PMH: asthma, no history of intubations
Allergies: aspirin (causes a rash) & shellfish (reaction at a
young age of facial swelling)
Medications: occasional use of albuterol
Family history: noncontributory
Social history: recently started cooking school
ROS: short of breath, anxious

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 Case Three: Exam
Vitals: T 98.6F, HR 110, BP
90/50, RR 34
General: anxious-appearing
woman sitting upright with
difficulty breathing, unable to
speak in full sentences
Respiratory: tachypneic,
using accessory muscles,
bilateral rhonchi
Skin: periorbital edema,
scattered erythematous
wheals on the trunk

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 Case Three, Question 1
What is the next course of action in this
patient?
a. Administer IV metoprolol
b. Assess ABCs (airway, breathing,
circulation)
c. Give systemic corticosteroids
d. Make a food diary
e. Apply super-potent topical corticosteroid

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 Case Three, Question 1
Answer: b
What is the next course of action in this patient?
a. Administer IV metoprolol
b. Assess ABCs (airway, breathing,
circulation)
c. Give systemic corticosteroids
d. Make a food diary
e. Apply super-potent topical corticosteroid

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 Anaphylaxis
Anaphylaxis is a serious allergic reaction that is rapid
in onset and may cause death
Patients with anaphylaxis may have no skin lesions,
lesions of angioedema, and/or typical urticarial
wheals
Morphology of the skin lesion does not matter
Patients with angioedema are not more likely to have
anaphylaxis compared to patients with urticaria
ABCs first!
Recruit more help. May need to triage to higher level
of care (in clinic this means calling 911).

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 Anaphylaxis: Treatment
First-line therapy for anaphylaxis includes
epinephrine, IV fluids and oxygen
Administer 0.3-0.5ml in 1:1000 epinephrine dilution
IM repeating every 10-20min as necessary; for
children <30kg, the dose is 0.01mL/kg/dose.
Make sure airway is patent or else intubation may be
emergently necessary
Patients who have severe reactions requiring
epinephrine should be monitored in the hospital

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 Take Home Points
Urticaria (hives) is a vascular reaction of the skin characterized
by wheals surrounded by a red halo or flare.
Urticaria is classified as acute or chronic. Acute urticaria is
defined as periodic outbreaks of urticarial lesions that resolve
within six weeks.
Over 50% of chronic urticaria is idiopathic.
The most common cause of urticaria in kids is a viral illness.
Oral H1 antihistamines are first-line treatment for acute and
chronic urticaria.
The presence of systemic symptoms should signal the
possibility that an urticarial rash is not ordinary urticaria.

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 Take Home Points
Anaphylaxis is a serious allergic reaction that is rapid in
onset and may cause death.
Remember to ask about symptoms of anaphylaxis,
including: chest tightness or difficulty breathing, hoarse
voice or throat tightness, nausea, vomiting, abdominal
pain, lightheadedness.
The 1st step in management of a patient with signs and
symptoms of anaphylaxis is to assess airway, breathing,
circulation, and adequacy of mentation.
Call for help if you suspect a patient has anaphylaxis.

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 Acknowledgements
This module was developed by the American Academy of
Dermatology Medical Student Core Curriculum Workgroup
from 2008-2014.
Primary authors: Sarah D. Cipriano, MD, MPH; Eric
Meinhardt, MD; Timothy G. Berger, MD; Kieron Leslie, MD.
Peer reviewers: Susan K. Ailor, MD; Patrick McCleskey, MD;
Erin Mathes, MD.
Revisions and editing: Sarah D. Cipriano, MD, MPH; Jillian
W. Wong; Peter Lio, MD; Michelle Gallagher, DO
Last revised December 2015.
Thanks to the Society for Pediatric Dermatology for their help
with revisions.

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 References
Lack G. Food Allergy. N Engl J Med. 2008;359:1252-60.
Peroni A, Colato C, Zanoni G, Girolomoni G. Urticarial lesions: If not urticaria,
what else? The differential diagnosis of urticaria. Part II. Systemic diseases. J
Am Acad Dermatol 2010;62:557-70.
Poonawalla T, Kelly B. Urticaria, A Review. Am J Clin Dermatol. 2009;10:9-21.
Bingham CO. New onset urticaria: Diagnosis and treatment. In: UpToDate,
Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
Bingham CO. New onset urticaria: Epidemiology, clinical manifestations, and
etiologies. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
Kahn DA. Chronic urticaria: Standard management and patient education. In:
UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
Kaplan Allen P, "Chapter 37. Urticaria and Angioedema" (Chapter). Wolff K,
Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's
Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2958607.

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To take the quiz, click on the following link:

https://www.aad.org/quiz/urticaria-learners

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