Urticaria in Adult
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Synopsis
Urticaria can be triggered by a variety of mechanisms, both allergic and nonallergic. Urticaria is categorized as acute (new-onset or recurring episodes of up to 6 weeks' duration) or chronic (recurring episodes lasting longer than 6 weeks).
In half of acute urticaria cases, the inciting factor is never identified; 40% of cases are associated with an upper respiratory infection, 9% with drugs, and 1% with foods. Drugs causing acute urticaria include NSAIDs, radiocontrast media, opiates, and angiotensin-converting enzyme (ACE) inhibitors.
Chronic urticaria is more common in women and individuals aged 40 years and older, whereas acute urticaria is more commonly seen in children. Disease resolves within 2 years in approximately 50% of individuals with chronic urticaria; however, 20% of individuals may have symptoms that persist for more than 10 years. Chronic urticaria is subdivided into chronic inducible urticaria and chronic spontaneous urticaria, based on whether definite triggers exist and can be identified. Chronic inducible urticaria is triggered consistently, reproducibly, and exclusively by a specific stimulus. These stimuli further define chronic inducible urticaria subtypes: symptomatic dermographism, cold urticaria, delayed pressure urticaria, solar urticaria, heat urticaria, and vibratory angioedema are physical urticarias, whereas cholinergic urticaria, contact urticaria, aquagenic urticaria, and adrenergic urticaria are not.
Chronic spontaneous urticaria may be exacerbated by triggers such as NSAIDs, alcohol, and stress, but triggers are not definite, as stimuli do not always produce symptoms. While the cause of chronic spontaneous urticaria is unknown, the presence of mast cell-activating autoantibodies in many patients raises the possibility of an autoimmune origin. It is also associated with other autoimmune conditions, including autoimmune thyroid disease, vitiligo, type 1 diabetes mellitus, rheumatoid arthritis, and autoimmune gastritis.
Other associated factors:
- Acute urticaria – high population density, allergic disease
- Chronic urticaria – hepatitis B virus, hepatitis C virus, Epstein-Barr virus, mycoplasma, systemic lupus erythematosus, neoplasms (especially lymphoreticular cancers and lymphoproliferative cancers), and oral contraceptive pills (OCPs)
- Chronic induced urticaria – environment (temperature, altitude), allergic disease
- Chronic spontaneous urticaria – gastrointestinal tract infection (Helicobacter pylori, bowel parasites) and inflammation (gastritis, reflux esophagitis, cholangitis), bacterial infection of the nasopharynx, cancer, depression, anxiety, and metabolic syndrome
- Vibratory urticaria – mutation in ADGRE2 (EMR2), which affects mast cell function
Codes
ICD10CM:L50.9 – Urticaria, unspecified
SNOMEDCT:
126485001 – Urticaria
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Serum sickness / serum sickness-like reaction – Associated with fever, lymphadenopathy, arthralgias, dusky skin lesions, and recent drug (ie, beta-lactam) or sera exposure.
- Urticarial vasculitis – Individual lesions last longer than 24 hours and are associated with pain, purpura, and/or arthralgias or arthritis (joint swelling or refusal to use extremities).
- Mastocytosis (urticaria pigmentosa) – Has persistent yellow-brown macules and plaques that urticate with stroking.
- Bullous pemphigoid and dermatitis herpetiformis may present with urticarial lesions, but individual lesions last longer than 24 hours and progress to vesicles or erosions. These are exceptionally pruritic as well.
- Sweet syndrome (acute febrile neutrophilic dermatosis) – Urticarial plaques lasting over 24 hours, accompanied by fever, leukocytosis, arthralgia, malaise, headache, and myalgia.
- Insect bites (papular urticaria) – Lesions are often excoriated and last longer than 24 hours.
- Immunoglobulin A vasculitis (formerly Henoch-Schönlein purpura) – Associated with fever, edema, palpable purpura, and renal, gastrointestinal, musculoskeletal, and central nervous system disease.
- Erythema multiforme – Fixed for several days, does not respond to antihistamines, and is associated with dusky, necrotic centers (rather than the pale edematous center of urticaria).
- Contact dermatitis (irritant, allergic) – May have an unusual geometric shape correlating to the inciting irritant and often develops blisters. May be secondary to a food allergen.
- Lupus erythematosus – Often with epidermal changes (scaly, atrophic, or ulcerated).
- Herpes zoster – May initially be urticarial, but lesions are painful and evolve into blisters and crusts.
- Erythema annulare centrifugum – Often with epidermal changes (scale), and lesions persist for weeks.
- Wells syndrome (granulomatous dermatitis with eosinophilia / eosinophilic cellulitis)
- Melkersson-Rosenthal syndrome
- Cellulitis
- Fixed drug eruption
- Exanthematous drug eruption
- Lyme disease
- Erythema marginatum
- Bedbug bite
- Loiasis
- Schistosomiasis
- Strongyloidiasis
- Toxocariasis – A common cause of chronic urticaria.
- African trypanosomiasis
- Cryopyrin-associated periodic syndromes – Muckle-Wells syndrome, familial cold autoinflammatory syndrome (familial cold urticaria), and neonatal-onset multisystem inflammatory disease.
- Acquired autoinflammatory syndromes – Schnitzler syndrome, adult onset Still disease, episodic angioedema with eosinophilia (Gleich syndrome), systemic capillary leak syndrome.
- Phospholipase Cg2–associated antibody deficiency – Lifelong cold-induced urticaria with variable antibody deficiency and increased risk for infection, autoimmunity, and granulomatous disease.
- Alpha-gal syndrome – Mammalian meat allergy induced by a tick bite that elicits immunoglobulin E (IgE) antibodies to galactose-alpha-1,3-galactose (alpha-gal), resulting in urticaria, angioedema, and anaphylaxis symptoms 3-6 hours (delayed onset) after ingesting the meat. Implicated tick bites have been noted to be pruritic for 2 or more weeks.
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:12/12/2022
Last Updated:12/26/2022
Last Updated:12/26/2022
Patient Information for Urticaria in Adult
Overview
Hives (urticaria), also known as welts, is a common skin condition with an itchy rash of pink or red bumps (papules) that appears and disappears anywhere on the body. In darker skin colors, the redness may be harder to see, but the swollen skin bumps can be felt by the touch. An individual hive typically lasts a few hours (up to 24 hours) before fading away, and new hives can appear as older areas disappear.Hives can be considered acute (new or periodic episodes lasting less than 6 weeks) or chronic (periodic episodes lasting more than 6 weeks). Although many people have a single episode of acute hives that goes away within a few days to weeks, some individuals may have chronic hives that persist intermittently for years.
Hives can be caused by many triggers, including:
- Medications, especially aspirin, ibuprofen, naproxen, narcotic painkillers, and antibiotics.
- Infections with viruses, bacteria, and fungi.
- Environmental allergies such as insect bites, pollen, mold, and animal dander.
- Physical exposures such as heat, cold, water, sunlight, and pressure.
- Medical conditions such as some blood diseases and cancer.
- Food allergies such as to strawberries, eggs, nuts, and shellfish.
Who’s At Risk
Hives appear in people of any age, race / ethnicity, and sex. Hives are very common; it is estimated that up to 20% of the population develops them at some point in their lives. Individuals with a family or personal history of atopic conditions (asthma, hay fever, eczema) are more prone to developing hives.Acute hives are most common in children and young adults, and chronic hives are more often seen in females, especially middle-aged women.
Signs & Symptoms
The most common locations for hives include the:- Trunk.
- Upper arms or upper legs.
- Hands and feet.
- Face.
Dermographism is a type of urticarial reaction that appears within a few minutes of scratching the skin. The rash is usually seen in a straight line (linear) pattern. This is typically a sign of a person with sensitive skin.
Swelling of the eyes, mouth, hands, feet, or genitals can sometimes occur with hives. This swelling, called angioedema, usually goes away within 24 hours, but it can be quite severe and life-threatening when swelling of the airway occurs.
Hives are usually itchy, but they can also burn or sting.
Self-Care Guidelines
If you are experiencing mild hives, you can try:- Taking cool showers.
- Applying cool compresses.
- Wearing loose-fitting clothes.
- Avoiding strenuous activity.
- Using an over-the-counter antihistamine such as cetirizine (Zyrtec), fexofenadine (Allegra), loratadine (Claritin), or diphenhydramine (Benadryl).
When to Seek Medical Care
Call 911 if you are feeling lightheaded or are having difficulty breathing or swallowing associated with your hives.In nonurgent situations with hives, see a medical professional if the hives do not improve with treatment or if they continue to appear for more than a few days.
Before visiting the medical professional, try to pay attention to what might be triggering your hives and whether it improves or worsens with exposure to heat, cold, pressure, or vibration. Take a list of every medication (prescription and over the counter), supplement, and herbal remedy you may have taken recently. Also consider any recent illnesses you may have had because some illnesses (and their treatments) can trigger hives.
Treatments
After confirming that you have hives, the medical professional will work with you to discover the possible cause. They will also take a detailed medical history and may do blood work, urine tests, or x-rays.The best treatment for hives is to discover any triggers and stop your exposure to them. However, most people with hives do not know the cause and require medications to get rid of them.
The most common medications for hives include:
- Non-sleep-causing (nonsedating) antihistamines such as loratadine (Claritin), fexofenadine (Allegra), desloratadine (Clarinex, Aerius), or cetirizine (Zyrtec).
- Sleep-causing (sedating) antihistamines such as diphenhydramine (Benadryl), hydroxyzine (Vistaril, Atarax), or doxepin (Sinequan, Adapin, Zonalon).
- Other antihistamines such as cimetidine (Tagamet) or famotidine (Pepcid).
- Montelukast (Singulair), zafirlukast (Accolate), or zileuton (Zyflo).
Urticaria in Adult