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Symptoms of urticaria: The hallmarks of urticaria are itchy, red skin plaques that can occur alone or in groups on any part of the skin.1 Urticaria may also present as wheals that vary in size, change shape, and appear and fade repeatedly as the reaction runs its course.1 Patients with urticaria may also have swelling under the skin (angioedema), which results from mast cell and basophil activation deep in the dermis and subcutaneous tissues.1 This symptom may present on the lips, eyelids, and inside the throat.1 Patients with chronic urticaria may have periods of exacerbation and remission that may persist for years.1
Diagnosing urticaria will rely on information from a variety of sources, including a physical exam, patient history, and possibly test results.
In the case of acute urticaria, your diagnostic efforts will largely be focused on identifying the possible triggers and allergies. You can acquire these insights through a thorough history, which should cover medications (e.g., non-steroidal analgesic drugs) and foods.4 Your patient history should also cover infections (e.g., acute viral upper respiratory infections), as they are one of the most frequent causes of acute urticaria. However, taking blood samples to determine antiviral antibodies may not be recommended due to low specificity.4
If your allergy-focused patient history finds strong symptoms or a history of sensitizations, you may wish to follow the current guidelines and conduct diagnostic tests.1 Skin prick testing (SPT) and specific IgE blood testing can help you rule in or rule out allergen sensitization, which may give you the ability to correctly diagnose and improve clinical management.5,6
Allergy-related acute urticaria can be difficult to identify and manage as polysensitization is common. Up to 80 percent of patients are sensitized to more than one allergen.8 Furthermore, identifying the obvious allergen is not always enough. Allergic responses can develop to previously tolerated substances, and sensitization to seasonal and perennial allergens often add up to trigger symptoms.
It is known that urticaria can be an immune-mediated response to certain chronic disorders.9 For example, chronic urticaria is sometimes associated with connective tissue disorders, particularly systemic lupus erythematosus (SLE) or Sjögren’s Syndrome and thyroid disorders.10 Urticaria pigmentosa is a subvariant of cutaneous mastocytosis and mastocytosis should be evaluated.1,11
The following types of allergens may trigger an immune-mediated response:
Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv
i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238
Skin disorders, including atopic dermatitis (eczema) and urticaria (wheals) are commonly seen by healthcare providers and managing patients with these conditions can often be challenging. Results from studies have demonstrated that atopic dermatitis and urticaria have a profoundly negative impact on health-related quality of life (HRQoL), particularly impacting social functioning and psychological well-being. And many patients with one or both conditions report problems attributable to their skin in facets of everyday life including home management, personal care, mobility, sleep, rest, school, and work.12,13
The management of acute urticaria involves antihistamines, oral corticosteroids, and eliminating suspected triggers. The management of chronic urticaria involves nonpharmacologic and pharmacologic approaches, and including, but not limited to, antihistamines, anti-inflammatory agents, and avoidance of triggers.14
Practice parameters have been developed to help guide the management and treatment of patients with skin allergies.