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Acute Urticaria Clinical Presentation

Updated: Sep 13, 2016
Author: Henry K Wong, MD, PhD; Chief Editor: Michael A Kaliner, MD more...

PRESENTATION

History
Pruritus (itching) and rash are the primary manifestations of urticaria, and permanent hyperpigmentation or
hypopigmentation is rare.

Lesions commonly last 20 minutes to 3 hours, disappear, and then reappear in other skin areas. An entire
episode of urticaria often lasts 24-48 hours; individual lesions usually fade within 24 hours or so, but new
lesions may be developing continuously. Rarely, acute urticaria can last 3-6 weeks. [29] Scars do not
develop.

With delayed pressure urticaria, lesions may last as long as 48 hours. The lesions of urticarial vasculitis,
which are palpable and purpuric, may last for several days or more and may lead to residual
hyperpigmented changes. [30]

Typical lesions described by patients are edematous pink or red wheals of variable size and shape that are
pruritic. [31] The lesions are often described as welts or hives, including pressure-induced hives, which can
occur with elastic or tight clothing, as shown in the images below. [32] Patients may report a painful or
burning sensation; such lesions are often associated with angioedema. [33] Pruritus of nonlesional skin may
also occur.

Photograph of dermographism.
View Media Gallery

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Pressure urticaria (dermatographia) developed after strokes.

View Media Gallery

Acute urticaria associated with dermatographism.

View Media Gallery

Determining whether the lesions have an allergic (IgE) or nonallergic (non-IgE) basis is helpful in the
management of the patient. A complete thorough medical and travel history is important to provide clues to
urticaria resulting from a new infectious or medical problem. Questions asked to determine possible allergic
and nonallergic causes include the following:

Are the hives associated with any foods? Have any new foods been added to the diet?
Is the patient taking any regular medications, or have any new medicines been started? In particular,
ask about aspirin, NSAIDs, antibiotics, over-the-counter (OTC) medications, herbs, and supplements.
Does the patient have any recent or chronic infections?
Are the hives caused by any physical stimuli (eg, heat, cold, pressure, vibration)?
Does the patient have any chronic medical conditions?
Is the urticaria associated with any substances that are inhaled or come in contact with the skin
(which may occur in an occupational setting)?
Is the urticaria associated with insect bites or stings?

Physical Examination
If any features of anaphylaxis (eg, hypotension, respiratory distress, stridor, gastrointestinal distress,
swallowing problems, joint swelling, joint pain) are present, immediate medical intervention should occur.

Assess for any features of angioedema (deep tissue or submucosal edema). [34] Angioedema appears as
swellings of the tissues, with indistinct borders around the eyelids and lips. Swellings may also appear on
the face, trunk, genitalia, and extremities. The face, hands, and feet are involved in 85% of patients. As
many as 50% of children who have urticaria exhibit angioedema with swelling of the hands and feet.
Hereditary angioedema (C1 inhibitor deficiency) accounts for only 0.4% of cases of angioedema but is
associated with a high mortality rate.

Lesions of urticaria can be polymorphic and vary from several millimeters to large, continuous edematous

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plaques that have smooth surfaces with polycyclic curved borders. The lesions do not have scales but
show an intense erythema in the newest areas, with a trailing clearing region in older areas. The central
clearing can cause a target configuration in expanding plaques. The advancing border shows a discrete
edge followed by a faint, trailing, diffuse border.

Look for any atypical skin lesions. Lesions that are purpuric, nonblanchable, and palpable are
characteristic of urticarial vasculitis. These lesions may leave residual pigmented changes. Tiny pinpoint
hives are characteristic of cholinergic urticaria. [35]

Edema can be observed by slightly stretching the skin to demonstrate whitish centers. Occasionally, large
annular urticarial lesions as large as 30 cm in diameter with polycystic borders are observed.

Examine for dermographism, as it is often observed in conjunction with urticaria. Itching, erythema, and a
raised wheal occur in areas that are scratched or stroked with a blunt object, such as a tongue blade. [36]
The examiner can use the end of a tongue blade or similar blunt object to scratch the patient's skin and
observe the area over the next 5-15 minutes for the development of whealing with erythema, as shown in
the following image.

Photograph of dermographism.
View Media Gallery

The remainder of the physical examination should be used to investigate any suspicions that were raised
by the history.

Staging
According to a study, the cutaneous biopsy of urticaria lesions may be divided into the following categories,
as the response to treatment could be different:

Class 1 - A mixture of perivascular dermal inflammatory infiltrates composed of lymphocytes,

monocytes, and neutrophils, eosinophils, or both
Class 2 - Inflammatory infiltrate chiefly composed of neutrophils [37]
Class 3 - Inflammatory infiltrate mainly composed of eosinophils

Differential Diagnoses

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Media Gallery

Urticaria associated with a drug reaction.

Urticaria developed after bites from an imported fire ant.
Local urticaria on a patient with latex allergy who was touched with a latex glove.
Urticaria from drug reaction.
Photograph of dermographism.
Pressure urticaria (dermatographia) developed after strokes.

22/05/17 18.07
Acute Urticaria Clinical Presentation: History, Physical Examination, ... http://emedicine.medscape.com/article/137362-clinical

Acute urticaria associated with dermatographism.

Urticaria associated with acute group A beta-hemolytic streptococci infection.
Acute urticaria in a toddler affecting the face. Likely cause is postviral syndrome.

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Contributor Information and Disclosures

Author

Henry K Wong, MD, PhD Professor and Chairman, Department of Dermatology, University of Arkansas for
Medical Sciences College of Medicine

Henry K Wong, MD, PhD is a member of the following medical societies: American Academy of
Dermatology, International Society for Cutaneous Lymphomas, Medical Dermatology Society, Society for
Investigative Dermatology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Seattle
GEnetics, Actillion, Celgene<br/>Serve(d) as a speaker or a member of a speakers bureau for:
Amgen<br/>Received income in an amount equal to or greater than $250 from: Celgene<br/>Received
honoraria from Amgen for speaking and teaching; Received grant/ Received grant/research funds from
Celgene for none; Received grant/research funds from Abbott Labs for independent contractor; Received
grant/research funds from Amgen for none; Received honoraria from Seattle Genetics for consulting. for:
Actelion-Advisory board, grants;Seattle Genetics - Advisory board.

Coauthor(s)

Javed Sheikh, MD Assistant Professor of Medicine, Harvard Medical School; Clinical Director, Division of
Allergy and Inflammation, Clinical Director, Center for Eosinophilic Disorders, Beth Israel Deaconess
Medical Center

Javed Sheikh, MD is a member of the following medical societies: American Academy of Allergy Asthma
and Immunology, American College of Allergy, Asthma and Immunology

Disclosure: Received grant/research funds from Genentech for other.

Umer Najib, MD Clinical Research Fellow, Department of Medicine, Division of Allergy and Inflammation,
Beth Israel Deaconess Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine;
Medical Director, Institute for Asthma and Allergy

Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy
Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma
and Immunology, American Society for Clinical Investigation, American Thoracic Society, Association of
American Physicians

Disclosure: Nothing to disclose.

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Acknowledgements

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of

Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences
Consulting fee Consulting; Celgene Honoraria Safety Monitoring Committee; GSK - Glaxo Smith Kline
Consulting fee Consulting; TenXBioPharma Consulting fee Safety Monitoring Committee

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General

Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director,
Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician,
Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics,
American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Stephen C Dreskin, MD, PhD Professor of Medicine, Departments of Internal Medicine, Director of
Allergy, Asthma, and Immunology Practice, University of Colorado Health Sciences Center

Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy
Asthma and Immunology, American Association for the Advancement of Science, American Association of
Immunologists, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and
Joint Council of Allergy, Asthma and Immunology

Disclosure: Genentech Consulting fee Consulting; American Health Insurance Plans Consulting fee
Consulting; Johns Hopkins School of Public Health Consulting fee Consulting; Array BioPharma Consulting
fee Consulting

Dirk M Elston, MD Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University
College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Shih-Wen Huang, MD Professor Emeritus, Pulmonology and Allergy, Department of Pediatrics University
of Florida College of Medicine

Shih-Wen Huang, MD, is a member of the following medical societies: American Academy of Allergy
Asthma and Immunology

Disclosure: Nothing to disclose.

Harumi Jyonouchi, MD Associate Professor, Division of Pulmonary Allergy/Immunology and Infectious

Diseases, Department of Pediatrics, UMDNJ-New Jersey Medical School

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy
Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists,
American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for

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Experimental Biology and Medicine, Society for Mucosal Immunology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics,
Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New
Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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