Chronic Urticaria: Following Practice Guidelines

Erin P. Westby, MD; Charles Lynde, MD, FRCPC; Gordon Sussman, MD, FRCPC, FACP, FAAAI


Skin Therapy Letter. 2018;23(3):1-4. 

In This Article


A thorough history is the critical component of any initial patient evaluation, urticaria being no exception. Duration and frequency of intermittent symptoms will help establish chronicity of disease, whereas duration of individual urticarial lesions can help distinguish underlying pathogenesis, i.e. lasting greater than 24 hours would suggest vascular component rather than an immunoglobin E (IgE)-mediated phenomenon. When patients report identifiable triggers that would suggest chronic inducible urticaria, i.e., cold urticaria, delayed pressure urticaria, solar urticaria, heat urticaria, vibratory angioedema, cholinergic urticaria, contact urticarial, or aquagenic urticaria, specific provocation and threshold testing should be performed. If chronic spontaneous urticaria is suspected, initial blood work should be limited to complete blood count with differential and erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP). Omission of suspected drugs [e.g., nonsteroidal antiinflammatory drugs (NSAIDS)] should also be trialed. The American Joint Task Force on Practice Parameters (JTFPP) also include liver enzymes, renal function and thyroid-stimulating hormone (TSH) testing in their initial workup and recommends these laboratory investigations for all patients presenting with chronic spontaneous urticaria. Unless strongly suggested by history, extensive and costly screening programs for causes of urticaria are not recommended, which could include investigating for underlying infectious etiology (e.g., Helicobacter pylori), type I allergy, functional autoantibodies, thyroid hormones and autoantibodies, pseudoallergen-free diet for 3 weeks, tryptase, autologous serum skin test, and lesional skin biopsy (Table 1).[9–12]