Clinical Points in the Diagnosis and Management of Chronic Urticaria

Urticaria – a common presentation during childhood, affects up to 15% of British children and is marked by sudden wheals, angioedema, or both. The condition arises acutely, often triggered by viral infections or antibiotics, and about one-third of cases progress to chronic or recurrent urticaria. A recent review article explored chronic urticaria subtypes, diagnostic approaches, and treatments in children.

Acute urticaria lasts less than six weeks, whereas chronic urticaria persists for six weeks or more. Chronic urticaria involves daily or frequent wheals/angioedema that can be spontaneously triggered or inducible. Inducible urticarias have specific triggers, either physical – for instance, cold, heat, or pressure, or non-physical – cholinergic or contact allergy. Chronic urticaria can impact the patient’s quality of life, particularly in older children.

The diagnosis is usually clinical; a focused history is essential and extensive investigations are rarely necessary. Chronic urticaria includes chronic spontaneous urticaria – autoimmune in about 40% of older children, and inducible urticarias – like cold urticaria and dermographism. Isolated angioedema may indicate hereditary angioedema.

Treatment involves avoiding triggers and using non-sedating antihistamines. Higher doses are often well-tolerated. Leukotriene receptor antagonists may further improve symptoms in some patients, while tranexamic acid can relieve isolated angioedema. Short courses of oral steroids are an option for acute episodes or severe chronic urticaria. For non-responders, monoclonal anti-IgE antibody therapy is the primary second-line treatment, though some may require ciclosporin.

Management aims for total symptom relief through identifying causes and symptomatic control, with most cases managed in primary or secondary care. Monitoring every 3-6 months is recommended due to the fluctuating nature of the disease.

Source: Fawbert K, Leech S. Paediatrics and Child Health. 2024 Apr 4.