Spontaneous Urticaria and/or
Angioedema
Key Messages
Urticaria and angioedema may be allergic or non-allergic (spontaneous). In
spontaneous urticaria/angioedema there may be exacerbating factors (eg heat, cold,
pressure, stress, some medications).
Acute urticaria (lasting less than 1-2 days) do not need routine referral unless there
are specific questions. This referral pathway deals with chronic urticaria only.
Assessment
The clinical history of the symptoms and suspected precipitants/exacerbating factors
is paramount, along with examination of the symptoms if possible.
The history should include
- Date of onset
- Nature and severity of symptoms
- Exacerbating factors (eg heat, cold, pressure, stress, medications)
- Treatment required and efficacy
- Thorough assessment to exclude underlying pathology (eg chronic infection)
- Suspected triggers (likely only if the symptoms are predictably associated with
exposure, and remit upon avoidance. If the symptoms persist despite
avoidance the suspect can be excluded as a cause).
- If associated with airway/breathing/circulation/neurological features see
anaphylaxis pathway
- If history suggests food or drug allergy (in the absence of anaphylaxis) please
click for appropriate pathway.
ACE inhibitor treatment can cause angioedema (without urticaria) even after
months or years of treatment and must be stopped in patients presenting with
angioedema.
Angioedema in the absence of urticaria also raises the possibility of
hereditary/acquired angioedema; check complement C4 to exclude this.
Investigations
No investigations are routinely indicated, and should only be performed if there is a
specific indication. The exception is complement C4 levels in angioedema alone.
Management
1. Spontaneous urticaria and angioedema should be treated initially with nonsedating antihistamines.
Version: 3
Date last edited 10/06/15
Locality: Devon wide
Amendments by: Kevin Bishop
a. Treatment may be as required or prophylactic depending on symptom
frequency of symptoms.
b. Higher than licensed doses may be required (eg cetirizine 10mg or
fexofenadine 180mg up to 4x/day). This is supported by British and
European guidelines and there is good safety data.
c. These increased doses must not be used in pregnancy, and attention
should be paid to interactions with other drugs.
2. Swelling involving the mouth/tongue can cause patients considerable
concern. If tongue swelling is mild treatment with additional antihistamine and
a single dose of prednisolone 20-30mg may be used.
a. Long term regular corticosteroids are not advised.
3. Any systemic involvement (eg airway, breathing, circulation, neurological)
prescription of 2 x 0.3mg self-injectable adrenaline pens, instruction in their
use, and be referred to a specialist allergy service.
4. All patients with angioedema should avoid ACE inhibitors.
5. Patients with urticaria and/or angioedema should be advised to use NSAIDS
with caution.
Referral
Referral criteria
1. Patients with troublesome symptoms (rash or swelling) despite high dose
prophylaxis with non-sedating antihistamines (3-4x/day).
a. Ranitidine 150mg BD +/- montelukast 10mg daily may be tried in
addition to antihistamines.
2. Any systemic features to suggest anaphylaxis.
3. If there is diagnostic uncertainty
4. Patients with angioedema and a low C4
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Referral Instructions
Refer to Peninsula Immunology and Allergy Service
Refer via DRSS for NEW Devon CCG patients
Choose and Book Selection
Specialty: Allergy
Clinic type: Allergy
Service: DRSS- Western –Allergy & Immunology - CCG - 99p
Referral forms
DRSS Referral form
Version: 3
Date last edited 10/06/15
Locality: Devon wide
Amendments by: Kevin Bishop
Supporting Information
http://www.guidelines.co.uk/skin_bsaci_urticaria_angio
http://onlinelibrary.wiley.com/doi/10.1111/cea.12494/pdf
http://southwest.devonformularyguidance.nhs.uk/formulary/chapters/3.respiratory/3.4.1-antihistamines
www.ga2len.net/464D9d01.pdf
Patient Information
http://www.patient.co.uk/health/chronic-urticaria-hives
Pathway Group
This guideline has been signed off by the Western Locality on behalf of NEW Devon
CCG.
Publication date: June 2015
Review date: May 2017
Version: 3
Date last edited 10/06/15
Locality: Devon wide
Amendments by: Kevin Bishop