A practical approach to the diagnosis and management of chronic urticaria

Urticaria commonly occurs in childhood, affecting up to 15% of British children. It is characterized by the sudden onset of wheals, angioedema, or both. Episodes are usually acute, often triggered by viral infections or antibiotics, with approximately a third progressing to chronic or recurrent urticaria. This review focuses on chronic urticaria subtypes, diagnosis and treatment options for children. The diagnosis is usually made clinically, and a focused history is key. Detailed investigation is usually unnecessary. Chronic urticaria is divided into chronic spontaneous urticaria and the inducible urticarias. Chronic spontaneous urticaria is autoimmune in origin, in approximately 40% of older children. Cold urticaria and dermographism are the most common inducible urticarias. Isolated angioedema should prompt consideration of hereditary angioedema. The mainstay of treatment is trigger avoidance combined with non-sedating antihistamines. Higher doses of antihistamines may be required but these are usually tolerated well. We provide guidance on antihistamine updosing strategies. There is an improvement in symptoms for most children, but leukotriene receptor antagonists can provide additional improvements in some children. Tranexamic acid may provide symptomatic relief for isolated angioedema. Short courses of oral steroids may be used in acute episodes or highly symptomatic patients with chronic urticaria. Second line treatment for non-responders is primarily monoclonal anti-IgE antibody therapy but a small number of children and young people continue to have significant symptoms despite this and in these children ciclosporin may be useful. Urticaria usually resolves and almost all children and young people are disease free after 7 years.