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Urticaria and Angioedema

 

There are good guidelines on the BSACI website at www.bsaci.org


History (good history taking essential):

  • Whether child was well or ill before event (often triggered by a viral illness some time before, illness can be minor and may have been forgotten)
  • Whether child acutely unwell during event, ask about fevers in particular
  • Timing of onset / potential triggers (if food suspected, must be within 1-2 hours of exposure and reproducible) 
  • Appearance of rash +/- swelling (parents often take photo)
  • How long lesions lasted (usually < 24 hrs per lesion but can move around the body) 

 

Note that angioedema is often present with the urticaria (some 40% of the time) but can rarely (around 10% of the time) occur without urticaria. The swelling usually affects the lips, peri-orbital area and cheeks.

It is rare for swelling to affect the airway.

 

Common Causes (that are not due to IgE – mediated allergy):

  • Acute Episodes of urticaria +/- angioedema as above, can be spontaneous
     
  • Chronic Spontaneous Urticaria (CSU) = classical urticarial rash on most days for > 6 weeks. ‘Idiopathic’ form common.

Affects 0.1 – 3% of UK children.

Usually starts with viral illness then Mast Cells become ‘primed’ and excitable, triggering rash at random times.

Can last many years in some children

Unlike in adults, a specific disease or causative drug is rarely found 

  • Physical Urticarias e.g. heat, cold, pressure are often obvious from history and can be acute or chronic relapsing / remitting

 

 Management:

There are useful guidelines for management of Chronic Urticaria and Angioedema on BSACI website at www.bsaci.org

  • Tests are rarely useful in CSU or physical urticarias unless there are other symptoms compatible with thyroid dysfunction or coeliac disease
  • First-line treatment is a non-sedating (second generation) antihistamine such as Cetirizine or Loratadine (licensed for > 2yrs). Some children need trials of different antihistamines until find one that works best. Some need higher than recommended doses.
  • Next step is a month’s trial of leukotriene receptor antagonist. If this is no help, refer.
  • Short courses (e.g. 3 days) of oral steroids can also help as a ‘one – off’ e.g. an important weekend away

 

Refer to Allergy Clinic:

  • Symptoms suggesting angioedema of airway
  • A suspicion of C1 esterase inhibitor deficiency (rare, plaques of angioedema, airway swelling, no urticaria, not itchy, may be a family history)

 

 

Refer to General Paediatrics:

  • Troublesome, chronic urticaria (on most days for >6 weeks) not responding to trials of different antihistamines/double dose of antihistamine or monteleukast as per BSACI guidelines
  • Obvious history of Cold Urticaria

 

 

Refer to Dermatology / Advice & Guidance:

  • Lesions suspicious of vasculitis
  • Lesions suspicious of mastocytosis e.g. wheal occurs on rubbing permanent freckles or macules

 

 

No need to refer if:

  • Chronic Urticaria responding to treatment as above
  • Short – lived, infrequent episodes (<24 hrs), and no airway involvement (can often be attributed to viral infection and may recur intermittently)
  • Short lived episode of redness / hives around mouth after tomatoes, berries, acidic or spicy foods that at other times or in other forms are tolerated.

 

 

Date:                            February 2025

Review Date:               February 2027

Specialty Lead GP:      Dr M Schick, RMS 

Authors:                       Simon Bedwani, Consultant Paediatrician, RCHT

                                    Dr S Burns GP RMS

 

Version No.  1.2