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New-onset urticaria

Riccardo Asero, MD
Section Editors
Sarbjit Saini, MD
Jeffrey Callen, MD, FACP, FAAD
Deputy Editor
Anna M Feldweg, MD


Urticaria, or hives (sometimes referred to as welts or wheals), is a common disorder, with a prevalence of approximately 20 percent in the general population [1]. A typical urticarial lesion is an intensely pruritic, erythematous plaque (picture 1). Urticaria is sometimes accompanied by angioedema, which is swelling deeper in the skin. A presumptive trigger, such as a drug, food ingestion, insect sting, or infection, may be identifiable in patients with new-onset urticaria, although no specific cause is found in many cases, particularly when the condition persists for weeks or months. (See 'Etiologies' below.)

The epidemiology, clinical manifestations, etiologies, diagnosis, and management of new-onset urticaria will be reviewed here. Chronic urticaria and isolated angioedema are discussed separately. (See "Chronic urticaria: Clinical manifestations, diagnosis, pathogenesis, and natural history" and "Chronic urticaria: Standard management and patient education" and "An overview of angioedema: Clinical features, diagnosis, and management".)


Urticaria (with or without angioedema) is commonly categorized by its chronicity:

Acute urticaria — Urticaria is considered acute when it has been present for less than six weeks.

Chronic urticaria — Urticaria is considered chronic when it is recurrent, with signs and symptoms recurring most days of the week, for six weeks or longer.

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Literature review current through: Nov 2017. | This topic last updated: Oct 16, 2017.
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  1. Kaplan AP. Urticaria and angioedema. In: Middleton's Allergy: Principles and practice, 7th, Adkinson NF, Bochner BS, Busse WW, Holgate ST, Lemanske RF, Simons FER (Eds), Mosby, St Louis, MO 2009. Vol 2, p.1063.
  2. Sackesen C, Sekerel BE, Orhan F, et al. The etiology of different forms of urticaria in childhood. Pediatr Dermatol 2004; 21:102.
  3. Kaplan AP. Clinical practice. Chronic urticaria and angioedema. N Engl J Med 2002; 346:175.
  4. Ying S, Kikuchi Y, Meng Q, et al. TH1/TH2 cytokines and inflammatory cells in skin biopsy specimens from patients with chronic idiopathic urticaria: comparison with the allergen-induced late-phase cutaneous reaction. J Allergy Clin Immunol 2002; 109:694.
  5. Mortureux P, Léauté-Labrèze C, Legrain-Lifermann V, et al. Acute urticaria in infancy and early childhood: a prospective study. Arch Dermatol 1998; 134:319.
  6. Plumb J, Norlin C, Young PC, Utah Pediatric Practice Based Research Network. Exposures and outcomes of children with urticaria seen in a pediatric practice-based research network: a case-control study. Arch Pediatr Adolesc Med 2001; 155:1017.
  7. Imbalzano E, Casciaro M, Quartuccio S, et al. Association between urticaria and virus infections: A systematic review. Allergy Asthma Proc 2016; 37:18.
  8. Minciullo PL, Cascio A, Barberi G, Gangemi S. Urticaria and bacterial infections. Allergy Asthma Proc 2014; 35:295.
  9. Caubet JC, Kaiser L, Lemaître B, et al. The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge. J Allergy Clin Immunol 2011; 127:218.
  10. Wu CC, Kuo HC, Yu HR, et al. Association of acute urticaria with Mycoplasma pneumoniae infection in hospitalized children. Ann Allergy Asthma Immunol 2009; 103:134.
  11. Shah KN, Honig PJ, Yan AC. "Urticaria multiforme": a case series and review of acute annular urticarial hypersensitivity syndromes in children. Pediatrics 2007; 119:e1177.
  12. Cribier B. Urticaria and hepatitis. Clin Rev Allergy Immunol 2006; 30:25.
  13. Friedman D, Picard-Dahan C, Grossin M, et al. Chronic urticaria revealing an HIV infection. Eur J Dermatol 1995; 5:40.
  14. Di Campli C, Gasbarrini A, Nucera E, et al. Beneficial effects of Helicobacter pylori eradication on idiopathic chronic urticaria. Dig Dis Sci 1998; 43:1226.
  15. Del Pozo MD, Audícana M, Diez JM, et al. Anisakis simplex, a relevant etiologic factor in acute urticaria. Allergy 1997; 52:576.
  16. Sussman GL, Beezhold DH. Allergy to latex rubber. Ann Intern Med 1995; 122:43.
  17. Wang J, Sampson HA. Food allergy. J Clin Invest 2011; 121:827.
  18. Asero R, Antonicelli L, Arena A, et al. EpidemAAITO: features of food allergy in Italian adults attending allergy clinics: a multi-centre study. Clin Exp Allergy 2009; 39:547.
  19. Bourrain JL. Occupational contact urticaria. Clin Rev Allergy Immunol 2006; 30:39.
  20. Robledo T, Cimarra M, Agustin P, Martinez-Cocera C. Adverse reaction to dextromethorphan. Allergy 2004; 59:890.
  21. Anderson BE, Miller CJ, Adams DR. Stinging nettle dermatitis. Am J Contact Dermat 2003; 14:44.
  22. Cummings AJ, Olsen M. Mechanism of action of stinging nettles. Wilderness Environ Med 2011; 22:136.
  23. Uslu S, Bulbul A, Diler B, et al. Urticaria due to Urtica dioica in a neonate. Eur J Pediatr 2011; 170:401.
  24. Oliver F, Amon EU, Breathnach A, et al. Contact urticaria due to the common stinging nettle (Urtica dioica)--histological, ultrastructural and pharmacological studies. Clin Exp Dermatol 1991; 16:1.
  25. Poole JA, Rosenwasser LJ. Chronic idiopathic urticaria exacerbated with progesterone therapy treated with novel desensitization protocol. J Allergy Clin Immunol 2004; 114:456.
  26. Shank JJ, Olney SC, Lin FL, McNamara MF. Recurrent postpartum anaphylaxis with breast-feeding. Obstet Gynecol 2009; 114:415.
  27. Bandino JP, Thoppil J, Kennedy JS, Hivnor CM. Iatrogenic autoimmune progesterone dermatitis caused by 17alpha-hydroxyprogesterone caproate for preterm labor prevention. Cutis 2011; 88:241.
  28. Le K, Wood G. A case of autoimmune progesterone dermatitis diagnosed by progesterone pessary. Australas J Dermatol 2011; 52:139.
  29. Bernstein IL, Bernstein DI, Lummus ZL, Bernstein JA. A case of progesterone-induced anaphylaxis, cyclic urticaria/angioedema, and autoimmune dermatitis. J Womens Health (Larchmt) 2011; 20:643.
  30. Prieto-Garcia A, Sloane DE, Gargiulo AR, et al. Autoimmune progesterone dermatitis: clinical presentation and management with progesterone desensitization for successful in vitro fertilization. Fertil Steril 2011; 95:1121.e9.
  31. Confino-Cohen R, Chodick G, Shalev V, et al. Chronic urticaria and autoimmunity: associations found in a large population study. J Allergy Clin Immunol 2012; 129:1307.
  32. Charlesworth EN. The spectrum of urticaria: All that urticates may not be urticaria. Immunol Allergy Clin North Am 1995; 15:641.
  33. Beltrani VS. Urticaria and angioedema. Dermatol Clin 1996; 14:171.
  34. Charlesworth EN. Urticaria and angioedema: a clinical spectrum. Ann Allergy Asthma Immunol 1996; 76:484.
  35. Beltrani VS. Urticaria: reassessed. Allergy Asthma Proc 2004; 25:143.
  36. Laman SD, Provost TT. Cutaneous manifestations of lupus erythematosus. Rheum Dis Clin North Am 1994; 20:195.
  37. Leznoff A, Sussman GL. Syndrome of idiopathic chronic urticaria and angioedema with thyroid autoimmunity: a study of 90 patients. J Allergy Clin Immunol 1989; 84:66.
  38. deShazo RD, Kemp SF. Allergic reactions to drugs and biologic agents. JAMA 1997; 278:1895.
  39. Namazy JA, Simon RA. Sensitivity to nonsteroidal anti-inflammatory drugs. Ann Allergy Asthma Immunol 2002; 89:542.
  40. Grattan CE, Humphreys F, British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol 2007; 157:1116.
  41. Zuberbier T. A Summary of the New International EAACI/GA(2)LEN/EDF/WAO Guidelines in Urticaria. World Allergy Organ J 2012; 5:S1.
  42. Zuberbier T, Asero R, Bindslev-Jensen C, et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy 2009; 64:1417.
  43. Joint Task Force on Practice Parameters. The diagnosis and management of urticaria: a practice parameter part I: acute urticaria/angioedema; part II: chronic urticaria/angioedema. Ann Allergy Asthma Immunol 2000; 85 Suppl (6 pt 2):525.
  44. Weldon D. When your patients are itching to see you: not all hives are urticaria. Allergy Asthma Proc 2005; 26:1.
  45. Sicherer SH, Sampson HA. Auriculotemporal syndrome: a masquerader of food allergy. J Allergy Clin Immunol 1996; 97:851.
  46. Karunananthan CG, Kim HL, Kim JH. An unusual case of bilateral auriculotemporal syndrome presenting to an allergist. Ann Allergy Asthma Immunol 2002; 89:104.
  47. Beno SM, Nadel FM, Alessandrini EA. A survey of emergency department management of acute urticaria in children. Pediatr Emerg Care 2007; 23:862.
  48. Zuberbier T, Asero R, Bindslev-Jensen C, et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy 2009; 64:1427.
  49. Grattan C, Powell S, Humphreys F, British Association of Dermatologists. Management and diagnostic guidelines for urticaria and angio-oedema. Br J Dermatol 2001; 144:708.
  50. Geha RS, Meltzer EO. Desloratadine: A new, nonsedating, oral antihistamine. J Allergy Clin Immunol 2001; 107:751.
  51. Ring J, Hein R, Gauger A, et al. Once-daily desloratadine improves the signs and symptoms of chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled study. Int J Dermatol 2001; 40:72.
  52. Purohit A, Melac M, Pauli G, Frossard N. Comparative activity of cetirizine and desloratadine on histamine-induced wheal-and-flare responses during 24 hours. Ann Allergy Asthma Immunol 2004; 92:635.
  53. Simons FE, Early Prevention of Asthma in Atopic Children (EPAAC) Study Group. Safety of levocetirizine treatment in young atopic children: An 18-month study. Pediatr Allergy Immunol 2007; 18:535.
  54. Garg G, Thami GP. Comparative efficacy of cetirizine and levocetirizine in chronic idiopathic urticaria. J Dermatolog Treat 2007; 18:23.
  55. Snidvongs K, Seresirikachorn K, Khattiyawittayakun L, Chitsuthipakorn W. Sedative Effects of Levocetirizine: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. Drugs 2017; 77:175.
  56. Goyal V, Gupta A, Gupta O, et al. Comparative Efficacy and Safety of Ebastine 20 mg, Ebastine 10 mg and Levocetirizine 5 mg in Acute Urticaria. J Clin Diagn Res 2017; 11:WC06.
  57. Jáuregui I, Bartra J, del Cuvillo A, et al. Bilastine and quality of life. J Investig Allergol Clin Immunol 2011; 21 Suppl 3:16.
  58. Church MK. Safety and efficacy of bilastine: a new H(1)-antihistamine for the treatment of allergic rhinoconjunctivitis and urticaria. Expert Opin Drug Saf 2011; 10:779.
  59. González-Núñez V, Bachert C, Mullol J. Rupatadine: global safety evaluation in allergic rhinitis and urticaria. Expert Opin Drug Saf 2016; 15:1439.
  60. Potter P, Mitha E, Barkai L, et al. Rupatadine is effective in the treatment of chronic spontaneous urticaria in children aged 2-11 years. Pediatr Allergy Immunol 2016; 27:55.
  61. Kaplan AP. Chronic urticaria: pathogenesis and treatment. J Allergy Clin Immunol 2004; 114:465.
  62. Adelsberg BR. Sedation and performance issues in the treatment of allergic conditions. Arch Intern Med 1997; 157:494.
  63. Källén B. Use of antihistamine drugs in early pregnancy and delivery outcome. J Matern Fetal Neonatal Med 2002; 11:146.
  64. Schatz M, Petitti D. Antihistamines and pregnancy. Ann Allergy Asthma Immunol 1997; 78:157.
  65. Schatz M, Zeiger RS. Asthma and allergy in pregnancy. Clin Perinatol 1997; 24:407.
  66. Lin RY, Curry A, Pesola GR, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med 2000; 36:462.
  67. Fedorowicz Z, van Zuuren EJ, Hu N. Histamine H2-receptor antagonists for urticaria. Cochrane Database Syst Rev 2012; :CD008596.
  68. Monroe EW, Cohen SH, Kalbfleisch J, Schulz CI. Combined H1 and H2 antihistamine therapy in chronic urticaria. Arch Dermatol 1981; 117:404.
  69. Guevara-Gutierrez E, Bonilla-Lopez S, Hernández-Arana S, Tlacuilo-Parra A. Safety and efficacy of cetirizine versus cetirizine plus ranitidine in chronic urticaria: Double-blind randomized placebo-controlled study. J Dermatolog Treat 2015; 26:548.
  70. Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med 1995; 26:547.
  71. Zuberbier T, Iffländer J, Semmler C, Henz BM. Acute urticaria: clinical aspects and therapeutic responsiveness. Acta Derm Venereol 1996; 76:295.
  72. Barniol C, Dehours E, Mallet J, et al. Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. Ann Emerg Med 2017.