Urticaria and Angioedema

Urticaria can look different from person to person and across different skin tones. The wheals can be small or large and may join together to form larger patches.

Symptoms of urticaria can include:

• raised, swollen areas of skin called wheals or hives

• intense itching

• wheals that change shape, size, or location

• individual wheals that usually disappear within 24 hours

• swelling that may be red or pink on lighter skin, while redness may be less obvious on brown or black skin

Angioedema can cause:

• sudden swelling beneath the skin

• swollen lips or eyelids

• swelling of the hands or feet

• swelling of the tongue or inside the mouth

• swelling around the genitals

• tightness, tenderness, pain, or a burning sensation in the swollen area

• abdominal pain if swelling affects the bowel

When is urticaria or angioedema an emergency?

Urticaria itself does not usually develop into anaphylaxis, but hives and angioedema can occur as part of an anaphylactic reaction.

Call 999 immediately if you or someone else develops sudden swelling of the mouth, lips, tongue, or throat alongside symptoms such as:

• difficulty breathing

• wheezing

• a tight throat

• difficulty swallowing

• severe dizziness

• confusion

• fainting

These can be signs of anaphylaxis and need emergency medical treatment.

Urticaria happens when mast cells release histamine and other chemicals into the skin. There are many reasons why this can happen, and a specific cause is not always found.

Acute urticaria can sometimes develop in response to:

• certain foods

• medicines, including some antibiotics

• insect stings

• viral or other infections

• contact with certain substances

However, acute urticaria often occurs without an obvious cause.

Chronic spontaneous urticaria is different. Although people often assume long-lasting hives are caused by an allergy, most cases don’t have a specific allergic trigger. In some people, the immune system appears to play a role by activating the mast cells that release histamine.

Some people have chronic inducible urticaria, where symptoms appear following a particular physical stimulus. Possible triggers include:

• scratching or rubbing the skin (dermatographism) 

• pressure from tight clothing or carrying a heavy bag (pressure urticaria)

• cold temperatures (cold urticaria)

• heat (heat urticaria)

• sweating or exercise (cholinergic urticaria)

• sunlight (solar urticaria)

• water (aquagenic urticaria)

• contact with certain substances (contact urticaria)

Factors such as heat, alcohol, stress, and some medicines can also make existing urticaria worse in some people.

Angioedema without urticaria needs careful assessment because it can have different causes.

Some medicines can cause angioedema without hives. One important example is angiotensin-converting enzyme (ACE) inhibitors, which are medicines used to treat high blood pressure and some heart conditions. A reaction can sometimes develop even if you’ve taken the medicine for a long time without problems.

Rarely, recurrent angioedema without hives can be caused by hereditary angioedema. This is an inherited condition involving a different chemical pathway from most cases of urticaria and needs specialist investigation and treatment.

At your initial consultation, your specialist will ask about your symptoms, medical history, medicines, possible triggers, and how long each episode lasts. They may also examine your skin during the appointment if you have symptoms.

Because hives can disappear before you see a consultant, taking clear photographs when your symptoms appear is helpful. You may also want to keep a record of when symptoms develop and anything that happened shortly beforehand.

In many cases, your symptoms and medical history are enough to diagnose urticaria. There’s no single test that can identify the cause of chronic spontaneous urticaria, and routine allergy testing is usually unnecessary when there’s no clear link between symptoms and a possible allergen.

Your consultant may recommend further investigations if your symptoms or medical history suggest another condition. These may include:

• blood tests

• targeted allergy tests if there is a clear history suggesting an allergic trigger

• tests for specific forms of inducible urticaria

• blood tests for hereditary or acquired forms of angioedema if you experience recurrent swelling without hives

Your consultant will choose tests based on your individual symptoms rather than carrying out broad allergy testing without a clear reason.

It’s not always possible to prevent urticaria, particularly chronic spontaneous urticaria, because there may be no identifiable external trigger.

If you have a known trigger, avoiding or reducing exposure to it may help prevent flare-ups. Depending on your individual symptoms, your consultant may recommend:

• avoiding known physical triggers where possible

• wearing loose clothing if pressure or friction makes symptoms worse

• keeping cool and avoiding overheating if heat triggers your hives

• discussing medicines that appear to make your symptoms worse with your doctor

• limiting alcohol if you notice that it makes your symptoms worse

• taking prescribed antihistamines regularly if advised by your consultant

Do not stop prescribed medication without medical advice. If your consultant suspects that a medicine is causing your symptoms, they can discuss suitable alternatives with you.

There’s usually no need to avoid large groups of foods unless there’s a clear and repeatable connection between a particular food and your symptoms. Unnecessary restrictive diets can make it harder to get the nutrition you need.

For most people, urticaria is uncomfortable but doesn’t cause lasting damage to the skin or general health. However, persistent itching and unpredictable flare-ups can interfere with sleep, work, exercise, social activities, and emotional wellbeing.

Angioedema also usually settles without causing lasting problems. However, swelling involving the tongue or throat can become serious if it affects your airway.

Recurrent angioedema without hives also needs specialist assessment because some forms, including hereditary angioedema and medicine-related angioedema, require different treatment from ordinary urticaria.

If an individual wheal remains in exactly the same place for more than 24 hours, is painful rather than itchy, or leaves bruising or discolouration as it fades, tell your consultant. These features are less typical of ordinary urticaria and may need further investigation.

Treatment depends on the type of urticaria or angioedema you have, how often your symptoms occur, their severity, and whether your consultant identifies a trigger or underlying cause.

Treatment options can include:

• second-generation antihistamines (cetirizine, loratadine, fexofenadine, for example) – these medicines block the effects of histamine and are the main treatment for most types of urticaria

• an adjusted antihistamine dose – your consultant may recommend increasing the dose when a standard dose does not control chronic symptoms

• avoiding or managing known triggers – this can be particularly useful for chronic inducible urticaria

• short courses of corticosteroids – these may occasionally be considered for severe flare-ups, but are not suitable for routine long-term treatment

• specialist treatments – those whose chronic urticaria remains uncontrolled despite antihistamines may be offered other medicines, including biological treatment such as omalizumab (Xolair), immunosuppression (ciclosporin) or remibrutinib (Rhapsido)

• treatment for an underlying cause – angioedema caused by certain medicines or rarer conditions requires a different treatment plan

Your consultant will create a treatment plan based on your symptoms and medical history. You should only take antihistamines above the standard recommended dose when a healthcare professional has advised you to do so.

At Welbeck, our consultant allergists are experts in their field and are dedicated to providing world-class care to every patient.

With access to colleagues across other specialties, our consultants are also able to refer within the Welbeck ecosystem if required to ensure you receive the treatment you need as quickly as possible, all under one roof.

All appointments, testing, treatment, and follow-up appointments take place within our state-of-the-art facilities, enabling us to deliver accurate diagnostics and advanced treatments.

Your health is important to us, so we strive to offer same-day appointments whenever possible.

Our consultants are recognised by the major health insurance companies. If you have private health insurance, your treatment at Welbeck can begin once you have obtained authorisation. We also provide care to self-paying patients. Learn more about the different payment options at Welbeck.

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