Urticaria commonly affects 1 in every 5 people during their lifetime. It presents as itchy, raised lumps, called weals or hives. Weals may persist up to a few hours and resolve without any trace. However, deeper, longer-lasting or tender swellings affecting the eyelids, lips or mouth may also be reported.

‘Acute’ urticaria persists for <6 weeks, while ‘chronic’ lasts longer. Chronic urticaria when occurs spontaneously is known as chronic spontaneous urticaria; or when induced by various triggers is known as chronic inducible urticaria, such if by friction then dermographism, if by pressure then delayed-pressure urticaria, if by sweating then cholinergic urticaria, if by cold then cold urticaria, if by the sun then solar urticaria or if by water then aquagenic urticaria.

A recent guideline explains how to manage these different types of chronic urticaria. These can only be controlled as there is no cure yet. It usually does not demand investigations.

Avoid factors that make urticaria worse, like some drugs are important. Itching may be relieved by menthol-containing cream.

All types of chronic urticaria are treated initially with a low-sedating antihistamine, which can be increased if needed and safe, above the licensed dose. Sedating antihistamines should be avoided. 

Adding montelukast may help chronic spontaneous urticaria or using steroid tablets (prednisolone) for a few days can also calm a bad flare.

Omalizumab injections can be given in the second step in severe chronic spontaneous urticaria with ciclosporin tablets as the alternative. 

Omalizumab may also be given in severe chronic inducible urticaria if the local body approves its use. In episodes of collapse, self-injectable adrenaline can be given. The type of chronic inducible urticaria also directs the treatment modality like phototherapy for dermographism or ciclosporin for cold urticaria.

Further, this guideline also directs treatment in pregnancy, lactation and children. 

Source: Sabroe RA, Lawlor F, Grattan CEH, et al. British Association of Dermatologists guidelines for the management of people with chronic urticaria 2021. Br J Dermatol. 2022;186(3):398-413.