What factors lead to the development of chronic urticaria?

Updated: Jul 31, 2018
  • Author: Marla N Diakow, MD; Chief Editor: William D James, MD  more...
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Although thyroid autoantibodies are identified more frequently in patients with chronic urticaria compared with the general population, there is no clear evidence that management of chronic urticaria or the course of chronic urticaria differs in this subgroup, nor is there persuasive evidence that administration of thyroid hormone supplementation in such cases is associated with improved outcomes. Because the clinical relevance of these autoantibodies for evaluation and treatment of patients with chronic urticaria has not been established, routine testing for thyroid autoantibodies is not recommended. [9]

Urticaria may be caused or exacerbated by a number of drugs. Among the more common culprits are aspirin and other NSAIDs, opioids, angiotensin-converting enzyme (ACE) inhibitors, and alcohol.

Urticaria has been reported to be associated with a number of infections; however, these associations are not strong and may be spurious. Infectious agents reported to cause urticaria include hepatitis B and C viruses, Streptococcus and Mycoplasma species, Helicobacter pylori, [17, 18] Mycobacterium tuberculosis, and herpes simplex virus (HSV).

There is limited evidence that if H pylori colonization is present, eradication may result in an improvement in chronic urticaria symptoms and thus, screening for H pylori is not recommended. [19]

The nematode Anisakis simplex is often the cause of chronic urticaria in areas where the population frequently consumes raw or marinated fish. A report of adults seen at an allergy center in Bari, Italy, found that 106 (50%) of 213 patients with chronic urticaria had A simplex hypersensitivity; all of the hypersensitive patients regularly ate marinated fish. In comparison, only 16% of a control population without chronic urticaria had sensitization to A simplex. [20] Chronic urticaria disappeared in 82 (77%) of 106 patients who gave up raw fish for 6 months; the condition cleared up in only one (2%) of 42 patients who did not give up raw fish. Additionally, 88% who returned to eating raw fish after their condition disappeared had a relapse of chronic urticaria, compared with 14% of those who remained on the diet. [20]

Some patients report the onset of acute urticaria associated with the consumption of certain foods, such as shellfish, eggs, nuts, strawberries, or certain baked goods. However, food allergy is rarely the basis of chronic urticaria.

Contactants may give rise to contact urticaria syndrome, a term referring to the onset of urticaria within 30-60 minutes of contact with an inciting agent. The lesions may be localized or generalized. Precipitating agents include latex (especially in healthcare workers), plants, animals (eg, caterpillars, dander), medications, and food (eg, fish, garlic, onions, tomato).

Arthropod bites or stings are the most common cause of papular urticaria. Although patients who are bitten by mosquitoes are likely to be aware of the source of the problem, patients with scabies, bedbug bites, flea bites, or other similar problems may not be aware. Ask patients about exposure to animals, recent moves, hobbies, travel, or the presence of a similar skin condition in other members of the household.

Urticaria is a feature of some autoinflammatory diseases, such as Muckle-Wells syndrome (characterized by amyloidosis, nerve deafness, and urticaria) and Schnitzler syndrome [21] (characterized by fever, joint or bone pain, monoclonal gammopathy, and urticaria).

Little evidence exists to support the concern that chronic urticaria may be a cutaneous sign of occult internal malignancy. In a study of 1155 patients with chronic urticaria in Sweden, Sigurgeirsson found no association with cancer, although acquired angioedema associated with C1 inhibitor depletion may be associated with malignancy. [22] In a population-based cohort study in Taiwan, a slightly increased risk of cancer, especially hematologic malignant tumor, was observed among patients with chronic urticarial. [23] However, evidence is not sufficient to suggest any causality. Routine screening for malignancies in chronic urticaria is not suggested; it is only warranted if patient history dictates.

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