Diagnosis and Management of Intermittent Urticaria

Initial Clinical Assessment

The American Academy of Pediatrics recommends distinguishing urticaria from anaphylaxis, and treating as anaphylaxis with intramuscular epinephrine first if urticaria occurs with respiratory symptoms, hypotension, or gastrointestinal symptoms after known allergen exposure 2
Food exposures, particularly peanut, tree nuts, milk, shellfish, and fish, should be systematically inquired about in patients with intermittent urticaria 2
Medications, especially NSAIDs, aspirin, codeine, and ACE inhibitors, can trigger or worsen urticaria and should be avoided 3
The Urticaria Control Test (UCT) can be used to quantify disease burden and guide treatment decisions in patients with intermittent urticaria 4

Skin biopsy is recommended only if individual wheals persist >24 hours to rule out urticarial vasculitis 1
Avoid NSAIDs in all urticaria patients as they can trigger or worsen urticaria through non-IgE mechanisms 3
Consider subspecialty referral for chronic urticaria unresponsive to high-dose second-generation antihistamines (up to 4× standard dose) 5
Wheals persisting >24 hours require biopsy to rule out urticarial vasculitis 1