All information is correct at time of printing and is subject to change without notice. The Devon Formulary and Referral Website is not in any way liable for the accuracy of any information printed and stored by users. For the most up-to-date information, please refer to the website.
Referral
Contact us about this page
Urticaria, Angioedema and Mastocytosis
Scope
This guideline refers to children under 18 who may require further investigation and management of urticaria, angioedema or mastocytosis.
Chronic Urticaria occurs in 3% children, and acute urticaria occurs in 4.5-15% children.
Angioedema is much rarer occurring in 1/5000 patients.
Urticaria alone occurs in 50% of patients, angioedema with urticaria in 40% patients and angioedema alone in 10%.
The true incidence of mastocytosis is unknown
Out of scope
Anaphylaxis – see alternative referral pathway
History and Examination
History and examination of the child suggestive of urticaria or angioedema:
Urticaria is characterised by fluctuating weals and/or angio-oedema. A weal consists of three typical features:
- a central swelling of variable size, almost invariably surrounded by a reflex erythema
- associated itching or, sometimes, burning sensation
- a fleeting nature, with the skin returning to its normal appearance, usually within 1–24 hours
Angio-oedema is characterised by:
- a sudden, pronounced swelling of the lower dermis and subcutis, which is pale rather than pink and may be painful rather than itching
- frequent involvement below mucous membranes
- resolution that is slower than for weals and can take up to 72 hours
The history must rule any possible triggers such as food ( see food guideline), latex, stings, and drugs.
Please ensure you check for infections:
- childhood viral illnesses
- ebstein Barr virus
- viral hepatitides
- parasites
Consider physical causes
- cold, heat, pressure, vibration, exertion
Check the drug history including NSAIDs and opiates.
Consider underlying vasculitic process
- Urticaria often painful and persists over 24 hours, initial weal fades away and leaves a"stain" or discolouration
Airway compromise with angioedema +/- urticaria
- Treat as anaphylaxis
Rubbing freckles or macules causes an urticated lesion
Baseline investigations can include
- Full blood count (FBC)
- Erythrocyte sedimentation rate and C-reactive protein (ESR +/- CRP)
- Liver and renal function
- Thyroid function and thyroid antibodies
A non-sedating antihistamine should be started (syrup or tablet, as per BNFc doses)
If this is insufficient to control the symptoms after a month the dose can be doubled.
The BSACI management of chronic urticaria and angioedema algorithm may be helpful.
Referral Criteria
Please refer in to the paediatric allergy clinic if:
- Urticaria last for more than 4 weeks
- Urticaria does not respond to double doses of non-sedating antihistamine
- Angioedema occurs alone
- Wheals fade to leave pigmentary changes
- Wheal occurs on rubbing freckles or macules
Referral Instructions
e-Referral Service Selection
- Specialty: Children's and Adolescent Services
- Clinic Type: Allergy
- Service: DRSS-Western-Child & Adolescent -Devon ICB-15N
Referral Form
Patient Information
Evidence
NICE - Angio-oedema and anaphylaxis
RCPCH - Care pathway for urticaria, angio-odema or mastocytosis
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: January 2017
