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

​Assessment

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.

Red Flags

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

​Investigations

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

​Management

A non-sedating antihistamine should be started (syrup or tablet, as per BNFc doses)

Chapter 13 - Skin

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

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 & Adolescent
  • Clinic Type: Allergy
  • Service: DRSS-Western-Child&Adolescent-CCG-99P

Referral Forms

DRSS referral form

​Supporting Information

Patient Information

NHS Choices Angioedema

Evidence

NICE - Urticaria

NICE - Angio-oedema and anaphylaxis

BSACI Primary Care Guidelines

RCPCH - Care pathway for urticaria, angio-odema or mastocytosis

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: January 2017

 

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