The following pre-referral guideline covers urticaria/angioedema for children of all ages. Please see the following pre-referral guidelines for further information.

• Allergic reaction - Anaphylaxis
• Food allergies Eczema

Initial work-up

Urticaria is a distressing but generally benign and self-limiting condition.

Rule out severe allergic reaction symptoms

Severe systemic allergic reaction (anaphylaxis):

• Difficulty breathing.
• Swelling of the tongue and/or throat.
• Difficulty talking.
• Hoarse voice, wheezing or persistent coughing.
• Loss of consciousness and/or collapse. Infants and young children appearing pale and floppy.

Mild to moderate systemic allergic reaction:

• Swelling of lips, face or eyes.
• Hives or welts.
• Abdominal pain, vomiting.  

Take a history

• History of possible triggers.
  • This is the most important issue to clarify as it will differentiate a specific allergy from isolated urticaria.
• History of urticaria - duration of symptoms, characteristics of individual lesions, presence or absence of systemic symptoms, circumstances surrounding the onset of symptoms, aggravating and relieving factors.
• History of any other allergic reactions and nature of reaction.
• Urticaria occurring on a daily basis, whether it be for 2 weeks or 2 years, is rarely related to a specific allergy.
• If urticaria results from an acute allergic reaction (e.g. to food, insect or drug), refer to  allergic reaction pre-referral guidelines.
• Consider physical urticarias - lesions transient less than 4 hours for individual wheals. Examples include:
  • Pressure - tight clothing.
  • Cold - drying off after swimming.
  • Cholinergic - fine 1-2mm urticarial rash following sweating/heat.
• Idiopathic urticarias - diagnosis of exclusion:
  • Acute usually 1-2 weeks.
  • Chronic > 6 weeks, usually 6-9 months.
• History of atopy (eg. atopic eczema/ allergic rhinitis).
• Family history of allergic disease.

Diagnostic

• For isolated urticaria, allergy testing (ie. RAST, Skin Prick Test) are not required unless part of a more generalised allergic reaction (eg. food allergy).

Pre-referral assessment/treatment

• Acute idiopathic urticaria (with no anaphylaxis) - treat symptoms.
• Chronic idiopathic urticaria - consider possible underlying disease, such as connective tissue disease and Auto Immune disorders and consider referral to Allergy or Rheumatology. Lower priority referral.
• For physical urticaria avoid observed trigger factors e.g. heat, tight clothing, aspirin and alcohol. REFER IF ANAPHYLAXIS.
• Elimination diets are usually not helpful. Not recommended.
• Less sedating oral antihistamines first line of treatment. Loratidine (Claratyne) and certirizine (Zyrtec) are suitable for children over 1 year old.
• Refer if chronic urticaria is not controlled by antihistamine therapy, as other treatments (ie. H2 antagonists, corticosteroids or other immunomodulatory agents) may be appropriate.

When to refer

RCH Department of Allergy and Immunology

Do not refer children with acute urticaria to RCH Allergy and Immunology.

Refer when:

• Acute urticaria is associated with symptoms of a specific moderate to severe allergic reaction.
• Chronic urticaria - if suspicious of underlying connective tissue/ autoimmune disorder (ie.splenomegaly, other rash, joint symptoms (eg. weight loss, fever).
• Physical urticaria or cholinergic urticaria - if difficult to manage and not controlled by avoidance and antihistamine treatment.

Contact information

Resources

• Clinical practice guidelines
• Information booklet
• Parent information website Kids Health Info
• Kids Connect (RCH Primary Care Liaison) www.rch.org.au/kidsconnect
  Contains all referral forms, clinic information, other pre-referral guidelines and parent information.
• Clinical Services Directory
• Feedback
  We welcome your feedback on this guideline: kids.connect@rch.org.au / tel (03) 9345 4645 / fax (03) 9345 4650.

References

The Asthma Management Handbook (2006). Asthma and Allergy (pp57-63) National Asthma Council Australia.

Australiasian Society of Clinical Immunology website www.allergy.org.au.

ASCIA Education Resources

Copyright and Disclaimer

Copyright 2006, Royal Children's Hospital (RCH) Victoria, Australia. Adapted with permission from Children's Hospital and Regional Medical Center, Seattle, WA, USA.

The RCH and Children's Hospital and Regional Medical Center are not responsible in any way for application of the procedures or guidelines to patient care at your facility. They are guidelines only and your professional judgment must always prevail. Guidelines may not be reproduced without permission. RCH Kids Connect - Primary Care Liaison. www.rch.org.au/kidsconnect

These guidelines were developed by specialists at the Royal Children's Hospital and reviewed by a working group of metropolitan and rural general practitioners in Victoria. Last reviewed in December 2008.