Mild: does not impact significantly on activities of daily living 

• For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
• Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
• Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for up to 3 months.

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

• For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
• Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
• Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing up to quadruple dose, reducing to lower doses when symptoms controlled. 
• Suggest a FBC differential, ESR/CRP and TSH/TFT for patients where symptoms persist. 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

• For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers (stop histamine-releasing drugs and avoid triggers for inducible urticarias, as for mild/moderate urticaria) 
• Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, fexofenadine, or loratadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing to quadruple dose, reducing to lower doses when symptoms controlled 
• Give a short course of an oral corticosteroid (for example prednisolone 40 mg daily for 4-5 days) in addition to the low-sedating oral antihistamine if not controlled. Longer term steroids are not advised for chronic urticaria management in primary care. 
• Referral if an oral corticosteroid is indicated in a child younger than 16 years of age.   
• If rebound symptoms occur, seek specialist advice. Do not repeat the course of oral corticosteroid. 
• Suggest a FBC differential, ESR/CRP and TSH/TFT. 
• NICE guidance recommends montelukast as a second-line agent (unlicenced indication)

Mild: does not impact significantly on activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty. 

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamine treatment, or when disease is having a significant effect on quality of life.  

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

Seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamines or other treatments listed above, or when disease is having a significant effect on quality of life. Refer people with forms of chronic inducible urticaria that may be difficult to manage in primary care, for example, solar or cold urticaria. 

Refer people with acute severe urticaria which is thought to be due to a food or latex allergy – check locally whether referral to specialist immunology services more appropriate. 

• There are other treatment options in secondary care, including omalizumab and ciclosporin. 

DLQI clinical tool: https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires/dermatology-life-quality-index  

UAS7 clinical tool:  

NICE CKS – Urticaria: 

NICE scenarios – Managing urticaria:  

BAD Urticaria guidelines (2007):  

PCDS guidance – Chronic spontaneous urticaria  

BSACI- Urticaria:  The EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis and management of urticaria - Zuberbier - 2021 – Allergy 

DermnetNZ – Urticaria   

• Patients with urticaria have a higher incidence of thyroid receptor antibodies than the general population. 
• Check C4 levels (complement) in patients with angioedema without urticaria. 
• UAS7 can be a useful tool in estimating severity and response to treatment. 
• Chronic spontaneous urticaria is rarely associated with food allergy, and patch testing is unhelpful and not recommended. 

1. BAD leaflet – Urticaria and angioedema
2. Patient.info leaflet – Urticaria
3. NHS Conditions- Hives
4. Angioedema
5. NHS Inform Scotland- Urticaria (Hives) 

Inflammatory 

ICD11 code - EB00