Paeds · allergy-and-immunology
Urticaria and angioedema
Also known as Hives · Nettle rash · Chronic spontaneous urticaria · Angio-oedema · Hereditary angioedema · CSU
A fellowship-grade approach to urticaria and angioedema in children: how to read a transient rash against the clock of six weeks, how to separate the common histamine-mediated majority from the rare but dangerous bradykinin-mediated minority, how to escalate treatment from second-generation antihistamines through omalizumab, and when angioedema of the larynx demands adrenaline or C1-inhibitor concentrate rather than another tablet.
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Target exams
Red flags
- Stridor, drooling, voice change or dysphagia with angioedema — laryngeal oedema is an airway emergency
- Hypotension, collapse, respiratory distress or gastrointestinal symptoms with acute urticaria — treat as anaphylaxis
- Angioedema without wheals that recurs or runs in the family — suspect C1-inhibitor deficiency (bradykinin pathway)
- Urticaria with fever, arthralgia, weight loss or night sweats — search for an autoinflammatory or systemic cause
- Painful, non-itchy swelling lasting more than 24–48 hours, or leaving bruising — not simple urticaria
- Chronic urticaria unresponsive to up-titrated antihistamine — refer to allergy or immunology
- Angioedema in a child taking an ACE inhibitor — the drug may be the cause and antihistamines will not help
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics
- Recognise, classify and manage urticaria and angioedema in children, including the distinction of histamine- from bradykinin-mediated angioedema
- Apply the stepwise treatment of chronic spontaneous urticaria from antihistamine up-titration through biologics, and recognise hereditary angioedema
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- Infection, Immunology and Rheumatology: recognises and manages allergic and immunological conditions including urticaria and angioedema
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- Allergy: applies the stepwise management of chronic spontaneous urticaria
- Applied Knowledge in Practice (AKP)
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- History
- Communication
- Video
- General Pediatrics Content Outline — Allergy and Immunology
- General Pediatrics Content Outline — Emergency and Critical Care
- General Pediatrics Content Outline — Universal Task 3: Diagnosis
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Medical Knowledge: Allergic and immunologic disorders
- Medical Expert
- Pediatrics: Foundations — Recognizing and managing allergic conditions including urticaria, angioedema and anaphylaxis
Overview & Definition
Picture a six-year-old who wakes with itchy pink lumps over her trunk. Each one moves and fades within hours, replaced by new ones elsewhere, and by morning she is back to normal skin. Her parents are frightened; the child is mostly annoyed. That picture — transient, migratory, intensely itchy wheals that individually resolve within twenty-four hours leaving normal skin — is urticaria, and recognising its rhythm is what separates it from every other childhood rash. [1] [5]
Urticaria is the appearance of wheals (raised, erythematous, oedematous papules or plaques with a pale centre), angioedema, or both. A wheal has three hallmarks: a raised central swelling of variable size surrounded by a reflex erythema, an associated itch — sometimes a burning sensation — and a fleeting nature, with the skin returning to normal within twenty-four hours. The driving event is mast-cell activation in the superficial dermis, with release of histamine and other mediators that produce vasodilation and extravasation of fluid. [1] [14]
Angioedema is the deeper sibling: swelling in the dermis, subcutaneous tissue or submucosa. It may accompany urticaria — as it does in about half of children with acute urticaria — or it may occur alone, and when it occurs alone the mechanism question changes entirely. Angioedema with wheals is almost always histamine-mediated. Angioedema without wheals may be bradykinin-mediated, and that single distinction changes the entire management. [1] [10]
The six-week clock is the other hinge. Acute urticaria lasts under six weeks and is overwhelmingly self-limiting, usually triggered by infection, drug or food in children. Chronic urticaria — defined as symptoms persisting or recurring on most days for six weeks or more — is further divided into chronic spontaneous urticaria (no identifiable external trigger) and chronic inducible urticaria (reproducibly triggered by a specific physical stimulus such as cold, pressure or dermographism). This time threshold is not arbitrary: it separates a condition that resolves on its own from one that needs a stepwise escalation plan and a search for mimics. [1] [4]
The numbers that frame the problem
References14ShowHide
- [1]Zuberbier T The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria Allergy, 2022.PMID 34536239
- [2]Fricke J Prevalence of chronic urticaria in children and adults across the globe: Systematic review with meta-analysis Allergy, 2020.PMID 31494963
- [3]Ensina LF Managing Chronic Urticaria in Children: An Update Current Allergy and Asthma Reports, 2025.PMID 40192928
- [4]Caffarelli C Management of chronic urticaria in children: a clinical guideline Italian Journal of Pediatrics, 2019.PMID 31416456
- [5]Marques-Mejías MA Acute urticaria in the pediatric emergency department: Management and possible triggers Annals of Allergy, Asthma & Immunology, 2020.PMID 31981615
- [6]Santa C Acute urticaria in children: from pediatric Emergency Department to allergology consultation at a Central Hospital European Annals of Allergy and Clinical Immunology, 2022.PMID 33944542
- [7]Maurer M Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria New England Journal of Medicine, 2013.PMID 23432142
- [8]Maurer M Dupilumab in patients with chronic spontaneous urticaria (LIBERTY-CSU CUPID): Two randomized, double-blind, placebo-controlled, phase 3 trials Journal of Allergy and Clinical Immunology, 2024.PMID 38431226
- [9]Farkas H International Guideline on the Diagnosis and Management of Pediatric Patients With Hereditary Angioedema Allergy, 2026.PMID 41618059
- [10]Maurer M The international WAO/EAACI guideline for the management of hereditary angioedema-The 2021 revision and update Allergy, 2022.PMID 35006617
- [11]Hashkes PJ Autoinflammatory syndromes Pediatric Clinics of North America, 2012.PMID 22560579
- [12]Romano M The 2021 EULAR/American College of Rheumatology points to consider for diagnosis, management and monitoring of the interleukin-1 mediated autoinflammatory diseases Annals of the Rheumatic Diseases, 2022.PMID 35623638
- [13]Abrams EM Anaphylaxis Allergy, Asthma & Clinical Immunology, 2024.PMID 39654057
- [14]Zuberbier T The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria Allergy, 2018.PMID 29336054