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Diagnosis and evaluation of urticaria aim to confirm the clinical pattern of the condition, determine its duration and triggers, and rule out underlying disorders that may require specific attention. Because urticaria is primarily a clinical diagnosis, evaluation focuses on detailed history-taking and careful physical examination rather than extensive testing in every case.
A structured approach helps distinguish between acute, chronic, and inducible forms and supports appropriate treatment planning.
History is the cornerstone of diagnosis.
A thorough medical history provides essential information about symptom behavior and potential triggers. Evaluation focuses on the onset, duration, frequency, and characteristics of wheals, as well as associated symptoms such as itching or swelling.
Important history elements include
• Duration of symptoms and recurrence pattern
• Timing of wheal appearance and resolution
• Presence of angioedema
• Potential triggers such as infections, medications, foods, or physical stimuli
• Personal or family history of allergic or autoimmune conditions
Duration longer than six weeks suggests chronic urticaria.
Examination confirms clinical features.
During physical examination, the clinician assesses the appearance and distribution of wheals and any associated swelling. Because lesions may resolve quickly, examination findings are sometimes limited, making patient descriptions and photographs helpful.
Key examination findings include
• Raised, erythematous wheals with smooth surfaces
• Absence of scaling or crusting
• Transient lesions that may change location
• Signs of angioedema in deeper tissues
The examination also looks for features suggesting alternative diagnoses.
Duration guides evaluation strategy.
Urticaria is classified as acute if symptoms last less than six weeks and chronic if they persist beyond six weeks. This distinction is critical, as evaluation differs significantly between these forms.
Acute urticaria often requires limited investigation, while chronic urticaria may prompt broader assessment.
Triggers may be reproducible.
For inducible urticaria, evaluation focuses on identifying specific physical triggers. Symptoms typically appear consistently after exposure to a particular stimulus.
Triggers may include
• Cold or heat
• Pressure or friction
• Exercise or sweating
• Sunlight or water exposure
Careful correlation between exposure and symptom onset supports diagnosis.
Testing is selective, not routine.
Routine laboratory testing is not required for most cases of urticaria, especially acute forms. In chronic urticaria, limited testing may be considered to exclude underlying conditions when suggested by history or examination.
Testing may be considered if
• Symptoms are persistent and unexplained
• Systemic symptoms are present
• There is suspicion of autoimmune or inflammatory disease
Normal test results are common in chronic spontaneous urticaria.
Accurate distinction prevents mismanagement.
Certain skin conditions resemble urticaria but differ in behavior and cause. These include urticarial vasculitis, eczema, drug reactions, and other inflammatory dermatoses.
Features suggesting alternative diagnoses include
• Lesions lasting longer than 24 hours
• Residual bruising or pigmentation
• Pain rather than itching
• Systemic symptoms such as fever
Such findings prompt further evaluation.
Deeper swelling requires attention.
When angioedema occurs, evaluation focuses on its frequency, triggers, and associated symptoms. Angioedema without wheals may suggest a different underlying mechanism and may require separate assessment.
Distinguishing between isolated angioedema and urticaria-associated angioedema is important for management.
Patient input supports diagnosis.
Because urticaria lesions are transient, patients may be encouraged to document episodes through photographs or symptom diaries. This information helps confirm the diagnosis and identify patterns or triggers.
Urticaria may evolve.
Follow-up evaluation allows reassessment of symptom patterns, response to treatment, and emergence of new features. Chronic urticaria may change behavior over time, requiring adjustment of management strategies.
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It is diagnosed mainly through history and physical examination.
No, tests are used only when clinically indicated.
It helps distinguish acute from chronic urticaria.
Yes, especially if lesions behave atypically.
Yes, photos and diaries can be very helpful.
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