Pediatric Urticaria

UrticariaUrticaria (AKA Hives) are commonly encountered in the ED. When they occur with respiratory distress, vomiting, trouble swallowing / intra-oral swelling, or hypotension we become quite aggressive (See Anaphylaxis); however, if they occur in isolation, we may become less vigilant. “It’s an allergy, but it isn’t serious right now,” can be a reassuring statement, but can also set up unrealistic expectations and cause problems. Similar to “it’s just constipation,” or “it’s just a virus,” we need to be mindful of the phrases we use when dealing with kids who present with urticaria. Not all urticaria is due to allergic reactions. Let’s take a moment to digest a Morsel on Pediatric Urticaria:

 

Pediatric Urticaria: Basics

  • Urticaria typically have: [Tsakok, 2014]
    • Redness
    • Well-defined borders with central pallor
    • Itchy
    • Transient appearance 
  • Urticaria may also have: [Tsakok, 2014]
    • Associated swelling / angioedema
    • Confluence with adjacent hives
  • Urticaria is common!
    • Up to 25% of humans will experience urticaria in their lifetime. [Tsakok, 2014]
    • CHRONIC urticaria is much less common: diagnosed in 0.1 – 3% of children [Balp, 2018]
  • Urticaria can be Acute or Chronic.
    • There are several classification systems, but one “simple” one is: [Tsakok, 2014]
    • ACUTE URTICARIA:
      • May last up to 6 weeks!
      • Most resolve within 15 days though.
      • Most common presentation.
    • CHRONIC URTICARIA:
      • Lasts > 6 weeks!
      • Has been shown to have similar impact on quality of life as other chronic childhood illnesses. [Balp, 2018; Zuberbier, 2014; Tsakok, 2014]
      • Etiologies:
        • May be unclear etiology = Chronic Spontaneous Urticaria
        • May be a known trigger = Chronic Inducible Urticaria

 

Pediatric Urticaria: Triggers/Associations

  • Infections
    • Both acute and chronic urticaria are commonly due to infections. [Tsakok, 2014]
    • Viral infections are the leading infection!
      • Another great reason to avoid unnecessary antibiotics for well-appearing children with febrile illnesses (ex, “sinusitis“)
      • Is the urticaria due to the viral infection or the unnecessary antibiotics that were given?
    • Bacterial infections also known to be associated:
      • Mycoplasma pneumoniae
      • Beta-hemolytic Streptococci
      • Urinary Tract Infections, even occult (consider checking U/A and Culture) [Tsakok, 2014]
    • Parasites also associated – consider this in endemic areas.
  • Medications
    • Drug hypersensitivity is implicated in both acute and chronic urticaria.
    • Antibiotics and NSAIDs are the most commonly associated with urticaria.
      • Of course, the concurrent viral infection may have something to do with the urticaria… so causation is often difficult to discern.
  • Food
    • Acute urticaria is a cardinal feature of IgE-mediated food hypersensitivity, but this is a less common cause in children. [Tsakok, 2014]
    • Eggs, Milk, Soy, Peanut, Wheat, and Seafood are typical items.
    • Reactions, however, may be due to the food preservatives or coloring agents.
  • Physical Triggers
    • Associated with Chronic Urticaria.
    • May occur concurrently with other forms for urticaria.
    • Examples:
      • Cholinergic Urticaria – occurs when person is sweating or has elevated body temperature (ex, after hot bath).
      • Solar Urticaria
      • Dermographic Urticaria
      • Aquagenic Urticaria
      • Cold Urticaria
      • Vibratory Urticaria
      • Exercise-induced Urticaria
  • Autoreactivity
    • Autoimmune conditions can present with urticaria, although more likely to be associated with adults than children. [Tsakok, 2014]
    • Conditions:
      • Thyroid Disease
      • Celiac Disease
      • Juvenile Rheumatoid Arthritis
      • Systemic Lupus Erythematosus
      • Type 1 Diabetes
  • Malignancy
    • Case reports describe this association, although it is still unclear.
    • Worth considering… look for other signs of occult malignancy… but don’t get a CBC on every kid with urticaria!

 

Pediatric Urticaria: Mimics

  • Urticaria can be difficult to discern at times.
  • Consider mimics if there is a history of prolonged duration AND: [Youssef; 2017; Mathur, 2013]
    • Arthritis
    • Fever
    • Neurologic / Ocular symptoms
    • Hepatomegaly
  • Potential Mimics to be considered: [Mathur, 2013]
    • Serum Sickness-Like Reaction
    • Urticaria Multiforme
    • Urticarial Vasculitis
    • Juvenile Idiopathic Arthritis
    • Cryopyrin-Associated Pediodic Syndromes

 

Chronic Urticaria: Treatment

  • ABC’s first! Look for evidence of anaphylaxis first! Chronic Urticaria is unlikely to be life-threatening… but remain vigilant!
  • Second-Generation H1 Antihistamines are first line [Zuberbier, 2014; Tsakok, 2014]
    • May need to use higher doses than recommended, but start at recommended dose.
    • Even 4 times recommended dose has been used for refractory cases. [Zuberbier, 2014; Tsakok, 2014]
    • Increasing dose is recommended over adding second line medication. [Zuberbier, 2014]
    • Should take medication in scheduled fashion rather than as needed. [Zuberbier, 2014]
  • Second Line options:
    • H2 Antihistamines (ex, ranitidine) can be added to regimen, but should not be used in lieu of Type 1 antihistamines.
    • Omalizumab (anti-IgE) may be helpful. [Zuberbier, 2014]
    • Steroids may be helpful in short courses, but should not be done over prolonged time periods. [Zuberbier, 2014]
    • Cyclosporine has been an effective 2nd line medication for refractory chronic urticaria. [Tsakok, 2014]
    • Many other immunomodulatoring medications have been tried, but there is no strong evidence to support the use in children as of yet.

 

Moral of the Morsel

  • Don’t just blame the bees (or other mysterious allergens)! Not all urticaria is due to an allergic reaction. Saying it is may lead to unnecessary confusion and testing.
  • Be a Sherlock! Look for signs of systemic involvement that may point toward a mimic of chronic urticaria.
  • Don’t be dismissive. It might not be anaphylaxis (which is good), but chronic urticaria can negatively affect quality of life.

 

References

Balp MM1, Weller K2, Carboni V3, Chirilov A4, Papavassilis C1, Severin T1, Tian H5, Zuberbier T2, Maurer M2. Prevalence and clinical characteristics of chronic spontaneous urticaria in pediatric patients. Pediatr Allergy Immunol. 2018 Apr 21. PMID: 29679413. [PubMed] [Read by QxMD]

Youssef MJ1, Chiu YE2. Eczema and Urticaria as Manifestations of Undiagnosed and Rare Diseases. Pediatr Clin North Am. 2017 Feb;64(1):39-56. PMID: 27894451. [PubMed] [Read by QxMD]

Pattanaik D1, Lieberman JA2. Pediatric Angioedema. Curr Allergy Asthma Rep. 2017 Aug 8;17(9):60. PMID: 28791569. [PubMed] [Read by QxMD]

Smallwood J. Urticaria: “You’re Probably Just Allergic to Something”. Pediatr Ann. 2016 Nov 1;45(11):e399-e402. PMID: 27841923. [PubMed] [Read by QxMD]

Tsakok T1, Du Toit G, Flohr C. Pediatric urticaria. Immunol Allergy Clin North Am. 2014 Feb;34(1):117-39. PMID: 24262693. [PubMed] [Read by QxMD]

Zuberbier T1, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, Church MK, Ensina LF, Giménez-Arnau A, Godse K, Gonçalo M, Grattan C, Hebert J, Hide M, Kaplan A, Kapp A, Abdul Latiff AH, Mathelier-Fusade P, Metz M, Nast A, Saini SS, Sánchez-Borges M, Schmid-Grendelmeier P, Simons FE, Staubach P, Sussman G, Toubi E, Vena GA, Wedi B, Zhu XJ, Maurer M; European Academy of Allergy and Clinical Immunology; Global Allergy and Asthma European Network; European Dermatology Forum; World Allergy Organization. The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014 Jul;69(7):868-87. PMID: 24785199. [PubMed] [Read by QxMD]

Mathur AN1, Mathes EF. Urticaria mimickers in children. Dermatol Ther. 2013 Nov-Dec;26(6):467-75. PMID: 24552410. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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