Reviews and feature article
The diagnosis and management of acute and chronic urticaria: 2014 update

https://doi.org/10.1016/j.jaci.2014.02.036Get rights and content

These parameters were developed by the Joint Task Force on Practice Parameters (JTFPP), representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and ACAAI have jointly accepted responsibility for establishing “The diagnosis and management of acute and chronic urticaria: 2014 update.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the JTFPP, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology.

The JTFPP understands that the cost of diagnostic tests and therapeutic agents is an important concern that might appropriately influence the work-up and treatment chosen for a given patient. The JTFPP recognizes that the emphasis of our primary recommendations regarding a medication might vary, for example, depending on third-party payer issues and product patent expiration dates. However, because a given test or agent's cost is so widely variable and there is a paucity of pharmacoeconomic data, the JTFPP generally does not consider cost when formulating practice parameter recommendations. In extraordinary circumstances, when the cost/benefit ratio of an intervention is prohibitive, as supported by pharmacoeconomic data, commentary might be provided. These parameters are not designed for use by pharmaceutical companies in drug promotion.

The JTFPP is committed to ensuring that the practice parameters are based on the best scientific evidence that is free of commercial bias. To this end, the parameter development process includes multiple layers of rigorous review. These layers include the workgroup convened to draft the parameter, the task force reviewers, and peer review by members of each sponsoring society. Although the task force has the final responsibility for the content of the documents submitted for publication, each reviewer comment will be discussed, and reviewers will receive written responses to comments, when appropriate.

To preserve the greatest transparency regarding potential conflicts of interest, all members of the JTFPP and the practice parameter workgroups will complete a standard potential conflict of interest disclosure form, which will be available for external review by the sponsoring organization and any other interested individual. In addition, before confirming the selection of a Work Group chairperson, the Joint Task Force will discuss and resolve all relevant potential conflicts of interest associated with this selection. Finally, all members of parameter workgroups will be provided a written statement regarding the importance of ensuring that the parameter development process is free of commercial bias.

Practice parameters are available online at www.jcaai.org and www.allergyparameters.org.

Section snippets

Table of contents

  • I.

    Executive summary

  • II.

    Acute urticaria

  • III.

    Diagnosis and management of chronic urticaria

  • IV.

    Physical urticaria/angioedema

  • V.

    Differential diagnosis

  • VI.

    Treatment for acute and chronic urticaria

Contributors

The JTFPP has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the JTFPP will ensure that appropriate recognition of such contributions is made subsequently.

Chief editors

Jonathan A. Bernstein, MD

Department of Medicine

University of Cincinnati College of Medicine

Department of Internal Medicine

Division of Immunology/Allergy Section

Cincinnati, Ohio

David M. Lang, MD

Department of Medicine

Department of Allergy and Clinical Immunology

Respiratory Institute

Cleveland Clinic Foundation

Cleveland, Ohio

David A. Khan, MD

Department of Medicine

Division of Allergy & Immunology

University of Texas Southwestern Medical Center

Dallas, Texas

Workgroup contributors

Timothy Craig, DO

Department of Medicine and Pediatrics

Penn State University

Hershey, Pennsylvania

David Dreyfus, MD, PhD

Department of Pediatrics

Yale School of Medicine

New Haven, Connecticut

Fred Hsieh, MD

Department of Allergy and Clinical Immunology

Respiratory Institute

Department of Pathobiology, Lerner Research Institute

Cleveland Clinic

Cleveland, Ohio

Javed Sheikh, MD

Department of Medicine

Harvard Medical School

Boston, Massachusetts

David Weldon, MD

Department of Internal Medicine

Texas A&M University

Task force reviewers

David I. Bernstein, MD

Department of Medicine and Environmental Health

Division of Immunology, Allergy and Rheumatology

University of Cincinnati College of Medicine

Cincinnati, Ohio

Joann Blessing-Moore, MD

Department of Immunology

Stanford University Medical Center

Palo Alto, California

Linda Cox, MD

Department of Medicine

Nova Southeastern University

Davie, Florida

Richard A. Nicklas, MD

Department of Medicine

George Washington Medical Center

Washington, DC

John Oppenheimer, MD

Department of Internal Medicine

Invited reviewers

M. Aquino, MD

Aleena Banerji, MD

Warner Carr, MD

Stephen Dreskin, MD

Luz Fonacier, MD

S. Saini, MD

General membership reviewers

Arturo Bonnin, MD, Javier Chinen, MD, PhD, Leonard Cohen, MD, PhD, John Ekman, MD, Daniel Ein, MD, Mario Geller, MD, David Goetz, MD, Stanley Goldstein, MD, Richard Gower, MD, Gisoo Ghaffari, MD, William Hark, MD, Robert Lemanske, MD, Robert Lin, MD, Vinay Mehta, MD, Talal Nsouli, MD, Mark Sands, MD, Alan Schocket, MD, Fanny Silvu-Dan, MD, Alan Wanderer, MD, John Weiler, MD, and Pamela Williams, MD

Category of evidence

  • Ia

    Evidence from meta-analysis of randomized controlled trials

  • Ib

    Evidence from at least 1 randomized controlled trial

  • IIa

    Evidence from at least 1 controlled study without randomization

  • IIb

    Evidence from at least 1 other type of quasiexperimental study

  • III

    Evidence from nonexperimental descriptive studies, such as comparative studies

  • IV

    Evidence from expert committee reports or opinions or clinical experience of respected authorities or both

Strength of recommendation

  • A

    Directly based on category I evidence

  • B

    Directly based on category II evidence or

Executive summary

Acute urticaria and angioedema are differentiated from CU based on the duration of illness. Urticaria and angioedema with duration of less than 6 weeks is termed acute urticaria.2,3 If urticaria of less than 6 weeks' duration has features suggesting it might progress to a chronic illness (see the sections on autoimmune, physical, and CU), such patients should be periodically re-evaluated until a diagnosis is clarified. Acute urticaria and angioedema should be differentiated from anaphylaxis.

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Disclosure of potential conflict of interest: J. A. Bernstein is a Professor of Medicine at the University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy section; is a partner in Bernstein Allergy Group and a member of Bernstein Clinical Research; has received research support from Dyax, Shire, CSL Behring, Viropharma, Pharming, and Novartis; has consultant arrangements with Dyax, Shire, CSL Behring, and Viropharma; has received payment for lectures from Dyax, Shire, CSL Behring, and Viropharma; is on the Board of Directors for the American Academy of Allergy, Asthma & Immunology (AAAAI); is a fellow of the American College of Allergy, Asthma & Immunology (ACAAI); is Chairman of the American Academy of Immunologists; is on the advisory board for the Hereditary Angioedema Association; is Editor in Chief of the Journal of Asthma; serves on the Editorial Boards for the Journal of Allergy and Clinical Immunology, the Annals of Allergy, Allergy Proceedings, and the Journal of Angioedema; and is the Editor of the Joint Task Force Guidelines on Urticaria and Angioedema. D. M. Lang is a Professor of Medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Respiratory Institute, Department of Allergy and Clinical Immunology; is on the Board of Directors of the AAAAI; serves as Chair of the AAAAI Practice, Diagnostics, and Therapeutics Committee; has received travel support from AAAAI; is a speaker for Genentech/Novartis, GlaxoSmithKline, and Merck; has consultant arrangements with GlaxoSmithKline, Merck, and Aerocrine; and has received research support from Genentech/Novartis and Merck. D. A. Khan is a speaker for Genentech, Merck, Baxter, and Viropharma; has received research support from the Vanberg Family Foundation and the National Institutes of Health (NIH)/National Institute of Mental Health; is the Allied Health Chair for the ACAAI; and is a member of the Joint Task Force on Practice Parameters for the Joint Council on Allergy, Asthma, and Immunology. T. Craig is an Interest Section Leader for the AAAAI; is a board member for the ACAAI, the ALA-PA, and the Joint Council on Allergy, Asthma, and Immunology; has consultant arrangements with CSL Behring, Dyax, Viropharma, and Shire; has provided expert testimony to support a physician in anaphylaxis case; has received research support from Viropharma, CSL Behring, Shire, Dyax, Pharming, Forrest, Genentech, Biota, GlaxoSmithKline, and Grifols; has received research support from Viropharma, CSL Behring, Dyax, Merck, Novartis, Genentech, and TEVA; and has received salary support for development of educational presentations from the Vietnam Education Foundation. F. Hsieh has received research support from the Howard Hughes Medical Institute. J. Sheikh has consultant arrangements with CSL Behring and Allergy/Immunology Medical Malpractice; is a member of the ACAAI; is on the executive board for the Massachusetts Allergy Society; and is on the executive board and is CME Director for the New England Society of Allergy. D. Weldon has provided expert testimony on behalf of the Texas Allergy, Asthma, and Immunology Society in a lawsuit; is on the Board of Regents for the ACAAI; and is the Chair of the Practice Standards Committee for the Texas Allergy, Asthma, and Immunology Society. B. Zuraw has received research support from Shire, the NIH, the Department of Defense, and the Department of Veterans Affairs; is the Chair of the Medical Advisory Board for the Hereditary Angioedema Association; and has consultant arrangements with CSL Behring, Dyax, Isis, and Biocryst. D. I. Bernstein has received research support from TEVA, Genentech, Pfizer, Merck, Meda, GlaxoSmithKline, Array, Cephalon, and MedImmune and has provided legal consultation/expert witness testimony in cases related to anaphylaxis, contact dermatitis, and occupational asthma. J. Blessing-Moore is a speaker for Meda, Alcon, Teva, Sunovion, Genentech/Novartis, Merck, and AstraZeneca; has received research support from Meda; and is a committee member for the American College of Chest Physicians, the ACAAI, the AAAAI, and the American Thoracic Society. L. Cox has consultant arrangements with Stallergenes; has received travel support from the AAAAI; has received fees for participation in review activities from Circassia and Novartis; has received payment for writing or reviewing the manuscript from Blue Cross Blue Shield Technology Evaluation Center; is on the American Board of Allergy and Immunology; has consultant arrangements with the Food and Drug Administration's Allergenic Products Advisory Committee; has provided expert testimony in cases related to chronic cinguteria; and has received payment for lectures from the Southeastern Allergy, Asthma, and Immunology Association and the Virginia Allergy, Asthma, and Immunology Society. R. A. Nicklas is a committee chair for the ACAAI. J. Oppenheimer has received research support from AstraZeneca, GlaxoSmithKline, Merck, Boehringer Ingelheim, Novartis, and MedImmune; has provided legal consultation/expert testimony on behalf of the defense in cases related to medical malpractice; is chairman of the American Board of Allergy and Immunology; and has consultant arrangements with GlaxoSmithKline, Mylan, Novartis, and Sunovion. J. M. Portnoy is a speaker for Thermo Fisher and Mylan and has consultant arrangements with Thermo Fisher and Sanofi. C. R. Randolph is a speaker for GlaxoSmithKline, TEVA, Viropharma, Merck, and Dey; has received research support from GlaxoSmithKline, Merck, Amgen, and Genentech/Novartis; and has consultant arrangements with AstraZenca and Meda. S. L. Spector has stock in GlaxoSmithKline and Merck; has consultant arrangements with Hycor; has received research support from AstraZeneca, GlaxoSmithKline, Amgen, Genentech, Novartis, TEVA, Mylan, and Sanofi; and is a speaker/moderator for the ACAAI. S. A. Tilles is a consultant for SRxA, Sunovion, and Hycor; has received research support from Astellas, Amphastar, MedImmune, Cephalon, Genentech, Merck, TEVA, Sunovion, Boehringer Ingelheim, Nutricia, Array, Rigel, and AstraZeneca; is Associate Editor of AllergyWatch and the Annals of Allergy; is Assistant Editor of the Joint Task Force on Practice Parameters; and is on the Executive Committee for the Seattle Food Allergy Consortium. D. Wallace has received honoraria for talks from the ACAAI; is a speaker for TEVA and Mylan Labs; is an advisor for Sanofi and Sunovion; is on the Executive Committee of the ACAAI; and is on the Board of Directors for the World Allergy Organization. The rest of the authors declare that they have no relevant conflicts of interest.

Corresponding author: Joint Council of Allergy, Asthma & Immunology, 50 N Brockway St, #3-3, Palatine, IL 60067. E-mail: [email protected].

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