Urticaria in Children: Indian Academy of Pediatrics Guidelines
Urticaria-also known as hives, weals, welts or nettle rash-is a raised, itchy rash that appears on the skin. It may appear on one part of the body or be spread across large areas.
The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Urticaria. The lead author for these guidelines on Urticaria is Dr Jayakar Thomas and o-Authors Dr Bindusha S and Dr Mukesh Gupta .The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT, and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.
Urticaria is a condition characterized by the development of wheals, angioedema, or both.
Following are the major recommendations of guidelines:
A wheal has three typical features:
Source:Indian Academy of Pediatric Guidelines
1. Sharply circumscribed superficial central swelling of variable size and shape, almost
invariably surrounded by reflex erythema
2. Itching or sometimes burning sensation
3. Resolves usually within 30 minutes to 24 hours.
Symptoms:
Angioedema is characterized by:
- Sudden, erythematous, or skin-colored deep swelling in the lower dermis and subcutaneous plane or mucous membranes
- Tingling, burning, tightness, and sometimes pain rather than itch
- Resolution can take up to 72 hours (slower than that of wheals).
Differences between acute urticaria and chronic urticaria are presented in Table 1.
| TABLE 1: Differences between acute urticaria and chronic urticaria. | |
| Acute urticaria | Chronic urticaria |
|
|
Causes:
Acute urticaria may occur by immunoglobulin E (IgE)-mediated or non-IgE-mediated pathway (Fig. 1)
Source:Indian Academy of Pediatric Guidelines
*(EBV: Epstein–Barr virus; NSAIDs: nonsteroidal anti-inflammatory drugs)
Common infections producing acute urticaria are shown in Figure 2
Source:Indian Academy of Pediatric Guidelines
Urticarial Vasculitis:
Autoinflammatory diseases like systemic lupus erythematosus (SLE) can produce urticarial vasculitis. These lesions have a burning sensation (rather than itching), will not blanch, last beyond 24 hours, and heal by scarring. Urticarial vasculitis should be differentiated from urticaria.
Chronic Urticaria: (Fig. 3)
Source:Indian Academy of Pediatric Guidelines
Chronic Spontaneous/Idiopathic Urticaria:
Chronic urticaria, which is not related to an allergic reaction, may be associated with the presence of antithyroid antibodies, especially antithyroid peroxidase (TPO) antibodies. 35–40% may have a positive autologous serum skin test (pathergy test). Some patients may have anti-IgE or anti-IgE receptor antibodies.
Chronic Inducible Urticaria:
The different types of physical urticaria are given in the below boxes:
| Cold urticaria Intense itching, erythema, and urticaria on exposure to cold. Isomorphic cold reaction can be elicited by keeping an ice cubes on the skin for 5 minutes. | Cholinergic urticaria Small punctate pruritic urticaria, surrounded by flare. Occurs after exercise, hot showers, or sweating. Resolves in 30–60 minutes. | Pressure-induced urticaria Symptoms appear 4–6 hours after pressure was applied or on dependent body parts. Can coexist with other physical urticara. |
| Solar urticaria | Aquagenic urticaria | Dermatographism |
| Occurs within minutes of sun exposure. Subsides within 1-3 hours after stopping the exposure. Six different types are based on wavelength. | Urticaria occurs on exposure to water, irrespective of the temperature. Direct exposure of the skin to water is used for testing for this. | Also known as urticaria facticia. Ability to write on the skin using blunt objects. Can be an isolated disorder or associated with physical urticaria. |
Diagnosis:
Diagnosis is mainly clinical. A detailed history will help in identifying the inciting event or cause and will help in making a correct diagnosis.
Keeping a food/event diary may help in identifying the allergen in patients with recurrent urticaria.
Allergy skin testing is not usually indicated for patients with acute urticaria.
If chronic idiopathic urticaria is suspected, test for anti-TPO antibodies and do an autologous serum skin test.
Testing for different types of physical urticaria has to be done if the history is suggestive of physical/inducible urticaria.
Treatment of Acute Urticaria:
Antihistamines:
- Antihistamines are the first-line drugs used.
- Second-generation antihistamines, which are less sedating, are preferred whenever sedation is a concern such as for older school-going children and adolescents.
- However, in infants and toddlers, first-generation may be used to reduce irritability and improve sleep.
- The dosages of antihistamines are given in Table 2.
| TABLE 2: Dosage of antihistamines. | |
| Drug | Dosage |
| Hydroxyzine | 2 mg/kg/day in three divided doses |
| Diphenhydramine | 0.5 mg/kg/dose Q6–8 hourly |
| Cetirizine | 2–5 years—2.5 mg OD, 6–11 years—5 mg OD, >12 years—10 mg OD |
| Levocetirizine | 2–5 years—1.25 mg OD, 6–11 years—2.5 mg OD, >12 years—5 mg OD |
| Fexofenadine | 6–11 years—30 mg BD, >12 years—60 mg BD |
| Loratadine | 2–5 years—5 mg OD, >6 years—10 mg OD |
Adrenaline:
It is used for extensive urticaria and angioedema. Dose—injection adrenaline 0.01 mL/kg of 1/1,000 adrenaline solution, subcutaneous or intramuscular.
Oral Steroids:
It is indicated only in severe urticaria or urticaria not responding to antihistamines. Tablet prednisolone 1–2 mg/kg/day for 3–5 days.
Treatment of Chronic Urticaria:
Second-generation antihistamines are the mainstay of management (Fig. 4).
Source:Indian Academy of Pediatric Guidelines
A short course (3–5 days) of oral steroids may be used in a severely symptomatic patient. But steroids are not recommended for long-term treatment of chronic urticaria.
Reference:
 Godse K, De A, Zawar V, Shah B, Girdhar M, Rajagopalan M, et al. Consensus statement for the diagnosis and treatment of urticaria: a 2017 update. Indian J Dermatol. 2018;63(1):2-15.
 Zuberbier T, Aberer W, Asero R, Abdul Latiff AH, Baker D, Ballmer-Weber B, et al. The EAACI/GA²LEN/ EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria. Allergy. 2018;73(7):1393-414.
 Zuberbier T, Abdul Latiff AH, Abuzakouk M, Aquilina A, Asero R, Baker D, et al. The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. 2021;00:1-33.
*The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/
