Clinical Hours: Mon-Fri, 8AM - 3PM(905) 493-5700
1885 Glenanna Road, Suite 220, Pickering, ON, L1V 6R6
Chronic urticaria is a persistent condition characterised by recurrent wheals and angioedema, often requiring specialist evaluation and advanced therapies.
Urticaria, commonly known as hives, is a condition characterised by the sudden appearance of raised, itchy wheals on the skin. When these episodes persist for longer than six weeks, the condition is classified as chronic urticaria. Chronic urticaria affects approximately 0.5 to 1 percent of the general population and can have a significant impact on quality of life, sleep, and daily functioning.
Chronic urticaria is broadly divided into two categories: chronic spontaneous urticaria (CSU), in which wheals arise without a clearly identifiable external trigger, and chronic inducible urticaria (CIndU), in which specific physical stimuli provoke the reaction. Many patients experience chronic urticaria for months to years, and specialist evaluation is often required to optimise management.
In the majority of chronic spontaneous urticaria cases, a definitive external cause is not identified. The underlying mechanism is thought to involve autoimmune activation of mast cells, either through autoantibodies directed against the high-affinity IgE receptor (FcepsilonRI) or against IgE itself. This autoimmune pathway leads to inappropriate mast cell degranulation and histamine release, resulting in the characteristic wheals and pruritus.
Chronic inducible urticaria is triggered by identifiable physical stimuli. The most common subtypes include:
Certain medications, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), can exacerbate chronic urticaria. Infections, thyroid autoimmunity, and stress are also recognised as aggravating factors. There is a female predominance in chronic spontaneous urticaria, and the condition is more prevalent in adults between the ages of 20 and 50.
The hallmark of urticaria is the wheal, a raised, erythematous, and oedematous plaque that is typically intensely pruritic. Individual wheals are transient, usually resolving within 24 hours without leaving a mark, although new lesions may appear continuously. The most commonly reported signs and symptoms include:
If individual wheals persist for longer than 24 hours or leave bruise-like discolouration, urticarial vasculitis should be considered as an alternative diagnosis.
The diagnosis of chronic urticaria is primarily clinical, based on a detailed history and physical examination. A thorough history includes assessment of the duration, frequency, and pattern of wheals, potential triggers, medication use, and associated symptoms such as angioedema or systemic complaints.
Laboratory investigations may be performed to evaluate for underlying causes or associations. Commonly requested tests include a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and thyroid function with thyroid autoantibodies. Provocation testing may be used to confirm specific subtypes of chronic inducible urticaria.
When individual wheals persist beyond 24 hours or are associated with purpura, a skin biopsy may be performed to rule out urticarial vasculitis. If an allergic component is suspected, patch testing or other allergy investigations may be considered as part of the diagnostic workup.
The management of chronic urticaria follows a stepwise approach guided by international consensus guidelines. The goal of treatment is complete symptom control with the least amount of medication necessary. Identification and avoidance of known aggravating factors, including NSAIDs and specific physical triggers, is an important component of the management plan.
Second-generation (non-sedating) antihistamines are the cornerstone of chronic urticaria management. Cetirizine, loratadine, desloratadine, bilastine, and fexofenadine are among the most commonly prescribed options. If standard doses do not provide adequate relief, guidelines support updosing second-generation antihistamines up to four times the standard dose under dermatologist supervision.
For patients who remain symptomatic despite updosed antihistamines, omalizumab (a monoclonal antibody targeting IgE) is the recommended next step. Omalizumab has demonstrated significant efficacy in reducing wheal activity and pruritus in chronic spontaneous urticaria and is administered as a subcutaneous injection. The Centre for Medical and Surgical Dermatology offers biologic and advanced small molecule therapy for patients with chronic urticaria who require this level of treatment.
In refractory cases where omalizumab does not achieve adequate control, additional options may be considered. Ciclosporin, an immunosuppressant, can be used as an off-label adjunctive therapy for severe chronic spontaneous urticaria. Leukotriene receptor antagonists (montelukast) may provide modest benefit when added to antihistamines, particularly in patients with NSAID-exacerbated urticaria. Short courses of systemic corticosteroids may be used for acute flares but are not recommended for long-term management due to the risk of adverse effects. All systemic therapies require monitoring through a prescription management programme to ensure safety and efficacy.
Medical evaluation by a dermatologist is recommended when hives persist for more than six weeks, are not adequately controlled by over-the-counter antihistamines, or are accompanied by angioedema. Patients experiencing significant disruption to sleep, work, or daily activities due to chronic urticaria should seek specialist assessment.
A referral from a family physician or walk-in clinic is the typical pathway to access dermatology services in Ontario. Dr. Maksym Breslavets at the Centre for Medical and Surgical Dermatology provides comprehensive evaluation and management of chronic urticaria, including biologic therapy for refractory cases.
Your feedback helps us improve our condition information
A physician referral is required to access our medical services. Contact your primary care provider to begin the referral process.