**4. Diagnosis of urticaria - medical history, clinical signs and symptoms, histopathology, laboratory testing and associated conditions**

#### **4.1 Medical history**

Urticaria is characterised by the presence of wheals or angioedema. A detailed history and physical examination are essential for correct urticaria diagnosis and appropriate therapy. They help to exclude alternative diagnoses and are guide to what additional investigations are required.

An easy tool checklist for establishing a complete medical history for CU can be seen in **Table 4**.

#### **4.2 Clinical signs and symptoms**

CSU is characterised by the onset of pruritic hives and/or angioedema. Hives are well circumscribed areas of non-pitting oedema with blanched centres and raised borders that involve only superficial portion of the dermis and occur with surrounding skin erythema [4]. Wheals can be anywhere on the body and can be distributed widely [2, 5] (**Figure 1**). They can be a few millimetres to several centimetres in diameter, red or white in colour although they are bright red when they flare [4] (**Figures 2** and **3**). They can last from few minutes to several hours, can take any shape or form and can change shape before they resolve. They can be round and form rings or giant patches. They can have a map-like pattern [2]. The wheals tend to resolve in less than 24 hours and can occur at certain times during the day [2]. Hives are more persistent in CSU than CINDU.

#### **Checklist for complete CU Medical History**


#### **Table 4.**

*Checklist for establishing a complete medical history for CU [2, 3, 5].*

**Figure 1.** *Widely distributed wheals (courtesy of Dr. Stephen Orpin, Solihull hospital, Birmingham).*

**Figure 2.**

*Solitary wheal (courtesy of Dr. Stephen Orpin, Solihull hospital, Birmingham).*

Dermographism (**Figures 4** and **5**) is inducible and comprises of wheal development when the skin is stroked. It can occur on its own but also in the context of CSU and CINDU. When elicited it can support the diagnosis of urticaria.

Angioedema is more often localised and commonly affects the face in perioral and periorbital distribution, the lips, tongue, eyelids, hands, feet, genitalia and rarely bowel [2, 5]. Lesions tend to be fainter in colour and often painful (**Figure 6**). It can occur in combination with wheals.

Up to 16% of CU patients can experience systemic symptoms during a flare [5]. Systemic symptoms include fatigue, arthralgia and abdominal pain (30%), but also headache, myalgia, retrosternal oppression, wheezing, dyspnoea, rhinorrhoea, flushing, palpitations, and ocular irritation [2, 5, 16].

*Chronic Spontaneous Urticaria – Diagnosis and Management DOI: http://dx.doi.org/10.5772/intechopen.97646*

**Figure 4.** *Dermographism (courtesy of Dr. Stephen Orpin, Solihull hospital, Birmingham).*

**Figure 5.** *Dermographism - higher power (courtesy of Dr. Stephen Orpin, Solihull hospital, Birmingham).*

**Physical examination** should include assessment of skin [2, 5, 8, 9] for:


#### **Figure 6.** *Angioedema of lips (courtesy of Dr. Stephen Orpin, Solihull hospital, Birmingham).*

#### **Conditions that are associated with urticaria +/− angioedema**

#### **Syndromes presenting with urticaria +/− angioedema:**


#### **Diseases related to urticaria:**


Hives are not always itchy and are often flatter in appearance

#### **Table 5.**

*Diseases that can present with urticarial lesions [2, 5].*
