In South Africa, chronic Urticaria is managed by allergy & immunologists. Chronic urticaria is the recurrent appearance of itchy, raised, pale-centered wheals with a red flare and/or deep tissue swelling (angioedema) that persist or recur for more than six weeks. Individual lesions resolve within 24 hours without bruising, but new ones continually appear in different locations.
Chronic urticaria (ICD-10: L50.1 idiopathic, L50.8 other) is defined by the international EAACI/GA²LEN/EuroGuiDerm/APAAACI 2022 guideline as the appearance of wheals (hives), angioedema, or both for more than six weeks. The condition is classified into two main subtypes: chronic spontaneous urticaria (formerly chronic idiopathic urticaria), where wheals appear without an identifiable trigger; and chronic inducible urticaria, where a specific physical or environmental trigger reproducibly elicits lesions (cold, heat, pressure, exercise, vibration, sunlight, water, cholinergic stimulation). Both subtypes can coexist in the same patient. Pathophysiologically, mast-cell activation and degranulation in the skin release histamine, leukotrienes, and other mediators causing the characteristic wheal-and-flare reaction; recent evidence implicates type IIb autoimmune mechanisms (IgG against IgE or the high-affinity IgE receptor FcεRI) in roughly 40-50% of chronic spontaneous urticaria.
The key symptoms of Chronic Urticaria are: Itchy, raised, pale-centered wheals (hives) with surrounding redness, varying from a few millimeters to many centimeters, appearing on any part of the body., Individual wheals fade within 24 hours without bruising, scarring, or pigmentation change, but new ones continually arise so the rash appears persistent., Angioedema — deep, painful swelling of lips, eyelids, hands, feet, or genitals — accompanies wheals in 30-50% of chronic spontaneous urticaria cases and resolves over 48-72 hours., Severe pruritus that worsens at night, often interferes with sleep, and prompts scratching; the itch is typically described as burning or stinging rather than purely itchy., Skin tingling or burning that may precede visible wheals by minutes., Wheals reproducibly triggered by cold, pressure, heat, sunlight, water, or exercise in chronic inducible urticaria., Cyclical or unpredictable disease activity with day-to-day variability and frequent flares related to infection, NSAIDs, alcohol, stress, or menstruation..
Diagnosis is clinical, based on the characteristic appearance of wheals and/or angioedema for more than six weeks. Routine extensive laboratory testing is not recommended for typical chronic spontaneous urticaria. The international 2022 guideline recommends a minimum workup of complete blood count and C-reactive protein or erythrocyte sedimentation rate for all patients with chronic spontaneous urticaria, with additional targeted tests guided by history (e.g., thyroid function and anti-thyroid peroxidase antibody if autoimmunity is suspected, vitamin D, infection screening for H. pylori or chronic hepatitis where clinically warranted). Disease activity is measured using the Urticaria Activity Score over 7 days (UAS7), which combines daily wheal count (0-3) and itch intensity (0-3) for a total of 0-42; clinically meaningful improvement requires a UAS7 reduction of at least 11 points. Angioedema-only disease is assessed by the Angioedema Activity Score (AAS). The Urticaria Control Test (UCT) and CU-Q2oL track patient-reported control and quality of life. Chronic inducible urticarias require provocation testing: ice cube test for cold urticaria, calibrated dermographometer for symptomatic dermographism, pulse-controlled ergometer for cholinergic urticaria, and standardized weight test for delayed pressure urticaria. Skin biopsy is reserved for cases where individual wheals persist beyond 24 hours, leave bruising, or are painful — to exclude urticarial vasculitis. Allergy skin prick and specific IgE testing are not routinely indicated for chronic spontaneous urticaria.
Outlook is favorable: roughly 50% of chronic spontaneous urticaria patients achieve remission within 1 year, and 80% within 5 years. Disease duration is longer in those with concurrent angioedema, autoimmune subtype, severe baseline activity, or chronic inducible features (especially cold urticaria, which often persists 5-10 years). Modern stepped therapy achieves disease control in 85-95% of patients overall: 50-65% on high-dose antihistamines, an additional 20-30% on omalizumab, and the remainder with cyclosporine or newer biologics. Quality of life improves substantially even before complete clearance: meaningful UAS7 improvement is reported within 4-12 weeks of starting omalizumab. Mortality from chronic urticaria is essentially nil; complications are dominated by mental health and sleep impacts. Pediatric chronic urticaria has a higher spontaneous remission rate than adult disease, often within 1-2 years.
Allergy and immunology specialists or dermatologists with urticaria experience can confirm the diagnosis, exclude urticarial vasculitis and angioedema mimics, perform provocation testing for inducible forms, and prescribe biologic therapy. Specialist referral is recommended when symptoms persist beyond 4 weeks of high-dose antihistamines, when angioedema is prominent, when individual wheals last more than 24 hours, or when systemic features are present.
Find specialists →Standard-dose antihistamines may reduce symptoms within hours; full effect within 1-2 weeks. High-dose antihistamines: response evaluated at 2-4 weeks. Omalizumab: first response often within 1-4 weeks; full effect by 12 weeks. Cyclosporine: response within 4-8 weeks. Spontaneous remission of chronic spontaneous urticaria typically occurs within 1-5 years; chronic inducible forms (especially cold urticaria) may last longer.
Regular exercise improves overall wellbeing and is safe for most patients with chronic urticaria. In cholinergic urticaria, take a second-generation antihistamine 30-60 minutes before exercise, warm up gradually, and stop if widespread wheals develop. In cold urticaria, avoid swimming alone in cold water — sudden generalized cold exposure can cause systemic reactions and drowning. Inform exercise partners and instructors about the condition and emergency plan.
Look for board certification in allergy and immunology (ABMS in the US, equivalent international boards) or dermatology with documented urticaria expertise. Specialized urticaria centers (UCARE — Urticaria Centers of Reference and Excellence) accredited by GA²LEN provide structured care and access to clinical trials. Confirm experience with omalizumab and inducible urticaria provocation testing.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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