PAEDIATRIC URTICARIA

GUIDELINE

Compiled by: Dr Muna Ahmad

Dr Carolyn Hore

In Consultation with: Dr Fiona MacCarthy

Dr Haddad

Ratified by: Paediatric Guidelines Group

Date Ratified: July 2020

Date Reviewed: July 2020

Next Review Date:

References:

 RCPCH Allergy Care Pathways for Children Urticaria/Angio-oedema/Mastocytosis https://www.rcpch.ac.uk/sites/default/files/RCPCH_Care_Pathway_for_Children_with_ Urticaria_Angio-oedema_or_Mastocytosis.pdf  https://www.rch.org.au/clinicalguide/guideline_index/Urticaria/  NICE guidelines for management of urticaria https://cks.nice.org.uk/urticaria#!scenario  https://www.bsaci.org/Guidelines/chronic-urticaria-and-angioedema

First Ratified: January 2016 Last Reviewed: July 2020 Version Number: 2 Page 1 of 5

This guideline is intended for use in A&E and general paediatric OPD to assist with the management of urticaria in children aged 6 months-18 years.

Definitions

Urticaria: Urticaria is a superficial swelling of the skin (epidermis and mucous membranes) that results in a red (initially with a pale centre), raised itchy rash or wheal formation. It can be acute or chronic depending on its duration.

Fig 1: Urticarial Rash Fig 2: Angioedema

Angioedema: Angioedema is a deeper form of urticaria with swelling in the dermis, submucosal or subcutaneous tissues, often affecting face (lips, tongue, eyelids), genitalia, hands, or feet. Urticaria and angioedema can co-exist but either can occur separately. In children, 50-80% of those with chronic urticaria have accompanying angioedema.

Prevalence: Acute urticaria: More prevalent, affecting 4.5 – 15% of children in the UK.

Chronic urticaria: Less prevalent, affecting 0.1-3% of children in the UK.

Acute Spontaneous Urticaria – an urticarial rash occurring for < 6 weeks.

It is usually self-limiting, short-lived and occur spontaneously or in response to a trigger. Some of the known factors/ triggers can be:

 Viral infection

 Stress, Exercise

 Drugs: such as penicillin, aspirin, cefaclor, NSAIDS and vaccination

 Insect bites and stings

 Food (such as milk, eggs, peanuts, tree nuts, shellfish etc)

 Contact Allergens (latex, animal, plants)

 Physical triggers (pressure, cold, exercise, rarely water)

Note that food allergies present within 15min-1 hour of ingestion of the food. If the child woke up with the rash, it is not a food allergy and more likely a viral urticaria

First Ratified: January 2016 Last Reviewed: July 2020 Version Number: 2 Page 2 of 5

MANAGEMENT OF ACUTE URTICARIA

Acute Onset Acute Urticaria <6 weeks Urticaria > 6weeks Urticaria Associated No respiratory or cardiovascular symptoms See Chronic Urticaria with difficulty breathing or collapse HISTORY

Time of onset Treat for History consistent with History NOT consistent Duration, severity ANAPHYLAXIS allergic reaction with allergic reaction See Protocol Shape, size, distribution

Angioedema Intercurrent Refer to Allergy Associated triggers OPD for SPT Infection Systemic symptoms

History of infections

YES NO Atopic history

Co-existing medical conditions Atypical Features Regular non-sedating Residual bruising/ Use of medication/ H1RA + GP follow up fever/joint pain/ response lesions >24hrs Drug history

Family history CETIRIZINE

1-2 years 0.25mg/kg BD

2-6 years 2.5mg BD YES NO 6-12 years 5mg BD Urinalysis, BP, Review Hx for Senior Review physical causes, 12-18 years 10mg OD Specialist referral, regular H1RA, if required GP follow up Dose may be doubled to achieve

control- for 6 weeks (duration based on clinical judgment) If avoidable triggers are identified, give clear instructions on avoidance strategies before discharge Steroids should not be routinely

Prognosis: Excellent, most children respond well to standard treatment and do not need admission

First Ratified: January 2016 Last Reviewed: July 2020 Version Number: 2 Page 3 of 5

MANAGEMENT OF CHRONIC URTICARIA

Chronic urticaria+/- angioedema Angioedema alone Immediate allergic > 6 weeks duration symptoms < 2hrs after contact. Reproducible. Check for association with NSAIDS or allergen Consider other Diagnosis e.g. Systemic features e.g. No systemic nephrotic syndrome, joint pain/fever/weight features Infection, any allergic loss/lesions lasting >24hr Remove allergic trigger , HAE stimulus, Treat with antihistamine. Consider need for FBC+ film, U&E, autoinjector. Refer to If suspect allergy or ESR, Urinalysis, allergy clinic HAE Autoantibodies, TFT, Refer to allergy clinic. Antithyroid antibodies D/W consultant, if any Autoimmune screen, Mild infrequent Frequent and

urgent concerns Coeliac screen urticaria severe urticaria Consider Skin biopsy

Non-sedating H1 -Consider investigations: LFT, Specialist referral receptor antagonist, hepatitis screen, TFT, ESR, urinalysis, FBC, coeliac screen, (Derma/Rheumatolog dose may need to be Physical challenge tests y) as required – D/W doubled. Consultant - Personalized management COMPLICATIONS plan/Avoidance strategies -Maintain symptom diary -UAS7 Skin infection Routine F/U & -Regular non-sedating AH (up Reassess to 4 times recommended dose) Scaring improvement +/- old H1 AH in the evening (3- 6months) Poor sleep -Short course steroid (3-5 days) Reduced performance for severe exacerbations

at school -Leukotriene antagonist (for 1-4 weeks) Anxiety and -Tranexamic acid (angioedema) depression - Anti Ig- E (Omalizumab) YES NO GP follow up Reassess & Review Reduced quality of life diagnosis

Refer to Allergy clinic

Consider Referral to clinical psychologist- for patients, whose symptoms are adversely affecting their quality of life and causing significant social and psychological problems

First Ratified: January 2016 Last Reviewed: July 2020 Version Number: 2 Page 4 of 5

Chronic Urticaria – an urticarial rash occurring on most days for > 6 weeks. It can be:

1- Chronic spontaneous urticaria: No known external cause. However, it may be aggravated by heat, stress, certain drugs or infection.

2- Autoimmune urticaria: 30-50% of chronic urticaria cases and may be associated with other autoimmune conditions (e.g. thyroiditis, coeliac disease)

3- Chronic inducible urticaria (CINDU): occurs in response to physical stimulus. It can be

 Aquagenic urticaria (after contact with hot or cold water)

 Cholinergic urticaria (after active or passive warming e.g. from exercise or emotion)

 Cold urticaria (after exposure of skin to cold)

 Heat urticaria (after exposure of skin to heat)

 Symptomatic dermatographism (itchy and/or burning skin and the development of strip-shaped weal due to shear force acting on skin).

 Delayed pressure urticaria (after application of sustained pressure e.g. after sitting or lying or due to tight clothing)

 Solar urticaria (after visible or UV light exposure)

 Vibratory angioedema (after exposure to vibration e.g. from use of vibratory tools)

 Contact urticaria (After contact with eliciting agent)

Indications for Referral to Specialist:

 Individual lesions persist> 24 hours  Lesions leave bruising/staining after resolution  Fever, pain, or other constitutional symptoms are associated  Elevated ESR/abnormal urinalysis  Raised ANA

Prognosis:

Chronic urticaria: Reassure parents - not a severe disease, may remit and relapse

25% of children with CSU are disease free 3 years after presentation and 96% after 7 years.

URTICARIA ACTIVITY SCORE- UAS7 Proforma https://www.bidermato.com/wp-content/uploads/2018/04/UAS7-Questionnaire-EN.pdf

First Ratified: January 2016 Last Reviewed: July 2020 Version Number: 2 Page 5 of 5