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Paediatric Urticaria Guideline

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Paediatric Urticaria Guideline 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 .
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