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ACUTE URTICARIA IN CHILDREN
Janilson Barros de Sá1
João Guilherme de Sá Santos2
Vinicius Carvalho de Sá3
Abstract: Acute urticaria is a common condition in children, characterized by itchy skin lesions that
appear suddenly. Although usually self-limiting, it can cause signicant discomfort. Triggers include
infections, food allergies, and drug reactions. Management mainly involves antihistamines, with
corticosteroids in more severe cases. A systematic analysis of the literature is necessary to optimize
the diagnosis and treatment of acute urticaria, seeking to consolidate evidence that helps health
professionals in clinical practice. This research uses the systematic literature review method, with the
objective of gathering and analyzing the most relevant studies on acute urticaria in children published
between 2014 and 2024. Acute urticaria presents with urtices rashes, pruritic, and angioedema alone
or in association with urtices. It can be triggered by infections, food allergies, or medications, but often
the cause is idiopathic. Most episodes are self-limiting, with symptoms that disappear in less than 24
hours. Educating caregivers about possible triggers and monitoring allergic reactions are key to effective
treatment. Acute urticaria in children is common but often underdiagnosed. Although most cases are
self-limiting, identifying triggering factors is crucial to preventing recurrences. Proper management is
critical for treatment. Educating caregivers about the condition and seeking medical attention in serious
situations are essential to ensure the child’s well-being.
Keywords: Acute urticaria. Allergies. Urticaria in childhood
1 Pediatrician, Paraiso College.
2 Undergraduate in Medicine, Pernambuco Faculty of Health.
3 Undergraduate in Medicine, Faculty of Medicine of Olinda.
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INTRODUCTION
Acute urticaria is a relatively common condition in children, characterized by erythematous
and itchy skin lesions, which appear suddenly and can be triggered by various factors, such as infections,
food, and medications. Although in most cases urticaria is self-limiting, its presentation can generate
great discomfort and concern, both for the child and for their caregivers. It is estimated that up to 20%
of children experience at least one episode of urticaria throughout their lifetime, which underscores
the importance of understanding the factors that inuence its manifestation and appropriate treatment
(Kudryavtseva, A. et al, 2019).
The pathophysiological mechanisms of acute urticaria involve the release of histamine and
other inammatory mediators, which lead to vasodilation and increased vascular permeability. However,
pinpointing the exact causes can be challenging, since the condition is often idiopathic. Recent studies
highlight the role of viral and bacterial infections as common triggers in children, especially in younger
age groups (Imbalzano, E et al, 2016).
Another relevant aspect in the study of acute childhood urticaria is the prevalence of food
allergies and adverse drug reactions. Foods such as milk, eggs, and peanuts are among the main triggers
in pediatric patients, as described by authors such as Santa, C et al. (2021), while antibiotics, such as
penicillins, also play a signicant role.
The clinical management of acute urticaria in children mainly includes the use of antihistamines
to control symptoms and improve patients’ quality of life. However, there is a growing discussion
about the effectiveness of different generations of antihistamines, with the most modern versions
having a lower incidence of side effects, such as sedation. In addition, in more severe cases, the use of
corticosteroids may be necessary (Antia, C et al, 2018). These treatments aim to interrupt the cycle of
itching and edema, factors that compromise children’s well-being.
Despite the relative benignity of acute urticaria, it can be associated with a decrease in quality
of life and affect the daily routine of patients and families. Thus, it is essential that health professionals
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are prepared to identify signs of complications and provide emergency interventions when necessary.
Clinical guidelines highlight the importance of a thorough evaluation, including detailed clinical history
and laboratory tests, to exclude differential diagnoses and ensure appropriate treatment (Chang, J et al,
2021).
Thus, this study aims to perform a systematic review of the literature on acute urticaria in
children, gathering information on risk factors, diagnostic approaches, therapeutic options, and the
impact of this condition on child health. By consolidating the available evidence, it is expected to
contribute to a more grounded and effective clinical practice in the treatment of pediatric acute urticaria.
Acute urticaria in children is a frequent condition, but its effective management still presents
signicant clinical challenges due to the diversity of triggers and the difculty of accurate diagnosis.
Although in many cases the cause is idiopathic, viral infections, food allergies, and drug reactions
are among the main associated factors. In addition, therapeutic options vary widely, from the use of
antihistamines to corticosteroids in more severe cases, raising the question about the efcacy and safety
of each approach.
The problem question used in this review: “What are the main triggering factors, diagnostic
methods, and most effective therapeutic strategies in the management of acute urticaria in children,
according to the available scientic literature?”. This research seeks to investigate, through a systematic
review of the literature, the main scientic advances that guide clinical practice in the treatment of
pediatric acute urticaria, aiming to consolidate evidence to optimize the diagnosis and treatment of this
condition.
The general objective was to analyze the main triggering factors, diagnostic methods and
therapeutic strategies for the management of acute urticaria in children, based on a systematic review of
the scientic literature. The specic objectives are: (i) to identify the main etiological factors associated
with acute urticaria in children, such as infections, food and medications; (ii) to evaluate the diagnostic
methods used in clinical practice to differentiate acute urticaria from other pediatric allergic and
dermatological conditions; (iii) to compare the efcacy and safety of different therapeutic approaches,
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focusing on the use of antihistamines and corticosteroids, in the treatment of acute childhood urticaria.
Acute urticaria, despite being widely recognized in clinical practice, there are still gaps in
the understanding of the factors that trigger acute urticaria in children, as well as the most effective
methods for its diagnosis and treatment (Imbalzano, E et al, 2016). The medical literature points out that
infections, food allergies, and medications are among the main triggers, but the proper management of
these cases varies according to the severity and underlying cause. Thus, a systematic analysis of the
available studies is essential to offer clearer and more informed guidance to health professionals.
In addition, advancement in the treatment of acute childhood urticaria depends on a deeper
understanding of the effectiveness of different therapeutic approaches, such as the use of antihistamines
and corticosteroids. A systematic review can gather and compare the results of previous clinical studies
and reviews, enabling a more cohesive view of the most appropriate therapeutic options to ensure
symptom relief safely. By addressing these knowledge gaps, this research is justied by its contribution
to the improvement of pediatric clinical practice, allowing a more ef cient management of acute u rticaria
and, consequently, promoting a better quality of life for pediatric patients.
METHODOLOGY
This research uses the systematic literature review method, with the objective of gathering
and analyzing the most relevant studies on acute urticaria in children published between 2014 and
2024. Systematic review is a structured approach that allows the identication, critical evaluation, and
synthesis of the results of multiple scientic studies, ensuring a complete overview of the subject. This
methodology is widely used in literature reviews to ensure that the data collected is comprehensive,
rigorous, and adequate to answer the proposed research question.
The collection of studies was carried out in the scientic databases: PubMed, Scielo, Google
Scholar, using standardized descriptors in Portuguese and English. The search terms were: acute urticaria
in children, treatment of acute urticaria, diagnosis of acute urticaria, and triggers of acute urticaria. The
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combination of these descriptors was used to ensure the broad capture of relevant articles, avoiding
the exclusion of studies essential for the understanding of the theme, with the use of the Boolean terms
“AND” and “OR”.
The inclusion criteria established for the selection of articles included: original studies,
systematic reviews, and literature reviews on acute urticaria in children, published between 2014
and 2024, with full texts available in Portuguese or English, with information on etiological factors,
diagnostic methods, or therapeutic approaches to the condition.
Studies outside the pediatric population that were not related to the management of acute
urticaria, as well as publications that were not available in full text or did not undergo peer review, were
excluded.
After the selection of the articles and detailed reading of the titles and abstracts, followed by
a complete evaluation of the texts that met the inclusion criteria. The data extracted from the studies
were organized in a table containing information such as the year of publication, country of origin, type
of study, number of participants, main triggering factors, diagnostic methods used, and therapeutic
approaches described. The qualitative analysis of the results allowed the identication of frequent
approaches and trends in the management of acute urticaria in children over the last decade.
Finally, the results were synthesized and discussed in the light of the proposed objectives,
identifying the main contributions of the literature to the pediatric clinical practice of acute urticaria
and suggesting possible areas for future research. By using a rigorous and systematic method, this
literature review offers a comprehensive and up-to-date view of the diagnosis and treatment of acute
childhood urticaria, helping health professionals and researchers to make more informed and evidence-
based decisions.
TITLE AUTHOR/YEAR GOALS METHODOLOGY CONCLUSIONS
Clinical practice
guideline for
diagnosis and
management of
urticaria
Limpongsanurak et
al. (2016)
Inform about clinical
practice guidelines
for diagnosis and
management of
urticaria.
Bibliographic review.
The only strong, evidence-based
alternative regimen for CSU is an anti-
IgE: omalizumab; due at a very high
cost, however, it may not be affordable
in lower-middle-income countries.
Non-pharmacotherapeutic means for
Minimizing hyper-responsiveness
of the skin are also important and
recommended, such as preventing skin
dryness, avoiding hot bath, rubbing and
excessive exposure to the sun.
Acute urticaria
in children: from
pediatric emergency
d e p a r t m e n t
to allergology
consultation at a
central hospital
Santa et al. (2021)
To characterize the
prevalence, etiology,
and management
of acute urticaria
in children who
present themselves
to an emergency
department of a
Portuguese central
hospital and report
to follow-up
investigation when
drug or food allergy
is suspected.
Prospective study of
clinical records of
children admitted to
the emergency room
with acute conditions
urticaria over a period
of one year.
These data suggest that allergy is not
the main trigger of acute urticaria in
children with ED, but when suspected,
reference
to an allergy department to complete
the allergological investigation was
insufcient.
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RESULTS AND DISCUSSION
RESULTS
After an extensive search, 6 main publications were selected for the composition of this article,
presented in Chart 2. With a description of the title, authors, year of publication, objectives, methodology
and conclusions.
Chart 2 – Articles analyzed according to selection from the systematic review.
TITLE AUTHOR/YEAR GOALS METHODOLOGY CONCLUSIONS
Clinical practice
guideline for
diagnosis and
management of
urticaria
Limpongsanurak et
al. (2016)
Inform about clinical
practice guidelines
for diagnosis and
management of
urticaria.
Bibliographic review.
The only strong, evidence-based
alternative regimen for CSU is an anti-
IgE: omalizumab; due at a very high
cost, however, it may not be affordable
in lower-middle-income countries.
Non-pharmacotherapeutic means for
Minimizing hyper-responsiveness
of the skin are also important and
recommended, such as preventing skin
dryness, avoiding hot bath, rubbing and
excessive exposure to the sun.
Acute urticaria
in children: from
pediatric emergency
d e p a r t m e n t
to allergology
consultation at a
central hospital
Santa et al. (2021)
To characterize the
prevalence, etiology,
and management
of acute urticaria
in children who
present themselves
to an emergency
department of a
Portuguese central
hospital and report
to follow-up
investigation when
drug or food allergy
is suspected.
Prospective study of
clinical records of
children admitted to
the emergency room
with acute conditions
urticaria over a period
of one year.
These data suggest that allergy is not
the main trigger of acute urticaria in
children with ED, but when suspected,
reference
to an allergy department to complete
the allergological investigation was
insufcient.
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A Case of Urticaria
Multiforme in a
Child
Santos et al. (2020)
OBJECTIVE: To
report the case of
a 1-year-and-9-
month-old child
with exuberant skin
lesions associated
with systemic
manifestations, with
complete recovery
of the condition
after treatment
with antihistamines
and intravenous
corticosteroids in an
intensive care unit.
Case report.
Urticaria multiforme is an acute
hypersensitivity reaction, being a
morphological subtype of urticaria.
It is more common in children and,
since its clinical presentation resembles
other dermatoses, such as erythema
multiforme, urticarian vasculitis,
and sero-like disease, it has been
underdiagnosed.
Acute urticaria
and anaphylaxis:
differences and
similarities in
clinical management
Ensina et al. (2022)
To analyze the
differences and
similarities in the
clinical management
of acute urticaria
and anaphylaxis,
in order to identify
appropriate
treatment guidelines
and interventions to
optimize the care of
patients with these
conditions.
Bibliographic review.
Acute urticaria is a common condition
presenting with papules and/or
angioedema. However, these symptoms
are also frequent in anaphylaxis, a
potentially fatal reaction which should
be immediately diagnosed and treated.
In both, mast cells play a central role in
pathophysiology. The causes and triggers
of acute urticaria and anaphylaxis are
similar in general, but some peculiarities
can be observed. The diagnostic
approach. They may differ, according
to the condition, suspected causes, age
groups and regions. Adrenaline is the
rst-line treatment for anaphylaxis,
but not for acute urticaria, where H1
antihistamines are the rst choice.
Urticaria in children
and adolescents: an
updated review of
the pathogenesis and
management
Kudryavtseva et al.
(2019)
The present research
represents the most
recent data on
the diagnosis and
management of
Infantile urticaria.
Case study.
It was noted that, unlike the 2014
guidelines, the 2018 clinical practice
guidelines for the diagnosis and
management of urticaria again
recommend a 4-step treatment regimen,
designating omalizumab for Step 3
and cyclosporine A for Step 4, in case
the therapeutic efcacy of the previous
step is low or impossible. Leukotriene
antagonists (LTRAs) have been removed
from basic management and are now
considered for alternative programs.
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Source: Sá, J.B. and collaborators.
DISCUSSION
According to Limpongsanurak et al. (2016) Urticaria, a heterogeneous group of diseases, is
characterized by papules and rashes that sometimes present concomitantly with angioedema (edema
in the deep dermis and subcutaneous tissue). Urticaria can be caused by a number of factors, including
physical stimuli, immune response to food, medications, and infectious agents, or as part of inammatory
or malignant conditions. However, the most common cause is idiopathic in nature.
Pruritus is the most prevalent symptom of urticaria. Other characteristic signs include papules
and rashes that vary in size, with individual papules usually disappearing within 24 hours without
leaving residual hyperpigmentation. In some cases, urticaria can occur simultaneously with angioedema,
which typically affects the deep dermis and subcutaneous fat, especially in areas such as the periorbital
tissues, lips, tongue, and hands (Limpongsanurak et al., 2016).
Angioedema may persist for up to 72 hours, and is usually accompanied by a burning sensation
and/or mild pain. Itching is uncommon in angioedema. Urticaria, with or without angioedema, may
be a manifestation of anaphylaxis. Other manifestations of anaphylaxis include chest discomfort,
hoarseness, wheezing, abdominal pain, and diarrhea. The respiratory distress and circulatory collapse
associated with anaphylaxis can progress to anaphylactic shock, a serious and life-threatening condition
(Limpongsanurak et al., 2016).
In turn, Santa et al. (2021) Children with acute urticaria were referred to the emergency
department (ED) in 0.58% of the total pediatric visits, and in most cases the etiology was not determined.
Upper respiratory tract infections were the most common etiologic factor. This study supported the
view that allergy is not the main trigger of acute urticaria in children, with only 6 patients presenting a
conrmed diagnosis of drug or food allergy, among the 50 patients with a suggestive clinical history.
Most importantly, we found that in 52% of patients with suspected drug or food allergies, referral to an
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allergology department for a thorough evaluation was not performed.
It is critical for physicians practicing emergency medicine to provide appropriate aftercare
guidance for patients with suspected allergies and refer these patients for evaluation by an allergist
to ensure a careful and thorough diagnosis. We reinforce the need for training physicians in pediatric
emergencies in relation to allergic diseases, in addition to the implementation of criteria for appropriate
referral for complementary investigation (Santa, C et al., 2021).
Santos et al. (2020) points out that acute annular urticaria is a morphological subtype of
urticaria that occurs most frequently in children aged 4 months to 4 years. Clinically, it is characterized
by erythematous or polycyclic macules, papules, or plaques, often with an ecchymotic or violaceous
center. These lesions are short-lived and may be associated with angioedema. Systemic symptoms, such
as fever, are usually mild and short-lived (1-3 days). The rash is self-limiting, resolving within 8 to 10
days, and may be triggered by infections or medications. The diagnosis is essentially clinical, but it is
often confused with other conditions, such as erythema multiforme, urticaria vasculitis, and, rarely,
serum sickness.
Urticaria vasculitis is a rare condition in children, characterized by recurrent episodes of
urticaria with histopathological features of leukocytoclastic vasculitis, similar to acute hemorrhagic
edema of childhood. Although more common in middle-aged adults, it should be considered in the
pediatric differential diagnosis, as it can cause urticarial lesions, ecchymotic lesions
Skin lesions are itchy, last more than 24 hours, and may develop into extensive plaques with
purpuric elements. Systemic symptoms such as fever, arthralgia, and malaise may also occur, in addition
to gastrointestinal and ocular manifestations. The correct diagnosis is essential to avoid unnecessary
tests and monitor the evolution of the condition, which can have systemic repercussions (Santos et al.,
2020)
It points out that current guidelines recommend that acute urticaria generally does not require a
diagnostic work-up, as it tends to be self-limiting. Although often caused by viral or infectious diseases,
extensive evaluation for specic viral pathogens or antiviral therapy is not indicated unless suggested
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by clinical history. (Kudryavtseva, A et al., 2019)
Recent guidelines from the European Academy of Allergology and Clinical Immunology
(EAACI), the European Allergy and Asthma Network (GA2LEN), the European Dermatology Forum
(EuroGuiDerm) and the Asia-Pacic Association of Allergy, Asthma and Clinical Immunology
(APAAACI) state that the only exception is the suspicion of acute urticaria due to a type I food allergy
in sensitized patients or the presence of other triggers, as non-steroidal anti-inammatory drugs
(NSAIDs) (Kudryavtseva, A et al., 2019).
An allergic cause is possible if the clinical history indicates a specic trigger to which the
patient was exposed shortly before the onset of symptoms (usually within 1 to 2 hours of exposure). If
the history suggests a possible allergy, skin tests and serological tests for allergen-specic IgE antibodies
are appropriate. However, interpretation of allergy tests should be performed with caution; A positive
result suggests but does not conrm an allergy, while a negative result does not exclude the possibility
(Kudryavtseva, A et al., 2019).
Patient education is essential to avoid re-exposure to relevant causative factors. In some
situations, it may be essential to conrm the diagnosis of allergy in acute urticaria with complementary
tests in order to avoid mislabeling patients as allergic. Although skin biopsy is not indicated in most
cases of acute urticaria, it can occasionally help differentiate this condition from other inammatory
disorders (Kudryavtseva, A et al., 2019).
According to Kudryavtseva et al. (2019), in most cases, acute urticaria is the only episode in the
patient’s life. Chronic urticaria in children also has a more favorable outcome than in adults. According
to studies conducted to identify the natural course of chronic urticaria in the pediatric population,
remission rates after one, three, and ve years of symptom onset were 16.5-37%, 36-54%, and 50-
67.5%, respectively. After seven years, 96% of children were free of urticaria, compared with adults, of
whom at least 20% remain symptomatic after 10 years.
However, regression tends to occur more rapidly in children with low urticaria activity scores,
controlled by standard doses of antihistamines. Currently, there are therapeutic approaches that allow
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doctors to control the course of the disease and improve the quality of life of patients (Kudryavtseva,
A et al., 2019).
Acute urticaria is a common childhood condition characterized by itchy rashes and edema,
which can appear suddenly and usually last less than six weeks. These lesions can manifest as papules,
macules, or erythematous plaques and may be of allergic origin, associated with factors such as viral
infections, medications, or food. Acute urticaria can be triggered by several agents, and the identication
of the responsible factor is crucial for the effective management of the condition (Tsakok, T et al, 2014).
The incidence of acute urticaria in children is signicant, affecting up to 20% of the child
population at some point in life. Studies have shown that most episodes of acute urticaria are self-
limiting and resolve spontaneously, and clinical intervention is often required only to relieve symptoms.
The condition is particularly prevalent in young children, and understanding the clinical features and
triggers is essential for pediatricians and dermatologists (Caffarelli, C et al, 2019).
Management of acute urticaria in children usually involves the use of antihistamines to control
itching and inammation. According to the American Academy of Allergy, Asthma, and Immunology,
second-generation antihistamines such as cetirizine and loratadine are often preferred due to their safety
and efcacy prole. In addition, careful clinical evaluation and history are key to determining the need
for additional interventions or diagnostic testing (Jalan, L et al, 2015).
Although acute urticaria is usually self-limiting, it is important to monitor patients for the
development of chronic urticaria or anaphylaxis. Chronic urticaria, dened as episodes lasting more
than six weeks, can arise after repeated episodes of acute urticaria, and its management can be more
complex. Anaphylaxis, a severe allergic reaction, can also manifest with hives and edema, requiring
immediate interventions, including the administration of epinephrine (Lee, S et al, 2013).
Finally, education of patients and their caregivers about acute urticaria is critical in management.
Teaching about possible triggers, such as certain foods or medications, and the importance of seeking
medical attention in case of severe symptoms can help prevent future episodes. Regular follow-up and
communication between health professionals and families are essential to ensure effective treatment
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and improvement in the quality of life of children affected by acute urticaria.
FINAL CONSIDERATIONS
Acute urticaria in children is a common but often underdiagnosed condition that can cause
signicant discomfort. Although most cases are self-limiting, with spontaneous resolution, the
identication of triggering factors is crucial to prevent recurrences. Understanding the clinical features
and possible causes of acute urticaria allows healthcare professionals to offer more effective and targeted
treatment, reducing anxiety for patients and their families.
Management of acute urticaria involves the use of antihistamines, and in more severe cases,
corticosteroids may be necessary. Educating patients about the condition and its potential triggers is
essential, as this can help prevent future are-ups. It is important for caregivers to be aware of the need
to seek immediate medical attention in cases of severe symptoms, such as angioedema or difculty
breathing, which may indicate a more severe allergic reaction, such as anaphylaxis.
The pathophysiology of acute urticaria in children is still limited, and further studies are
needed to better understand its mechanism and associated risk factors. The continuous knowledge
and updating of health professionals on management guidelines are essential to ensure quality care. In
addition, multicenter studies may help elucidate the specic features of acute urticaria in the pediatric
population.
Another important point is the need for a multidisciplinary approach to the management of
urticaria, involving pediatricians, dermatologists, and allergists. This ensures a more comprehensive
patient assessment and an appropriate treatment plan. Collaboration between specialists can make it
easier to detect potential underlying conditions and ensure that patients receive the best possible care.
Finally, acute urticaria in children, although usually benign, should not be underestimated.
Proper follow-up and ongoing communication between health professionals and families are essential
to ensure the child’s well-being. By providing a patient-centered approach and educating about the
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condition, it is possible to minimize the impact of acute urticaria on the lives of children and their
families, promoting a better quality of life.
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