Health condition · Clinically reviewed
Urticaria (hives), acute and chronic — antihistamines to biologics.
Itchy raised welts (weals) with or without swelling (angioedema). Acute cases are usually self-limiting; chronic urticaria responds to a stepwise medication ladder including biologics.
Why trust this guide
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Clinically reviewed
Written by our editorial team and reviewed by a registered UK clinician before publication.
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Sourced from guidance
Checked against EAACI/GA²LEN/EDF, NICE CKS and BAD guidance you can see at the end.
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Current for 2026
Reflects modern UK care including anti-IgE biologics for chronic spontaneous urticaria.
Key facts
Urticaria at a glance.
The essentials, in plain English — what it is, how it’s classified, how it’s worked up, and how it’s treated in the UK today.
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What it is
Wheals (raised itchy welts) with or without angioedema — individual lesions are transient and settle within 24 hours.
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Acute vs chronic
Acute urticaria lasts less than 6 weeks; chronic urticaria persists beyond 6 weeks and often recurs daily.
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Most common form
Chronic spontaneous urticaria (CSU) — no obvious external trigger, driven by mast-cell activation.
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Angioedema alone
Angioedema without wheals needs a C1-inhibitor work-up to exclude hereditary or ACE-inhibitor-related angioedema.
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First-line treatment
Second-generation non-sedating antihistamines, up-titrated to four times the standard licensed dose if needed.
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Modern biologic
Omalizumab (anti-IgE) has transformed chronic spontaneous urticaria — most patients respond within weeks.
Why this guide matters
A common condition, a modern ladder.
Urticaria is often dismissed as a rash — but chronic disease is exhausting, and modern treatment works. The three points below shape everything else on this page.
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Antihistamines are the foundation
Second-generation, taken daily, up-titrated when needed — the licensed and evidence-based first line.
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Angioedema alone is different
Swelling without wheals needs a hereditary and ACE-inhibitor work-up — a different diagnostic path.
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Biologics change severe disease
Omalizumab has transformed chronic spontaneous urticaria — don’t put up with uncontrolled symptoms.
How the diagnosis is made
From first wheal to a clear plan.
The steps a UK GP, dermatologist or allergist will normally follow, in order — so you know what to expect and why.
Phase 1 · Recognising
Pattern, triggers and severity
Phase 2 · Confirming
Bloods and physical urticaria testing
Phase 3 · Managing
Specialist referral and angioedema work-up
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Recognising
Symptom pattern and timing
How long each wheal lasts, daily frequency, associated swelling and any obvious triggers — the pattern usually makes the diagnosis.
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Recognising
Rule out drug triggers
NSAIDs, opiates, iodinated contrast and ACE inhibitors can trigger or worsen urticaria and angioedema — always reviewed first.
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Recognising
UAS7 severity scoring
A simple 7-day diary of wheal number and itch intensity — used to guide treatment escalation and monitor response.
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Confirming
Bloods if chronic
FBC, CRP and TFTs, with autoimmune screening where indicated — checks for underlying inflammation or thyroid autoimmunity.
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Confirming
Physical urticaria testing
Considered where cold, pressure, heat or exercise clearly provoke lesions — ice-cube test, pressure test and exercise challenge.
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Managing
Specialist referral
Dermatology or allergy referral for chronic disease not controlled on up-titrated antihistamines, for biologics assessment.
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Managing
Angioedema without wheals
Send C4 and C1-inhibitor levels to exclude hereditary angioedema or ACE-inhibitor-related angioedema — different treatment pathway.
Typical timeline: a first visit to a settled plan in weeks, not months.
Symptoms
What urticaria actually looks and feels like.
The classic pattern of transient wheals and itch, the physical subtypes — and the features that mean it’s time to call for help.
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Wheals
Raised, itchy pink or pale welts — individual lesions come and go within 24 hours, leaving no mark.
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Itching
Intense itch is the dominant symptom, often worse in the evening and at night.
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Angioedema
Deeper swelling of lips, eyelids, hands, feet or genitals — lasts up to 72 hours and can be uncomfortable.
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Dermographism
Wheals appear where the skin has been stroked or scratched — a classic sign of inducible urticaria.
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Cold urticaria
Wheals triggered by cold air, cold water or ice — swimming and sudden cold immersion carry an anaphylaxis risk.
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Delayed pressure urticaria
Deep, painful swelling appearing 4-6 hours after sustained pressure — belts, straps, prolonged sitting or standing.
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Cholinergic (exercise) urticaria
Small, pinpoint wheals with exercise, heat or emotion — driven by a rise in core body temperature.
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Red flag — airway swelling
Anaphylaxis or airway angioedema is a 999 emergency — use adrenaline auto-injector if prescribed, then call for help.
Treatment
How urticaria is treated in the UK.
A stepwise ladder — non-sedating antihistamines first, up-titration, add-ons, then omalizumab and cyclosporin for refractory disease.
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Second-generation antihistamine
Cetirizine, loratadine or fexofenadine once daily — the licensed first-line treatment for wheals and itch.
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Up-titrate to 4× standard dose
If symptoms persist after 2-4 weeks, the daily dose can be increased up to four times the licensed dose under clinician guidance.
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Add an H2 blocker
Adding an H2 antagonist (famotidine) is sometimes helpful as an adjunct — evidence is modest but the risk is low.
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Add montelukast
A leukotriene receptor antagonist added on top of antihistamines — a reasonable next step before biologic escalation.
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Omalizumab (anti-IgE)
A subcutaneous biologic for chronic spontaneous urticaria not controlled on high-dose antihistamines — most respond within 4-12 weeks.
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Cyclosporin
A specialist immunosuppressant for refractory disease when omalizumab is unsuitable or not tolerated.
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Adrenaline auto-injector
Prescribed where there is a history of anaphylaxis, airway angioedema or high-risk cold urticaria.
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Trigger avoidance
Stopping NSAIDs, avoiding overheating, and pacing physical or cold exposure where a physical trigger is identified.
What this guide is based on
The sources behind every claim on this page.
International urticaria guidance, UK national primary-care guidance and specialist patient information — current at the time of last review.
Key references
Guidelines and standards we relied on.
A quiet reminder
This guide is for information, not medical advice.
Your GP, dermatologist or allergist knows your history and can tell you which parts apply to you. If in doubt, get seen.
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EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria.
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NICE CKS. Urticaria.
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British Association of Dermatologists (BAD). Patient information on urticaria.
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Anaphylaxis UK. Patient information and emergency guidance.
Red flags
When urticaria needs urgent attention.
Most of the time, urticaria is uncomfortable but not dangerous. These are the situations where it isn’t — and you should act today.
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Anaphylaxis
Wheals with breathing difficulty, throat tightness, wheeze or collapse — call 999, give adrenaline if prescribed and lie flat.
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Airway angioedema
Swelling of tongue, throat or voice change — a same-day emergency, treat as anaphylaxis until proven otherwise.
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Isolated angioedema without wheals
Consider hereditary angioedema or ACE-inhibitor-related angioedema — different pathway, different treatment.
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Systemic symptoms with urticaria
Fever, joint pain and wheals lasting more than 24 hours in one spot — think urticarial vasculitis, needs biopsy.
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Fever with wheals
Suggests infection-driven or inflammatory urticaria — needs a same-week GP review to identify the cause.
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Autoimmune urticaria features
Thyroid autoimmunity or other autoimmune disease alongside chronic disease — often responds better to omalizumab.
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Cholinergic + exercise-induced anaphylaxis
Pinpoint wheals that progress to full anaphylaxis with exercise — needs allergist review and an auto-injector.
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Chronic disease affecting mental health
Sleep loss, anxiety and low mood are common in chronic urticaria — deserve escalation, not endurance.
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Pregnancy management
Antihistamine choice, dose adjustment and omalizumab use in pregnancy need shared decision-making with a specialist.
Living with it
A frustrating condition, but a very treatable one.
Four things that make the biggest difference day to day — tracking, trigger awareness, daily dosing and knowing when to escalate.
A quiet reminder
Steady blockade beats chasing flares.
Daily antihistamines, kept up consistently, do more than higher doses taken only when things flare.
- 01 Track
Keep a UAS7 diary
A simple daily score of wheals and itch tells you and your clinician whether treatment is working.
- 02 Triggers
Know what makes yours worse
Heat, alcohol, NSAIDs, tight clothing and stress commonly amplify chronic urticaria.
- 03 Doses
Don’t stop antihistamines early
Daily dosing works better than as-needed — steady blockade prevents flares rather than chasing them.
- 04 Escalate
Ask about omalizumab
If you’re still miserable on high-dose antihistamines, biologics have transformed chronic urticaria — don’t put up with it.
Frequently asked
Everything we get asked about urticaria.
Quick answers on antihistamines, angioedema, omalizumab and when to worry.
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What is urticaria?
A skin condition where itchy raised welts (wheals) appear and disappear within 24 hours, sometimes with deeper swelling called angioedema. It can be acute (under 6 weeks) or chronic (over 6 weeks).
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What causes chronic urticaria?
In most chronic cases there is no external trigger — this is called chronic spontaneous urticaria and is driven by mast-cell activation, sometimes with an autoimmune component.
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How is urticaria diagnosed?
By the pattern of transient wheals and itch, along with a UAS7 diary. Chronic cases have basic bloods; angioedema without wheals is investigated for hereditary angioedema.
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What is the first-line treatment?
A second-generation non-sedating antihistamine taken daily — cetirizine, loratadine or fexofenadine. The dose can be up-titrated to four times the standard dose under clinician guidance.
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What is omalizumab?
An anti-IgE injectable biologic given every four weeks for chronic spontaneous urticaria not controlled on high-dose antihistamines. Most people respond within four to twelve weeks.
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When should I call 999?
Any swelling of the tongue, throat or voice, difficulty breathing, wheeze or collapse — treat as anaphylaxis, use an adrenaline auto-injector if prescribed and call 999 immediately.