Review of Physical Urticarias and Testing Methods

  • Mario Sánchez-BorgesEmail author
  • Luis González-Aveledo
  • Fernan Caballero-Fonseca
  • Arnaldo Capriles-Hulett
Allergic Skin Diseases (L Fonacier, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Allergic Skin Diseases


Purpose of Review

This review aims to update the information available on the prevalence, clinical picture, diagnostic methods, and treatment of urticarias induced by external physical stimuli.

Recent Findings

Physical urticarias are present in up to 5% of the general population, and in 10 to 50% of patients with chronic urticaria. Recent investigations have provided evidence that the presence of physical urticaria alone or when comorbid with chronic spontaneous urticaria is associated with a worse prognosis and duration.


Most frequent subtypes of physical urticaria are dermographism and delayed pressure urticaria. The diagnosis is established through specific provocation tests and the management encompasses avoidance measures, pharmacologic therapy with nonsedating antihistamines, and alternative medications in refractory cases.


Angioedema Chronic urticaria Dermographism Inducible urticaria Physical urticaria Urticaria 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, Church MK, Ensina LF, Giménez-Arnau A, Godse K, Gonçalo M, Grattan C, Hebert J, Hide M, Kaplan A, Kapp A, Abdul Latiff AH, Mathelier-Fusade P, Metz M, Nast A, Saini SS, Sánchez-Borges M, Schmid-Grendelmeier P, Simons FE, Staubach P, Sussman G, Toubi E, Vena GA, Wedi B, Zhu XJ, Maurer M; European Academy of Allergy and Clinical Immunology; Global Allergy and Asthma European Network; European Dermatology Forum; World Allergy Organization. The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014: 69: 868–87. Important because this is the current internationally accepted document helpful for the diagnosis and treatment of chronic spontaneous and inducible urticarias. Google Scholar
  2. 2.
    • Magerl M, Altrichter S, Borzova E, Giménez-Arnau A, Grattan CE, Lawlor F, et al. The definition, diagnostic testing, and management of chronic inducible urticarias—the EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision. Allergy. 2016;71:780–802. An updated review of all forms of inducible urticarias, especially helpful as a resource on validated diagnostic methods for such diseases CrossRefPubMedGoogle Scholar
  3. 3.
    Weller K, Altrichter S, Ardelean E, Krause K, Magerl M, Metz M, et al. Chronic urticaria. Prevalence, course, prognostic factors and impact. Hautarzt. 2010;61:750–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Sánchez-Borges M, Caballero-Fonseca F, Capriles-Hulett A. Subtypes of chronic urticaria in patients attending allergy clinics in Venezuela. Eur Ann Allergy Clin Immunol. 2014;46:210–5.PubMedGoogle Scholar
  5. 5.
    • Maurer M, Weller K, Bindslev-Jensen C, Giménez-Arnau A, Bousquet PJ, Bousquet J, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA2LEN task force report. Allergy. 2011;66:317–30. Here authors indicate areas of uncertain knowledge for understanding chronic urticaria that need further investigation CrossRefPubMedGoogle Scholar
  6. 6.
    Hiragun M, Hiragun T, Mihara S, Akita T, Tanaka J, Hide M. Prognosis of chronic spontaneous urticaria in 117 patients not controlled by a standard dose of antihistamine. Allergy. 2013;68:229–35.CrossRefPubMedGoogle Scholar
  7. 7.
    • Sánchez-Borges M, Caballero-Fonseca F, Capriles-Hulett A, González-Aveledo L, Maurer M. Factors linked to disease severity and time to remission in patients with chronic spontaneous urticaria. J Eur Acad Dermatol Venereol. 2017; doi: 10.1111/jdv. 14221. This paper highlights that the presence of physical urticaria confers a worse prognosis for patients with urticaria
  8. 8.
    Kozel MM, Mekkes JR, Bossuyt PM, Bos JD. Natural course of physical and chronic urticaria and angioedema in 220 patients. J Am Acad Dermatol. 2001;45:387–91.CrossRefPubMedGoogle Scholar
  9. 9.
    Dice JP. Physical urticaria. Immunol Allergy Clin N Am. 2004;24:225–46.CrossRefGoogle Scholar
  10. 10.
    Trevisonno J, Balram B, Netchiporouk E, Ben-Shoshan M. Physical urticaria: review on classification, triggers and management with special focus on prevalence including a meta-analysis. Postgrad Med. 2015;127:565–70.CrossRefPubMedGoogle Scholar
  11. 11.
    Barlow RJ, Warburton F, Watson K, Black AK, Greaves MW. Diagnosis and incidence of delayed pressure urticaria in patients with chronic urticaria. J Am Acad Dermatol. 1993;29:954–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Katsarou-Katsari A, Makris M, Lagogianni E, Gregoriou S, Theoharides T, Kalogeromitros D. Clinical features and natural history of acquired cold urticaria in a tertiary referral hospital: a 10-year prospective study. J Eur Acad Dermatol Venereol. 2008;22:1405–11.CrossRefPubMedGoogle Scholar
  13. 13.
    Chong WS, Khoo SW. Solar urticaria in Singapore: an uncommon photodermatosis seen in a tertiary dermatology center over a 10-year period. Photodermatol Photoimmunol Photomed. 2004;20:101–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Carrillo DC, Sánchez-Borges M, García E, Egea E, Serrano CD. Omalizumab vs placebo in the management of chronic idiopathic urticaria: a systematic review. World Allergy Organ J. 2014;7:72.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    •• Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, Gower R, Kahn DA, Kaplan AP, Katelaris C, Maurer M, Park HS, Potter P, Saini S, Tassinari P, Tedeschi A, Ye YM, Zuberbier T; WAO Scientific and Clinical Issues Council. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J. 2012: 5: 125–47. A review of chronic urticaria with recommendations for its treatment according to evidence based medicine. Google Scholar
  16. 16.
    Leigh IM, Ramsay CA, Calnan CD. Cold urticaria—‘desensitisation’. Trans St Johns Hosp Dermatol Soc. 1979;60:40–2.Google Scholar
  17. 17.
    Black AK, Sibbald RG, Greaves MW. Cold urticaria treated by induction of tolerance. Lancet. 1979;2:964.CrossRefPubMedGoogle Scholar
  18. 18.
    Leigh IM, Ramsay CA. Localized heat urticaria treated by inducing tolerance to heat. Br J Dermatol. 1975;92:191–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Ramsay CA. Solar urticaria treatment by inducing tolerance to artificial radiation and natural light. Arch Dermatol. 1977;113:1222–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Soter NA, Wasserman SI. Physical urticaria/angioedema: an experimental model of mast cell activation in humans. J Allergy Clin Immunol. 1980;66:358–65.CrossRefPubMedGoogle Scholar
  21. 21.
    Krause K, Ardelean E, Kessler B, Magerl M, Metz M, Siebenhaar F, et al. Antihistamine-resistant urticaria factitia successfully treated with anti-immunoglobulin E therapy. Allergy. 2010;65:1494–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Metz M, Altrichter S, Ardelean E, Kessler B, Krause K, Magerl M, et al. Anti-immunoglobulin E treatment of patients with recalcitrant physical urticaria. Int Arch Allergy Immunol. 2011;154:177–80.CrossRefPubMedGoogle Scholar
  23. 23.
    Toda S, Takahagi S, Mihara S, Hide M. Six cases of antihistamine-resistant dermographic urticaria treated with oral ciclosporin. Allergol Int. 2011;60:547–50.CrossRefPubMedGoogle Scholar
  24. 24.
    Borzova E, Rutherford A, Konstantinou GN, Leslie KS, Grattan CE. Narrowband ultraviolet B phototherapy is beneficial in antihistamine-resistant symptomatic dermographism: a pilot study. J Am Acad Dermatol. 2008;59:752–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Johnsson M, Falk ES, Volden G. UVB treatment of factitious urticaria. Photo-Dermatology. 1987;4:302–4.PubMedGoogle Scholar
  26. 26.
    Barlow RJ, Ross EL, MacDonald D, Black AK, Greaves MW. Adhesion molecule expression and the inflammatory cell infiltrate in delayed pressure urticaria. Br J Dermatol. 1994;131:341–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Nettis E, Colanardi MC, Soccio AL, Ferrannini A, Vacca A. Desloratadine in combination with montelukast suppresses the dermographometer challenge test papule, and is effective in the treatment of delayed pressure urticaria: a randomized, double-blind, placebo-controlled study. Br J Dermatol. 2006;155:1279–82.CrossRefPubMedGoogle Scholar
  28. 28.
    Rodríguez-Rodríguez M, Antolin-Amerigo D, Barbarroja-Escudero J, Sánchez-González MJ, Alvarez-Mon M. Successful treatment of severe delayed pressure angio-oedema with omalizumab. Allergol Immunopathol. 2014;42:78–80.CrossRefGoogle Scholar
  29. 29.
    Bindslev-Jensen C, Skov PS. Efficacy of omalizumab in delayed pressure urticaria: a case report. Allergy. 2010;65:138–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Grundmann SA, Kiefer S, Luger TA, Brehler R. Delayed pressure urticaria—dapsone heading for first-line therapy? J Dtsch Dermatol Ges. 2011;9:908–12.PubMedGoogle Scholar
  31. 31.
    Swerlick RA, Puar N. Delayed pressure urticaria: response to treatment with sulfasalazine in a case series of seventeen patients. Dermatol Ther. 2015;28:318–22.CrossRefPubMedGoogle Scholar
  32. 32.
    Magerl M, Philipp S, Manasterski M, Friedrich M, Maurer M. Successful treatment of delayed pressure urticaria with anti-TNF-alpha. J Allergy Clin Immunol. 2007;119:752–4.CrossRefPubMedGoogle Scholar
  33. 33.
    Kalogeromitros D, Kempuraj D, Katsarou-Katsari A, Gregoriou S, Makris M, Boucher W, et al. Theophylline as “add-on” therapy in patients with delayed pressure urticaria: a prospective self-controlled study. Int J Immunopathol Pharmacol. 2005;18:595–602.CrossRefPubMedGoogle Scholar
  34. 34.
    Wanderer AA, Grandel KE, Wasserman SI, Farr RS. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. J Allergy Clin Immunol. 1986;78:417–23.CrossRefPubMedGoogle Scholar
  35. 35.
    Hochstadter EF, Ben-Shoshan M. Cold-induced urticaria: challenges in diagnosis and management. BMJ Case Rep. 2013; doi: 10.1136/bcr-2013-010441.
  36. 36.
    Kaplan AP, Gray L, Shaff RE, Horakova Z, Beaven MA. In vivo studies of mediator release in cold urticaria and cholinergic urticaria. J Allergy Clin Immunol. 1975;55:394–402.CrossRefPubMedGoogle Scholar
  37. 37.
    Stankovic K, Grateau G. Auto inflammatory syndromes: diagnosis and treatment. Joint Bone Spine. 2007;74:544–50.CrossRefPubMedGoogle Scholar
  38. 38.
    Ombrello MJ, Remmers EF, Sun G, Freeman AF, Datta S, Torabi-Parizi P, et al. Cold urticaria, immunodeficiency, and autoimmunity related to PLCG2 deletions. New Engl J Med. 2012;366:330–8.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Kolivras A, Theunis A, Ferster A, Lipsker D, Sass U, Dussart A, et al. Cryopyrin-associated periodic syndrome: an autoinflammatory disease manifested as neutrophilic urticarial dermatosis with additional perieccrine involvement. J Cutan Pathol. 2011;38:202–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Aróstegui JI, Aldea A, Modesto C, Rua MJ, Argüelles F, González-Enseñat MA, et al. Clinical and genetic heterogeneity among Spanish patients with recurrent autoinflammatory syndromes associated with the CIAS1/PYPAF1/NALP3 gene. Arthritis Rheum. 2004;50:4045–50.CrossRefPubMedGoogle Scholar
  41. 41.
    Wanderer AA, Grandel KE, Wasserman SI, Farr RS. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. Immunol Allergy Clin N Am. 2004;24:259–86.CrossRefGoogle Scholar
  42. 42.
    Hoffman HM, Wanderer AA, Broide DH. Familial cold autoinflammatory syndrome: phenotype and genotype of an autosomal dominant periodic fever. J Allergy Clin Immunol. 2001;108:615–20.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Martinez-Escala ME, Curto-Barredo L, Carnero L, Pujol RM, Giménez-Arnau AM. Temperature thresholds in assessment of the clinical course of acquired cold contact urticaria: a prospective observational one-year study. Acta Derm Venereol. 2015;95:278–82.CrossRefPubMedGoogle Scholar
  44. 44.
    Magerl M, Abajian M, Krause K, Altrichter S, Siebenhaar F, Church MK. An improved Peltier effect-based instrument for critical temperature threshold measurement in cold- and heat-induced urticaria. J Eur Acad Dermatol Venereol. 2015;29:2043–5.CrossRefPubMedGoogle Scholar
  45. 45.
    • Siebenhaar F, Degener F, Zuberbier T, Martus P, Maurer M. High-dose desloratadine decreases wheal volume and improves cold provocation thresholds compared with standard-dose treatment in patients with acquired cold urticaria: a randomized, placebo-controlled, crossover study. J Allergy Clin Immunol. 2009;123:672–9. A study showing improvement of cold urticaria with increased doses of nonsedating antihistamines CrossRefPubMedGoogle Scholar
  46. 46.
    • Krause K, Spohr A, Zuberbier T, Church MK, Maurer M. Up-dosing with bilastine results in improved effectiveness in cold contact urticaria. Allergy. 2013;68:921–8. Confirmation of the usefulness of increased doses of bilastine in patients with acquired cold urticaria CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Boyce JA. Successful treatment of cold-induced urticaria/anaphylaxis with anti-IgE. J Allergy Clin Immunol. 2006;117:1415–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Möller A, Henning M, Zuberbier T, Czarnetzki-Henz BM. Epidemiology and clinical aspects of cold urticaria. Hautarzt. 1996;47:510–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Bodar EJ, Simon A, de Visser M, van der Meer JW. Complete remission of severe idiopathic cold urticaria on interleukin-1 receptor antagonist (anakinra). Neth J Med. 2009;67:302–5.PubMedGoogle Scholar
  50. 50.
    Gualdi G, Monari P, Rossi MT, Crotti S, Calzavara-Pinton PG. Successful treatment of systemic cold contact urticaria with etanercept in a patient with psoriasis. Br J Dermatol. 2012;166:1373–4.CrossRefPubMedGoogle Scholar
  51. 51.
    Bentley-Phillips CB, Black AK, Greaves MW. Induced tolerance in cold urticaria caused by cold-evoked histamine release. Lancet. 1976;2:63–6.CrossRefPubMedGoogle Scholar
  52. 52.
    Kring Tannert L, Stahl Skov P, Bjerremann Jensen L, Maurer M, Bindslev-Jensen C. Cold urticaria patients exhibit normal skin levels of functional mast cells and histamine after tolerance induction. Dermatology. 2012;224:101–5.CrossRefPubMedGoogle Scholar
  53. 53.
    Bullerkotte U, Wieczorek D, Kapp A, Wedi B. Effective treatment of refractory severe heat urticaria with omalizumab. Allergy. 2010;65:931–2.CrossRefPubMedGoogle Scholar
  54. 54.
    Carballada F, Nuñez R, Martin-Lazaro J, Juárez Y, Castiñeira I, Carballada F, et al. Omalizumab treatment in 2 cases of refractory heat urticaria. J Investig Allergy Clin Immunol. 2013;23:519–21.Google Scholar
  55. 55.
    Farr PM. Solar urticaria. Br J Dermatol. 2000;142:4–5.CrossRefPubMedGoogle Scholar
  56. 56.
    Botto NC, Warshaw EM. Solar urticaria. J Am Acad Dermatol. 2008;59:909–20.CrossRefPubMedGoogle Scholar
  57. 57.
    Duchini G, Bäumler W, Bircher AJ, Scherer K. Failure of omalizumab (Xolair®) in the treatment of a case of solar urticaria caused by ultraviolet A and visible light. Photodermatol Photoimmunol Photomed. 2011;27:336–7.CrossRefPubMedGoogle Scholar
  58. 58.
    Arasi S, Crisafulli G, Caminiti L, Guarneri F, Aversa T, Porcaro F, et al. Treatment with omalizumab in a 16-year-old Caucasian girl with refractory solar urticaria. Pediatric Allergy Immunol. 2015;26:583–5.CrossRefGoogle Scholar
  59. 59.
    Levi A, Tal Y, Dranitzki Z, Shalit M, Enk CD. Successful omalizumab treatment of severe solar urticaria in a 6-year-old child. Pediatric Allergy Immunol. 2015;26:588–90.CrossRefGoogle Scholar
  60. 60.
    Güzelbey O, Ardelean E, Magerl M, Zuberbier T, Maurer M, Metz M. Successful treatment of solar urticaria with anti-immunoglobulin E therapy. Allergy. 2008;63:1563–5.CrossRefPubMedGoogle Scholar
  61. 61.
    Waibel KH, Reese DA, Hamilton RG, Devillez RL. Partial improvement of solar urticaria after omalizumab. J Allergy Clin Immunol. 2010;125:490–1.CrossRefPubMedGoogle Scholar
  62. 62.
    Edström DW, Ros AM. Cyclosporin A therapy for severe solar urticaria. Photodermatol Photoimmunol Photomed. 1997;13:61–3.CrossRefPubMedGoogle Scholar
  63. 63.
    Puech-Plottova I, Michel JL, Rouchouse B, Perrot JL, Dzviga C, Cambazard F. Solar urticaria: one case treated by intravenous immunoglobulin. Ann Dermatol Venereol. 2000;127:831–5.PubMedGoogle Scholar
  64. 64.
    Haylett AK, Nie Z, Brownrigg M, Taylor R, Rhodes LE. Systemic photoprotection in solar urticaria with α-melanocyte-stimulating hormone analogue [Nle4-D-Phe7]-α-MSH. Br J Dermatol. 2011;164:407–14.CrossRefPubMedGoogle Scholar
  65. 65.
    Roelandts R. Pre-PUVA UVA desensitization for solar urticaria. Photo-Dermatology. 1985;2:174–6.PubMedGoogle Scholar
  66. 66.
    Hudson-Peacock MJ, Farr PM, Diffey BL, Goodship TH. Combined treatment of solar urticaria with plasmapheresis and PUVA. Br J Dermatol. 1993;128:440–2.CrossRefPubMedGoogle Scholar
  67. 67.
    Duschet P, Leyen P, Schwarz T, Höcker P, Greiter J, Gschnait F. Solar urticaria: treatment by plasmapheresis. J Am Acad Dermatol. 1986;15:712–3.CrossRefPubMedGoogle Scholar
  68. 68.
    Roelandts R. Diagnosis and treatment of solar urticaria. Dermatol Ther. 2003;16:52–6.CrossRefPubMedGoogle Scholar
  69. 69.
    Beissert S, Ständer H, Schwarz T. UVA rush hardening for the treatment of solar urticaria. J Am Acad Dermatol. 2000;42:1030–2.CrossRefPubMedGoogle Scholar
  70. 70.
    Hölzle E, Hofmann C, Plewig G. PUVA-treatment for solar urticaria and persistent light reaction. Arch Dermatol Res. 1980;269:87–91.CrossRefPubMedGoogle Scholar
  71. 71.
    Epstein PA, Kidd KK. Dermo-distortive urticaria: an autosomal dominant dermatologic disorder. Am J Med Genet. 1981;9:307–15.CrossRefPubMedGoogle Scholar
  72. 72.
    Pressler A, Grosber M, Halle M, Ring J, Brockow K. Failure of omalizumab and successful control with ketotifen in a patient with vibratory angio-oedema. Clin Exp Dermatol. 2013;38:151–3.CrossRefPubMedGoogle Scholar
  73. 73.
    Ting S, Reimann BE, Rauls DO, Mansfield LE. Nonfamilial, vibration-induced angioedema. J Allergy Clin Immunol. 1983;71:546–51.CrossRefPubMedGoogle Scholar
  74. 74.
    Fukunaga A, Bito T, Tsuru K, Oohashi A, Yu X, Ichihashi M, et al. Responsiveness to autologous sweat and serum in cholinergic urticaria classifies its clinical subtypes. J Allergy Clin Immunol. 2005;116:397–402.CrossRefPubMedGoogle Scholar
  75. 75.
    Metz M, Maurer M. Omalizumab in chronic urticaria. Curr Opin Allergy Clin Immunol. 2012;12:406–11.CrossRefPubMedGoogle Scholar
  76. 76.
    Seize MB, Ianhez M, de Souza PK, Rotta O, Cestari CS. Familial aquagenic urticaria: report of two cases and literatura review. An Bras Dermatol. 2009;84:530–3.CrossRefPubMedGoogle Scholar
  77. 77.
    Parker RK, Crowe MJ, Guin JD. Aquagenic urticaria. Cutis. 1992;50:283–4.PubMedGoogle Scholar
  78. 78.
    Martinez-Escribano JA, Quecedo E, De la Cuadra J, Frias J, Sanchez-Pedreno P, Aliaga A. Treatment of aquagenic urticaria with PUVA and astemizole. J Am Acad Dermatol. 1997;36:118–9.CrossRefPubMedGoogle Scholar
  79. 79.
    Bayle P, Gadroy A, Messer L, Basex J. Localized aquagenic urticaria: efficacy of a barrier cream. Contact Dermatitis. 2003;49:160–1.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Mario Sánchez-Borges
    • 1
    • 2
    Email author
  • Luis González-Aveledo
    • 3
  • Fernan Caballero-Fonseca
    • 1
    • 4
  • Arnaldo Capriles-Hulett
    • 1
    • 4
  1. 1.Allergy and Clinical Immunology DepartmentCentro Médico Docente La TrinidadCaracasVenezuela
  2. 2.Allergy and Clinical Immunology ServiceClínica El AvilaCaracasVenezuela
  3. 3.Dermatology ServiceCentro Médico de CaracasCaracasVenezuela
  4. 4.Allergy and Immunology ServiceCentro Médico de CaracasCaracasVenezuela

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