Contact Urticaria Syndrome Clinical Presentation

Updated: Jan 30, 2020
  • Author: Shweta Shukla, MD; Chief Editor: Dirk M Elston, MD  more...
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History of atopy

Many agents are capable of causing contact urticaria syndrome; therefore, a detailed history is essential in establishing the etiology. A history of previous anaphylaxis should be sought, as should a personal or family history of atopy.

In the aforementioned Hawaiian study, Elpern demonstrated that 46% of patients with contact urticaria syndrome had a personal history of atopy and that 44% had a family history of atopy. Only 21% of patients without contact urticaria syndrome had a personal history of atopy. [2, 31, 32]

A Polish study found that among patients with contact urticaria attending an urticaria clinic, only 1 of 5 patients had a personal or family history of atopy, a lower percentage than in the Elpern study.

Onset of symptoms

Contact urticaria reactions appear within minutes to approximately 1 hour after exposure of the urticarial causal agent to the skin. The patient may report a local burning sensation, tingling, or itching. Swelling and redness may be seen (wheal and flare). 

Exposure history to causal agents

The patient may be able to associate the symptoms to exposure to a specific substance. In some cases, this exposure may include the application of cosmetic or personal care products, especially to the face (cosmetic intolerance syndrome).

Details of the patient's employment provide insight into possible causes in the workplace, especially if the symptoms are temporally related to work. Bakers, agricultural workers, butchers, plastics workers, medical personal, chefs, and painters are at high risk for contact urticaria.

The patient may be able to identify what he or she was doing at the onset of symptoms, again allowing the medical practitioner to narrow down the possible causes.

Extracutaneous involvement 

The extent of extracutaneous involvement (eg, asthma, rhinitis, conjunctivitis, difficulty breathing, oral swelling, and GI upset) should be ascertained.


Physical Examination

Signs upon physical examination may be variable depending on when the patient presents to the clinic. At one extreme, the patient may be asymptomatic, while at the other extreme, the patient may have a generalized urticaria with extracutaneous symptoms. [34]

Immunologic and nonimmunologic contact urticaria can display site specificity; for example, the neck and perioral areas are more sensitive than the forearm. [35] This finding can be important in diagnostic testing.

Cutaneous findings

Localized or generalized wheals may be present, especially on the hands, or eczematous skin may be observed if contact urticaria syndrome has progressed to or developed in association with an eczematous dermatitis. Contact urticaria in the setting of hand eczema may be overlooked. Urticarial lesions appear as an erythematous swelling with a surrounding pallor. There may be one or multiple. By definition, contact urticaria syndrome lesions disappear within 24 hours of onset. Therefore, the skin may appear healthy, depending on when the patient presents to for care. Lack of urticaria on physical examination should not dissuade the provider from considering contact urticaria as a possible diagnosis.

Patients may demonstrate head and neck swelling or oral swelling, which should raise clinician suspicion for anaphylaxis.

An ordinal scale for scoring erythema is as follows [36] :

  • Slight erythema, either spotty or diffuse - 1+
  • Moderate uniform erythema - 2+
  • Intense redness - 3+
  • Fiery redness with edema - 4+

An ordinal scale for scoring edema is as follows [37] :

  • Slight edema, barely visible or palpable - 1
  • Unmistakable wheal, easily palpable - 2
  • Solid, tense wheal - 3
  • Tense wheal, extending beyond the test area - 4

Mucosal findings

The patient may be in varying degrees of respiratory distress if a respiratory component to the contact urticaria syndrome is involved. Rhinitis may be present, and wheezing may be heard upon auscultation. Lip swelling or tongue swelling may be present. Results of the examination, however, may be normal if the disease is quiescent or if no extracutaneous expression is present.

Ocular findings

Conjunctivitis may be seen in active extracutaneous disease.


The following staging system for contact urticaria syndrome has been described by Amin and Maibach [38] :

  • Stage 1 - Localized urticaria (redness and swelling); dermatitis (eczema); nonspecific symptoms (eg, itching, tingling, burning sensation)
  • Stage 2 - Generalized urticaria
  • Stage 3 - Bronchial asthma (wheezing); rhinitis, conjunctivitis (eg, runny nose, watery eyes); oropharyngeal symptoms (eg, lip swelling, hoarseness, difficulty in swallowing); GI symptoms (eg, nausea, vomiting, diarrhea, cramps)
  • Stage 4 - Anaphylactoid reactions (shock)

Stages 1 and 2 are characterized only by cutaneous reactions, while stages 3 and 4 demonstrate extracutaneous and systemic reactions that are more serious and require immediate attention.



Anaphylaxis is the major complication of contact urticaria as it may result in rapid hemodynamic decompensation and death.