When should I refer a patient with chronic urticaria to a specialist for further evaluation?

Refer a patient with chronic urticaria to a specialist (dermatologist or immunologist) for further evaluation if:

• The urticaria is painful and persistent, suggesting possible vasculitic urticaria.
• Symptoms are not well controlled despite antihistamine treatment, including cases where increasing antihistamine doses or switching antihistamines has been ineffective.
• The patient has angio-oedema without wheals that does not respond to first-line treatment.
• There is acute severe urticaria suspected to be caused by food or latex allergy.
• The patient has forms of chronic inducible urticaria that are difficult to manage in primary care, such as solar or cold urticaria.
• There is a need for secondary care treatment options like cyclosporine, omalizumab, mycophenolate mofetil, or tacrolimus.
• The patient’s quality of life is significantly affected, and psychological support may be needed.

Additionally, consider referral if oral corticosteroids are indicated in children under 16 years or if rebound symptoms occur after corticosteroid treatment.

Use validated tools such as the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) or the Urticaria Activity Score (UAS7) to assess disease severity and impact, which can guide referral decisions.

These recommendations align with good clinical practice and are supported by UK guidelines and expert consensus.

References: NICE CKS