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A practical approach to the urticarial syndromes–a dermatologist's view

The main theme of this review is that the aetiology of about 70% of cases of urticaria or angio-oedema which present to specialist departments is quite obscure and that we should be ready to admit this fact. The clinical diagnosis of the remaining 30% is relatively easy. The other main theme is that too much effort and cost can go into investigations, whereas talking to the patient is far more important. Demonstrable IgE-mediated allergy, what we all spend so much time searching for, accounts for no more than 3-4% of our cases of urticaria. No doubt a different figure would emerge for patients attending a general practitioner, for patients attending an allergy clinic, and for patients in other countries where patterns of referral differ. These differences in selection of cases may be at least partly responsible for the fact that allergists may feel that dermatologists do not look hard enough for an allergy cause, whereas dermatologists may feel that allergy enthusiasts jump to conclusions too readily. Another great source of misunderstanding arises because so many cases of urticaria are multifactorial in origin, removal of one factor not being the whole answer. These remarks on the hazards in diagnosis of urticaria of course extend equally or even more so to the related problem of atopic dermatitis and the role of allergy.