European Journal of Cardiovascular Medicine

Urticaria is a mast cell-driven inflammatory skin disorder characterized by transient pruritic wheals, angioedema, or both. Chronic urticaria is defined by recurrence of these manifestations for more than six weeks and is broadly classified into chronic spontaneous urticaria, in which no definite external eliciting stimulus is required, and chronic inducible urticaria, in which reproducible physical or environmental stimuli provoke symptoms. International estimates indicate that chronic urticaria affects a meaningful proportion of the population, with variation across regions and age groups. Women are affected more frequently than men, and the condition commonly presents during young and middle adulthood. Although individual wheals usually resolve within 24 hours, repeated episodes can continue for months or years and generate a substantial cumulative burden. 1,2,3

The clinical expression of chronic urticaria is

heterogeneous. Some patients experience wheals alone, whereas others have concurrent angioedema, extensive body involvement, nocturnal symptoms, or physical inducibility. Angioedema is clinically relevant because it is associated with greater disease burden and impaired quality of life. Recurrent pruritus can disturb sleep, restrict routine activities, impair work productivity, and contribute to psychological distress. Real-world studies have demonstrated that the impact of chronic urticaria extends beyond skin symptoms to health-care utilization, occupational productivity, and emotional well-being. 4,5,6,7.

Patients frequently attribute symptom exacerbations to foods, medications, infections, heat, cold, pressure, exercise, or emotional stress. However, perceived triggers do not always represent true causal factors. Food allergy is an uncommon explanation for chronic spontaneous urticaria, while non-specific cofactors and pseudoallergens can aggravate symptoms in selected individuals. Psychological stress has also been linked with disease activity through neuroimmune and inflammatory pathways. Careful history-taking is therefore essential to distinguish reproducible inducible triggers from coincidental exposures and to prevent unnecessary dietary or lifestyle restrictions. 8,9,10

Treatment is primarily directed toward complete symptom control using non-sedating second-generation H1-antihistamines, with dose escalation and advanced therapies for inadequately controlled disease according to guideline-based algorithms. 1,11 In routine practice, however, patients often receive fragmented care, use over-the-counter medicines, intermittently take systemic corticosteroids, change clinicians, or stop treatment after temporary relief. Delayed specialist assessment can prolong uncontrolled symptoms and reinforce misconceptions regarding food and drug triggers. Understanding treatment-seeking pathways alongside the clinical phenotype is therefore important in settings where patients move between self-medication, primary care, alternative systems, and dermatology services. 6,11

The present study was undertaken to evaluate patients with chronic urticaria attending a tertiary-care dermatology department in coastal Andhra Pradesh. The objectives were to describe their demographic and clinical profile, identify self-reported precipitating or aggravating factors, characterize prior and current treatment-seeking behaviour, and examine selected factors associated with delayed specialist consultation.

Study design and setting. This prospective observational study was conducted in the Department of Dermatology, Venereology and Leprosy (DVL), Konaseema Institute of Medical Sciences and Research Foundation (KIMS&RF), Amalapuram, Andhra Pradesh, India, from January 2020 to December 2020. The department provides outpatient and inpatient dermatology services to Amalapuram and surrounding areas of the Konaseema region. The study documented clinical characteristics, perceived precipitating factors, and treatment-seeking practices without altering routine management.

Study population and eligibility. Consecutive patients aged 18 years or older with recurrent wheals, angioedema, or both for more than six weeks and a clinical diagnosis of chronic urticaria were screened. Patients with acute urticaria, isolated angioedema when an alternative bradykinin-mediated disorder was suspected, urticarial vasculitis, systemic disorders with urticaria-like lesions, or incomplete information for study variables were excluded. Patients unwilling to provide written informed consent were not enrolled. Diagnosis and classification were based on clinical history and examination consistent with urticaria recommendations. 1

Sample size and sampling. Assuming an expected proportion of 50% for the principal descriptive characteristics, 95% confidence, and 10% absolute precision, the calculated minimum sample size was approximately 96 using n = Z²p(1-p)/d². The target was rounded to 100. Consecutive sampling continued until this number was achieved.

Data collection and clinical assessment. A structured case-record form was completed through interview and dermatological examination. Variables included age, sex, residence, disease duration, frequency and distribution of wheals, angioedema, dermatographism, nocturnal aggravation, sleep disturbance, personal or family history of atopy, and classification as chronic spontaneous or chronic inducible urticaria. Patients were asked about perceived aggravating factors including emotional stress, foods, medications, infections, pressure or friction, heat, sweating, cold, exercise, sunlight, and menstrual association. Multiple responses were permitted. Treatment-seeking variables included first source of care, self-medication, over-the-counter drug use, prior antihistamines or systemic corticosteroids, alternative or traditional medicine, unsupervised dietary restriction, treatment discontinuation after relief, changing clinicians or treatment systems, adherence, previous investigations, and interval from persistent symptom onset to dermatology consultation.

Bias control. Consecutive recruitment reduced selective enrolment. A uniform questionnaire and predefined definitions were applied to all participants. Trigger information was recorded as patient-reported rather than assumed causal. Clinical findings were documented at the same visit, and forms were checked for completeness before analysis.

Statistical analysis. Continuous variables were summarized as mean ± standard deviation or median with interquartile range; categorical variables were expressed as frequency and percentage. Pearson's chi-square test assessed associations with delayed specialist consultation. A two-sided p value <0.05 was considered statistically significant.

Ethical considerations. Institutional Ethics Committee approval was obtained before study initiation of study. Written informed consent was obtained from every participant, and confidentiality was maintained. 

A total of 108 patients with clinically suspected chronic urticaria were assessed during the study period. Eight were excluded because predefined eligibility criteria were not satisfied or essential clinical information was incomplete. The remaining 100 patients were enrolled and included in the final analysis. The mean age was 34.8 ± 11.6 years (range, 18-68 years). Patients aged 21-40 years constituted 60% of the cohort, and females accounted for 61%. The median duration of disease was 11 months (IQR, 7-24 months); 43% had symptoms for more than one year. The baseline demographic and selected clinical characteristics are summarized in Table 1.

Table 1. Demographic and baseline characteristics of patients with chronic urticaria

Recurrent pruritic wheals were present in all participants. Chronic spontaneous urticaria was the predominant phenotype, observed in 69 patients, while 31 had chronic inducible urticaria. Generalized wheals were reported by 58%, and 42% described predominantly localized involvement. Angioedema accompanied urticaria in 28%, dermatographism was identified in 24%, and symptoms occurring on most days of the week were reported by 55%. Nocturnal aggravation occurred in 46%, with sleep disturbance in 41%. The detailed clinical profile is presented in Table 2.

Table 2. Clinical profile of chronic urticaria

At least one self-reported precipitating or aggravating factor was identified by 72 patients, while 28 reported no consistent trigger. Emotional stress was the most frequent perceived aggravating factor (34%), followed by food-related exposures (27%), pressure or friction from tight clothing (19%), heat or excessive sweating (18%), medication-related worsening (15%), and recent or recurrent infections (13%). Cold exposure, exercise, and sunlight were less frequently reported. Among women, 7 of 61 (11.5%) described a temporal relationship with menstruation. Because multiple factors could be reported by the same patient, the percentages exceed 100% when summed (Table 3).

Table 3. Self-reported precipitating or aggravating factors

Note: Patients could report more than one factor; therefore, percentages do not total 100%.

Treatment-seeking patterns were heterogeneous. A dermatologist was the first source of treatment for 38 patients, whereas 26 initially consulted a general practitioner or physician, 21 practiced self-medication, and 15 first used alternative or traditional systems. Forty-seven patients delayed dermatology consultation for more than three months after persistent symptoms began. Previous antihistamine use was reported by 82%, and 23% had received systemic corticosteroids. Over-the-counter medication use was reported by 35%, 32% stopped prescribed treatment after symptomatic relief, and 29% changed clinicians or treatment systems because symptoms recurred. Only 56% described regular adherence to prescribed therapy. Treatment-seeking characteristics are shown in Table 4.

Table 4. Treatment-seeking behaviour among patients with chronic urticaria

Delayed specialist consultation was significantly associated with longer disease duration. Among patients with disease duration exceeding one year, 27 of 43 (62.8%) delayed dermatology consultation beyond three months, compared with 20 of 57 (35.1%) among those with disease duration of one year or less (χ² = 7.55, p = 0.006). Initial self-medication was also associated with delayed specialist care: 15 of 21 patients who initially self-medicated had delayed consultation compared with 32 of 79 among those who did not initially self-medicate (χ² = 6.37, p = 0.012). These associations are presented in Table 5.

Table 5. Factors associated with delayed specialist consultation

This prospective observational study characterized chronic urticaria in 100 adults attending a tertiary dermatology service and demonstrated a clear predominance of young and middle-aged patients, with women accounting for 61% of the cohort. The mean age of 34.8 years is consistent with the recognized tendency of chronic spontaneous urticaria to affect adults in the third to fifth decades and with epidemiological evidence showing greater disease frequency among women. 2,3 Chronic spontaneous urticaria represented 69% of cases, while 31% had a clinically inducible pattern. This distribution supports the clinical importance of distinguishing spontaneous disease from reproducible stimulus-associated urticaria because classification influences counselling and trigger avoidance. 1

Angioedema occurred in 28% of participants, and dermatographism was present in 24%. A recent meta-analysis reported that angioedema is common in chronic spontaneous urticaria, although estimates vary substantially across populations and study methods. 12 The slightly lower proportion in our cohort can reflect differences in referral patterns, disease severity, and patient recall. Nocturnal worsening and sleep disturbance were also frequent. These observations are clinically relevant because chronic urticaria has a recognized negative effect on quality of life, daily functioning, and productivity, with greater impairment reported in patients with more active disease and concomitant angioedema. 4,5,7,13

Nearly three-quarters of patients reported at least one perceived precipitating or aggravating factor. Emotional stress was the most frequently reported factor, followed by food-related exposures, pressure or friction, heat and sweating, medications, and infections. The prominence of stress is biologically plausible and agrees with evidence describing bidirectional neuroimmune interactions between psychological stress and chronic urticaria. 9 Nevertheless, patient-perceived triggers require cautious interpretation. Chronic spontaneous urticaria is rarely explained by classical food allergy, although pseudoallergens, infections, inflammatory states, and psychological factors can influence disease activity in selected patients. 10 This distinction is important because unnecessary food avoidance can add nutritional and psychological burden without improving disease control.

Treatment-seeking patterns identified important gaps in care. Only 38% consulted a dermatologist first, whereas 21% initially self-medicated and 15% sought alternative or traditional treatment. Almost half delayed specialist consultation beyond three months, 32% stopped treatment after symptomatic improvement, and 23% had previously used systemic corticosteroids. Real-world studies similarly describe substantial treatment burden, repeated health-care utilization, and persistent symptoms despite available guideline-based management. 6,8,11 International guidance recommends second-generation H1-antihistamines as first-line therapy, followed by stepwise escalation when control remains inadequate. 1 In the present study, delayed dermatology consultation was significantly associated with disease duration exceeding one year and initial self-medication. Use of validated control instruments such as the Urticaria Control Test can further support structured follow-up and treatment adjustment. 14 These findings emphasize early specialist access, clear counselling regarding the chronic fluctuating course, and continuity of evidence-based care.

LIMITATIONS

This study was conducted at a single tertiary-care dermatology department with a modest sample, which limits generalizability to community populations and other regions. Precipitating factors and previous treatment practices were based partly on patient recall and were not confirmed by challenge testing, prescriptions, or pharmacy records. Disease activity and quality of life were not quantified using validated longitudinal scores, and long-term treatment response was not assessed.

Chronic urticaria in this tertiary-care cohort predominantly affected young and middle-aged adults and showed a clear female preponderance. Chronic spontaneous urticaria was the commonest clinical pattern, while angioedema, dermatographism, nocturnal worsening, and sleep disturbance contributed to the clinical burden. Emotional stress and food-related exposures were frequently perceived as aggravating factors, although such associations require careful clinical interpretation. Treatment pathways were often fragmented, with self-medication, delayed dermatology consultation, intermittent corticosteroid exposure, and premature treatment discontinuation. Longer disease duration and initial self-medication were associated with delayed specialist care. Structured counselling, early dermatological assessment, appropriate trigger evaluation, and guideline-based stepwise therapy can improve continuity of care and reduce avoidable treatment practices.

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