Is there an association between Coronavirus disease (COVID-19) infection and the development of severe urticaria?

From the Guidelines

There is an association between COVID-19 infection and the development of severe urticaria, as COVID-19 has been linked to various dermatological manifestations, including urticaria. The exact mechanism of this association is not fully understood, but it is thought to involve immune system dysregulation triggered by the viral infection, with mast cell activation and histamine release leading to the characteristic itchy wheals and angioedema 1. Some studies suggest that the use of oral steroids, such as prednisone, may be beneficial in the treatment of severe urticaria associated with COVID-19, particularly in the early stages of the disease 1. However, the use of oral steroids in COVID-19 patients is still a topic of debate, and more research is needed to fully understand their effects 1. In general, treatment of urticaria associated with COVID-19 typically follows standard urticaria management protocols, including non-sedating H1 antihistamines like cetirizine (10mg daily) or fexofenadine (180mg daily) as first-line therapy. For severe cases, short courses of oral corticosteroids such as prednisone (20-40mg daily for 3-5 days) may be necessary. If symptoms persist beyond 6 weeks, becoming chronic, the dose of antihistamines can be increased up to fourfold, and referral to a dermatologist or allergist should be considered for additional therapies like omalizumab. Patients should be advised that post-COVID urticaria is usually self-limiting, though it may persist for weeks to months in some cases. Key points to consider in the management of urticaria associated with COVID-19 include:

• The use of oral steroids, such as prednisone, may be beneficial in the early stages of the disease
• Standard urticaria management protocols, including non-sedating H1 antihistamines, should be followed
• Referral to a dermatologist or allergist should be considered for additional therapies like omalizumab
• Patients should be advised that post-COVID urticaria is usually self-limiting, though it may persist for weeks to months in some cases.

From the Research

Association between COVID-19 and Severe Urticaria

• There is evidence to suggest that COVID-19 infection can lead to the exacerbation of chronic spontaneous urticaria (CSU) 2, 3, 4, 5, 6.
• A study found that 33% of CSU patients were impacted by SARS-CoV-2, with 71% developing a moderate-severe form of COVID-19 2.
• Another study reported that the majority of patients (69%) with urticaria and/or angioedema due to COVID-19 infection were over 50 years old, but urticaria in younger ages was not uncommon 3.
• The management of urticaria in COVID-19 patients should involve antihistamines, and low-dose prednisolone should be considered on an individualized basis 3.
• A cross-sectional study found no statistically significant relationship between COVID-19 RT-PCR positivity and the type of treatment administered for chronic urticaria 4.
• A study comparing the features of COVID-19 infection-induced chronic CSU and acute urticaria (AU) found that the mean duration of urticaria for CSU and AU following COVID-19 was 13.0 months and 7.1 days, respectively 5.
• The onset of urticaria more than 2 weeks after COVID-19 infection may serve as an indicator for urticaria chronicity beyond 6 weeks 5.
• A telemedicine follow-up study found that COVID-19, as well as COVID-19 vaccination, may trigger CSU relapse or worsening, but both are unspecific triggers, and urticaria shows a very short duration in most cases 6.

Clinical Features and Outcomes

• The clinical features of urticaria triggered by COVID-19 infection include recurrent attacks of urticaria, angioedema, and skin rash 2, 3, 4, 5, 6.
• The outcomes of urticaria triggered by COVID-19 infection vary, with some patients experiencing complete recovery, while others require adjustments to their treatment or experience relapse or worsening of symptoms 2, 3, 4, 5, 6.
• The use of antihistamines and corticosteroids is common in the management of urticaria triggered by COVID-19 infection 3, 6.
• Telemedicine can be an effective tool for the follow-up of patients with CSU, allowing for remote monitoring and adjustment of treatment as needed 6.