Management of Hematoma with Erythematous Borders and Urticaria
This presentation requires immediate assessment for urticarial vasculitis rather than simple urticaria, and you should obtain a lesional skin biopsy if individual lesions persist beyond 24 hours, as this distinguishes ordinary urticaria from urticarial vasculitis. 1
Critical Diagnostic Distinction
The key clinical discriminator is lesion duration:
- Ordinary urticaria wheals: Last 2-24 hours and resolve without trace 1, 2
- Urticarial vasculitis: Lesions persist >24 hours and may leave residual hyperpigmentation or bruising 1
- The presence of a hematoma with erythematous borders suggests a more persistent lesion pattern consistent with vasculitis rather than simple urticaria 1
Immediate Diagnostic Workup
Obtain lesional skin biopsy when urticarial vasculitis is suspected, looking for: 1
- Leucocytoclasia
- Endothelial cell damage
- Perivascular fibrin deposition
- Red cell extravasation
Order complement testing (C3 and C4) to distinguish normocomplementemic from hypocomplementemic disease, as this affects prognosis and treatment intensity 1
Acute Management Algorithm
If Lesions Last <24 Hours (Ordinary Urticaria):
First-line treatment: Non-sedating second-generation H1-antihistamines 3, 2, 4, 5
- Cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine 2
- Can be titrated to greater than standard doses if inadequate response 4
- Over 40% show good response to antihistamines alone 3
Adjunctive measures: 2
- Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream)
- Identify and avoid triggers
- Minimize aggravating factors (overheating, stress, alcohol)
Second-line additions for resistant cases: 3
- H2-antihistamines
- Antileukotrienes
- Short corticosteroid burst (3-4 weeks) for severe acute urticaria only 3
If Lesions Persist >24 Hours (Suspected Urticarial Vasculitis):
Do not rely on antihistamines alone - these lesions require different management based on biopsy confirmation and complement levels 1
Refer to rheumatology/dermatology for immunosuppressive therapy consideration if vasculitis confirmed 1
Critical Medications to Avoid
- NSAIDs and aspirin (inhibit cyclooxygenase and exacerbate urticaria)
- ACE inhibitors (must be avoided in angioedema without wheals; use cautiously when angioedema accompanies urticaria)
When to Escalate Care
Rule out anaphylaxis immediately if patient has: 6, 7, 8
- Respiratory symptoms (wheezing, dyspnea, upper airway obstruction)
- Cardiovascular symptoms (hypotension, tachycardia, vascular collapse)
- Gastrointestinal symptoms with systemic features
Administer epinephrine for life-threatening reactions with urticaria plus angioedema or systemic symptoms 6, 7, 8
Common Pitfall
The presence of a hematoma suggests this is not a typical transient urticarial wheal that resolves without trace. The combination of hematoma formation with erythematous borders indicates either trauma with secondary urticaria, or more likely urticarial vasculitis with vessel damage causing red cell extravasation 1. Do not dismiss this as simple urticaria - document lesion duration carefully and obtain biopsy if lesions persist beyond 24 hours 1.