What is the likely cause and recommended treatment for an intermittent raised urticarial rash on a healthy child's side of the face, behind the ears, and neck?

Intermittent Raised Urticarial Rash on Child's Face, Ears, and Neck

This presentation most likely represents acute episodic urticaria, which is the most common pattern in children and should be treated with long-acting, non-sedating H1-antihistamines as first-line therapy. 1, 2

Most Likely Diagnosis

The intermittent nature of raised hives (wheals) on the face, behind ears, and neck in a child is characteristic of acute episodic urticaria rather than atopic eczema. 1, 2

Key distinguishing features that point to urticaria:

• Raised wheals with hives - urticaria presents as raised, circumscribed lesions, whereas eczema typically shows erythema with scaling and lichenification 1, 3
• Intermittent pattern ("comes and goes") - individual urticarial wheals last less than 24 hours and resolve without scarring, while eczema lesions persist for days to weeks 1, 2
• Location pattern - while eczema in young children commonly affects cheeks and outer limbs, the specific pattern of behind ears and neck with raised hives is more consistent with urticaria 1

Common Triggers in Pediatric Acute Urticaria

Acute episodic urticaria in children is most commonly triggered by: 2

• Viral infections (most common cause in children)
• Food allergies (especially in younger children)
• Medications (antibiotics, NSAIDs)
• Contact with chemicals or irritants
• Physical stimuli (heat, pressure from clothing)

In approximately 50-80% of acute urticaria cases, no specific trigger is identified (idiopathic). 2

First-Line Treatment

Non-sedating, long-acting H1-antihistamines are the cornerstone of treatment: 1, 2, 4

• These should be given daily, not just when lesions are visible, since urticaria is intermittent
• Examples include cetirizine or loratadine at age-appropriate doses
• Continue treatment for at least 2-4 weeks after symptoms resolve

Sedating antihistamines may be added at bedtime only if sleep is significantly disrupted, but their benefit comes from sedation rather than superior anti-pruritic effects. 5, 2

What NOT to Do

Avoid these common pitfalls: 5, 2

• Do not use topical corticosteroids for urticaria - they are ineffective since urticaria involves deeper dermal vessels, not surface inflammation
• Do not use oral corticosteroids routinely - reserve only for severe acute episodes, as they cause rebound flares
• Do not perform extensive allergy testing unless there is a clear temporal relationship between specific food/medication exposure and symptoms 1
• Do not assume positive IgE testing or skin prick tests alone confirm food allergy - these require clinical correlation 1

When to Reassess or Escalate

Immediate evaluation needed if: 2

• Difficulty breathing, wheezing, or throat swelling (anaphylaxis - requires epinephrine)
• Fever accompanying the urticaria (consider autoinflammatory syndromes) 6
• Individual lesions lasting >24 hours or leaving bruising (consider urticarial vasculitis) 1

Refer to specialist if: 1, 2

• Symptoms persist beyond 6 weeks (chronic urticaria)
• Recurrent episodes despite antihistamine therapy
• Associated systemic symptoms like fever, joint pain, or malaise 6

Alternative Diagnosis to Consider

If lesions are persistent rather than intermittent, with scaling, crusting, or weeping, consider atopic eczema with secondary infection instead. 1 This would require emollients, topical corticosteroids, and potentially systemic antibiotics if infected. 1, 5