Introduction
Cholinergic urticaria is a type of physical urticaria (hives) that is triggered by an increase in body temperature. It is characterised by the rapid appearance of small, itchy wheals (hives) on the skin, often accompanied by a burning or prickling sensation. This condition is particularly common among adolescents and young adults, but it can affect individuals of any age.
What Is Cholinergic Urticaria?
Cholinergic urticaria is a hypersensitivity reaction of the skin that occurs when the body’s core temperature rises. The name “cholinergic” refers to the involvement of acetylcholine, a neurotransmitter that plays a role in the body’s response to heat and stress. When body temperature increases—due to exercise, hot showers, emotional stress, spicy foods, or even a warm environment—acetylcholine is released, which can trigger the symptoms of urticaria in susceptible individuals.
Causes and Triggers
The exact cause of cholinergic urticaria is not fully understood, but it is believed to result from an abnormal response of the skin’s mast cells to acetylcholine. Common triggers include:
- Physical exercise or strenuous activity
- Hot weather or exposure to heat
- Hot showers or baths
- Emotional stress or anxiety
- Consumption of spicy or hot foods
Symptoms
Symptoms typically develop within minutes of exposure to a trigger. The main features include:
- Small (1–5 mm), red, itchy wheals surrounded by larger areas of redness
- Burning, tingling, or prickling sensation, especially on the face, neck, chest, and upper limbs
- Wheals that may merge to form larger patches in severe cases
- Profuse sweating (in some cases)
- Rarely, systemic symptoms such as headache, nausea, dizziness, or even difficulty in breathing (anaphylaxis)
The rash usually resolves within 30 minutes to a few hours after the trigger is removed.
Diagnosis
Diagnosis is primarily clinical, based on the characteristic history and appearance of the rash. A doctor may perform a “provocation test” by inducing sweating or raising the patient’s body temperature (for example, through exercise or a hot water bath) to observe the reaction.
Other conditions that can mimic cholinergic urticaria, such as heat rash (miliaria), exercise-induced anaphylaxis, or other types of urticaria, must be ruled out. In some cases, allergy testing or blood tests may be recommended to exclude other causes.
Management and Treatment
There is no definitive cure for cholinergic urticaria, but the condition can often be managed effectively. Treatment strategies include:
- Avoidance of Triggers: Identifying and avoiding known triggers, such as strenuous exercise or hot environments, is crucial.
- Antihistamines: Non-sedating antihistamines are the first-line treatment and can help prevent or reduce symptoms if taken before exposure to triggers.
- Cooling Measures: Wearing loose, breathable clothing and taking cool showers may help minimise symptom severity.
- Desensitisation: Gradually increasing exposure to triggers under medical supervision may help in some cases.
- Other Medications: In severe or refractory cases, additional medications such as anticholinergics or leukotriene receptor antagonists may be considered under specialist care.
Patients with a history of severe reactions (e.g., breathing difficulty) should carry an emergency adrenaline (epinephrine) auto-injector and seek immediate medical attention if systemic symptoms occur.
Prognosis
Cholinergic urticaria is generally a benign condition, but it can significantly affect quality of life due to discomfort and restrictions on daily activities. Many cases improve or resolve spontaneously over time. With proper management and avoidance of triggers, most individuals can lead a normal, active life.
Nursing Care of Patients with Cholinergic Urticaria
As frontline healthcare providers, nurses play a crucial role in not only providing symptomatic relief but also in patient education, emotional support, and long-term management. This document provides a thorough overview of the nursing care required for patients with cholinergic urticaria, encompassing assessment, interventions, patient education, and collaborative care.
Assessment
Subjective Assessment
- Obtain a detailed history of the patient’s symptoms, including frequency, duration, and severity of outbreaks.
- Identify known triggers, such as exercise, stress, hot environments, or specific foods.
- Assess the impact on daily activities, social life, and emotional well-being.
- Inquire about associated symptoms: difficulty breathing, dizziness, or swelling (suggestive of severe reaction).
Objective Assessment
- Observe for typical lesions — small, pruritic wheals on the trunk, face, and extremities.
- Monitor for signs of severe allergic reaction, including angioedema, hypotension, or respiratory distress.
- Document all physical findings and correlate with patient history and triggers.
Nursing Diagnoses
Based on the assessment, common nursing diagnoses include:
- Ineffective Skin Integrity related to allergic response and scratching.
- Impaired Comfort related to pruritus and burning sensations.
- Anxiety related to unpredictability of outbreaks and potential for severe reactions.
- Deficient Knowledge regarding triggers, prevention, and management of symptoms.
- Risk for Ineffective Airway Clearance if anaphylaxis occurs.
Planning and Goals
The primary goals in the nursing care of patients with CU are:
- Provide symptomatic relief of pruritus and discomfort.
- Educate the patient about trigger avoidance and self-care strategies.
- Reduce the frequency and severity of urticaria episodes.
- Promote optimal skin integrity.
- Minimize anxiety and psychosocial impact.
- Ensure prompt recognition and management of severe reactions.
Nursing Interventions
1. Symptom Management
- Apply cool compresses or take cool showers to soothe affected skin and reduce itching.
- Encourage the patient to wear light, loose-fitting clothing to minimize heat and friction on the skin.
- Avoid use of harsh soaps or skin products that may aggravate symptoms.
- Advise short, clean fingernails to prevent skin damage from scratching.
2. Medication Administration
- Administer prescribed non-sedating antihistamines (e.g., cetirizine, loratadine) as first-line therapy.
- Monitor for side effects of antihistamines, including drowsiness or dry mouth (especially with first-generation agents).
- For refractory cases, document use of adjunct therapies such as leukotriene receptor antagonists, omalizumab, or immunosuppressants as per medical orders.
- Ensure emergency medications (e.g., epinephrine auto-injector) are available for patients with a history of severe reactions.
3. Trigger Avoidance and Environmental Control
- Educate the patient on common triggers and strategies to avoid them (e.g., moderate intensity of exercise, avoid hot environments, plan activities during cooler parts of the day).
- Recommend gradual acclimatization to activities that may precipitate sweating, under supervision.
- Encourage patients to keep a symptom diary to identify individual triggers and effective interventions.
4. Skin Care
- Promote the use of fragrance-free moisturizers to maintain skin hydration and barrier function.
- Monitor for signs of secondary infection (redness, swelling, pus) due to persistent scratching and refer as needed.
- Provide wound care for excoriated or broken skin, using gentle cleansing and sterile dressings.
5. Patient and Family Education
- Explain the nature of cholinergic urticaria, emphasizing the benign nature in most cases but the importance of recognizing severe symptoms.
- Teach the patient and caregivers how to recognize the signs of anaphylaxis: swelling of lips/tongue, difficulty breathing, rapid pulse, confusion.
- Instruct on the use and storage of emergency medications, including demonstration of epinephrine auto-injector use if prescribed.
- Provide written materials and resources for ongoing education and support.
6. Psychosocial Support
- Address the emotional impact of recurrent, unpredictable symptoms, and potential social isolation.
- Offer counseling or referrals to support groups for patients coping with chronic conditions.
- Encourage open communication about concerns related to school, work, or sports participation.
7. Monitoring and Follow-Up
- Regularly assess the effectiveness of treatment and adjust interventions as needed in collaboration with the healthcare team.
- Monitor for new or worsening symptoms that may suggest a change in disease pattern or the emergence of complications.
- Coordinate with dermatologists, allergists, and primary care providers for multidisciplinary management.
Special Considerations
Pediatric Patients
- Provide age-appropriate education and use play therapy to reduce anxiety in children.
- Involve parents in trigger identification, symptom monitoring, and medication administration.
Adolescents and Young Adults
- Discuss the potential psychosocial impact, including effects on self-esteem, peer relationships, and participation in activities.
- Empower this age group with knowledge and coping strategies to foster independence in self-care.
Patients with Severe or Refractory Cholinergic urticaria
- Be vigilant for signs of systemic involvement, including respiratory symptoms or hypotension.
- Ensure that action plans for emergency management are in place and understood by the patient and family.
Documentation
Comprehensive and accurate documentation is essential. Nurses should record:
- Date, time, and description of symptoms and triggers.
- Interventions provided and patient response.
- Patient and family education delivered, including understanding and skill demonstration.
- Any referrals or follow-up arrangements.
Evaluation
The effectiveness of nursing care is evaluated by:
- Reduction in frequency and severity of urticaria episodes.
- Improved comfort and skin integrity.
- Increased patient and family knowledge regarding the condition and its management.
- Demonstrated ability to recognize and respond to severe reactions.
- Enhanced psychosocial well-being and quality of life.
REFERENCES
- American College of Asthma, Allergy & Immunology (ACAAI). Hives. https://acaai.org/allergies/allergic-conditions/skin-allergy/hives/. Last reviewed 6/11/2018.
- DermNet NZ (New Zealand). Cholinergic urticaria. https://dermnetnz.org/topics/cholinergic-urticaria.
- Fukunaga A, Oda Y, Imamura S, Mizuno M, Fukumoto T, Washio K. Cholinergic Urticaria: Subtype Classification and Clinical Approach. Am J Clin Dermatol. 2023 Jan;24(1):41-54. doi: 10.1007/s40257-022-00728-6. Epub 2022 Sep 15. PMID: 36107396; PMCID: PMC9476404.
- Rujitharanawong C, Tuchinda P, Chularojanamontri L, Chanchaemsri N, Kulthanan K. Cholinergic Urticaria: Clinical Presentation and Natural History in a Tropical Country. https://www.hindawi.com/journals/bmri/2020/7301652/. BioMed Research International. 2020 May; Article ID 7301652. Last reviewed 7/2022.
- Ritzel D, Altrichter S. Chronic Inducible Urticaria. Immunol Allergy Clin North Am. 2024 Aug;44(3):439-452. doi:10.1016/j.iac.2024.03.003
- Muñoz M, Kiefer LA, Pereira MP, Bizjak M, Maurer M. New insights into chronic inducible urticaria. Curr Allergy Asthma Rep. 2024 Aug;24(8):457-469. doi:10.1007/s11882-024-01160-y
- Tokura Y. Direct and indirect action modes of acetylcholine in cholinergic urticaria. Allergol Int. 2021 Jan;70(1):39-44. doi:10.1016/j.alit.2020.05.006
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
