No Days Off: The Mental Burden of Chronic Urticaria

Written by: Noha Benharira

Reviewed by: Nektaria Riso, Katie Kugler, and Ethan Bendayan

Introduction

Chronic urticaria (CU) is a common, yet often misunderstood, dermatological condition with significant physical symptoms and psychological consequences. While the condition’s cutaneous manifestations are well recognized, its broader impact on patients’ quality of life, emotional well-being, and daily functioning is frequently underestimated.

What is Chronic Urticaria?

Chronic urticaria is a common condition affecting approximately 1% of the population. It is defined by development of wheals (hives) and/or angioedema nearly every day for over 6 weeks. Evidence shows that nearly 60% of patients have experienced angioedema, a non-pitting swelling that involves the deeper subcutaneous and submucosal layers of tissue. Beyond the cutaneous manifestations, CU patients suffer from debilitating itch (pruritus).

CU can be further classified into chronic spontaneous urticaria (CSU) in the absence of identifiable triggers and chronic inducible urticaria (CIndU) when symptoms are triggered by specific stimuli. Common stimuli include pressure, heat, cold, exercise, ultraviolet light, water, and vibration, but can vary from person to person. While CU can affect anyone, it is most prevalent among women between the ages of 30 and 50. Additionally, in comparison to men, evidence shows that women have a higher disease burden, poorer symptomatic control, more systemic symptoms, sleep disturbances, and angioedema, as well as poorer quality of life.

Though the pathophysiology of CU is still largely debated by experts, current evidence suggests it is primarily due to mast cell dysfunction. In other words, the cutaneous manifestations are due to inappropriate activation and degranulation of cutaneous mast cells. To date, CU is recognized as an autoimmune-driven disorder in most cases.

How to Manage Chronic Urticaria?

Urticarial lesions are often self-limited. However, treatment is available to provide symptomatic relief. First-line treatment includes second-generation H1-antihistamines. However, the literature suggests that symptomatic relief is achieved in only half of patients with just antihistamines alone. The most recent international EAACI/GA²LEN/EuroGuiDerm guidelines suggest fourfold up-dosing of antihistamines if symptoms are still present. In antihistamine-refractory CU, the addition of omalizumab, an antibody targeting IgE (a mediator of histamine release), is recommended. Other options for non-responsive cases include cyclosporine (an immunosuppressant) or dupilumab (another antibody).

How Does Chronic Urticaria Affect Mental Health?

The psychological impact of CU on patients is well-known and well-documented in the medical literature. The challenging management, high symptom burden, and unpredictability of this condition all contribute to its substantial effect on emotional health. Chronic pruritus and pain, the main manifestations of CU, significantly disrupt patients’ sleep, mood, and ability to perform their activities of daily living. Measuring the social and emotional impact of this condition can be challenging, but various tools have been created to better understand the toll CU has on patients. These tools include the Chronic Urticaria Quality of Life Questionnaire (CU-Q₂oL), the Angioedema Quality of Life Questionnaire (AE-QoL), the Urticaria Activity Score over 7 days (UAS7), and the Urticaria Control Test (UCT). The UAS7 and UCT measure symptom frequency and disease burden respectively; they are commonly used due to their concise and easily understandable nature.

In the National Health and Wellness Survey (NHWS), CU patients receiving prescription treatment demonstrated significantly lower health-related quality of life, higher work impairment, and increased rates of depression, anxiety, and sleep disturbances. Another study comparing the impacts of CU and psoriasis on patients found that 50% of CU patients suffered from sleep problems due to the persistent nighttime pruritis. A chronic lack of sleep can negatively affect patients’ physical, mental and cognitive health long-term by contributing to emotional instability or exacerbating pre-existing medical conditions.

Interestingly, it was found that patients with CU have higher rates of comorbid psychiatric conditions when compared to the general population. A study by Ozkan et al. revealed that 60% of the study sample had a psychiatric diagnosis, with the most frequent being depressive disorders (40%).  In this same study, 76% of patients reported a distorted perception of their body image and poor self-esteem due to the wheals/angioedema caused by CU. Poor body image can affect patients’ ability to form and maintain relationships with loved ones or in social spaces.

Despite the significant psychosocial implications of CU, its impact can often be underestimated in the medical community, as it is often not life-threatening, and causes mostly temporary disfigurement. Nonetheless, it is a condition with serious consequences on patients’ daily living. In fact, one study demonstrated that the degree to which CU impaired quality of life was similar to that of coronary artery disease, especially in people awaiting coronary artery bypass grafting.

In short, the biopsychosocial impact of CU cannot be ignored, and has serious consequences on work, school, relationships, and self-esteem. The cumulative effect of this condition on patients can be seen by using the Dermatology Life Quality Index. Recent studies show that approximately 40% of patients reported a very large or extremely large negative effect on quality of life, corresponding to a Dermatology Life Quality Index >10. Therefore, it is important to be aware of this impact when treating patients with CU, as adopting a more holistic approach which encompasses mental health will benefit patients.

Conclusion

Chronic urticaria is a complex, multifactorial disease that profoundly affects patients’ quality of life. Recognizing and addressing its biopsychosocial burden is crucial to providing comprehensive care. By integrating psychological and emotional support into management, we can improve the physical symptoms of CU and enhance overall well-being for patients.

References                                                                      

1. Lang David, M., Chronic Urticaria. New England Journal of Medicine, 2022. 387(9): p. 824-831.

2. Greiner, B., et al., Pathophysiology, Diagnosis, and Management of Chronic Spontaneous Urticaria: A Literature Review. Clinical Reviews in Allergy & Immunology, 2022. 63(3): p. 381-389.

3. Young, M.C. and A. Banerji, Angioedema without urticaria: Diagnosis and management. Allergy Asthma Proc, 2025. 46(3): p. 185-191.

4. Maurer, M., J.W. Fluhr, and D.A. Khan, How to Approach Chronic Inducible Urticaria. The Journal of Allergy and Clinical Immunology: In Practice, 2018. 6(4): p. 1119-1130.

5. Kolkhir, P., et al., Chronic Spontaneous Urticaria: A Review. JAMA, 2024. 332(17): p. 1464-1477.

6. Kocatürk, E., et al., Sex matters in CSU: Women face greater burden and poorer urticaria control, especially in midlife-CURE insights. J Eur Acad Dermatol Venereol, 2025.

7. Agache, I., et al., Efficacy and safety of treatment with omalizumab for chronic spontaneous urticaria: A systematic review for the EAACI Biologicals Guidelines. Allergy, 2021. 76(1): p. 59-70.

8. Zuberbier, T., et al., The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. Allergy, 2022. 77(3): p. 734-766.

9. Vestergaard, C., et al., Treatment of chronic spontaneous urticaria with an inadequate response to H1-antihistamines: an expert opinion. Eur J Dermatol, 2017. 27(1): p. 10-19.

10. Maurer, M., et al., The burden of chronic spontaneous urticaria is substantial: Real-world evidence from ASSURE-CSU. Allergy, 2017. 72(12): p. 2005-2016.

11. Mendelson, M.H., et al., Patient-reported impact of chronic urticaria compared with psoriasis in theUnited States. J Dermatolog Treat, 2017. 28(3): p. 229-236.

12. Vietri, J., et al., Effect of chronic urticaria on US patients: analysis of the National Health and Wellness Survey. Ann Allergy Asthma Immunol, 2015. 115(4): p. 306-11.

13. Balp, M.M., et al., The Impact of Chronic Urticaria from the Patient's Perspective: A Survey in Five European Countries. Patient, 2015. 8(6): p. 551-8.

14. Özkan, M., et al., Psychiatric morbidity and quality of life in patients with chronic idiopathic urticaria.Annals of Allergy, Asthma & Immunology, 2007. 99(1): p. 29-33.

15. O'Donnell, B.F., et al., The impact of chronic urticaria on the quality of life. Br J Dermatol, 1997. 136(2): p. 197-201.

16. Caine, N., et al., Prospective study of quality of life before and after coronary artery bypass grafting.Bmj, 1991. 302(6775): p. 511-6.