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The Histopathology of Urticaria Revisited—Clinical Pathological Study

Barzilai, Aviv MD, MSc*,†; Sagi, Lior MD*; Baum, Sharon MD*; Trau, Henri MD*; Schvimer, Michael MD; Barshack, Iris MD; Solomon, Michal MD*

The American Journal of Dermatopathology: October 2017 - Volume 39 - Issue 10 - p 753–759
doi: 10.1097/DAD.0000000000000786
Original Study

Background: The classic histopathological findings of urticaria include dermal edema and a sparse perivascular infiltrate of neutrophils, eosinophils, macrophages, and lymphocytes. However, this pattern is inconsistently described.

Objective: To describe the histological and immunofluorescence characteristics of urticaria and to identify distinctive patterns.

Methods: A retrospective study was performed in which the medical files and biopsy specimens of 58 patients with acute and chronic classical urticaria were reviewed. Pathological parameters were quantified.

Results: We recognized 2 distinctive patterns of urticaria: lymphocyte and neutrophil predominant; the former was characterized by a perivascular location, whereas the latter was associated with an interstitial location and a denser infiltrate. Mast cells were relatively sparse, better demonstrated with special stains. Tryptase stain demonstrated more mast cells than Giemsa stain. Extravasated erythrocytes were present in 50% of the cases, but vasculitis was not observed.

Conclusions: Histological findings in classical urticaria show a spectrum of findings from a sparse superficial perivascular to a deep perivascular and interstitial infiltrate. Distinctive groups based on the dominant cell type can be identified, accounting for the similarity to neutrophilic urticarial dermatosis. Lesions may have a purpuric appearance, but leukocytoclastic vasculitis is never present.

*Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Israel; and

Institute of Pathology, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Reprints: Aviv Barzilai, MD, MSc, Department of Dermatology, Sheba Medical Center, 52621 Tel-Hashomer, Israel (e-mail:

A. Barzilai and L. Sagi are equal contributors.

The authors declare no conflicts of interest.

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