British Journal of Dermatology 1997; 136: 1 9 7 - 2 0 1 .

The impact of chronic urticaria on the quality of life

B.F.O'DONNELL. RLAWLOR, J.SIMPSON,* M.MORGAN* AND M.W.GREAVES
St John's Institute of Dermatology and *Departnient of Public Health Medicine. United Medical and Dental School.
St Thomas' Hospital. London SEl 7EH. U.K.
Accepted for publication 3 July 1996

Summary The impact of chronic urticaria (CU) on the quality of life is undocumented. We assessed quality of life
in patients with CU, including patients with associated delayed pressure urticaria (DPU). One
hundred and forty-two out-patients completed self-administered questionnaires: a disease-specific,
purpose designed questionnaire, and the Nottingham health profile (NHP). Many patients reported
problems attributable to their skin condition in facets of everyday life including home management,
personal care, recreation and social interaction, mobility, emotional factors, sleep, rest and work. The
NHP part I scores showed restriction in the areas of mobility, sleep, energy, and demonstrated pain,
social isolation and altered emotional reactions. Part II of the NHP showed that patients experienced
difficulties in relation to work, looking after the home, social life, home relationships, sex life, hobbies
and holidays. The patients with DPU had significantly more problems with mobility, gardening and
choice of clothing than the uncomplicated CU patients. They also suffered more pain, had more
problems with work and were more restricted in their hobbies.

Urticaria describes short-Uved, erythematous, cuta-
neous swellings due to transient dermal oedema and
vasodilatation. The weals are usually itchy and last less
than 24 h. Chronic urticaria (CU) is defined as a 6-week
or longer history of widespread wealing.^ Almost 50%
of CU patients have concurrent angio-oedema^ and
approximately 45% have associated delayed pressure
urticaria (DPU).^ In DPU cutaneous erythema and
subcutaneous oedema occur between 30 min and 9 h
after the application of pressure to the skin.* The
lesions, provoked by standing, walking, sitting on a
hard surface, using a screw-driver or wearing tight
clothing are itchy, painful or burning and may last up
to 48 h.''
The World Health Organization defines 'disability' as
any restriction or lack of ability to perform an activity
within the range considered normal for a human
being,' while 'handicap' focuses on the disadvantages
to the sufferer in carrying out a role considered normal
for that individual.*' People's feelings and self image are
also important. Quality of life reflects the way an
individual perceives and reacts to health status and to
other non-medical aspects of his or her life.'^ It embraces
physical and emotional well-being and satisfaction with
social functioning.^ The degree of disability and handi-
cap experienced by patients with CU with or without
DPU has not been formally studied. We have documented
the disability, handicap and the impact on the quality of
life of people suffering from CU and from combined CU
and DPU, and have compared our findings with those of
a group of patients suffering from a severe medical
condition.'
Patients and methods
Patients were recruited from the urticaria clinics at St
John's Institute of Dermatology, their usual treatments
having been continued. All who were invited to com-
plete the questionnaires agreed and gave informed
consent. Patients with CU in association with physical
urticarias apart from DPU were excluded. The diagnosis
of DPU was made on the basis of history and clinical
findings and confirmed by positive pressure challenge
tests using a dermographometer or weighted rods.^
Questionnaires
Patients completed the questionnaires in the out-patient
department while awaiting their appointments. The
questionnaires comprised a disease-specific question-
naire which we purpose-designed for urticaria, and a
general health status measure, the Nottingham health
profile (NHP).^'^ We developed the disease-specific ques-
tionnaire after establishing clarity and repeatability on a
group of 20 patients. The questionnaire comprised 40
questions. Answers related to a patient's experiences

1997 British Association of Dermatologists 197

198 B.F.O'DONNELL

during the preceding 4 weeks, to allow for the fluctuat- Results

ing nature of CU and to help patients recall their
symptoms accurately. The questions examined seven Patients
areas: home management, personal care, recreation One hundred and forty-two patients (45 male, 97
and social interaction, mobility, emotional factors, female) had CU± DPU. Sixty-nine patients suffered
sleep and rest, and work. A final question invited the spontaneous wealing and 73 had associated DPU. The
patient's comments on the worst aspect of his or her mean age was 39-7 years (range 1 4 - 7 1 years). The
skin condition. disease had been present for less than 1 year in 30%,
The second questionnaire, the NHP, is a validated^^ 1-5 years in 42% and more than 5 years in 28% of
and reliable^^ health status measure. It was developed patients. The majority of the patients (89%) were white.
in the U.K.^° and is applicable to English-speaking
persons with a minimum reading age of 12 years. ^^
Part I measures subjective health status and requires The disease-specific questionnaire
people to tick yes or no responses to a series of 38 All data refer to the month prior to completing the
statements describing problems experienced 'at the questionnaire.
moment'. The statements relate to limitations in six
dimensions: physical mobility, pain, sleep, energy, social Home management. The home management section
isolation and emotional reactions. Statements in any addressed problems relating to housework, cooking,
given dimension have been weighted relative to each gardening, DIY and whether or not the temperature of
other, ^* and the possible scores for each dimension the house needed adjustment because of the patient's
range from 0 to 100. The higher the score the greater condition. Between 49 and 71% of patients experienced
the limitation in the different life parameters studied or problerns (Table 1).
in the distress experienced. Part II of the NHP examines
seven aspects of daily living: work, looking after the Personal care. Seventy per cent of patients limited their
home, social life, home life, sex life, interests and choice of clothing or footwear because of the provoca-
hobbies, and holidays. Patients respond 'yes' or 'no' tion or aggravation of lesions when tight clothes or
depending on whether that aspect is being affected by shoes were worn. Fifty-seven per cent avoided public
the current state of their health. Part II has no weight- changing rooms on occasions and 24-58% altered the
ings and the results are expressed as the percentage of temperature of the water used for washing. Fifty-four
patients who give an affirmative response. per cent of patients restricted their diet in an effort to
The NHP has been widely employed for different improve their symptoms.
disease conditions^'^^'^^'^^'^^ and the present study
compared findings for urticaria patients with the results Recreation and social interaction. Many patients restricted
of a previous study of 98 males (mean age 51 years, exercise. Social life, specifically going out for a drink or to
range 37-59), awaiting coronary artery bypass graft- dinner, was curtailed. Seventy-three per cent of patients
ing, the majority of whom had three-vessel coronary cancelled invitiations to social events because of their
artery disease.' skin disease. In seventy-three per cent the urticaria
interfered with their sexual relationships (Table 2).
Statistical analysis
Mobility. Mobility was restricted. Some patients always
Descriptive statistics are presented for each of the (12%) or sometimes (43%) shortened the distances they
questions and for the NHP scores. Any patient who
felt that a particular question did not apply to his or Table 1. Home management (percentage affected)
her lifestyle was omitted from the total for that
question. Multiple regression techniques were used Never A little A lot Always
with adjustment for age and sex to examine whether
there are significant differences in disability, handicap Housework (n = 119) 29 42 20 9
and quality of life between CU and CU -I- DPU patients. Cooking (11= 117) 51 29 15 5
Gardening (n = 97) 42 18 28 12
All statistics were computed using the SAS statistical DIY (n = 104) 37 31 19 13
package and any P-value <0-05 was considered statisti- Home heating (n = 118) 38 35 10 17
cally significant.

1997 British Association of Dermatologists, British Journal of Dermatology, 136. 197-201

 CHRONIC URTICARIA AND QUALITY OF LIFE 199

Table 2. Recreation and social interaction (percentage affected)

Not affected Slightly affected Moderately affected Greatly affected

Restriction of
physical activities (ii = 123) 27 22 24 27
going out for dinner/drink (n = 128) 16 26 26 32
invitations cancelled {n = 127) 27 27 22 24

Not at all A little A lot

Interference with sexual relationships (ii = 120) 27 39 34

walked and some patients were always (10%) or some- of their urticaria. The mean nurhber of days lost was 6-4
times (35%) unable to run. Eighteen per cent always (range 1-31 days). Seventy-four per cent of patients
and 42% sometimes avoided prolonged standing. reported that their work performance had deteriorated.

Emotional factors. Urticaria had a negative impact on
our patients' self image and attitude to others. Many felt
less attractive than previously. They felt different from
other people and self conscious and embarrassed. Some
reacted by feeling aggressive and frustrated. Some
avoided other people but very few felt that other people
were avoiding them (Table 3).
The patients also had specific and non-specific anxi-
eties during episodes of urticaria. Sixty-three per cent
complained of non-specific anxiety. Specifically, 46%
worried that their condition would worsen and 42%
were very concerned about the unpredictable nature of
the attacks. Twenty-five per cent of our patients were
afraid that the urticaria was caused by an underlying
more serious disease. Approximately 20% were afraid
they might choke or become unable to breathe.
Sleep and rest. The effect of urticaria on sleeping and on
relaxation was considerable. Thirty-eight per cent repor-
ted marked sleep disruption and a further 54% had some
sleep interference. Daytime relaxation was a major prob-
lem for 50% of patients and 41% reported some difficulty.
Work. Fifty-seven per cent of our patients were working
full-time and 17% had part-time jobs. Of the 103 work-
ing patients 56% lost at least 1 day from work because
The worst aspect of urticaria. The majority of patients
gave more than one answer to the question enquiring
about the worst aspect of their skin disease. The prob-
lems were: the swellings (59%), itch (42%), pain (22%),
and feelings of being tired, irritable, weak or a feeling of
loss of control over their lives (22%). The unpredict-
ability of attacks upset 20%. Other problems were the
social restrictions (18%), feeling embarrassed (13%),
time off work (7%), restriction of food or clothing (7%),
side-effects of drugs (5%) and being unable to relax or sit
(3 •6%).
The Nottingham Health Profile
The scores for part I of the NHP (range 0-100)
confirmed restriction in the areas of mobility (7-1),
pain (15'8), sleep (324), energy (47), social interaction
(13'3) and emotional reactions (29). In Fig. 1 we
compare the NHP scores (part I) of the urticaria patients
with those of patients with those of patients with
ischaemic heart disease. Comparison of the scores
shows that, while limitation of mobility and pain were
more severe in the heart disease patients, sleep disrup-
tion was a greater problem for patients with CU. The
scores for energy, social isolation and emotional reac-
tions were similar in the two patient groups. Part II of

Table 3. Emotional factors (percentage

affected) Not at all Sometimes Definitely

I feel less attractive than I used to (;i = 140) 32 35 33

I feel odd and different (« = 139) 44 35 21
I feel self-conscious and embarrassed (?i = 140) 25 39 36
I feel aggressive/frustrated (ii = 140) 14 28 58
I avoid other people {n = 140) 49 41 10
I feel that other people are avoiding me (n = 138) 84 14 2

© 1997 British Association of Dermatologists. British Journal of Denmtology. 136, 1 9 7 - 2 0 1

200 B.F.O'DONNELL et al.
80 -
70 -
60
Mean 50
score
40 •
30
20
10
I JJ
Mobility Pain Sleep Energy Sociai Emotion
Figure 1. Comparison of the Nottingham Health Profile (part I) scores
in patients with chronic urticaria (CU. H. n = 134) and in patients
with ischaemic heart disease (IHD, • , n = 98) awaiting coronary
artery bypass grafting.'
the NHP showed the percentage of urticaria patients
who were experiencing problems with seven aspects of
daily living: work (40-8%), looking after the home
(40%), social life (51%), home relationships (38-5%),
sex life (47-3%), interests and hobbies (56%), and
holidays (49%). These percentages are overall less
than the results for patients awaiting coronary artery
bypass grafting (70, 61, 56, 34, 67, 74 and 68%,
respectively).^
The impact of delayed pressure urticaria (DPU)
We compared the 69 patients with uncomplicated CU
with those who had concurrent DPU (M — 73). Follow-
ing adjustment for age and sex, patients with DPU were
significantly more limited in the distances they could
walk (P = 0-0001), in their ability to run (P = 0-04)
and in their tolerance of prolonged standing
(P = 0-015) than those with CU only DPU patients
were more restricted in the type of clothing worn
(P = 0-002) and they had significantly more problems
with gardening (P = 0-03). DPU patients had a signifi-
cantly higher NHP pain score (P = 0-002). Finally NHP
part II demonstrated that they had significantly more
problems related to their employment (P = 0-001) and
they were more restricted in the pursuit of interests and
hobbies (P = 0-04) than those patients with CU only.
Discussion
The results of our disease-specific questionnaire highlight
the limitations of activities and psychosocial well-being
experienced because of urticaria. In addition, the questions
inviting the patient's comments on the worst aspect of their
skin disease, emphasized both the symptoms (cutaneous
swellings, itch and pain) as well as the unpredictable nature
of the attacks and the social restrictions. The NHP, part I
showed that urticaria patients suffered considerable loss of
1997 British Association of Dermatologists. British journal of Dermatology. 136, 1 9 7 - 2 0 1
energy, sleep disturbance and emotional upset while part n
showed that between 38-5 and 5 6% experienced difficulties
with seven aspects of daily living. We have shown the
greater problems experienced by patients who suffer from
DPU compared with those who have CU only, in the areas
of mobility, choice of clothing, gardening, employment
and hobbies. They also suffered more pain.
We used the NHP as a measure of general health as it
is shorter and more convenient than the Sickness
Impact Profile. It facilitated the comparison of urticaria
patients with patients who had coronary artery dis-
ease.' Part I of the NHP, regarded as more comprehen-
sive than part 11,^^ shows almost identical scores for
energy, social isolation, and emotional reactions,
between the two groups suggesting that patients with
CU feel similarly lacking in energy, socially isolated and
emotionally upset as the heart disease patients. CU
patients perceived fewer problems with physical mobi-
lity (7-1 vs. 18), had a slightly lower pain score (15-9 vs.
21-9) but their score for sleep disturbance was greater
(32-4 vs. 25-4).
The assessment of quality of life in some dermato-
logical diseases has been addressed by Finlay and
colleagues who developed the dermatology life quality
index,^'' the psoriasis disability index"^^'^' and the atopic
dermatitis disability index.^° Using the Sickness Impact
Profile they showed that psoriatic patients experienced
disability that was at least at a level equivalant to that of
patients with angina or hypertension. However, psoriatic
patients were not as disabled as patients with cardiac
failure.^^
The results of this study highlight the deprivation
suffered by patients with CU ± DPU. Because urticaria is
largely non-life-threatening, and any disfigurement is
temporary, its impact may be underestimated, with impli-
cations for resource allocation decisions. This is illustrated
by the Oregon Health Plan which ranked 745 dermatolo-
gical diseases in order of priority for reimbursement, with
CU listed as 684, below uncomplicated herpes simplex
(654) and well below the cut-off point (606) for the
funding of treatment.^^ However, our results of hospital
out-patients with CU ± DPU indicate that they suffer
considerable disability, handicap and reduction of quality
of life. The impact of CU ± DPU has not previously been
documented but is comparable with that experienced by a
group of older patients with ischaemic heart disease.
Acknowledgments
We acknowledge the support of the Eleanor Naylor
Dana Charitable Foundation, the Dunhill Trust and
 CHRONIC URTICARIA AND QUALITY OF LIFE
the Kieckhefer Foundation. We thank Dr A.Kobza Black
for allowing us to study patients under her care.
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