Diagnostic utility of challenge procedures for physical urticaria/angioedema syndromes: a systematic review

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Purpose of review

Physical urticaria/angioedema syndromes (PUAs) are commonly encountered. They are identified by a history of physical factors provoking cutaneous symptoms, and confirmed by provocation testing. Recent guidelines have recommended use of challenge procedures for diagnosis; however, their positive/negative likelihood ratios have not been established.

Recent findings

We conducted a systematic review to determine the diagnostic utility of recommended office procedures for three common PUAs: dermatographia (DERMATO), cholinergic urticaria (CHOL), and delayed pressure urticaria/angioedema (DPUA). In this study, we were unable to identify studies of sufficient methodologic quality to calculate positive/negative likelihood ratios for recommended diagnostic challenges for PUAs.


The study highlights the need for well designed studies to aid the clinician in interpretation of diagnostic challenges for patients with DERMATO, CHOL, and DPUA. There are limited high-quality data available to support the diagnostic utility of office challenges for PUAs. There is a low sensitivity associated with methacholine intradermal challenge for confirming a diagnosis of CHOL.

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