Cholinergic Urticaria - Clinical Significance in Athletes and Physically Active Individuals: A Narrative Review

Abstract

Introduction. Cholinergic urticaria (CholU) is a subtype of chronic inducible urticaria triggered by increases in core body temperature and sweating. Its trigger profile, encompassing exercise, passive warming, emotional stress, and hot environments, renders it particularly relevant to athletes and physically active individuals, in whom these stimuli are frequent and often unavoidable.

Purpose. This narrative review aimed to summarize current evidence on the clinical significance, diagnostic challenges, differential diagnosis, and practical management of cholinergic urticaria in athletes and physically active populations.

Current knowledge. CholU predominantly affects young adults and involves heterogeneous pathophysiological mechanisms, including mast cell activation, sweat hypersensitivity, and acetylcholine-mediated pathways. In athletes, recurrent symptoms such as wheals, pruritus, and burning sensations may interrupt training, reduce exercise tolerance, and impair psychological well-being. Diagnosis relies on provocation testing, while differential diagnosis must exclude exercise-induced anaphylaxis, food-dependent exercise-induced anaphylaxis, and other inducible urticarias. Management centers on second-generation antihistamines, trigger modification, and, in refractory cases, omalizumab, which has enabled some patients to resume full athletic participation.

Conclusions. CholU poses a distinct and underrecognized burden in physically active individuals. Individualized management combining pharmacotherapy with exercise modification can allow most patients to maintain safe participation in physical activity, though further research is needed to optimize treatment strategies.