Persistence, chronicity, and recurrence of infection-associated urticaria following viral infections in children and adults: a systematic review.

Background: Viral infections are recognized triggers of acute urticaria; however, the long-term outcomes of infection-associated urticaria, including persistence, recurrence, and progression to chronic disease, remain incompletely characterized. Objective: To systematically review the available evidence on the persistence, chronicity, and recurrence of infection-associated urticaria following viral infections in children and adults. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420261319656). Electronic databases (PubMed, Embase, CINAHL, Scopus, and Web of Science) were searched from inception to 17 March 2026. Observational studies reporting long-term outcomes of infection-associated urticaria following viral infection were included. Data extraction and risk of bias assessment using the Newcastle-Ottawa Scale were performed independently by two reviewers. Due to substantial heterogeneity, findings were synthesized narratively. Results: Five studies involving 596 participants were included. Most cases of infection-associated urticaria occurred during the acute phase of infection and resolved within weeks to months. However, persistence beyond 6 months was reported in up to 9.5% of cases, and a small proportion demonstrated persistent symptoms extending beyond 1 year. Reported recurrence and chronicity rates ranged from approximately 7% to 30%, although several estimates were derived from mixed-etiology cohorts in which infection-related cases were not analyzed separately. Delayed-onset urticaria, particularly following SARS-CoV-2 infection, was associated with an increased likelihood of progression to chronic spontaneous urticaria. However, interpretation is limited by the inclusion of mixed-etiology cohorts in which viral infection was not always laboratory-confirmed or analyzed separately. Conclusion: Infection-associated urticaria is typically self-limiting; however, a small but potentially clinically relevant subset of patients may develop persistent or chronic symptoms. Recognition of potential risk patterns, particularly delayed-onset urticaria in the context of SARS-CoV-2 infection, may support improved patient counselling and follow-up. Current evidence remains limited by heterogeneous study designs, mixed aetiologies, and inconsistent pathogen-specific reporting. Further prospective studies with standardized definitions and pathogen-specific analyses are needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=1319656, identifier CRD420261319656.