I'm wondering which is the cause and which is the effect. I suspect it could be that treatment is often delayed or not given when cutaneous symptoms are absent. That was our experience in the ER with DS (albeit 18 years ago) - his vocal chords were swollen, he was gasping for air and snot was pouring from his nose and mouth like a faucet, but the doctor refused to treat it as an allergic reaction since "he doesn't have hives." 😡 Doctors may be more up-to-date now, but I can't tell you the number of times I've seen/heard lay persons looking for hives as a determination of allergic reaction.