Chronic hives (urticaria)
Filed under: Beauty & Plastic Surgery
Chronic hives, also known as urticaria, are batches of raised, red or
white itchy welts (wheals) of various sizes that appear and disappear.
While most cases of hives go away within a few weeks or less, for some
people they are a long-term problem. Chronic hives are defined as hives
that last more than six weeks or hives that go away, but recur
In most cases of chronic hives, a cause is never clearly identified. In
some cases, chronic hives may be related to an underlying autoimmune
disorder, such as thyroid disease or lupus.
While the underlying cause of chronic hives is usually not identified,
treatment can help with symptoms. For many people, antihistamine
medications provide the best relief.
* Appear as small round wheals, rings or large patches and may change shape
* Itch and may be surrounded by a red flare
* Occur in batches, and often appear on the face or the extremities
Individual hives can last from 30 minutes to 36 hours. As some hives disappear, new hives may develop.
About 40 percent of people with chronic hives also have angioedema.
Signs and symptoms of angioedema include large welts or swelling of the
skin that may occur around the eyes and lips, hands, feet, genitalia and
inside the throat. Swelling in the throat can obstruct breathing and
requires emergency treatment. Angioedema may itch less than hives do,
but can cause pain or burning.
Symptoms may not occur all the time. They may come and go with no
apparent trigger. For some people certain conditions, such as heat,
exertion or stress, can make symptoms worse.
When to see a doctor
Although chronic hives and angioedema usually aren't life-threatening,
they can be debilitating — and in some cases are a sign of an underlying
See your doctor if you have:
* Severe hives
* Hives that don't respond to treatment
* Hives that continue to appear for more than a couple of days
Seek emergency care if you:
* Feel lightheaded
* Have difficulty breathing
* Feel your throat is swelling
Chronic hives are an inflammation of the skin triggered when certain
cells (mast cells) release histamine and other chemicals into your
bloodstream, causing small blood vessels to leak. The exact cause of
chronic hives isn't well understood — and triggers can be difficult to
pinpoint. Chronic hives are thought to be caused by an immune system
(autoimmune) disorder and may be linked to another health problem, such
as thyroid disease or lupus.
Rarely, a reaction to medication, food, food additives, insects,
parasites or infection is identified as an underlying cause of chronic
hives. But in most cases, the cause of chronic hives is never identified
even after testing and monitoring symptoms. Heat, cold, pressure,
sunlight or other environmental stimuli may worsen chronic hives.
Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin,
others), also can worsen chronic hives.
Complications of hives and angioedema may include:
* Itching. Hives and angioedema can cause itching and discomfort.
* Difficulty breathing. In more-serious cases — when swelling occurs
inside your mouth or throat — complications can include difficulty
breathing, leading to a loss of consciousness. If you have a swollen
throat, seek medical care immediately.
* Anaphylactic shock (anaphylaxis). This is a serious allergic
reaction involving your heart or lungs that can also be associated with
hives and angioedema. Your bronchial tubes narrow, it's difficult to
breathe, and your blood pressure drops, causing dizziness and perhaps
loss of consciousness or even death. Anaphylactic shock occurs rapidly
and requires immediate medical care.
Preparing for your appointment
You'll probably first visit your family doctor or a general
practitioner. However, you may then be referred to a doctor who
specializes in allergic disease.
Because appointments can be brief, and there's often a lot of ground to
cover, it's a good idea to be well prepared for your appointment. Here's
some information to help you get ready for your appointment, and what
to expect from your doctor.
What you can do
* Write down any symptoms you're experiencing, including any that
may seem unrelated to the reason for which you scheduled the
* Write down key personal information, including any major stresses or recent life changes.
* Make a list of all medications, vitamins and supplements you're taking.
* Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions
ahead of time will help you make the most of your time together. List
your questions from most important to least important in case time runs
out. For chronic hives, some basic questions to ask your doctor include:
* What's the most likely cause of my symptoms?
* Are there other possible causes for my symptoms?
* How long will these hives last?
* What kinds of tests do I need? Do these tests require any special preparation?
* What treatments are available, and which do you recommend?
* Do these treatments have any side effects?
* Is there a generic alternative to the medicine you're prescribing me?
* I have other health problems; are the recommended treatments compatible?
* Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend?
In addition to the questions that you've prepared to ask your doctor,
don't hesitate to ask questions during your appointment at any time that
you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to
answer them may reserve time to go over any points you want to spend
more time on. Your doctor may ask:
* When did you first begin experiencing symptoms?
* Have you taken any new medications recently?
* Have you tried any new foods?
* Have you traveled to a new place?
* Does anything seem to improve your symptoms?
* What, if anything, appears to worsen your symptoms?
What you can do in the meantime
If you're experiencing mild hives, these tips may help relieve your symptoms:
* Avoid irritating affected areas.
* Cool the affected area with a shower, fan, cool cloth or soothing lotion.
* Wear loose, light clothing.
* Minimize vigorous activity, which can release more irritants into your skin.
* Use over-the-counter antihistamines to help relieve the itching.
Tests and diagnosis
Physical exam and medical history
Your doctor will ask you a number of questions and do a physical exam.
Your doctor also may ask you to keep a diary to keep track of:
* Your activities
* Any medications or herbal supplements you take
* What you eat and drink
* Where hives appear and how long individual hives last
Although it isn't always possible to determine the underlying cause of
chronic hives, your doctor will want to learn as much as possible about
what might be causing your symptoms. Depending on your symptoms and
medical history, your doctor may order one or more tests, including:
* Blood tests. Your doctor may ask for blood tests to check for levels and function of specific blood cells and proteins.
* Allergy tests. Your doctor may use skin or blood tests to see
whether your hives may be caused by an allergic reaction, especially if
the hives seem related to specific triggers.
* Tests to rule out underlying conditions. You may need additional
tests to make certain your hives are not caused by an underlying health
condition, such as hepatitis or thyroid disease.
Treatments and drugs
Finding an effective treatment for chronic hives can be challenging. In
cases in which a trigger is identified — such as a reaction to a certain
food, medication or physical stimulus — treatment includes avoiding the
trigger. If your chronic hives are caused by an underlying health
condition, they may improve when the underlying condition is treated.
Symptoms can be treated effectively in most people with over-the-counter
or prescription medications. Work with your doctor to find the
medication — or combination of medications — that works best for you. If
the first medication you try doesn't relieve your symptoms, talk to
your doctor about trying something else.
These medications block the symptom-producing release of histamine,
controlling symptoms for the majority of people with chronic hives — but
they do not treat the underlying cause of the rash. You may need to
take antihistamines every day. Some of these medications are available
over-the-counter, whereas others require a prescription. A combination
of antihistamines may work best.
Your doctor may have you start with newer, nonsedating or low-sedating antihistamines, such as:
* Loratadine (Claritin)
* Fexofenadine (Allegra)
* Cetirizine (Zyrtec)
* Levocetirizine (Xyzal)
* Desloratadine (Clarinex)
Check with your doctor before taking any of these medications if you're
pregnant, have a chronic medical condition or are taking any other
If a nonsedating antihistamine doesn't work, your doctor may recommend
taking a different type of antihistamine. These antihistamines, which
can make you drowsy, include:
* Hydroxyzine (Vistaril)
* Diphenhydramine (Benadryl, others)
* Chlorpheniramine (Chlor-Trimeton)
If antihistamines alone don't relieve your symptoms, other possible treatments include:
* H2 antagonists. These medications, such as cimetidine (Tagamet),
ranitidine (Zantac) and famotidine (Pepcid AC), can be used along with
* Oral corticosteroids. Oral corticosteroids, such as prednisone,
can help lessen swelling, redness and itching — but are usually used
only a short term for severe hives or angioedema because they can cause
serious side effects. Topical corticosteroids usually aren't effective
for chronic hives.
* Tricyclic antidepressants. The tricyclic antidepressant doxepin
(Zonalon) has antihistamine properties and can help relieve itching.
* Epinephrine. For a severe attack of hives or angioedema, you may
need an emergency injection of adrenaline (epinephrine) and a trip to
the emergency room. If you have repeated attacks, despite treatment,
your doctor may prescribe — and instruct you how to use — injectable
adrenaline (EpiPen) to carry with you for use in emergency situations.
Other medications are still being studied to determine whether they may be useful for treating chronic hives. These include:
* Leukotriene receptor antagonists. Montelukast (Singulair) is the
only medication of this type currently available in the United States.
This type of medication may be helpful when used along with
* Cyclosporine. This immune system suppressant can help with
symptoms, but it can cause serious side effects and needs to be
* Omalizumab (Xolair). This medication is normally given by
injection to treat allergic asthma. It may help people who have chronic
hives caused by an autoimmune response that haven't been helped by
antihistamines. Only very small studies have been completed, so more
clinical trials are needed.
The following precautions may help prevent hives and angioedema:
* Avoid known triggers. These may include certain foods or food
additives, alcohol, medications or situations such as temperature
extremes, tight clothing or emotional stress.
* Keep a diary. Track all of your activities, when and where hives
occur, and what you eat. This may help you and your doctor identify
* Avoid medications that may trigger hives. These include aspirin,
nonsteroidal anti-inflammatory drugs (NSAIDs), codeine or any other
medication that you've noticed can trigger your hives.