Chronic Hives (Urticaria)

Hives are an allergic skin reaction characterized by red or white itchy bumps (welts) on the surface of the skin.

You might be having chronic hives, chronic urticaria, if the welts on your skin persist for more than six weeks or come back over months or years.

Though not a serious medical condition, chronic hives can cause significant discomfort and may affect your daily activities.

The cause of chronic hives is not known in most cases or it might appear secondary to an underlying health problem, such as thyroid disease or lupus.

If you have chronic hives, you may try various treatments. However, anti-allergic medications and anti-itch medications are more likely to ease your symptoms. 

The signs and symptoms of Chronic Hives (Urticaria) include:

• Red or white bumps (welts or wheals) on the face, trunk, arms or legs
• Differently sized welts that change shape
• Welts appear and go away frequently as the reaction runs its course
• Severe itching 
• Pain and burning swelling (angioedema), more common inside the throat and around the eyes, cheeks, lips, hands, feet and genitals 
• The signs and symptoms may be triggered by heat, exercise and stress 
• Recurring pattern of the symptoms 

When to see a doctor?

Visit your doctor if you have severe hives that are unresponsive to treatment and persist for longer.

Following signs require emergency care:

• Dizziness
• Severe chest tightness or breathing problems
• Swelling of tongue or throat

The cause of chronic hives may not be clear in all the cases. Release of histamines and other chemicals into your bloodstream in response to certain triggering factors causes hives to appear.

Some triggers for skin reaction include:

• Pain killers
• Insects or parasites
• Infection
• Scratching 
• Heat or cold 
• Stress 
• Exposure to sunlight 
• Exercise 
• Alcohol, food or food additives 
• Pressure on the skin, as from a tight waistband

There is no definitive test to diagnose chronic hives.

If you experience any signs or symptoms of hives, visit your primary care doctor who may refer you to a skin specialist (dermatologist) or to an allergy specialist.

How to prepare yourself for the visit?

Getting prepared for the visit can optimize the therapy and help make the visit more fruitful. List out all the symptoms. Write down your key medical information. Write down the names of all your medications, vitamins or supplements. Ask a friend or a family member to accompany you during the visit.

Make a list of the questions to ask your doctor

Some typical questions can be:

• What could be possible cause of my symptoms?
• How long will the recovery take? 
• What tests are required? 
• Do I need any special preparation for these tests? 
• What are the treatment options and their side effects? 
• Can over-the-counter medications help to ease my condition? 

What your doctor wants to know?

A clear talk with your doctor can optimize the therapy and improve the outcomes. Prepare yourself to answer some essential questions from your doctor.

Your doctor might ask you typical questions like:

• What are your symptoms and when did they start appearing?
• Do your chest or throat feel tight?
• Do you have nausea or breathing problems? 
• Have you had any viral or bacterial infections recently? 
• Have you tried any new foods recently and what about travel to a new place? 
• Do you have a family history of hives or angioedema? 
• Does anything improve or worsen your symptoms?

What you can do in the meantime?

For mild hives, follow these tips to alleviate the symptoms:

• Don’t scratch or do anything that irritates the affected areas.
• Apply a cool cloth or lotion over the affected area.
• Wear loose, light clothing. 
• You may take over-the-counter (OTC) anti-allergic medications.

The diagnosis begins with a physical exam followed by a conversation regarding the condition and probable causes.

Your doctor can suggest you to keep a record of:

• Your activities
• Any medications, herbal remedies or supplements that your taking
• What you eat and drink
• Where hives appear and how long do they persist

Tests

Though there is no definitive test to diagnose chronic hives, your doctor may order tests like:

• Blood tests
• Allergy tests
• Tests to exclude underlying conditions

The first line of treatment for your chronic hives includes using over-the-counter anti-allergic medications (antihistamines) to relieve the symptoms.

No one, not even your doctor knows which medication works for you. So, have patience and keep trying medications under your doctor’s directions.

If your hives do not improve with these, you can ask your doctor about using prescription medications or combination of drugs. Some other treatment approaches are:

Treating underlying causes

If any underlying cause has been identified, treating the cause can provide relief. For example, if hives and inflamed thyroid co-occur, you can benefit from treating the thyroid problem.

Take nondrowsy antihistamines

Antihistamines improves symptoms of hives by blocking the effects of inflammation causing histamine. Older antihistamines can cause drowsiness and impaired attention. Second-generation antihistamines such as loratadine, fexofenadine, cetirizine, levocetirizine, desloratadine do not cause drowsiness. 

Take older antihistamines

You may use older antihistamines such as hydroxyzine, diphenhydramine or chlorpheniramine at bedtime if newer forms do not help. Take special precaution if you are pregnant or breast-feeding, have a chronic medical condition, or are taking other medications.

Consider using other antihistamines

You may also try histamine (H-2) blockers such as cimetidine, ranitidine, nizatidine and famotidine, which are given orally or by injection. Common side effects include digestive problems or headache.

Inflammation lowering medications

Your doctor may recommend short term use of oral corticosteroids, such as prednisone, to reduce swelling, redness and itching. Chronic hives do not generally respond to corticosteroids creams that are applied to the skin. Remember that using corticosteroids for prolonged time can cause serious side effects like weakening your immune system.

Mood lifting medications

Antidepressants such as doxepin may help to relieve itching when applied as a cream on the affected areas.

Discuss if new options work for you. Following drugs have shown promising results in treating resistant chronic hives:

• Drug for asthma: Omalizumab, a drug given by injection is found to have significant success rate in treating resistant forms of chronic hives, without side effects. But you may be concerned about its high cost and non-coverage by insurance.

• Combination of asthma drug and antihistamines: Combination of asthma drugs such as montelukast and zafirlukast, which block the action of substances responsible for asthma symptoms, may be helpful when used with antihistamines.

• Immune suppressing agents: Medications that reduce immune response, such as, cyclosporine, tacrolimus and mycophenolate relieve signs of chronic hives. The most notable side effect of these drugs is an increased risk of infection. If you are pregnant, do not use mycophenolate as it increases the risk of miscarriage and birth defects.

Some alternative remedy approaches that might help alleviate symptoms of chronic hives include:

• Follow diet restrictions, such as avoiding yeast, food additives and other potential allergy-causing substances (allergens)
• Take some supplements, such as vitamins B-12, C and D, fish oil, and quercetin
• Manage stress
• Try acupuncture

Lifestyle modifications are necessary in order to help you prevent or soothe symptoms of chronic hives:

• Wear loose, light clothing.
• Do not scratch or use harsh soaps.
• Apply a cool cloth or lotion over the affected area.
• Record your activities when the hives begin appearing like what you were doing, what you were eating, and so on. This can help detect triggers.
• Stay away from known triggers, such as
  • certain foods or additives,
  • alcohol,
  • pain relievers,
  • heat,
  • cold,
  • exertion,
  • and stress.

There are several risks and complications associated with chronic hives.

Risk factors are:

• Sex: The number of cases in females is double of that in males.
• Age: A young adult is more likely to have chronic hives.

Chronic hives complications include:

• Breathing problems: Swellings inside your mouth or throat can cause breathing problems. If you feel your swelling in tongue or throat, ask for immediate medical care.
• Serious allergic reaction: Seek emergency medical attention if you experience signs of anaphylactic shock (anaphylaxis) or feel dizzy. Anaphylaxis occurs suddenly and affects your heart or lungs causing dangerously low blood pressure and difficulty breathing.

Chronic hives increase your risk of:

• Thyroid disease
• Lupus
• Rheumatoid arthritis
• Sjogren's syndrome
• Celiac disease
• Type I diabetes