Urticaria (Hives)

Urticaria is a phenomenon in which the skin develops itchy, red or pink blotches. Most people refer to this skin finding as “hives”, and some call the skin blotches “welts”. These itchy areas tend to arise and disappear within a few hours, but others often emerge as the former ones disappear. The cause of urticaria is usually allergic in nature. One example would be an acute episode of hives after a person eats a certain seafood or perhaps strawberries. Most people will get at least one episode of hives in their lifetime.

The vast majority of cases are termed acute urticaria (hives) because they arise and go away within a few days or weeks. That is, the crops of lesions eventually disappear on their own. In these cases, a definite allergic cause can sometimes be found. Examples might include drug reactions, bug bites, certain infections, foods (e.g. seafood), emotional stress, heavy exercise and even extreme changes in temperature. However, there are many times when a cause is not discovered, and health care providers often call this “idiopathic” (which basically means we aren’t sure of the cause).

In some patients, the episodes of urticaria persist for much longer. If urticaria lasts for more than six weeks, doctors refer to the diagnosis as chronic urticaria. Like acute urticaria, an allergic cause might be the trigger. However, the possibility of definitely discovering the trigger in these cases is much less likely. In fact, a specific cause of the hives in cases of chronic urticaria is found in less than 5% of cases.

Treatment Information

Your provider will give you a treatment plan that is individualized, so only some of the following may apply to your specific situation.

In general, medication is prescribed that is directed at reducing the itching associated with hives. Antihistamine medications are the mainstay of treatment. Some of these medicines (e.g. Hydroxyzine (Atarax), Doxepin, Benadryl) can make you drowsy, and you should be aware of this when it comes to driving or performing other activities where concentration is important. In fact, you should not drive within 8 hours of taking sedating antihistamines. There are other antihistamines that work very well and do not cause drowsiness as often. They may also be just as effective. These medicines, however, might be a bit more expensive. Examples include Claritin, Allegra, Zyrtec and Xyzal. These are now available in generic and some are over the counter. In many cases, your provider will prescribe a combination of products for you to use such as one in the morning and a different product at bedtime.

In general, topical medications are less beneficial in urticaria than oral ones. However, topical steroids (such as Triamcinolone, Fluocinonide, Clobetasol, or Elocon) sometimes help with the itching. Aveeno oatmeal bathes and other anti-itch creams are sometimes employed. Other examples of these topical meds include Sarna Lotion (OTC) and Zonalon cream.

For particularly problematic cases, other medications are sometimes added to the patient’s treatment plan. Your doctor can discuss these options with you. Among these are steroids (e.g. Prednisone by mouth or Kenalog by injection), Methotrexate and Azathioprine. In addition, a systemic “biologic agent” called Xolair has provided very promising results, but it is reserved for refractory casesdue to its high cost.

In extremely rare cases, patients get urticaria so badly that they have major symptoms such as difficulty breathing, throat tightening or wheezing. These can be very serious, and you should go to the Emergency Room if these occur.

Do not lose heart if you have urticaria or if the first treatment strategy doesn’t work. There are many options to consider, and your provider will help you get benefit with continued attention to your problem.

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