Hives are a skin reaction that causes red or white itchy welts. The welts vary in size and appear and fade repeatedly as the reaction runs its course.

Chronic hives are a condition in which the welts last more than six weeks or recur over months or years. Chronic hives usually aren't life-threatening. But the condition can be very uncomfortable and interfere with sleep and daily activities.

Often, the cause of chronic hives is not clear. In some cases, chronic hives are a sign of an underlying health problem, such as thyroid disease or lupus.

You can try various treatments to relieve your symptoms. For many people, antihistamine and anti-itch medications provide relief from chronic hives.

Chronic hives are also called chronic urticaria (ur-tih-KAR-e-uh).

Chronic hives signs and symptoms include:

  • Batches of red or white welts (wheals), usually on the face, trunk, arms or legs
  • Welts that vary in size, change shape, and appear and fade repeatedly as the reaction runs its course
  • Itching, which may be severe
  • Swelling that causes pain or burning (angioedema), especially inside the throat and around the eyes, cheeks, lips, hands, feet and genitals
  • A tendency for signs and symptoms to flare with triggers such as heat, exercise and stress
  • A tendency for symptoms to recur frequently and unpredictably, sometimes for months or years

When to see a doctor

See your doctor if you have:

  • Severe hives
  • Hives that don't respond to treatment
  • Hives that continue to appear for several days

Seek emergency care if you:

  • Feel dizzy
  • Have severe chest tightness or trouble breathing
  • Feel your tongue or throat swelling

The welts that come with hives arise when certain cells release histamine and other chemicals into your bloodstream.

Doctors often can't identify the reason for this skin reaction, or why it sometimes turns into a long-term problem (chronic hives). But the skin reaction may be triggered by:

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

Factors that increase your risk of developing chronic hives include:

  • Being female, as women are affected twice as often as men
  • Being a young adult

Chronic hives complications include:

  • Difficulty breathing. When swelling occurs inside your mouth or throat, you may have difficulty breathing and pass out. Seek emergency medical care if you feel your tongue or throat swelling.
  • Serious allergic reaction. Anaphylactic shock (anaphylaxis) is a serious allergic reaction involving your heart or lungs. Your bronchial tubes narrow, it's difficult to breathe, and your blood pressure drops. You may feel dizzy, pass out or even die. Anaphylactic shock happens fast. Seek emergency medical care if you feel this type of allergic reaction coming on.

People with chronic hives may be at increased risk of developing these immune system disorders:

  • Thyroid disease
  • Lupus
  • Rheumatoid arthritis
  • Sjogren's syndrome
  • Celiac disease
  • Type 1 diabetes

You'll probably first visit your primary care doctor. But he or she may then refer you to a doctor who specializes in skin diseases (dermatologist) or to an allergy specialist.

Preparing a list of questions will help you make the most of your time with your doctor. For chronic hives, some basic questions to ask your doctor include:

  • What is likely causing 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?
  • Do I need prescription medication, or can I use over-the-counter medications to treat the condition?
  • Does the medicine you're prescribing me have a generic version?
  • I have other health problems. Is the treatment you recommend compatible with those conditions?

What to expect from your doctor

Your doctor is likely to ask you questions such as:

  • What symptoms do you have, and when did you first begin experiencing them?
  • Do you have tightness in your chest or throat, nausea, or difficulty breathing?
  • Have you had any viral or bacterial infections recently?
  • What medications, herbal remedies and supplements do you take?
  • Have you tried any new foods recently?
  • Have you traveled to a new place?
  • Do you have a family history of hives or angioedema?
  • What, if anything, appears to improve or 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 the affected areas.
  • Cool the affected area with a shower, fan, cool cloth or soothing lotion.
  • Wear loose, light clothing.
  • Use over-the-counter antihistamines to help relieve the itching.

Your doctor will do a physical exam and ask you a number of questions to try to understand what might be causing your symptoms. He or she may also ask you to keep a diary to keep track of:

  • Your activities
  • Any medications, herbal remedies or supplements you take
  • What you eat and drink
  • Where hives appear and how long it takes a welt to fade

Tests

It isn't always possible to determine the underlying cause of chronic hives. If the first-choice therapies haven't worked for you, your doctor may order one or more tests, including:

  • Blood tests
  • Allergy tests, though only if your medical history and food diary haven't helped identify the cause of your hives
  • Tests to rule out underlying conditions

Your doctor will likely recommend you treat your symptoms with home remedies, such as over-the-counter antihistamines. If self-care steps don't help, talk with your doctor about finding the prescription medication or combination of drugs that works best for you.

Treat any underlying factors causing your symptoms. If your doctor can determine that your hives are caused by another condition, he or she will first try to treat that. For example, people with chronic hives and inflamed thyroid (thyroiditis) may best be helped by treating the thyroid problem.

Take nondrowsy forms of antihistamine pills. Taking antihistamines pills daily helps block the symptom-producing release of histamine. The newer forms of the drugs (second-generation antihistamines) have fewer side effects, such as drowsiness, than older antihistamines:

  • Loratadine (Claritin, Alavert)
  • Fexofenadine (Allegra)
  • Cetirizine (Zyrtec)
  • Levocetirizine (Xyzal)
  • Desloratadine (Clarinex)

Take older forms of antihistamine pills. If the newer antihistamines don't help you, your doctor may recommend you take an older form of the drug, but only before bedtime, as it can make you drowsy. Examples include:

  • Hydroxyzine (Vistaril)
  • Diphenhydramine (Benadryl)
  • Chlorpheniramine (Chlor-Trimeton)

Check with your doctor before taking any of these medications if you are pregnant or breast-feeding, have a chronic medical condition, or are taking other medications.

Try other medications. If antihistamines alone don't relieve your symptoms, other drugs that may help include:

  • Histamine (H-2) blockers. These medications, also called H-2 receptor antagonists, may be injected or taken orally. Examples include cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid) and famotidine (Pepcid). Side effects range from digestive problems to headache.
  • Anti-inflammation medications. Oral corticosteroids, such as prednisone, can help lessen swelling, redness and itching. These usually are used only for a short time to control severe hives or angioedema because they can cause serious side effects.

    Corticosteroids creams applied to the skin usually aren't effective for chronic hives. Corticosteroids can weaken your immune system, making it easier for you to get an infection or worsening an infection you already have.

  • Antidepressants. The tricyclic antidepressant doxepin (Zonalon), used in cream form, can help relieve itching. This drug may cause dizziness and drowsiness.

Ask about other options. Several medications under study show promise for people whose chronic hives resist treatment:

  • An injectable asthma drug. Several studies show the drug omalizumab (Xolair) is very effective against difficult-to-treat chronic hives, without side effects. But it is more costly than other options and is not usually covered by insurance.
  • Asthma drugs with antihistamines. Medications that interfere with the action of leukotriene modifiers may be helpful when used with antihistamines. Examples are montelukast (Singulair) and zafirlukast (Accolate). Side effects may include behavior and mood changes.
  • Cyclosporine. The drug cyclosporine (Gengraf, Neoral, others) affects the immune system and provides relief from chronic hives. Possible side effects range from headache and nausea to an increased risk of infection and reduced kidney function.
  • Tacrolimus. Similar to cyclosporine, this drug reduces the immune system response that causes hives. And it, too, may cause a range of side effects, from minor to serious.
  • Mycophenolate. This immune-suppressing drug also improves hives signs and symptoms. But for pregnant women, it increases the risk of miscarriage and birth defects.

The following precautions may help prevent or soothe the recurring skin reactions of chronic hives:

  • Wear loose, light clothing.
  • Avoid scratching or using harsh soaps.
  • Cool the affected area with a shower, fan, cool cloth or soothing lotion.
  • Keep a diary of when and where hives occur, what you were doing, what you were eating, and so on. This may help you and your doctor identify triggers.
  • Avoid known triggers, such as certain foods or additives, alcohol, pain relievers, heat, cold, exertion, and stress.

More study is needed, but some evidence supports the following alternative medicine approaches for providing relief of symptoms:

  • Diet restrictions, such as eliminating yeast, food additives and other things that may cause the skin reaction (allergens)
  • Supplements, such as vitamins B-12, C and D, fish oil, and quercetin
  • Relaxation techniques
  • Acupuncture, sometimes with an herbal wash of burdock
Jun. 13, 2014