For most people prone to hives, the welts disappear in 24 hours or less without leaving any bruises or scars. But for some people, the welts don’t disappear in a day — or even a week. Urticaria are defined as chronic when they last longer than six weeks, either continuously or intermittently, according to Mark Aronica, MD, a physician in the department of pulmonary, allergy, and critical care medicine who specializes in asthma and allergic disorders at the Cleveland Clinic in Ohio. Although chronic hives are not generally considered dangerous, their itchiness can negatively impact quality of life. Most cases of chronic hives are idiopathic, with no identifiable cause. Unlike chronic idiopathic urticaria, so-called “inducible” hives can result from certain types of stimulation, such as cold or heat, exercise, sweating, or pressure from something like a bra strap or backpack strap, says Aronica. While people often believe that hives are a response to stress, “Stress can lower the threshold for developing hives, but it’s not the underlying cause,” Aronica says. Even though chronic hives are rarely triggered by allergies, people who have allergies are a little more likely to have an episode of chronic urticaria at some point in their lives, says Aronica. Hives are not contagious; they can’t spread from person to person. But when hives become chronic (lasting longer than six weeks), physicians typically order a comprehensive medical workup that includes a number of lab tests. A physician might perform a skin biopsy or order certain bloodwork if the urticaria are persistent or linked with additional symptoms, such as fever, painful hives, individual hives that last for days at a time, or hives associated with bruising.
Prognosis of Chronic Idiopathic Urticaria
Still, it’s not uncommon for hives to reoccur, even several years later. “When I ask patients if they have a history of hives, it sometimes comes out that they experienced them in childhood, even if it was only for a brief period,” says Aronica. For acute hives and localized urticaria, some patients find relief with topical steroids, but that’s not recommended for chronic hives lasting six weeks or longer, says Aronica. “Topical steroid cream shouldn’t be used for longer than two weeks because it can damage and thin the skin,” he says. Additionally, many patients with chronic urticaria have outbreaks in multiple places on their body. “If you use a topical steroid over large portions of your skin there is some systemic absorption, and that can cause unwanted side effects,” says Aronica. The first-line therapy for patients who are having frequent episodes of chronic hives is a long-acting, nonsedating antihistamine. Many of these medications are available over the counter. These medications include Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Clarinex (desloratadine), and Xyzal (levocetirizine). Successfully managing chronic hives often requires a dose higher than the one printed on the package. Don’t try to figure that out on your own; your provider will recommend the appropriate dose, says Aronica. Histamine (H2) blockers These medications, also called H2 receptor antagonists, are injected or taken orally. Examples include Tagamet HB (cimetidine) and Pepcid (famotidine). Anti-inflammation medications Oral corticosteroids, such as prednisone, can help with symptoms such swelling, discoloration, and itching, but shouldn’t be used long-term. Asthma drugs with antihistamines These medications can help with itching and hives in some people when used together with antihistamines. Examples are Singulair (montelukast) and Accolate (zafirlukast). Monoclonal antibodies The drug Xolair (omalizumab) may be used for a type of difficult-to-treat chronic hives. It’s an injectable medicine usually given once a month. Immune-suppressing drugs These include cyclosporine, methotrexate, and tacrolimus and are usually limited to short-term use.
Diet Options
Some patients with chronic urticaria opt to follow a low-histamine diet, says Aronica. “I tell them if that helps them, that’s fine with me. The data is a little mixed, but it is something our guidelines suggest people can try,” he says. A low-histamine diet is one that avoids or limits foods have higher levels of histamine, such as seafood, fermented foods (aged cheeses, dry sausage, fermented soy), tomatoes, eggplant, spinach, and avocado. Once the symptoms improve, the person doesn’t necessarily have to continue avoiding those foods, notes Aronica.
Alternative and Complementary Therapies
Vitamin D “There is some evidence that there may be slightly higher risk of chronic urticaria in people with vitamin D deficiency. In some cases, if you address the deficiency, the hives may improve,” says Aronica.
NSAID medications, including ibuprofen, naproxen, and aspirin, and any type of narcotic (opioid) medication Talk with your healthcare provider about other drugs that can help you cope with pain.Alcohol Avoiding alcohol may improve your chronic hives.Lack of sleep Doctors recommend that adults get an average of 7 to 9 hours of sleep per night.Stress Lowering your stress level may help with your hives.
Wear clothing that is loose and light.Avoid soaps or lotions with harsh chemicals.Take a soothing bath and follow it up with fragrance-free lotion or anti-itch cream.
Severe angioedema can be a complication of chronic urticaria. “Although it’s exceedingly rare, very severe cases of urticaria angioedema may cause swelling in the inside of the throat, windpipe, and the tongue, which causes difficulty breathing and could be life-threatening,” says Aronica. He adds that chronic urticaria angioedema is much less likely to be life-threatening than anaphylaxis. “I rarely prescribe EpiPens for my patients with urticaria angioedema unless they are concerned or if they’ve had a throat-swelling episode. For most people with chronic urticaria, it’s a skin-only manifestation,” he says. Depression and anxiety Although chronic hives may not be life-threatening, the condition is very uncomfortable and may be highly visible, which can cause a patient to experience high levels of emotional distress, says Aronica.
The Skin of Color Society
This nonprofit works to increase awareness of dermatological issues as they impact people of color. A “Find a Doctor” database helps people with skin of color — including Black Americans, Asians, Hispanics or Latinos, Native Americans, and Pacific Islanders — connect with a clinician who is right for them.
