Urticaria

Several factors can increase the likelihood of developing acute or chronic hives, including:

• Allergic reactions, whether they are pre-existing or newly acquired.
• A personal history of hives.
• Family history of hives, especially hereditary angioedema (though rare).
• A known condition linked to hives, such as infections (e.g., urinary tract infections, strep throat, hepatitis, rheumatoid arthritis, or type 1 diabetes).
• Viral infections.
• Certain medications, including codeine, aspirin, morphine, and NSAIDs.
• Skin sensitivity or dermatitis (skin inflammation).
• Sensitivities to chemicals, colors, perfumes, or disinfectants.
• Emotional factors, including stress and anxiety.

Urticaria can be diagnosed by various medical professionals, although family doctors are typically the first to assess the condition.

Physical Examination

A dermatologist usually diagnoses hives through a physical exam. However, there are no specific tests to identify hives in most cases, as many triggers are nonspecific or idiopathic. If a particular trigger, such as a medication, is suspected, and the hives resolve after discontinuing the drug, this can confirm it as the cause. If symptoms persist despite stopping the medication, it is less likely to be the cause.

During the examination, the doctor will take a detailed medical history and discuss symptoms to pinpoint the underlying cause, such as an allergy, followed by a thorough physical check-up.

Questions that may be asked include:

• How long have you been experiencing symptoms?
• How did the skin marks appear initially?
• Have they changed in size or shape over time?
• Have certain factors improved or worsened your symptoms before the visit?
• Do the skin marks cause any irritation, burning, or stinging sensations?
• Have the marks disappeared without leaving a trace, like bruising?
• Have you been tested for allergies, and if so, which ones?
• Have you experienced a similar skin issue in the past?
• Have you eaten anything new recently?
• Have you used any new cleaning products?
• Have you been bitten or stung by an insect recently?
• Are you on any new medications (including over-the-counter or supplements)?
• Have you introduced any new pets into your home?
• Is there a family history of similar skin problems?

Allergy Test

The doctor may perform a physical examination and evaluate the current skin marks. If allergies are suspected, a skin prick test can identify the specific chemical causing the reaction. If urticaria occurs soon after consuming certain foods like shellfish or peanuts, or exposure to sun or water, the allergen is easier to identify.

Once a trigger is identified, the doctor will recommend avoiding exposure to the allergen or related substances. In some cases, the doctor may conduct an oral food or drug test where the patient is given a controlled amount of the suspected allergen to provoke a reaction, under careful observation with emergency measures in place. However, these tests are avoided if there is a high risk of severe reactions, like anaphylaxis.

Blood Tests

Blood tests may be recommended to check for underlying conditions that could trigger hives or to analyze specific proteins, which could indicate a genetic predisposition (such as hereditary angioedema). Occasionally, a urine sample may also be collected.

Note: Blood tests are typically unnecessary for acute urticaria (lasting less than 6 weeks).

For chronic urticaria, the following tests may be suggested:

• Complete blood count (CBC): To check for anemia or infection signs.
• Thyroid function tests: To assess if the thyroid is overactive or underactive (hyperthyroidism or hypothyroidism).
• Liver function tests: To check for liver conditions.
• Erythrocyte sedimentation rate (ESR): To detect immune system abnormalities.
• Stool test: To check for parasitic infections.
• Antinuclear antibody (ANA) test: To rule out autoimmune conditions like lupus.
• Angioedema tests: A C1 esterase inhibitor test and complement levels (C2 and C4) to detect deficiencies that might lead to edema and inflammation.

Solar Hives (Urticaria) Test

• Photo-testing: This test involves exposing the skin to UV radiation from a sun lamp with varying wavelengths to identify which wavelength causes a reaction.
• Patch testing: Suspected irritants are applied to the skin under a patch for 24-48 hours. The skin is then exposed to UV light. If a reaction occurs, solar hives can be confirmed.

Cholinergic Hives Tests

• Exercise challenge test: The patient may be asked to exercise to provoke a reaction, and various metrics will be measured.
• Passive warming test: The doctor may increase the body temperature using warm water or ambient heat to induce a response.
• Methacholine skin test: This test uses methacholine to stimulate the parasympathetic nervous system and provoke a potential response.

Other Tests

• Imaging studies: Generally unnecessary unless prompted by specific symptoms or signs.
• Punch biopsy: May be recommended if urticarial vasculitis (inflammation of blood vessels) is suspected.

Extensive testing is typically not advised for minor or isolated hive outbreaks. Chronic hives are rarely caused by allergies, so other underlying causes, such as autoimmune diseases, are usually explored.

Lifestyle modifications that help prevent or reduce hives flare-ups are generally the most effective approach. Complete prevention is not always possible, but avoiding known triggers (e.g., foods, medications, pets) can help manage outbreaks. If the cause is unknown and flare-ups are frequent, tracking patterns between potential causes and reactions (such as food or environmental exposure) may help identify and avoid triggers.

For solar hives, reducing sun exposure during peak hours (10 am - 4 pm) and gradually increasing outdoor time in spring or autumn may help. Wearing loose, light clothing that provides full coverage, as well as clothing with a UPF rating of at least 40, can offer protection. Also, applying broad-spectrum sunscreen as recommended by your doctor is crucial.

Managing stress is key, as emotional triggers can provoke hives. Effective stress-management practices like regular exercise, meditation, and mindfulness can be beneficial.

Avoid harsh soaps and skin care products that may irritate the skin. Use mild, fragrance-free soaps designed for sensitive skin. For moisturizing, opt for gentle, non-irritating creams, and apply them shortly after washing to alleviate itching.

Sunglasses, broad-brimmed hats, and umbrellas can also provide protection from sun exposure.

Specialists to Consult

In most cases, urticaria can be managed with over-the-counter medications and lifestyle changes. However, if the hives are persistent, unusual, or worsen over time, it is important to consult a doctor. If the symptoms last for more than six weeks or reoccur regularly, seek medical attention to determine the cause and receive appropriate treatment.

The following specialists may be helpful in managing urticaria:

• Dermatologist
• Rheumatologist
• Immunologist
• Internist
• Allergist
• Pediatrician (for children)

If the symptoms are mild, treatment may not be necessary, as hives and angioedema can often resolve on their own. However, for severe itching, discomfort, or prolonged symptoms, treatment can offer relief.

Medications

Prescription medications, as listed below, are commonly used to manage hives and angioedema.

Anti-itch medications (antihistamines)

Non-drowsy antihistamines are the standard treatment for hives and angioedema, forming the first line of therapy for urticaria patients.

Some H1 antihistamines that cause drowsiness include:

• Chlorpheniramine
• Chlorpheniramine Maleate
• Hydroxyzine
• Diphenhydramine

Non-sedating second-generation H1 antihistamines include:

• Loratadine
• Cetirizine
• Terfenadine
• Mizolastine

Second-generation H1 antihistamines also include:

• Desloratadine
• Levocetirizine
• Fexofenadine

H2 antihistamines like:

• Cimetidine
• Ranitidine
• Famotidine
• Nizatidine

Treatment generally starts with a non-sedating antihistamine during the day and a sedating one at night. All antihistamines are equally effective when taken at the recommended dose. If patients don’t respond to the standard dosage, increasing the dose of non-sedating antihistamines is a common next step.

If indigestion or acidity is reported, H2 antihistamines may be used. Combination therapy can sometimes provide better results, with fexofenadine showing superiority in some trials over generic levocetirizine. However, approximately 40% of patients may not respond to these combinations, necessitating the use of second-line treatments.

Anti-inflammatory medications

In some cases, a doctor may prescribe oral corticosteroids, such as prednisone, to reduce swelling, redness, and itching associated with severe hives or angioedema.

Immune-suppressing medications

If antihistamines and corticosteroids prove ineffective, doctors may opt for immune-suppressing medications to help control an overactive immune system.

Emergency situations

Acute urticaria can quickly progress to severe angioedema and/or anaphylactic shock. Anaphylaxis typically manifests as rapid-onset shock without accompanying urticaria or angioedema.

In the event of a severe outbreak, a visit to the emergency department and an epinephrine injection (adrenaline) may be required. For individuals with recurring severe episodes, doctors may recommend carrying an epinephrine autoinjector for emergencies.

If bronchospasm is present, nebulized albuterol may be necessary. Continuous monitoring with ECG, blood pressure, and pulse oximetry is often required, along with intravenous crystalloids if the patient is hypotensive and supplemental oxygen as needed.

Urticaria can sometimes lead to anaphylaxis, one of the most severe complications. Anaphylaxis is an intense allergic reaction that can be fatal. It typically occurs rapidly after exposure to allergens like peanuts or insect stings.

The reaction is caused by the release of chemicals by the immune system, which can lead to shock. The signs of anaphylaxis include:

• Rapid, weak pulse
• Skin rash
• Nausea and vomiting
• Swelling in the throat, potentially blocking the airways

Common anaphylaxis triggers include certain foods, medications, insect venom, and latex.

Home remedies for urticaria include:

1. Cold compress: A cold compress can effectively soothe irritated skin.
2. Oatmeal scrub: Oatmeal’s anti-inflammatory properties make it a good option for calming inflamed skin. A lukewarm shower with oatmeal soap or a baking soda scrub may help.
3. Aloe vera gel: Aloe vera’s antibacterial properties make it an effective treatment for redness and discomfort associated with hives.

Ayurvedic treatment

To manage urticaria with Ayurvedic remedies:

1. Take a paste made from neem leaves, guduchi (giloy) leaves, or aloe vera pulp daily in a dose of 5 to 7 grams.
2. Consume 1 teaspoon of turmeric powder two to three times daily with milk or water to strengthen the immune system.
3. Massage mustard oil into the skin for 15 minutes before bathing in lukewarm water.
4. Mix ½ teaspoon of black pepper with ½ teaspoon of desi ghee and consume it first thing in the morning on an empty stomach for up to three months.

For mild cases of hives or angioedema, the following home remedies may provide symptom relief:

• Avoid known triggers: Steer clear of foods, medications, pollen, pet dander, latex, and insect bites.
• Over-the-counter anti-itch medications: Antihistamines such as loratadine, cetirizine, and diphenhydramine can help alleviate itching.
• Cool compress: Applying a cold, damp cloth to the affected area can soothe irritated skin and help reduce scratching.
• Cool baths: A cold bath or shower can provide relief from itching. Adding oatmeal or baking soda to the bath may also be helpful, although this is not a long-term solution for chronic itching.
• Comfortable clothing: Wearing loose-fitting, smooth-textured cotton clothes can help prevent skin irritation.
• Avoid sun exposure: Stay in the shade to prevent aggravating rashes and itching.

Around 20% of the population experiences hives, which are typically caused by an allergic reaction to food or medication. They usually subside quickly.

While hives can be itchy and unpleasant, they can also affect emotional well-being by isolating individuals socially and affecting their ability to work or study. Chronic idiopathic urticaria (CIU) or chronic spontaneous urticaria (CSU) occurs when new outbreaks appear frequently, lasting for over six weeks. It affects less than 1% of the population, with those aged 20-40 being most at risk. These outbreaks usually resolve within 24 hours, but new hives often develop after that.

Urticaria vs. Contact Dermatitis vs. Insect Bites

Though the terms are often confused, they refer to distinct conditions:

• Hives (urticaria): Raised, itchy welts caused by an allergic reaction, often appearing and disappearing rapidly. Chronic hives recur over months or years.
• Contact dermatitis: This condition causes localized swelling and redness after direct contact with an irritant. It should be distinguished from contact urticaria, which occurs immediately after contact.
• Insect bites: While bug bites may resemble hives, they remain in one spot, unlike hives, which can shift and change shape.

Urticaria in Pregnancy

Chronic urticaria is unlikely to worsen during pregnancy. However, conditions like pruritic urticarial papules and plaques of pregnancy (PUPPP) and pemphigoid gestationis may appear during the second or third trimester and typically resolve after childbirth. Sex hormones are thought to play a role in these conditions.