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Hives

(Urticaria; Wheals)

By

Thomas M. Ruenger

, MD, PhD, Georg-August University of Göttingen, Germany

Last full review/revision Apr 2021
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Hives are red, itchy, slightly elevated swellings. The swelling is caused by the release of chemicals (such as histamine) from mast cells in the skin, which cause fluid to leak out of small blood vessels temporarily. Itching may be severe. Hives have clearly defined borders and may have a pale center. Typically, crops of hives come and go. One hive may remain for several hours, then disappear, and later, another may appear elsewhere. After the hive disappears, the skin usually looks completely normal.

Angioedema

Hives may occur with angioedema Angioedema Angioedema is swelling of areas of tissue under the skin, sometimes affecting the face and throat. Angioedema can be a reaction to a drug or other substance (trigger), a hereditary disorder... read more Angioedema , which, like hives, involves swelling. However, the swelling of angioedema is under the skin rather than on its surface. Sometimes angioedema affects the face, lips, throat, tongue, and airways. It can be life threatening if the swelling interferes with breathing.

Causes of Hives

Hives may occur when certain chemicals are inhaled, consumed, injected, or touched. These chemicals can be in the environment, foods, drugs, insects, plants, or other sources. They are harmless in most people. But if people are sensitive to them, these chemicals (called triggers or allergens) can cause an allergic reaction. That is, the immune system overreacts to the chemicals.

However, most of the time, hives are not part of an allergic reaction and an allergen (the cause of the allergic reaction) cannot be identified. For example, they may result from autoimmune disorders Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers autoimmune disorders is not known. Symptoms vary depending on... read more . In these disorders, the immune system malfunctions, misinterpreting the body's own tissues as foreign and attacking them. Also, some drugs cause hives directly without triggering an allergic reaction. Some physical stimuli (such as heat, cold, pressure, friction, or sunlight) may cause hives for reasons that are not well understood.

Hives usually last less than 6 weeks and are classified as acute. If hives last more than 6 weeks, they are classified as chronic.

Acute hives

If a cause can be identified, acute hives are most commonly caused by

  • Allergic reactions (such as foods and food additives, drugs, or insect bites)

  • Nonallergic reactions (such as drugs, physical stimuli, or autoimmune disorders)

Allergic reactions are often triggered by foods, particularly eggs, fish, shellfish, nuts, and fruits; food additives; drugs; or insect bites or stings. Eating even a tiny amount of some foods can suddenly cause hives. But with other foods (such as strawberries), an allergic reaction occurs only after a larger amount is eaten. Many drugs, particularly antibiotics, may cause hives. Immediate allergic reactions may also occur when a substance comes into direct contact with the skin (such as latex), after an insect bite or sting, or as a reaction to a substance that is inhaled into the lungs or through the nose.

Nonallergic causes of hives include infections, some drugs, and some physical stimuli (such as pressure or cold).

In more than half of cases, a specific cause of acute hives cannot be identified.

Chronic hives

Possible identifiable causes of chronic hives are the same as those of acute hives. However, in the vast majority of cases, a cause cannot be identified (is idiopathic). Most cases of chronic hives that have no identifiable cause are thought to be due to an autoimmune reaction that itself has no detectable cause. Nevertheless, all efforts should be made to identify a cause, because elimination of a cause is the best approach to treatment.

Sometimes the cause is easily overlooked, as when people repeatedly consume a food not known to be a trigger, such as a preservative or dye in foods or penicillin in milk. Often, despite the best efforts, the cause remains unidentified.

Chronic hives can last for months or years, then sometimes go away for no apparent reason.

Evaluation of Hives

Not every episode of hives requires immediate evaluation by a doctor. The following information can help people decide whether a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

Certain symptoms and characteristics are cause for concern:

  • Swelling of the face, lips, throat, tongue, or airways (angioedema)

  • Difficulty breathing, including wheezing

  • Hives that are deeply colored, that become open sores, or that persist for more than 48 hours

  • Fever, swollen lymph nodes, jaundice, weight loss, and other symptoms of a bodywide (systemic) disorder

When to see a doctor

People should call an ambulance if

  • They have difficulty breathing or are wheezing.

  • Their throat feels as if it is closing up.

People should go to an emergency department or a doctor's office as soon as possible if

  • Their symptoms are severe.

  • They feel progressively weak or light-headed or have severe fever or chills.

  • They are vomiting or have abdominal pain or diarrhea.

People should see a doctor if

  • A bee sting triggers hives or swelling (to obtain advice about treatment if another bee sting occurs).

  • They have other symptoms, such as fever, joint pains, weight loss, swollen lymph nodes, or night sweats.

  • Hives recur without exposure to a trigger.

  • Symptoms last for more than 2 days.

If children have hives that appear suddenly, disappear quickly, and do not recur, an examination by a doctor is usually unnecessary. The cause is usually a viral infection.

What the doctor does

Doctors first ask questions about the symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see Table: Some Causes and Features of Hives Some Causes and Features of Hives Hives are red, itchy, slightly elevated swellings. The swelling is caused by the release of chemicals (such as histamine) from mast cells in the skin, which cause fluid to leak out of small... read more Some Causes and Features of Hives ).

The trigger is not always clear from the history, often because the trigger is something that may have been tolerated previously.

During the physical examination, doctors first check to see whether the lips, tongue, throat, or airways are swollen. If there is swelling, they begin treatment right away. Then doctors note how the hives look, determine which parts of the body are affected, and check for other symptoms that may help confirm the diagnosis. Doctors may use various physical stimuli to see whether they can trigger the hives. For example, they may apply light pressure, heat, or cold to the skin or stroke the skin.

People themselves should not try to trigger their hives, because a severe reaction could occur.

Table
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Testing

Usually, testing is not needed for a single episode of hives unless symptoms suggest a specific disorder that requires treatment (such as some infections). But if hives have unusual characteristics, recur, or persist, tests are usually done.

Typically, tests include a complete blood cell count and blood tests to measure levels of electrolytes, sugar (glucose), and thyroid-stimulating hormone and to determine how well the kidneys and liver are functioning.

Skin tests, such as a skin prick test Diagnosis Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance. Usually, allergies make people sneeze; the eyes water and itch... read more Diagnosis , are done by an allergist (a doctor who specializes in allergic disorders) to identify specific allergens. Imaging and other blood tests are done based on results of the history and physical examination. If results suggest that the cause is a bodywide disorder, a thorough evaluation is needed to identify the cause.

Treatment of Hives

  • Avoidance of triggers

  • Measures to relieve itching

  • Drugs

Hives often go away on their own after a day or two. If the cause is obvious or if the doctor identifies a cause, people should avoid it if possible. If the cause is not obvious, people should stop taking all nonessential drugs until the hives subside.

Bathing and showering with only cool water, refraining from scratching, and wearing loose clothing may help relieve symptoms.

Drugs

Antihistamines Antihistamines Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance. Usually, allergies make people sneeze; the eyes water and itch... read more Antihistamines taken by mouth are used for hives. These drugs partially relieve the itching and reduce the swelling. To be effective, they must be taken regularly, rather than as needed. Several antihistamines, including cetirizine, diphenhydramine, and loratadine, are available without a prescription. Diphenhydramine is an older drug that is more likely to cause drowsiness than the other two. Other antihistamines include desloratidine, fexofenadine, hydroxyzine, and levocetirizine. Antihistamine creams and lotions are not used because they may sensitize the skin and worsen itching.

Corticosteroids taken by mouth (such as prednisone) are used if symptoms are severe and other treatments are ineffective. They are given for as short a time as possible. When taken by mouth for more than 3 to 4 weeks, corticosteroids have many, sometimes serious, side effects (see Corticosteroids: Uses and Side Effects Corticosteroids: Uses and Side Effects Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more Corticosteroids: Uses and Side Effects ). Corticosteroid creams do not help.

Epinephrine is a chemical that narrows blood vessels and opens airways in the lungs. It is given to people who have severe reactions or angioedema Angioedema Angioedema is swelling of areas of tissue under the skin, sometimes affecting the face and throat. Angioedema can be a reaction to a drug or other substance (trigger), a hereditary disorder... read more Angioedema who then are admitted to the hospital. People who have these severe reactions should carry a self-injecting epinephrine pen (epinephrine autoinjector) and, if a reaction occurs, use it immediately.

In about half the people with chronic hives, the hives disappear without treatment within 2 years. In some adults, the antidepressant doxepin, which is also a potent antihistamine, helps relieve chronic hives. Omalizumab, a monoclonal antibody, may be used by people whose chronic hives have continued to occur despite other treatments.

Essentials for Older People

Older people are more likely to have side effects when they take the older antihistamines (such as hydroxyzine and diphenhydramine). In addition to drowsiness, these drugs can cause confusion and delirium and can make starting and continuing to urinate difficult. Usually, older people should not take these drugs for hives.

Key Points about Hives

  • Hives may or may not be an allergic reaction.

  • For most people, a cause cannot be identified.

  • If a cause is identified in hives that have lasted less than 6 weeks, the cause is usually an allergic reaction to a specific substance, an acute infection, or a nonallergic reaction to a specific substance.

  • If hives have lasted 6 weeks or more, the cause usually cannot be identified (is idiopathic).

  • People should call an ambulance if they have difficulty breathing or if their throat feels as if it is closing up.

  • People with mild symptoms should avoid any known or suspected triggers and can take antihistamines to relieve symptoms.

  • People who have severe reactions should carry a self-injecting epinephrine pen and, if a reaction occurs, use it immediately.

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