What is Urticaria (hives)
Urticaria is the medical name for hives. These are welts; pink
swellings that come up on any part of the skin. They itch and each
individual hive lasts a few hours before fading away, leaving no
trace. New hives appear as old areas fade. They can be pea sized
or join to cover broad areas of the body. While the itch can be
intense, the skin is usually not scabbed or broken. In some people
the hives burn or sting.
Hives are very common with 10-20 percent of the population having
at least one episode in their lifetime. Hives can sometimes occur
in deeper tissues of the eyes, mouth, hands or genitals. These
areas mat develop a swelling that is frightening in appearance,
but usually goes away in less than 24 hours. This swelling is
called angioedema.
In many cases, a single attack of hives is due to an infection or
virus and these go away within a few days to a few weeks. Some
people get repeated attacks that occur as an allergic reaction to
a variety of things (foods, most commonly nuts, chocolate, fish,
tomatoes, eggs, fresh berries and milk, insect stings, and
medications). In this case, they usually break out within a few
hours of the exposure. Usually, the patients figure out the cause
by themselves, and they never bother coming to a doctor.
Certain people can develop recurrent hives from sunlight, cold,
pressure, vibration or exercise. These are called the physical
urticarias. If hives develop from scratching or firmly rubbing the
skin it is called dermatographism. It is the most common of the
physical urticarias and it affects about 5 percent of the
population. It doesn't always itch. This condition sometimes also
occurs along with other forms of hives.
Some people react to anything that makes them hot or sweaty with
hives. This can be sunlight, exercise, hot baths, blushing or
anger. These are tiny intensely itchy hives with a big red blotch
around them and are called cholinergic urticaria.
Pressure urticaria shows up as a deep welt in an area of prolonged
pressure. Occasional people react to the cold. Even more rare is a
reaction to sunlight.
Occasionally, a person will continue to have hives for many years.
These hives, called chronic urticaria, can be one of the most
frustrating problems dermatologists see in their patients. This is
defined as hives lasting longer than 6 weeks. Patients like this
come in miserable and worried with this problem, often having seen
multiple specialists. Neither the patient nor the doctor can
determine the cause of the hives. Patients will often say, "It has
got to be something causing these hives." The truth is hard to
accept for some patients.
In the overwhelming majority of cases it is not "something"
causing the chronic hives, it is "nothing." That is, in about 95%
of chronic hives cases, the hives are "idiopathic" (a medical term
that means there is no discernible cause). Because of those 5% of
cases with a cause, it is worthwhile to see a physician to
determine if any underlying disease is present (e.g. thyroid
problems, liver problems, skin diseases, sinusitis) or if there is
an allergic cause (i.e. a reaction to a drug, insect, food, etc.).
This can be accomplished by a good history and physical, a few
blood and urine tests and sometimes a skin biopsy. Some patients
with chronic hives and elevated anti-thyroid antibodies in the
blood improve when given thyroid supplement even if the thyroid
function is normal.
In about half of patients with chronic idiopathic hives, the
explanation is that body's immune system is, in a sense,
overactive. The urticaria is "autoimmune". The immune system is
attacking the normal tissues of the body and causing hives as a
result. We know certain urticaria sufferers have other signs of
autoimmune problems. Some have autoimmune thyroid disease,
vitiligo, swollen joints, or certain abnormalities in the blood
(especially the ANA test). A new treatment has recently emerged
for autoimmune urticaria. This is the use of Plaquenil, a drug
originally used for malaria. In a recent trial 83% improved or
cleared completely when used for three months or more.
So, in many patients with chronic hives, there is really no
exposure (drug, food, insect, chemical) to blame for the urticaria.
The patient must understand and accept this for their ideal
management. Basically, all that needs to be done is treat the
hives. The main treatment of hives is antihistamines, and they
will work if they are used properly. Common reasons for lack of
effectiveness of antihistamines are 1) the particular
antihistamine used is not strong enough 2) the antihistamine is
not used in a high enough dose 3) the antihistamines are not
continued for a long enough period.
The most well tolerated initial treatment is the non-sedating
antihistamine Claritin. Zyrtec is similar but may sometimes cause
sedation. If that doesn't eliminate the hives, a sedating-type of
antihistamine (hydroxyzine, cyproheptadine or doxepin) is added at
night. High doses may be needed and this will cause sedation.
Fortunately, most patients will become less affected by sedation
after they have taken the drug regularly for a while.
If that doesn't work, some doctors may try a short course of
cortisone (steroids) to clear the hives completely. Then the
patient can maintain the effect with the much safer
antihistamines, since steroids have significant side effects if
used long term.
A drug used for psoriasis and kidney transplants, cyclosporin, is
almost always effective in clearing even the most severe cases of
chronic hives at low doses. However, it causes significant side
effects if taken for a long time.
There are other medications that may be added to the
antihistamines, but these non-standard therapies are not always
effective. However, if the hives are not responding, they are
worth a try. Examples are anti-acid pills (Tagamet, Zantac),
dapsone and sulfasalazine (anti-inflammatory antibiotics),
nifedipine (a blood pressure medicine), Accolate (an asthma drug),
colchicine (a drug for gout), and several others.
The important thing is that the patient is given enough medication
(antihistamines, perhaps in conjunction with other drugs) to
suppress the hives. Whatever it is that controls a patients hives,
should be the daily regimen, taking the drugs every day, whether
or not they have the hives on any given day. The idea is that one
is preventing the hives from breaking out.
Some doctors suggest that medications should be continued for long
periods - perhaps even a month after the hives have disappeared.
Again, the exception to this is the cortisone/steroid-type
medications, which should only be used for short periods initially
to quiet down the urticaria. Remember that one must work closely
with their doctor to find a medication regimen that suppresses the
hives until they resolve on their own.
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