Hives

 

An estimated 20 percent of people will have hives at some point in their lives.

Chronic or recurrent hives can affect your quality of life. Their appearance may affect your social life. The itching can not only be annoying, but also cause sleep issues. It is normal to feel frustrated. This is especially true if the cause of your hives is unknown.

What are hives?

Hives (or urticaria) are a type of skin reaction. Hives are raised bumps or welts that are often red and itchy. Hives are quite common, and anyone can get them. 

If you are experiencing hives along with other signs of a serious allergic reaction known as anaphylaxis, use your epinephrine and seek immediate medical care.

Image of a southeast Asian person's neck with a breakout of hives.

Image of a young woman's neck with a breakout of hives.

Image of a Black man's legs. He has one leg rested over the other and is scratching his feet because of hives.

What do hives look like?

Hives often appear as red itchy bumps or an itchy rash and will feel raised when touched. When pressed on, the center of the hive will turn white. While typically red, the redness can be harder to see on darker skin.

Hives come in various shapes and sizes. Individual hives can be as small as one millimeter or as large as 6 to 8 inches in diameter. Someone can have a single hive or a few hives in a single location on the body. This is known as localized hives. Or someone can have severe hives that cover several areas of the body or the entire body.

 

How long do hives last?

A person can develop acute hives (or acute urticaria) or chronic hives. Acute hives typically last from a few days to 1-2 weeks. However, some people develop hives that can last up to six weeks.

If hives last more than six weeks, your doctor may diagnose your hives as a case of chronic urticaria.

Are hives contagious?

Hives themselves are not contagious — however what is causing the hives may be contagious. For example, if your hives are caused by an infection such as strep throat or COVID-19, the infection is contagious and can spread to other people.

Do hives itch?

For many people who develop hives, itch is a big concern. It can feel like an unending cycle of itching and scratching, and then itching and scratching again as symptoms worsen. It can affect quality of life and impact sleep, especially in children. Talk with your doctor about treatment options to help decrease the severity of itching.

Infographic of what can cause hives: allergic reactions, allergies, sunlight, exercise.

Are hives serious?

Acute hives are often not serious and will go away after treatment. Acute hives along with other signs of a severe allergic reaction are known as anaphylaxis.

Anaphylaxis is a life-threatening allergic reaction. Symptoms may include hives along with:

  • breathing difficulties
  • swelling of the mouth or tongue
  • weakness
  • fainting
  • vomiting

Anaphylaxis is a medical emergency. The first line of treatment for anaphylaxis is epinephrine. Anyone experiencing an anaphylactic reaction needs to administer epinephrine and seek emergency care at a hospital.

Here are a few options if you can’t afford the cost of  your epinephrine medication.

What causes or triggers hives?

While many people think of hives as part of an acute allergic reaction, they can occur for other reasons. Infections may be responsible for as many as 60% of hives cases. But there are also common triggers for hives including:

  • Allergic reactions to:
  • Foods
  • Certain medications
  • Plants (such as poison ivy, poison oak)
  • Insect bites or stings
  • Animal dander or saliva
  • Latex
  • Pollen
  • Viral or bacterial infections (such as strep throat or even COVID-19)
  • Autoimmune diseases
  • Environmental or physical stimuli (temperature, water, sunlight, physical pressure)
  • Exercise
  • Unknown causes (also known as idiopathic urticaria)
  • Alcohol

Can stress cause hives?

Stress does not cause hives, but it can lead to or worsen symptoms. It’s believed psychological factors such as stress play a role in about 50 percent of cases of hives. If stress is playing a role in your hives, you may benefit from working with a counselor or other mental health professional to help manage your stress.

Can pregnancy cause hives?

Pregnancy does not cause hives specifically. However, hormonal changes during pregnancy may play a role in women developing hives during pregnancy.

What autoimmune diseases cause hives?

In patients with chronic hives (hives lasting longer than 6 weeks), about 21% had an autoimmune disease. Thyroid disease, rheumatoid arthritis and antiphospholipid antibody syndrome are the three main autoimmune conditions found in people with chronic hives.

See Webinar: Understanding Urticaria (Hives): The What, Why and Itch

What causes hives in children?

The most common cause of hives in children is an infection, such as viruses or urinary tract infections. Viral infections cause more than 80 percent of cases of hives in children. Food allergy and medications can also cause hives.

Photo of baby legs with baby bare feet. The infant has a rash of hives on their ankle

How to diagnose hives?

Your doctor will perform a physical exam and look at your skin to confirm that your skin rash is really hives. Your doctor may also want to run some tests, such as a blood test or skin prick test. These will help identify if there is an underlying problem.

Doctors will ask a lot of questions to explore possible triggers and determine the exact cause of hives. Have you eaten a new food? Started a new medication? Has there been a recent infection? Is there anything upsetting your body system that suggests an autoimmune disease? The history of symptoms is very important in figuring out what is causing hives.

If there is no obvious trigger or the trigger is unknown, this is called idiopathic urticaria.

Person with severe hives on their back.
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How do I manage hives?

Beyond medications, here are some strategies to consider that can help you prevent hives from developing or provide relief.

  • Avoid known triggers, including foods.
  • Wear loose-fitting, light clothing. Don’t wear materials such as wool, which could irritate the skin.
  • Avoid scented soaps and laundry detergents.
  • Soothe the affected skin with a cool wet cloth, lotion or anti-itch cream.
  • Cover itchy areas with bandages to avoid scratching them.
  • If you must scratch, try pressing on the itchy area or stroking it using the top side of the hand instead of fingernails.
  • Drink water often. Hydration can help the skin.

Are hives a symptom of COVID-19?

A recent study from Spain found hives in 19% of people with COVID-19. So hives do appear to be one of the many symptoms of COVID-19.

For more information, visit our COVID-19 Information Center.

How to get rid of (or treat) hives?

One of the best ways to get rid of hives is to identify what causes the symptoms and then work to avoid those triggers. If a avoiding the trigger is not possible, the trigger is not known, or symptom relief is needed, the first line of treatment is an antihistamine. If you have hives, it’s also recommended you avoid aspirin, non-steroidal anti-inflammatories (NSAIDs), alcohol and tight clothing, as these can worsen symptoms.

While antihistamines are the first line of treatment, the American Academy of Dermatology has outlined other treatment options for hives symptoms.

Image of a woman with hives on her back shoulder

Epinephrine

Epinephrine is the first-line treatment for hives associated with anaphylaxis.

Antihistamines

Antihistamines block the production of histamine. They are intended to help ease symptoms of itch and swelling. They do not get rid of hives permanently.

Can Benadryl help with hives?

For years, doctors prescribed a class of antihistamines called first-generation H-antihistamines to patients with hives. The most commonly known first-generation H-antihistamine is Benadryl. Benadryl is also known as diphenhydramine. First-generation antihistamines tend to have more side effects, such as drowsiness.

Doctors now prefer to prescribe second-generation H-antihistamines because they have fewer side effects. Some of the most common second-generation H-antihistamines include cetirizine (Zyrtec), loratadine (Claritin), desloratadine (Clarinex), fexofenadine (Allegra) and levocetirizine (Xyzal).

Corticosteroids

For severe hives, doctors may prescribe a short course of oral corticosteroids. Corticosteroids, such as prednisone, help reduce swelling, itching and inflammation. If taken long-term, they can cause serious side effects, so follow your doctor’s prescription instructions.

Milder cases of hives can be treated with topical corticosteroids on the affected areas.

Omalizumab

Omalizumab (Xolair®) is used to treat chronic hives (chronic urticaria). It is an injectable biologic medication given once per month. Omalizumab is sometimes used when treatment with antihistamines has failed.

Itch Creams

Topical creams or lotions containing menthol may provide temporary relief of symptoms.

Light Therapy

Light therapy, known as phototherapy, may be prescribed by your doctor if treatment with antihistamines fails. Light therapy often requires therapy several times a week for the few months at a treatment center.

Other Treatment Options

For hives that fail to respond to traditional treatment, it is important to work closely with your doctor to discuss treatment options. There are medications that work by reducing your body’s immune response. This treatment should ideally be supervised by a doctor with a specialty in treating hives.

What are rare types of hives?

Man with rare hives on his chin and cheeks. He is holding up his hand towards his chin, pointing out his discomfort.

Hives are often attributed to an allergic reaction or virus. They are mostly short-lived. Yet, in rare cases, some people develop hives that last more than six weeks or recur with triggers. This is known as chronic urticaria. Chronic urticaria is categorized as either spontaneous or inducible. 

Chronic idiopathic urticaria

Chronic idiopathic urticaria (CIU) is sometimes called chronic spontaneous urticaria (CSU). It is a form of chronic hives that comes and goes without a known trigger.

Chronic inducible urticaria

Chronic inducible urticaria (CIndU) is characterized by hives and/or angioedema. CIndU is a form of chronic urticaria that is triggered by environmental or physical stimuli. There are two types of chronic inducible urticaria: physical and non-physical.

Types of physical urticaria

  • Dermographism – triggered by skin friction such as rubbing, scratching, or pressure. This is the most common form of CIndU.
  • Delayed-pressure urticaria – triggered by sustained pressure to the skin. Symptoms appear 4-6 hours after contact.
  • Exercise-induced urticaria – triggered by exercise.
  • Cold urticaria– triggered by skin exposure to cold or cold water. Hives are usually limited to exposed skin.
  • Heat urticaria – triggered by exposure to heat.
  • Solar urticaria – triggered by sun exposure to UV rays.
  • Vibratory urticaria – triggered by exposure to vibration.

Types of non-physical urticaria

  • Cholinergic urticaria – triggered by active or passive body warming.
  • Contact urticaria – triggered by skin contact from an external substance.
  • Aquagenic urticaria – triggered by direct contact with water.

If you or a loved one are dealing with chronic hives or recurrent hives, make an appointment with an allergist. An allergist can help with diagnosis of chronic hives, understanding triggers for chronic hives, and recommend how to treat chronic hives.

Are there other conditions that can look like or complicate allergies

There are other types of conditions that can mimic allergies, but are different than an IgE-mediated allergy. The symptoms, diagnosis and treatment can vary depending upon the condition. Here are some of them.

Food-related conditions that can have symptoms similar to food allergies include:

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Reviewed by:
Purvi Parikh, MD, FACAAI is an adult and pediatric allergist and immunologist at Allergy and Asthma Associates of Murray Hill in New York City. She is on faculty as Clinical Assistant Professor in both departments of Medicine and Pediatrics at New York University School of Medicine.