Chronic Urticaria: Symptoms, Causes and Diagnosis

Do you or someone you care about have seemingly constant hives? Round and swollen bumps on the skin? Do they come and go, or show up when you least expect them, and last for more than 6 weeks? You could have a skin condition called chronic urticaria (also called chronic hives).

At a Glance: Chronic Urticaria Symptoms, Causes, and Diagnosis

  • Two main types. 1) Acute urticaria (lasts less than 6 weeks and is usually caused by an allergy), and 2) chronic urticaria (lasts more than 6 weeks sometimes with an unknown cause).
  • The 6-week rule. If you have hives on the skin for more than six weeks, it is considered “chronic.”
  • Types of urticaria. Hives are either “spontaneous” (happen out of nowhere) or “inducible” (triggered by things like cold, heat, water or pressure).
  • Chronic spontaneous urticaria is often a mystery. For many people, there is no specific trigger like food or pollen allergy.
  • You are not alone. Chronic hives are serious and frustrating, but they are not dangerous, and they are not your fault.

People with chronic urticaria have an itchy, inflamed skin rash most days of the week for 6 weeks or longer. This can take both a physical and mental health toll on people with chronic urticaria.

The more you know about chronic urticaria, the better prepared you’ll be to recognize symptoms. It’s an essential step in developing a treatment plan with your healthcare provider – and finding relief.

Close-up of a person scratching their neck, which has visible red patches of skin irritation or hives. The plain background highlights the affected area on the neck and shoulder.

What Are the Symptoms of Chronic Urticaria?

  • Red, raised bumps or circular welts on people with lighter skin tone.
  • Raised bumps or circular welts on people with skin of color that either…
    • match the skin color of the surrounding skin;
    • appear as slightly darker than the skin color;
    • appear as slightly lighter than the skin color.
  • Skin often feels itchy, tender or sometimes painful to the touch. There may be a burning or stinging sensation in affected areas.
  • Swelling beneath the skin (called angioedema). It’s most common around the eyes, lips, cheeks, hands, feet and genitals.
  • The hives may appear, disappear, and then reappear again, sometimes on different parts of the body.
the back of a woman who has issues with chronic hives

What Does Chronic Urticaria Look Like?

In people with light skin, chronic urticaria appears as red, raised bumps or circular welts. In people with skin of color, the hives may not appear red. Rather, they may match the color of the surrounding skin. They may also appear as slightly lighter or darker.

You may have systemic symptoms with a rash dispersed across the entire body. Or it may be localized with the rash confined to a particular part of the body. This is especially true for urticaria that is triggered by something in the environment.

What Causes Chronic Urticaria (CU)?

Urticaria is caused by the release of histamine and other mediators. When this happens in the outer layers of the skin, it results in hives on the skin.

Chronic urticaria (hives present for 6 weeks or longer) can be inducible or spontaneous.

Chronic inducible urticaria (CIndU)

Chronic inducible urticaria occurs when physical and non-physical factors trigger symptoms. Types of physical hives include:

  • Delayed-pressure urticaria, resulting from pressure to the skin
  • Dermographism, or skin friction resulting from rubbing, scratching or pressure
  • Exercise-induced urticaria, resulting from exercise or physical activity
  • Cold urticaria, triggered by exposure to the cold or cold water
  • Heat urticaria, triggered by exposure to heat
  • Solar urticaria, triggered by exposure to the sun’s UV rays
  • Vibratory urticaria, resulting from exposure to vibration

Types of non–physical hives include:

  • Aquagenic urticaria, resulting from direct contact with water
  • Cholinergic urticaria, triggered by the body warming up or excessive sweating
  • Contact urticaria, caused by exposure to a substance or compound such as food, preservatives, fragrances or metals

Chronic spontaneous urticaria (CSU)

Chronic spontaneous urticaria (CSU) is a type of hives that occurs without an obvious external trigger. Unlike allergic hives, which may be caused by foods, medications, or other exposures, CSU is believed to result from within the body, often involving the immune system. It is formerly called chronic idiopathic urticaria.

Studies show as many as 80-90% of people with chronic urticaria don’t know the cause of symptoms. Autoimmune conditions may play a role in some cases of chronic urticaria. There are also systemic diseases, such as certain types of cancer, that can cause hives.

Whatever the cause of your hives, it’s important to remember that chronic urticaria is a medical condition, not something you caused. Living with visible skin symptoms and ongoing itching can take an emotional toll.

If your condition is affecting your mental or emotional well-being, talk with your healthcare provider. Get a referral to a mental health professional who can help you cope with the challenges of living with a chronic condition.

What are Common Triggers for Acute and Chronic Hives?

Acute and chronic hives are two different conditions.

Acute hives are often triggered by infections or allergic reactions. They are often short-term hives with symptoms getting better within 1-3 days.

Chronic hives are usually caused by underlying immune system activity. They rarely occur due to a specific allergy.

For people with CSU, there is no obvious trigger.

Key differences in Acute and Chronic Hives

Hive TypeCommon Causes of SymptomsData Source
Acute (Children)Infections / AllergiesFrontiers in Allergy (2023)
Acute (Adults)Infections / Allergies / Unknown CausesResearchGate / Clinical Review (2025)
Chronic Spontaneous (CSU)Autoimmune / Unknown CausesStatPearls / NCBI (2025)

External factors do not cause chronic spontaneous urticaria. However, they can make hives worse or trigger flare-ups in some people. These factors include:

  • Changes in body temperature – this can result from exposure to heat or cold
  • Pressure from tight clothing rubbing against the skin
  • Exercise
  • Sunlight
  • Alcohol
  • Water (aquagenic urticaria)
  • Certain medications such as aspirin, ibuprofen and other non-steroidal anti-inflammatory drugs (NSAID)
  • Repeat vibrations, such as from using a lawnmower or power tool
  • Stress

CSU hives may occur more often in people with certain autoimmune conditions. These may include asthma, thyroid disease, lupus, rheumatoid arthritis, Celiac disease, Type 1 diabetes, vitiligo, and vasculitis.

closeup of hives on the neck of a person

How Long Do Symptoms of Chronic Urticaria Last?

Chronic urticaria can last from 6 weeks to years. They can last for weeks at a time, go away for a while, and then come back later. This can go on for years.

That’s why it’s essential to develop a treatment plan with your healthcare provider that keeps chronic hives under control.

How is Chronic Urticaria Diagnosed?

It may be hard for you and your healthcare provider to determine what’s causing your chronic urticaria. To aid in the diagnosis, you’ll likely need to see a board-certified allergist or dermatologist.

Step 1: Determine if urticaria is acute or chronic.

The first step is to determine how long your symptoms have lasted:

  • Acute urticaria: Hives for 6 weeks or less.
  • Chronic urticaria: Hives occur daily or almost daily for more than 6 weeks.

If your symptoms are chronic, your healthcare provider will move on to the next step.

Step 2: Determine if urticaria is inducible or spontaneous.

There are two main types of chronic urticaria:

  1. Chronic inducible urticaria (CIndU): Hives are triggered by a specific factor, such as heat, cold, pressure, exercise, or sunlight.
  2. Chronic spontaneous urticaria (CSU): Hives occur without an obvious trigger.

If no clear trigger can be identified, your healthcare provider may diagnose CSU.

Step 3: Rule out underlying causes.

If no underlying cause is found, then chronic spontaneous urticaria is the diagnosis.

This may seem like it’s a straightforward process for diagnosis, but there may be hurdles along the way. Your doctor may look for clues into what is causing your symptoms. This could be a lengthy and frustrating process.

What does it look like in practice? Your healthcare provider will first review your medical history, examine your skin, and ask you questions about when your hives appeared.

Some health issues can mimic hives. Insect bites, eczema (atopic dermatitis) and other skin diseases can look like hives. With urticaria, there is also often swelling underneath the skin, called angioedema.

After the physical examination, your doctor may explore possible triggers to determine the exact cause of chronic hives. Some questions you may hear:

  • Have you been exposed to heat or direct sunlight? Cold weather?
  • Do symptoms occur after baths or swimming in a pool?
  • Is there anything upsetting your body system that suggests an autoimmune disease?
  • Could this be a reaction to an activity or something in your environment?

The history of symptoms is often very important to figuring out what is or isn’t causing your hives. 

Diagnosis is often based on a process of elimination – considering what might or might not be causing your hives. Allergy testing is not needed unless there is a clear history of a reaction to specific allergens. Overtesting can lead to unnecessary elimination of foods which can cause weight loss, nutritional deficiencies and anxiety.

What causes acute hives is usually obvious. Symptoms can be treated without delay. Chronic urticaria is different from acute hives. It takes more time and investigation to determine what’s causing chronic hives. If no cause is found, it’s chronic spontaneous urticaria (CSU).

Sometimes it’s useful to keep an “urticaria diary” for several weeks. An urticaria diary can be used to record the frequency and intensity of symptoms. You can keep track of when symptoms occur. If you start noticing a trend, you may have found your trigger.

red raised patches of Urticaria on womans leg

Chronic Urticaria Questions & Answers (Q&A)

Here are some common questions about chronic urticaria that we are often asked. If you have an additional question you’d like to see answered here, please email the editor.

Both can help diagnose, manage and treat chronic urticaria.

  • Allergists specialize in allergies and immune system conditions.
  • Dermatologists specialize in conditions that affect the skin.

The most important thing is to see a healthcare provider with experience treating chronic urticaria. If your symptoms are affecting your daily life, it may be best to make an appointment with whichever specialist is available sooner. Early diagnosis and treatment can help you get symptoms under control more quickly.

One way to prevent chronic urticaria is to learn what triggers a reaction and then avoid those triggers. In some cases of chronic urticaria, such as heat, cold or water, avoidance is not possible. Speak with your doctor about prevention strategies and medications.

Foods do not usually trigger chronic urticaria, except in rare cases. They can trigger acute or short-term hives, however.

If a food is causing your skin to flare up in hives, whether acute or chronic, reduce or eliminate those foods from your diet. Get tested by an allergist to determine if food allergies are causing your hives.

Hives themselves are not contagious. Infections such as the flu, strep throat or COVID-19 that can sometimes cause acute hives are contagious. These infections can spread to other people, usually through respiratory droplets or shared germs.

Chronic hives may go away on their own. About half of people who have chronic hives will stop having flare-ups within one year. But many people have them for 1 to 5 years.

For a small number of people, it can last even longer. There is no known cure, but medications and lifestyle changes can help you feel better.

Chronic urticaria is not a life-threatening condition, but it can be very difficult to live with. The persistent itching, swelling, and discomfort can affect sleep, work, school and daily activities. Many people also have stress, anxiety or frustration when symptoms continue for months or even years.

Chronic urticaria can be managed with antihistamines and other treatments. Working with a healthcare provider can help you find a treatment plan that controls symptoms and improves your quality of life.

About 30-40% of chronic spontaneous urticaria cases are related to an autoimmune condition and can be considered autoimmune urticaria.

Autoimmune urticaria is a type of chronic hives caused by an autoimmune condition. The most common autoimmune conditions that cause chronic urticaria are:

  • Celiac disease
  • dermatomyositis
  • Type 1 Diabetes
  • lupus
  • polymyositis
  • rheumatoid arthritis
  • thyroid disease
  • vitiligo

While most chronic hives are “spontaneous,” some are linked to underlying autoimmune issues, such as thyroid disease. This is why your doctor may run blood tests during your diagnosis. Treating the underlying condition can sometimes help hives improve.

Yes, the hormonal changes women experience during pregnancy can cause chronic hives. The treatment is usually antihistamines and it’s considered safe for mother and baby. Talk with your doctor about medications before taking them.

Some women may also experience a flare during their menstrual cycle or during menopause. Symptoms may also develop with the use of hormonal contraceptives or hormone replacement therapy.

Yes, children can develop chronic hives. It is less common than acute urticaria but it has a worse impact on quality of life. Treatment is the same in children as it is for adults – typically non-sedating antihistamines is the first-line therapy.

People with chronic hives experience swelling, itching and pain. This can cause sleep disturbances. It may lead to stress and emotional difficulties including anxiety and depression. All these contribute to a lower quality of life. The more severe the urticaria is, the greater the impact on quality of life.

Chronic urticaria is known to affect patients’ personal care and family life. It may impact work or school productivity and the ability to do housekeeping or yard work. Patients may need to make more frequent trips to doctor offices, disrupting their daily work schedule.

A recent study found some patients with chronic urticaria may go to the doctor as often as 12 times more per year than people without chronic urticaria. They also had more emergency department visits and hospitalizations, according to the study.

People with chronic hives report having trouble falling asleep. They also may wake up at night with itching and other symptoms. Not getting enough sleep at night because of these factors causes daytime fatigue.

With severe hives, or hives that last a long time, you can develop symptoms like joint pain or swelling, headache and fatigue.

Emotional stress and anxiety are not triggers for chronic hives but they can trigger acute or short-term hives in some people.

Nighttime is when the body’s natural anti-itch chemicals are at their lowest. People with chronic hives may find their symptoms itch worse at night. Your healthcare provider may recommend taking an antihistamine 1-2 hours before bedtime to keep symptoms in check at night.

Chronic hives can be debilitating for some people. They may have difficulty performing basic activities of daily life. Some may have an inability to sleep, to go along with mental health issues stemming from social isolation, anxiety and depression.

If your chronic urticaria symptoms are severe enough, then you may qualify for a disability and you may be eligible for benefits. The hives must be considered so severe that they limit your ability to maintain substantial gainful activity.

Veteran groups have a category for disability from chronic urticaria. But the requirements vary and are based on different levels of symptom impairment. An impairment rating determines how much a patient receives in compensation.

Reviewed by:
Payel Gupta, MD, is an Assistant Clinical Professor at both SUNY Downstate Medical Center and Mt. Sinai Medical Center in New York. She is triple board-certified in allergy and immunology, internal medicine and pediatrics. Dr. Gupta practices in Brooklyn, New York, treating both adult and pediatric patients with allergic diseases.​ She is past president of the New York Allergy & Asthma Society. Dr. Gupta also serves as co-host of “The Itch Podcast,” a podcast dedicated to helping patients better understand allergic condition.