What is Chronic Urticaria?

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Do you or someone you care about have hives? Round and swollen welts on the skin? Do symptoms show up when you least expect them and last for more than six weeks? It could be chronic hives, also known as chronic urticaria.

People living with urticaria experience an itchy rash on their skin. In people with chronic urticaria, the rash appears most days of the week for more than six weeks. The condition can take both a physical and psychological toll on those living with it. It is important to understand causes, symptoms and treatment options.

What is urticaria (hives)?

Urticaria is also known as hives. Hives are a rash that causes round, swollen areas on the skin. They often have very itchy skin and can sometimes be painful.

What’s the difference between hives and chronic hives?

There are two types of hives: acute and chronic urticaria. Hives that appear for a short period of time are called acute hives. They can last less than a day, or up to six weeks.

Chronic hives last longer – 6 weeks or more. Sometimes they go away for a period of time and then come back. There are different types of chronic hives.

What are chronic hives?

Chronic hives occur most days of the week for more than six weeks. People may experience symptoms on their whole body or in one particular area of the body. There are two types of chronic urticaria: chronic spontaneous urticaria and chronic inducible urticaria.

  • Chronic spontaneous urticaria is not triggered by external factors. In many cases, the cause could be something autoimmune or unknown. It is sometimes referred to as chronic idiopathic urticaria.
  • Chronic inducible urticaria is caused by certain environmental and physical factors.

How common is chronic urticaria?

Chronic urticaria is a rare condition.  More than 500,000 people live with chronic urticaria in the United States. It occurs in 0.23% (or 23 out of every 10,000) of people. However, there are estimates that rates of chronic urticaria may be higher since many times people do not report or recognize symptoms.

Chronic urticaria is most common in adults between ages 40 and 59. More women than men are affected. And more Black Americans and other ethnic groups are affected than white people.

Close up of boy's neck with chronic urticaria. He is scrating them and is very uncomfortable.

What causes chronic urticaria (CU)?

Urticaria is caused by a release of histamine and other mediators. When this release happens in the outer layers of the skin, it results in hives. Most of the time, it is a case of acute hives, which resolves quickly. But the hives can become chronic.

Doctors often don’t know what causes chronic hives. For as many as 80-90% of people with chronic urticaria, the cause of symptoms is unknown.

Autoimmune conditions such as systemic lupus erythematosus 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.

Physical and non-physical factors can trigger chronic urticaria. 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

Sometimes there is no identifiable cause for chronic urticaria. This is known as chronic spontaneous urticaria or chronic inducible urticaria.

No matter what’s causing your hives, it’s important that you don’t blame yourself for your condition. Urticaria is a natural reaction in your body. If you’re feeling anxiety or shame about your skin condition, talk with your doctor and/or get a referral to a mental health specialist.

Top portion of woman's back from a slight side angle showing her hives that won't go away.

What are some common triggers for chronic hives?

For many people with chronic hives, there is no obvious trigger. This usually results in a diagnosis of chronic spontaneous urticaria or chronic idiopathic urticaria.

Common triggers for chronic hives usually involve external factors:

  • Changes in body temperature – this can result from exposure to heat or cold
  • Pressure from tight clothing rubbing against the skin
  • Certain diseases including asthma, Celiac disease, diabetes, lupus, polymyositis, rheumatoid arthritis, thyroid disease, vasculitis and vitiligo

In rare cases, common triggers for acute or short-term hives can lead to chronic hives. These triggers may involve:

  • Viral or bacterial infections (such as strep throat or COVID-19)
  • Allergens to food, certain medications, pollen, insect venom, animal dander or saliva, and latex
  • Exposure to poison ivy or poison oak
  • Alcohol
  • Certain types of drugs, including antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen.

What does chronic urticaria look like?

Chronic urticaria appears as red, raised bumps or circular welts on people with light skin. 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 are the symptoms of chronic urticaria?

  • Red, raised bumps or circular welts on people with white skin.
  • 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.

Southeast Asian person's neck with a breakout of hives.

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.

As a comparison, acute urticaria symptoms last anywhere from a day to several weeks. If symptoms are present most days of the week and last longer than 6 weeks, then it is considered chronic.

Closeup of woman's leg with hives

How is chronic urticaria diagnosed?

It may be difficult for you and your healthcare team 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.

Once your healthcare provider confirms that you have urticaria, then it is time to determine your type. The three main types of urticaria are:

  1. acute
  2. chronic inducible
  3. chronic spontaneous

Your healthcare provider may take a step-based approach to diagnosing your condition.

Step 1: Determine if urticaria is chronic or acute.

  • Acute urticaria – symptoms 6 weeks or less.
  • Chronic urticaria – daily (or almost daily) symptoms for 6 weeks or more.

If the symptoms are determined to be chronic urticaria, move on to step 2.

Step 2: Determine if urticaria is spontaneous or inducible.

  • Inducible urticaria – symptoms have a specific trigger.
  • Spontaneous urticaria – no obvious trigger.

If the symptoms are determined to be spontaneous urticaria, move on to step 3.

Step 3: Rule out underlying causes.

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

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. The history of symptoms is often very important to figuring out what is causing your hives. Diagnosis is often based on a process of elimination – looking at what might or might not be causing your hives.

Your healthcare provider may do a physical examination of your skin and perform allergy tests, laboratory tests or a skin biopsy to rule out other conditions.

A lot of health issues can look like hives. These include insect bites, eczema (atopic dermatitis) and other skin diseases. With urticaria, there is 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 very important in figuring out what is causing hives. What’s causing acute hives is usually obvious and 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 called chronic idiopathic urticaria (CIU) or chronic spontaneous urticaria (CSU).

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

What is the treatment for chronic urticaria?

Chronic urticaria is not a life-long condition; it usually goes away by itself over a period of weeks, months or even years.

It may not be possible to get rid of chronic hives simply by avoiding triggers. Sometimes you may not know the trigger at all. In these cases, disease management focuses on the most appropriate treatment to control symptoms.

The first line of treatment for most cases of chronic urticaria is a long-lasting antihistamine. It’s best to create a treatment plan with your allergist, dermatologist or primary care doctor.

You should avoid taking aspirin or non-steroidal anti-inflammatories (NSAIDs). You should also avoid alcohol and tight clothing. Any of these may worsen symptoms.

Chronic urticaria international guidelinesrecommend a step-based approach to treatment. Here’s a closer look at the medication options:

One hand putting cream on the other hand with severe eczema

Antihistamines

Antihistamines block the production of histamine. They can reduce or eliminate your hives and help ease symptoms of itch and swelling. Prescription and over-the-counter versions are available.

First-generation antihistamines such as diphenhydramine (Benadryl®) can cause drowsiness. These may be helpful at bedtime to help with sleeping.

Doctors prefer to prescribe newer antihistamines that are second-generation because they have fewer side effects and make you feel less drowsy. Some of the most common second-generation antihistamines include:

  • Cetirizine (Zyrtec®)
  • Loratadine (Claritin®)
  • Desloratadine (Clarinex®)
  • Fexofenadine (Allegra®)
  • Levocetirizine (Xyzal®)

You may start with a standard dose of antihistamines, but your doctor may step up dosing if symptoms do not improve.

Itch creams

Topical creams or lotions containing menthol may provide relief of mild symptoms that do not cover the entire body.

Corticosteroids

Mild cases of hives may be treated with topical corticosteroids. These medications work by reducing inflammation and irritation. They are available as creams, ointments and lotions.

For severe hives, doctors may prescribe a short course of oral corticosteroids. Oral corticosteroids, also known as prednisone, can help reduce swelling, itching and inflammation. If taken orally long-term, however, these medications can cause serious side effects. Side effects may include weight gain, diabetes, high blood pressure, thinning of the skin, eye cataracts or bone loss. Sometimes symptoms can come back after you stop taking oral corticosteroids.

It’s important to follow your doctor’s instructions when taking these medications.

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

Additional treatments for chronic urticaria

If antihistamines alone do not help your chronic hives, your doctor may recommend you combine it with other medications. These include:

  • leukotriene modifiers such as montelukast that help calm inflammation by reducing your body’s immune response and blocking an allergic reaction before it can start;
  • H2 blockers that block the production of histamine.

It is important to work closely with your doctor should your hives not respond to treatment.

Sometimes hives are accompanied by angioedema, which is swelling on the skin. The swelling can include the lips, tongue and throat. Talk to your doctor about medications to address swelling. Angioedema may require epinephrine.

Biologics

Omalizumab (Xolair®) is a biologic medication used to treat chronic hives. Biologics work by targeting cells and interrupting the inflammatory process to stop or reduce symptoms. It’s an injectable medication given once per month. Omalizumab treats severe chronic urticaria when antihistamines have not worked. It can be taken along with antihistamines as needed.

Cyclosporine

When chronic urticaria symptoms do not respond to antihistamines or omalizumab, then your doctor may recommend cyclosporine as the next step. Cyclosporine is an immunosuppressive medication, meaning it suppresses the immune system to prevent hives. It can be taken along with antihistamines as needed.

As an immunosuppressive, cyclosporine can decrease the body’s ability to fight infections. It can also cause serious side effects, such as kidney problems.

Light therapy

Light therapy, also known as phototherapy, is a treatment option for very severe hives. It involves exposing the affected skin to ultraviolet (UV) light. Light therapy may be prescribed by your doctor if other treatments have not worked.

Light therapy is done at a treatment center. It often requires therapy several times a week for a few months. Do not attempt light therapy at home without medical direction. If done incorrectly, you may further damage your skin.

Photo of Woman scratching her arm

What’s the best treatment to reduce itching?

The best treatment is the one that is most effective in reducing or eliminating hives and controlling the itch. It could be antihistamines, topical or oral corticosteroids, a biologic or another medication. Work with your doctor to find the best treatment for you. Combine prescription medications with at-home remedies.

Are there any home remedies for chronic urticaria?

Home remedies that can be used to treat hives include the following:

  • Apply a cool cloth to the area of the hives or take a cool bath. This can relieve the skin and reduce itching. Some people find relief from colloidal oatmeal baths. Colloidal oatmeal can be expensive, so another option is to put oatmeal in an old sock or nylon stocking. Tie a knot in the sock to keep the oatmeal from coming out.
  • Use air conditioning to keep yourself cool.
  • Wear loose-fitting clothing to let the skin breathe and reduce irritation from rubbing against fabrics.
  • Choose clothing that is less likely to irritate your skin, such as cotton or smooth fabrics. Wool, linen, denim or fabrics with a texture or nap can bother sensitive skin.
  • Avoid scratching the itchy hives. For children, it can help to put socks over their hands (you can make it fun like sock puppets.) For adults, look for distractions from itching and keep your hands busy.
  • Consider meditation, deep breathing and guided imagery to reduce the stress and anxiety from the discomfort of hives.
  • Consider aloe vera lotion which can provide relief from itching.
  • Some supplements may help. These include vitamins B-12, C, and D, fish oil and quercetin.

Discuss any home remedies with your doctor first to make sure it’s safe for you.

What can healthcare professionals do to be most helpful to people dealing with chronic urticaria?

The first helpful thing that a healthcare professional can do is listen. Allow patients with chronic urticaria to express their concerns and share their experiences. Work with the patient to make shared decisions about treatments and care. This helps create a management plan that the patient can follow. It allows them to live their daily life with as few symptoms as possible.

Doctor talking to patient in medical consultation, checkup and visit in clinic, hospital and healthcare center. Professional, gp and frontline worker explaining symptoms while asking woman questions.

How can patients talk to their doctor about chronic urticaria?

Come prepared to your doctor appointments to discuss your condition in detail. Don’t be hesitant to explain how the symptoms are affecting you.  Some questions to ask yourself might include:

  • How am I sleeping?
  • Am I feeling depressed or anxious or experiencing any other effects on my mental health?
  • How is my work affected?
  • How is my disease affecting my family?

All these things should be shared with your healthcare provider as chronic urticaria can affect all areas of your life. Use Shared Decision Making to partner with your healthcare provider to determine the best treatment options for you.

Monitoring Chronic Urticaria

Keep a chronic urticaria diary to document your symptoms and their frequency and severity. Photos can be part of your diary – take pictures of your hives and their locations regularly. Your healthcare provider may take photos of your hives at appointments.

Several chronic urticaria questionnaires are available to help assess the impact of the disease on your quality of life. These include the Dermatology Life Quality Index (DLQI), SKINDEX-29, Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL), Chronic Urticaria Patient Perspective (CUPP) and Angioedema Quality of Life Questionnaire (AE-QoL). Ask your healthcare provider about using these questionnaires.

If you’re digitally inclined, consider using an app to manage and track your chronic urticaria symptoms. Then share digital results with your healthcare team.

  • MyHivesDiary is a free IOS-based app from Genentech. It allows users to document itch severity, number and size of hives, and the presence of angioedema.

Living with Chronic Urticaria

Chronic urticaria is a challenging disease to live with – it not only affects your physical health, but also your mental health and relationships.

Chronic Urticaria and Mental Health

Up to one out of every three people with chronic urticaria live with anxiety or depression. Many may have difficulty sleeping, which can impact quality of life.

First, know that you are not alone. If you feel you are struggling with mental health, talk about it with a healthcare provider. Your doctor may recommend taking medication to address mental health. Or you may benefit from talking to a therapist or participating in a support group.

Chronic Urticaria and Its Impact on Family and Friends

Humans don’t live in bubbles, so if something is affecting you, it is also probably affecting your family and friends. You may feel on edge from your symptoms, so you might find yourself withdrawing from people or more short-tempered. People in your life may feel helpless to see your struggle. They might not be supportive or think you are exaggerating your symptoms.

You may find it helpful to have someone you trust come with you to an appointment to have your healthcare provider explain your condition. If relationships are suffering, feel free to seek out therapy either individually or with your family and friends.

Coping Strategies for Living with Chronic Urticaria

One of the most important things you can do is partner with your healthcare team to find the most effective treatment for your chronic urticaria. If your symptoms are better controlled, it will be easier to cope with the disease.

Then, work on things that help you control stress and improve your ability to cope with challenges. Maybe it is just going for a walk and listening to music or a book or podcast to get your mind off your illness. Talk to a trusted person. Look into joining a support group, either in-person or online. Most importantly, find something that works for you!

Talking about Chronic Urticaria with Your Family, Friends, and Others

Discussing a chronic illness is different for everyone. Maybe you value your privacy and sharing is not something you like to do. Or maybe you are an open book and talking comes naturally to you. Wherever you are on the spectrum, you will likely need to tell someone what you are dealing with and how it is affecting you.

When you do share, it is important to not only discuss the actual symptoms, but also how those symptoms affect you on a daily basis. This will allow family and friends to get a better understanding of what you are dealing with and find ways to support you.

Chronic Urticaria Questions & Answers (Q&A)

Here are some questions about chronic urticaria that are often asked.

How can I prevent chronic urticaria?

One way is to learn what triggers your chronic urticaria and try to avoid them. 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.

What foods trigger chronic urticaria?

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, you should reduce or eliminate those foods from your diet. Get tested by an allergist, who can help you to determine if allergies are causing your hives.

Is there a chronic urticaria diet?

Many people and doctors recommend a low-histamine diet for chronic hives. Low-histamine foods include:

  • Most vegetables

  • Fresh meat

  • Certain varieties of fresh fish (including salmon, cod and trout)

  • Dairy products (except cheese and yogurt)

  • Bread

  • Pasta

  • Rice

Foods to avoid include:

  • Vegetables such as spinach, tomatoes and eggplant

  • Fruits, such as strawberries and cherries

  • Preserved meats

  • Canned, frozen, and smoked fish (including tuna, anchovies and sardines)

  • Cheese and yogurt

  • Fermented foods

  • Fast food

  • Seasonings, such as chili powder, cinnamon, cloves and vinegar

  • Alcoholic beverages

Is chronic urticaria contagious?

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

Does chronic urticaria ever go away?

Chronic hives may go away on their own. About half the 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.

Is chronic urticaria serious?

Chronic urticaria is a frustrating and uncomfortable condition. But thankfully it’s not a life-threatening condition. Treatment with antihistamines or other medications will usually clear up symptoms. But chronic urticaria can have a significant impact on a person’s quality of life.

What autoimmune diseases cause chronic hives?

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

Can pregnancy cause chronic urticaria?

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.

Can children develop chronic urticaria?

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.

What are the impacts of chronic urticaria on quality of life?

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 urticara 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.

Does chronic urticaria cause fatigue?

People with chronic hives report having trouble falling asleep. They also report waking up at night with itching and other symptoms. This causes daytime fatigue.

Is chronic urticaria an autoimmune disease?

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

Does chronic urticaria cause joint pain?

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

Can stress cause chronic urticaria?

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

Why is chronic urticaria worse at night?

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.

Is chronic urticaria a disability?

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, they 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:
Jacqueline Eghrari-Sabet, MD, FACAAI, is board-certified in allergy, immunology and pediatrics. She is the Medical Director of Telehealth for Allergy & Asthma Network. Dr. Eghrari-Sabet is the founder of Family Allergy & Asthma Care and the FAAR Institute in the Washington, DC area, where she has been in private practice since 1994. Dr. Eghrari-Sabet is Assistant Clinical Professor at George Washington University School of Medicine and Health Sciences where she mentors the next generation of doctors. She is also President of White Coat Resources, a health education consulting service.

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