What is Chronic Urticaria?

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Chronic Urticaria Toolkit

Circle icon of chronic hives. Chronic Urticaria

Circle icon of various types of hives. Different Kinds of Hives

Circle icon of medication rubbing on hives. Chronic Urticaria Management

Circle icon of water drops Aquagenic Urticaria

Circle icon with hand showing Chronic Idiopathic Urticaria. Chronic Idiopathic Urticaria

Circle icon of thermometer with snowflake. Cold Urticaria

Do you or someone you care about have hives? Round and swollen welts on the skin? Do they 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.

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

What is urticaria (hives)?

Urticaria is also known as hives. Hives are a rash that causes round, swollen areas on the skin. They often are 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.

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.

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

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?

The cause of chronic urticaria can sometimes be difficult to determine. Your doctor will likely review your medical history, examine your skin, and ask you questions about when your hives appeared.

The history of your 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 doctor will perform a physical examination and evaluarte your skin. Your doctor may also want to do some laboratory tests or even perform 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. For acute hives, the cause is usually obvious and can be treated without delay. Chronic urticaria is different from acute hives that are caused by an allergic reaction to a food. 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 or months.

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 an 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 guidelines recommend a step-based approach to treatment. Let’s explore some of the treatment 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.

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

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

 

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.

For severe hives, doctors may prescribe a short course of oral corticosteroids. Corticosteroids, such as prednisone, can help reduce swelling, itching and inflammation. If taken orally long-term, however, they can cause serious side effects. These side effects include weight gain, diabetes, high blood pressure, bone loss, 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.

Biologics

Omalizumab (Xolair®) is a biologic medication used to treat chronic hives. It is an injectable medication given once per month. Omalizumab is sometimes considered for severe urticaria and when other treatments, such as antihistamines or topical corticosteroids, have not worked.

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 the few months. Do not attempt light therapy at home without medical direction. If done incorrectly, you may further damage your skin.

Other treatment options

For hives that fail to respond to traditional treatment, it is important to work closely with your doctor. Discuss treatment options. Medications are available that work by reducing your body’s immune response, calming inflammation (leukotriene modifiers such as montelukast) and blocking the production of histamine (H2 blockers). Treatment should be supervised by a doctor who specializes in treating hives.

If chronic hives involve swelling of the tongue or lips, your doctor may prescribe an epinephrine auto-injector to use in case of an emergency.

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 cool cloths 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.

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 ca 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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