Chronic hives (defined as lasting six weeks or more) can last from months to years. The evaluation of this condition is difficult, and allergy testing and other laboratory tests are only occasionally useful in such cases. The accurate evaluation of this condition requires the patient to give his or her physician precise information regarding their complete medical history, personal habits, and oral intake. Occasionally, it may be necessary to limit specific foods or drugs for a time to observe any affect upon the skin condition. Certain systemic diseases and infections, including parasitic infestations, may occasionally present in the skin as hives. If an inciting cause can be determined, then specific treatments for that condition ought to be effective, or in the case of food or drug allergy, strict avoidance would be necessary. There are additionally rare forms of chronic urticaria that are produced when the patient makes antibodies against molecules on the surface of their own mast cells. There are tests available to identify this type of hives.
Chronic cases are much more likely to be related to autoimmune causes than allergies. In the autoimmune form of urticaria and angioedema, a person makes antibodies against a component of their mast cells, triggering the release of histamine and causing symptoms.
While avoiding these triggers could prevent hives from returning, Dr. Li says your doctor may be able to provide an antihistamine that could solve a weather- or temperature-based problem. That way, you can enjoy a hike on a sunny summer day or hold a cold can of beer on the weekend without worrying about a potential hives outbreak.
Grattan CE, O’Donnell BF, Francis DM, Niimi N, Barlow RJ, Seed PT, et al. Randomized double-blind study of cyclosporin in chronic ‘idiopathic’ urticaria. Br J Dermatol. 2000 Aug. 143(2):365-72. [Medline].
Hives are red and sometimes itchy bumps on your skin. An allergic reaction to a drug or food usually causes them. Allergic reactions cause your body to release chemicals that can make your skin swell up in hives. People who have other allergies are more likely to get hives than other people. Other causes include infections and stress.
Urticarial vasculitis tends to run a chronic course. Mortality is low, unless renal or pulmonary disease occurs. The goal of treatment is to achieve long-term control with the least amount of toxicity.
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Patients with urticarial vasculitis present with an urticarial eruption, often accompanied by a painful or burning sensation. Lesions are generalized wheals or erythematous plaques, occasionally with central clearing, lasting for more than 24 hours in a fixed location (in contrast to urticaria, which resolves in minutes to hours or migrates continually). Petechiae may be noted within the lesions, and they may resolve with ecchymoses or postinflammatory hyperpigmentation. Patients may have photosensitivity, lymphadenopathy, arthralgia, angioedema (40%), fever, abdominal pain, dyspnea, and pleural and pericardial effusions. Most cases of urticarial vasculitis are idiopathic.
If Aspirin & Salicylate intolerance is suspected then all forms of Salicylate including toothpaste, muscle rubs and peppermints should also be avoided. Aspirin sensitive individuals tolerate the newer Cyclo-oxygenase-2 selective inhibitors or COX-2 anti-inflammatory (NSAI) medications such as Celecoxib and Meloxicam.
The majority of stinging insects in the United States are from bees, yellow jackets, hornets, wasps, and fire ants. Severity of reactions to stings varies greatly. Avoidance and prompt treatment are essential. In selected cases, allergy injection therapy is highly effective.
Antihistamine tablets can ease symptoms. Antihistamines block the action of histamine which is one of the chemicals involved in causing hives. You can get antihistamines on prescription. You can also buy them without a prescription from pharmacies. There are several types. The pharmacist will advise. The ones most often used for hives are:
Clinical examination may reveal urticaria, dermographism or angioedema or signs of a connective tissue disease or urticarial vasculitis, but it is often normal. Similarly, investigations are very often normal, particularly if there is a long history of urticaria, with no obvious triggering factors and if the patient is clinically well. Recent guidelines from the British Association of Dermatologists  and the British Society of Allergy and Clinical Immunology  suggest that investigations are not needed in all patients; however, individual patients may be reassured by a series of normal results. Depending on the clinical history, tests may include: full blood count (FBC) and differential, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), routine biochemistry, glucose, thyroid function, thyroid autoantibodies, anti-nuclear antibody (ANA), immunoglobulins and protein electrophoresis, complement C3 and C4, cryoglobulins, SIgE tests, serology for infections, stool sample for ova, cysts and parasites and urine analysis (for evidence of infection or renal vasculitis). Further investigations may, of course, be required if the initial screening tests are abnormal. For example, the presence of a normochromic, normocytic anaemia, lymphopaenia and strongly positive ANA would prompt further investigations for SLE.
Drugs that block histamine-1 (H1) receptors (antihistamines) are the primary treatment for urticaria. The use of both H1 and H2 receptor blockers has been recommended but has not been proven more effective. Patients should avoid identified allergens. Doxepin, calcium channel blockers, or immunosuppresive drugs may be needed for symptoms that are not well controlled with antihistamines. Known triggers of urticaria should be avoided.
Initially it is helpful to explain to patients what urticaria is and that very often it is not due to ‘an allergy’. They may be reassured that in nearly all cases there is no serious underlying medical problem causing the rash; that safe, effective treatments are available and that the long-term prognosis is usually good. A patient information leaflet, such as that available from the British Association of Dermatologists , is helpful.
Check CH50, C3, C4, Clq, and antibodies to Clq in urticarial vasculitis patients. If these test results are positive, evaluate renal function and urinalysis to check for the effects of vasculitis on the kidneys.
Mutations in the CIAS1 gene, which codes for cryopyrin, cause autoinflammatory syndromes, one of which is Muckle–Wells syndrome , also known as urticaria–deafness–amyloidosis (UDA). It is a rare, autosomal dominant condition which presents with urticaria, sensorineural deafness, episodic fevers and arthralgia and it may progress to renal amyloid.
Other drugs such as Colchicine, Warfarin, Nifedipine, Dapsone, Methotrexate and Sulfasalazine have been used with some success reported in chronic urticaria. Auto-immune thyroid disease with associated urticaria may respond to oral Thyroxine supplementation even if normal thyroid function. Immune suppressive therapy such as Cyclosporin is effective but can cause serious side effects such as kidney damage and uncontrolled hypertension. Oral Sodium Cromoglycate may benefit Food related Exercise induced Urticaria. Stress (public speaking, examinations, exercise and arguments) may trigger Cholinergic Urticaria and Propranolol will reduce symptoms.
Once you know what triggers your outbreaks, limiting your exposure to these will reduce your risk of developing hives. Keep in mind though that sometimes hives appears to be spontaneous with no known trigger.
Occasionally women notice that their urticaria seems to fluctuate in severity in relation to their menstrual cycle, and there is a rare cyclical form of urticaria, known as autoimmune progesterone urticaria, which occurs 7–10 days premenstrually . In pregnancy urticaria will often improve, but there is a distinct clinical condition known as polymorphic eruption of pregnancy or ‘pruritic urticarial papules and plaques of pregnancy’ (PUPPP) , in which the rash starts as itchy, urticarial papules and plaques in striae on the abdomen and thighs and then spreads to affect the whole trunk and limbs. It usually begins in the third trimester and is most common in first pregnancies or the first multiple pregnancy. In vitro fertilization, with the increased chance of multiple pregnancies, has increased the incidence of this condition. Treatment is with emollients, anti-histamines, topical steroids and occasionally, in severe cases, oral steroids. The rash usually resolves within days of delivery and generally does not recur. There is no adverse effect on the fetus. Urticaria occurring only during pregnancy and recurring during subsequent pregnancies has been reported .
The skin reaction usually becomes evident soon after the scratching, and disappears within 30 minutes. Dermatographism is the most common form of a subset of chronic hives, acknowledged as “physical hives”.
An allergy refers to a misguided reaction by our immune system in response to bodily contact with certain foreign substances. When these allergens come in contact with the body, it causes the immune system to develop an allergic reaction in people who are allergic to it. It is estimated that 50 million North Americans are affected by allergic conditions. The parts of the body that are prone to react to allergies include the eyes, nose, lungs, skin, and stomach. Common allergic disorders include hay fever, asthma, allergic eyes, allergic eczema, hives, and allergic shock.
Apply calamine lotion. Calamine lotion is a mixture of zinc oxide and zinc carbonate. It can be applied to hives to relieve the itching as often as needed. When the itching subsides or you want to reapply, rinse off the calamine lotion with cool water.
An allergy skin test helps identify triggers for one’s allergic reactions. Small amounts of allergy-provoking substances (allergens) are scratched into the skin. Redness and swelling develop if one is allergic to the substance. A positive allergy skin test implies that the person has an IgE antibody response to that substance. The test is rapid, simple, and relatively safe.
Oral steroids (prednisone, [Medrol]) can help severe cases of hives in the short term, but their usefulness is limited by the fact that many cases of hives last too long for steroid use to be continued safely. Other treatments have been used for urticaria as well, including montelukast (Singulair), ultraviolet radiation, antifungal antibiotics, agents that suppress the immune system, and tricyclic antidepressants (amitriptyline [Elavil, Endep], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan, Adapin]). Evidence to support the benefit of such treatments is sparse. In ordinary cases, they are rarely needed. A new treatment now indicated for chronic urticaria is the monthly subcutaneous injection of a monoclonal antibody, omalizumab (Xolair), directed against the IgE receptor on human mast cells.
The type I allergic immunoglobulin (Ig) E response is initiated by antigen-mediated IgE immune complexes that bind and cross-link Fc receptors on the surface of mast cells and basophils, thus causing degranulation with histamine release.
Sil A, Tripathi SK, Chaudhuri A, Das NK, Hazra A, Bagchi C, et al. Olopatadine versus levocetirizine in chronic urticaria: an observer-blind, randomized, controlled trial of effectiveness and safety. J Dermatolog Treat. 2012 Nov 19. [Medline].
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Jump up ^ Engin, B; Uguz, F; Yilmaz, E; Ozdemir, M; Mevlitoglu, I (2007). “The levels of depression, anxiety and quality of life in patients with chronic idiopathic urticaria”. Journal of the European Academy of Dermatology and Venereology. 22 (1): 36–40. doi:10.1111/j.1468-3083.2007.02324.x. PMID 18181971.
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 skin lesions of urticarial disease are caused by an inflammatory reaction in the skin, causing leakage of capillaries in the dermis, and resulting in an edema which persists until the interstitial fluid is absorbed into the surrounding cells.
Everyone reacts to stress differently. You might experience only a few of these signs or you might notice that more signs develop, especially when you don’t address your stress. Paying attention to your body’s reaction to stress can help you address it immediately, instead of waiting for stress cause you to break out in hives.
59. Vena GA, Cassano N, Colombo D, Peruzzi P, Pigatto P NEO-I-30 Study Group. Cyclosporine in chronic idiopathic urticaria: a double-blind, randomised, placebo controlled trial. J Am Acad Dermatol. 2006;55:705–9. [PubMed]