How Urticaria (Hives) Is Treated

Urticaria (hives) is a common skin condition that affects up to 20 percent of people at some point in their lives. While many hive eruptions go away on their own without treatment, others may require medications and self-care therapies. The choice of treatment is largely based on the underlying cause and may include over-the-counter antihistamines, corticosteroids, anti-inflammatory drugs, monoclonal antibodies, or even a simple cooling bath.

Home Remedies

Most cases of acute urticaria are allergy-related. Chronic urticaria (hives lasting over six weeks or recurring over months or years) is believed to be caused by an autoimmune response. In both cases, the hives are caused by a substance or condition that the body reacts abnormally to.

The reaction may be triggered by any number of things, including foods, drugs, pollen, or substances like latex or nickel. Even certain physical triggers—such as heat, cold, pressure, sun, exercise, and vibration—can set off an immune response that leads to the formation of hives.

Simply removing yourself from the trigger may be enough to provide relief. By and large, acute hives are self-limited and will usually resolve within hours or several days without treatment.

If the hives are especially itchy, you can use a wet, cold compress to soothe the itch and reduce swelling. The simplest way to do this is to soak a washcloth in a bowl of ice water and apply it directly to the skin.

To further ease the discomfort, wear loose clothing either made of cotton or a smooth, lightweight synthetic like rayon. Avoid wool, linen, denim, or any textured fabric that can irritate the skin. You should also avoid getting overheated, as this can exacerbate symptoms. And, whatever you do, do not scratch.

Over-the-Counter Remedies

Antihistamines are the best, first-line treatment for hives. These drugs work by suppressing histamine, a chemical produced by the immune system that instigates the symptoms of allergy. For most types of urticaria, an over-the-counter (OTC) antihistamine may provide ample relief.

Unlike older generation antihistamines, the newer options are typically non-drowsy and may last for as long as 24 hours. They include:

Side effects tend to be mild and include dizziness, dry mouth, nausea, constipation, and cough.

Benadryl (diphenhydramine), an older antihistamine, is generally avoided during the daytime due to its sedating effect, but it may help you sleep if the itchiness is keeping you up at night.

Histamine H2-receptor antagonists, also known as H2 blockers, are another class of drug sometimes used in tandem with antihistamines. Commonly prescribed to treat heartburn, H2 blockers work by narrowing blood vessels in the skin and, by doing so, relieve redness and inflammation. They include such popular OTC brands as:

  • Tagamet (cimetidine)
  • Zantac (ranitidine)
  • Pepcid (famotidine)

Side effects include a headache, dizziness, diarrhea, muscle ache, joint pain, and rash.

Prescriptions

OTC antihistamines may not be strong enough to treat all forms of urticaria. In fact, certain chronic forms may require altogether different medications, particularly if the trigger is physical rather than allergic.

Among the prescription drugs commonly used are antihistamines, corticosteroids, leukotriene modifiers, and a monoclonal antibody specifically approved to treat chronic urticaria.

Antihistamines

Clarinex (desloratadine) is an antihistamine similar to Claritin and Zyrtec, but it is only available by prescription. It is much faster-acting than the OTC formulations and may be appropriate for a severe or widespread outbreak.

If non-drowsy antihistamines fail to provide relief, your doctor may prescribe Vistaril (hydroxyzine pamoate) to be taken at bedtime. It is a stronger antihistamine used to treat a wide range of skin reactions including chronic urticaria, contact dermatitis, and histamine-related itch (pruritis). Side effects include a headache, stomach upset, and blurred vision.

Corticosteroids

If antihistamines fail to provide relief even at higher doses or cause intolerable side effects, your doctor may opt to treat you with corticosteroids to quickly bring down the swelling and itchiness.

Corticosteroids are able to dampen the immune system as a whole. So whether the cause is allergic or autoimmune (both of which are mediated by the immune system), these drugs can "dial down" the symptoms when other drugs can't. Prednisone is most commonly prescribed for this and may be delivered either by injection or in pill form.

Corticosteroids can only be used for short-term treatment due to the risk of serious side effects, including osteoporosis, glaucoma, and diabetes.

Leukotriene Modifiers

Leukotriene modifiers are drugs commonly used to treat asthma. They work by preventing the release of leukotriene, a substance that not only triggers the narrowing of air passages but promotes inflammation.

By tempering the latter effect, leukotriene modifiers appear effective in treating certain forms of acute urticaria (particularly those triggered by food or aspirin), as well as chronic forms (such as heat- or exercise-induced cholinergic urticaria).

Leukotriene modifiers may be used alone or in combination with an antihistamine. The two currently recommended options include:

  • Accolate (zafirlukast)
  • Singulair (montelukast)

Common side effects of leukotriene modifiers include a headache, nausea, vomiting, insomnia, and irritability.

Doxepin

Doxepin is a tricyclic antidepressant that also acts as a powerful antihistamine. When prescribed in a low dose, doxepin can be extremely effective in treating hives that are persistent and of unknown origin (referred to as chronic idiopathic urticaria).

Doxepin must be used under medical supervision as it is known to cause suicidal thoughts in children and young adults with a history of depression or other mental illness. Other side effects include drowsiness, dry mouth, dehydration, headache, fatigue, dizziness, and mood changes.

Doxepin is marketed under various brand names including Silenor, Zonalon, and Prudoxin.

Xolair (Omalizumab)

Xolair (omalizumab) is an injectable drug originally prescribed for people with asthma who failed to respond to corticosteroids. More recently, it has been approved to treat chronic idiopathic urticaria if all other treatments have failed.

Xolair is a monoclonal antibody that blocks a protein, known as immunoglobulin E (IgE), which plays a central role in allergies and certain types of urticaria and dermatitis. With that being said, scientists are not quite sure how Xolair works insofar as chronic hives, unlike acute hives, are not allergy-related or influenced by IgE.

Common side effects including injection site swelling and pain, cough, dizziness, fatigue, rapid heartbeat, and chest tightness.

Complementary Medicines (CAM)

While many complementary and alternative medicines (CAMs) have been proposed to treat acute and chronic urticaria, the evidence thus far remains weak. This is especially true with chronic urticaria, the condition of which we still don't fully understand.

Some CAMs may not only be non-beneficial, they may aggravate the symptoms rather than improve them. One such example is turmeric, a natural spice widely touted as a hives remedy. Despite these claims, curcumin (the ingredient that gives turmeric its yellow color) has been known to trigger contact dermatitis as well as chronic urticaria in some people.

Other topical remedies, such as aloe vera gel, may cool the itch but will unlikely do anything more than a cool compress would.

If you choose to use a supplement or traditional medicine of any sort, be sure to advise your doctor and ensure that it doesn't interact with medications you may be taking. (St. John's Wort, for example, can reduce the concentration of antihistamines in your blood).

Among the complementary therapies that may help:

Colloidal Oatmeal Baths

If the itchiness and swelling are driving you mad, the fastest form of relief may be a cooling bath. It immediately reduces dilated blood vessels and tempers hyperactive nerve signals. One additive that may help further relieve localized inflammation is colloidal oatmeal.

While the current research is far from conclusive, some smaller studies have suggested that colloidal oatmeal—a finely milled oatmeal suspended in liquid, gel, or cream—can reduce the severity of itching while softening inflamed skin. It is widely available as a bath additive and a soothing lotion.

For added relief, store your colloidal oatmeal lotion in the refrigerator

Mind-Body Therapies

While stress does not "cause" urticaria per se, it is clear that it can aggravate the symptoms, particularly in long-term sufferers. People often to turn to mind-body therapies as they acknowledge the role thoughts and emotions play in overall health and perception of well-being.

Certain practices may be beneficial in alleviating stress. They include:

  • Meditation, which teaches you how to redirect your thoughts from physical sensations
  • Deep breathing (pranayama), a meditative practice in which your focus is centered on rhythmic breathing routines
  • Guided imagery, in which you create calming mental images
  • Progressive muscle relaxation (PMR), in which you mentally tense and release your muscles one by one
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