Symptoms of Urticaria (Hives)

The effects of urticaria (hives) can be very noticeable, but the symptoms can be similar to those of other skin conditions such as eczema, rosacea, and pityriasis rosea. While areas of hives on the skin (also referred to as wheals or weals) can vary in their distribution and appearance, they are characterized by itchy, raised welts on the skin's surface that are either red or skin-colored.

urticaria symptoms
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Frequent Symptoms

Urticaria is caused by an inflammatory reaction that prompts capillaries in the dermis (the layer of tissue just beneath the outer skin) to leak fluid. When this happens, the accumulation of fluid results in a defined area of raised skin that persists until the fluid is eventually reabsorbed into the surrounding cells.

Identifying Hives

Hives have specific characteristics that set them apart from other skin conditions:

  • The elevated area of skin has a clearly defined border.
  • When you press the rash, it will "blanches" (turns white).
  • They will be itchy, sometimes intensely so. They may also be paired with pain or a burning sensation.
  • They can appear anywhere on the body and change shape, move around, disappear, and reappear over short periods of time.
  • When they resolve, the skin will return to normal without scarring.
  • Most will not be accompanied by systemic reactions such as fever, nausea, muscle aches, joint pain, or headaches.

Urticaria is classified as being either acute or chronic depending on the duration of the eruption. Acute hives last for less than six weeks, while chronic hives extend well beyond six weeks.

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Hives on legs
Hives on legs. Raimo Suhonen / DermNet / CC BY-NC-ND 

Acute urticaria is more common in children and young adults. The majority are classified as idiopathic, meaning that we don't know the cause. Most cases are self-limited; individual lesions tend to resolve on their own within a few hours. An eruption rarely lasts more than several days, although it may recur over weeks. If a cause is found, it is usually related to an infection, insect bite, or a food or drug allergy.

Chronic urticaria, by contrast, often requires medical treatment. In one 2013 study, 70% of people with chronic hives had symptoms that lasted for longer than a year, while 14% had symptoms for five or more years. In half of the cases, no underlying medical condition was discovered.

Urticaria is known to affect up to 20% of the population and strikes people irrespective of age, race, or gender. Hives most often appear in the evening or early morning just after waking. Itching is typically worse at night, often interfering with sleep.

By Type

The distribution and appearance of hives can vary significantly. Some may be widespread or diffuse, while others may be limited to a single, small weal. The appearance of a hive can sometimes give a clue as to the underlying cause.

For example:

  • Cold urticaria: This type is caused by exposure to cold temperatures, and usually manifests with welts that are between a quarter of an inch to an inch in size and either slightly reddish or skin-colored. Fainting can occur if large areas of skin are involved.
  • Cholinergic urticaria: Also known as heat rash, this type is caused by excessive sweating and will appear as very small weals surrounded by bright red flares. Strenuous exercise is a common cause.
  • Dermographism urticaria: This type is caused by the firm stroking of the skin and manifests with hives along the line of contact. The weals tend to appear five to 10 minutes after contact and generally disappear 10 to 15 minutes after they occur.
  • Pressure urticaria: It's caused by any pressure placed on the skin, including tight clothing or standing on your feet too long. It manifests with a dense, localized eruption that is red, itchy, and maybe even a little painful.
  • Solar urticaria: Exposure to ultraviolet (UV) light, can cause hives to appear in areas of exposed skin, often within minutes of exposure. The rash is very itchy and appears "angry," often with intense redness and warmth. As with cold urticaria, fainting can occur if the hives are widespread.
  • Vibratory urticaria: Vibration, including clapping or a bumpy car ride, can cause hives. It tends to be short-lasting, appearing and disappearing within an hour. While difficult to distinguish by appearance alone, vibratory hives are sometimes accompanied by unusual symptoms such as flushing, headaches, blurry vision, or a metallic taste in the mouth.
  • Water urticaria (aquagenic urticaria): This is a rare form of hives caused by contact with water. The hives tend to be small and most often develop on your neck, upper trunk, and arms. As with vibratory urticaria, it tends to come and go within an hour.

Rare Symptoms

Less commonly, urticaria may progress to a severe, all-body allergic reaction known as anaphylaxis. Anaphylaxis is often caused by a hyperallergic response that triggers the development of hives, angioedema (a related skin condition affecting deeper layers of tissue), and severe respiratory symptoms.

Common allergy triggers are food, medications, vaccines, and insect stings, although some cases have no known causes.

Symptoms of anaphylaxis include:

  • Widespread hives and angioedema
  • Coughing, sneezing, and wheezing
  • Throat tightness and shortness of breath
  • Swelling of the lips and/or tongue
  • Rapid or irregular heartbeat
  • Dizziness or lightheadedness
  • Stomach cramps
  • Nausea, vomiting, and diarrhea
  • Chest pains
  • Breathing restriction advancing to airway obstruction
  • Confusion
  • A feeling of impending doom
  • Fainting and collapse
  • Seizures

If left untreated, anaphylaxis can lead to shock, asphyxiation, coma, cardiac or respiratory failure, and death.

When to See a Healthcare Provider

If a case of hives is uncomplicated with no accompanying symptoms other than itching, you can usually treat it at home. Most will resolve within a few hours to several days. If it persists for more than a week or starts to worsen, see a healthcare provider as soon as possible.

Hives Healthcare Provider Discussion Guide

Get our printable guide for your next healthcare provider's appointment to help you ask the right questions.

Doctor Discussion Guide Woman

If your symptoms are recurrent and unexplained, ask your healthcare provider for a referral to either a dermatologist, who can run tests to identify possible triggers, or an allergist, who can check whether an allergen (allergic trigger) is to blame. Your healthcare provider may also want to check for undiagnosed infections (such as hepatitis B) or autoimmune diseases (such as Hashimoto's thyroiditis), for which recurrent hives are common.

Symptoms That Are an Emergency

If your hives are accompanied by symptoms such as breathing difficulty, widespread swelling, heartbeat irregularities, and/or vomiting, call 911 or have someone rush you to the nearest emergency room.

Frequently Asked Questions

What are hives?

Hives (urticaria) are a common skin reaction that cause itchy welts ranging in size from small spots to blotches as large as a plate. They are often accompanied by angioedema, a condition characterized by the swelling of deeper tissues.

What causes hives?

Hives can occur when the body's immune system responds abnormally to environmental or medical conditions and triggers the release of histamine into the bloodstream. This causes the rapid dilation of blood vessels and leakage of fluid into the upper layers of skin. Sometimes there's no identifiable cause.

What do hives look like?

Hives cause reddish areas of raised tissues, often well-defined, that blanch (turn white) when pressed. Unlike a rash, which may or may not be itchy, hives always cause itchiness ranging from mild to severe.

How long do hives last?

How long hives last depends on the underlying cause. Hives often go away on their own spontaneously and quickly; other cases may be persistent or recurrent. Chronic urticaria is defined as daily hives lasting for more than six weeks.

What are common triggers for hives?

Common triggers for hives include:

  • Food allergies
  • Drug hypersensitivity
  • Airborne allergens
  • Contact allergens
  • Insect bites
  • Stress
  • Exercise
  • Environmental changes (like changes in temperature, excessive sun exposure, or extreme vibrations)
  • Applying direct pressure to the skin (such as wearing tight clothing)
  • Certain medical conditions (like HIV or hepatitis)
  • Blood transfusion

How do you get rid of hives?

Depending on the severity of hives, your healthcare provider may recommend an over-the-counter or prescription antihistamine to reduce itchiness and swelling. Severe cases may require use of a biologic medication called Xolair (omalizumab) that is FDA approved for the treatment of chronic hives or an immunosuppressant used off-label like cyclosporine.

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