Why Do I Get Chronic Hives?

Do you have a problem with chronic hives and wonder about the reason behind it? Here we could have an answer to your question.

Hives occur due to the secretion of histamine and other chemicals in our skin. The reason the body secretes histamine  is exposure to  a trigger - sometimes identifiable (such as a skin irritant) and  in some chronic hive cases, unidentifiable. If you are able to identify a certain trigger and can avoid it, this might help prevent an episode of hives.¹

Chronic hives might affect your quality of life as they can cause difficulty sleeping or performing your daily activities. However, knowing how to manage your hives is the key to considerably increasing your quality of life.

What are chronic hives

Hives (traditionally known as wheals or nettle rash) is an itchy, raised, red rash. In modern medical terms, it is also known as urticaria. 

Acute urticaria is used for the cases in which a hive rash lasts for up to six weeks. Acute intermittent urticaria is usually caused by an allergen and lasts for a day or twobut reoccurs on repeated allergen exposure.

Chronic urticaria is when a hive rash lasts more than six weeks. Individual lesions of chronic urticaria last less than 24 hours and recur most days. 

There are also different types of chronic urticaria depending on the cause: 

• Chronic autoimmune urticaria - where antibodies are excessively produced at the site of hives on the body 
• Chronic inducible urticaria - where a specific hive rash trigger identified 
• Chronic spontaneous (idiopathic) urticaria - where the cause of hive rash is unknown (most common form)^3,4 

There is also hereditary angioedema which is associated with recurrent episodes of severe swelling due to a deficiency of an enzyme in the body called C1 inhibitor.^3,4 

Angioedema is a cause of reactive swelling, mostly of the face or lips. Swellings can be painful rather than itchy and occurs alongside urticaria in some patients. Angioedema can also occur without urticaria but this is less common. Unlike urticaria, swellings of angioedema can persist for a few days.^2,3

Causes of chronic hives

Chronic hives is caused by some substances released in the body in response to a specific trigger (chronic inducible urticaria) or due to autoimmunity (chronic spontaneous urticaria). Certain substances such as histamine, bradykinin, prostaglandins, leukotrienes and eosinophils are released mast cells, which play a role in the body’s immunity. The release of these substances is also responsible for the symptoms of hives.⁴ 

Common triggers for chronic inducible urticaria include:

• Environmental triggers such as heat, cold, extreme humidity and pressure, water and sunlight 
• Excessive movement such as vibration and during exercise 
• Sweating 
• Stress
• Non-steroidal Anti-inflammatory Drugs (NSAIDs)
• Certain antibiotics (beta-lactams)
• Certain foods (notably peanuts, eggs, chocolate)
• Hot and spicy food
• Alcoholic beverages
• Latex
• Grass
• Animals
• Viral infection^3,4

There is an association between chronic hives and some autoimmune diseases such as thyroid disease (hypothyroidism or hyperthyroidism), celiac disease, Sjögren syndrome, systemic lupus erythematosus, rheumatoid arthritis, and type 1 diabetes mellitus.⁴ According to a study, there is also a significant association between chronic hives and irritable bowel syndrome.⁵

Signs and symptoms of chronic hives

Chronic hives typically present with wheals that are: 

• Raised 
• Restricted to one area 
• Round in shape 
• Red in colour 
• Sized anywhere between a few millimeters to several centimeters 
• Lesions that may come together to form a larger plaque 

If you are taking antihistamines, your lesions might appear flattened rather than raised. Additionally, although any part of the body may be affected, areas subjected to pressure and rubbing such as armpits are more commonly affected.

Wheals usually last 30 minutes to 24 hours and disappear without leaving marks. Lesions can be intensely itchy and the itch usually worsen at night time. Sometimes, there might be pricking or burning sensation as well.

Angioedema is present in almost half of the chronic hives patients. Swelling of angioedema is more likely to have a numb or tingling sensation or pain rather than being itchy. Angioedema is usually present on lips, cheeks, limbs, genitals and around the eyes. 

Some patients may present with systemic (full-body) symptoms such as fatigue, headache, joint pain, flushing, wheezing, heart-racing, feeling sick, and tummy pain. This subgroup of patients tend to have a more severe and long-lasting disease.

Stroking the skin with a firm object might cause a linear wheal and flare response in some patients. This is called dermographism or dermatographia.⁴

Management and treatment for chronic hives

As hives are often acute at the time of onset and can affect large areas of the skin, it can be alarming. However, there are many things you can do to manage your hives. Two main points of management are avoiding any known triggers and therapy by certain medications. However, most of the patients with chronic hives are not able to identify triggers in which case, treatment is mainly symptomatic (when your symptoms arise). 

Symptomatic treatment of chronic hives starts with medications called antihistamines. If your symptoms do not improve on a low dose of antihistamine medication your doctor might consider increasing the dose, adding another antihistamine medication or adding another type of medication in order to control the symptoms. 

Hives that cannot be controlled by high-dose antihistamines may be further treated with anti-inflammatory medications such as corticosteroids or immunosuppressant medications. However, corticosteroids are advised to be used only for flare-ups for short periods of time (3-7 days) due to their side effects.

Once chronic hives symptoms are controlled with antihistamines alone, it is recommended that the medication be withdrawn periodically in order to identify when, how and if you go through a period of spontaneous remission of the condition. Treatment should continue until this occurs.

Certain antihistamines might cause side effects such as: 

• Sedation 
• Drowsiness and feeling sleepy during daytime  
• Difficulty concentrating 

Therefore, it is important not to drive while experiencing these side effects.⁴ 

FAQs

How common are chronic hives

Up to 1% of the general population in the USA and Europe are affected by chronic hives at some point in their lifetime. Although chronic hives can be seen in both children and adults, adults are affected more compared with children (typically aged 20-59).  It is also seen 2x as often in women compared to men.⁴

How are chronic hives diagnosed

Chronic hives are diagnosed after a detailed medical history is taken and examination is done by your doctor. You might be asked about the frequency, circumstances of onset, triggers, timing, pattern of recurrence and duration of attacks. Photographs of the rash can also be helpful in confirming the nature of the lesions. 

Some other questions which you might be asked include:

• Could it be related to any medications you are taking? (Aspirin, NSAIDs, ACE inhibitors)
• Does it occur only within 60 minutes of eating a particular food? (exceptions meat and some seafood)
• Does it occur only if a particular food has been eaten followed by exercise
• Does it occur after contact with an allergen? (animals, grass, food, latex, etc)
• Are the episodes persistent rather than self-limiting
• Does the rash last more than 24 hours
• Are the rash tender and painful rather than itchy
• Are there bruising or bleeding spots on your skin
• Do you have any other symptoms such as fever, fatigue, joint pain, high blood pressure or blood in your urine

Depending on the presentation and response to treatment, your doctor might need to order certain investigations such as allergy testing or blood tests to rule out the other possible underlying causes.³

Can I prevent chronic hives

Chronic hives can last for months or years and the average duration of chronic hives is around two to five years. About two-thirds of children and almost a half of adults with no identified triggering factor or underlying disease can go into spontaneous remission after 5 years. It is shown that disease duration increases with severity of chronic hives.⁴

There are some steps that you can take to help you manage chronic hives including:

• Try to avoid triggers
• Use an oral antihistamine to ease your symptoms
• Apply a cold compress to soothe the itchy area of skin 
• Take a cool shower or bath (you can try sprinkling baking soda or oatmeal powder into the bath water for an extra soothing effect)
• Apply an anti-itch cream or lotion such asa menthol cream to help soothe the skin
• Wear loose, smooth-textured cotton clothing and try to avoid clothing that is tight, scratchy and made from wool
• Protect your skin from the sun
• Keep a diary to track your symptoms to help identify your triggers

When should I call a doctor

The NHS recommends that you should see your GP if you have any of the following:

• No improvement in your symptoms after 2 days
• The rash is spreading
• Hives keeps coming back
• High temperature and feeling unwell
• Swelling under your skin

If your child has a rash that could be hives and you are worried, don’t hestitate to reach out to your GP or other health practioner.  

You must seek urgent medical attention by calling ambulance or going to your nearest emergency medical department if you experience any of the following:

• Wheezing
• Tightness in your chest or throat
• Trouble breathing or talking
• Swelling of your mouth, face, lips, tongue or throat

These symptoms could be due to a serious, life-threatening allergic reaction called anaphylaxis..

Summary

Chronic hives or urticaria is a condition that is characterised by an itchy raised rash lasting for more than 6 weeks. Although there are identified triggers in certain cases, most cases can have no specific cause  identified. A diagnosis is made mainly based on medical history and a physical examination after which treatment will start. Antihistamines might help your hives enough to go into remission after a while. However, your hives may persist for many years, significantly affecting your quality of life. 

It is important to note that if your case of hives involves symptoms of wheezing, tightness in your chest or throat, difficulty breathing or talking and any swelling of your mouth, face, lips, tongue, or throat, you need to seek medical attention immediately as these may be indicative of a life-threatening allergy called anaphylaxis.