Urticaria (Hives) Treatment to Improve Symptoms

Acute urticaria (hives) is a common skin condition that affects up to 20% of people at some point in their lives, and can transition into chronic urticaria for up to 8% of the population. Hives tend to go away on their own without treatment, but self-care strategies like taking a cooling bath can help manage discomfort.

Some people, however, may require medication such as an antihistamine, anti-inflammatory drug, corticosteroid, or monoclonal antibodies. The choice of treatment for hives is based largely on the underlying cause and whether or not you respond to first-line treatment.

This article offers a detailed overview of the options for treating hives, including home remedies, over-the-counter medications, prescription drugs, and complementary and alternative therapies.

What Causes Hives?

Knowing the cause of hives can help determine treatment. Hives typically occur as a reaction to an allergen or another physical trigger, such as heat. They can also be caused by an underlying health condition. In some cases, there is no known cause for an outbreak of hives. 

Some common triggers of urticaria include:

• Foods you are allergic to, such as nuts or eggs
  
• Certain plants like stinging nettles or poison ivy
• Medications such as antibiotics or certain blood pressure medications
• Ingredients in cosmetics or other products
• Latex
• Exposure to sunlight or hot temperatures
• Viral or bacterial infections
• Certain autoimmune conditions such as celiac disease, rheumatoid arthritis, and autoimmune hypothyroidism
  

Types of Urticaria

Urticaria is usually classified as acute or chronic. The major difference depends on how long the symptoms last.

Acute

Acute cases of urticaria are those that come on suddenly and are short-lived. Most are allergy-related. The skin comes in contact with a normally harmless substance that the immune system mistakes as something it needs to eliminate, which triggers the skin reaction.

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

Chronic

Hives are considered chronic if they last for more than six weeks. They're thought to be caused by an autoimmune response, not an allergic one. Autoimmune means that the immune system is attacking healthy cells in the body as if they were invaders. This may be due to an autoimmune disease or an unknown cause.

Autoimmune hives may improve by treating the underlying cause. For example, chronic urticaria is sometimes related to autoimmune thyroid disease. There is evidence that treating the thyroid condition may also improve urticaria symptoms. 

How Are Hives Treated?

The best way to treat hives is to avoid getting them in the first place. If they're caused by an allergic reaction or an environmental trigger, it is important to find out what those triggers are. Taking steps to avoid your triggers is the best thing you can do on your own to treat acute hives.

If your hives are chronic, it is important to see a healthcare provider so you can learn the underlying cause.

Acute Urticaria

If your hives appear suddenly after you've been exposed to a trigger and your symptoms are mild, you can treat them at home. Remedies that may be helpful include:

• Apply a wet, cold compress: The simplest way to do this is to soak a washcloth in a bowl of ice water and apply it directly to the skin. A cooling bath can also help.
• Wear loose clothing: This type of clothing allows for airflow and reduces friction on the skin.
• Choose fabrics wisely: Opt for articles made of cotton or a smooth, lightweight synthetic like rayon. Avoid wool, linen, denim, or any textured fabric that can irritate the skin.
• Stay cool: Avoid getting overheated by dressing in layers that you can remove, if needed, choosing to shower in cool water, and staying in air conditioning when it's hot outside.
• Do not scratch: It's more than tempting, but scratching your skin can make your hives worse.
• OTC antihistamines: Antihistamines are the best, first-line treatment for hives. They work by suppressing histamine, a chemical produced by the immune system that triggers allergy symptoms. Allegra (fexofenadine), Claritin (loratadine), Xyzal (levocetirizine dihydrochloride), and Zyrtec (cetirizine) are some examples. Benadryl (diphenhydramine), an older antihistamine, is generally avoided during the daytime as it can cause drowsiness, but it may help you sleep if itching is keeping you up at night.
• H2 blockers: Histamine H2-receptor antagonists, also known as H2 blockers, are another class of drug sometimes used with antihistamines. Commonly used to treat heartburn, H2 blockers work by narrowing blood vessels in the skin. This helps relieve redness and swelling. H2 blockers like Tagamet (cimetidine) and Pepcid (famotidine) are available over-the-counter. Side effects can include headache, dizziness, diarrhea, muscle ache, joint pain, and rash.
• Prescription antihistamines: Clarinex (desloratadine) is an antihistamine similar to Claritin and Zyrtec, but it is only available by prescription. It is less likely to cause drowsiness compared to other older antihistamines. If non-drowsy antihistamines fail to provide relief, your doctor may prescribe Vistaril (hydroxyzine pamoate) to be taken at bedtime. Vistaril is a stronger antihistamine used to treat a wide range of skin reactions, including chronic urticaria and contact dermatitis. Common side effects can include headaches, stomach upset, and blurred vision.
• Corticosteroids: If prescription antihistamines don't help or cause intolerable side effects, your healthcare provider may prescribe corticosteroids (steroids) to quickly bring down the swelling and itchiness. Corticosteroids work by suppressing the immune system as a whole. They are intended for short-term use only. Prednisone is the most commonly prescribed option, delivered either by injection or pill.

Chronic Urticaria

If your hives are caused by an autoimmune response, you won't have any triggers to avoid. But many of the same tips for treating itchiness and swelling due to acute hives can still help, including cold compresses, wearing loose clothing and lightweight fabric, staying cool, and avoiding scratching. Medications like antihistamines and H2 blockers can also help people with chronic urticaria.

For some people, however, OTC medication may not be strong enough. Certain chronic types of urticaria may require different medications, particularly if the trigger is physical rather than allergic. Some of these include:

• Prescription antihistamines: Medications such as Clarinex (desloratadine) and Vistaril may be prescribed if OTC antihistamines aren't effective.
• Corticosteroids: If you have chronic hives, your healthcare provider may prescribe corticosteroids for the short-term treatment of flare-ups. The long-term use of prednisone is linked to an increased risk of osteoporosis, glaucoma, and diabetes.
• Leukotriene modifiers: These drugs work by blocking the effects of or production of leukotrienes. These are substances that can trigger the narrowing of air passages and promote inflammation, among other things. Your healthcare provider may prescribe these if you have chronic hives and antihistamines are not helping. Singulair (montelukast) is the most common leukotriene modifier prescribed for hives. Accolate (zafirlukast) is also sometimes also used to treat hives.
• Doxepin: Doxepin is a tricyclic antidepressant that also acts as a powerful antihistamine. It's marketed under various brand names including Silenor, Zonalon, and Prudoxin. When prescribed in a low dose, doxepin can be extremely effective in treating chronic or idiopathic (of unknown origin) hives. Doxepin must be used under medical supervision as it can cause suicidal thoughts in children and young adults with a history of depression or mental illness.
• Neoral: Neoral (cyclosporine) is a calcineurin inhibitor. It is typically used to prevent organ transplant rejection and is sometimes also used for psoriasis and rheumatoid arthritis. Cyclosporine can also effectively treat severe cases of chronic urticaria. It should not be used long-term because it may cause serious side effects.
• Xolair: Xolair (omalizumab) is an injectable drug originally prescribed for people with asthma. It has also been approved to treat chronic idiopathic urticaria if all other treatments fail. Xolair is a monoclonal antibody that works by blocking a protein that instigates an allergic response. Even so, scientists are not exactly sure how Xolair works insofar as most chronic hives are not allergy-related.
• Anti-inflammatory antibiotics: These include the prescription drugs Aczone (dapsone) and Azulfidine (sulfasalazine). These drugs don't work for everyone, but your healthcare provider might decide to prescribe them if you aren't responding well to first-line treatment.
• Procardia (nifedipine): Procardia is a calcium channel blocker typically used to treat high blood pressure. For some people, it may be effective as a second-line treatment for chronic urticaria.
• Mitigare (colchicine): Mitigare (colchicine) is sometimes prescribed to treat gout, but it may also work against chronic urticaria. It is typically used for patients who don't respond to first-line antihistamine treatment.
  

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Complementary and Alternative Medicines

While many complementary and alternative medicines are used to treat acute and chronic hives, the evidence supporting their use remains weak. Not only may some have no effect, but a few may also end up aggravating symptoms.

One such example is turmeric, a spice widely touted as a hives remedy. Studies have shown that curcumin, the substance that gives turmeric its yellow color, can trigger skin irritation and hives in some people.

If you choose to use a natural remedy, speak with your doctor first to ensure that it doesn't interact with any medications you may be taking.

Colloidal Oatmeal

If the itching and swelling are driving you mad, the fastest form of relief may be a cooling bath. It helps reduce swelling and tempers hyperactive nerve signals that trigger itchiness.

One additive that may help further relieve symptoms is colloidal oatmeal.

Some smaller studies have suggested that colloidal oatmeal—a finely milled oatmeal suspended in liquid, gel, or cream—can reduce the intensity of itching while softening inflamed skin.

Colloidal oatmeal is widely available as a bath additive and is an ingredient in some soothing lotions. For added relief, store your colloidal oatmeal lotion in the refrigerator.

Mind-Body Therapies

Stress does not cause urticaria but can aggravate the symptoms, particularly when the condition is chronic.

People often turn to mind-body therapies to relieve stress and the many health problems stress and anxiety can cause.

These include practices such as:

• Meditation
• Deep breathing exercises
• Guided imagery: A relaxation technique involving the conjuring of mental images that can help you "escape"
• Progressive muscle relaxation (PMR): A methodical tensing and relaxing of all of your major muscle groups
• Biofeedback: A provider uses information from instruments that monitor your body's functions to advise you as to how to alter them on your own
  

When to See Your Healthcare Provider

Seek emergency care at once if you have hives along with symptoms of anaphylaxis such as:

• Wheezing
• Shortness of breath
• Swelling of the tongue or throat
• Fainting or dizziness
• Racing heart

Hives may also be a symptom of Alpha-gal syndrome. This condition is a medical emergency and may also include gastrointestinal symptoms such as: 

• Nausea and vomiting
• Diarrhea
• Stomach pain
• Indigestion or heartburn
  

Make an appointment with your healthcare provider if you have hives that:

• Last longer than a few days 
• Appeared when you started taking a new medication or supplement
• Are recurrent, meaning they go away and then come back again
• Don't respond to OTC treatments such as antihistamines
• Are accompanied by swelling or pain
• Cover your entire body
  

Summary

There are many possible ways to treat urticaria (hives) depending on the underlying cause. These include home remedies like a cold compress or over-the-counter drugs like antihistamines and H2 blockers.

Chronic or treatment-resistant hives may benefit from prescription antihistamines as well as approved and off-label drugs like Xolair (omalizumab), doxepin, or Singulair (montelukast).

Complementary therapies may also help, including colloidal oatmeal baths or mind-body practices like meditation that can reduce the stress that makes chronic hives worse.