Urticaria (hives) is a skin condition characterised by wheals which are skin coloured to red swellings of variable size which can occur over any part of the skin and remain for a few minutes to several hours. They are usually associated with itching and may be acute or chronic. Urticaria treatment can sometimes be difficult especially in chronic urticaria (lasting for more than 6 weeks).

To know about the causes of urticaria and it’s trigger factors, check out All About Urticaria.

How do you treat urticaria?

The treatment of urticaria should be tailored to the individual patient. General measures include removal of any identifiable cause, explanation, information and reassurance. Avoidance of certain food products, certain drugs like aspirin and other NSAIDs are recommended because these drugs aggravate chronic urticaria in about 30% of patients. Treatment of underlying diseases, e.g. Thyroid disease, Helicobacter pylori (a stomach infection) is also important as a part of urticaria treatment.

Avoidance of trigger factors

In addition to medical management, the cause of urticaria should be eliminated if known e.g. drug or food allergy. Avoidance of relevant allergens clears urticaria within 48 hours.

Treat identified chronic infections such as H pylori.
Avoid aspirin, opiates and nonsteroidal anti-inflammatory drugs (paracetamol is generally safe).
Minimise dietary pseudo allergens for a trial period of at least three weeks.
Avoid known allergens that have been confirmed by your doctor by a positive skin prick test.
Cool the affected area with a fan, cold flannel, ice pack or soothing moisturising lotion.

Avoid physical triggers for inducible urticaria

The physical triggers for inducible urticaria should be minimised; see examples below. However, sometimes symptoms can persist despite this in which case you may need to combine medical therapy to your urticaria treatment.

Symptomatic dermographism: Reduce friction, e.g. avoid tight clothing.
Cold urticaria: Dress up carefully in cold or windy conditions and avoid swimming in cold water.
Delayed pressure urticaria: Don’t hang heavy bags on your shoulders or wear tight belts.
Solar urticaria: Cover your skin with full sleeves and apply broad-spectrum sunscreens.

Some patients with inducible urticaria benefit from daily induction of symptoms to induce tolerance. Phototherapy may be helpful for symptomatic dermographism.

Lifestyle and home remedies to treat urticaria

Chronic urticaria can go on for months or years. They can interfere with sleep, work and other activities. The following precautions may help prevent or soothe the recurring skin reactions of chronic hives:

Wear loose, light clothing.
Avoid scratching or using harsh soaps.
Soothe the affected area with a cool bath, lotion or anti-itch cream.
Keep a diary of when and where hives occur, what you were doing, what you were eating, and so on. This may help you and your doctor identify triggers.
Avoid known triggers.
Avoiding certain foods may help. Foods known to trigger histamine production include spinach, fish, yoghurt, fish, tomato, processed, meats, chocolate, and strawberries.
Apply sunscreen before going outside.
Cut down on alcohol or abstain.
Avoiding certain medications.
Avoiding stress, if possible, perhaps with meditation or relaxation techniques.

Some recommend supplements such as evening primrose oil, vitamin C, D and others. It is important to speak to a doctor before using supplements, as some supplements can cause flare-ups. Keeping a record of flareups can help identify a trigger.

Medical Management

First line treatment

For urticaria treatment, the first step in medical management is to start with antihistamines. The newer generation H1 antihistamines have a less sedating effect and fewer side effects so they are preferred over the older generation H1 antihistamines as the initial choice of therapy. In pregnancy, certain antihistamines are safer so consult your skin specialist to know which is the best and safest option for you.

Certain antihistamines have been proposed as preferred for particular subtypes of chronic urticaria, such as hydroxyzine for cholinergic urticaria and cyproheptadine for cold-induced urticaria. Second generation nonsedating (or less sedating) antihistamines like levocetirizine, bilastine, loratidine, fexofenadine, desloratadine etc. can also be used for urticaria treatment.

It is common to double or triple the dosage of nonsedating antihistamines if patients do not respond to the standard dosage. The EAACI/GA2 LEN recommendation of using nonsedating H1 antihistamines up to four-fold above the recommended doses appears to be effective with mild sedation. If the response is less, then the tricyclic antidepressant doxepin,10-25 mg initially up to 75 mg at night or H2 antihistamines or mast cell stabilizers can be added.

Second line treatments

Your doctor may prescribe short courses of systemic steroids for 3-4 weeks, in resistant cases of chronic urticaria, but long term therapy can not be given because of known adverse effects. If urticaria relapses after a short course of steroid therapy, and symptoms are not adequately controlled by H1 antihistamines, leukotriene-receptor antagonists can be tried. These have been shown to have a beneficial effect in the treatment of chronic urticaria especially in cases which were aggravated by the NSAIDs and food additives.

Resistant/severe cases:

Cyclosporine has been shown to be effective in severe unresponsive cases.

Omalizumab has been tried in patients with chronic autoimmune urticaria resistant to antihistamines and is currently the second line if up dosing antihistamines don’t control the hives as per the European guidelines. Treatment with omalizumab 150-300 mg once or twice a month depending upon weight and IgE levels resulted in a significant reduction in the patients’ hives, reduced the need for additional medication to control symptoms, and improved patients’ quality of life.

Plasmapheresis has been used to treat some patients with auto-antibody positive severe chronic urticaria.

Low-dose methotrexate, hydroxychloroquine, sulfasalazine and dapsone, which have immunomodulatory properties, have been used effectively in the treatment of chronic urticaria. Cyclophosphamide has also shown a beneficial effect in treating severe autoimmune chronic urticaria.

Phototherapy with UV light or photochemotherapy has been used to treat urticaria, but the reported results have been variable.

ASST has been used successfully by many skin specialists in their practice for autoimmune urticaria which is an advanced form of whole blood therapy.

Histaglobulin has been used successfully by many skin specialists to reduce the severity and flares of urticaria.

Alternative medicine

Few authors have suggested that acupuncture is effective in up to 90% of cases of chronic idiopathic urticaria.

Psychological therapy

Complementary psychological treatment of patients suffering from chronic urticaria, particularly hypnosis and relaxation techniques may help in the improvement of the urticarial wheals.

Future prospects in urticaria treatment

Right now, the management of chronic urticaria is to stop the histamine release but there is no permanent cure and it may return after months or years. Medical science is constantly evolving. Today, we can treat so many conditions which did not have any treatment a decade ago.

Read about some common myths and FAQs about urticaria.