Urticaria

Urticaria, commonly known as hives, is a prevalent skin condition characterised by itchy, raised welts on the skin. These welts can vary in size and appear anywhere on the body. While often acute and self-limiting, some individuals experience chronic urticaria, leading to significant discomfort and impact on daily life. Understanding the causes, symptoms, and management strategies is crucial for effective control and relief.

Urticaria is an inflammatory skin disorder resulting in transient, itchy welts (wheals) that can appear suddenly and may last from a few hours to several days. These wheals are often red or skin-coloured and can be accompanied by swelling known as angioedema, particularly around the eyes, lips, hands, and feet. The condition arises due to the release of histamine and other chemicals from mast cells in the skin, leading to increased blood flow and fluid leakage into the superficial layers of the skin.

Urticaria can be classified based on duration and triggers:

Acute Urticaria: Lasts less than six weeks and is often triggered by infections, foods, or medications.
 

Chronic Urticaria: Persists for more than six weeks and is subdivided into:

• Chronic Spontaneous Urticaria (CSU): Occurs without identifiable external triggers.
• Chronic Inducible Urticaria (CIndU): Triggered by specific stimuli such as pressure, cold, heat, sunlight, or exercise.

Urticaria, or hives, can be triggered by a wide range of factors. While acute cases often have identifiable causes, chronic urticaria may have no clear origin. Below are the key known and suspected causes:

1. Allergic Reactions

This is a common cause of acute urticaria. When the body encounters an allergen, it releases histamines, which cause the classic red, itchy welts.

Common allergens include:

• Certain foods (e.g., nuts, shellfish, eggs, milk)
• Insect stings or bites
• Medications (antibiotics, NSAIDs, vaccines)
• Latex
   

2. Physical Triggers (Physical Urticaria)

Certain physical stimuli can provoke wheals or hives in susceptible individuals.

These include:

• Pressure (tight clothing, straps)
• Temperature extremes (cold urticaria or heat urticaria)
• Exercise or sweating (cholinergic urticaria)
• Sun exposure (solar urticaria)
• Vibration or friction (dermographism)
   

3. Infections

Bacterial, viral, and parasitic infections can lead to urticaria, especially in children.

• Viral: hepatitis, common cold, EBV
• Bacterial: urinary tract infections, streptococcus
• Parasitic: more common in developing countries
   

4. Autoimmune Conditions

In chronic spontaneous urticaria (CSU), the immune system mistakenly targets the body’s own cells, causing hives. This form is often associated with:

• Thyroid disorders (Hashimoto’s, Graves’)
• Lupus
• Rheumatoid arthritis
   

5. Stress and Anxiety

Emotional distress does not directly cause urticaria but can act as a trigger or worsen existing symptoms.

6. Food Additives and Preservatives

Artificial colouring, flavouring, preservatives like sodium benzoate, or MSG may provoke hives in some people.

7. Idiopathic Causes

In many chronic cases, no clear cause is identified even after thorough testing. These are termed idiopathic urticaria and often require symptom management.

• Raised, Red Welts: Itchy, red or skin-coloured welts that can vary in size and shape.
• Itching: Intense itching, which may be worse at night.
• Angioedema: Swelling of deeper layers of the skin, often around the eyes, lips, hands, feet, or genitals.
• Transient Nature: Individual hives typically last less than 24 hours but may recur.
• Burning or Stinging Sensation: Some individuals may experience a burning or stinging feeling in the affected areas.

Diagnosing urticaria involves a mix of patient history, physical examination, and, in some cases, investigative tests. Here’s how doctors typically approach diagnosis:

1. Detailed Medical History

The doctor will ask about:

• Duration and frequency of hives
• Appearance and location of rash
• Associated symptoms (swelling, breathing difficulty)
• Recent diet changes, new medications, or insect bites
• Exposure to cold, heat, pressure, or sunlight
• Personal or family history of allergies or autoimmune conditions
   

2. Physical Examination

A simple inspection of the rash can often identify urticaria. Key features:

• Raised, red welts (wheals)
• Blanching on pressure
• Temporary nature (usually disappearing within 24 hours)
   

3. Allergy Testing

May be done for acute urticaria when a food, medicine, or insect sting is suspected:

• Skin prick test
• Specific IgE blood tests
   

4. Blood Tests and Screening

Recommended in chronic urticaria or when an autoimmune or systemic cause is suspected:

• Complete blood count (CBC)
• Thyroid function tests (T3, T4, TSH, anti-TPO)
• Erythrocyte sedimentation rate (ESR) or CRP
• ANA (antinuclear antibodies) for autoimmune screening
   

5. Challenge Tests

In cases of physical urticaria, the doctor may perform:

• Ice cube test (for cold urticaria)
• Exercise test (for cholinergic urticaria)
• Dermographism test (stroking the skin)
   

6. Elimination Diet

If food allergy is suspected, an elimination diet under supervision may be used to identify the culprit.

Treatment for urticaria focuses on relieving symptoms and preventing recurrence. The approach differs based on whether the condition is acute or chronic.

1. Avoiding Triggers

Identifying and eliminating known triggers is key. Common steps include:

• Discontinuing suspect foods or medications
• Wearing loose, breathable clothing
• Avoiding extreme temperatures and stress
   

2. Antihistamines (First-Line Treatment)

These are the mainstay of urticaria treatment. They block histamine, the chemical responsible for wheal formation and itching.

• Non-sedating antihistamines (preferred for daytime use): Cetirizine, Loratadine, Fexofenadine, Levocetirizin
• Sedating antihistamines (for night-time relief): Diphenhydramine, Hydroxyzine (Brand available: Atarax, Altam)
• Up-dosing: In chronic urticaria, doses can be increased up to four times the standard under medical supervision.
   

3. Corticosteroids

Used short-term for severe flares when hives are widespread or unresponsive to antihistamines.

• Prednisolone is commonly prescribed
• Not for long-term use due to side effects
   

4. Biologic Therapies (for Chronic Urticaria)

If symptoms persist despite antihistamines, the following may be used:

• Omalizumab (Xolair): A monoclonal antibody that blocks IgE; highly effective for chronic spontaneous urticaria
• Cyclosporine: An immunosuppressant used in difficult cases
   

5. Other Medications

• Leukotriene receptor antagonists (e.g., Montelukast) for aspirin-sensitive or cold urticaria
• H2 blockers (e.g., Ranitidine) in combination with H1 antihistamines
• Tricyclic antidepressants (e.g., Doxepin) – also have antihistaminic properties
   

6. Topical Creams and Lotions

While not highly effective for hives, soothing lotions (calamine, menthol) or corticosteroid creams may be used for minor irritation.

7. Lifestyle Measures

• Cool compresses for temporary relief
• Oatmeal or baking soda baths to soothe itching
• Stress management techniques like yoga, mindfulness, and meditation

• Age: Younger individuals are more commonly affected.
• Gender: Women are more frequently affected than men.
• Personal or Family History: Of allergies or autoimmune diseases.
• Stress: Emotional stress can trigger or worsen symptoms.
• Existing Health Conditions: Such as thyroid disorders or other autoimmune diseases.

• Anaphylaxis: Severe allergic reactions can occur, though rare.
• Chronic Discomfort: Persistent itching and discomfort can affect quality of life.
• Sleep Disturbances: Due to nocturnal itching.
• Emotional Impact: Anxiety and depression may develop in chronic cases. 

• Stay Cool: Heat can exacerbate symptoms; use cool compresses.
• Wear Loose Clothing: Tight clothing can irritate the skin.
• Use Gentle Skin Care Products: Avoid harsh soaps and lotions.
• Regular Follow-ups: Keep in touch with your healthcare provider to manage the condition effectively.

Seek medical attention if you experience:

• Persistent hives lasting more than six weeks
• Hives that recur frequently without an obvious trigger
• Swelling of lips, tongue, or throat
• Difficulty breathing or dizziness (possible sign of anaphylaxis)
• Hives interfering with sleep or daily activities

A dermatologist or allergist can help identify causes, recommend appropriate tests, and formulate an effective treatment plan.

When visiting a healthcare provider for urticaria, it’s helpful to come prepared with questions that can guide treatment and deepen your understanding of your condition. Consider asking:

• What type of urticaria do I have – acute or chronic?
• What might be triggering my symptoms?
• Are there specific tests you recommend?
• Which treatment options are best suited for my condition?
• How long will it take for my symptoms to improve?
• Are there any side effects of the medication you’re prescribing?
• Should I make changes to my diet or lifestyle?
• Do I need to see a specialist like an allergist or dermatologist?
• Could this be linked to an autoimmune issue?
• How should I manage future flare-ups?

Urticaria, though often short-lived and benign, can significantly impact daily life—especially when it becomes chronic. Identifying triggers, using appropriate treatments like antihistamines or advanced therapies, and maintaining a healthy lifestyle can go a long way in controlling symptoms. If you’re struggling with hives that don’t seem to go away or frequently return, don’t ignore the signs—consult a healthcare provider for timely diagnosis and management.