Urticaria (Chronic Hives) – Causes, Types, Diagnosis & Treatment

What is Urticaria?

Urticaria (chronic hives) is a skin rash, which proceeds with erythema (redness), papules (rise above the surrounding skin) and itching or burning sensation.

Urticaria
Source: www.commons.wikimedia.org

According to the nature of the flow, the condition is divided into Acute [2] urticaria (up to 6 weeks, and which is primarily due to allergic reactions) and Chronic [3] (which lasts for more than 6 weeks and is rarely caused by an allergy).

Urticaria is due to the release of histamine and other inflammation mediators (cytokines) from the skin cells. This process can be the result of an allergic or non-allergic reaction, differing in the induction of the release mechanism of histamine. The main difference is that the allergic urticaria, IgE antibodies (immunoglobin E), causing mast cell degranulation [4], which releases histamine.

In non-allergic asthma, the antibodies (also called immunoglobulins, are large Y-shaped proteins which function to identify and help remove foreign antigens or targets such as viruses and bacteria) directed to the FcεRI  receptor on mast cells cause its chronic stimulation.

    Depending on the causes hives are divided into:

Allergic urticaria

It is caused by various allergens (substances that cause allergic reaction of the body)

Allergic urticaria
Figure 4: Redness on forearm and and elbow as a result of chlorhexidine allergy
Source: www.openi.nlm.nih.govFoods – cow’s milk and dairy products (cheese, cottage cheese, yogurt), eggs and products made with eggs – creams, mayonnaise, soup condiments… (the egg white is much more allergenic than egg yolks). Preservatives – substances widely used in the food industry to extend the shelf life and storage of various foods (benzoates, sodium bisulfite, acetylsalicylic acid etc.), Colouring agents used in the food industry; Fish, clams, oysters and other seafood. Fruits, groundnuts, citrus fruits, strawberries, raspberries, soybeans, walnuts, almonds, apricots, peaches. Other substances added to foods such as antibiotics, pesticides, herbicides microbes.
  • Commonly used legal drugs – antibiotics are one of the most common allergens (substances inducing an allergic reaction). beta-lactam antibiotics, penicillin, ampicillin, amoxicillin, methicillin, oxacillin, cloxacillin, carbenicillin, azlocillin, imipenem, cefazolin, cephalothin, cefaclor, and zinacef and others.  Antibiotics of the tetracycline and macrolide group can also provoke urticaria flare-up. Quite common causes of allergic reactions including drugs with anti-inflammatory activity such as Aspirin, Ibuprofen, Indomethacin… chemotherapeutics-Biseptol. Antidiabetic agents, glimepiride (Amaryl, Neoglim), Piracetam, Codeine and some anticonvulsants.
  • Infections and Parasites:

– Viral infections, urticaria viral Hepatitis, Infectious mononucleosis and Mycoplasma;

– bacterial infections, sinusitis, dental abscess;

– parasites, Echinococcosis (dog tapeworm), strongyloidiasis, Blastocyst;

Solar urticaria

It affects areas of the skin, which are usually exposed to the sun: face, neck, arms and legs. Appears within minutes after exposure to sunlight and disappears just as quickly – from several minutes to 2 hours. The rash can rarely persist for 24 hours.

Solar Urticaria
Figure 2: Acute photosensitivity reaction in EPP.
Source: www.openi.nlm.nih.gov

Cold urticaria

It is caused by exposure of the skin to extreme cold, wet and windy conditions and occurs in two forms. The rarer form is hereditary and occurs throughout the body for about 9 to 18 hours after exposure to cold. The most common form of cold urticaria is demonstrated by the rapid appearance of hives on face, neck or hands after exposure to cold. Severe reactions can also occur after contact with cold water. Ex. swimming in cold water is the most common cause of the severe reaction. This can lead to a massive release of histamine which leads to lowered blood pressure, even temporary loss of consciousness, shock, and even death. Cold urticaria is diagnosed by skin contact with an ice cube, placed in the forearm area for 1 to 5 minutes. If the patient suffers from cold urticaria, hives will appear. The condition is different from the normal redness and can be seen in people without cold urticaria. Patients with cold urticaria should learn to protect themselves from the rapid decrease in body temperature.

Cold-induced Urticaria
Cold-induced urticaria with a familial transmission: a case report and review of the literature.
Source: www.openi.nlm.nih.gov

Delayed pressure urticaria

It occurs in people doing physical exercises [8]. They receive typical rash, pruritus, shortness of breath, and lowered blood pressure from 5 to 30 minutes after the beginning of the training session. These symptoms may progress to shock, even sudden death. Jogging is the most common physical activity that causes this type of urticaria. Immediate symptoms of Delayed pressure urticaria could be treated with antihistamines, epinephrine. Avoiding exercise or foods that cause urticaria is very important. In particular circumstances, the prophylaxis can be performed with regular exercises, under medical supervision.

Delayed Pressure Urticaria
Figure 5: Pressure testing for delayed pressure urticaria (a). Swelling after application of 14.6 kPa pressure with a 5 kg heavy metal rod for 15 min (b)
Source: www.openi.nlm.nih.gov

Cholinergic urticaria

It is provoked by sweating, exercise, bathing, staying in a heated environment, or emotional stress [9]. Hives are typically smaller than the usual hives and also have a short duration.

Cholinergic Urticaria
Figure 1: Clinical photographs of cholinergic urticaria. (A) Typical non-follicular wheals. (B) Follicular wheals. (C) Mixed type of follicular wheals (arrows) and non-follicular wheals (arrowheads). (D) Erythema without wheals. (E) Multiple red spots on the palm without a perilesional halo.
Source: www.openi.nlm.nih.gov

Dermographism

The term means “writing on the skin”[10] and is a chronic form of urticaria (hives). This condition usually has no symptoms, and most people with dermographism are healthy.

However, symptomatic dermographism may limit activity and thus reduce the quality of life. It usually occurs in 4-5% of the population and is one of the most common types of urticaria. The reaction of the skin usually becomes evident immediately after scratching and disappears within 30 minutes.

Dermographism is a common form of chronic urticaria. The swelling typically goes away within an hour. The condition does not need treatment, but antihistamines, such as diphenhydramine (Benadryl), fexofenadine (Allegra) or cetirizine (Zyrtec), can reduce inflammation.

Dermographism
Figure 1: Dermographic urticaria resulting from pressure through clothing.
Source: www.openi.nlm.nih.gov

Pressure urticaria

This type of urticaria can occur immediately as a response to sustained pressure on the skin. The delayed form of pressure urticaria is represented by rashes appearing after about six hours of initial application of pressure on the skin.

Rashes can last from eight hours to three days. The source of pressure on the skin can be obtained by tight clothing, belts, clothing with tension straps and others. The condition most often affects the arms, legs, buttocks, abdomen, and face. This form of the disease is very rare.

Pressure urticaria
f3-wjem-16-163: Skin findings include tense bullae on erythematous bases and urticaria on the left anterior thigh.
Source: www.openi.nlm.nih.gov

Aquagenic urticaria (water induced urticaria)

This type of urticaria is also rare and is provoked after a contact with water [5]. The reaction is not dependent on the water temperature and the skin looks similar to the cholinergic form of the disease. Rashes appear within one to 15 minutes after contact with water and can last from 10 minutes to two hours.

Most researchers believe that this condition is actually due to skin sensitivity to additives in the water, such as chlorine. Water-induced urticaria is diagnosed by spraying the skin with tap and distilled water. The symptoms are usually treated with Zostrix. In some cases, complete control of symptoms with antihistamine has been reported, whereas in other cases, there is a failure to adequately control symptoms.

Aquagenic urticaria
Figure 1: Pin-head to match-head sized wheal surrounded by erythema on the upper trunk after the water provocation test.
Source: www.openi.nlm.nih.gov

Non-allergic urticaria 

Most of the reasons why urticaria appears are due to an autoimmune genesis [6]. The patients often have other autoimmune diseases such as Hashimoto’s thyroiditis, celiac disease, type 1 diabetes, rheumatoid arthritis, Sjogren’s syndrome, vitiligo, or systemic lupus erythematosus.

Some cases of chronic urticaria are caused by chronic infection with Helicobacter pylori, or intestinal parasites, Morphine treatment, various skin diseases known as porphyrias causing drug-induced solar urticaria, scombroid food poisoning in direct consumption of histamine released by bacterial decay in fish meat as well as chronic stress.

Clinical manifestation

The main symptom of urticaria is presented by typical rash unit – hives – raised above the surrounding skin with a sharp boundary (like nettle), with redness, sometimes more intense in the periphery to faded in the center of the rash.

Another characteristic is the intense itching or burning of the skin, dynamic development (for about 1-2 hours hives can increase in size, then decrease or disappear completely and reappear in other locations).

Urticaria may be accompanied by other allergic reactions such as sneezing, runny nose, shortness of breath, severe anaphylactic reactions, such as abdominal pain, nausea, vomiting, palpitations, low blood pressure, swelling of the eyelids, lips, soft tissues of the throat (Quincke’s edema) causing a suffocation.

Diagnosis

Diagnosis [7] can be made on the basis of clinical examination, laboratory tests, skin testing and others. According to The National Center for Biotechnology Information:

„Complete blood count, Erythrocyte sedimentation rate and C-reactive protein are important investigations for diagnosis of infections in urticaria.”

Treatment

The basis of the treatment of acute and chronic urticaria is educating the patient to avoid factors provoking appearance of hives.

Chronic urticaria can be difficult to treat and can lead to significant disability.

Unlike acute form, 50-80% of people with chronic urticaria suffer from distinct rash-provoking factors. Fortunately, 50% of people with chronic urticaria enter remission period (spontaneous recovery) within 1 year of the beginning of the disease.

Usually, the treatment is symptomatic and is divided into stages.

The goal for urticaria treatment is to relieve symptoms as the condition resolves itself. The most commonly used treatments are antihistamines which prevent the effects of histamine. The main side effect of such drugs, however, is sleepiness.

Most of the antihistamines are available without a prescription. The daily intake can be up to three times a day, but since they can cause sleepiness, it is recommended to take the pill before bedtime. Drivers should be especially careful as well as people who engage in other activities requiring mental alertness.

Steroids can help in more severe cases of urticaria, their effect is almost immediate. Such medications are usually prednisone-based, which can help to relieve severe acute hives that do not get better with antihistamines.

However, oral steroids may be used temporarily to relieve chronic hives, but they should not be used for long-term treatment. Steroid treatment can have serious side effects when taken for long periods of time.

Topical treatment of urticaria

This treatment is usually not effective. It includes creams and lotions that help numb the nerves and reduce the itching. Many of these topical preparations do not require a prescription.

Cortisone-containing creams (steroids)

Such products require a prescription, but they are not very useful in controlling the severe itching caused by urticaria.

The most successful treatment for urticaria would be to find what triggers the allergic reaction and avoid the allergen!

There’s no “best treatment” as it depends on each individual.

That being said, the first step in the treatment of hives is a change in diet. You should avoid or eliminate all possible triggers from your food list. The common foods you should avoid are eggs, milk, peanuts, shellfish, certain berries, and additives.

If you suffer from chronic hives, it’s strongly recommended that you consult a qualified practitioner to help you find the best treatment.

Home remedies

Baking Soda

The antiseptic baking soda [1] is a popular remedy for reducing hives symptoms. The inflammatory properties of soda agent help to reduce inflammation, and the accompanying itching.

You can add around 200mg of baking soda to a tub full of hot water, which will immediately soothe your skin. Mix the ingredients (soda and water) well and then soak in the water for twenty minutes to half an hour.

An alternative recipe is the following -put two tablespoons of baking soda in a small bowl. Add enough water to make a thick paste. Spread the paste on the affected area. Leave it on for 10 minutes before rinsing it off with warm water.

These procedures can be done once a day or several times – as needed.

Apple cider vinegar

The precious apple cider vinegar is an indispensable remedy for hives. Its antihistamine properties quickly relieve inflammation and also regulate the immune response of the organism. It has a powerful regenerating effect on the skin.

Add apple cider vinegar (two cups) to the tub full of water (warm). Stay in it about 15 to 20 minutes once a day.

+ Cider vinegar in equal proportions water use for washing damaged skin three times daily.

The mix of apple cider vinegar (one to two tablespoons) with water (one cup) lemon juice and honey and drink the mixture three times daily.

You can follow these recipes until your condition is visibly improved or the symptoms resolve completely.

Ginger

Known as the “wonder drug”, ginger is a very popular cure for urticaria because of its strong anti-inflammatory and antihistamine properties. The effect of the constituents of ginger root is focused directly to the enzymes that cause inflammation. It improves circulation to the skin, relieves swelling and reduces unpleasant itching.

Boil 1/4 cup of raw sugar (brown) and 1tbsp fresh ginger in 3/4 cup of vinegar for a few minutes. Mix these ingredients of this solution with the water (hot) and apply several times a day on the affected skin.

The application of shredded ginger on the inflamed skin is another alternative treatment for urticaria. The treatment has a better effect on the skin if applied 3 times a week. You can also leave the ginger root in the refrigerator if you would like to add a cooling effect.

Ginger tea will also soothe the irritated skin. You can even try chewing fresh ginger to help the healing process.

Aloe vera

The Magical plant can be applied topically in order to reduce the inflammation and itching sensation caused by hives. The plant contains anti-inflammatory and antibacterial agents, reducing the severity of symptoms.

The benefits of aloe vera oral intake are related to immunity stimulation and toxins elimination2 tbsp daily would be enough to provide with a soothing effect.

The topical application of fresh gel on the affected skin (for about 15 minutes), ensures complete healing of the irritated skin. You can apply fresh aloe vera gel over a long period of time.

Nettles

Even if it seems ridiculous, stinging nettles is a perfect urticaria treatment and all the unpleasant symptoms arising from the condition.

Herbalists recommend it as the most powerful natural remedy for inflammation of the skin. With its powerful antihistamines, anti-inflammatory and astringent properties, it relieves swelling, inflammation, and itching.
Boil Dried nettle leaves (1tbsp. per cup of water) for 15 minutes. Strain and add honey. Drink nettle tea twice or three times daily until the condition improves.

Stinging nettle capsules and tablets can be taken orally. Five 300-mg nettle capsules/tablets daily will reduce the skin irritation.

Turmeric

Turmeric has a lot of physiological healing effects similar to steroids. Proven by research, it treats inflammation caused by urticaria.

Turmeric is considered to be very effective natural antihistamine and antioxidant.

Just add 1 tbsp. Turmeric powder to 200 ml of hot milk (prepare 2 times a day until you see improvement).

Note: Do not take turmeric in any form if you are taking blood-thinning medications!

Peppermint

Due to its cooling effect, peppermint is another popular remedy for skin inflammation. Its anti-inflammatory and antioxidant agents help reduce itching and the burning sensation.

Add 2 tbsp. chopped fresh mint leaves to a glass of water (hot) and leave it until it cools. Use this refreshing mint water as a lotion for the irritated skin several times a day.

You can also crush mint leaves (1 tbsp.) and add sugar to it (2 tbsp.) and put it in a glass of water for about five minutes. Drink the mixture at least twice daily or depending on the severity of your condition.

References

  1. https://tspace.library.utoronto.ca/bitstream/1807/48072/1/dv08045.pdf
    Management of autoimmune urticaria
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492902/
    An approach to the patient with urticaria
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276885/
    CHRONIC URTICARIA
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721257/
    Mast cell degranulation – a mechanism for the anti-arrhythmic effect of endothelin-1?
  5. https://rarediseases.info.nih.gov/diseases/10901/aquagenic-urticaria
    Aquagenic urticaria
  6. https://www.ncbi.nlm.nih.gov/pubmed/24620551
    [A challenge for pediatrician: non-allergic urticaria].
  7. https://medlineplus.gov/ency/article/000874.htm
    Hypersensitivity vasculitis
  8. https://www.ncbi.nlm.nih.gov/pubmed/6127359
    Delayed pressure urticaria.
  9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710039/##
    Anaphylaxis-like cholinergic urticaria
  10. https://www.clinicaltrials.gov/ct2/show/NCT02169115
    Urticaria Facticia Treatment With Omalizumab (UFO) (UFO)

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