Hives Treatments and Medications

If you have ever broken out in hives, you know the tell-tale signs: itching and red spots on the skin. Hives are the classic sign of an allergic reaction—although hives could erupt for reasons other than allergies. For most people, hives are little more than a temporary nuisance. Other times it can be the first step in a worsening situation. Here’s what you need to know about hives.

What are hives?

Hives (or urticaria) are a common and usually harmless skin condition marked by spots on the skin that are itchy, red, and raised. Called wheals, these lesions may be round or ring-shaped. Hives are usually a temporary condition. Called acute urticaria, the rash fades in two to three hours but could hold on for as long as six weeks. Chronic urticaria lasts longer than six weeks.

While popularly thought of as an allergic reaction, hives can be brought on by many causes including:

• Allergens (contact urticaria)

• Insect stings or bites

• Poisonous plants

• Foods

• Chemicals

• Medicines

• Infections

• Emotional stress

• Thyroid problems

• Autoimmune disorders

• Physical causes (physical urticaria) such as cold (cold urticaria), sweating (cholinergic urticaria), water, sun exposure, or pressure on the skin (dermatographism)

Whatever the cause of hives, they all involve triggering specialized cells in the body, called mast cells, which then release histamines into the skin tissues. Histamines are the immune system’s intruder alarm and cause the redness and swelling characteristic of hives. Histamines also stimulate “itch” nerves, so itching and even pain accompany the histamine overload.

If enough histamines are released, the skin may swell up with fluid from the bloodstream, a condition called angioedema, which can occur with or without hives. This swelling occurs deeper in the skin, below the layer of fat tissue. Angioedema is most common in the hands, face, and feet, though in severe cases, it occurs in the throat or respiratory tract, which could make breathing difficult. Anaphylaxis, a condition that causes respiratory failure and a dangerous drop in blood pressure,, is the most serious and life-threatening complication of a histamine overload.

One in five people will experience acute urticaria at some point in their lives. However, about one in a hundred people have chronic urticaria. Some chronic cases have identifiable triggers, but most have no known cause (chronic idiopathic urticaria).

How are hives diagnosed?

While hives are immediately identifiable in a physical exam, it can sometimes be difficult to determine the underlying cause. If you experience hives regularly, you can help a doctor arrive at the correct diagnosis by keeping a symptom diary. You should record urticarial breakouts, where on the body it occurs, how long it lasts, as well as all your activities in the hour or two before a breakout.

During a physical exam, a general practitioner or dermatologist will note additional reactions such as swelling, wheezing, difficulty breathing, or low blood pressure, as well as any signs of an underlying condition. In many cases, the healthcare provider will want a blood test. If the doctor suspects allergies, you may be referred to an allergist to perform allergy testing such as a skin test.

Hives treatment options

Treatment of hives centers on reducing symptoms and avoiding future outbreaks. An underlying infection or thyroid problem will be treated with the appropriate medications.

Medications

For transient urticaria due to an insect bite or exposure to an unusual substance, anti-itch lotions can be helpful in reducing symptoms. Because urticaria is caused by histamines released by skin cells, non-sedating or topical antihistamines are the first-line treatment. More severe or chronic cases may involve corticosteroids or prescription drugs that block this immune system reaction.

Prevention

In cases where hives are regularly induced by an allergen, food, or other physical cause, the best treatment is to avoid those triggers. Diet modification, lifestyle changes, and protective clothing can effectively prevent breakouts.

Hives medications

Hives cannot be cured, but the swelling, redness, and itching can be managed with both over-the-counter and prescription medications.

Antihistamines

Hives are caused by the release of histamines by specialized cells (mast cells) in the body. The redness, swelling, and itching are all caused by histamines. The first-line therapy for hives, then, are a type of antihistamine called H1 receptor antagonists. These drugs effectively neutralize histamines by blocking their ability to attach to skin or immune system cells. Well-known over-the-counter antihistamines— diphenhydramine, loratadine, levocetirizine, cetrizine, and fexofenadine—reduce swelling, redness, itching, and other problems such as wheezing or difficulty breathing. A healthcare provider may, however, prescribe a more powerful antihistamine such as Semprex (acrivastine) or desloratadine. Chronic urticaria is usually treated with a three- to six-month regimen of antihistamines.

If any of these antihistamines are not effective, the patient can switch to a different antihistamine. If none of them work, a healthcare professional may also add a different type of antihistamine, called an H2 receptor antagonist, such as ranitidine or cimetidine. These are drugs normally used to treat stomach acid problems but could help with reducing hives.

Leukotriene inhibitors

For chronic or severe urticaria that does not respond to antihistamines, doctors will turn to prescription leukotriene inhibitors. Leukotrienes are produced by white blood cells when they are activated by histamines and produce swelling. Leukotriene inhibitors such as montelukast, zafirlukast, and zileuton prevent white blood cells from producing leukotrienes and so rapidly dial back the inflammatory processes responsible for hives. Leukotriene inhibitors are taken as a single-dose pill once per day and can be combined with anti-histamines.

Corticosteroids

For severe cases that involve swelling and other problems, such as difficulty breathing, a doctor may prescribe a few days of oral corticosteroids such as prednisone to rapidly reduce swelling and itching.

Epinephrine

For severe reactions, a doctor will prescribe epinephrine to handle emergencies. Similar to adrenaline, epinephrine rapidly opens swollen airways and increases blood pressure. Patients will carry epinephrine auto-injectors in case of a severe reaction that requires immediate treatment. If you use an epinephrine auto-injector, you must still seek emergency treatment.

Monoclonal antibodies

Patients with chronic idiopathic urticaria—a persistent case of hives with no known cause—may be prescribed Xolair (omalizumab) injections. Omalizumab is a synthetic antibody that glues itself to the antibodies (IgE antibodies) that trigger histamine release, essentially shutting them down. Xolair is given as a subcutaneous injection by a nurse or health care provider once per month.

Immunosuppressants

A very small number of patients with severe and debilitating urticaria, airway obstruction, and chronic low blood pressure may not get better with antihistamines or leukotriene inhibitors. Those difficult cases are usually due to autoimmune disorders, that is, conditions where the immune system overreacts and attacks healthy tissues. A doctor may prescribe immune suppressants such as cyclosporine, tacrolimus, or mycophenolate mofetil, all of which reduce the ability of the immune system to function.

What is the best medication for hives?

While antihistamines are the first-line treatment, there is no “best” medication for hives. Patients may need to try more than one antihistamine to discover the most effective medication with the fewest side effects.

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Best medications for hives