What are the treatments for persistent hives?
The release of a chemical called histamine under the skin is involved in causing hives (urticaria). Antihistamines block the action of the histamine. Most affected people have at least partial relief, and sometimes total relief, of their symptoms with antihistamines. The most commonly used antihistamines for hives are cetirizine, fexofenadine and loratadine. These do not usually cause drowsiness. Your doctor may advise doses which are higher than the usual recommended dose in order to control the rash. If the itch is making it difficult to sleep, sometimes an antihistamine which makes you sleepy can also be taken at night. Examples of antihistamines used in this way include chlorphenamine or hydroxyzine.
Antihistamines can be bought over the counter without a prescription. However, if you need to take them for more than a few days, it is best to see your doctor for further advice. Do not take more than the recommended dose without discussing it with your doctor. Antihistamines are not usually advised in pregnancy.
Soothing the rash
Creams such as menthol in aqueous cream are useful to cool the skin and help to relieve itch. Calamine lotion can also help. A tepid bath or shower may relieve the itch before bedtime and help you to sleep.
Avoiding triggers or aggravating factors
Occasionally a trigger such as a food is identified as causing the rash. You may then be able to avoid it. However, it is unusual to identify a trigger. For example, if a food trigger is suspected then you may be asked to keep a food diary to try to identify which food is responsible.
Various other factors may make symptoms worse (but are not the main trigger). The following are tips that some people have found helpful; however, there is little proof that they work in everybody:
- Try avoiding tight clothes if weals occur at sites of local pressure. For example, under belts, under tight-fitting shoes, etc.
- Try keeping cool, as hives may tend to flare up in warmer conditions. In particular, keep the bedroom cool at night.
- For some people alcohol, hot baths, strong sunlight, and undue emotion make symptoms worse. If you think any of these are making symptoms worse then it may be helpful to avoid them.
- See a doctor if you think a medicine is making symptoms worse, as a change in medication may be an option. Some medicines that may be triggers include aspirin, anti-inflammatory painkillers, and angiotensin-converting enzyme (ACE) inhibitors.
Steroids reduce inflammation and may ease hives. However, it is not a usual treatment, due to the serious side-effects which are likely to occur if you take steroids regularly. A short course of steroids may be advised occasionally for a bad flare-up of symptoms. The steroid usually used is prednisolone, taken daily for seven days.
If antihistamines are not working, you may be referred to a specialist. This might be a skin specialist (dermatologist) or a specialist in the immune system (immunologist). Other treatments for severe chronic urticaria which may be tried by a specialist include:
- Omalizumab. This is a newer medication which acts against autoantibodies produced by the body's own immune system. It has to be given by injection once a month. It is very effective for chronic urticaria but the rash may return when the injections are stopped.
- Ciclosporin. This medication suppresses the immune system. This isn't often used as there is a risk of serious side-effects.
- Tablets such as montelukast, usually used for asthma. This also acts on the immune system.
- Dietary advice from a nutritionist if there is any evidence that any kind of food is a trigger for your rash. For most people there is no evidence that diet changes are helpful.
Treatment of associated angio-oedema
Antihistamines usually help to reduce the swelling of angio-oedema. Occasionally, an adrenaline (epinephrine) injection and emergency hospital treatment are necessary if anaphylaxis occurred. See separate leaflet called Angio-oedema for more details.
What is the outlook for persistent hives?
Persistent hives (chronic urticaria) tend to come and go. You may have times when the rash appears on most days, and then times when the rash may go away for a while. The severity of the rash and itch varies from person to person. Some things such as heat, cold, menstrual periods, stress, or emotion may make the rash flare up worse than usual.
- Symptoms may go away completely after a few months; however, the condition lasts several years in some cases.
- In about half of cases, symptoms go within 3-5 years after the condition first starts.
- In about 1 in 5 cases the symptoms persist on and off for more than 10 years.
Further reading and references
BSACI guideline for the management of chronic urticaria and angioedema; British Society for Allergy and Clinical Immunology (Feb 2015)
Urticaria; NICE CKS, May 2016 (UK access only)
Zuberbier T, Aberer W, Asero R, et al; The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014 Jul69(7):868-87. doi: 10.1111/all.12313. Epub 2014 Apr 30.
Urticaria; DermNet NZ
Urticaria and angio-oedema: an overview; Primary Care Dermatology Society
Omalizumab for previously treated chronic spontaneous urticaria; NICE Technology Appraisal Guidance, June 2015
Sharma M, Bennett C, Cohen SN, et al; H1-antihistamines for chronic spontaneous urticaria. Cochrane Database Syst Rev. 2014 Nov 14(11):CD006137. doi: 10.1002/14651858.CD006137.pub2.
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