— Laurie, Florida Hives (known in the medical community as urticaria) are very itchy spots, pink to red, that appear on the skin, feel raised up from the surrounding skin, and then disappear without a trace (unless the person has scratched and damaged the skin). An individual hive can range from the size of a pencil eraser to the size of a dinner plate. Hives are not rare, and most people experience a brief bout of them at least once in their lives. They typically last a few days or a week and then go away as suddenly as they came. This can happen after someone has a mild infection, including everyday viruses, or in association with taking antibiotics. Hives can also be part of a more serious allergic reaction, such as a reaction to a food, medicine, or insect sting. Anyone who develops hives plus other symptoms — such as difficulty breathing, dizziness or light-headedness, throat tightness, nausea or vomiting, or passing out — should be seen by a health care provider immediately. Sometimes outbreaks of hives keep happening for weeks or months, as you describe in the case of your daughter. This condition is called chronic hives, or chronic urticaria, and it’s characterized by the presence of hives on most days of the week for six weeks or more. This disorder, less common than short-lived hives, affects about one in 100 people. It is very distressing to the person who has it because it is uncomfortable, unpredictable, and interferes with sleep, school, and work. However, it is almost never related to a more serious medical problem or to an allergy. Researchers do not know with certainty what causes chronic urticaria, but there are a couple of leading theories. One is that chronic hives are caused by changes in white blood cells called basophils. Another is that some people begin to make antibodies (proteins that normally fight infections) that cause cells (mast cells) to release natural chemicals. These mast cells are in the skin, and the chemicals cause swelling in the skin around the cells, creating hives. It isn’t clear, according to this theory, what starts the process, but the good news is that the problem eventually corrects itself in most people after a period of time — a few months to as much as a year is typical. However, a small number of unfortunate people have chronic hives for years on end. Many people with hives notice that the symptoms seem to be related to diet in some way, but testing for food allergy usually shows that a person with hives is not allergic to any food. This is because while some foods contain natural chemicals that aggravate hives, there are so many foods that do this that avoiding enough of them to make a real difference in the symptoms would be difficult and impractical. People with hives almost always require antihistamines to control the symptoms. Antihistamines are considered the safest and most effective initial treatment. Certain antihistamines, such as cetirizine (Zyrtec), fexofenadine (Allegra), and loratadine (Claritin), cause less drowsiness and dry mouth than others, such as diphenhydramine (Benadryl) and chlorpheniramine. Doctors often need to combine different types of antihistamines or double the dose of one medicine. To figure out the right medication or combination of medications for your daughter, you’ll need to discuss with her doctor her age and how well she responds to the various medications. If hives are still not controlled on full doses of two or more antihistamines, many doctors will add a medicine called montelukast (Singulair) for a month or so, and some patients then improve. Every patient is different, though, and it can take weeks to find a set of medicines that work. The process can be frustrating, so be patient. Q2. I have had chronic hives for the past six months. The only thing that controls them temporarily is prednisone. As soon as I am off of it, they come back with a vengeance within 24 hours or less. Is there anything else that might help? I already take Zyrtec and Zantac. I am desperate and would appreciate any suggestions. — Gail, Massachusetts Hives are raised, intensely itchy spots or patches that appear in crops, last for a few hours, and then resolve without leaving any residual marks on the skin. They can range in size from as big as a pencil eraser to the size of a dinner plate. Hives can appear anywhere on the body, although the legs, arms, abdomen, armpits, and neck are the areas where they most commonly surface. Most people will develop hives at least once in their lives, and the trigger is often not obvious. “Chronic hives” are hives that occur in episodes, daily or nearly every day, for more than six weeks. For a benign condition, hives certainly cause a lot of suffering for those that have them. As your doctor has probably mentioned, there is no identifiable allergy or underlying medical condition to explain chronic hives in about 85 percent of those who suffer from them. If you visit the message boards on this site, you will find plenty of people writing in under the thread titled, “Crazy Itching.” Just reading through what others have posted, you can get a sense of how exasperating this problem can get. Also, you can see that different treatments work for different people, and what seems to be a miracle treatment for one person has minimal effect on another. The bottom line is this: There are no magic cures for hives. Most of the time, people try various medications until they find some combination that works for them. The combination of Zantac (ranitidine) and Zyrtec (cetirizine) helps many people, although you may need to double the regular Zyrtec dose to 10 mg twice a day for decent relief. The Zantac you take should be at least 150 mg twice a day. In addition to this, some people benefit from 10 to 20 mg of doxepin before bed. Doxepin is an antidepressant when taken at higher doses, but at lower doses acts as a strong antihistamine. It is very sedating however, and some people feel groggy in the morning. Another antihistamine that can be helpful is hydroxyzine, taken at a dosage of 25 mg every six to eight hours if needed, although it is also sedating. Prednisone will calm down hives in most cases, but it can have severe side effects if taken continuously for months or years. Dramatic and sudden changes in medication often cause the hives to flare again, so sometimes I have success lowering the prednisone dose very, very slowly. For example, once you get down to 10 mg, try dropping one milligram every four days or so: in other words, 9 mg a day for four days; 8 mg a day for the next four days, etc. Once you reach 4 or 5 mg, try changing to taking prednisone every other day for a week, and then stop. When lowering and stopping the prednisone, you also have to keep the antihistamines going at full strength, and if you’re lucky, they will offer enough relief by themselves. Make sure you are not inadvertently doing anything that could be aggravating the hives. Things that seem to aggravate hives and itching in most everyone include:
Dramatic temperature changes (hot showers, cooling down after a workout)AlcoholMedications like aspirin and other over-the-counter pain medications. (Acetaminophen — Tylenol or generic — is usually fine.)StressPoor sleepDramatic changes in diet (rich restaurant meals, very spicy foods)Nighttime. Hives and itching often worsen at night because that’s when the body’s natural anti-itch chemicals are at their lowest.
This list is just good to keep in mind if you have an itching problem, even if you can’t control many of the things on it. Try to keep your eating and sleeping patterns as regular as possible. Q3. I get hives after exercise. Is this some kind of allergic reaction? If it is, what can I do to treat or prevent it? There are many people who get hives and other allergic symptoms after exercising, a condition known as exercise-induced urticaria. If you see hives developing, it’s best to stop exercising for five to 10 minutes and see if they fade. However, this doesn’t mean you have to give up exercise entirely. Talk to your doctor about this condition, and he or she may recommend a quick-acting, non-sedating antihistamine that you can take prior to exercise. Also, it may be worthwhile to work out with a buddy just in case the symptoms become more extensive than hives (shortness of breath, dizziness). Some patients with this condition carry auto-injectable adrenaline in case of a life-threatening allergic reaction. Learn more in the Everyday Health Allergy Center.
