What Is Hives

Hives, also referred to as urticaria, wheals, welts, or nettle are red, itchy, or raised areas of skin that appear seemingly out of the blue. In addition to itching, which can be mild to severe, hives may burn or sting. Hives can occur on any part of the body such as throat, ears, face, lips. The blotches can range in size from small spots to several inches in diameter. This problem affects about 20% of all people at some time during their lives.

Hives are sometimes triggered by an allergic reaction—an allergen. When the body has an allergic reaction, it releases a protein called histamine. With the release of this protein, the capillaries leak fluid, which accumulate in the skin and cause a rash

Hives are not contagious. Women and children are affected more commonly than men. Hives often goes away in 24 hours or less. As old ones fade, however, new hives can occur.

Acute Urticaria or Acute Hives. When you are symptomatic under six weeks it is considered acute. This is most common, and In 25 % of cases of acute hives the person affected also has angioedema – swelling in the deeper layers of the skin. The swelling causes burning and typically occurs on the eyelids and lips. It generally lasts longer than hives but the swelling typically dissipates in 24 hours

Chronic Urticaria or Chronic Hives. The hives are considered chronic when they last over six weeks. This occurs for 1 in every 1000 people who are afflicted with hives. The cause is likely linked with our immune system. In some cases chronic hives is related to an underlying autoimmune disorder such as lupus. Approximately 50 % of people with chronic hives have angioedema

Anaphylaxis. Urticaria and angioedema are closely related to anaphylaxis – an extremely dangerous condition that can lead to death within minutes or hours. This is an overwhelming allergic reaction that can lead to a multitude of horrors such as collapse of blood circulation, shock, suffocation, swelling of internal organs… It may be caused by the same factors that trigger hives. The most well-known cause is bee sting allergy.

What Causes Hives

Experts say in half of all cases, the cause of hives is never discovered.  Here are some known triggers: 

Causes of Acute Hives and Angioedema

  • Allergic reactions to:
    • Fruits, especially citrus. Also milk, eggs, peanuts, shellfish, chocolates, tree nuts, tomatoes. Fresh food causes hives more often than cooked foods.
  • Insect bites and stings
  • Animals
  • Pollen
  • Allergy shots
  • Sunlight exposure
  • Stress
  • Touching something to which you are allergic, such as latex
  • Ibuprofen, codeine, aspirin, meds for high blood pressure (ACE inhibitors)
  • Cosmetics
  • Intestinal parasites
  • Dust mites

Causes of Chronic Hives and Angioedema

Specific triggers hardly ever cause chronic hives, rather, chronic hives start as an autoimmune response in which certain cells (mast cells) cause the release of histamine and various chemicals to be released under the skin, causing the leakage of tiny blood cells under the skin. These in turn cause wheals and swelling

In some cases the cause may be:

  • Thyroid cancer
  • Hepatitis
  • Infection
  • Autoimmune disorders such as Hashimoto’s Disease (this might be caused by gluten or other food sensitivity)
  • Abnormal MTHFR genes. If this is the case special forms of folic acid and vitamin B12 are helpful
  • Inflammation of the blood vessels, or vasculitis, can also cause hives that are more painful than itchy, may cause a bruise to the skin, and can last more than a day 

Causes of Physical Hives or Urticaria

These are a type of chronic urticaria which is caused by direct stimulation of the skin:

  • Rubbing or scratching. This is the most frequent cause. Hives typically appear within a few minutes and disappear within an hour. Called dermographism aka “skin writing,” raised, itchy welts appear where the skin was scratched or rubbed
  • Exposure to cold, heat, sun exposure. Cold urticaria can occur after exposure to cold temperature followed by re-warming
  • Pressure or constriction. Delayed pressure hives can appear six hours after the pressure has been applied from belts or restrictive clothing. Symptoms can also occur from body parts under constant pressure – such as soles of the feet
  • Cholinergic Hundreds of red, small, itchy bumps appear within 15 minutes of physical exercise or exertion. They disappear before you can get to a doctor

Risk Factors For Hives

Risk factors for hives include:

• Having had hives and/or angioedema in the past
• Being exposed to something to which you are allergic. This can range from foods to cleaning products to medications
• Having had other allergic reactions
• Having a disorder associated with hives and angioedema such as thyroid disease, lupus or lymphoma
• Family history of hives, angioedema or hereditary angioedema
• Physical irritation. Sitting for long periods, wearing tight clothes, a belt rubbing your body…
• Feeling overly stressed
• Being a woman. Females develop chronic hives twice as often as men
• Being between 30 and 60 years old


Diagnosing Hives

Often, a dermatologist can make a diagnosis of hives by simply looking at the skin. Finding the cause, though, is considerably more nuanced and possibly difficult. With half the cases of acute hives, the cause is ultimately unknown. This is a quick rundown of diagnostic procedure for hives:

Acute Hives
• Allergy tests (blood work or on the skin)
• Skin biopsy
• Blood work (to rule out infection or illness)
• A skin biopsy is performed by removing a small piece of affected skin and examining it under a microscope
• If the dermatologist thinks your hives are allergy-related (acute), he or she may send you to an allergy clinic.

Chronic Hives. If it is chronic, tests can include:

• Full blood test count. This is to identify is you have iron deficiency anaemia
• Stool sample. This is to identify intestinal parasites
• Thyroid function test
• Erythrocyte sedimentation rate (ESR) test. This helps pinpoint problems with your immune system
• Liver function tests

Symptoms of Hives

The symptoms of hives are unmistakable:

• Raised, itchy bumps – red or skin-colored
• Blanching. When you press it the center of a red hive turns white
• Roughly oval or shaped like a worm
• A few millimeters to several inches across

Hives typically are not life threatening, unless you suffer swelling in the throat or any symptom that restricts breathing. In this event, get to the ER immediately

Chronic hives occur almost daily for six weeks. Each hive lasts approximately 24 hours. They don’t scar or leave bruising

Determining whether it’s hives or angioedema:
It is angioedema (swelling of tissue beneath the skin surface) if:
• There is swelling of the hands, feet, mouth, in the eyes, or mouth
• You have difficulty breathing, stomach cramps, or chemosis (swelling of the lining of the eyes)
• Symptoms last longer that urticarial wheals, up to three days

With vasculitic urticarial, the weals can also last longer than 24 hours. The weals are often painful, become dark red and can leave a red mark on the skin


Most hives disappear quickly, with the affected skin going back to normal. This is typically the case even when the hives recur over several weeks without a known cause. If the hives persist for several days and/or are extremely itchy, consult a doctor

With chronic hives, there may be times when the rash disappears for a while. The severity of the rash and itch varies from person to person – it can be affected by heat, cold and stress.Symptoms may disappear completely after a few months for some people, or several years in other cases.

In half of cases the symptoms go away within three to fives years from when they first began.

In one in five cases, symptoms persist on and off for over 10 years.

Living With Hives

Acute hives disappear quickly with no lasting impact.

Living with chronic hives is a much more difficult situation. Indeed, one study found that sufferers find their quality of life and mood negatively impacted with one in seven people reporting a psychological or emotional problem such as stress, anxiety or depression. See your GP if this is the case for treatment. Also, talk to friend and family rather than isolating

Other tools:

• Maintain as healthy as lifestyle as you can – i.e.: no smoking, healthy diet, exercise
• Examine recent changes in diet and/or medications, chemical based consumer products such as detergents within one to two months prior to hives onset
• Find a good doctor who can check autoimmune markers, often called an autoimmune panel of blood work
• Visit an allergist for food and environmental allergy testing

Be aware of the latest medical developments. Only half of patients find some relief with antihistamines. Omalizumab, known as Xolair, recently FDA-approved, is promising. In clinical trials, 65 % to 70 % of patients responded to treatment, with 40 % and 45 % seeing the hives all but disappear

During an outbreak:

• Apply cool compresses or wet cloths to affected areas
• Work and sleep in a cool room
• Wear loose-fitting lightweight clothes


Here are some suggestions for preventing acute hives:

• If your hives are caused by allergies but you don’t know what you are allergic to, start keeping a daily diary. Keep a record of foods, drinks, medications, supplements… Even if you don’t see obvious connections with food, notate in your diary factors like stress levels, weather, the amount of time you stay in the sun. This can help you make a link between a lifestyle choice and hives
• Foods most likely to trigger hives are fresh berries, tomatoes, milk, shellfish, nuts, preservatives in certain foods and wine, such as sulfites. Once you identify a food trigger, eliminate it from your diet and see if hives lessen
• Consider getting an allergy shot
Drug triggers include antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Other drug triggers can be antacids, arthritis medications, vitamins, diet supplements, douches, eardrops, laxatives.
• Reduce stress. Take up meditation, yoga, listen to music.
• If you’ve recently had an outbreak, try to avoid tight clothing as that might cause another hives attack

Common Treatment

The best treatment for hives and angioedema is to determine the trigger and remove it. This is not an easy task but here are some common suggestions from doctors:

• For a mild or moderate case of hives over-the-counter non-sedating antihistamine provide relief for the itching.
• For hereditary angioedema blood protein controllers might be prescribed to help regulate the levels of certain blood proteins and for symptom relief
• For severe outbreaks an injection of epinephrine or a cortisone medication may be administered
• For chronic hives the doctor might prescribe an antihistamine, which should be taken everyday as a preventive. Ask about the med’s propensity to cause drowsiness. This antihistamine might be combined with other medicines. These include cortisones (for short term use), Dapsone (an antibacterial) and other medicines that fight inflammation. The biologic drug, omalizumab (Xolair) has been FDA-approved
• For chronic hives perhaps the most important factor is determining and treating the underlying factor – – i.e.: a hives sufferer with an inflamed thyroid needs to treat the thyroid

Complementary and Alternative Treatment

Here are some alternative treatments for hives:

• Take a cool bath or apply a cold compress. (The only time this isn’t helpful is when the hives are caused by a cold.) The cool temperature shrinks blood vessels, thus blocking further release of histamine. Adding colloidal oatmeal ( to the bath and soaking for 15 minutes can further relieve the itching
• Dab welts with calamine lotion or witch hazel. Astringents also help shrink blood vessels
• An alternative to histamine is nettle. Take up to six 400-milligram capsules daily
• Mix one teaspoon of vinegar with one cup of lukewarm water. Apply mixture to your hives with a cotton ball or tissue to help alleviate itchiness
• Cold packs. Apply a bag of ice, ice pack of ice or frozen vegetable package (peas are best) wrapped in thin cloths for 10 minutes at a time

When To Contact A Doctor

With acute hives or angioedema, self-care is usually sufficient. Here are some guidelines for the type of care to seek, in specific situations.

Call 911 or an ambulance if:
• You have a swollen tongue with rapid onset
• Hoarseness or cough with rapid onset
• In the past you’ve had severe allergic reaction to similar substance
• So weak you can’t stand
• Feel confused
• Difficulty breathing or you are wheezing

Call a doctor NOW if:
• You feel very weak or very sick
• Your throat is swelling or if you’re having trouble breathing
• Hives began after a bee sting, unusual food or medicine and no previous reactions

Call a doctor within 24 hours if:
• Hives interfere with normal activities even after taking antihistamine every six hours for 24 hours
• Fever, abdominal pain or joint swelling

Call a doctor if:
• Hives persist over a week
• Unexplained hives occurred three or more times in past year

Questions For A Doctor

It’s helpful to write down a list of questions before your appointment. For chronic hives basic questions can include:

• What is likely causing my symptoms?
• How long will these hives last?
• What kind of tests do I need, and how should I prepare for them?
• Do I need prescriptions or can I use over-the-counter meds?
• Does the medicine you’re prescribing have a generic version?

The doctor will ask questions like:

• What symptoms do you have, and when did they begin?
• Have you had any viral or bacterial infections recently?
• What medications, herbal remedies and supplements do you take?
• Do you have tightness in your chest or throat, nausea or difficulty breathing?
• Have you tried any new foods recently?
• Have you traveled to a new place?

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