Hives (Urticaria)

Hives (Urticaria): Overview

Hives – also called urticaria – are localized, raised red areas in the superficial portion of the skin that may join together to form larger lesions.  Hives are closely related to angioedema.

Incidence; Causes and Development

Hives are relatively common with at least 20% of the population having had at least one episode during their lifetime.  Although seen in all ages, they seem to be more prevalent among young adults.

The reaction involves the release of histamine from either mast cells or basophils causing an IgE (immediate type) mediated antibody response.

The causes of urticaria are many and in 80% of cases never determined; not knowing the cause often results in an on-going problem.  The most common causes of chronic urticaria are drug reactions, stress, food sensitivities and fungal infections.  Some initiating factors include:

  • Allergic urticaria: plants, pollens, drugs (including aspirin), foods (such as shellfish, eggs, nuts, strawberries, certain baked goods) and food additives, animal dander, cosmetics, toxins from jellyfish, caterpillars or fleas, "contactants" such as latex (especially in health care workers).
  • Physical urticaria: heat or sun, cold, light, pressure from bracelets and clothes or scratching, vibration, exercise
  • Secondary urticaria: infections (e.g.  hepatitis B virus, candida albicans, streptococcal bacteria), collagen vascular diseases, autoimmune diseases or other metabolic disorders, cancer, psychological, hypothyroidism, polycythemia vera, protoporphyria (even without excessive sun exposure).  Mechanical, physical or emotional factors might play a role.

Signs and Symptoms

Itching is usually the first symptom.  The wheals are white or red, occasionally with a pale center.  Plaques are developed by 50% of patients and the lesions often come and go in different areas.

Diagnosis and Tests

Lab findings are often unremarkable in cases of acute urticaria.  For chronic urticaria, lab work should include CBC, ESR, UA, histamine levels and dental/sinus examinations to rule out hidden pathology.

Treatment and Prevention

Instead of just treating the symptoms (which is obviously important as well), a physician needs to get the the bottom (if there is one) of why the patient is getting them in the first place.

Acute urticaria lasts from 1 to 7 days and treatment is not usually needed except to reduce the itching.  The inciting agent must be dealt with, be it food, external agent or an emotion.  In severe cases, epinephrine, as found in a bee sting kit, may be required.

Prognosis; Complications

In cases of chronic urticaria of over three weeks' duration, 50% of patients experience spontaneous remission within two years, even though in the majority of cases the cause is never identified.

In extreme cases, swelling in the throat may lead to a medical emergency.

Signs, symptoms & indicators of Hives (Urticaria):

Symptoms - Allergy

Risk factors for Hives (Urticaria):

Allergy

Allergy to Foods (Hidden) often increases risk of Hives (Urticaria) Allergy to Foods (Hidden)

Foods and drugs are common causes of hives.  A reaction that occurs immediately after ingestion of certain foods, producing hives and difficulty breathing is termed anaphalactic and is potentially dangerous.  Delayed reactions are less serious but more difficult to pinpoint.  Some patients get hives occasionally only when they ingest a specific food or food additive.  Others develop hives as a chronic problem that can continue for years.  Most studies of chronic hives suggest that only a low percentage are due to food allergy; this is usually because diet revision attempts were inadequate for revealing the hidden food causes.

Autoimmune

Chronic Thyroiditis often increases risk of Hives (Urticaria) Chronic Thyroiditis

Amongst patients with chronic hives and either treated hypothyroidism or a normally functioning thyroid gland, it is reasonable to test for anti-thyroid antibodies.  In a study of 10 patients with chronic hives, thyroxine (T4) was administered for a minimum of 12 weeks.  Of 7 patients with elevated anti-thyroid antibodies at baseline, all had complete resolution of hives or marked improvement within 4 weeks.  Two patients required an increase in the thyroxine before complete resolution was seen.  In 2 others, already on thyroxine therapy for hypothyroidism, an increase in the dose also resulted in resolution of the hives.

The initial dose was on average 100mcg per day, which was increased if the initial dose failed to produce clinical improvement.  The highest dose used was 250mcg per day.  The 3 patients without elevated anti-thyroid antibodies did not respond to thyroxine therapy.  There was a recurrence of hives after treatment was stopped which resolved again after treatment was restarted.  There was no consistent correlation between improvement in symptoms and reduction in thyroid antibody levels.  [J Allergy Clin Immunol 1995;96: pp.901-5]

Autoimmune Tendency may increase risk of Hives (Urticaria) Autoimmune Tendency

Some forms of chronic hives have an autoimmune origin which means, in about 30% of patients, that the immune system is producing antibodies against normal substances in the body and triggering the release of histamine by mast cells.  [Journal of the American Academy of Dermatology, March 1999, 40(3); pp.443-450]

Hormones

Mental

Metabolic

Hives (Urticaria) suggests the following may be present:

Autoimmune

Hives (Urticaria) often suggests Autoimmune Tendency Autoimmune Tendency

Some forms of chronic hives have an autoimmune origin which means, in about 30% of patients, that the immune system is producing antibodies against normal substances in the body and triggering the release of histamine by mast cells.  [Journal of the American Academy of Dermatology, March 1999, 40(3); pp.443-450]

Recommendations for Hives (Urticaria):

Amino Acid / Protein

L-Tyrosine often helps with Hives (Urticaria) L-Tyrosine

One older study reported that L-tyrosine (200mg), vitamin B6 (2.5mg) and niacinamide (10mg) when given in combination for the treatment of hay fever, hives, allergic headaches and poison oak dermatitis produced significant symptomatic relief when 1-3 tablets were taken four times per day in milder cases and up to 6 tablets 4-6 times per day in more severe cases.

In some cases characterized by more chronic disorders, such as chronic sinusitis, a worsening of symptoms often occurred during the first few days of treatment.  This study found that treatment with each of the nutrients individually, or with any two in combination, was ineffective.  [Widmann RR, Keye JD Epinephrine precursors an control of allergy.  Northwest Med 1952:51: pp.588-590]

Drug

Conventional Drug Use may help with Hives (Urticaria) Conventional Drug Use

For many patients with hives of unknown cause, treatment with antihistamines is effective.  This is because in people with hives, histamine is being released by mast cells in the tissues which in turn initiaties the irritation and accumulations of fluid.  Other inflammatory white blood cells, including lymphocytes and polymorphonuclear cells, have also been implicated.  Antihistamines inhibit this inflammatory process.

On occasion and especially with pressure hives, antihistamines are ineffective, probably because of the nature of the molecular mediators operating in this condition.  If antihistamines do not help, then several second-line treatments are used.  The most effective are corticosteroids.  Others include doxepin, dapsone, attenuated androgens, calcium antagonists, antimalarials, gold and methotrexate.

Hormone

Thyroid Medications often helps with Hives (Urticaria) Thyroid Medications

A study suggests that administration of thyroxine to patients with chronic urticaria associated with elevated thyroid antibodies can result in remission of the hives.  [J Allergy Clin Immunol 1995;96: pp.901-5]

Lab Tests/Rule-Outs

Test for Food Allergies often helps with Hives (Urticaria) Test for Food Allergies

Numerous clinical studies demonstrate that diets that are free of foods or food additives that commonly trigger allergic reactions typically produce significant reductions in 50-75% of people with chronic hives.

Nutrient

Physical Medicine

Hydrotherapy often helps with Hives (Urticaria) Hydrotherapy

An alkaline sponge bath may be helpful to reduce the itching.  Add one teaspoon of baking soda to each pint of very hot bath water and soak.

Vitamins

Vitamin C (Ascorbic Acid) often helps with Hives (Urticaria) Vitamin C (Ascorbic Acid)

High doses of vitamin C, such as mineral ascorbates, can help those with hives by lowering histamine levels.  Taking 2gm every hour in water may bring relief.

Vitamin Niacinamide often helps with Hives (Urticaria) Vitamin Niacinamide

Should be taken in combination with Tyrosine.  See Hives/Tyrosine note.

Vitamin B6 (Pyridoxine) often helps with Hives (Urticaria) Vitamin B6 (Pyridoxine)

Should be taken in combination with Tyrosine.  See Hives/Tyrosine note.

Vitamin B12 (Cobalamine) may help with Hives (Urticaria) Vitamin B12 (Cobalamine)

Vitamin B12 injections, at least 1000mcg weekly, has been reported to reduce the frequency and severity of urticaria in chronic cases.  [J Am Geriatr Soc 1964;12: pp.79-85]

Preventive measures against Hives (Urticaria):

Diet

Food Additive Avoidance often prevents Hives (Urticaria) Food Additive Avoidance

Food additives that have been shown to trigger hives include colorants (azo dyes), flavorings (salicylates), artificial sweeteners (aspartame), preservatives (benzoates, nitrites, sorbic acid), antioxidants (hydroxytoluene, sulfite, gallate), and emulsifiers/stabilizers (polysorbates, vegetable gums).

Digestion

Hydrochloric Acid (Trial) often prevents Hives (Urticaria) Hydrochloric Acid (Trial)

Lack of hydrochloric acid (HCl) secretion by the stomach has been linked to chronic hives probably as a result of increasing the likelihood of developing food allergies.  In one study of 77 patients with chronic hives, 24 (31%) were diagnosed as having achlorhydria, and 41 (53%) were shown to be hypochlorhydric.  [Rev Gastroenterol 1951;18: pp.267-71]

Vitamins

Bioflavonoids may help prevent Hives (Urticaria) Bioflavonoids

The flavonoid quercetin inhibits the manufacture and release of histamine and other allergic compounds involved in allergies.  This suggests an as yet unproven preventative effect in managing hives.  Some types of hives will respond, while others will not.

KEY

Weak or unproven link: may increase risk of
Weak or unproven link:
may increase risk of
Strong or generally accepted link: often increases risk of; often suggests
Strong or generally accepted link:
often increases risk of; often suggests
Definite or direct link: is a sign or symptom of
Definite or direct link:
is a sign or symptom of
May be useful: may help with; may help prevent
May be useful:
may help with; may help prevent
Moderately useful: often helps with; often prevents
Moderately useful:
often helps with; often prevents
Very useful: is highly recommended for
Very useful:
is highly recommended for