Updated 15 July 2021

Hives (Urticaria) – Symptoms, Diagnosis, and Treatment

Patient with itchy hives on arm.

Urticaria (Hives) - Symptoms, Diagnosis, and Treatment

 

What are Hives (Urticaria)?

Urticaria is a skin condition that occurs in the form of red and bumpy rashes on the skin. These inflammatory changes on the skin are also known as hives and can occur almost anywhere on the body. This condition can be classified into 2 categories, either acute or chronic urticaria. Acute urticaria occurs very temporarily over hours to weeks. In comparison, chronic hives can last longer than 6 weeks. Approximately 25% of Australians will experience acute hives, whilst only 3% will suffer from chronic hives at some point in their lives [1]. 
 

Hives Symptoms

The hallmark of hives is the sudden breakout of red, rashy and bumpy lumps on the skin. Usually, this is accompanied by itchy and burning sensations over the affected areas.   

What do hives look like?

GPs will typically look out for specific traits when looking out for hives. Examples of signs associated with this condition include [2]:
  • Angioedema or the swelling on the surface of the skin
  • Itchy bumps on skin like mosquito bites
  • Swollen face including lips, around eyes and cheeks
  • Raised welts on the body including limbs and genitals
  • Urticarial rashes which vary in shape and size (i.e. ranging from millimetres to centimeters in size)
 

What Causes Hives?

Acute Hives

There are many potential causes and triggers of acute hives. Identifying these causes is important for preventing future allergic skin reactions. Examples of some common triggers which can be associated with hives, including [2]:
  • Insect bites (e.g. mosquito, sand flies, etc.)
  • Certain medications (e.g. specific painkillers, laxatives, antibiotics, etc.) 
  • Particular foods could trigger allergic reactions, including fish, eggs, nuts, dairy products and strawberries.
  • Viral infections, which are more prevalent causes of hives in children 
  • Bacterial infections (e.g. E.coli)
  • Contact with allergens and irritants (e.g. latex, animal products, perfumes, etc.)
  • Environmental triggers (e.g. cold climates, exercise, exposure to the sun, etc.)
 

Chronic Hives

As causes of chronic hives are less obvious, further investigations and/or referrals to specialists may be required. However, there is evidence to suggest that potential triggers, such as:
  • Autoimmune disease [3]
  • Bacterial infection (particularly Heliobacter pylori) [4]
  • Environmental triggers (e.g. changes in weather, high-intensity exercise, etc.)
  • Anxiety and stress
 

Tests and Diagnosis

In most circumstances, extensive testing is not required. With skin allergies, pinpointing the source of the hives can help with administering appropriate treatment and preventing future breakouts. Additionally, thorough testing also helps rule out similar conditions, such as mastocytosis and vasculitis [2]. Noted below are examples of common assessments that doctors may recommend.

Blood Tests

Samples of your blood are taken to determine whether any viral or bacterial infections are causing the condition. Your GP will test for certain factors in your blood, indicating whether this may be the case. 

Autologous Serum Skin Testing

The purpose of this test is to determine whether any autoimmune problems are contributing to chronic hives. During this test, the patient’s blood serum will be injected back into their body (mainly the forearm). The formation of welt(s) may indicate that there is a positive relationship between the two. Typically, referrals to a specialist may be needed for these tests.

Skin Prick Tests

Identifying any triggers or allergens is necessary for avoiding future episodes of hives. Prick tests involve injecting small amounts of potential allergens under the skin. Any flare-ups on top of the skin may indicate that the substance may be a trigger.

Skin Biopsies

Although less common, GP’s can take samples of the skin to diagnose chronic hives. Information from the biopsy can help make a formal diagnosis if there is any uncertainty. 
 

Are Hives Contagious?

Most hives are not contagious. Typically, they appear in response to the body’s reaction to specific triggers. However, some causes of hives that are contagious could spread to others, including bacterial and viral infections.
 

Urticaria (Hives) Treatment

Whether treatment is necessary will depend on a thorough evaluation by a GP. In most cases, acute hives will not require any extensive treatment as the symptoms typically disappear within days or weeks. However, those with persistent chronic hives may require additional assistance. 

Acute Hives

As noted previously, those with acute hives tend to recover within a short period. No treatment is usually required. However, GPs can recommend some strategies for symptomatic relief [2]. Examples include:
  • Cool baths
  • Calamine lotions
  • Anti-histamine medications
Those with recurrent skin allergies (particularly hives in children) may also benefit from strategies around preventing exposure to allergens and triggers. 

Chronic Hives

Those with chronic hives require a thorough assessment with a GP to determine the best course of management. Factors such as potential triggers and the progression of the condition may be discussed prior to deciding what types of treatments should be used. Strategies such as managing stress and the application of non-medicated lotions (e.g. menthol) can help ease symptoms. Additionally, certain medications can be prescribed if conservative treatments are not working. 

Hives Medications

Anti-histamines are usually the first-line medications prescribed. Their purpose is to reduce inflammation in the body to help clear skin rashes and welts. Around 60% of patients will respond to anti-histamine medications [5]. If anti-histamines are deemed not safe or effective, second-line therapies could also be prescribed. Corticosteroids and doxepin are alternative anti-inflammatory medications. However, they also present side effects, such as drowsiness, weight gain and osteoporosis [5].  In more situations where these types of medications are not safe or responding, GPs may also recommend other drug therapies. 
 

Hives Recovery

As noted earlier, the timeline for recovery is significantly different between acute and chronic hives. In most cases, acute hives will resolve by themselves, while chronic hives will often require additional treatment.

How long do hives last?

Acute hives will usually last from 2-3 days to a few weeks. However, chronic hives will be present for at least six weeks. Research [6] has shown that 35% will experience no symptoms whilst another 29% will have reduced severity within a year. 
 

Complications

Those who have been diagnosed with hives can experience repeated episodes even after it has improved. Studies [6] indicate that 48-54% of people who have had hives may have remission within 3 years. This can be disruptive to quality of life, sleep and even within a social context.  Additionally, any allergic reactions could lead to more severe events, such as anaphylaxis and even death.
 

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References

  1. https://www.aph.gov.au/Parliamentary_Business/Committees/House/Health_Aged_Care_and_Sport/Allergiesandanaphylaxis/Report/section?id=committees%2Freportrep%2F024422%2F72559 
  2. Clarke, P. (2004). Urticaria. Australian family physician, 33(7). 
  3. Ludvigsson, J. F., Lindelöf, B., Rashtak, S., Rubio-Tapia, A., & Murray, J. A. (2013). Does urticaria risk increase in patients with celiac disease? A large population-based cohort study. European journal of dermatology: EJD, 23(5), 681.
  4. Özkaya-Bayazit, E., Demir, K., Özgüroğlu, E., Kaymakoğlu, S., & Özarmağan, G. (1998). Helicobacter pylori eradication in patients with chronic urticaria. Archives of dermatology, 134(9), 1165-1167.
  5. Perera, E., & Sinclair, R. (2014). Evaluation, diagnosis and management of chronic urticaria. Australian family physician, 43(9), 621-625.
  6. Schaefer, P. (2017). Acute and chronic urticaria: evaluation and treatment. American family physician, 95(11), 717-724.