You’re going about your day when you feel it. Those intensely itchy welts that appeared on your skin a few days ago and then disappeared are back. Hives often come and go in this way. You may also see swelling.

If these flare-ups occur daily or on most days of the week for 6 weeks or longer, you have chronic (long-lasting) urticaria. The word “urticaria” means hives. When what’s causing the hives is unknown, the condition is called chronic spontaneous urticaria. It’s also referred to as chronic idiopathic urticaria. The words “spontaneous” and “idiopathic” mean “cause unknown.”

“Even when you don’t know what’s causing hives, you can get relief.” says board-certified dermatologist Viseslav Tonkovic-Capin, MD, FAAD. Today’s treatments can relieve the itch, stop the swelling, and prevent new hives.

What can relieve the itch?

Antihistamines often provide the most relief from itch. Take one that offers:

• 24-hour relief
• Non-drowsy formula
• One of these active ingredients: Cetirizine, fexofenadine, or loratadine

If this fails to relieve the itch, a dermatologist can choose an appropriate antihistamine and adjust the dosage to fit your needs.

─ Keely Morris Marshall, MD, PhD, FAAD

An antihistamine can often treat the itch due to hives.

If an antihistamine that you can buy without a prescription fails to bring relief, a dermatologist can create a customized treatment plan for you. I often treat my patients who have hives with an antihistamine. After one week, we reassess. When necessary, I change the dose or add a second antihistamine.

─ Viseslav Tonkovic-Capin, MD, FAAD

Board-certified dermatologist Keely Morris Marshall, MD, PhD, FAAD, adds, “Some pain medications like ibuprofen and aspirin can worsen the itch. If you have hives and need a pain reliever, try acetaminophen. It’s less likely to worsen the itch. And if you’re taking a prescription medication for pain and having flare-ups, tell the doctor who prescribed this medication that you have hives.”

How do dermatologists treat hives without knowing the cause?

Dermatologists have conducted many research studies on chronic hives. Through years of research, they’ve found treatments that work even when the cause remains unknown.

Much of this research has focused on antihistamines. Dr. Tonkovic-Capin says, “When treating hives with an antihistamine, the keys to success are to use the proper dosage required for each antihistamine and to combine these medications in such a way that research shows can be effective.”

Using this approach, Dr. Marshall can often reset her patients’ skin with antihistamines.

Dr. Marshall adds, “Treatment is the same, whether we find the cause or not. Over 50% of the time, we never find what’s causing hives.”

Hives can be stubborn

It’s important to understand that it can take time to find treatment that works for you. If this happens, your dermatologist may switch medications or add another treatment. For example, you might stay on an antihistamine and begin light therapy or start taking a second medication.

“Today, there are many effective treatments,” says Dr. Tonkovic-Capin. Newer medications include omalizumab (Xolair), which the U.S. Food and Drug Administration (FDA) has approved to treat chronic spontaneous hives. This medication is a biologic that works to calm your immune system, which can stop new flare-ups.

Dr. Marshall says that some of the newer medications for eczema can also be effective. Dupilumab (Dupixent), also a biologic, is one of these eczema medications.

Since it can take time to find an effective treatment plan, Dr. Marshall gives this advice. “Ask your dermatologist when you should expect to feel better with the prescribed treatment. For example, if you should feel better 3 weeks after starting treatment and you’re not, let your dermatologist know.”

If symptoms persist, Dr. Tonkovic-Capin may introduce a patient to stress reduction techniques, like meditation, mindfulness, yoga, or deep breathing. He says, “These therapies can help alleviate flare-ups triggered by stress. So can a good night’s sleep.”

Skin care can also play an important role. When hives develop, the skin is often easily irritated. That’s why dermatologists frequently talk with their patients about skin care.

Proper skin care can help reduce flare-ups

Hives can make your skin extremely sensitive. To reduce the risk of irritating your skin with everyday products, Drs. Marshall and Tonkovic-Capin recommend the following:

• Use mild, fragrance-free skin care products. Fragrance can irritate your skin, causing a flare-up. Even your cleanser and soap should be fragrance free.
  
  Keep in mind that fragrance free and unscented are not the same. When choosing products, select only those that are fragrance free. Unscented products contain fragrance that’s masked, so you don’t smell it. Masked fragrance can irritate your skin.

• Keep your skin moisturized. Dr. Marshall tells her patients, “Dry skin is more likely to become irritated and itchy.” She recommends using a moisturizer that’s a cream rather than a lotion because creams are more hydrating than lotions.

• Wear loose, comfortable cotton clothing. This includes wearing white, cotton underwear.

• Use fragrance-free, dye-free laundry detergent. Dr. Tonkovic-Capin also tells his patients to use an extra rinse cycle, as well as avoid fabric softeners and dryer sheets.

When to partner with a dermatologist

When hives last 6 weeks or longer, it's helpful to see a board-certified dermatologist.

Your dermatologist can give you an evaluation to rule out some causes. While it's true that the cause is often never found, this evaluation can find a few. Possible causes include infections, certain medical conditions, and medications. Be sure to tell your dermatologist about all medication that you take or have taken recently.

Your dermatologist can also tell you whether a physical trigger (something that causes hives when it touches your skin) is responsible. Physical triggers include cold, sunlight, and pressure on your skin from carrying a backpack or purse.

Partnering with a dermatologist can also be helpful if you have swelling or feel that the flare-ups are affecting your quality of life. Treatment can help both. If you’re unsure whether you have hives, you'll also want to see a dermatologist. Many skin conditions can look alike.

No one knows your skin better than a board-certified dermatologist. To find a board-certified dermatologist, go to Find a Dermatologist.

Images
Courtesy of Keely Morris Marshall, MD, PhD, FAAD, and Viseslav Tonkovic-Capin, MD, FAAD

Written by:
Paula Ludmann, MS

Reviewed by:
Carrie L. Kovarik, MD, FAAD
Keely Morris Marshall, MD, PhD, FAAD
Natalie H. Matthews, MD, FAAD
Darrell S. Rigel, MD, FAAD
Viseslav Tonkovic-Capin, MD, FAAD

Last updated: 5/30/24