Medicines That Can Help Manage Chronic Hives Flare-Ups

If you’ve been diagnosed with chronic hives (chronic idiopathic urticaria), itchy, angry red welts are frequent visitors. And they require a different treatment approach than acute hives.

Allergy and immunology specialist Sonya Parashar, MD, explains how to manage chronic hives flare-ups.

Understanding chronic hives

Chronic hives appear out of nowhere and are rarely the result of an allergy. That’s in contrast to acute hives, which are an allergic reaction to a specific trigger that you touched, ate or inhaled.

To be diagnosed with chronic idiopathic and spontaneous urticaria, your hives flares must:

• Occur at least twice a week
• Continue for six weeks or longer
• Have no clear trigger at least 80% to 90% of the time

What exactly causes your chronic hives to flare may be a mystery, but Dr. Parashar says that chronic spontaneous urticaria is usually a reaction to something happening in your body. Common culprits include viral or bacterial infections, hormone fluctuations, stress and more.

“When people with chronic hives come in, I tell them how sorry I am that they’re dealing with this,” she shares. “These flares can be very frustrating and really uncomfortable, but with help, they can be managed.”

Managing chronic hives flares

There are many medical approaches you and your provider can take to ease (and, hopefully, prevent) flare-ups.

“Flare-wise, everyone is a little different,” Dr. Parashar clarifies. “Your doctor will partner with you to find a treatment plan that gets you the relief you need.”

Allergy medicine

Allergies don’t typically cause chronic hives, but allergy medicine can help soothe the itching and discomfort they bring.

“Some people can manage their hives with a standard dose,” Dr. Parashar says. “But when you’re having flares a few times a week, your provider may direct you to take more until things calm down. The trick is working with your provider to find that sweet spot, and to know what to do if things escalate.”

If your hives symptoms make it hard to sleep, consider taking a diphenhydramine product like Benadryl®, Unisom® or ZzzQuil® before bed. Just don’t take them during the day — they’ll leave you drowsy and sluggish.

BTK inhibitors

If over-the-counter antihistamines aren’t managing your symptoms, your provider may prescribe a new oral medication called remibrutinib (Rhapsido®). It’s a BTK inhibitor, which is a class of drugs that helps calm an overactive immune system.

Biologics

If non-drowsy antihistamines aren’t enough to keep you comfortable, your treatment plan may also include one of the following prescription biologics:

• Dipulimab (Dupixent®)
• Omalizumab (Xolair®)

Steroids

Some providers prescribe corticosteroids like prednisone (Deltasone® or Rayos®) to tackle symptoms that don’t get better with allergy treatments.

Dr. Parashar avoids long-term steroid use because of side effects. But taking them may be necessary if you have severe flares that aren’t getting any better.

Other drugs

There’s a surprisingly wide range of medications that can help tame chronic hives flare-ups. For example, your provider may recommend:

• Monoclonal antibodies: A monthly injection may help ease symptoms over time.
• Hydroxychloroquine: Research shows this anti-malarial may be effective as an add-on treatment when antihistamines don’t fully control flares.
• Cyclosporine: This immunosuppressant is effective for treating chronic hives at low or moderate doses, but it can cause serious side effects when taken for too long.
• Antidepressants or antianxiety medications: If stress and anxiety are your primary hives triggers, ask your doctor if these types of medications could help.

When to see a doctor for a flare-up

If you have chronic spontaneous urticaria, call your provider about hives that:

• Itch, burn or sting more than normal
• Are unusually red, swollen or hot to the touch
• Cause severe pain
• Weep, blister or ooze
• Bruise or scar your skin
• Are accompanied by a fever or chills

“These are red flags,” Dr. Parashar states. “There’s a big difference between hives that itch normally and hives that are wildly itchy and painful.”

Unusually bad hives symptoms could point to a condition called urticarial vasculitis. It looks like hives, but it’s really blood vessel inflammation, which requires different treatment.

Can flare-ups be an emergency?

Living with chronic spontaneous urticaria, you may be used to hives popping up without warning. But it’s still possible to have a sudden outbreak of hives as part of an allergic reaction.

Call 911 or emergency services if you break out in hives and are also:

• Vomiting
• Swelling up
• Feeling dizzy or lightheaded
• Having trouble breathing or swallowing

These are common symptoms of a life-threatening allergic reaction called anaphylaxis.

Building a chronic hives treatment plan

Your chronic hives management plan will focus on calming flares — or stopping them altogether. No two plans are the same. If you figure out your personal triggers, for example, avoiding them could be all it takes to put chronic urticaria in the rearview mirror.

“Let’s say you’ve figured out that every time you wear a certain pair of running pants, you get a flare-up,” Dr. Parashar illustrates. “You’d ask, what it is about the pants that trigger hives. Maybe they’re too tight. Or maybe the fabric traps more moisture than your other workout clothes. Either way, once you stop wearing those pants, you’ll stop getting hives.”

But even if you never figure out why you keep breaking out in hives, relief is possible. It will just take some experimenting.