How To Manage Frustrating Chronic Hives Flare-Ups

When you think about hives, you probably picture red, itchy welts popping up all over your skin. Maybe you get them a couple of hours after petting a dog, eating a peanut butter sandwich or slathering on a new body lotion.

Those are acute hives. An allergic reaction from eating or contact with something kicks your immune response into overdrive. And once you treat the allergy, the hives go away.

But what if you keep getting hives a few times a week and they linger for weeks or months? Without you ever eating nuts, touching an animal or trying a new product. Would you be surprised to learn allergies aren’t usually at fault with these flares?

Chronic hives, or chronic idiopathic or spontaneous urticaria, appear out of nowhere. These fun facts set chronic hives apart from acute ones:

• They flare up at least twice a week.
• Flares last for six weeks or longer.
• About 80% to 90% of the time, there’s no trigger.

“While acute hives practically tell you the diagnosis, chronic hives are trickier,” says allergy and immunology specialist Sonya Parashar, MD. “‘Idiopathic’ and ‘spontaneous’ mean ‘unknown.’ And that not knowing can be frustrating.”

What causes chronic hives to flare up?

So, how can you manage flare-ups if these hives are such a mystery?

Chronic hives most likely pop up from an immune system response. But the exact reason this happens is still murky. While most cases don’t have obvious outbreak triggers, things happening in your body can set them off. Viral or bacterial infections, autoimmune conditions, stress, and anxiety are major culprits.

External factors, known as inducible triggers, can also cause chronic flares. Some common ones include:

• Water that’s too hot.
• Cold weather.
• Clothing that’s too tight.
• Sunlight.
• Nonsteroidal anti-inflammatory drugs (NSAIDs).

“When you have chronic hives, you feel like you’re harming your body,” Dr. Parashar relays. “And that’s not a good feeling. But your body’s telling you something’s going on in other parts of your life.”

How to manage chronic hives flare-ups

For some, chronic hives often go away without treatment within a year. For others, there are ways to manage and ease these long-lasting flare-ups. To soothe chronic hive symptoms, you may want to:

• Place cool compresses on the hives several times a day (unless cold temperatures make your hives worse).
• Take a cool bath or shower (again, but not if your hives flare with cold temperatures).

If you’ve discovered the physical trigger for your hives, you’ll want to change how you do things and avoid that trigger.

“Let’s say you’ve figured out that every time you wear a certain bra, you get a flare-up,” Dr. Parashar illustrates. “Think about what it is about this bra that’s triggering the hives. Maybe the band is too tight. Or maybe it’s the strap. Once you realize this, you stop wearing that bra — and you stop getting hives.”

So, if you know what’s causing them, you may want to make some lifestyle changes.

When to see a doctor for chronic hives flare-ups

Relentless chronic hives may not respond to at-home care. If so, it’s time to see a healthcare provider. But what kind of doctor treats hives? Allergists/immunologists do. And you’ll want to make an appointment with one if you have:

• Severe itching or burning.
• Scarring.
• Redness.
• Swelling.
• Pus.
• Bruising.

“These are red flags,” Dr. Parashar states. “There’s a big difference between hives that itch normally and ones that itch like crazy and are painful. It could be something called urticarial vasculitis. It looks like hives, but it’s really blood vessel inflammation. And it needs different treatment.”

You’ll also want to call a doctor if you’re throwing up, feeling dizzy or lightheaded or having trouble breathing, as chronic hives shouldn’t cause these common anaphylaxis symptoms.

What to expect at your appointment

When you meet with your doctor, they’ll ask questions about your symptoms and what’s happening when you get a flare. They’ll also take a close look at your hives.

Because hives and other skin conditions can closely resemble each other, Dr. Parashar says she often shows her patients pictures of hives compared to other rashes to help them better understand their diagnosis.

You may also get orders for blood tests. These can help your doctor uncover any infections or other health conditions that may trigger these welts.

“Flare-wise, everyone is a little different,” she clarifies, adding that there are different ways to treat chronic hive breakouts.

Common chronic hives treatments

Besides uncovering chronic hive triggers, treatment will focus on getting your hives to calm down and your flares to lessen or stop. No two chronic hives care plans will be the same. Your doctor will go over all recommendations and share the pros and cons of the treatments they think will work best for you.

Allergy medications

Allergic reactions rarely cause chronic hives. But allergy medications like antihistamines Zyrtec® or Allegra®, known as second-generation histamine blockers, can help reduce itching, redness and swelling. Your doctor may put you on a higher dose than usual to get your flare-up under control.

“Some people can manage their hives with one or two tablets daily,” Dr. Parashar says. “But if they’re having flares a few times a week, they may need a third or fourth tablet until things calm down. The trick is finding that sweet spot for a daily dose and what you may need if things escalate.”

She adds that she tries to avoid sedating allergy medications like Benadryl® because those can cause daytime sleepiness and sluggishness. And that can interfere with your life and work.

Steroids

Some providers may prescribe corticosteroids like prednisone (Deltasone® or Rayos®) to tackle symptoms that don’t get better with allergy medications. Dr. Parashar says she tries to avoid steroid treatments, too, because of the long-term side effects. But taking them may be necessary if you have severe flares that aren’t getting any better.

Other medications

Other drugs can help tame chronic hives. Your provider may recommend a monoclonal antibody as a monthly injection to help ease symptoms over time. They may also put you on the anti-malarial drug hydroxychloroquine, which research has shown may be effective as an add-on treatment when antihistamines don’t fully control flares. A third medication, the immunosuppressant cyclosporine is effective for treating chronic hives at low or moderate doses, but it should be taken sparingly, as it can cause serious side effects when taken too long.

If stress and anxiety are your major triggers, ask your doctor if they feel antidepressants or anti-anxiety medications would help.

Moving forward from chronic hives flare-ups

Pinpointing the cause of your chronic hives — and getting the best treatment for them — can be tricky. The good news? It’s possible to manage flare-ups and stop them altogether.

While there’s no single treatment that does this, your doctor can work with you to find a treatment plan that tackles these spontaneous hives so they settle down. It’s important to remember that results aren’t always instantaneous.

“When patients with chronic hives come in, I tell them how sorry I am that they’re dealing with this,” Dr. Parashar shares. “It’s very frustrating and really uncomfortable.

“You’ll want to work closely with your allergist. They can help you find the best plan to manage your flares. And often, once you’re on the right medication, we can get your hives to calm down over time.”