What is the treatment for hives?
A mild case of hives may not necessarily require prescription treatment, unless related to an allergy or other underlying medical condition. For the most part, treatment can help to alleviate symptoms (itching and burning or stinging sensations) causing discomfort, and reduce the likelihood of flare-ups.
Treatment is essentially aimed at alleviating the discomfort of symptoms while the welts and markings heal.
For mild outbreaks of hives, a doctor may recommend the following:
- Taking antihistamines / H-2 blockers (to block leakage of histamine and alleviate symptoms of itching and swelling, as well as prevent the formation of new outbreaks or flare-ups)
- Prescription anti-inflammatory medications (oral corticosteroids can help to reduce itching, redness and swelling by suppressing an allergic reaction, or for severe cases of hives or angioedema offer short-term treatment)
- Prescribed immune system suppressant medications (for the relief of an overactive immune system or where antihistamines and anti-inflammatory medications are proving ineffective)
- Avoiding hot water on the skin and direct sunlight (this can sometimes aggravate an outbreak of hives) (14)
- Bathing in cool or lukewarm water with added colloidal oatmeal (finely ground oatmeal)
- Avoiding any irritants to the affected skin areas (such as clothing)
- Avoiding scratching the affected skin areas
- Avoiding exercise, caffeine, alcoholic beverages and emotional stress which can worsen symptoms
For chronic hives, a doctor may:
- Recommend antihistamines (15)
- Prescribe corticosteroid medications (oral) or non-steroidal anti-inflammatories
- Prescribe antibiotics to treat swelling and inflammation
- Prescribe an EpiPen (epinephrine autoinjector) to self-inject epinephrine during severe or chronic flare-ups (this must be kept on hand at all times to alleviate early signs of anaphylaxis quickly)
- If a cause of chronic hives is determined as idiopathic, a doctor may request that an affected person keep a journal for a period of time to track activities, foods and drinks ingested, medication or supplement use (if applicable), and general habits. These can be compared with any hive flare-ups, the nature of which can also be noted in the journal (when hives appeared, how long they lingered for, and the nature of other symptoms, such as sensation severity etc.). Sometimes a trigger may not be an underlying cause of hives, but can be determined as an aggravator. A diary / journal can help a doctor to determine the differences.
For severe hives and angioedema, a doctor may:
- Administer an injection of adrenaline (epinephrine) – often used in an emergency situation
- Prescribe cortisone medication
- Prescribe blood protein controller medications to help with regulation and alleviate symptoms
- Prescribe an EpiPen should an emergency situation or severe flare-up occur
- Give the patient intravenous (IV) fluids to increase blood pressure (this is normally a saline solution)
- In an emergency situation where breathing is difficult, oxygen may be given via a face mask or through a breathing tube (inserted through the nose)
Any severe case which has resulted in a hospitalisation will require the patient to be monitored for some time, as recurrence risk is fairly high.
Solar hives (urticaria) often resolves on its own, but can be treated with:
- Medications such as corticosteroids and some used to treat asthma or hydroxychloroquine (an antimalarial drug)
- Phototherapy (this helps to ‘prepare the skin’ for sunlight exposure by administering low doses of sunlamp ultraviolet radiation to desensitise the body to its effects – results may not be long-term, however)
- Immunosuppressants, plasma exchange (separation and removal of plasma – white and red blood cells and platelets - in the blood, which are then returned to the system), photophoresis (a form of photodynamic therapy and aphoresis which treats blood with a photosensitising agent, and this is then irradiated with light wavelengths) and intravenous immunoglobulin (can help with raising low red blood cell counts)
Cholinergic hives can be treated:
- With lifestyle modifications (especially relating to physical and strenuous exercise activity which may need to be modified so as not to elevate body temperature too much – e.g. limited outdoor exercise activities during warmer months of the year)
- By managing anxiety and stress-related triggers (if applicable)
- Through the administration of medications that may be recommended or prescribed to alleviate symptoms (such as antihistamines / H1 antagonists) or manage the amount of perspiration produced by the body (methantheline bromide), beta blockers, immunosuppressants or those used to treat UV light exposure.
- With an EpiPen, if severe symptoms are a risk for exercise-induced anaphylaxis complications
Before taking any prescription or over-the-counter medications, it is advisable to discuss all known side-effects with a doctor to ensure optimum comfort while taking the drugs. Antihistamines are known to cause a little drowsiness (often a reason why they are taken at night before bed), dry mouth, dizziness, nausea, vomiting, concentration problems and trouble with urination. They are generally long-lasting and provide some of the most effective relief of hive symptoms as welts heal.
Some medications may not be recommended or prescribed for women who are pregnant or breastfeeding. Symptoms will be assessed and alternative home care treatments, or medications deemed safe, may be recommended instead. If a chronic medical health condition is already under treatment or other medications are currently being taken, a doctor will assess benefits over risks, and potential drug interactions before recommending any medicinal treatment, so as to avoid adverse effects.
Side-effects of corticosteroid medications can include swelling, elevated blood pressure, elevated eye pressure, weight gain, cataracts, elevated blood sugar levels and reduced hormone release from the adrenal glands. This is often why long-term use, particularly for severe or chronic hives is not typically recommended (lower doses or supervised transition to creams are sometimes prescribed instead).
Other medications which may be recommended when antihistamines are not effective include:
- Injectable man-made monoclonal antibodies (for difficult-to-treat hives which occur on a chronic basis)
- Some asthma medications (leukotriene modifiers) used along with antihistamines
Topical creams and lotions may be recommended to help numb nerve endings and in this way, alleviate itching or stinging sensations. Many topical ointments, however, are not very effective and especially for those with heightened sensitivity. Camphor, aloe Vera, calamine, pramoxine, diphenhydramine and menthol are some lotion containing substances which can provide some relief.
A skin patch test may be done before any topical creams or lotions (even those containing natural compounds and ingredients) are applied as contact dermatitis can occur. Cortisone-containing lotions (which are normally prescribed) are not terribly effective either, even if quite strong. Sometimes a tricyclic antidepressant (in cream form), which has a strong antihistamine effect, may be prescribed for some topical relief from itching but may cause a little drowsiness or dizziness as side-effects.
If an EpiPen is used, a person must visit the emergency room as soon as possible following use for a thorough check-up by medical professionals.
Home care – Managing an outbreak of hives
The following may help to alleviate mild symptoms:
- Use cool compresses, moist dressings or bandages and damp cloths, applied to affected skin to help soothe and prevent the urge to scratch (scratching the itching markings should be avoided as this can worsen an outbreak)
- Maintain a cool temperature in the home (during the day and at night), or if cold temperatures are a trigger, a mild temperature that does not aggravate symptoms
- Wear lightweight and loose-fitting clothing (i.e. soft cotton fabrics instead of wool which can scratch the skin)
- Avoid allergens and triggers
- Take frequent cool / lukewarm (or tepid) baths (as needed), with a sprinkling of uncooked oatmeal or colloidal oatmeal (this helps to alleviate itching)
- Avoid using harsh soaps while bathing (try gentle soaps made for sensitive skin instead)
- Apply a sunscreen (approved by a treating doctor) when heading outdoors
- Avoid smoking or consuming alcohol, especially while taking medications (this can aggravate and worsen symptoms)
Is a follow-up appointment necessary?
No, not always. Mild to moderate hive outbreaks normally resolve without complications or long-term effects. If any recurring or new symptoms develop, however, a medical professional should be consulted.
Some signs needing medical evaluation include:
- A new or recurring rash (especially if it is worse than before)
- Severe side-effects from medication use
- Swelling or sores on the tongue, in the mouth or throat
- Fever (or chills)
- Difficulties with swallowing and or / breathing
Outlook for hives
More often than not, an outbreak of hives is not a serious condition, although an occurrence is understandably uncomfortable. Generally, an outbreak is harmless, resolving itself and very rarely becomes a life-threatening reaction. Severe reactions can quickly become dangerous and if not effectively treated can be life-threatening for the person concerned.
Hives can be both predictable (triggered by a known cause) and not, often disappearing and then popping up again. Most cases of hives can be effectively controlled and do not typically leave any long-term damage or adverse effects following an outbreak.
14. Victoria State Government - Better Health Channel. April 2017. Hives: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hives [Accessed 29.08.2018]
15. US National Library of Medicine - National Institutes of Health. March 2016. Guideline of Chronic Urticaria Beyond: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4921693/ [Accessed 29.08.2018]