Hives (Urticaria) and Angioedema Overview
Hives or welts, also known as urticaria, are itchy, raised, pink or reddish bumps on the skin. About a quarter of the general population can have hives during their life. Hives often appear without warning and may start at any age.
Angioedema is swelling below the surface of the skin and fatty tissue. Areas of swelling may be painful. Angioedema usually occurs in the face, throat, hands and feet. Swelling can also occur in the abdomen or other areas of the body. Throat swelling can be life threatening and requires immediate medical attention. It is important to understand that angioedema is a medical term to describe swelling. It can be found with many different disorders. Angioedema can occur with or without hives. There are several different ways swelling can occur. Understanding the underlying mechanism of swelling or the specific disease is important in figuring out the best treatment.
Hives and Angioedema Symptoms & Diagnosis
Hives:
• Are itchy and can occur anywhere on the body including the face, arms and legs, groin, chest or back.
• May range in size from just a few millimeters to several centimeters.
• Usually fade individually within a 24-hour period and the skin returns to normal without leaving any marks or bruising.
Doctors will classify your hives based on how long you have had them. This helps doctors think about possible causes of your hives. When hives occur for less than six weeks, we call this acute urticaria. When hives last longer than six weeks, we change the name to chronic urticaria. Sometimes hives can occur with angioedema.
There are two types of chronic urticaria: chronic inducible urticaria and spontaneous urticaria. Neither form of chronic urticaria is dangerous. Chronic inducible urticaria is caused by an environmental trigger such as heat, cold or pressure applied to the skin. The most common form of inducible urticarias is called dermatographic urticaria. It can occur in all age groups. Dermatographic urticaria is triggered by shearing forces against the skin, such as scratching or pressure from tight clothing, resulting in the linear appearing hives. Stroking or scratching the skin with a firm object will elicit the response in five to seven minutes. Hives can last from 15 minutes to three hours.
Often the cause of chronic spontaneous urticaria is not fully known, but it is not usually caused by allergies. This is a constant finding of medical authorities and researchers around the world. The absence of an identifiable trigger can be frustrating for patients. Sometimes chronic hives may be autoimmune in nature or related to an autoimmune condition including autoimmune thyroid disease, rheumatoid arthritis or systemic lupus erythematosus, but in these cases, there are usually other signs of the autoimmune disease, such as joint pain or fevers.
Antihistamines are frequently an effective form of treatment for chronic urticaria. Spontaneous remission can occur in two to three years.
Classifications
Acute urticaria:
• Less than six weeks
• Spontaneous hives and/or angioedema
• Often due to:
- Viral infections (most common)
- Food allergy
- Drug allergy
- Environmental allergy
- Insect bites
Chronic (spontaneous or inducible) urticaria
• More than six weeks
• Spontaneous hives and/or angioedema
• Spontaneous hives may have an association with autoimmunity or thyroid antibodies
• Inducible urticaria (or physical urticaria, non-allergic hives from physical triggers)
- Scratching/rubbing (dermatographic urticaria)
- Pressure/tight clothes (pressure urticaria)
- Sweating/increased temperature (cholinergic urticaria)
- Cold exposure, ice (cold urticaria)
- Swelling from vibration (vibration induced angioedema)
- Sunlight (solar urticaria)
- Water (aquagenic urticaria)
Angioedema without urticaria: a special situation
Talk to your doctor if swelling occurs without hives. This may suggest a special situation requiring additional evaluation. Sometimes high dose antihistamines may not improve your swelling. This is because the cause of swelling may be due to something other than hives.
Swelling without hives may be:
• Spontaneous
- Unknown cause or autoimmune
• Medication induced
- Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
- ACE (angiotensin converting enzyme) inhibitors (a class of blood pressure medications)
The generic names of these medications end in “pril” such as lisinopril. ACE inhibitors can cause swelling at any time during the course of therapy, even after years of being on the medication.
Due to underlying disease
• Hereditary angioedema (HAE) is a rare genetic disorder in which patients have a defect in the gene that controls a protein called C1 inhibitor. When C1 inhibitor does not work properly, fluids can move out of the blood and into tissues to cause swelling. Antihistamines, steroids and epinephrine will not help in treating swelling in patients with HAE, however targeted treatments are available once your diagnosis is established. Over 50% of patients with HAE will have their first swelling episode before age 12.
• Acquired angioedema is an acquired form of C1 inhibitor deficiency that can occur in certain diseases. This is not hereditary or passed to your children.
Hives and Angioedema Treatment & Management
The goals of treatment are to:
• Provide relief from itching
• Make hives more tolerable
• Provide complete resolution of your hives
Medications will help your itching and reduce hives. Medications will not “cure” hives but can help to completely resolve them. Antihistamines are the best initial medication to treat your hives. Sometimes, a combination of several antihistamines or a high dose of one antihistamine may be recommended.
Older antihistamines such as Benadryl (sedating antihistamines) may make you sleepy, cause dryness and only last for several hours. Newer non-sedating antihistamines are less likely to make you sleepy. They have fewer side effects and last much longer. Non-sedating antihistamines (shown below) are often the first medication doctors will prescribe for your hives. High dosages, up to four times the recommended dose, are often well tolerated and can help control your itching. This will also help to prevent the use of other medications that have more side effects.
About 50% of chronic spontaneous urticaria (hives over six weeks with no identifiable cause) will respond to antihistamine as discussed above. For those who do not improve on antihistamines, 65% respond to omalizumab. Omalizumab is an FDA approved treatment of chronic urticaria. This medication is injected under the skin once a month. Another injectable medication that has FDA approval for the treatment of chronic urticaria is dupilumab, which can help reduce itching and hives. Most recently, a novel oral tyrosine kinase inhibitor called remibrutinib has received FDA approval to treat chronic spontaneous urticaria in adults. Corticosteroids, such as prednisone or prednisolone may help hives. These are not ideal treatments for long-term use but may have a role to relieve severe symptoms for a few days. Other medications that can be used include cyclosporine, which has been shown to improve symptoms in 54-73% of patients and can be an option for those patients that don’t improve with newer agents. If these medications do not help, in rare cases, under the supervision of a specialist, your treatment team may also consider other medications that affect the immune system.
Your doctor will outline a treatment plan that allows you to increase treatment during an outbreak of hives or swelling and reduce medications when the hives or angioedema are not as bothersome.
Chronic hives can last for many years but will often go away. Hives will resolve in half of patients within one to two years and 80-90% of patients will improve within five years. Even if a patient’s hives improve, it is not unusual to see the hives recur months to years later.
The treatment of angioedema is dependent on whether or not it is mediated by histamine (associated with hives). If it is associated with hives, antihistamines, like the ones listed below, or steroids can help. If it is related to medication, your doctor will usually talk to you about stopping or changing your medication. If is related to hereditary angioedema, the treatment is different and involves very specialized medications.
Antihistamines commonly used to treat urticaria
Sedating antihistamines
• Hydroxyzine (Atarax)
• Diphenhydramine (Benadryl)
Non-sedating antihistamines
• Cetirizine (Zyrtec)
• Levocetirizine (Xyzal)
• Fexofenadine (Allegra)
• Loratadine (Claritin)
• Desloratadine (Clarinex)
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10/2/2025