How to Treat Urticaria (Hives): Evidence-Based Guide

Urticaria, commonly known as hives, appears as raised, itchy welts on your skin that can range from small spots to large patches. These red or pink bumps typically turn white when pressed and can appear anywhere on your body. While hives usually resolve on their own, effective treatments can provide relief and prevent recurrence.

Understanding the type of urticaria you have and available treatment options can help you manage symptoms effectively and know when professional care is needed.

Acute vs Chronic Urticaria

Acute urticaria lasts less than six weeks and often results from allergic reactions to foods, medications, or insect stings. Chronic urticaria persists for six weeks or longer and affects about 1-2% of the population. In 80-90% of chronic cases, no specific trigger can be identified, making it chronic spontaneous urticaria.

First-Line Treatment: Antihistamines

Second-generation antihistamines are the recommended first-line treatment for urticaria. These medications block histamine release that causes hives and include cetirizine, loratadine, fexofenadine, and levocetirizine. Unlike older antihistamines, these cause less drowsiness and can be taken once daily.

If standard doses don't provide relief, your doctor may increase the dose up to four times the typical amount. Studies show that less than 10% of patients achieve complete control with standard antihistamine doses alone.

Home Remedies for Immediate Relief

Several home remedies can provide temporary symptom relief:

• Apply cold compresses to affected areas for 10-15 minutes to reduce swelling and numb itching
• Take cool (not hot) baths or showers, as heat can worsen symptoms
• Add colloidal oatmeal to baths for its anti-inflammatory properties
• Wear loose, breathable clothing to avoid irritating affected skin
• Avoid scratching, which can worsen inflammation

Over-the-Counter Options

Most second-generation antihistamines are available without prescription. Look for products containing cetirizine, loratadine, or fexofenadine. Take them consistently rather than only when symptoms appear for better control. Some people benefit from combining these with H2 antihistamines like famotidine, though you should consult a doctor before combining medications.

Prescription Treatments for Severe Cases

When antihistamines don't provide adequate relief, doctors may prescribe stronger treatments. Omalizumab, a biologic medication given by injection every four weeks, is FDA-approved for chronic spontaneous urticaria in patients 12 and older. Clinical trials show that 66-84% of patients achieve significant improvement with this treatment.

Other options include short courses of corticosteroids for acute flares, though these aren't recommended long-term. In 2024, the FDA approved dupilumab for chronic spontaneous urticaria, providing another option for difficult-to-treat cases.

Identifying and Avoiding Triggers

Common urticaria triggers include:

• Foods: Especially shellfish, nuts, eggs, and milk
• Medications: Antibiotics (particularly penicillin), NSAIDs, and aspirin
• Physical factors: Pressure, cold, heat, sunlight, or vibration
• Infections: Viral illnesses commonly trigger acute hives
• Stress: Can worsen existing urticaria

Keeping a symptom diary can help identify patterns. Note when hives appear, what you ate, medications taken, activities, and stress levels. Your doctor may recommend allergy testing if food or environmental allergies are suspected.

When to Seek Emergency Care

Call 911 immediately if you experience:

• Difficulty breathing or wheezing
• Throat swelling or tightness
• Dizziness or feeling faint
• Rapid pulse
• Swelling of lips, tongue, or face

These symptoms may indicate anaphylaxis, a life-threatening allergic reaction requiring immediate epinephrine and emergency medical care.

Long-Term Management Strategies

For chronic urticaria, consistent management is key. Take antihistamines daily as prescribed, even when symptoms improve. Avoid known triggers whenever possible and manage stress through relaxation techniques or counseling. Regular follow-up with your doctor helps optimize treatment and adjust medications as needed.

Most people with acute urticaria see improvement within days to weeks with proper treatment. Chronic cases may take longer but often respond well to step-up therapy with biologics or other prescription options.

When to See a Dermatologist

Schedule an appointment with a dermatologist or allergist if:

• Hives persist longer than a few days despite over-the-counter treatment
• You develop hives almost daily for six weeks or more
• Symptoms significantly impact your quality of life or sleep
• Over-the-counter antihistamines don't provide adequate relief
• You experience recurring episodes without clear triggers

A specialist can perform comprehensive testing, identify potential triggers, and prescribe more advanced treatments like omalizumab or dupilumab when needed. They can also rule out underlying conditions that may cause chronic hives.

Frequently Asked Questions

How long do hives typically last?

Individual hives usually last less than 24 hours, but new ones may continue appearing. Acute urticaria resolves within six weeks, while chronic urticaria persists longer and may last months to years.

Can I take antihistamines long-term?

Yes, second-generation antihistamines are safe for long-term use under medical supervision. They're the recommended treatment for chronic urticaria and can be taken daily for extended periods.

Will hives go away without treatment?

Many cases of acute urticaria resolve on their own within days. However, treatment with antihistamines provides faster relief and prevents new hives from forming. Chronic urticaria typically requires ongoing treatment for symptom control.