Urticaria

Urticaria, also known as hives, typically manifests as red or skin-colored lumps or welts with distinct borders. They can range in size from as small as a pen tip to as large as a dinner plate. Pressing the center of a red hive can cause it to become white, a phenomenon known as blanching. Hives may appear as a single lesion or as blotches or linked patches. They help regulate the body's allergic reaction to certain stimuli. It is common for individuals to mistake hives for other conditions, but they can be distinguished by a few characteristics. The duration and movement of the rash can help determine if hives are the cause. The following symptoms are commonly associated with hives:

• Red or skin-colored lumps or welts with distinct borders that usually disappear within 24 hours but may reappear in another location.
• Bumps or welts that appear alone or in clusters, covering a larger area.
• Itchiness and/or swelling in the area of the bumps or welts.
• Pain or stinging may occur at the site of the bumps or welts.

The disease's etiology might be caused by a variety of reasons. Factors that are frequently encountered include:

1. Medications

   Urticaria can be caused by certain medicines such as:

   • Penicillin
   • Aspirin
   • Nonsteroidal anti-inflammatory drugs
   • Sulfonamides
   • Thiazide diuretics
   • Oral contraceptives
   • Angiotensin-converting enzyme inhibitors
   • Vitamins
   • Codeine
   • Morphine
   • Curare and its derivatives
   • Synthetic adrenocorticotropic hormone
   • Radiocontrast agents

   Urticaria rashes may appear anywhere from 1 to 2 hours to 15 days after oral consumption of the medicine or drug. They appear faster when medicines are administered intravenously compared to oral administration.

2. Foods

   Foods that are common causes of urticaria include:

   • Nuts
   • Eggs
   • Fish
   • Shellfish
   • Chocolate
   • Meat
   • Cow's milk
   • Fruits (citrus fruits, grapes, plums, pineapples, bananas, apples, and strawberries)
   • Vegetables (tomatoes, garlic, onions, peas, beans, and carrots)
   • Mushrooms
   • Fermented foods
   • Spices
   • Spirits

   Note: Preservatives such as azo dyes, benzoic acid derivatives, salicylates, and food colors are also major causal factors. Urticaria generally appears 1 to 2 hours after intake of food. Children are more likely to develop food-related urticarial rashes.

3. Respiratory allergens

   Urticaria can be induced by the inhalation of allergens like:

   • Pollen
   • Mold spores
   • Mites
   • Animal dandruff
   • Animal hairs

   Note: Smoking is also a significant component since it includes numerous chemicals that might aggravate urticaria. Urticaria induced by respiratory allergens often develops shortly after contact.

4. Medical conditions

   Urticaria can be caused by infections such as:

   • Sinusitis
   • Tonsillitis
   • Dental abscesses
   • Urinary tract infections
   • Hepatitis
   • Infectious mononucleosis

   Note: Urticaria is caused by parasites, particularly in youngsters.

5. Contact urticaria

   Urticaria can be caused through contact with:

   • Latex
   • Cosmetics
   • Chemicals
6. Insect bites

   Insect bites may also cause urticaria, particularly in children.

7. Psychogenic factors

   Stress, sorrow, and despair can worsen pre-existing urticaria as well as cause it.

8. Systemic disorders

   Systemic disorders, in particular, can induce persistent urticaria. Thyroid and rheumatic disorders such as systemic lupus erythematosus, lymphoma, leukemia, and carcinomas may be examined if necessary. It should be mentioned that urticaria can arise during pregnancy.

9. External stimuli

   Stimuli like pressure, heat, cold, and dermographism can all cause urticaria. Urticaria caused by pressure usually appears 3 to 4 hours after exposure. As a result, they are known as delayed pressure urticaria.

10. Hereditary urticaria

    Urticaria can be hereditary and manifest in forms such as angioedema and familial cold urticaria.

11. Idiopathic urticaria

    Sometimes, urticaria may occur because of unrecognized causes. Skin allergies can be caused due to various factors that range from changes in weather to exposure to environmental toxins.

Any of the following factors can raise the risk of acute or chronic hives:

• Allergic reactions (whether pre-existing or newly developed).
• A personal history of hives.
• A family history of hives (especially in cases of hereditary angioedema, although rare).
• A well-known condition related to hives (infections such as urinary tract infection, strep throat, hepatitis, rheumatoid arthritis, or type 1 diabetes).
• Viral infections.
• Medications (including codeine, aspirin, morphine, and NSAIDs).
• Skin sensitivity or dermatitis (inflammation of the skin).
• Sensitivities to disinfectants, colors, chemicals, or perfume scents.
• Emotional triggers (association with stress and anxiety).

Diagnosis of Urticaria

Urticaria can be diagnosed by various medical specialists, although family doctors (general practitioners) make the majority of diagnoses.

Physical Examination

A dermatologist diagnoses hives through a physical examination. Generally, no specific tests are available to diagnose hives due to the non-specific or idiopathic nature of triggers in many cases. In certain situations, a trigger, such as a specific medication, can be identified. If an outbreak of hives resolves after discontinuing the drug, it can be determined if it was a trigger. If it does not resolve, the medication is unlikely to be the cause.

During the appointment, a doctor will gather a full medical history and discuss symptoms to establish an underlying cause of hives, such as an allergic response, followed by a thorough physical examination. The questions a doctor may ask during a consultation include:

• How long have the symptoms been present?
• How did the skin marks appear when they initially emerged?
• Have the marks altered in any way (for example, size or shape) since then?
• Is there anything that has made your symptoms better or worse prior to your consultation?
• Do the skin blemishes irritate, burn, or sting?
• Have any markings vanished without leaving a trace, such as a bruise?
• Have you been tested for allergies? If so, which ones?
• Has a similar skin issue ever developed before?
• Have you tried any new foods recently?
• Have any new products, such as cleaning detergents, been introduced?
• Have you been bitten or stung by an insect lately?
• Are you currently taking any new medications (prescription or over-the-counter, including herbal supplements)?
• Has a new pet been brought into the home?
• Is there anyone in your family who has had a similar skin problem?

Allergy Test

The doctor will perform a physical examination and assess the skin marks that are present. If allergies are suspected, a skin prick test may be conducted to identify the chemical causing the response. The trigger may be easily identified if urticarial rashes occur shortly after intake of shellfish or peanuts, exposure to sunlight or water, a scrape to the skin, or vigorous activity. Once a trigger allergen is identified, the doctor will advise avoiding contact with or consumption of the specific food or item containing the allergen. If deemed safe, the doctor may prescribe an oral food/drug test, where the affected individual is given a defined amount of the suspected allergen to elicit a hive reaction. The patient is closely monitored during the test, with emergency equipment or medication on standby. If there are significant risks of severe reactions, such as anaphylaxis, these tests may not be conducted. If you experience any symptoms of allergy, consider getting an allergy panel done.

Blood Tests

Blood tests may also be recommended to screen for certain diseases associated with hive outbreaks and to analyze blood proteins for a possible genetic tendency (as in hereditary angioedema). A urine sample may occasionally be collected as well. Note: Laboratory studies are generally not indicated for acute urticaria (< 6 weeks). In cases of chronic hives, the following tests may be advised as applicable:

• Complete blood count (CBC) to check for signs of anemia or infections.
• Thyroid function test to determine if the thyroid is hyperactive or underactive (hyperthyroidism or hypothyroidism).
• Tests for liver function to identify any underlying liver conditions.
• Erythrocyte sedimentation rate (ESR) test to assess any immune system abnormalities.
• Stool test to identify any parasites causing an infection.
• Antinuclear antibody (ANA) test to rule out autoimmune disorders such as lupus.

Angioedema Tests

C1 esterase inhibitor test evaluates complement protein levels and helps detect underlying causes of edema. Complement components (C2 and C4) may also be screened for deficits, as low levels can cause symptoms of edema and inflammation in the body.

Solar Hives (Urticaria) Test

• Photo-testing: A doctor or allergist can evaluate skin responses to UV radiation from a sun lamp using various wavelengths. The wavelength to which the skin reacts will help identify the type of solar allergy.
• Patch testing: This involves applying suspected sensitizing chemicals to the skin and covering them with a patch or dressing for a period (usually 24 to 48 hours). The area is then examined to determine the likelihood of a response. The skin may subsequently be exposed to UV light via a sun lamp. If the skin responds, solar hives can be diagnosed. Blood samples (and occasionally skin biopsies) may be taken to check for autoimmune or metabolic signals to establish an underlying cause.

Cholinergic Hives Tests

• Exercise challenge test: The patient may be asked to engage in an exercise program to elicit a comparable response. Medical devices may also be used to obtain various measures during the challenge.
• Passive warming test: A doctor would use warm water or increased ambient temperature to elevate the patient's internal body temperature and monitor for a probable reaction.
• Skin test for methacholine: Methacholine, a non-selective muscarinic receptor, would be administered to activate the parasympathetic nervous system and monitor for a potential response.

Other Tests

Other studies that may be considered include:

• Imaging studies: Generally not indicated unless suggested by specific symptoms or signs.
• Punch biopsy: Recommended if urticarial vasculitis (inflammation of blood vessels) is suspected.

Extensive testing is not generally recommended by medical specialists in cases of minor hive breakouts or a single incident. Chronic hives are rarely associated with an allergic reaction due to the frequency of recurrences lasting more than 6 weeks. It is more likely that the cause is not of external origin. Relevant tests are performed to identify an underlying cause, which may be an autoimmune illness or another medical condition.

Making lifestyle changes that minimize or prevent hive flare-ups is generally the most effective strategy to lessen the chance of an outbreak or recurrence. It is not always possible to entirely avoid a hive breakout. A confirmed allergy or a known cause such as medicines, environmental factors, foods, or exposure to specific pets is a one-way trigger that can be easily avoided. Specific allergy treatment can also be used to minimize the risk and relieve breakouts. If the reason is unknown and flare-ups occur often, maintaining a record that draws parallels between cause and effect (e.g., food ingested and a probable response) might help discover and avoid potential triggers.

Careful management of sun exposure can be beneficial for solar hives. This includes:

• Refraining from being out in the sun when it is at its strongest, often between 10 am and 4 pm.
• Gradually increasing time outdoors during spring and autumn to better adapt to stronger sunlight exposure.

Other preventative measures include:

• Wearing lightweight or loose woven clothes that provide maximum coverage, such as long pants or skirts and sleeved items.
• Choosing clothes with a UPF (ultraviolet) protection rating of at least 40 and applying a broad-spectrum sunscreen recommended by your medical professional regularly.
• Maintaining calm, as hives can be triggered by stress. Practice effective stress-reduction strategies, including daily exercise, meditation, and mindfulness.
• Avoiding products that may irritate the skin. Use a mild soap designed for delicate skin, which is generally free of scent and other irritants. Avoid heavy moisturizers and creams; when in doubt, use a solution designed for sensitive skin. Applying it shortly after washing may also help with itching.
• Using anti-sun aids such as sunglasses, broad-brimmed hats, and umbrellas to protect against sun rays.

If your symptoms are minor, you might not require therapy. Hives and angioedema often resolve on their own. However, therapy can provide relief for severe itching, significant discomfort, or symptoms that linger.

Medications

Prescription medicines may be used to treat hives and angioedema:

• Anti-itch medications (antihistamines)

Antihistamines that do not cause drowsiness are the conventional treatment for hives and angioedema. They are the first-line therapy for all urticaria patients. Some class H1 antihistamines with drowsiness as a side effect include:

• Chlorpheniramine
• Chlorpheniramine Maleate
• Hydroxyzine
• Diphenhydramine

Examples of non-sedating second-generation H1 antihistamines are:

• Loratadine
• Cetirizine
• Terfenadine
• Mizolastine

Second-generation H1 antihistamines include:

• Desloratadine
• Levocetirizine
• Fexofenadine

Examples of H2 antihistamines include:

• Cimetidine
• Ranitidine
• Famotidine
• Nizatidine

Treatment usually begins with a non-sedating antihistamine during the day and a sedating antihistamine at night. All antihistamines are equally effective at the licensed dosage. If patients do not respond to the standard dosage, it is common to double or triple the dose of non-sedating antihistamines. If patients complain of indigestion or acidity, H2 antihistamines might be administered. Combination therapy is frequently beneficial. In a short experiment, fexofenadine outperformed generic levocetirizine. Many patients do not respond to these combinations, necessitating the use of second-line treatments. According to some research, 40% of patients did not respond to antihistamines.

Anti-inflammatory Medications

Doctors may occasionally prescribe an oral corticosteroid medication such as prednisone to decrease swelling, redness, and itching caused by severe hives or angioedema.

Immune Suppressing Medications

If antihistamines and corticosteroids do not work, your doctor may prescribe immune suppressing medication that might calm a hyperactive immune system.

Situations of Emergency

Acute urticaria may progress to life-threatening angioedema and/or anaphylactic shock in a very short period. Anaphylaxis usually presents as rapid-onset shock with no urticaria or angioedema. A trip to the emergency department and an emergency injection of epinephrine—a form of adrenaline—may be required if you have a severe episode of hives or angioedema. If you have had a major attack or if your attacks continue after therapy, your doctor may advise you to carry a pen-like device that allows you to self-inject epinephrine in an emergency. If associated bronchospasm is present, prehospital nebulized albuterol may be warranted. Other measures may include continuous ECG, blood pressure and pulse oximetry monitoring, administering intravenous crystalloids if the patient is hypotensive, and administering oxygen.

If someone has minor hives or angioedema, the following methods may help ease their symptoms:

• Stay away from triggers and take appropriate precautions. Common triggers include foods, medicines, pollen, pet dander, latex, and insect bites. If you suspect a medicine is causing your rash, discontinue its use and notify your primary care practitioner.
• Use over-the-counter itch relievers to reduce itching. Some non-prescription antihistamines include loratadine, cetirizine, and diphenhydramine.
• Apply a cool washcloth to the affected area to soothe irritated skin and help avoid scratching.
• A relaxing bath in cold water or a cold shower may provide relief from itching. Bathing in cool water sprinkled with baking soda or oatmeal powder can be beneficial, though this is not a long-term solution for chronic itching management.
• Dress in loose-fitting, smooth-textured cotton to help avoid skin irritation.
• Stay out of the sun and seek shade when outdoors to prevent aggravation of painful rashes and itching.

Urticaria may lead to anaphylaxis, one of the most serious complications of hives. Anaphylaxis is an allergic reaction that is often severe and may even be fatal. It usually occurs within seconds to minutes of exposure to a potential allergen such as peanuts or bee stings. An anaphylactic reaction is triggered by a rapid release of chemicals by the immune system, which can result in shock. Anaphylaxis is characterized by a rapid drop in blood pressure and constriction of airways, preventing the sufferer from breathing.

The signs and symptoms of anaphylaxis include:

• Fast and weak pulse
• Skin rash
• Nausea and vomiting
• Swelling in the throat, which can cause a life-threatening obstruction of the airways

Certain foods, some medications, insect venom, and latex are common triggers for anaphylaxis.

• Use a cold compress: The cold temperature of water or ice effectively soothes irritated skin. Soak a cloth or towel in cold water and apply it to the hive-affected areas of skin.
• Make use of an oatmeal scrub: Oatmeal's anti-inflammatory properties make it an excellent hydrating and relaxing scrub for the skin. To soothe inflamed skin, take a lukewarm shower every morning and gently clean the areas affected by hives with an oatmeal soap bar or scrub with baking soda.
• Apply aloe vera gel: Aloe vera gel serves as a natural hydrator and contains beneficial antibacterial components. Applying a thick coating of aloe vera gel before bedtime significantly relieves the redness and discomfort associated with hives.

Ayurvedic Treatment for Urticaria

• To minimize urticaria, take a 5 to 7 gram dosage of a paste made from neem leaves, guduchi (giloy) leaves, or aloe vera pulp every day.
• Take 1 teaspoon of turmeric powder two to three times a day with a glass of milk or water. This is a fantastic remedy for boosting the body's immunity.
• Massage the skin for 15 minutes with mustard oil before bathing in lukewarm water.
• Mix ½ teaspoon of black pepper (kali mirch) powder with ½ teaspoon of desi ghee and consume it first thing in the morning on an empty stomach. For best results, continue for up to three months.

Eczema, a form of skin inflammation, is commonly characterized by itchiness, red skin, small bumps, and thickened skin over time. Here’s more information about home remedies for eczema.

Hives, also known as urticaria, are itchy red or skin-colored welts that affect about 20% of the population. They are frequently the result of an allergic reaction to a meal or medication and usually dissipate quickly. Hives may be very itchy and unpleasant. Although hives are a physical burden, they can also negatively impact emotional well-being, isolating individuals socially and hindering their performance at work or school, especially if they have suffered from hives for an extended period. For a small percentage of people, hives recur without a recognized cause. Chronic idiopathic urticaria (CIU) or chronic spontaneous urticaria (CSU) occurs when fresh outbreaks happen almost daily for six weeks or longer, affecting one percent or less of the population. Individuals between the ages of 20 and 40 are the most likely to suffer from it. A single outbreak of CIU generally lasts no more than 24 hours, but additional outbreaks may follow.

Urticaria vs. Contact Dermatitis vs. Insect Bites

Although often used interchangeably, these three terms have different meanings:

• Hives (urticaria): Itchy, red welts caused by an allergic response. The welts vary in size and emerge and disappear regularly as the response progresses. Chronic hives occur when welts form for more than six weeks and repeatedly recur over months or years.
• Contact dermatitis: Characterized by immediate but temporary localized swelling and redness on the skin upon direct contact with an offending chemical. Contact urticaria should be distinguished from contact dermatitis, which occurs hours to days after contact with the offending agent.
• Insect bites: Bug bites may resemble hives in appearance, but they behave differently. Hives can change shape and move around the body, whereas a bug bite remains in one spot. Rosacea often manifests as redness on the face, with enlarged blood vessels visible.

Urticaria in Pregnancy

It is unlikely that chronic urticaria would flare up during pregnancy. Pruritic urticarial papules and plaques of pregnancy (PUPPP) and pemphigoid gestationis are specific skin conditions that do not cause inflammation during pregnancy, presenting urticaria-like lesions that appear during the second or third trimester and disappear after delivery. Sex hormones may play a role in the pathophysiology of these conditions.