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If you have ever broken out in hives, you know the tell-tale signs: itching and red spots on the skin. Hives are the classic sign of an allergic reaction—although hives could erupt for reasons other than allergies. For most people, hives are little more than a temporary nuisance. Other times it can be the first step in a worsening situation. Here’s what you need to know about hives.
What are hives?
Hives (or urticaria) are a common and usually harmless skin condition marked by spots on the skin that are itchy, red, and raised. Called wheals, these lesions may be round or ring-shaped. Hives are usually a temporary condition. Called acute urticaria, the rash fades in two to three hours but could hold on for as long as six weeks. Chronic urticaria lasts longer than six weeks.
While popularly thought of as an allergic reaction, hives can be brought on by many causes including:
- Allergens (contact urticaria)
- Insect stings or bites
- Poisonous plants
- Foods
- Chemicals
- Medicines
- Infections
- Emotional stress
- Thyroid problems
- Autoimmune disorders
- Physical causes (physical urticaria) such as cold (cold urticaria), sweating (cholinergic urticaria), water, sun exposure, or pressure on the skin (dermatographism)
Whatever the cause of hives, they all involve triggering specialized cells in the body, called mast cells, which then release histamines into the skin tissues. Histamines are the immune system’s intruder alarm and cause the redness and swelling characteristic of hives. Histamines also stimulate “itch” nerves, so itching and even pain accompany the histamine overload.
If enough histamines are released, the skin may swell up with fluid from the bloodstream, a condition called angioedema, which can occur with or without hives. This swelling occurs deeper in the skin, below the layer of fat tissue. Angioedema is most common in the hands, face, and feet, though in severe cases, it occurs in the throat or respiratory tract, which could make breathing difficult. Anaphylaxis, a condition that causes respiratory failure and a dangerous drop in blood pressure,, is the most serious and life-threatening complication of a histamine overload.
One in five people will experience acute urticaria at some point in their lives. However, about one in a hundred people have chronic urticaria. Some chronic cases have identifiable triggers, but most have no known cause (chronic idiopathic urticaria).
How are hives diagnosed?
While hives are immediately identifiable in a physical exam, it can sometimes be difficult to determine the underlying cause. If you experience hives regularly, you can help a doctor arrive at the correct diagnosis by keeping a symptom diary. You should record urticarial breakouts, where on the body it occurs, how long it lasts, as well as all your activities in the hour or two before a breakout.
During a physical exam, a general practitioner or dermatologist will note additional reactions such as swelling, wheezing, difficulty breathing, or low blood pressure, as well as any signs of an underlying condition. In many cases, the healthcare provider will want a blood test. If the doctor suspects allergies, you may be referred to an allergist to perform allergy testing such as a skin test.
Hives treatment options
Treatment of hives centers on reducing symptoms and avoiding future outbreaks. An underlying infection or thyroid problem will be treated with the appropriate medications.
Medications
For transient urticaria due to an insect bite or exposure to an unusual substance, anti-itch lotions can be helpful in reducing symptoms. Because urticaria is caused by histamines released by skin cells, non-sedating or topical antihistamines are the first-line treatment. More severe or chronic cases may involve corticosteroids or prescription drugs that block this immune system reaction.
Prevention
In cases where hives are regularly induced by an allergen, food, or other physical cause, the best treatment is to avoid those triggers. Diet modification, lifestyle changes, and protective clothing can effectively prevent breakouts.
Hives medications
Hives cannot be cured, but the swelling, redness, and itching can be managed with both over-the-counter and prescription medications.
Antihistamines
Hives are caused by the release of histamines by specialized cells (mast cells) in the body. The redness, swelling, and itching are all caused by histamines. The first-line therapy for hives, then, are a type of antihistamine called H1 receptor antagonists. These drugs effectively neutralize histamines by blocking their ability to attach to skin or immune system cells. Well-known over-the-counter antihistamines— diphenhydramine, loratadine, levocetirizine, cetrizine, and fexofenadine—reduce swelling, redness, itching, and other problems such as wheezing or difficulty breathing. A healthcare provider may, however, prescribe a more powerful antihistamine such as Semprex (acrivastine) or desloratadine. Chronic urticaria is usually treated with a three- to six-month regimen of antihistamines.
If any of these antihistamines are not effective, the patient can switch to a different antihistamine. If none of them work, a healthcare professional may also add a different type of antihistamine, called an H2 receptor antagonist, such as ranitidine or cimetidine. These are drugs normally used to treat stomach acid problems but could help with reducing hives.
Leukotriene inhibitors
For chronic or severe urticaria that does not respond to antihistamines, doctors will turn to prescription leukotriene inhibitors. Leukotrienes are produced by white blood cells when they are activated by histamines and produce swelling. Leukotriene inhibitors such as montelukast, zafirlukast, and zileuton prevent white blood cells from producing leukotrienes and so rapidly dial back the inflammatory processes responsible for hives. Leukotriene inhibitors are taken as a single-dose pill once per day and can be combined with anti-histamines.
Corticosteroids
For severe cases that involve swelling and other problems, such as difficulty breathing, a doctor may prescribe a few days of oral corticosteroids such as prednisone to rapidly reduce swelling and itching.
Epinephrine
For severe reactions, a doctor will prescribe epinephrine to handle emergencies. Similar to adrenaline, epinephrine rapidly opens swollen airways and increases blood pressure. Patients will carry epinephrine auto-injectors in case of a severe reaction that requires immediate treatment. If you use an epinephrine auto-injector, you must still seek emergency treatment.
Monoclonal antibodies
Patients with chronic idiopathic urticaria—a persistent case of hives with no known cause—may be prescribed Xolair (omalizumab) injections. Omalizumab is a synthetic antibody that glues itself to the antibodies (IgE antibodies) that trigger histamine release, essentially shutting them down. Xolair is given as a subcutaneous injection by a nurse or health care provider once per month.
Immunosuppressants
A very small number of patients with severe and debilitating urticaria, airway obstruction, and chronic low blood pressure may not get better with antihistamines or leukotriene inhibitors. Those difficult cases are usually due to autoimmune disorders, that is, conditions where the immune system overreacts and attacks healthy tissues. A doctor may prescribe immune suppressants such as cyclosporine, tacrolimus, or mycophenolate mofetil, all of which reduce the ability of the immune system to function.
What is the best medication for hives?
While antihistamines are the first-line treatment, there is no “best” medication for hives. Patients may need to try more than one antihistamine to discover the most effective medication with the fewest side effects.
| Best medications for hives | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Calamine | Anti-itch medication | Topical | Using a pad or cloth, cover the affected area with lotion | Redness, itching rash |
| Benadryl (diphenhydramine) | H1 histamine receptor antagonist | Oral or topical | One to two 25 mg tablets taken every six hours. Apply topical cream or lotion to affected area three to four times per day. | Drowsiness, dizziness, dry mouth |
| Claritin (loratadine) | H1 histamine receptor antagonist | Oral | One 10 mg tablet every 12 to 24 hours, depending on formulation | Headache, dry mouth, nervousness |
| Allegra (fexofenadine) | H1 histamine receptor antagonist | Oral | One 60 mg tablet twice a day, or one 180 mg tablet taken once daily with water | Headache, dry mouth, dizziness, vomiting |
| Zyrtec (cetirizine) | H1 histamine receptor antagonist | Oral | One 10 mg tablet daily | Drowsiness, dry mouth, fatigue |
| Clarinex (desloratadine) | H1 histamine receptor antagonist | Oral | One 5 mg tablet daily | Dry mouth, sleepiness,, diarrhea |
| Singulair (montelukast) | Leukotriene inhibitor | Oral | One 10 mg tablet daily | Upper respiratory infection, headache, sore throat, stomach pain |
| Prednisone | Corticosteroid | Oral | Dosage will vary. Initial dose will be high and taper off daily over one to two weeks | Behavior and mood changes, acne, fluid retention |
| Xolair (omalizumab) | Monoclonal antibody | Subcutaneous injection | Dosing depends on weight and blood test results. Varies between 75 mg and 375 mg injection | Injection site reaction, body aches, congestion, headache |
| Sandimmune (cyclosporine) | Immune suppressant | Oral | Dose depends on weight | Kidney dysfunction, high blood pressure, unwanted hair growth |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of hives medication?
All medications have side effects that will vary based on the type of medication. This is not a complete list of possible side effects. A healthcare professional can provide more information about both side effects and drug interactions caused by hives medications.
The most common side effect of antihistamines is drowsiness, but this is less of a problem with the non-sedating antihistamines used to treat hives. Other possible side effects include headache,, mood changes, nausea, and dry mouth.
Taken over a few days to two weeks, oral corticosteroids commonly cause side effects such as mood swings, behavior changes, fluid retention, increased appetite, weight gain, thinning skin, and acne. The most serious side effects include high blood pressure, high blood sugar, glaucoma, infections, and potentially severe allergic reactions.
Leukotriene inhibitors also cause psychological changes such as mood swings, aggressiveness, attention problems, and depression. Headache, earache, diarrhea, and flu-like symptoms are also common side effects.
Epinephrine is chemically similar to adrenaline, so an epinephrine injection typically feels like an “adrenaline rush,” so one can experience anxiousness, high energy, nervousness, fast heartbeat, trembling, and sweating. Elevated blood pressure is a serious and potentially hazardous side effect. People should always seek immediate medical care after self-injecting epinephrine.
The most common side effects of Xolair are headache, joint pain, muscle pain, ear pain, fatigue, and cold symptoms. Severe and even life-threatening allergic reactions, though rare, is the most serious possible side effect of the injection.
Because immune suppressants weaken the immune system, infections are a common side effect. Severe infections and cancer are the most serious side effects of immune suppressants. Headache, dizziness, nausea, diarrhea, stomach upset, and gum problems are common side effects.
What is the best home remedy for hives?
Hives generally go away in a few hours, but some people may live with chronic hives or regular episodes. A few proven home remedies can help get you through the itchiness and discomfort.
Use a cold compress
An ice pack or washcloth soaked in cold water can provide rapid relief from pain and itchiness. Use it several times a day until symptoms subside.
Use anti-itch cream
Anti-itch creams can quickly help with discomfort. Calamine lotion, menthol creams, capsaicin creams, or hydrocortisone creams are the most effective, but topical anesthetics such as lidocaine cream can provide relief against more stubborn itching and pain.
Take a cool bath
The cool water will soothe the skin, especially if you add an anti-inflammatory substance such as colloidal oatmeal or baking soda.
Avoid triggers
The best home remedy for hives is to not get a rash in the first place. If you are repeatedly experiencing hives, keep a symptom diary to help you identify foods, allergens (such as dander or pollen), chemicals, activities, or medications that might be provoking outbreaks. Avoid any triggers that you discover in your diary.
Frequently asked questions about hives
How do you get rid of hives fast?
Hives are a temporary condition that typically resolves in a couple of hours. It is caused by histamines produced by mast cells in the skin. Over-the-counter antihistamines can provide the quickest route to symptom relief. Anti-itch lotions and creams as well as topical anesthetics can provide instant relief from the pain and itchiness of hives, but they will not relieve the swelling or redness.
How long does it take for hives to go away?
Hives are a temporary reaction that usually goes away in two or three hours without treatment. In some people, however, hives may persist for weeks or months.
What is the best medicine for hives?
Because hives are caused by histamines produced by specialized skin cells, the first-line medicines for hives are antihistamines. Second-generation antihistamines such as diphenhydramine and loratadine are advised because they are less likely to cause drowsiness and dizziness.
What kind of medications cause hives?
NSAIDs (nonsteroidal anti-inflammatory medications) such as ibuprofen and aspirin as well as codeine and other pain relievers are the primary culprits in medicine-induced hives. The primary chemicals in NSAIDs are salicylates. Many foods contain salicylates, such as celery, vinegar, honey, apricots, olives, peppers, tomatoes, oranges, grapes, and many spices (ginger, cinnamon, turmeric, etc.). These foods, too, can fire up hives in the same way as aspirin or ibuprofen.
What does Benadryl do for hives?
Hives are caused by the release of histamines by mast cells in skin tissues. The histamines induce an immune reaction characterized by redness, swelling, edema, and low blood pressure. Diphenhydramine, the active ingredient in Benadryl, is an antihistamine. It works by attaching to histamine receptors on skin and immune system cells, essentially neutralizing the excess histamines.
What can I drink for hives?
Hives can be caused by food, particularly animal or plant proteins or foods high in salicylates, the chemical found in drugs like aspirin or ibuprofen. No drink will help treat or prevent hives, but there certainly are drinks that may trigger hives in some people, such as orange juice, pineapple juice, tomato juice, coffee, and any berry juice.
What should I eat when I have hives?
Hives have many causes. Some people are triggered by food allergies or by substances in foods such as proteins or salicylates, chemicals similar to aspirin or ibuprofen. Histamine-rich foods, such as avocados, spinach, shellfish, dried fruits, and fermented foods (including alcoholic beverages), can trigger hives in some people.
What is the best cream to put on hives?
Calamine lotion is the safest and most effective anti-itch cream. Other anti-itch creams with hydrocortisone or topical anesthetics may provide more relief, but side effects are more likely.
Can sugar cause hives?
People with a sugar allergy may experience hives as part of the allergic reaction.
Why do hives get worse at night?
The body produces substances, called corticosteroids, which naturally reduce swelling, redness, and itchiness. Corticosteroids are the body’s natural defense against hives. When we sleep, however, the body dramatically dials back its production of corticosteroids, so inflammatory conditions such as hives tend to get worse.
Does scratching make hives worse?
Hives are caused by histamines released by specialized skin cells. Among many other effects, histamines stimulate “itch” nerves in the skin. When itching nerves start firing, the natural response is to scratch. However, scratching induces the skin to produce histamines. They get added to the histamine overload and, of course, set off the “itch” nerves all over again. As a result, hives can degenerate into an endless cycle of itching and scratching. Instead of scratching the itch, use a cold compress or an anti-itch cream. Calamine, capsaicin, menthol, or, if you need the powerful stuff, hydrocortisone or lidocaine can provide sufficient relief.