Ask the Allergist: Hives That Keep Coming Back

Q: I have this rash that comes and goes … I think it may be hives. Is it an allergy? 

David Khan 1David Khan, MD: Hives are raised, red spots or welts on the skin that are almost always itchy. Anyone who experiences them should see a physician. Acute hives that arise quickly after being exposed to a food or insect sting can be a sign of life-threatening anaphylaxis and may require immediate treatment with an epinephrine auto-injector.

Hives that keep recurring for 6 weeks or more are called chronic hives – and they are rarely caused by allergy. They are likely related to the immune system, so an allergist/immunologist trained to recognize underlying conditions is an appropriate specialist to see.

Sometimes we can’t identify the exact cause of the outbreaks and call it CIU, or chronic idiopathic urticaria – episodes of hives that break out for no apparent reason, go away, then come back again, often on different parts of the body. Chronic means long-lasting; idiopathic means we don’t know the cause; and urticaria means hives.

Q: What is the treatment for CIU?

Dr. Khan: First you should see a physician to (1) determine if the condition really is hives; (2) see if you and the doctor can identify a cause; and (3) work together on a treatment plan and how to manage it effectively.

Even though we may not know what causes the hives, we do know how to treat them and bring relief for most patients. Topical skin creams don’t help because it’s a whole body condition, so we use oral medications that reduce the itching and inflammation.

CIU guidelines recommend a step-based approach, starting with antihistamines, preferably nonsedating ones. If that doesn’t work, we go to histamine 2 blockers. We might add montelukast, which blocks leukotrienes, a chemical involved in inflammation. Another option is omalizumab, which is given by injection and blocks IgE antibodies in the blood involved in the production of histamine.

CIU outbreaks are not life-threatening, but they are extremely uncomfortable and difficult to live with, so I work closely with my patients to find a treatment that works for each individual. The good news is we have numerous options – and CIU is not a life-long condition. It often goes away by itself.

Read more about CIU, and how it’s diagnosed and treated, in the winter 2015 issue of Allergy & Asthma Today.

Dr. David A. Khan is Professor of Internal Medicine at the University of Texas Southwestern Medical Center in Dallas. He is the Training Program Director for the Allergy & Immunology fellowship program at Southwestern. He is the Director of the Asthma Clinic at Parkland Memorial Hospital. Dr. Khan is a Past President of the Texas Allergy, Asthma and Immunology Society and is a member of the Joint Task Force on Practice Parameters for Allergy & Immunology.