Hives (Urticaria): Causes, Treatment and Prevention

Nationwide Children’s Hospital

Overview

Signs & Symptoms

Causes

Treatment

What to Expect

When to Seek Help

What Are Hives?

Hives are red, raised bumps on the skin that can be itchy. Hives are also called urticaria. About 1 in 5 people will get hives at some point in their lives.

What Are the Signs and Symptoms of Hives?

Hives can be found anywhere on the body. They can be small, like mosquito bites, or several inches wide. Even if they look different, hives often have common symptoms.

• People may have one hive or groups of hives that cover large areas of the body.
• Hives can move around on the body. They may start in one place, then move to another place on the body. 
• Hives may go away quickly or come and go for many weeks or months. 
• Skin swelling is common with hives. It may happen on the lips, ears, eyelids, fingers, or toes. This is common and not dangerous. 
• Less commonly, hives can occur as part of a more severe allergic reaction called anaphylaxis. Anaphylaxis can cause the airway to swell, making it hard to breathe. This is a life-threatening reaction that needs to be treated right away. 

What Causes Hives?

Hives happen when the body releases a chemical called histamine. It can be released because of allergies or other things, like stress, infections, or some illnesses. Whatever is causing histamine to be released is called a trigger.

• Hives not related to allergies are more common. Their triggers are:
  • Viruses or infections, like a cold, strep throat, or a urinary tract infection (UTI).
  • Emotional stress, like anxiety, anger, fear, or sadness.
  • Exercises that make the body warm.
  • Vibrations from using a lawn mower, horseback riding, or mountain biking.
  • Temperatures that are too hot or too cold.
  • Sunlight or tanning beds (sunlamps).
  • Pressure on the skin, like being rubbed too hard or scratched, or by wearing clothes that are too tight.

Hives that are related to allergies are less common. Their triggers are:

• Foods or medicines (anaphylaxis may occur) – Symptoms include nausea, throwing up (vomiting), mouth/throat swelling, and trouble breathing. This can be very dangerous.
  • Some common foods that cause allergies include eggs, peanuts, tree nuts, milk, and shellfish. 
  • Some medicines that cause allergies include aspirin, ibuprofen (Advil®, Motrin®), and naproxen sodium (Aleve®).
• Contact with the skin that can lead to irritation. These are usually not dangerous.
  • Plants, grasses, weeds
  • Acidic foods or sauces
  • Scents or fragrances (soaps, detergents, lotions)
  • Animal dander
  • Latex or other materials

When to Get Emergency Help

Call 911 or take your child to the closest emergency room if they have hives and any symptoms of anaphylaxis:

• Trouble breathing, swallowing, or talking
• Swelling of the mouth or tongue
• Nausea or vomiting

If they have an epinephrine auto-injector, like EpiPen®, Auvi-Q®, or Adrenaclick®, use it right away.

How Are Hives Treated?

Treatment depends on how bad the itching is. Even with treatment, hives can last days to weeks. The goals of treatment are to:

• Control the itching
• Avoid things that may trigger hives

For mild hives:

• Give an over-the-counter (OTC) antihistamine each day. Some examples are:
  • Loratadine (Claritin®)
  • Fexofenadine (Allegra®)
  • Cetirizine (Zyrtec®)
  • Levocetirizine (Xyzal®)
• Do not use Benadryl® creams. These may cause irritating rashes.
• Cool the skin using an ice pack or a cold bath or shower.
• Distract your child by playing games, singing songs, or reading books.
• Avoid known triggers, like animal dander or fragrance.

For severe hives:

• Give a higher dose of antihistamines or steroids, like prednisone. Oral steroids should not be used a lot. They may make hives worse when you stop taking the medicine.
• See a doctor or health care provider. They may prescribe a medicine, like Xolair® shots (injections), if you have long-term (chronic) hives.

Living With Hives

Living with hives isn’t easy, especially if you don’t know what’s causing them. It may help if you write down events that happened right before the hives appeared. This can help you and your child make a plan to keep the hives from coming back.

Depending on what’s causing your child’s hives, you can keep their hives from getting worse by having them:

• Avoid scratching or rubbing their skin.
• Wash their hands after touching pets or animals.
• Wear loose-fitting clothes. • Wear warm clothes. 
• Wear sunblock and long sleeves and pants in the sun.
• Avoid contact with cold water if they’re sensitive to cold.
• Use mild, unscented soap on their skin and for washing clothes.

When to Call the Doctor

Call the doctor or health care provider if your child’s hives get worse or prescribed medicine isn’t helping.

Hives (Urticaria) (PDF), Spanish (PDF), Somali (PDF)

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Hives (Urticaria) | Causes, Symptoms & Treatment

Chronic hives occur almost daily for more than six weeks and are typically itchy. Each hive lasts less than 24 hours. They do not bruise nor leave any scar. They typically do not have an identifiable trigger.

If your hives last more than a month or if they recur over time, see an allergist, who will take a history and perform a thorough physical exam to try and determine the cause of your symptoms. A skin test and challenge test may also be needed to identify triggers.

Therapies range from cool compresses to relieve itching to prescription antihistamines and other drugs, such as anti-inflammatory medications and medications that may modify your "}" data-sheets-userformat="{"2":8963,"3":{"1":0},"4":[null,2,16777215],"11":4,"12":0,"16":10}">The immune system is a collection of cells and proteins that works to protect the body from potentially harmful, infectious microorganisms (microscopic life-forms), such as bacteria, viruses and fungi. The immune system plays a role in the control of cancer and other diseases, but also is the culprit in the phenomena of allergies, hypersensitivity and the rejection of transplanted organs, tissues and medical implants.</span>” rel=”tooltip”>immune system.

Is It Hives or Angioedema?

Angioedema – swelling of tissue beneath the surface of the skin – can be mistaken for, or associated with hives. It can be caused by allergic reactions, medications or a hereditary deficiency of some enzymes. The following symptoms may indicate angioedema:

• Swelling in the eyes or mouth
• Swelling of the hands, feet or throat
• Difficulty breathing, stomach cramps or swelling of the lining of the eyes

The best way to identify your symptoms is to talk to an allergist who can diagnose and treat both hives and angioedema.

Diagnosis

In some cases, the trigger is obvious – a person eats peanuts or shrimp, and then breaks out within a short time. Other cases require detective work by both the patient and the physician because there are many possible causes. If the hives have gone on for a long time, the cause is not usually identified.

A single episode of hives does not usually call for extensive testing. If a food allergy is suspected, consider keeping track of what you eat. This will help you discover whether there is a link between what you’re eating and when you break out with hives.

Chronic hives should be evaluated by an allergist, who will ask about your and your family’s medical history, substances to which you are exposed at home and at work, exposure to pets or other animals and any medications you’ve taken recently. If you have been keeping a food diary, show it to your allergist.

Your allergist may want to conduct skin tests, blood tests and urine tests to identify the cause of your hives. If a specific food is the suspected trigger, your allergist may do a skin-prick test or a blood test to confirm the diagnosis; once the trigger is identified, you’ll likely be advised to avoid that food and products made from it. In rare instances, the allergist may recommend an oral food challenge – a carefully monitored test in which you’ll eat a measured amount of the suspected trigger to see if hives develop. If a medication is suspected as the trigger, your allergist can conduct similar tests, and a cautious drug challenge – similar to an oral food challenge, but with medications – may also be needed to confirm the diagnosis. Because of the possibility of ” rel=”tooltip”>anaphylaxis, a life-threatening allergic reaction, these challenge tests should be done only under strict medical supervision, with emergency medication and equipment at hand.

In cases where vasculitis (inflammation of the blood cells) may be the cause, your allergist may conduct a skin biopsy and send it to a specialist to examine under a microscope.

Management and Treatment

Researchers have identified many – but not all – of the factors that can cause hives. These include food and other substances you take, such as medications. Some people develop hives just by touching certain items. Some illnesses also cause hives. Here are a few of the most common causes:

• Some food (especially peanuts, eggs, nuts and shellfish)
• Medications, such as antibiotics (especially penicillin and sulfa), aspirin and ibuprofen
• Insect stings or bites
• Physical stimuli such as pressure, cold, heat, exercise or sun exposure
• Latex
• Blood transfusions
• Bacterial infections, including urinary tract infections and strep throat
• Viral infections, including the common cold, infectious mononucleosis and hepatitis
• Pet dander
• Pollen
• Some plants

Antihistamines – available either over the counter or by prescription – are a frequently recommended treatment for hives. They work by blocking the effect of </span>” rel=”tooltip”>histamine, a chemical in the skin that can cause allergy symptoms, including welts. Antihistamines that don’t make you drowsy are preferred. They are effective and long-lasting (may be taken once a day) and have few side effects. Your allergist may recommend a combination of two or three antihistamines to treat your hives, along with cold compresses or anti-itch balms to ease the symptoms.

Severe episodes of urticaria may require temporary treatment with prednisone, a similar corticosteroid medication or an immune modulator, which can reduce the severity of the symptoms.

If your reaction involves swelling of your tongue or lips, or you have trouble breathing, your allergist may prescribe an epinephrine (adrenaline) auto-injector for you to keep on hand at all times. These can be early symptoms of anaphylaxis, a potentially fatal allergic reaction that impairs breathing and can send the body into shock. The only treatment for anaphylaxis is It is one of two chemicals (the other is norepinephrine) released by the adrenal gland. Epinephrine increases the speed and force of heart beats and thereby the work that can be done by the heart. It dilates the airways to improve breathing and narrows blood vessels in the skin and intestine so that an increased flow of blood reaches the muscles and allows them to cope with the demands of exercise. Epinephrine has been produced synthetically as a drug since 1900. It remains the drug of choice for treatment of anaphylaxis."}" data-sheets-userformat="{"2":8963,"3":{"1":0},"4":[null,2,16777215],"11":4,"12":0,"16":10}">Epinephrine is a naturally occurring hormone, also called adrenaline. It is one of two chemicals (the other is norepinephrine) released by the adrenal gland. Epinephrine increases the speed and force of heart beats and thereby the work that can be done by the heart. It dilates the airways to improve breathing and narrows blood vessels in the skin and intestine so that an increased flow of blood reaches the muscles and allows them to cope with the demands of exercise. Epinephrine has been produced synthetically as a drug since 1900. It remains the drug of choice for treatment of anaphylaxis.</span>” rel=”tooltip”>epinephrine. If you develop hives and your injector is not nearby – or if using the auto-injector doesn’t cause the symptoms to immediately improve – call 911 or go to an emergency room immediately. Emergency medical services carry epinephrine and can provide prompt treatment. You should also go to the emergency room after using an auto-injector.

If the cause of hives can be identified, the best treatment is to avoid the trigger or eliminate it:

• Foods: Don’t eat foods that have been identified to cause your symptoms.
• Rubbing or scratching: Avoid harsh soaps. Frequent baths may reduce itching and scratching – beneficial because itching and scratching can make the hives feel worse.
• Constant pressure: Avoid tight clothing. Pressure hives can be relieved by wearing loose-fitting clothes.
• Temperature: If you develop hives when exposed to cold, do not swim alone in cold water and always carry an epinephrine auto-injector. Avoid exposure to cold air and use a scarf around your nose and mouth in cold weather. If you must be out in the cold, wear warm clothing.
• Sun exposure: Wear protective clothing; apply sunblock.
• Medications: Notify your physician or pharmacist immediately if you suspect that a specific medication is causing your hives.

Chronic hives

Some cases of hives last for more than six weeks and can last months or years. This condition is known as chronic hives.

If the cause cannot be identified, even after a detailed history and testing, the condition is called chronic idiopathic urticaria. (“Idiopathic” means “unknown.”) About half these cases are associated with some immune findings. Chronic hives may also be associated with thyroid disease, other hormonal problems or, in very rare instances, cancer. Even this condition usually dissipates over time.

Physical urticaria

In physical urticaria, the hives have a physical cause, such as exposure to heat, cold or pressure.

Common triggers include:

• Rubbing or scratching. This is the most frequent cause of physical urticaria. Symptoms appear within a few minutes in the place that was rubbed or scratched and typically last less than an hour.
• Pressure or constriction. Delayed pressure urticaria can appear as red swelling six to eight hours after pressure (belts or constrictive clothing, for example) has been applied. Symptoms can also occur in parts of the body under constant pressure, such as the soles of the feet.
• Change in temperature. Cold urticaria is caused by exposure to low temperatures followed by re-warming. This can be severe and life-threatening if there is a general body cooling – for example, after a plunge into a swimming pool.
• Higher body temperature. Cholinergic urticaria is due to an increase in body temperature because of sweating, exercise, hot showers and/or anxiety.
• Sun exposure. Solar urticaria may occur within a few minutes after exposure to the sun.

Inflammation of the blood vessels, or vasculitis, can also cause hives. These hives are more painful than itchy, may leave a bruise on the skin and often last more than a day.

Life’s too short to struggle with hives. Find answers with an allergist.

Insect bites – BU “Nizhnevartovsk city polyclinic”

Insect bites

1. Main
2. Useful articles
3. Insect bites

Insect stings

• Insect stings can cause allergic reactions, local infections and systemic illness.
• In Russia, insect vectors spread Lyme disease, tick-borne encephalitis, tularemia, Pogost disease and Inkoo virus encephalitis.
• Allergy to wasp or bee stings can lead to an anaphylactic reaction.
• If allergic to mosquito bites, prophylactic use of antihistamines may help.

Symptoms

• When an insect stings, an erythematous patch first appears on the skin, which may enlarge like a blister.
• There is usually a small petechia in the center of the bite site.
• A skin reaction is a combination of exposure to insect venom and an immunological reaction of the body, which explains a wide range of individual differences in reactions.
• Delayed allergic reactions may develop after insect bites. In their place, itchy papules or nodules persist for several weeks.
• Anaphylaxis usually develops extensive erythema and edema at the site of the bite, followed by general symptoms such as malaise and low blood pressure after a few minutes.
• In addition, acute urticaria is possible, as well as generalized or limited itching of the palms and soles.
• Anaphylactic reactions are especially common in persons allergic to hymenoptera stings. See Hymenoptera section below for testing and treatment.

Complications due to insect bites

• Severe local reaction (painful erythema, edema, angioedema) near mucous membranes (eg, pharynx or lips) may lead to airway obstruction.
• A purulent infection of the skin (pyoderma) may develop at the site of the bite. It is especially typical for tourists. See the article about skin problems in tourists.
• There are rare cases of abscess, erysipelas or cellulitis at the site of the bite.
• In persons sensitized to Hymenoptera venom, the bite may cause an anaphylactic reaction.
• Clinically significant infections spread by arthropods in Russia:
  • Lyme disease and tick-borne encephalitis (both diseases are spread by ticks)
  • tularemia spread by mosquitoes, sometimes ticks, midges or horseflies
  • Pogost’s disease and encephalitis caused by the Inko virus (both diseases are spread by certain types of mosquitoes).

Investigations

• Diagnosis based on history and clinical examination
• It is important to evaluate the bite site (erythema annulare, necrotic papule or ulcer, photograph) and other skin symptoms (eg, urticaria, pruritus), as well as mucosal and general symptoms (fever, joint and neurological symptoms).
• The diagnosis of Afzelius-Lipschütz erythema migrans and tularemia (scabbing ulcer) is clinical, which implies initiation of therapy based on clinical presentation.
• In hymenoptera venom anaphylaxis, skin prick tests and tests for specific serum IgE antibodies to wasp and bee venom should be performed.
• In case of purulent infection of the bite site, bacteriological culture may be required.
• In doubtful cases, histological examination of a skin biopsy may show a typical reaction to an insect bite, which, however, is not an absolute diagnostic criterion.

Diptera (mosquitoes and flies)

Mosquitoes

• A mosquito bite causes a rapid appearance of a papule like urticaria, which almost always disappears spontaneously, but in sensitized individuals may persist for a long time and be accompanied by itching.
• Large papules and even vesicles may appear.
• Antihistamines such as Cetirizinum (cetirizine) 10 mg once daily relieve symptoms of mosquito bite allergy, especially when taken prophylactically.

Blackflies

• Blackflies cannot bite through clothing, but they can bite when crawling under it. Many develop papules that can persist for up to several weeks.
• Individuals allergic to their venom may develop extensive swelling of local tissues.
• Midge bites usually cause severe itching, and scratching may lead to ulceration or secondary infection.

Horseflies

• A horsefly bite usually causes a large papule with a pale center.
• Treatment
  • For local treatment, ointments with class II-III glucocorticosteroids or their combination with an antiseptic 1-2 r/day can be used. within 1-2 weeks.
  • In the presence of a secondary infection at the site of the bite, the use of antibacterial ointments or creams 2-3 times a day for 1 to 2 weeks is recommended.
  • Wet and cold compresses or cooling gel can help relieve symptoms.
  • For severe reactions, a 3-day course of oral glucocorticosteroids, such as Prednisolonum (prednisolone) 40 mg/day, may be indicated.

Hymenoptera

• Due to the ingestion of venom at the site of a wasp, (honey) bee or bumblebee sting, severe pain and swelling immediately occur.
• Worldwide, hymenoptera venom sensitization causes many potentially fatal anaphylactic reactions each year.
• Persons allergic to wasp venom are not usually allergic to bee venom and vice versa.
• Treatment
  • The bite site must be immobilized to prevent further spread of the venom.
  • A bee sting remaining in the skin must be quickly removed to prevent the entire contents of the venom reservoir from being emptied into the skin. It is best to scrape it off the skin with a thin flat object (bank card, coin). A wasp or a bumblebee does not leave a sting in the skin.
  • Suitable first aid measures: cold compresses, lotions or cooling gel.
  • Individuals with multiple bites should be monitored for systemic reactions.
  • Anaphylactic reactions
    • Acute anaphylactic reactions are treated as anaphylaxis, with future contact with Hymenoptera to be avoided.
    • After the development of a systemic reaction (anaphylaxis) to a hymenoptera bite, allergy tests are recommended.
    • First aid: the patient should carry with him an anti-shock kit containing a solution of Adrenalini hydrochloridum (adrenaline hydrochloride) 0.1% 1.0 ml in ampoules; in addition, 40 mg of Prednisolonum (prednisolone) and an antihistamine preparation, for example, in the form of lozenges, are used once.
    • Anaphylaxis examinations
      • Hymenoptera venom allergy is diagnosed by a positive prick test and/or detection of IgE antibodies to bee or wasp venom following an anaphylactic reaction. An IgE reaction can only be determined 1-2 months after the bite.
      • If both tests are positive, an allergen-specific IgE antibody test may be performed to identify the true cause of the allergy.
      • In such cases, it is also recommended to send a serum sample for immunochemical analysis (spot immunoassay), if this service is available. Unfortunately, this technique is not used in the Russian Federation.
      • If a patient has had a typical systemic reaction to hymenoptera venom but tests for specific IgE are negative, these tests should be repeated and special tests considered in consultation with an allergist.
      • Serum tryptase measurement is recommended to rule out mastocytosis in patients who have had an anaphylactic reaction to hymenoptera venom. The assay should be performed in the non-acute phase (eg, 1-2 months after the reaction).
      • Desensitization (allergy to hymenoptera venom)
        • A severe systemic reaction (local reaction and cardiovascular or respiratory symptoms) to a hymenoptera (wasp or bee) sting is an absolute indication for desensitization.
        • In case of a mild systemic reaction (local reaction and urticaria or mucosal edema), desensitization may be considered if there is a high likelihood of re-bite or the fear of re-bite affects the patient’s quality of life.
        • Desensitization is not indicated for extensive local reactions.
        • In patients allergic to hymenoptera venom, desensitization should be continued for 5 years, after which almost all (at least 80%) will remain effective for at least 7 years.
        • Knowing that desensitization is likely to prevent anaphylactic reactions improves quality of life.

Lice (Anoplura)

• Blood-sucking species that parasitize humans: head, body and pubic lice.
• Head lice epidemics can occur in schools and kindergartens.
• Body lice are rare now; they appear mainly in alcoholics and people leading an antisocial lifestyle.
• Normal washing of clothes in a washing machine is sufficient for decontamination.
• Pubic lice are commonly transmitted sexually; symptoms: itching and pustules in the genital area, nits in the pubic hair.

Bed bugs and fleas

• Bed bugs live in old, dirty buildings. They can be transported with old furniture. Bed bugs suck blood at night.
• Small insects that parasitize birds, dogs, cats (eg the tick of the genus Cheyletiella) and rodents also bite humans.
  • Most often, symptoms appear in the spring (in people who work in a poultry house or go to country houses for the first time after winter).
  • Bedbug and flea bites cause hard, intensely itchy papules with a bite mark (petechia) in the center. They are most often noted on areas of the skin covered by clothing.
  • Skin manifestations may persist for several days, symptoms develop only in sensitized patients.
  • A blister or extensive swelling may immediately appear at the site of the bite, which is easily confused with erysipelas or another bacterial infection.
  • Papules usually appear in groups at the site of several bites, but rows of bites are also characteristic.
  • Fleas cause papular urticaria sometimes seen in children in summer (Strofulus). The patient is usually unaware of the cause of the rash, making diagnosis difficult.
  • Sensitization is necessary for the reaction to develop, which is why not all family members show symptoms.
  • Treatment
    • For bedbug and flea bites, the use of an ointment or solution with a class II–III glucocorticosteroid 1–2 r/day is usually sufficient. within 1-2 weeks.
    • Disinsection of bedbugs in residential buildings requires special knowledge about where they can hide and how to destroy them, and calling a special service.

Larvae

• The hairs of the larvae of some butterflies (eg crimson cocoon moth) can cause toxic and allergic reactions.

Ticks

• Ticks Ixodes ricinus are carriers of Lyme disease, tick-borne encephalitis, rarely tularemia.
• Tick bites are painless and may go unnoticed.
• In Russia, ticks are active from April to November, and their favorite habitat is lawns, grass, low shrubs and grassy cover in wooded areas.
• High boots and trousers are best suited for protection.
• When entering areas inhabited by ticks, skin and clothing should be inspected every evening and removed if found.
• For tick-to-human transmission of Borrelia, the tick must remain in the skin for at least several hours or even days; therefore, it must be found and removed as quickly as possible.
  • The most typical early symptom of Lyme disease is expanding erythema annulare migrans (Erythema migrans) within a week around the site of the tick bite.
  • Within a few days or weeks, the erythema usually reaches a size of 5-10 cm, sometimes much more, and may subsequently disappear spontaneously.
  • Typically, a skin lesion 5 cm in diameter observed within 5 days of a tick bite is indicative of ME. Faster, smaller reactions may be an inflammatory response to tick saliva components.
  • Lyme disease is always diagnosed on clinical grounds. In the vast majority of cases, the infection is diagnosed at an early stage, while testing for antibodies is impractical.
  • Laboratory testing (antibodies to Borrelia in serum) is needed for later diagnosis.
  • Tick removal
    • Grab the tick with tweezers (small, sharp-tipped) as close to the skin as possible.
    • Try to remove the entire tick by simply pulling it straight up slowly. Do not try to remove it with oils or ointments. If the head of the tick remains in the skin, it can be removed with a needle, after disinfecting the skin.

Spiders

• In the Russian Federation there are karakurt, tarantula, etc.
• Spiders usually bite a person only when accidentally pressed against the skin.
• The most dangerous spider in Russia is the karakurt. With untimely help, its poison can be fatal. Serum injection is required. The poison of the South Russian tarantula is not life-threatening, but can lead to swelling, severe pain at the bite site, and an allergic reaction. Water Spider Sting Effect ( Argyroneta aquatica ) is similar to a wasp sting.
• Bites from the hunter’s limb and large cross spiders can be painful.
• They are treated like hymenoptera bites.

Protection against insect bites

• Clothing should cover as much of the body as possible, which is especially important for young children.
• Light colored clothing with long sleeves and trousers is preferred. Mosquitoes, for example, can bite through thin fabric.
• Head covering is recommended, ankles and feet can be protected with socks and shoes. Pants can be tucked into socks. Closed shoes are preferable to sandals.

Repellents

• Active ingredients of repellents sold in Russia: diethyltoluamide (DETA), icaridin.
• The effect of the repellant usually lasts for several hours, but intense perspiration shortens this period.
• The strength and period of action of repellents are interdependent, i.e. the stronger the repellent, the longer the duration of its action.
• Preferably, the concentration of the active substance in mosquito repellents is at least 20%.
• Repellents containing DEET above 35% can be recommended for really high numbers of mosquitoes, if the repellent quickly evaporates from the skin, and for people traveling to tick habitats.
• Solutions 50% are effective against mites and 20% are effective against mosquitoes, midges and midges when used according to package directions.
• Repellents are not effective against deer bloodsuckers, wasps, bees and bumblebees.

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