We all get skin rashes or bumps which itch once in a while – and we usually think it is just an insect bite, so we don’t pay much attention to it.

However, if you’ve been having red or skin-coloured bumps that appear and disappear quickly at regular intervals and itch, then chances are that they are a skin condition called Urticaria or Hives.

But don’t worry. Urticaria is a common skin condition that affects about 20% of people at some time in their lives. In this article, we will give you a detailed understanding of this disease and what to do if you have it.

Types of Urticaria

Urticaria are mainly classified into two categories based on the duration of the disease:

1. Acute Urticaria

This is the most common form of urticaria which lasts for a shorter period, usually less than six weeks. Often triggered by allergic reactions to foods (such as nuts, fish, tomatoes, eggs, berries, chocolates or milk), medications, insect stings, or infections. This kind of urticaria is characterised by sudden onset of welts and itching, with symptoms resolving relatively quickly. Usually the face, toes, fingers, neck and sometimes men’s genitals are most affected by Acute Urticaria.

2. Chronic Urticaria

Chronic Urticaria usually persists for six weeks or more, with episodes occurring regularly. The exact cause may be challenging to identify, however, sometimes they are linked to diseases like thyroid, hepatitis or even cancer. Chronic Urticaria is characterised by recurrent episodes of welts and itching, which can significantly impact the individual’s quality of life.

Chronic Urticaria can further be classified into two types:

Symptoms of Urticaria

Most people suffering from Urticaria face the following symptoms:

• Red, Raised Welts: The hallmark symptom of urticaria is the appearance of red, raised welts on the skin. These welts can vary in size and shape and may be surrounded by an area of redness.
• Itching and Burning Sensation: Affected areas cause intense itching and a burning sensation, making it hard to resist scratching, but scratching worsens the condition and causes more irritation.
• Swelling: Swelling, known as angioedema, can happen in deeper layers of the skin, mainly around the eyes, lips and genitals. Severe cases of angioedema can cause breathing difficulties and need urgent medical help.
• Variable Duration: Urticaria is usually a sudden and short-term condition, but it can become chronic and last for more than six weeks with recurring episodes.
• Migratory Nature: Hives are unpredictable and can move around the body, making it difficult to predict how they will develop.

What Triggers Urticaria?

The factor that triggers urticaria takes the central stage in the diagnosis and treatment of the disease. Hence, an understanding of the triggers is very important:

• Food: Urticaria can be triggered by food items such as tomatoes, alcohol, fruits, nuts, seafood, certain herbs and spices, sugary food substances, food additives, food colouring and others.
• Weather Changes: Exposure to extreme temperatures, both hot and cold, can trigger chronic urticaria in some individuals. High humidity or sudden changes in humidity can also be a contributing factor.
• Allergens: Pollen from trees, grasses, and weeds can cause chronic urticaria, particularly in people with pollen allergies. Exposure to pet dander from cats, dogs, or other animals can contribute to urticaria outbreaks. Mold spores in the environment, particularly in damp or poorly ventilated areas, can be a trigger.
• Airborne Irritants: Pollution from vehicle emissions, industrial pollutants, and other airborne irritants may exacerbate chronic urticaria in susceptible individuals.
• Infections: Chronic urticaria outbreaks may be linked to viral infections. In some cases, the immune system’s response to an infection can lead to hives. Certain bacterial infections may also contribute to chronic urticaria.
• Occupational Exposures: Exposure to certain chemicals, solvents, or irritants in the workplace can trigger or worsen chronic urticaria. Some individuals may be exposed to allergens related to their occupation, leading to urticaria outbreaks.
• Stress, Anxiety, and Emotional Triggers: Another major factor that has been identified is linked to emotional well-being. Stress triggers the release of stress hormones, including cortisol, which can stimulate the release of histamine. Histamine is a key mediator in the development of hives. The physiological response to stress, including vasodilation (widening of blood vessels) and increased blood flow, can lead to the characteristic redness and itching associated with hives.
  Acute anxiety or panic attacks can lead to a rapid release of histamine, causing hives to develop suddenly. Anxiety activates the sympathetic nervous system, triggering a cascade of events that may contribute to the onset of hives.

How to identify if your urticaria is triggered by a food item?

One of the major aspects of treating urticaria is to be triggered by a food item. Here’s a step-by-step guide to help you identify and manage food allergies as a potential trigger for hives:

Step 1 – Keep a Detailed Symptom Diary:

• Document when hives occur, their severity, and the duration of each episode.
• Note the timing of meals, snacks, and any specific foods consumed before the onset of hives.

Step 2 – Elimination Diet:

Consult a healthcare professional before starting an elimination diet to make sure it is safe and appropriate. Remove common allergens like nuts, shellfish, dairy, eggs, and wheat from your diet. Gradually reintroduce eliminated foods one by one, while observing for any allergic reactions.

Step 3 – Allergy Testing:

Your dermatologist may suggest the following allergy tests to understand your food allergies:

• Skin Prick Test: Conducted by an allergist, this test involves exposing the skin to small amounts of potential allergens to observe any reactions.
• Blood Tests (IgE Testing): Measure the levels of specific antibodies related to common food allergies.

Step 4 – Pay Attention to Patterns:

• Immediate vs. Delayed Reactions: Some food allergies cause immediate reactions, while others may have a delayed onset. Pay attention to the timing of hives concerning food consumption.

Step 5 – Consider Food Additives:

• Some individuals may be sensitive to additives, preservatives, or colourings in processed foods. Keep track of ingredients and observe for patterns.

Diagnostic Tests Used to Identify the Cause of Urticaria

Now that you have a clear understanding of urticaria and its triggers, let us discuss what your dermatologist may do if they suspect that you are suffering from Urticaria.

• Physical Examination and Medical History: Your dermatologist will first assess the appearance of hives, and the presence of angioedema (swelling), and examine other parts of the body for additional clues. They will also ask you questions about the onset, duration, and characteristics of hives, as well as potential triggers and associated symptoms.
• Allergy Testing: They may suggest allergy testing methods such as the skin prick test and Specific IgE Testing.
• Complete Blood Count: Your dermatologist may also do a complete blood count to check for signs of infection or systemic conditions that may be associated with urticaria. Abnormalities in white blood cell counts or other blood components may suggest an underlying condition.
• Thyroid Function Tests: If you have a history of thyroid disease or the doctor deems it fit, they may suggest a thyroid function test to assess thyroid function, as thyroid disorders can be linked to chronic urticaria. Abnormal thyroid hormone levels may indicate an underlying thyroid condition.
• Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (CRP): Last, but not the least, the doctor may suggest an ESR and CRP test to measure inflammation levels in the body. Elevated levels may indicate an inflammatory or autoimmune component.

Treatment Options for Acute and Chronic Urticaria

Here are some of the most common treatment options used for both acute and chronic cases of urticaria:

1. Antihistamines

Antihistamines are the primary treatment for urticaria, as they block the effects of histamine, reducing itching and minimising the appearance of hives. Antihistamines used can be non-sedating (second-generation) such as Loratadine, cetirizine, fexofenadine or sedating (first-generation) such as Diphenhydramine, hydroxyzine (may cause drowsiness).

2. Corticosteroids

Short-term use of oral or topical corticosteroids may be recommended for severe acute urticaria or in chronic cases where other treatments are not effective.

3. Second-Line Medications

In cases resistant to antihistamines, other medications may be considered, such as leukotriene receptor antagonists (e.g., montelukast), omalizumab (anti-IgE therapy), or cyclosporine. These medications are usually prescribed by allergists or immunologists in more challenging cases.

4. Identifying and Avoiding Triggers

For both acute and chronic urticaria, identifying and avoiding specific triggers is crucial. If allergic triggers are identified through testing, avoiding those allergens is essential.

5. Allergen Immunotherapy

For chronic urticaria linked to specific allergens, allergen immunotherapy may be considered. The doctor may follow a desensitisation procedure which involves gradually exposing the individual to increasing amounts of the allergen to reduce sensitivity.

Living with Chronic Urticaria: Coping Strategies

Chronic Urticaria can severely impact one’s day-to-day life. Living with it can be uncomfortable, painful and difficult, but not impossible. By following a few coping strategies, you can improve your quality of life to a great extent.

Here are some coping strategies that can help you:

1. Educate Yourself

Learn about chronic urticaria, its potential triggers, and treatment options. Speak to your doctor and try to find out as much as possible about your specific condition. Knowledge empowers individuals to make informed decisions and actively participate in their care.

2. Work with Healthcare Professionals

Establish a relationship with your healthcare team such as allergists, dermatologists, or immunologists, who specialise in chronic urticaria. Schedule regular follow-ups to monitor progress, adjust treatment plans, and address any emerging concerns.

3. Keep a Symptom Diary

Maintain a detailed diary of daily activities, food intake, stress levels, and the onset of hives. This can help identify patterns and potential triggers.

4. Stress Management Techniques

Practice stress reduction techniques such as deep breathing, meditation, yoga, or progressive muscle relaxation to help manage emotional triggers.

5. Healthy Lifestyle Choices

There is no parallel to choosing a healthy lifestyle. Follow a healthy and balanced diet and avoid known trigger foods, if identified. Engage in regular physical activity, which can contribute to overall well-being and stress reduction. Prioritise sufficient and quality sleep to support the body’s immune system.

Sources:

• https://dermnetnz.org/topics/urticaria-an-overview
• https://acaai.org/allergies/allergic-conditions/skin-allergy/hives/
• https://www.drugs.com/cg/urticaria
• https://www.medicalnewstoday.com/articles/causes
• https://my.clevelandclinic.org/health/diseases/hives
• https://www.verywellhealth.com/chronic-urticaria-coping
• https://allergyasthmanetwork.org/news/chronic-hives-mental-health/
• https://www.health.com/hives-overview
• https://www.verywellhealth.com/how-to-diagnose-urticaria-and-hives
• https://www.health.com/hives-causes-and-risk-factors
• https://www.webmd.com/allergies/food-triggers
• https://www.verywellhealth.com/hives-pictures