Hives are localized, raised red areas in the superficial portion of the skin that may join together to form larger lesions. Hives are closely related to angioedema.
Hives, also called urticaria, are relatively common with at least 20% of the population having had at least one episode during their lifetime. Although seen in all ages, they seem to be more prevalent among young adults. The reaction involves the release of histamine from either mast cells or basophils causing an IgE (immediate type) mediated antibody response.
Itching is usually the first symptom. The wheals are white or red, occasionally with a pale center. Plaques are developed by 50% of patients and the lesions often come and go in different areas. In extreme cases, swelling in the throat may lead to a medical emergency.
The causes of urticaria are many and in 80% of cases never determined; not knowing the cause often results in an on-going problem. The most common causes of chronic urticaria are drug reactions, stress, food sensitivities and fungal infections. Some initiating factors include:
- Allergic urticaria: pollens, drugs, foods, animal dander, cosmetics, toxins from jellyfish or fleas
- Physical urticaria: heat or sun, cold, light, pressure from bracelets and clothes or scratching, vibration, exercise
- Secondary urticaria: infections (e.g. hepatitis B virus, candida albicans, streptococcal bacteria), collagen vascular diseases, cancer, psychological, hypothyroidism, polycythemia vera.
Lab findings are often unremarkable in cases of acute urticaria. For chronic urticaria, lab work should include CBC, ESR, UA, histamine levels and dental/sinus examinations to rule out hidden pathology.
Acute urticaria lasts from 1 to 7 days and treatment is not usually needed except to reduce the itching. The inciting agent must be dealt with, be it food, external agent or an emotion. In severe cases, epinephrine, as found in a bee sting kit, may be required.
In cases of chronic urticaria of over three weeks’ duration, 50% of patients experience spontaneous remission within two years, even though in the majority of cases the cause is never identified.
Angioedema
While hives develop on the skin’s surface, angioedema is a swelling of the deeper layers of the skin. It most often occurs on the hands, feet and face. In severe cases, normal breathing or swallowing can be blocked and emergency measures must be taken. This can occur if a person is extremely allergic to a specific food or drug.
Hives and angioedema may appear together or separately on the body. Angioedema usually lasts one or two days, and may reoccur with or without hives over an indefinite period of time.Hereditary angioedema is a rare inherited disease which can be fatal in some cases and in this respect differs from other types of chronic angioedema. Swelling can occur in the airways, such as the larynx, tongue and throat, as well as on the face and other extremities. It has been demonstrated that a blood protein deficiency is the cause of this inherited illness.
Angioedema without a history of urticaria can be caused by certain drugs (ACE inhibitors), certain malignancies, and by an inherited enzyme deficiency (C1 esterase inhibitor deficiency). Symptoms of the hereditary enzyme deficiency problem typically include attacks of abdominal pain, vomiting, upper airway obstruction and visible non-itchy angioedema. This relatively rare disease requires treatment different from that of chronic urticaria and angioedema.
Signs, symptoms & indicators of Hives
(History of) unexplained hives
Counter Indicators
Never having unexplained hives
Risk factors for Hives
Allergy / Intolerance to Foods (Hidden)
Foods and drugs are common causes of hives. A reaction that occurs immediately after ingestion of certain foods, producing hives and difficulty breathing is termed anaphylactic and is potentially dangerous. Delayed reactions are less serious but more difficult to pinpoint. Some patients get hives occasionally only when they ingest a specific food or food additive. Others develop hives as a chronic problem that can continue for years. Most studies of chronic hives suggest that only a low percentage are due to food allergy; this is usually because diet revision attempts were inadequate for revealing the hidden food causes.
Chronic Thyroiditis
In patients with chronic hives and either treated hypothyroidism or a normally functioning thyroid gland, it is reasonable to test for anti-thyroid antibodies. In a study of 10 patients with chronic hives, thyroxine (T4) was administered for a minimum of 12 weeks. Of 7 patients with elevated anti-thyroid antibodies at baseline, all 7 had complete resolution of hives or marked improvement within 4 weeks. Two patients required an increase in the thyroxine before complete resolution was seen. In 2 others, already on thyroxine therapy for hypothyroidism, an increase in the dose also resulted in resolution of the hives.
The initial dose was on average 100mcg per day, which was increased if the initial dose failed to produce clinical improvement. The highest dose used was 250mcg per day. The 3 patients without elevated anti-thyroid antibodies did not respond to thyroxine therapy. There was a recurrence of hives after treatment was stopped which resolved again after treatment was restarted. There was no consistent correlation between improvement in symptoms and reduction in thyroid antibody levels. [J Allergy Clin Immunol 1995;96: pp.901-905]
Autoimmune Tendency
Some forms of chronic hives have an autoimmune origin which means, in about 30% of patients, that the immune system is producing antibodies against normal substances in the body and triggering the release of histamine by mast cells. [Journal of the American Academy of Dermatology, March 1999, 40(3); pp.443-450]
Hydrochloric Acid Deficiency
Gastric analysis with histamine stimulation was performed on 40 patients with chronic hives (urticaria). Approximately 65% of the patients had either hypochlorhydria or achlorhydria. Of the patients with reduced acid output, 65% obtained almost complete or partial relief of symptoms with hydrochloric acid (HCl) therapy. These patients previously had been unresponsive to all other forms of treatment. The best results were obtained in the 22 patients with achlorhydria. In this group, 18 patients (82%) were almost completely relieved by HCl therapy. In another report, administration of dilute HCl altered the putrefactive flora ordinarily present in the small intestine of achlorhydric individuals.
According to the second report, therapeutic use of dilute HCl has fallen into disrepute, largely on theoretical grounds. However, many capable internists and dermatologists remain convinced, on the basis of clinical experience, that acid therapy is beneficial. [Rawls WB, Ancona VC. Chronic urticaria associated with hypochlorhydria or achlorhydria. Rev Gastroenterol 1951;18:267]
Hives suggests the following may be present
Autoimmune Tendency
Some forms of chronic hives have an autoimmune origin which means, in about 30% of patients, that the immune system is producing antibodies against normal substances in the body and triggering the release of histamine by mast cells. [Journal of the American Academy of Dermatology, March 1999, 40(3); pp.443-450]
Hydrochloric Acid Deficiency
Gastric analysis with histamine stimulation was performed on 40 patients with chronic hives (urticaria). Approximately 65% of the patients had either hypochlorhydria or achlorhydria. Of the patients with reduced acid output, 65% obtained almost complete or partial relief of symptoms with hydrochloric acid (HCl) therapy. These patients previously had been unresponsive to all other forms of treatment. The best results were obtained in the 22 patients with achlorhydria. In this group, 18 patients (82%) were almost completely relieved by HCl therapy. In another report, administration of dilute HCl altered the putrefactive flora ordinarily present in the small intestine of achlorhydric individuals.
According to the second report, therapeutic use of dilute HCl has fallen into disrepute, largely on theoretical grounds. However, many capable internists and dermatologists remain convinced, on the basis of clinical experience, that acid therapy is beneficial. [Rawls WB, Ancona VC. Chronic urticaria associated with hypochlorhydria or achlorhydria. Rev Gastroenterol 1951;18:267]
Recommendations for Hives
Tyrosine
One older study reported that L-tyrosine (200mg), vitamin B6 (2.5mg) and niacinamide (10mg) when given in combination for the treatment of hay fever, hives, allergic headaches and poison oak dermatitis produced significant symptomatic relief when 1-3 tablets were taken four times per day in milder cases and up to 6 tablets 4-6 times per day in more severe cases.
In some cases characterized by more chronic disorders, such as chronic sinusitis, a worsening of symptoms often occurred during the first few days of treatment. This study found that treatment with each of the nutrients individually, or with any two in combination, was ineffective. [Widmann RR, Keye JD Epinephrine precursors an control of allergy. Northwest Med 1952:51: pp.588-590]
Food Additive Avoidance
Food additives that have been shown to trigger hives include colorants (azo dyes), flavorings (salicylates), artificial sweeteners (aspartame), preservatives (benzoates, nitrites, sorbic acid), antioxidants (hydroxytoluene, sulfite, gallate), and emulsifiers/stabilizers (polysorbates, vegetable gums). Tartrazine (Yellow #5) has been implicated not only in ADHD, but also in asthma and hives. You will find Yellow #5 usually listed on food labels because it has been identified as one of the more troublesome additives in the United States, and it is listed by law.
Conventional Drugs / Information
For many patients with hives of unknown cause, treatment with antihistamines is effective. This is because in people with hives, histamine is being released by mast cells in the tissues which in turn initiaties the irritation and accumulations of fluid. Other inflammatory white blood cells, including lymphocytes and polymorphonuclear cells, have also been implicated. Antihistamines inhibit this inflammatory process.
On occasion and especially with pressure hives, antihistamines are ineffective, probably because of the nature of the molecular mediators operating in this condition. If antihistamines do not help, then several second-line treatments are used. The most effective are corticosteroids. Others include doxepin, dapsone, attenuated androgens, calcium antagonists, antimalarials, gold and methotrexate.
Thyroid Medications
A study suggests that administration of thyroxine to patients with chronic urticaria associated with elevated thyroid antibodies can result in remission of the hives. [J Allergy Clin Immunol 1995;96: pp.901-905]
Test for Food Allergies
Numerous clinical studies demonstrate that diets that are free of foods or food additives that commonly trigger allergic reactions typically produce significant reductions in 50-75% of people with chronic hives.
Hydrochloric Acid (Trial)
Lack of hydrochloric acid (HCl) secretion by the stomach has been linked to chronic hives probably as a result of increasing the likelihood of developing food allergies. In one study of 77 patients with chronic hives, 24 (31%) were diagnosed as having achlorhydria, and 41 (53%) were shown to be hypochlorhydric. [Rev Gastroenterol 1951;18: pp.267-71]
Test Thyroid Function
The presence of hives is sometimes linked to elevated thyroid antibodies. You can be tested for the presence of these autoantibodies.
Hydrotherapy
An alkaline sponge bath may be helpful to reduce the itching. Add one teaspoon of baking soda to each pint of very hot bath water and soak.
Vitamin C (Ascorbic Acid)
High doses of vitamin C, such as mineral ascorbates, can help those with hives by lowering histamine levels. Taking 2gm every hour in water may bring relief.
Vitamin Niacinamide
Should be taken in combination with Tyrosine. See Hives/Tyrosine note.
Vitamin B6 (Pyridoxine)
Should be taken in combination with Tyrosine. See Hives/Tyrosine note.
Vitamin B12 (Cobalamine)
Vitamin B12 injections, at least 1000mcg weekly, has been reported to reduce the frequency and severity of urticaria in chronic cases. [J Am Geriatr Soc 1964;12: pp.79-85]
Bioflavonoids
The flavonoid quercetin inhibits the manufacture and release of histamine and other allergic compounds involved in allergies. This suggests an as yet unproven preventative effect in managing hives. Some types of hives will respond, while others will not.
Key
| Weak or unproven link |
| Strong or generally accepted link |
| Proven definite or direct link |
| Very strongly or absolutely counter-indicative |
| May do some good |
| Likely to help |
| Highly recommended |
Glossary
Urticaria
Commonly known as hives, urticaria is one of the most common dermatological conditions seen by allergists. Urticaria is not just an allergic disease, however. It can be caused by metabolic diseases, medications, infectious diseases, autoimmune disease, or physical sensitivity. Traditional allergies to foods or medications as well as viral illness are frequent causes of acute urticaria which usually lasts only a few hours but may last up to 6 weeks. Chronic urticaria (lasting more than 6 weeks) is more complex, given the vast number of potential triggers. Symptoms include sudden onset; initial itching; then swelling of the surface of the skin into red or skin-colored welts (wheals) with clearly defined edges; welts turn white on touching; new welts develop when the skin is scratched; usually disappear within minutes or hours. Welts enlarge, change shape, spread or join together to form large flat raised areas.
Angioedema
Recurring attacks of transient, subcutaneous edema (water retention/swelling of tissue), often due to an allergic reaction.
Histamine
A chemical in the body tissues, produced by the breakdown of histidine. It is released in allergic reactions and causes widening of capillaries, decreased blood pressure, increased release of gastric juice, fluid leakage forming itchy skin and hives, and tightening of smooth muscles of the bronchial tube and uterus.
Basophil
The basophils account for about 1% of the granulocyte count (60 to 75% of the white blood cells). They release chemicals such as histamine and play a role in the inflammatory response to infection.
Antibody
A type of serum protein (globulin) synthesized by white blood cells of the lymphoid type in response to an antigenic (foreign substance) stimulus. Antibodies are complex substances formed to neutralize or destroy these antigens in the blood. Antibody activity normally fights infection but can be damaging in allergies and a group of diseases that are called autoimmune diseases.
Chronic
Usually Chronic illness: Illness extending over a long period of time.
Hepatitis B
A serious viral infection with the potential for long term consequences. It is caused by a DNA virus that has been found in virtually all body secretions and excretions. However, only blood, saliva, semen and vaginal fluids have been shown to be infectious. Transmission occurs through sexual contact, blood-to-blood contact (blood products, needle sharing, etc.), and from infected mother to infant. Virtually all affected infants and children, and many adults, receive a lesser, even symptom-free, infection. Symptoms, when present, tend to be more severe and prolonged than those for Hepatitis A: initially flu-like, with malaise, fatigue, muscle pain and chest pain on the right side. This is followed by jaundice (slight skin yellowing), anorexia, nausea, fatigue, pale stools, dark urine and tender liver enlargement, but usually no fever.
Virus
Any of a vast group of minute structures composed of a protein coat and a core of DNA and/or RNA that reproduces in the cells of the infected host. Capable of infecting all animals and plants, causing devastating disease in immunocompromised individuals. Viruses are not affected by antibiotics, and are completely dependent upon the cells of the infected host for the ability to reproduce.
Candidiasis
Infection of the skin or mucous membrane with any species of candida, usually Candida albicans. The infection is usually localized to the skin, nails, mouth, vagina, bronchi, or lungs, but may invade the bloodstream. It is a common inhabitant of the GI tract, only becoming a problem when it multiplies excessively and invades local tissues. Growth is encouraged by a weakened immune system, as in AIDS, or with the prolonged administration of antibiotics. Vaginal symptoms include itching in the genital area, pain when urinating, and a thick odorless vaginal discharge.
Bacteria
Microscopic germs. Some bacteria are "harmful" and can cause disease, while other "friendly" bacteria protect the body from harmful invading organisms.
Collagen
The primary protein within white fibers of connective tissue and the organic substance found in tendons, ligaments, cartilage, skin, teeth and bone.
Cancer
Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.
Hypothyroidism
Diminished production of thyroid hormone, leading to low metabolic rate, tendency to gain weight, and sleepiness.
Acute
An illness or symptom of sudden onset, which generally has a short duration.
ESR
Erythrocyte Sedimentaion Rate is a screening test and not considered diagnostic for any particular disorder. It is useful in detecting and monitoring inflammatory conditions, tuberculosis, tissue necrosis (tissue death), connective tissue disease, or an otherwise unsuspected disease in which symptoms are vague or physical findings are minimal.
Protein
Compounds composed of hydrogen, oxygen, and nitrogen present in the body and in foods that form complex combinations of amino acids. Protein is essential for life and is used for growth and repair. Foods that supply the body with protein include animal products, grains, legumes, and vegetables. Proteins from animal sources contain the essential amino acids. Proteins are changed to amino acids in the body.
Enzymes
Specific protein catalysts produced by the cells that are crucial in chemical reactions and in building up or synthesizing most compounds in the body. Each enzyme performs a specific function without itself being consumed. For example, the digestive enzyme amylase acts on carbohydrates in foods to break them down.
Anaphylactic
Intense allergic reaction to a foreign substance.
Allergy
Hypersensitivity caused by exposure to a particular antigen (allergen), resulting in an increased reactivity to that antigen on subsequent exposure, sometimes with harmful immunologic consequences.
Thyroid
Thyroid Gland: An organ with many veins. It is at the front of the neck. It is essential to normal body growth in infancy and childhood. It releases thyroid hormones - iodine-containing compounds that increase the rate of metabolism, affect body temperature, regulate protein, fat, and carbohydrate catabolism in all cells. They keep up growth hormone release, skeletal maturation, and heart rate, force, and output. They promote central nervous system growth, stimulate the making of many enzymes, and are necessary for muscle tone and vigor.
T4
Thyroxin, thyroid hormone also prepared synthetically, for treatment of hypothyroidism and myxedema.
Microgram
(mcg): 1/1,000 of a milligram in weight.
Autoimmune Disease
One of a large group of diseases in which the immune system turns against the body's own cells, tissues and organs, leading to chronic and often deadly conditions. Examples include multiple sclerosis, rheumatoid arthritis, systemic lupus, Bright's disease and diabetes.
Immune System
A complex that protects the body from disease organisms and other foreign bodies. The system includes the humoral immune response and the cell-mediated response. The immune system also protects the body from invasion by making local barriers and inflammation.
Hypochlorhydria
The condition of having low hydrochloric acid levels in the stomach, often the cause of digestive disorders.
Achlorhydria
The complete absence or failure of stomach acid secretion.
Hydrochloric Acid
(HCl): An inorganic acidic compound, excreted by the stomach, that aids in digestion.