Hives - Treating urticaria

Most cases of urticaria don't need treatment because the symptoms are usually mild and often get better within a few days.

Short-term urticaria

If your symptoms are troublesome or persistent, antihistamine medication is available over the counter from pharmacies.

See your GP or speak to your pharmacist if your symptoms get worse. If your symptoms are very severe, your GP may prescribe other medications, such as corticosteroid tablets. Go back to your GP if your symptoms get worse or if the treatment hasn't worked after two weeks.

Antihistamines

Antihistamines block the effects of histamine, so help stop the itchiness and reduce the rash. Examples of antihistamines include:

In most people, modern antihistamines don't cause drowsiness, although there are some exceptions. See how you react to the antihistamine before driving or operating heavy machinery. Antihistamines may also cause drowsiness if taken with alcohol. Always read the information leaflet that comes with the medication.

Antihistamines aren't usually prescribed to pregnant women, as it's unknown whether they're entirely safe. However, chlorphenamine may be recommended if it's believed that the benefits outweigh the risks. There is no evidence that chlorphenamine harms unborn babies.

Corticosteroid tablets

You may be prescribed a short course of high-dose corticosteroid tablets, such as prednisolone, if your symptoms are severe.

Corticosteroids suppress your immune system, which reduces the symptoms of urticaria. A course of prednisolone lasting between three and five days is usually recommended.

Taking steroid tablets on a long-term basis isn't usually recommended because it can lead to a wide range of side effects and complications, such as high blood pressure (hypertension), glaucoma, cataracts and diabetes (or it can make existing diabetes worse).

Long-term urticaria

Treatment for persistent urticaria involves trying to control your symptoms and avoiding any triggers that make them worse.

If you have chronic urticaria and angioedema (swelling of a deeper layer of skin), you may be referred to a dermatologist (skin specialist). This is because angioedema is potentially more serious and can cause breathing difficulties.

You should also be referred to a dermatologist if you just have chronic urticaria and the symptoms continue, despite treatment.

Antihistamines

Chronic urticaria is treated with antihistamines. You may have to take them regularly for as long as your symptoms last. As with short-term urticaria, you may be given a combination of non-drowsy and drowsy antihistamines to help you sleep.

An increased dose may be recommended if your symptoms don't respond to treatment. Increasing the dose can often help control symptoms that previously didn't respond to treatment. However, this should only be carried out under the instruction of the doctor in charge of your care.

A newer type of antihistamine called rupatadine has proved effective in treating more severe cases of chronic urticaria that don't respond to other antihistamines. The doctor in charge of your care can tell you if you could benefit from taking rupatadine.

Menthol cream

Menthol cream can be used as an alternative or in addition to antihistamines because it helps relieve itchiness. Your GP can prescribe this.

Corticosteroid tablets

Occasionally, more serious episodes of urticaria can be treated with short doses of corticosteroid tablets, such as prednisolone. Possible side effects of corticosteroid tablets include increased appetite and weight gain, mood change and difficulty sleeping (insomnia).

Long-term use of corticosteroids in chronic urticaria isn't recommended for the reasons mentioned above.

H2 antihistamines

The type of antihistamines you can get from the pharmacist are known as H1 antihistamines. However, there are several other types of antihistamines, including H2 antihistamines.

H2 antihistamines can sometimes be useful in treating chronic urticaria because they narrow blood vessels. This can often help reduce the redness of the skin.

H2 antihistamines can be used as an alternative to H1 antihistamines or in combination with them. Side effects of H2 antihistamines are uncommon, but include:

Don't drive or use tools or machinery if you feel dizzy after taking a H2 antihistamine.

Narrowband ultraviolet B phototherapy

Narrowband ultraviolet B phototherapy (NUVB) is a treatment that involves exposing areas of your skin to high-energy ultraviolet light. The light can help clear an otherwise persistent rash.

NUVB involves standing in a chamber that's similar in appearance to a shower. The chamber contains a number of fluorescent light bulbs which your skin is exposed to for a short period of time, usually just a few minutes.

You'll usually have between two and five sessions of NUVB a week. Most people need around 20 sessions before their symptoms improve significantly.

The light can cause your skin to burn, similar to a mild sunburn. You'll be given a cream to help soothe any burning.

Exposure to ultraviolet light carries a theoretical risk of causing skin cancer in later life. It's not clear exactly how high this risk is because NUVB is a relatively new treatment. However, most experts think the risk is small.

Leukotriene receptor antagonists

Leukotriene receptor antagonists are a type of medication that can help reduce redness and swelling of the skin.

They can be a useful long-term alternative to using corticosteroid tablets because they don't carry the same risk of causing wide-ranging side effects.

The side effects of leukotriene receptor antagonists are rare and relatively minor. They include headaches and nausea (feeling sick).

Ciclosporin

In around two-thirds of cases, a powerful medication called ciclosporin has proved effective in treating urticaria.

Ciclosporin works in a similar way to corticosteroids. It suppresses the harmful effects of the immune system and is available in capsule form or as a liquid.

Side effects of ciclosporin include:

high blood pressure (hypertension)
kidney problems
increased levels of blood cholesterol
headaches
involuntary shaking (tremors)
increased vulnerability to infection, particularly chest infections, urinary tract infections (UTIs) and a type of viral infection known as cytomegalovirus

There are also a number of other side effects that can occur when taking ciclosporin and you should discuss these thoroughly with your doctor before starting.

Side effects, such as high blood pressure and high cholesterol, are a particular cause for concern because they can increase your risk of heart disease and stroke.

Even if you still respond to treatment, it may be recommended that the medication is withdrawn after a few months.

Omaluzimab

For urticaria that hasn't responded to antihistamines, there are newer medications becoming available, such as omalizumab. Omalizumab is given by injection and is thought to reduce a type of antibody that can play a part in urticaria.

Diet

There's some uncertainty over the role of diet in people with long-term urticaria. There are two groups of chemicals in foods that may trigger urticaria in some people – vasoactive amines and salicylates (see below).

Avoiding or reducing foods that contain these chemicals may help improve your symptoms.

You could also keep a food diary to see whether avoiding certain foods helps your symptoms. If you restrict your diet, consult a dietitian, who can make sure that you're not avoiding foods unnecessarily and that your diet is healthy.

Vasoactive amines

Foods that contain vasoactive amines or cause histamine release include:

shellfish
strawberries
tomatoes
fish
chocolate
pineapple

Salicylates

Salicylates are naturally occurring aspirin-like compounds that are found in a wide variety of foods of plant origin. You can try cutting down on these, but don't completely avoid them. Foods that contain salicylates include:

tomatoes
spices
orange juice
raspberries
tea

Read more about histamine intolerance and following a low-histamine diet on the Allergy UK website.

Avoiding triggers

If you know what triggers your urticaria or makes it worse, avoiding the trigger may help keep your symptoms under control.

Triggers such as alcohol and caffeine can be easily avoided. If you think a certain medication may be triggering your symptoms, contact the doctor who prescribed it, because alternatives may be available.

Avoiding stress can be more difficult, particularly if your symptoms negatively affect your quality of life.

If you have severe or persistent urticaria, you may find that relaxation techniques, such as meditation or hypnosis, help reduce your stress levels and the severity of your symptoms.