Urticaria, also known as hives, is an itchy rash on the skin. Cholinergic urticaria, cold urticaria, or chronic urticaria may occur depending on the causes.

Urticaria

Overview

Urticaria is defined as an extremely irritating skin rash that results from an allergic reaction to allergens such as drugs, foods, infection, and even stress. Ingestion of the allergen or skin exposure can both cause urticaria.

Urticaria, also known as &ldquo;hives&rdquo;, is characterized by raised, red bumps (weals/wheals/welts) on the skin&rsquo;s surface. They are often pink or skin-colored and surrounded by redness (erythema). Along with itchiness, a stinging sensation may also be present. They can be short-lived (acute hives) or long-lasting (chronic hives). Treatment typically involves antihistamines and steroids.

Urticaria normally develops after an infection or an allergic reaction, such as a reaction to a medicine, insect bite, or food item. 
&nbsp;

The rash can appear on various body parts and last from minutes to days, leaving no long-term skin changes. It is generally an isolated event with no systemic reaction. Occasionally, it can be a precursor to an anaphylactic reaction.

Approximately 20% of people worldwide are affected by hives at some point in time<a href="#accordion">[1]</a>. 
&nbsp;

<ol>
	<li>
	<h5>Acute Urticaria</h5>
	</li>
</ol>

It is defined as the presence of hives, with or without angioedema, for less than 6 weeks<a href="#accordion">[3]</a>. The most common causes are infections, drugs (e.g., aspirin, ACE inhibitors, codeine), and foods (e.g., nuts, chocolate, berries, fish, milk). An estimated 1 in 5 people are affected by acute urticaria at some point in their lives<a href="#accordion">[10]</a>.

Acute urticaria often presents with angioedema and anaphylactic shock. Angioedema is defined as sudden swelling of the skin&rsquo;s dermis and subcutis, accompanied by pain. These swelling episodes typically resolve within 72 hours. 
&nbsp;

<ol start="2">
	<li>
	<h5>Chronic Urticaria</h5>
	</li>
</ol>

In chronic urticaria, hives last longer than six weeks and frequently recur over months or years. It affects 1-3% of the population9. Although the causative factors remain unknown, thyroid disease, cancer, and infections have been known to cause chronic urticaria. 
&nbsp;

<ol start="3">
	<li>
	<h5>Physical Urticaria</h5>
	</li>
</ol>

Also called inducible urticaria, these hives result from exposure to cold, heat, or sun. Other factors that stimulate the skin, such as exercise, vibration, and sweating can also cause physical urticaria. They typically appear within an hour of exposure. 
&nbsp;

<ol start="4">
	<li>
	<h5>Dermatographism</h5>
	</li>
</ol>

This is a mild form of physical urticaria that results from excessive scratching or firm stroking of the skin. It typically resolves on its own. 
&nbsp;

Signs and Symptoms

<ol>
	<li>
	<h5>Acute Urticaria</h5>
	</li>
</ol>

Hives can appear anywhere on the body. They typically range in size from a few millimetres to several centimetres. The raised welts often appear red against the pale skin. Each weal can last from a few minutes to several hours and can change shape. Weals can be round or shaped into rings, a map-like pattern, targetoid lesions, or massive patches. Other signs and symptoms include

<ul>
	<li>Blanching (hives become pale in the centre when pressed)</li>
	<li>Itchiness</li>
	<li>Angioedema (swelling under the skin)</li>
	<li>Fever</li>
	<li>Bruises</li>
	<li>Enlarged lymph nodes</li>
	<li>Joint discomfort 
	&nbsp;</li>
</ul>

<ol start="2">
	<li>
	<h5>Chronic Urticaria</h5>
	</li>
</ol>

The hives frequently begin as itchy patches and progress to swollen welts of varying sizes. As the reaction progresses, these welts develop and disappear randomly. Chronic hives can be extremely painful, and disrupt sleep and daily activities. Many individuals get relief from anti-itch medications (antihistamines).

Chronic hives can cause extreme discomfort, distress, and even <a href="https://merisehat.pk/disease/depression">depression</a>. Furthermore, hives can exacerbate stress. Anyone who believes that hives are interfering with their quality of life or mental well-being should consult a medical professional. 
&nbsp;

Causes

Hives can occur in response to

<ul>
	<li>An allergen.</li>
	<li>Other physical triggers, for example, exceptional temperatures.</li>
	<li>An underlying medical condition. 
	&nbsp;</li>
</ul>

There are times when hives occur for no apparent reason. Some experts believe that an autoimmune reaction causes chronic hives, but they are not certain. It is hypothesized that urticaria appears when histamine and other chemicals are released from beneath the skin&#39;s surface, causing swelling of the tissues. 
&nbsp;

<ol>
	<li>
	<h5>Acute Urticaria</h5>
	</li>
</ol>

In approximately half of all acute urticaria cases, the cause is unknown. However, some known triggers include:

<ul>
	<li>Foods such as peanuts, shellfish, eggs, and cheese</li>
	<li>Pollen, dust mites, or chemicals in the environment</li>
	<li>Latex (common among healthcare workers)</li>
	<li>Infections can range from relatively minor, such as a cold, to extremely serious, such as <a href="https://merisehat.pk/disease/hiv-61">HIV</a></li>
	<li>Insect stings and bites</li>
	<li>Emotional Strain</li>
	<li>Specific Medicines, for example, antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and aspirin</li>
	<li>Physical Triggers include skin pressure, temperature changes, sun exposure, exercise, and water 
	&nbsp;</li>
</ul>

Patients with cholinergic urticaria (CU) may experience relatively small, temporary hives for a short period as the body temperature rises, typically after sweating after exercise or bathing. Except for acetylcholine&#39;s involvement, the particular mechanism of hive appearance in CU has not been clearly understood<a href="#accordion">[4]</a>. 
&nbsp;

<ol start="2">
	<li>
	<h5>Chronic Urticaria</h5>
	</li>
</ol>

Chronic urticaria typically develops as an autoimmune response when the immune system attacks the body&#39;s tissues. Approximately one-third to half of all chronic urticaria cases are thought to be due to an autoimmune response<a href="#accordion">[10]</a>.

It is unknown what causes autoimmune urticaria, but it can occasionally occur in conjunction with other autoimmune conditions, such as

<ul>
	<li>Rheumatoid Arthritis - a type of arthritis in which the immune system attacks the joints.</li>
	<li>Lupus - a condition in which the immune system attacks the joints and skin, causing individuals to feel tired all of the time. 
	&nbsp;</li>
</ul>

Chronic urticaria can also be associated with the following chronic illnesses and infections:

<ul>
	<li>Hypo- or hyperthyroidism</li>
	<li>Viral hepatitis</li>
	<li>Intestinal parasites 
	&nbsp;</li>
</ul>

Chronic urticaria comes and goes. Many people discover that certain triggers cause it to reappear, or worsen existing signs and symptoms. Triggers can include things like

<ul>
	<li><a href="https://merisehat.pk/disease/anxiety">Anxiety</a></li>
	<li>Alcohol consumption</li>
	<li>Caffeine consumption</li>
	<li>Hot temperatures</li>
	<li>Extended compression on the skin (which can take place by wearing tight-fitting clothes)</li>
	<li>Medicine &ndash; for example, NSAIDs and the pain reliever codeine</li>
	<li>Specific food additives such as salicylates, which are present in tomatoes, orange juice, and tea</li>
	<li>Bites and stings from insects</li>
	<li>Exposure to heat, cold, pressure, or water 
	&nbsp;</li>
</ul>

ACE inhibitors, commonly used to manage hypertension, can be associated with deeper swellings of angioedema. 
&nbsp;

Diagnosis

Urticaria is typically detected by looking at the distinctive red rash. Several tests may be required to determine the underlying cause of persistent (chronic) urticaria. 
&nbsp;

<ol>
	<li>
	<h5>Acute Urticaria</h5>
	</li>
</ol>

Comprehensive patient history and physical evaluation are usually used to detect acute urticaria. By examining the rash, your doctor can usually diagnose acute urticaria. 
&nbsp;

They will also ask you a few questions to determine what caused your symptoms, such as

<ul>
	<li>When and where did the rash first appear?</li>
	<li>What you ate right before it started, as well as specific information about your usual diet?</li>
	<li>If you began taking a new medicine shortly before your signs appeared?</li>
	<li>If you reside or work in an environment where you might be exposed to potential triggers, for example, pets, chemicals, or latex gloves?</li>
	<li>Were you stung or bitten by an insect shortly before your signs appeared?</li>
	<li>What is your current health status, and have you had any infections recently?</li>
	<li>If you&#39;ve lately traveled abroad, and if you did, where?</li>
	<li>If you have a family history of urticaria? 
	&nbsp;</li>
</ul>

If your doctor believes your symptoms resulted from an allergic reaction, you may need to visit an allergy clinic. Allergy skin testing may be required to determine whether you are allergic to suspicious urticaria triggers. 
&nbsp;

<ol start="2">
	<li>
	<h5>Chronic Urticaria</h5>
	</li>
</ol>

If your urticaria lasts longer than six weeks, it&#39;s improbable that it&#39;s the result of an allergy, so allergy tests aren&#39;t generally advised. However, your doctor might inquire about anything that aggravates your urticaria, such as

<ul>
	<li>Any medications you are taking</li>
	<li>Your caffeine and alcohol intake</li>
	<li>Your levels of stress 
	&nbsp;</li>
</ul>

You may also be referred for a series of tests to determine if an underlying condition is responsible for causing chronic urticaria. These tests may include the following:

<ul>
	<li>A Complete Blood Count (CBC) which can detect <a href="https://merisehat.pk/disease/anemia">anaemia</a></li>
	<li>Tests To Determine Antibody Levels in your blood.</li>
	<li>A Stool Sample which can help detect intestinal parasites</li>
	<li>An Erythrocyte Sedimentation Rate (ESR) Test &ndash; assists in detecting issues with your immune system.</li>
	<li>Thyroid Function Tests &ndash; to determine whether the thyroid gland is underactive (hypothyroidism) or overactive (<a href="https://merisehat.pk/disease/hyperthyroidism">hyperthyroidism</a>).</li>
	<li>Liver Function Tests &ndash; to determine whether you have any liver issues. 
	&nbsp;</li>
</ul>

Treatment

The cause, and whether the problem is severe or long-term, determine the best treatment strategy. Most symptoms of urticaria are self-resolving and get better within a few days. 
&nbsp;

<ol>
	<li>
	<h5>Acute Urticaria</h5>
	</li>
</ol>

If the signs are moderate and appear due to a substance that causes an allergic reaction or irritant, home remedies can generally relieve the itching until the rash goes away.

A medical professional may suggest the following options<a href="#accordion">[5]</a>:

<ul>
	<li>Non-Sedating Antihistamines, such as cetirizine (Zyrtec) or fexofenadine (Allegra)</li>
	<li>Topical Steroids (used for a small time span)</li>
	<li>Antiseptic Creams to avoid secondary infection</li>
	<li>Soothing Creams to relieve itching 
	&nbsp;</li>
</ul>

In case the individual has swelling in their lips, tongue, or face, the medical professional may recommend they carry an epinephrine auto-injector for emergencies. 
&nbsp;

<ol start="2">
	<li>
	<h5>Chronic Urticaria</h5>
	</li>
</ol>

An individual suffering from this type of urticaria may require regular antihistamines until their symptoms subside. Omalizumab (Xolair) is an injectable medication that inhibits immunoglobulin E (IgE), a substance involved in allergic reactions. It can alleviate the signs and symptoms of chronic spontaneous urticaria.

A 2016 review concluded that acupuncture might assist in relieving chronic urticaria. Though, there is insufficient evidence to confirm that it is a harmless and successful treatment<a href="#accordion">[6]</a>. 
&nbsp;

<ul>
	<li>
	<h5>Angioedema</h5>
	</li>
</ul>

Angioedema is a type of swelling that appears in the deeper layers of the skin. The often serious complication is triggered by fluid accumulation. It affects about a quarter of people with acute urticaria and half of those with chronic urticaria<a href="#accordion">[10]</a>. 
&nbsp;

Angioedema signs and symptoms can have an impact on any part of the body, but they most commonly affect the following:

<ul>
	<li>Eyes</li>
	<li>Genitals</li>
	<li>Lips</li>
	<li>Feet</li>
	<li>Hands 
	&nbsp;</li>
</ul>

Antihistamines and short courses of oral corticosteroids (tablets) can be administered to reduce swelling. 
&nbsp;

<ul>
	<li>
	<h5>Emotional Affect</h5>
	</li>
</ul>

Living with any chronic condition can be challenging. Chronic urticaria can significantly impair an individual&#39;s mood and quality of life. Itchy skin can be especially distressing. 
&nbsp;

According to one study, chronic urticaria has the same harmful effect as ischemic heart disease<a href="#accordion">[7]</a>. Furthermore, one in every seven people with chronic urticaria has a psychological or emotional issue<a href="#accordion">[10]</a>, for example,

<ul>
	<li>Sadness or depression</li>
	<li>Stress</li>
	<li>Anxiety 
	&nbsp;</li>
</ul>

Consult your doctor if your urticaria is bothering you. There are successful treatments available to alleviate your signs and symptoms. Talking to friends and family can also assist you in feeling less isolated and managing your condition better. 
&nbsp;

<ul>
	<li>
	<h5>Anaphylaxis</h5>
	</li>
</ul>

Urticaria can be one of the initial signs of a serious allergic reaction, referred to as anaphylaxis. Anaphylaxis should be treated as a medical emergency at all times. 
&nbsp;

Hives are quite common. You are more likely to develop hives and angioedema if you:

<ul>
	<li>have had hives in the past.</li>
	<li>have had other types of allergic reactions.</li>
	<li>have a family history of hives, angioedema, or hereditary angioedema. 
	&nbsp;</li>
</ul>

Hives occur when certain triggers induce elevated amounts of histamine and different chemicals to be released into your skin. Triggers can include the following:

<ul>
	<li>Consuming specific foods</li>
	<li>Exposure to certain plants, animals, chemicals, and latex</li>
	<li>Cold &ndash; for example, cold water or wind</li>
	<li>Warm, sweaty skin &ndash; caused by exercise, emotional strain, or consuming spicy food.</li>
	<li>A reaction to a medication,</li>
	<li>An insect bite or sting.</li>
	<li>Scratching or putting stress on your skin - for example, wearing itchy or tight-fitting clothes.</li>
	<li>An infection.</li>
	<li>Immune system problems</li>
	<li>Water or sunlight &ndash; though this is uncommon. 
	&nbsp;</li>
</ul>

Try to figure out what causes your hives so you can avoid them. This may assist in avoiding an outbreak of hives. 
&nbsp;

Impact of allergic reactions and urticaria on mental health and quality of life<a href="#accordion">[8]</a>.

Allergic reactions such as urticaria can significantly impair one&rsquo;s mental health and overall quality of life. A recent cross-sectional study aimed to assess the severity of depression and evaluate the health-related quality of life of patients at an allergy clinic. The Beck Depression Inventory (BDI), the Dermatologic Life Quality Index (DLQI), and the three-level version of the EuroQol 5-Dimensional (EQ-5D-3L) scale were used to evaluate the 596 study participants.

Approximately 20% of the patients suffered from urticaria. The presence of allergies and/or urticaria was associated with higher depression severity and lower scores on the EQ5D-3L index. Thus, proving the need for regular screening methods to evaluate the mental health status of patients with allergies and/or urticaria. 
&nbsp;

Key Points

<ul>
	<li>Hives are the body&#39;s response to an allergic reaction or another cause. Red, itchy bumps, and skin inflammation are common symptoms.</li>
	<li>Antihistamines are a common drug class used to treat hives.</li>
	<li>Chronic hives are itchy rashes that can appear on any part of the body and last for more than six weeks. They can last anywhere from one to five years. However, some medications can temporarily relieve the symptoms until they disappear. 
	&nbsp;</li>
</ul>

[1] Jafilan L, James C. Urticaria and Allergy-Mediated Conditions. Prim Care. 2015 Dec;42(4):473–83.

[2] Wedi B, Raap U, Wieczorek D, Kapp A. Urticaria and infections. Allergy, Asthma \& Clin Immunol. 2009;5(1):1–12.

[3] Frigas E, Park MA. Acute urticaria and Angioedema. Am J Clin Dermatol. 2009;10(4):239–50.

[4] Horikawa T, Fukunaga A, Nishigori C. New concepts of hive formation in cholinergic urticaria. Curr Allergy Asthma Rep. 2009;9(4):273–9.

[5] Dabija D, Tadi P. Chronic urticaria. In: StatPearls [Internet]. StatPearls Publishing; 2021.

[6] Yao Q, Li S, Liu X, Qin Z, Liu Z. The effectiveness and safety of acupuncture for patients with chronic urticaria: a systematic review. Biomed Res Int. 2016;2016.

[7] O’donnell BF, Lawlor F, Simpson J, Morgan M, Greaves M. The impact of chronic urticaria on the quality of life. Br J Dermatol. 1997;136(2):197–201.

[8] Stadler P-C, Marsela E, Kämmerer T, Frommherz LH, Clanner-Engelshofen B, French LE, et al. Impact of allergic reactions and urticaria on mental health and quality of life. Allergol Immunopathol (Madr). 2022;50(2):124–30.