Hives: Itch now or never

While TA found these changes challenging at first—especially the dietary restrictions and adjustments to her skincare regimen—she showed remarkable dedication in following through. I encouraged her to remain observant and to record any patterns or potential triggers that might be linked to her flare-ups. Despite her consistent efforts, TA found the process of tracking triggers tiring and, at times, overwhelming. She mentioned that waking up on an empty stomach might make her symptoms worse, although she wasn’t certain. She even switched to a baby-safe laundry detergent, but her hives persisted.

TA expressed frustration, suspecting that factors such as heat, weather changes, or even minor pressure on her skin could be contributing to her symptoms.

Throughout our discussions, TA has remained proactive and resilient, despite the physical discomfort and emotional toll her condition has caused. We continue to explore possible triggers together and focus on approaches that can bring her lasting relief and improve her quality of life.

Chronic spontaneous urticaria is a distressing unpredictable inflammatory disorder that is recurrent. But before I delve into CSU, let us first talk about urticaria. Urticaria is a systemic condition affecting the skin, characterized by the development of wheals (pantal) and/or angioedema (swelling of the face). Classification is based on its duration (acute or chronic as in CSU) or based on its triggers (chronic inducible urticaria or CIndU)—this means that the wheals or pantal can be reproduced by using their trigger like heat or cold or chronic spontaneous urticaria (). In chronic inducible urticaria, wheals and/or angioedema appear following these known triggers such as: cold, heat, contactants, pressure, solar (sunlight), vibrations, cholinergic (anything that raises your body's core temperature, causing you to sweat, exercise, hot baths, saunas, hot weather, and fever, as well as emotional stress, anger, and eating spicy foods), aquagenic (contact with water) and symptomatic dermographism (when one tries to press on the skin like writing on it).

Wheals are pruritic, often described as itchy and/or burning, are of variable size and shape, and are usually surrounded by erythema. Angioedema may follow after the inducing trigger. Angioedema is a sudden, pronounced deep swelling in the lower skin layers: the dermis and subcutis or mucous membranes, often accompanied by tingling, burning, or tightness. CSU is another subtype of urticaria. In CSU, wheals appear spontaneously as a result of known or unknown causes; this pattern lasts for more than six weeks, with each isolated case typically resolving within 24 hours. Angioedema may also occur, typically resolving within 72 hours, but this is not a consistent feature of CSU. Approximately 57 percent of patients present with wheals only, 37 percent present with wheals and angioedema, and six percent present with angioedema only.

Although wheals can appear anywhere on the body, they are usually seen on the arms and legs, whereas angioedema most commonly occurs on the face. Signs and symptoms of CSU can occur daily or almost daily, or have an intermittent-recurrent course and occur at any time of the day but most commonly during the evening. CSU is the most common subtype of chronic urticaria, accounting for approximately 60 to 90 percent of all CU cases and occurs more commonly in adults than children. The typical age of CSU onset is six to nine years in children and 30 to 50 years in adults. Studies have shown that patients suffer a wide-ranging disease duration of one to 10 years, with approximately 40 percent of patients enduring the disease for longer than 10 years.

Approximately two-thirds of patients with CSU report systemic complaints, including joint pain and fatigue. In an observational study of 155 patients, 52 percent of patients who experienced systemic complaints had CSU for more than four years, compared with 31 percent of patients without systemic complaints. Many patients with CSU report disease exacerbation in response to triggering factors, both mental, such as stress, and physical stimuli, as in concomitant chronic inducible urticaria. Other reported triggers include diet, pseudoallergens, and parasitic infestations. Patients can also experience more severe disease following treatment with non-steroidal anti-inflammatory drugs (NSAIDs, pain relievers such as ibuprofen, naproxen). This is known as NSAID-exacerbated cutaneous disease and has been reported in up to 30 percent of patients with CSU. Viral infection can also lead to worsening urticaria symptoms. One virus, and its role in the exacerbation of CSU that has been reported frequently, is COVID-19.

Second-generation H1 antihistamines are the first-line treatment; partial or complete response, defined as a reduction in urticaria symptoms of greater than 50 percent, is observed in approximately 40 percent of patients. The 2022 international urticaria guideline recommends the monoclonal anti-IgE antibody omalizumab as second-line treatment for antihistamine-refractory chronic spontaneous urticaria. However, at least 30 percent of patients have an insufficient response to omalizumab, especially those with IgG-mediated autoimmune urticaria. Cyclosporine, used off-label, can improve symptoms in approximately 54 percent to 73 percent of patients, especially those with autoimmune chronic spontaneous urticaria and nonresponse to omalizumab, but has adverse effects such as kidney dysfunction and hypertension.

To date, TA continues to experience occasional hives that occur suddenly and without an apparent trigger. After taking the medication I prescribed, she reported feeling better. What has also helped significantly is maintaining adequate hydration, staying in a cool environment, avoiding foods high in histamine, and—most effectively—minimizing stress as much as possible.