How Are Hives (Urticaria) Treated?

Hives, medically known as urticaria, is an inflammatory skin condition characterized by red or skin-colored bumps called wheals, and sometimes with swollen areas—called angioedema. Over 60% of cases of this condition are acute, meaning they can resolve on their own or with treatment within six weeks; however, if symptoms persist for longer, the hives are considered chronic. Though hives are rarely life-threatening, they can cause itching, affect sleep, and negatively impact daily life.

For the treatment of hives, you can visit a healthcare provider, such as a primary care doctor, a dermatologist (a doctor who specializes in skin conditions), or an allergist (a doctor who specializes in allergic conditions). Treatment strategies depend on the type of hives and focus on easing and preventing symptoms.

The first step usually involves avoiding any known triggers, such as allergens, certain infections, exposure to heat or pressure, medications, and stress, among others. To manage symptoms, a healthcare provider may recommend an antihistamine—a type of drug that can reduce allergy symptoms. For chronic hives or severe symptoms that don’t improve, your provider may also prescribe other medications, such as a corticosteroid (to treat inflammation) and others.  

Treatments by Condition Type

The specific treatment approach depends on the type of hives you have, including whether your condition is acute or chronic. Types of hives also vary by the cause or trigger of the rash. In some cases, there may not be a known cause for the hives, but your healthcare provider can still provide treatments based on your symptoms.

There are some differences in how each type of hives is managed, though the treatment plans may be similar. Typically, your healthcare provider will employ a consistent, step-by-step approach: introducing certain treatments and then moving on to others if earlier attempts don’t yield results.

Treatments for Acute Urticaria 

Most acute urticaria cases resolve on their own within one week. Management of acute hives cases vary based on whether triggers are known or unknown. 

First-line Treatment of Acute Urticaria

The standard first-choice (first-line) treatment and symptom management of acute urticaria includes:

• Trigger avoidance: Some possible triggers for acute hives may include certain foods, pollen, or contact allergens, as well as sources of infections (viral, bacterial, parasitic, or fungal), such as contaminated water. If triggers are identified, figuring out ways to avoid them is a key preventive measure.
• Lifestyle changes: If you are actively experiencing hives, avoid drinking alcohol, as it may worsen symptoms. Your healthcare provider might also suggest not taking non-steroidal anti-inflammatory drugs (NSAIDs) like Bayer (aspirin) and Advil (ibuprofen), as they could also worsen hives. Wearing loose clothing can also help ease any discomfort.  
• Second-generation H1-antihistamines: This is a group of antihistamine drugs used to treat allergic reactions. Examples include Claritin (loratadine), Clarinex (desloratadine), Allegra (fexofenadine), Zyrtec (cetirizine), and Xyzal (levocetirizine).

For Acute Urticaria Following First-line Treatment

If the rash does not improve with initial treatments, your healthcare provider may recommend:

• First-generation H1-antihistamines: This is an older version of H1-antihistamines that have more possible side effects compared to second-generation types. Examples include Benadryl (diphenhydramine), Atarax (hydroxyzine), and Chlor-Trimeton (chlorpheniramine), among others. Side effects can include confusion, dizziness, decreased concentration, and more.
• H2-antihistamines: Another class of antihistamines , H2-antihistamines may be another option to treat acute hives. These medications include Tagamet HB (cimetidine) and Pepcid (famotidine). However, using H2-antihistamines for an extended period of time can increase your risk of liver damage.
• Systemic glucocorticoids: These are corticosteroid drugs used to reduce inflammation in severe cases. Some examples include Prednisone Intensol (prednisone) or Omnipred (prednisolone), both of which may be taken for three to 10 days, typically in combination with antihistamines. The dosage may depend on your condition and weight. Severe side effects of these corticosteroids include weakening of the bones, diabetes, glaucoma (eye conditions that can cause vision loss), stomach ulcers (open sores in the stomach lining), depression, suicidal thoughts, and confusion.

Treatments for Chronic Spontaneous Urticaria (CSU)

Chronic spontaneous urticaria (CSU), also called chronic idiopathic urticaria, is a type of chronic hives with no identifiable trigger or cause. This type accounts for about 60% to 90% of chronic hives cases. While there is no cure, treatments are available to help manage symptoms. 

First-line Treatment

The first choice (first-line) of treatment usually includes:

• Avoiding certain drugs: While this type of hives doesn’t have a known trigger, alcohol and NSAIDs may make symptoms worse. Your healthcare provider may recommend avoiding them. 
• Lifestyle changes: Avoiding physical factors such as hot showers or humid environments, can reduce flare-ups. Wearing looser clothing can also help.
• Second-generation H1-antihistamines: Similar to acute hives, this group of antihistamines is typically the first-line approach. As previously mentioned, examples include Zyrtec (cetirizine), Xyzal (levocetirizine), or Claritin (loratadine), among others. Since treatment courses can be long-term for chronic hives, there is a risk of severe side effects, including decreased blood pressure and increased heart rate.  

For Chronic Spontaneous Urticaria Following First-line Treatment

If first-line medications aren’t improving symptoms, your healthcare provider may prescribe a similar choice of treatments that are also used to treat acute hives following first-line treatments. These treatments include:

• First-generation H1-antihistamines (e.g. Benadryl, Atarax)
• H2-antihistamines (e.g. Tagamet HB, Pepcid, Zantac)
• Systemic glucocorticoids (e.g. Prednisone Intensol, Omnipred)

The dose and duration for these treatments may vary depending on your condition. As always, talk to your healthcare provider about possible side effects for each medication and any adverse effects associated with long-term use.

Other first-line treatments are only prescribed for chronic hives and not acute cases. This may include leukotriene-receptor antagonists, which represent another class of medication that may be taken to prevent inflammation. For adults, typical dosages include 10 mg of Singulair (montelukast) once a day and Accolate (zafirlukast) at 20 mg twice a day. There is a small chance of liver damage with prolonged use.

For Refractory Chronic Spontaneous Urticaria

Some cases of CSU may not respond to the previously mentioned standard therapies. This subtype of chronic hives is known as refractory CSU.

Your dermatologist or allergist may consider prescribing Xolair (omalizumab), which is FDA-approved to treat CSU. This is a monoclonal antibody—a drug that mimics immune proteins in your immune system and helps reduce inflammation in the body. This drug is typically injected subcutaneously (beneath the skin) in 300-milligram doses once a month for adults. Long-term use of Xolair can lead to malignant tumor growth.

Another treatment option is prescribing an immunosuppressant. This type of drug can block an overactive immune response that may be triggering hives. There are several types, such as Sandimmune, Neoral, or Gengraf (all brands of cyclosporine); Protopic, Envarsus XR, or Prograft (all brands of tacrolimus); Aczone (dapsone); Azulfidine (sulfasalazine); and Plaquenil (hydroxychloroquine).

Your healthcare provider will consider your condition, as well as any other health conditions you may have before selecting the appropriate treatment and dose. Using immunosuppressants can weaken your immune system and put you at a greater risk of contracting infectious diseases. 

Complementary Medicine for CSU

Alongside your treatments, your healthcare provider may recommend taking vitamin D supplements as a complementary medicine to help manage symptoms of chronic spontaneous urticaria. However, limited research shows mixed results, and more research is needed to examine the effects of vitamin D on hives.

Treatments for Inducible Urticaria 

Hives linked to specific physical or environmental triggers are a group of conditions known as inducible urticaria (IU)—also called physical urticaria. These forms of urticaria are treated in similar ways as the others. However, there’s no standardized approach for this type, and much depends on what’s causing the condition.

First-line Treatment of Inducible Urticaria

Your healthcare provider may first recommend:

• Trigger avoidance: Each type of inducible urticaria has a specific trigger that when exposed to the skin can lead to hives. Triggers include heat (for heat urticaria), cold (for cold urticaria), physical pressure (for delayed pressure urticaria) , water (for aquagenic urticaria), and sunlight (for solar urticaria). A first step to prevent and reduce hives is to identify the trigger and find ways to steer clear of these, though this may not always be possible.
• Second-generation H1-antihistamines: As with other types of hives, this class of antihistamines is a typical first choice of medication. For inducible urticaria, recommendations include starting with doses of 10 milligrams of Zyrtec (cetirizine), 180 milligrams of Allegra Allergy (fexofenadine), or 10 milligrams of Claritin (loratadine)—each of these may be taken twice a day. For chronic inducible hives, your healthcare provider may recommend higher doses. 

For Inducible Urticaria Following First-line Treatment

If first-line treatments aren’t enough to manage symptoms, your healthcare provider may recommend:

• H2-antihistamines: If second-generation H1-antihistamines alone aren’t effective, H2-antihistamines can be added to the treatment plan. An example is 20 mg of Pepcid (famotidine), taken orally twice a day.  
• First-generation H1-antihistamines: Hydroxyzine is the generic name for a common first-generation H1-antihistamine used to treat physical urticaria, along with other types of hives. Common brands include Vistaril and Atarax. It is prescribed at doses ranging from 10–100 milligrams, to be taken at night. Though rare, severe side effects include trembling in the limbs and rapid or slowed heart rate.   
• Doxepin: This is a tricyclic antidepressant that, in low doses, can also function as an antihistamine. There are several brands including Silenor, Zonalon, and Prudoxin. For adults, the amount indicated starts at 10–25 milligrams a day at night, which can be gradually scaled up to 100–150 milligrams.

For Refractory Inducible Urticaria

In cases where symptoms of inducible urticaria (IU) does not improve with antihistamines—known as refractory IU—then you may be prescribed other treatments.

One option is Xolair (omalizumab), a monoclonal antibody drug that was mentioned previously as a treatment for refractory CSU. While it is FDA-approved to treat CSU, some doctors may prescribe it off-label to treat refractory symptoms of IU that persist despite other treatments.

Another treatment option for refractory IU are systemic glucocorticoids—a group of corticosteroids that can also treat acute or chronic hives. This includes Prednisone Intensol (prednisone). This type of therapy is generally indicated for shorter courses of two to four weeks, after which amounts are gradually tapered off.  

Living With and Managing Hives

While hives is rarely life-threatening, the condition can be dangerous if the swelling affects the throat. Though acute hives can resolve on their own or with treatment, there is no cure for chronic spontaneous urticaria or inducible urticarias.

In general, having hives can affect your quality of life. In particular, chronic urticaria can lead to disrupted sleep, fatigue, and difficulty concentrating. People who experience daily or near-daily symptoms of urticaria are more likely to feelings of anxiety, sadness, embarrassment, and social stigmatization.

However, hives can be effectively managed with medical treatment and lifestyle changes that help prevent flare-ups and ease symptoms. This means identifying and avoiding any known triggers to prevent flare-ups, wearing loose-fitting clothing, and closely following your treatment plan.

A Quick Review

Hives, clinically known as urticaria, is a condition of itchy welts and bumps on the skin. While most cases of urticaria are acute and resolve within six weeks, some can be more severe and be chronic. Treatments for this condition focus on easing symptoms and can include lifestyle changes, as well as taking antihistamines, corticosteroids, and monoclonal antibodies, among others.