Urticaria is also known as ‘nettle rash’ or ‘hives’. This condition consists of wheals – spots or patches of raised red or white skin – each of which usually clears away in a few hours to be replaced by other fresh wheals. Urticaria is very common and affects one in five people at some point in their lives. The more common type of urticaria rash (hives) lasts up to 24 hours, produces larger wheals and may not completely clear for several days. It sometimes occurs together with swelling of various parts of the body (angioedema) – typically the face, hands and feet, although anywhere may be affected.
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There are a number of different forms of urticaria and they can be grouped as spontaneous urticaria, physical urticaria and other types of urticaria.
The forms of spontaneous urticaria are:
- Acute spontaneous urticaria: Hives are formed and fade away after hours or days, at the latest after six weeks.
- Chronic spontaneous urticaria: Hives or angioedemata are formed; the symptoms persist for more than six weeks.
The forms of physical urticaria are:
- Urticaria factitia: Rubbing, scratching, or scrubbing the skin.
- Cold urticaria: Contact between the skin and cold.
- Heat urticaria: Contact between the skin and warmth/heat.
- Solar urticaria: UV light or sunlight
- Pressure urticaria: Pressure
Other forms of urticaria include:
- Aquagenic urticaria: Contact between the skin and water.
- Cholinergic urticaria: Raised temperatures (for example due to hot baths).
- Contact urticaria: Contact between the skin and certain substances.
- Exercise-induced urticaria/anaphylaxis: Physical strain.
Chronic spontaneous urticaria (CSU) can be diagnosed with a detailed patient history. A GP will usually ask a patient to keep a symptom diary to record any potential triggers in order to exclude or confirm a diagnosis of CSU. It is important to record the onset, duration and course of CSU. The duration of the individual wheals and rash should also be recorded accurately. Any occurrence of angioedema should be noted. Further tests may include evaluations of the skin, blood and urine. If initial treatment is ineffective, GPs should refer patients to see a specialist dermatologist or immunologist for further treatment.
Until recently, antihistamines were the only licensed therapy option for people living with CSU. Medical guidelines recommend doctors increase the dosage up to four times the licensed dose; however 40% of people with CSU still do not experience relief from symptoms from this increased dose. Non sedating antihistamines are usually prescribed in the first instance, but sedating antihistamines may be prescribed, particularly at night to help with night time itch. However, patients may need to face the additional issues of dealing with fatigue and restriction on daily activities (such as driving), due to sedating treatment.
In the absence of alternative licensed treatments, guidelines suggest second-line therapy with drugs such as corticosteroids and montelukast. Third-line therapy includes treatments which act upon the immune system, such as ciclosporin, mycophenolate and methotrexate. Although not specifically licensed or designed to treat the condition, they may be successful in a percentage of patients. Recently, omalizumab, a drug that modifies the immune response, has received a licence for the treatment of CSU following publication of positive phase 3 trial data. The Specialised Dermatology Clinical Reference Group will make recommendations to NHS England on the inclusion of this treatment in a commissioning policy.
What is Chronic Spontaneous Urticaria?
Allergy UK has created an educational video to support people with this skin condition and to raise awareness for others suffering without a diagnosis and manageable treatment
Treatment for urticaria (hives) and angioedema
There are two important aspects of treatment for urticaria: avoidance of any reasonably suspected trigger, and treatment with medication.
Individuals who have urticaria due to aspirin may need to avoid foods that contain high levels of salicylates. As well as this, antihistamines are the mainstay of medication treatment for urticaria and angioedema. They may be taken just when required or regularly to prevent episodes occurring in chronic spontaneous urticaria.
Other prescription medication are used to treat urticarial and angioedema symptoms if ordinary antihistamines do not control the symptoms effectively.
For more detailed information about urticaria and angioedema and for more useful tips on management and treatment, please find further useful resources above.
- the symptoms do not improve after 2 days
- you’re worried about your child’s hives
- the rash is spreading
- hives keeps coming back – you may be allergic to something
- you also have a high temperature and feel generally unwell
- you also have swelling under the skin – this might be angioedema
A GP may prescribe menthol cream, stronger antihistamines or steroid tablets. If your urticaria does not go away with treatment, you may be referred to a skin specialist (dermatologist).
People living with CSU experience unpredictable outbreaks of itchy and painful wheals which can have a knock-on effect on their work, sleep, hobbies and social activities. Nearly three quarters of people living with CSU report having to miss out on social occasions because of their skin condition.
Most people living with the condition experience symptoms of CSU for at least a year, with a considerable proportion of people experiencing symptoms for much longer.
The unpredictable nature of CSU has a strong emotional and psychological impact and is associated with a more substantial effect on quality of life than other skin conditions. Couple this with the cosmetic disfigurement and embarrassment sometimes caused by CSU and you can see why many patients suffer from anxiety and depression. We hear from sufferers who are in utter despair over their treatment and feel completely trapped by the condition.
Angioedema is another skin allergy and is the name given to deeper swelling affecting the skin over the arms, legs, torso or face. It may also affect the tongue, mouth, throat and sometimes the upper airway. These swellings commonly last for more than 24hrs, and usually there is no itching. It is not possible to identify an underlying cause for angioedema in the vast majority of cases.
Urticaria and angioedema often occur at different times or together in the same person. They occur in about 15 per cent of the population at some time or other in their lives, with women more commonly affected than men.