Anyone who deals with itchy rashes like hives knows how frustrating it can be to figure out what’s causing them—and how to get them to subside. According to the American Academy of Allergy, Asthma and Immunology, about 25 percent of the population will experience hives at some point in their lives, often without warning and at any age.
To better understand chronic hives—including what they are, what causes them and how to treat them—we consulted a dermatologist to break down everything you need to know.
What Are Chronic Hives?
Chronic hives are also referred to as chronic spontaneous urticaria (CSU), explains Miami board-certified dermatologist Anna Chacon, MD. They are “recurrent episodes of itchy, raised welts (hives) that last for six weeks or longer without a clear external trigger,” she says. So, if you are experiencing hives lasting longer than six weeks without being able to identify the source, you could be dealing with this condition.
When it comes to symptoms, hives tend to appear quickly. “Individual hives typically appear suddenly, can move around the body and usually fade within 24 hours, although new ones may continue to develop,” says Dr. Chacon. In other cases, “Some patients also experience angioedema, which is deeper swelling, often affecting the lips, eyelids, hands or feet,” she says.
With chronic hives, itching is often the most noticeable symptom. “The itch can be intense and significantly disrupt sleep, work and quality of life,” says Dr. Chacon. If symptoms become disruptive, seeing a dermatologist or allergist is important, as they can help find a solution.
What Causes Chronic Hives?
What’s interesting about chronic hives is that, in most cases, they “are not caused by a traditional allergy,” explains Dr. Chacon. “Instead, they are often driven by immune system dysregulation.” This distinction is specific to chronic hives: Acute hives can still be caused by food or environmental allergies, but Dr. Chacon notes that it’s rare that those would be the ongoing cause of symptoms.
When it comes to chronic hives, it’s important to consider the role of the immune system, which is why seeing an allergist can be key for proper treatment. “Many patients have an autoimmune component, where antibodies activate mast cells in the skin, leading to histamine release and swelling,” says Dr. Chacon. “Chronic hives can also be associated with autoimmune thyroid disease and, less commonly, other systemic conditions.”
How Do You Treat Chronic Hives?
Because chronic hives are an immunological response, “Topical treatments have a limited role because the condition is driven internally,” says Dr. Chacon. Essentially, this means that cortisone creams or other anti-itch topicals won’t help long-term. However, you can still use them in a pinch: “Cooling lotions or anti-itch creams may provide temporary relief, but they do not control the disease,” she explains.
Rather, chronic hives are typically treated with medication prescribed by your doctor, starting with an oral antihistamine: “First-line therapy is a daily second-generation oral antihistamine, which is often increased up to four times the standard dose if needed,” says Dr. Chacon.
If you’re still experiencing uncontrolled symptoms, “the next step is typically a biologic medication,” says Dr. Chacon. One option is omalizumab, “an injectable anti-IgE antibody given monthly,” she says. “In more resistant cases, other systemic medications such as cyclosporine may be considered.”
Remibrutinib, also known as Rhapsido, is another potential new treatment option. “It is an oral Bruton’s tyrosine kinase (BTK) inhibitor that targets mast cell and B-cell signaling pathways involved in chronic hives,” says Dr. Chacon. “Clinical trials have shown meaningful reductions in itch and hive activity, including in patients who remain symptomatic despite antihistamines.”
This newer options stands out because it’s “an oral option with a relatively rapid onset of action,” she says. The real-world data are still evolving, but it’s an “exciting” addition to the treatment options available, “especially for patients who do not respond adequately to antihistamines or biologics,” she adds.
Overall, the goal with chronic hives is complete symptom control while maintaining safety, something that often goes beyond over-the-counter fixes and requires expert care.
