NY Dermatologist Joshua Fox, MD, Discusses Treatment Options for Acute and Chronic Hives
New studies currently underway may help pinpoint connections between chronic idiopathic urticaria (hives caused by an unknown source) and stress, good news for the majority of patients whose hives have no clear cause. Researchers are examining the connections between major life stressors and hives, post-traumatic stress disorder and hives, and the effect of hypnosis and relaxation techniques on hives. “When you stop to consider that the skin and nervous system develop from the same embryonic layer, it makes sense that stress can affect the skin,” said dermatologist Joshua Fox, M.D., medical director of Advanced Dermatology PC. “We already know, for example, that stress can promote hair loss and exacerbate skin conditions such as acne, eczema, psoriasis and rosacea.”
Hives are raised red or white welts that vary in size; appear anywhere on the body (including inside the mouth); cover all or parts of the body; cause itching, burning or stinging; while each individual hive does not last more than 24 hours, the condition can last from a few hours to six weeks (acute) or longer than six weeks (chronic). According to Dr. Fox, “they are rarely life threatening, requiring immediate medical attention, particularly when they cause swelling in the throat. Fortunately hives are typically treatable.”
In non-emergent situations, a dermatologist can work closely with a patient to determine if the hives are caused by food (milk, soy, eggs, nuts, shellfish and wheat are top culprits, along with additives and preservatives), medications (pain killers, antibiotics and blood pressure medications in particular), external stressors (exercise, water, sun exposure and extreme temperatures), and internal stressors (infection, illness and autoimmune disorders, liver disease, and allergic reaction to donor blood). Hives will sometimes disappear on their own without treatment, but when they don’t, dermatologists can help patients find the right medication or combination of medications to treat the condition.
A visual inspection is often all a dermatologist needs to diagnose hives; it’s pinpointing the cause of the hives that requires medical sleuthing. In addition to reviewing a patient’s health history and completing a physical, a dermatologist may conduct allergy tests (skin or blood), blood work (to rule out illness) and skin biopsies. Once the root cause is understood, treatment may begin and may include over-the-counter or prescription medications, or a combination of medications. Sometimes a dermatologist may also need the services of an allergist to scratch test the patient.
Antihistamines work to control symptoms by blocking the body’s release of histamines in response to an allergen. There are newer (second generation) and older (first generation) antihistamines, prescription and over-the-counter, and sometimes a combination will give the patient the best results. Antihistamines don’t treat the cause, only the symptoms.
Second-generation antihistamines are usually attempted first, since they are typically as effective as first-generation antihistamines, and better tolerated as they generally cause minimal sedation or tiredness. Some examples are Loratadine (Claritin, Alavert), Fexofenadine (Allegra), Cetirizine (Zyrtec), Levocetirizine (Xyzal) and Desloratadine (Clarinex).
First-generation antihistamines may be prescribed when non-sedating second-generation drugs don’t work. Because these drugs can cause drowsiness, and impair one’s ability, they are often taken before bedtime. Examples include Hydroxyzine (Vistaril), Diphenhydramine (Benadryl) and Chlorpheniramine (Chlor-Trimeton).
When antihistamines don’t relieve symptoms:
H-2 antagonists. Cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid) and famotidine (Pepcid AC) are sometimes used with antihistamines, but can cause side effects ranging from gastrointestinal problems to headache.
Corticosteroids. While topical corticosteroids are typically ineffective, oral corticosteroids such as prednisone can provide relief from the uncomfortable symptoms of severe hives by reducing swelling, redness and itching, but can’t be taken long term due because of the serious side effects they occasionally cause, such as weakening the immune system. Often the hives may return when stopping the corticosteroids.
Tricyclic antidepressants. Doxepin’s (Zonalon) antihistamine properties can relieve itching, but they also cause dizziness or drowsiness and other side effects.
When a physical or systemic cause is not evident, and indicators point to stress as a possible cause for hives, it’s still important to confer with a dermatologist. “Desperation may lead a patient to try anything and everything to cure hives,” said Dr. Fox, “but with guidance from a dermatologist, a patient can instead approach the process in a systematic fashion.”
Researchers are currently studying if hives can be lessened by hypnosis and other relaxation techniques; hypnosis has been shown to help patients suffering from psoriasis, warts and hair loss, and meditation, biofeedback and talk therapy have been shown to help psoriasis.