Chronic Hives: Making Progress in the Management of Chronic Urticaria

Health Professional

Imagine feeling as if your entire body had been attacked by hundreds of mosquitoes. Imagine intense itching going on for hours, resistant to your constant rubbing and scratching. Imagine the feeling of hopelessness when the itching fails to respond to pills you have taken and is accompanied by large disfiguring welts and facial swelling.

Many patients I see don't have to use their imagination to experience hives and swelling because they live with this often incurable condition, chronic urticaria and angioedema (CU). "Urticaria" is the technical term for hives, which look identical to welts. "Angioedema" is the term used for a deeper less well defined swelling of the skin which accompanies urticaria about fifty percent of the time. "Chronic" urticaria and angioedema means the skin eruptions have been recurring for six or more weeks continuously or intermittently.

CU does not require a blood test, x-ray or procedure to diagnose. Often diagnosis simply requires a convincing history that includes an appropriate description of the skin lesions (welts) and multiple skin eruptions associated with itching. Some patients, at the first office visit, are disappointed if they happen to be clear of hives (in between episodes). They think their diagnosis and treatment may be delayed or inaccurate because the hives are not active at the time of the evaluation. Actually hives don't have to be seen in order to make the diagnosis of CU.

The treatment of CU depends on the outcome of a full evaluation comprised of a detailed history, physical examination and selective testing. The historical information provided from the patient or parent is crucial to identifying a trigger although in CU a cause is found in only ten percent of cases.

Okay, not being able to identify a trigger in the setting of CU most of the time is the bad news, but the good news is it can be successfully managed 90% of the time. Success is determined by the degree to which further hives, itching and swelling can be suppressed.

Allergists are trained to look for possible external causes of CU as well as perpetuators. There may be multiple food or drug triggers unsuspected by the patient. Other medical conditions not typically involving the skin may be associated with CU. These include thyroid disorders, rheumatoid diseases (rheumatoid arthritis, lupus, scleroderma and others) some tumors, liver and kidney disease.

A recent article in the Journal of Allergy Asthma and Immunology reported on a survey to help doctors better manage CU. The survey is similar in design to the Asthma Control Test questionnaire (referenced below).

The survey consists of four questions which are answered on the basis of how you have felt over the preceding four weeks. Each question has five possible choices which are assigned point values ranging from 0-4. A score closer to zero means poor control, but a score closer to 16 (maximum score) suggests good control.

Here is the Urticaria Control Test (UCT):

  1. How much have you suffered from the physical symptoms of the urticaria (itch, hives (welts) and or swelling) in the last four weeks?

    1-very much 2-much 3-somewhat  4-a little   5-not at all

  2. How much was your quality of life affected by the urticaria in the last four weeks?

    1-very much  2-much  3-somewhat  4-a little  5-not at all

  3. How often was treatment for your urticaria in the last four weeks not enough to control your urticaria symptoms?

    1-very often  2-often  3-sometimes  4-seldom  5-not at all

  4. Overall, how well have you had your urticaria under control in the last four weeks?

    1-not at all  2-a little  3-somewhat  4-well  5-very well

What was your score? If you scored 12 or higher your urticaria is under pretty good control but if your scored 11 or lower you have poor control and probably need better treatment.

Final Words:

Chronic urticaria and angioedema can be managed successfully by teaming up with your doctor and specialist and establishing a maintenance plan and action plan. The action plan will give you guidelines on what to do if you have a moderate to severe flare up. The UCT may provide you and your doctors with a tool to further fine tune your treatment.