One Allergist Shares the Challenges of Treating Chronic Hives
Most people have probably experienced hives, also called urticaria, at some point in their lives, perhaps due to an allergic reaction. These itchy, raised welts on the skin are annoying and uncomfortable, but usually they resolve on their own within a day or so without treatment, according to the American Academy of Dermatology. Chronic hives, however, are in a whole other ballpark.
Chronic hives, or chronic idiopathic urticaria, is diagnosed when your hives last for at least six weeks, and there is no known cause. Because of these factors, the condition can wreak havoc on a patient’s life, and it can be difficult to find the right doctor to treat it.
Anitha Shrikhande, M.D., is an allergist at Westside Allergy Care in Rochester, New York. In her practice, she often treats people living with chronic hives. HealthCentral spoke with Dr. Shrikhande about what led her to a career in this field and what she wishes people knew about chronic hives.
HealthCentral (HC): What made you decide to pursue a career as an allergist?
Dr. Shrikhande: Allergy and immunology is a great field because you get to treat people of all ages. The conditions are interesting and affect a large percentage of the population. I have suffered from nasal allergies for most of my life and also have food allergies. Having to deal with allergies certainly peaked my interest in the field, and it has been very rewarding.
HC: What are the major challenges and rewards involved in treating chronic hives?
Dr. Shrikhande: Chronic urticaria can have a highly variable presentation from person to person. Some people can just take one antihistamine per 24 hours and go about the day hive free, while for others, it is much more of a struggle. It's important that we individualize treatment plans for each person.
The most challenging aspect of urticaria management is figuring out each person's threshold for hive control. For some, having a couple of hives here and there throughout the day is acceptable, but for others, even one urticarial lesion can be very distracting. It is important to establish goals of care early on and understand and manage each person's expectations.
Additionally, so many people believe they are causing the problem by eating something, touching something, or just doing something wrong. When chronic hive sufferers finally understand that they are not creating this problem for themselves, there are a lot of mixed emotions. There is an element of sadness that there is no easy fix for this nuisance of a problem and they are now stuck taking a lot of daily medications.
That said, patients also experience a sense of relief that they can stop worrying so much and go back to enjoying food without the nagging notion that eating will lead to hives. It is when a patient finally accepts that this is not an allergy to something that the physician feels that now they can really start properly helping you cope with this chronic problem that may take years to resolve.
HC: What’s one thing you wish more people knew about chronic hives?
Dr. Shrikhande: Chronic hives can affect children and adults. Hives can be accompanied by something called angioedema. Angioedema is when there is swelling of the lips or tongue. It is important to know that while allergies to foods and insects can be life threatening, chronic urticaria itself is typically not life threatening. Not all patients experience angioedema, but if it does happen, it can all be a part of the same process.
One of the biggest fears people have is that urticaria is a marker of a more severe underlying disease. While urticaria can be a manifestation of autoimmune disease, it is most commonly its own disease process and is present without any other underlying conditions. I think ongoing surveillance of the condition is very important, and patients should make routine follow-up visits with their allergists.
HC: Are there any interesting new developments in chronic hives treatment that are on the horizon?
Dr. Shrikhande: The approval of the biologic medication Xolair (omalizumab) for the treatment of chronic urticaria in 2014 has helped tremendously in the long-term care of patients with severe chronic urticaria. It's an injection given once a month, and many patients are able to wean to much lower doses of antihistamines, and some may not require antihistamines at all anymore. A patient with severe urticaria is one who is taking up to four times the recommend amounts of antihistamines and still has daily outbreaks.
Xolair doesn't work for everyone, but it has a generally low side effect profile. Some patients who are very severe may require other immune modulating medications such as cyclosporine. I find this medication to be very effective for severe urticaria, but it has side effects which require close monitoring.
Another interesting development in the field is that chronic idiopathic urticaria is now being referred to as chronic spontaneous urticaria, or CSU. I think adding the word “spontaneous” really highlights the salient feature of this condition — the skin outbreaks are spontaneous. Each patient might have their own exacerbating triggers, but for the most part, the condition is random, abrupt, and spontaneous.
It is thought that non-steroidal anti-inflammatory drugs (NSAIDS) can exacerbate hives in large numbers of CSU patients even if they have never had a problem with these medications in the past. The onset is abrupt, and for many people, the hives just one day seem to stop. This can be in a matter of months or several years. Once the hives stop, all of those exacerbating triggers are no longer a problem anymore either.
HC: For someone who has chronic hives — or thinks they might — what advice would you give them when they’re searching for a physician to help manage the condition?
I think finding an allergist you are comfortable with is very important. If your hives are severe, someone who is comfortable prescribing medications other than antihistamines will be best for long-term management.
Want to see Dr. Shrikhande in action and learn more about chronic hives? Watch the inspiring story of her partnership with Marisa Zeppieri, a woman living with chronic hives.
[Interview has been condensed and edited.]
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