Hives Treatment

Hives (urticaria) result from mast cell release of histamine, triggered by allergens, infections, medications, stress, or physical stimuli like pressure or cold. In chronic hives lasting more than 6 weeks, a specific trigger is identified in less than 50% of cases despite thorough evaluation.

Hives accompanied by throat tightness, difficulty swallowing, shortness of breath, dizziness, or tongue swelling indicate anaphylaxis — a life-threatening allergic reaction requiring immediate emergency care and epinephrine. This is distinct from ordinary hives.

Allergy testing is most useful when a specific allergen trigger is suspected based on history — such as a food or medication. For chronic spontaneous urticaria without an obvious trigger, allergy testing rarely identifies a cause and is not routinely recommended.

Second-generation antihistamines — cetirizine, loratadine, fexofenadine — are first-line treatment and control symptoms in most people. Higher doses or combinations are sometimes needed. For chronic hives unresponsive to antihistamines, omalizumab (Xolair) is an effective FDA-approved option.

Second-generation antihistamines cause minimal sedation at standard doses. First-generation antihistamines (diphenhydramine) cause significant drowsiness and are not preferred for regular use. Omalizumab is generally well tolerated — injection site reactions and rare anaphylaxis have been reported.