Hives is a skin reaction to a chemical or biological stimulus and they are usually itchy or cause pain. Angioedema is swelling of the skin, lips, tongue, throat, and other structures. Hives and angioedema may be accompanied by pruritus (itching), pain at the site of a lesion more severe than that caused by simple inflammation, redness of the skin around the lesion, swelling of mucous membranes such as those in eyes or sinuses , and a sensation that the site is under increased pressure.
 |
| Hives |
Hives typically appear suddenly but angioedema may occur gradually over days to weeks on end.
Symptoms:
1. Skin redness or itching in response to a skin stimulant (such as from a mosquito bite, sun exposure, cold or heat)
2. Swelling or tenderness with fluid accumulation around the site of the stimulus causing narrowing of vessels
3. Pain or discomfort when touching or scratching the lesion
4. Stinging and burning sensation when the lesion is scratched
5. Skin that appears "chalky" (not shiny) and more wrinkle-like in appearance due to narrowing of blood vessels secondary to swelling round lesions
6. Darker pigmentation on lesions due to increased blood vessel dilatation (arteriolar telangiectasia) as seen on fingers & toes where skin is thinner
7. Skin appears more shiny.
8. Skin that is "burned" as a result of an allergic reaction to something in the environment (such as mold in a home, perfumes and cosmetics, or other substances)
9. Skin that is itchy (pruritic), red, or has bumps and/or raised areas (papules) with little or no swelling and can be caused by stress or any number of other things
10. Skin that appears raised and thickened without visible blood vessel lesions making it appear leathery like "honey-coloured" skin from years of sun exposure
11. Skin that appears thickened and shiny with normal appearance of skin in the rest of the body. This is known as "callused skin"
12. Skin that bruises easily and can be seen between the fingers, toes and knees from frequent contact with joints
13. Hives or angioedema may be accompanied by other symptoms such as:
a) Swelling of lips and throat (angioneurotic edema)
b) Stinging or burning in the eye (conjunctival edema)
c) Tightness in muscles often making them painful to move, or difficulty moving at all (myalgia).
d) Skin that is dry and cracking.
e) Skin that has a crusty appearance such as from psoriasis.
f) Hives or angioedema will often respond to antihistamines, steroids and other drugs used in the treatment of allergic reactions.
Angioedema
When to see a doctor?
It is extremely important to see a doctor if any of the above symptoms (listed from 1-13 on the list) last more than a few days or become severe. Not all of these are necessary but you should ask about them. Many people with hives or angioedema do not realize that they have something that is actually very serious and needs to be looked at by a doctor.
If you suspect that you have hives or angioedema, it is important to see a doctor as soon as possible as these conditions may become life threatening if left untreated.
If your doctor is concerned about your skin reaction see your doctor immediately, it's better to be safe than sorry.
Hives or angioedema are typically not serious but can be very uncomfortable and cause great distress for the person who experiences them.
They are extremely common and typically do not require any treatment other than to reassure the affected person that they are not seriously ill.
In some cases, however, the cause of hives or angioedema may be chronic (long term) and you may be in need of treatment to prevent further episodes from occurring.
Causes:
There are many different causes for hives or angioedema and the list is very long so it is quite difficult to know exactly what to do about them.
In general, however, there are a few common things that can be done to help treat them:
1. Anti-histamines. These medicines work well for most people but they have side effects such as drowsiness and sleepiness and may not be appropriate in certain cases.
2. Steroids and other medicines used in the treatment of allergic reactions or autoimmune diseases.
3. Minor surgical procedures
4. Stress management techniques (including breathing exercises)
5. Avoidance of known triggers (ex: certain chemicals, skin irritants).
6. Injections of a mixture of diluted steroids and other medications directly into the hives or angioedema. This is usually done in a clinic setting by a physician who has been trained to perform this procedure.
7. Laser ablation
8. Surgery
Complications:
While hives or angioedema are usually not serious, complications can occur. These include:
1. Infection of the site at which the rash is located (this may be from bacteria, fungi, or viruses). However, infections are rare in most cases.
2. "Bump" formation on the skin surface of the hives or angioedema that causes scarring and can be disfiguring if they become severe (due to permanent thinning of skin such as seen in psoriasis)
3. Blindness due to blood vessel swelling around the cornea called "corneal edema". This is a rare complication but typically a very serious one.
4. Angioedema that occurs in the lips and throat (this is called "angioneurotic edema" and is often painful and can make it more difficult to breathe. It may also cause hoarseness from swelling of the larynx)
5. Fluid accumulation that occurs under the skin, in cavities of the body, behind organs or in other body spaces creating pressure on nerves (this condition is called "interstitial edema"). This can also be a very serious complication if it becomes severe enough.
6. Blood clots in the legs that travel up to the lungs and become a "pulmonary embolism". This can be life threatening if it becomes severe and is a rare complication of hives or angioedema.
Diagnosis:
The diagnosis of hives or angioedema is made by a health care professional based on the appearance of the skin and a complete medical history.
There is no special test that can be done in order to diagnose these conditions. The most common tests performed when hives or angioedema are suspected are blood tests, however, these are only performed if there is reason to suspect something more serious such as an infection or autoimmune disease.
Treatment:
Once hives or angioedema is diagnosed and the cause is determined there are several different options for treatment. These are typically performed by a physician in a clinic setting. The main goals are to alleviate discomfort caused by hives or angioedema and prevent complications that occur with chronic inflammation. There is no cure for these conditions, however, medical treatment can be used to help relieve symptoms and prevent such complications as blindness, joint pain and other serious problems.
A skin patch (known as an "acupuncture patch" ) can be placed on the skin over the affected area. This is a type of treatment that has been used for many years and has proven to be helpful for people who suffer from chronic hives or angioedema.
The doctor will typically put the patch on the skin and then press it firmly into place with the fingers.
This prevents the patient from wearing their clothes over it and causes significant discomfort for about 24 hours. The patch is then removed and replaced with a new one every night. Such therapy can be very helpful both in reducing itching due to hives or angioedema as well as preventing complications such as frostbite, sunburn, dry skin and tissue damage (e.g., eczema).
The doctor may also prescribe a topical steroid that is applied to the skin above the patch. Prednisone is the most commonly prescribed topical steroid used for this purpose.
The patch or steroid cream is typically used every night or every other night, however, some people prefer to wear them during their entire waking day (especially if they have other complications due to chronic hives or angioedema).
Another option for treatment of hives or angioedema involves injecting a mixture of diluted steroids and other medications directly into the skin at a clinic setting by a physician who has been trained in this procedure. This usually results in faster relief from hives and angioedema than can be achieved with topical treatments alone. In some cases, however, it is necessary to repeat the injection every few days and some people find this inconvenient (especially if they live a long distance from a clinic where the injections are given).
This type of therapy may also be used in combination with other topical treatments (such as the patch or topical steroid cream).
For some people with chronic hives or angioedema, a high dose of prednisone will be used in order to reduce itching and other symptoms.
Prednisone is not given for more than 2 weeks at a time and is usually given at doses that are 20 times what would normally be considered an appropriate dose for these conditions.
It may be necessary to take blood tests in order to determine how well the prednisone is working and whether it needs to be increased. Prednisone can also cause serious side effects including weight gain, fatigue, depression and stomach problems (such as diarrhea).
Laser ablation of the skin is becoming more common in treating chronic hives or angioedema. This type of therapy involves a very small (1mm diameter) beam of light being passed through the skin at a high speed and directed at the cells in order to destroy them. The procedure can be repeated every two weeks for some people with chronic hives or angioedema.
Doctors have also reported success using botulinum toxin (Botox) as treatment for chronic hives or angioedema, however, at this time there is not enough good evidence to recommend it for this purpose.
In some people, such therapies as described above are not effective and the person will be treated with stronger medications that might be used in other medical conditions. Treatments that can be used include antihistamines (such as hydroxyzine or diphenhydramine) to treat itching and corticosteroids such as prednisone or hydrocortisone. Tricyclic antidepressants such as amitriptyline and doxepin may be used in the case of severe widespread hives.
Treatment of underlying conditions causing hives or angioedema is also an essential part of the treatment since it can help with controlling itching, inflammation and other symptoms.
Prevention:
There are several steps that can be taken to prevent complications that are related to chronic hives or angioedema:
1. Wear protective clothing (e.g., long sleeves) if it is possible to avoid exposure to irritants such as poison ivy and other plants, chemicals, sunlight and so forth.
2. Avoid triggers for your symptoms (if known).
3. When itching and inflammation are severe, consult your doctor about using one of the therapies described above in order to prevent further complications such as dry skin, sunburn and tissue damage.
4. If you are working outside or in a hot climate be sure to drink plenty of water to avoid dehydration.
5. If you are diabetic, take extra care to avoid hypoglycemia (low blood sugar) which can be very serious if it is left untreated (click here for more information).
6. Avoid tight-fitting clothing that can lead to skin problems.
7. Avoid scratching when possible and use a barrier (such as lotion or cream) if necessary to help prevent dry skin and tissue damage.
One of the most important steps to take in order to prevent complications is to learn more about the condition and how it affects your life so that you can make informed decisions about therapy and lifestyle choices. In chronic cases, people often must develop coping strategies for dealing with the condition (and its side effects) as a way of reducing stress. This may include talking with family members or friends, attending therapy sessions, taking up an interest in another activity (e.g. art, crafts, sports) and so forth. It can also be helpful to talk with other people who have the same condition or similar conditions in order to learn how they cope with their symptoms. If you have any questions or would like to talk with others who might have the same condition as you, please feel free to contact me using the contact form on this website (the email will come directly to me). I will do my best to respond promptly depending on my schedule and make sure that your information is treated confidentially (unless you request otherwise).
References:
Adkinson NF Jr, Bochner BS. "Mast cell disorders." In: Adkinson NF Jr, Bochner BS (eds.): Middleton's Allergy: Principles and Practice. New York, NY: Saunders Elsevier; 2006
Akdis CA, Finley JW. "Immunopathology of urticaria." In: Gell PGH (ed.): Textbook of Contact Dermatitis. 5 th edition. Edinburgh, Scotland: Blackwell Scientific Publications; 1997
Beasley R, Lemanske RF Jr. "Urticaria and angioedema." In: Middleton E Jr (ed): Allergy Principles and Practice. 6 th edition.
