Itchy skin with chronic hives: What is the cause?

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Itchy skin is a key symptom of chronic hives. The welts themselves may be itchy, and so might the area around them.

Itchiness can also be a precursor to the development of hives. For example, if a person is having an allergic reaction that is causing chronic hives, itchy skin may develop just before the welts do.

Some people with chronic hives have also have a type of fluid buildup under the skin known as angioedema. Angioedema may occur around the lips, eyes, genitals, hands, and feet, which may also cause tight or itchy skin. However, the most commonly reported symptom is pain rather than itchiness.

Itchy skin is not the only symptom of chronic hives. The others include:

• Welts: These typically appear as raised, itchy bumps on the skin that are pink, red, or flesh-colored, typically with a paler spot in the middle. Some people also call them wheals. Each one typically lasts less than 24 hours without leaving any marks or scarring.
• Angioedema: Some people with chronic hives also experience general swelling under the skin. This occurs due to fluid buildup. For 10% of people, angioedema is their main symptom.
• Secondary symptoms: Those who scratch or pick the welts may have additional symptoms, such as crusts or lesions. These could potentially result in scars.

For a person to meet the criteria for chronic hives, the symptoms must occur every day, or on most days, for a minimum of 6 weeks.

The welts may appear with distinct borders, but they can also cluster together, forming larger raised bumps. As the symptoms continue, they will come and go, possibly migrating around the body.

It is not always clear what causes a person’s chronic hives. Some people have idiopathic hives, or chronic spontaneous urticaria (CSU), which means there is no identifiable cause.

Others have physical hives, or chronic inducible urticaria (CIndU), which means the hives reliably appear in response to specific triggers.

In either case, experts believe the mechanism behind chronic hives is an immune response. In the case of CSU, this may be an autoimmune response, meaning the body is targeting healthy cells by mistake. This triggers the release of histamine in the skin, which is a chemical that causes allergic reactions.

With CIndU, the immune system mistakenly perceives a substance or type of physical stimuli as a threat. This could include, but is not limited to:

• certain foods
• latex, or foods that contain substances similar to latex, such as kiwis, bananas, mangoes, and chestnuts
• physical touch, pressure, or friction from clothes or bags
• touching certain substances, animals, or plants
• hot or cold temperatures
• UV light from the sun, tanning beds, or other UV lamps
• medications, which could cause a reaction while taking the medication or potentially months or years later
• adrenaline from stress or exercise
• water or vibration, although this is rare

Infections resulting from specific bacteria, viruses, and parasites also have associations with chronic hives, such as:

A 2019 review also notes that some studies have found people with CSU have a higher rate of vitamin D deficiency and dysbiosis than others. Dysbiosis is an imbalance of microbes that live in the digestive tract. Experts need to conduct more research in this area.

It is possible that autoimmunity may be the cause of CSU, but scientists are still learning about this. Many people with CSU also have another autoimmune condition, suggesting a connection.

The most common autoimmune condition in people with CSU is hypothyroidism. This causes the thyroid gland in the neck to produce less thyroid hormone than it should. In an older 2012 study, 9.8% of people with CSU also had hypothyroidism.

Other autoimmune diseases with links to chronic hives include:

• rheumatoid arthritis
• systemic lupus erythematosus
• Sjorgen’s syndrome
• celiac disease
• type 1 diabetes mellitus
• Hashimoto’s thyroiditis
• pernicious anemia
• Graves’ disease
• vitiligo
• polyglandular syndrome with autoimmune thyroid disease, pernicious anemia, or vitiligo
• mixed connective tissue disease

To diagnose chronic hives, doctors will perform a physical examination of the skin and then ask questions to try and determine the cause or trigger.

They may take a full medical history, looking at other conditions a person has, medications they take, and what they were doing when the hives first began. If a person is unsure, the doctor may suggest keeping a diary to track flare-ups and help identify possible causes.

If a doctor suspects CSU but a person has no other autoimmune conditions, they may order blood tests to look for signs of inflammation or autoimmunity. Allergy testing, such as skin prick testing, is typically not useful in these cases.

If doctors cannot quickly determine the cause of chronic hives, there are steps people can take to reduce discomfort. Try:

• wearing loose-fitting clothes
• opting for soft, natural materials, such as cotton
• keeping the body at a comfortable temperature
• using products on the skin that contain no irritants or common allergens, such as fragrances
• applying cold compresses to the skin welts unless cold appears to trigger them
• using over-the-counter anti-itch creams such as calamine lotion or antihistamine creams
• practicing relaxation or mindfulness techniques to help manage stress

If or when doctors do identify the cause, they may be able to provide a person with more tailored treatment. This could include antihistamine medications or other drugs, such as omalizumab (Xolair) or cyclosporin. To manage a severe flare-up, doctors may sometimes recommend a short course of corticosteroids.

If a person with an autoimmune disease has chronic hives, managing the underlying condition may help manage itchy skin.

According to the American Academy of Dermatology Association (AAD), about 50% of people recover from chronic hives within 1 year. Between 80–90% of people will experience a reduction in symptoms within 5 years.

Chronic hives can reappear later on, but treatment can help manage them. Anyone who is concerned about recurring itchy skin and hives should speak with a doctor or dermatologist.

Itchy skin is a key symptom of chronic hives. The welts or wheals themselves are itchy, but itchiness can also occur in the surrounding area.

Doctors cannot always identify the cause, but several treatments and lifestyle changes can help relieve itchy skin with chronic hives, such as calamine lotion and antihistamines. Keeping a symptom diary can help with identifying triggers, which may enable people to reduce flare-ups.