Urticaria (hives) — itchy raised welts that come and go — is one of the most frustrating skin conditions for patients. Acute episodes settle in days; chronic urticaria can persist months or years. We use a stepwise treatment approach matching guideline recommendations.
Treatment ladder
- Step 1: Second-generation antihistamine (cetirizine, fexofenadine, levocetirizine) — standard dose
- Step 2: Same antihistamine at 2x to 4x dose (under supervision, off-label but evidence-based)
- Step 3: Add second antihistamine or H2 blocker
- Step 4: Omalizumab (anti-IgE biologic injection every 4 weeks) for refractory chronic urticaria
- Step 5: Cyclosporine (rare; for severe unresponsive cases)
For acute hives we look for triggers (drugs, foods, recent viral illness). For chronic hives we screen for thyroid autoimmunity, do basic labs, and discuss the often-idiopathic nature of the condition. Most patients gain full control on antihistamines alone.
Book a consultation for a structured assessment and treatment plan.
Urticaria — Frequently Asked Questions
What causes hives?
Acute hives (under 6 weeks): viral infection most commonly, sometimes drug or food trigger. Chronic hives (over 6 weeks): usually idiopathic — no identifiable trigger in 80 to 90 percent of cases. Autoimmune mechanisms in some.
Are antihistamines enough?
For most patients yes — but at higher doses than over-the-counter labels suggest (sometimes 2 to 4x normal dose under supervision). We may add second-line antihistamines or H2 blockers.
When do you use omalizumab?
For chronic spontaneous urticaria unresponsive to high-dose antihistamines. Subcutaneous injection every 4 weeks. Effective in 60 to 80 percent of resistant cases.
Should I get allergy tested?
For acute hives with clear trigger pattern, yes. For chronic spontaneous urticaria, allergy testing rarely identifies a cause — the condition is autoimmune more often than allergic. We test selectively based on clinical picture.
Is it dangerous?
Hives alone are not dangerous. Hives + facial/lip swelling + breathing difficulty can be anaphylaxis — go to ER immediately. Chronic hives are uncomfortable but not life-threatening.
Will it go away?
Acute hives: usually within 6 weeks. Chronic hives: about 50 percent resolve within 1 year, 80 percent within 5 years. Some persist longer; we manage long-term.
