Ashlee Williams, MD (Host): If you've ever had hives, you know how distracting they can be. The itching, the uncertainty, and wondering if something very serious can be wrong. Hives can come up when you least expect them, during a stressful week at work, after exercise, or even during sleep. And when they do, they do raise a lot of concern.

Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today, I'm joined by Dr. Paula Whittington, a board-certified allergist here at Kaiser Permanente. Today, we will review everything hives and all of your questions about them. Dr. Whittington, thank you so much for joining us today.

Paula Whittington, MD: Thank you for inviting me. I think this is an important topic. We have a lot of patients that come to see us that suffer from hives, and they want answers. So, let's start with the basics, I guess.

Host: So many questions. Yes, start with the basics. Okay. So, what are hives and what do they typically look like?

Paula Whittington, MD: So, hives can vary in size. But the most common thing that patients will describe, they're raised, they're very itchy. Sometimes the itch may be very intense that they describe it as a burning sensation. I say it kind of looks more like a mosquito bite sometimes. They come, they go. They can be pink or red, but also depending on your complexion, you might not even see the redness as much. they can move around your body. They don't usually just sit there, though. They come, they go, and they shouldn't leave a mark.

Host: So, what causes hives and why do they just show up on our bodies?

Paula Whittington, MD: That's a great question, and I really wish I had the answer to that one. And not having the exact answer of what's causing your hives can be really frustrating for a lot of patients. We know that certain cells in our body, like in our skin, called mast cells, sometimes they can be in our skin, but they're also in other parts of our body. They're a part of our immune system, and they help fight, you know, bacteria and viruses. But another important role that they have is fighting parasites. When they can be triggered, and sometimes, randomly triggered, you can get hives because it causes that swelling that you might see on the skin.

What do we know that triggers them? Well, there are some correlating factors that we found. stress. Stress is a really big trigger that I see in common with a lot of my hive patients, and it runs the gamut. It can be children, adults, men, women, all ethnicities suffer. And one thing I try to tell my patients is, "Don't suffer in silence, and you're not alone," because very many patients suffer from hives.

It's something we may see with stress. It could be your work, it could be family life. I have had a patient that recently his hives were really out of control. And we tried to manage them, and they were so intense. And then, he tells me, "Oh, I'm getting married in three weeks. I really need these under control." And that was like, "That's what's going on. That's why I can't control it." After he got married, I haven't heard from him since. So, it can be that.

So, we know it's some type of immune stimulation, so being sick. And in often kids, you can see, you know, a GI bug that can trigger hives. The flu, COVID can trigger hives. Sometimes the really hard-to-treat patients, I find that there may be some underlying autoimmune disease like lupus or thyroid disease that can be linked to it. We don't have an exact answer, but sometimes we know some correlating factors. For, instance, I've had patients that have lived outside the country, and sometimes they may have, "Oh, you know, I've had some stomach discomfort." and their H. pylori, which is a bacteria that can infect the stomach, that's positive. So, you know, there are so many things.

There are also some very small subset where they have physical triggers. We call them physical urticarias. So for example, a patient may describe, "When I exercise and my body temperature goes up, they'll break out into hives." Or if I go into the cold, the skin that's exposed to the cold will break out into hives. And pressure or tight clothing sometimes can also trigger it as well. There's one dermatographic urticaria, and urticaria is the medical term for hives, or skin writing dermatographia. So, you write on your skin or you have, like, some trauma with scratching, that can make them worse and make the mast cells release more histamine and make the hives so irritating.

Host: It seems like there's a very large range of things that can cause hives that you try to figure out what is the cause of your hives. And it seems like it can last at different amounts of times. Can you tell us more about how long you should expect a hive or hives to last?

Paula Whittington, MD: It's really tough. We can't really predict how long you're going to have hives. I would say that we know that if you're having hives more days than not for more than six weeks, then you're labeled as having chronic hives or chronic urticaria. And because we don't really know why you're having these hives, typically, we call it idiopathic urticaria. So, we don't know why you're having these hives. That's the translation.

I find that those patients that have them more than six weeks or chronic urticaria, they can last for years to decades. And sometimes if they go away, they'll have, like, a little break. They'll describe, "Oh, I had hives when I was a kid, and then they appeared again when I was an adult." So, they can have bouts of, you know, going away and then coming back.

If you're in the acute hive category, so less than six weeks, which is great, usually the hives resolve pretty quickly. Maybe you might need some medication, like steroids or antihistamines for a short period of time. But the problem is if you're having them and they're chronic, and it's really causing a decline in your quality of life, getting good sleep.

You know, you're having swelling in your face because the hives are pooling together, swelling in your hands. It can be really uncomfortable. And then, also the anxiety of, "I don't know why I have hives," that can fuel them as well. You're like, "I don't know why," you know. "Is there something really going on?" So, that's when I say reach out to your doctor, which you can do totally through KP, you know, through the app. You can reach out to your doctor. You can request to see an allergist if they're not controlled. You know, there are a lot of options that we have to help manage the hives and get you through them.

Host: So, is there a difference between the causes of acute versus chronic hives?

Paula Whittington, MD: I don't find that there's a big difference. However, I find that my patients that have chronic hives may have more of an underlying autoimmune or immuno—well, I'd say more of an autoimmune type of correlating factor with it that could be fueling that immune dysregulation.

Host: Okay. So, how are hives treated and when should someone see a doctor?

Paula Whittington, MD: First step, if, you know, they're really bothering you, reach out to your primary care provider or your allergist if you're seeing one. Long-acting antihistamines are the best option. Sometimes patients will say that they're taking Benadryl, but Benadryl only lasts probably four to six hours, and it can be very sedating. So, I say reach for a long-acting antihistamine, something like Allegra, the generic name of that is fexofenadine. And you can also look to Zyrtec or cetirizine. I find Claritin to be the least effective of the long-acting antihistamines in most patients. And if you're a healthy patient and you don't really have very many comorbidities, then you can go up and you can take that Allegra twice a day or that Zyrtec twice a day. Even some patients prefer Xyzal or levocetirizine. So, you can take it twice a day.

If you're still having breakthrough and it's not controlled, say, you're having, like, an intense flare, like my patient that was getting married, sometimes we might prescribe prednisone, oral prednisone. It's a big immunosuppressant, you know, that helps calm the inflammation. But we don't like to do that often because long-term use of steroids can have major side effects. So, for him, I was like, "Here, let's give you a steroid taper, you know, to help get that under control. And while you're on that, let's up you on your long-acting antihistamines." So, long-acting antihistamine second generation help with histamine 1 interference. And histamine's released by our mast cells. But sometimes you might need a little bit more help. So, we add in Pepcid, which is, yes, it's a stomach medicine, but it can also help. It helps with a little bit of histamine 2 interference over there.

And once you've upped your long-acting antihistamines, and say you're taking Pepcid, and you still might need a little control, I may offer certain patients the choice of taking something called Singulair or montelukast, which is an anti-leukotriene, which helps in the inflammation in the asthma and allergy pathway. But really, if you're having to take more than two long-acting antihistamines. So say, you're taking the Allegra or fexofenadine twice daily and you're still having severe symptoms, then I would say definitely you need to see an allergist to talk about other options.

And for my really tough patients, we may go on to injectables. So, they're on high dose of long-acting antihistamines, they're on Pepcid, they're on Singulair, they're still having uncontrollable symptoms, we would talk about some biologics that are available. some of those include Xolair and, more recently, Dupixent has been approved for idiopathic urticaria.

Host: We're certainly grateful for your wealth of knowledge, Dr. Whittington. Thank you so much for helping us better understand hives and why they can sometimes be so unpredictable.

Today, we learned what hives are, what can trigger them, and why some people may continue to get hives even when there isn't a clear cause. Here are the few takeaways to remember: One, hives can appear suddenly and are raised itchy welts that can change shape and location on the body, often appearing suddenly.

Two, they're caused by the release of histamines in the skin and can be triggered by many things, including stress, temperature changes, infections, pressure on the skin, and allergic reactions.

Three, for some people, hives can last longer than six weeks and often have no obvious cause.

And four, it's important to see a doctor if your hives are severe, they keep coming back, or don't improve with over-the-counter medications.

For more expert advice from our amazing doctors from Kaiser Permanente, visit kp.org/doctor and explore more episodes of Healthier You wherever you get your podcast. If you found this episode helpful, please subscribe and share with others. Please leave a comment of any other topics you would like to discuss. Thank you and from all of us at Kaiser Permanente, be well.