Hives and Stress - Bonnie

[Guest guest]

Urticaria is the medical name for Hives. These are welts, pink swellings

that come up on any part of the skin. They itch and each individual hive

lasts a few hours before fading away, leaving no trace. New hives appear as

old areas fade. They can be pea sized or join to cover broad areas of the

body. While the itch can be intense, the skin is usually not scabbed or

broken. In some people the hives burn or sting.

Hives are very common -- 10-20 percent of the population will have at least

one episode in their lifetime. Hives can sometimes occur in deeper tissues

of the eyes, mouth, hands or genitals. These areas mat develop a swelling

that is frightening in appearance, but usually goes away in less than 24

hours. This swelling is called angioedema.

In many cases, a single attack of hives is due to a infection or virus and

these go away within a few days to a few weeks. Some people get repeated

attacks that occur as an allergic reaction to a variety of things (foods,

most commonly nuts, chocolate, fish, tomatoes, eggs, fresh berries and milk,

insect stings, and medications). In this case, they usually break out within

a few hours of the exposure. Usually, the patient figures out the cause by

themselves, and they never bother coming to a doctor.

Certain people can develop recurrent hives from sunlight, cold, pressure,

vibration or exercise. These are called the physical urticarias. If hives

develop from scratching or firmly rubbing the skin it is called

dermatographism. It is the most common of the physical urticarias and it

affects about 5 percent of the population. It doesn't always itch. This

condition sometimes also occurs along with other forms of hives.

Some people react to anything that makes them hot or sweaty with hives. This

can be sunlight, exercise, hot baths, blushing or anger. These are tiny

intensely itchy hives with a big red blotch around them and are called

cholinergic urticaria.

Pressure urticaria shows up as a deep welt in an area of prolonged pressure.

Occasional people react to the cold. Even more rare is a reaction to

sunlight.

Occasionally, a person will continue to have hives for many years. These

Hives, called chronic urticaria, can be one of the most frustrating problems

dermatologists see in their patients. This is defined as hives lasting

longer than 6 weeks. Patients like this come in miserable and worried with

this problem, often having seen multiple specialists. Neither the patient

nor the doctor can determine the cause of the hives. Patients will often say

" it has got to be something causing these hives. " The truth is hard to

accept for some patients.

In the overwhelming majority of cases it is not " something " causing the

chronic hives, it is " nothing. " That is, in about 95% of chronic hives

cases, the hives are " idiopathic " (a medical term that means there is no

discernible cause). Because of those 5% of cases with a cause, it is

worthwhile to see a physician to determine if any underlying disease is

present (e.g. thyroid problems, liver problems, skin diseases, sinusitis) or

if there is an allergic cause (i.e. a reaction to a drug, insect, food,

etc.). This can be accomplished by a good history and physical, a few blood

and urine tests and sometimes a skin biopsy. Some patients with chronic

hives and elevated anti-thyroid antibodies in the blood improve when given

thyroid supplement even if the thyroid function is normal.

In about half of patients with chronic idiopathic hives, the explanation is

that body's immune system is, in a sense, overactive. The urticaria is

" autoimmune " . The immune system is attacking the normal tissues of the body

and causing hives as a result. We know certain urticaria sufferers have

other signs of autoimmune problems. Some have autoimmune thyroid disease,

vitiligo, swollen joints or certain abnormalities in the blood (especially

the ANA test). A new treatment has recently emerged for autoimmune

urticaria. This is the use of Plaquenil, a drug originally used for malaria.

In a recent trial 83% improved or cleared completely when used for 3 months

or more.

So, in many patients with chronic hives, there is really no exposure (drug,

food, insect, chemical) to blame for the urticaria. The patient must

understand and accept this for their ideal management. Basically, all that

needs to be done is treat the hives. The main treatment of hives is

antihistamines, and they will work if they are used properly. Common reasons

for lack of effectiveness of antihistamines are 1) the particular

antihistamine used is not strong enough 2) the antihistamine is not used in

a high enough dose 3) the antihistamines are not continued for a long enough

period.

The most well tolerated initial treatment is the non-sedating antihistamine

Claritin. Zyrtec is similar but may sometimes cause sedation. If that

doesn't eliminate the hives, a sedating-type of antihistamine (hydroxyzine,

cyproheptadine or doxepin) is added at night. High doses may be needed and

this will cause sedation. Fortunately, most patients will become less

affected by sedation after they have taken the drug regularly for a while.

If that doesn't work, some doctors may try a short course of cortisone

(steroids) to clear the hives completely. Then the patient can maintain the

effect with the much safer antihistamines, since steroids have significant

side effects if used long term.

A drug used for psoriasis and kidney transplants, Neoral, is almost always

effective in clearing even the most severe cases of chronic hives at low

doses. However, it causes significant side effects if taken for a long time.

There are other medications that may be added to the antihistamines, but

these non-standard therapies are not always effective. However, if the hives

are not responding, they are worth a try. Examples are anti-acid pills

(Tagamet, Zantac), dapsone and sulfasalazine (anti-inflammatory

antibiotics), nifedipine (a blood pressure medicine), Accolate (an asthma

drug), colchicine (a drug for gout), and several others.

The important thing is that the patient is given enough medication

(antihistamines, perhaps in conjunction with other drugs) to suppress the

hives. Whatever it is that controls a patients hives, should be the daily

regimen, taking the drugs every day, whether or not they have the hives on

any given day. The idea is that you are preventing the hives from breaking

out.

Some doctors suggest that medications should be continued for long periods -

perhaps even a month after the hives have disappeared. Again, the exception

to this is the cortisone/steroid-type medications, which should only be used

for short periods initially to quiet down the urticaria. Remember that you

must work closely with your doctor to find a medication regimen that

suppresses the hives until they resolve on their own.