​Looking to prevent hives (urticaria) and angioedema instead? Read this article here.

If you’re here, you should already have some idea of what hives (also known as urticaria) are. They’re not harmful, but they can be annoying and embarrassing to have. Hives are itchy, red bumps that appear on the skin.

You’ll notice that they come and go - sometimes disappearing and reappearing within a few days.

You may also have heard of the term ‘angioedema’. Angioedema is a closely related condition that causes swelling of skin or mucous membranes (mucous membranes are the thin layer of mucous or phlegm that is inside your organs and body).

We’ll talk more about angioedema management methods later.

If you're reading this to find out how to manage a hives breakout, you’re in the right place. We’ll learn about the two types of urticaria in the next section.

Managing Hives (urticaria)

2 Types of hives (urticaria): Acute and chronic

The two main types of hives include acute and chronic hives.

Types of hives (urticaria)
​Acute hives
​Chronic hives
​How long does it last

​Lasts for less than 6 weeks. You don’t need to follow up with your doctor unless there is an identifiable cause.

​Lasts for more than 6 weeks (the urticaria happens at least two times every week without medical treatment for more than 6 weeks) .

"The cause of acute urticaria is found in less than 50% of cases," explained Clinical Associate Professor Pang Shiu Ming, Senior Consultant from the Department of Dermatology at Singapore General Hospital (SGH), a member of the SingHealth group.

"The most comon cause of acute urticaria is viral infection (40%), followed by drug reactions (9.2%) and food intolerance (0.9%)," Dr Pang added.

Sometimes, hives mean you have a severe allergic reaction, which can be a life-threatening medical emergency!

When to go to the A&E for hives (urticaria)

Quickly go to the A&E (accident and emergency) department if you have hives with:

  • Swollen eyes, lips, mouth or throat associated with difficulty in swallowing food (dysphagia) and difficulty in breathing

  • Generalised hives associated with low blood pressure and fainting 

You can take the UCT (Urticaria Control Test) here, a tool to check how bad your hives and bring the results with you when you see your doctor.

Chronic hives (urticaria):  there are two types of chronic urticaria

Let’s start with chronic urticaria. There are 2 types of chronic urticaria - inducible (also called physical urticaria in the past) and spontaneous (CSU).

a) Chronic Inducible (Physical)

Inducible urticaria is caused by physical stimulus, also known as triggers. Your doctor will diagnose it with  instruments to simulate the physical stimuli.

It’s important to know what’s causing your inducible urticaria, because you can remove or prevent the trigger. That’s the best way to prevent inducible hives.

What kinds of inducible urticaria do most people have?

  • Dermographism (most common)

  • Cold-induced urticaria (second-most common)

  • Cholinergic (third-most common)

  • Solar (less common)

  • Vibration (less common)

  • Delayed-pressure (less common)

How to manage some types of physical (inducible) urticaria

1) Dermographism (skin writing)


Dermographism refers to hives that happen when you have friction (from rubbing or scratching) induces the urticaria.

  • Avoid rubbing skin
    Avoid rubbing or scrubbing the skin during shower. Pat dry after shower instead of rubbing the skin with a towel

  • Avoid tight clothes.

  • Avoid carrying heavy things on the forearms and shoulders.

  • Manage stress well
    Emotional stress can worsen your hives. Stress management includes mindfulness techniques like simple meditation and getting enough sleep. Mindfulness is a way to relax.
    Here’s how it works: It trains you to focus on the present moment, instead of worrying about everything else that’s going on in your life. How do you do simple meditation? Close your eyes and breathe in deeply. Focus on the breaths going in and out of your body.

2) Cold induced urticaira

Cold induced urticaria may be idiopathic (primary) or secondary to an underlying blood disease. Most cases are idiopathic. 

Treatment includes avoidance of a rapid drop in body temperature. Avoid doing aquatic activities that come into cold water (swimming or surfing or jogging in cold weather. 

Avoid cold shower and holding on very cold objects. Regular oral antihistamines are the first line treatment. 

3) Cholinergic Urticaria


Cholinergic urticaria happens when stimuli that induce sweating.  Stimuli includes exercise (the most common trigger), high temperature exposure ( bathing in hot water), spicy food ingestion and emotional stress.

  • Avoid spicy food, hot beverages and alcohol
    These can flare-up or make your hives worse.

  • Avoid precipitating stimuli that may induce sweating 
    These stimuli include exercises, hot environments, saunas, immersion in hot water (hot jacuzzi and hot bath/shower)

4) Solar Urticaria

Solar hives may happen if you expose your skin to UV light. Sun protection strategies include avoidance of sun protection, sun protective clothings and sunscreens

5) Delayed Pressure Urticaria

Delayed pressure urticaria happens when you keep putting pressure on the skin. You may not notice the hives immediately - sometimes they only appear 4-6 hours after you remove the pressure.

  • Loose-fitting clothes:
    Tight clothes will rub and press against your skin. So, you should try not to wear too much skin-tight clothing like skinny jeans and leggings. Instead, go for light, loose-fitting clothes like oversized t-shirts and flare pants.

  • Use wide or padded bag straps:
    Don’t carry bags with thin straps or straps made of materials like chains (especially shoulder handbags).

  • Avoid carrying heavy shopping bags or holding on the handrails of trolleys  

b) Chronic spontaneous urticaria (CSU)

Let’s move on to the next type of urticaria – chronic spontaneous urticaria or CSU.

Chronic spontaneous urticaria (CSU) has no known cause. Sometimes, chronic urticaria is caused by rare auto-inflammatory diseases that or due to urticarial vasculitis (inflammation of the blood vessels).

Since there is no known cause that can be identified in chronic spontaneous urticaria,  it can be challenging to treat chronic spontaneous urticaria. Patients can get frustrated. If you are one of them, know that you are not alone.

"In about half of the people who has chronic spotaneous urticaria, the rash can last for six to twelve months, then gradually disappears. It can however last considerably longer and the course is sometimes unpredictable. Thus the goal of treatment is to achieve symptom control so that urticaria does not interfere with your daily activites," said Dr Pang.

Chronic spontaneous urticaria may be associated with thyroid disorders, so your doctor may perform a thyroid function test. Your doctor may also check if your CSU is connected to auto-inflammatory disease and urticarial vasculitis.

For those cases of CSU that have a known trigger, the trigger is usually NSAIDS painkillers or alcohol. It’s not usually triggered by food.

Two tips to manage chronic spontaneous urticaria (CSU)

  • Use non-NSAIDS painkillers
    If you need pain relief, take non-NSAIDS painkillers like paracetamol instead. You can buy them from any local pharmacy (Guardian, Watsons, Unity).

  • Avoid alcohol
    Alcohol can cause or worsen spontaneous urticaria. Don’t drink too much alcohol, or, better still, don’t drink it at all.

General tips for managing hives (urticaria)

1. Diet

  • Keep a food record:
    Use your phone calendar, a printable diary or any empty notebook to track your food allergies.

  • Avoid high-histamine diets:
    High-histamine foods like shellfish can cause you to get hives or make your hives worse. Learn more about high-histamine foods in our previous article on hives prevention. 

2. Record flare-ups

  • Record flare-up episodes:
    This helps you find out what are the possible triggers that are causing you to get hives.

  • Take photos
    Your doctor will find it easier to assess how severe your hives are if you show them photos.

  • Use anti-itch cream or lotion:
    Use anti-itch cream, calamine lotion to relieve itching.

Treating hives (urticaria)

You may be wondering - can hives be treated? Will you have this condition for life? The good news is that hives can be treated by a doctor.

Hives treatment is usually done in a stepwise approach (meaning step-by-step, depending on how you respond to the treatment).

The first line of treatment uses non-sedating (non-sleepy) oral antihistamines (you may need to take up to 4 times the recommended dose).

Your doctor will usually tell you to take the antihistamine medication every day to have complete control of your condition.  The dose may be gradually decrease if the hive is controlled.

Doctors usually don’t recommend long-term oral corticosteroids to treat CSU

If oral antihistamine medicine doesn't work, your doctor may use medicines that target the immune system (immunosuppressants or biologics).

Managing angioedema

Angioedema is a medical condition causing deeper tissue swelling under the skin. It can happen together with hives. 

"Angioedema can affect any part of the body. It often affects the eyes, lips, and the genitalia. It is associated with burning sensation and is not itchy," explained Dr Pang.

There are multiple types of angioedema, including allergic, drug induced (angiotensin converting enzyme inhibitors ACEI, a type of antihypertensive medicine), idiopathic, and hereditary and acquired angioedema, Dr Pang added.

Although you may feel embarrassed and uncomfortable when angioedema symptoms appear, severe angioedema can be life-threatening.

​When to go to the A&E for angioedema

You should see a doctor immediately if you:

  • You find it hard to breathe or have a hoarse (rough and scratchy) voice from angioedema.

  • You find it hard to breathe and have severe stomach cramps (pain), which could be a rare genetic condition associated with angioedema.

Treating angioedema

The general approach is to identify and remove the triggers. Adequate observation in the hospital is necessary if angioedema progresses despite treatment. 

The treatment of the angioedema will be different in different types of angioedema. Depending on the severity or compromising airway emergency (analphylaxis), parenteral adrenaline and or oral prednisolone may be required.

  • For idiopathic angioedema or angioedema associated with urticaria. Oral antihistamine is the first line of treatment if the angioedema is mild.

  • Drug-induced – Identification and removal of the drug is the most important

  • Hereditary and acquired angioedema. There are special drugs to treat these conditions.

In conclusion, lifestyle changes and medication are needed to manage hives and angioedema. Monitor your triggers and discuss treatment options with your doctor for a good outcome.

Ref: H24

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