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Hives, also known as urticaria, is a very bothersome problem for those affected. They are usually quite itchy although they do not have to be. A hive is typically a raised welt, wheal, or bump on the skin that may have an accompanying red blotch surrounding the bump. Hives however can be flush with the skin in some cases. The shape and size of a hive is very variable, ranging from pinprick-looking dots to large irregularly-shaped blob-like skin lesions. Not only can hives occur anywhere on the skin, but in some cases, they may be in the soft tissues (e.g., throat, tongue, lips, eyelids) or internally such as the gastrointestinal system (e.g., stomach, intestines). If the hives occur in the throat, the individual may experience a throat-tightening sensation. If the hives affect the tongue, lips, or eyelids, the person may develop localized swelling in these tissues. On the other hand, if they occur in the stomach, the patient may experience abdominal cramping, abdominal pain, nausea, and/or vomiting Usually, multiple hives occur at one time, but it is also possible to just have 1 isolated hive appear from time to time. A hive generally resolves within 24 hours, but may last longer. Hives tend to come and go and generally do not stay in one place for days, week, or months as is common with some other skin disorders such as eczema (i.e., atopic dermatitis).

The causes of hives are numerous. Some of the more common causes may include allergies to a medication (e.g., aspirin, nonsteroidal anti-inflammatory drugs, antibiotics), food, (e.g., peanuts, tree nuts, egg, wheat, fish, shellfish, soy, milk), or flying insect sting (e.g., bee, wasp, yellow jacket, or hornet sting). Some other causes of hives may include personal care products, environmental agents, infections (e.g., viral, bacterial, fungal, parasitic), inflammatory conditions (e.g., vasculitis), autoimmune disorders (e.g., systemic lupus erythematosus, Sjögren’s syndrome, giant cell arteritis, polyarteritis nodosa, scleroderma, polymyositis, dermatomyositis), physical stimuli (e.g., cold, heat, exercise, vibration, pressure, solar exposure, water exposure), and/or rarely cancer.

Hives can be categorized into 2 basic types – acute and chronic. “Acute” urticaria is defined as one having hives for less than 6 weeks. “Chronic” urticaria, on the other hand, is defined as one having hives for 6 or more weeks. Approximately 20-25% of the U.S. population will have hives at some point in their life. Acute urticaria is much more common than chronic urticaria, although chronic urticaria is not that uncommon.

It should be noted that it is not uncommon for someone who has either the acute form or the chronic form of hives to also have associated swellings (i.e., angioedema). These swellings may occur in conjunction with one’s hives or they may occur separately from one’s hives.

The diagnosis of hives is generally made after an allergist performs a comprehensive history and physical examination. In many cases, bloodwork, urinalysis, allergy skin tests, chest X-ray, and/or skin biopsy may be needed, particularly when a diagnosis of chronic urticaria is made. In these cases, it is important to rule out an underlying condition that may be the cause of the hives. If such a condition is identified, treatment of the underlying disorder may be all that is necessary in order to free the person of their hives.

The treatment of hives primarily relies on the use of antihistamines. Since histamine is the primary chemical that is responsible for the development of hives, most cases of hives are responsive to antihistamines which block the action of histamine on the skin. In some individuals, avoidance of a particular food or medication is all that is needed. For others, there are a variety of treatment options, some of which include antihistamines , histamine-2 blockers , corticosteroids, immune modulators, and “biologicals” or various combinations of the above-mentioned medications.

The board certified allergy specialists at Black & Kletz Allergy have more than 50 years of experience in diagnosing and treating hives, as well as swelling episodes. They also diagnose and treat allergies, asthma, generalized itching, eczema, insect sting allergies, medication allergies, food allergies, eosinophilic disorders, mast cell activation syndrome, and immune disorders. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA and offer on-site parking at all locations. The Washington, DC and McLean, VA offices are Metro accessible and we provide a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To schedule an appointment, please call us or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy is proud to provide high quality allergy care to the Washington, DC, Northern Virginia, and Maryland metropolitan area residents in a welcoming and professional setting.

Some individuals have episodes of swelling or “angioedema” of various tissues that may occur without any known rhyme or reason.  They may have 1 episode or they may have multiple or recurrent episodes.  Most people with this condition are very surprised and nervous when they notice an area of their body swelling up right in front of their eyes.  The swelling can occur on any part of the body or even internally.  They may occur by themselves or they may be accompanied with hives (i.e., urticaria) and/or generalized itching (i.e., pruritus).  The severity of the swelling can range from very mild to extremely severe.  The swelling occurs because there is seepage of fluid through small blood vessel walls which in turn results in soft tissue swelling.

The allergic causes of angioedema are varied and may include the following:

• Allergies to Food – Peanuts (legumes), tree nuts, fish, shellfish, eggs, milk, etc.
• Insect Sting Allergies – Honey bees, wasps, yellow jackets, hornets, fire ants, etc.
• Medication Allergies – Penicillin, sulfa, erythromycin, tetracycline, aspirin, nonsteroidal anti-inflammatory drugs (NDAIDS), vaccines, etc.
• Natural Rubber Latex – Gloves, balloons, condoms, catheters, dental dams, etc.

The nonallergic causes of angioedema are also varied and may include the following:

• Autoimmune Disorders – Rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome, polymyositis, scleroderma, Grave’s disease, Hashimoto’s thyroiditis, etc.
• Certain cancers
• Infections – Hepatitis B, syphilis, etc.

Nonallergic reactions to some medications may cause angioedema and some of these medications may include:

• Angiotensin II Receptor Antagonists – Diovan (valsartan), Cozaar (losartan), Atacand (candesartan), Micardis (telmisartan), Benicar (olmesartan), Avapro (irbesartan), etc.
• Proton Pump Inhibitors – Prevacid (lansoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Prilosec (omeprazole), Aciphex (rabeprazole), Protonix (pantoprazole), etc.
• Angiotensin Converting Enzyme (ACE) Inhibitors – Altace (ramipril), Vasotec (enalapril), Zestril (Lisinopril), Capoten (Captopril), Lotensin (benazepril), Accupril (quinapril), etc.
• Selective Serotonin Reuptake Inhibitors (SSRI’s) – Lexapro (escitalopram), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), etc.
• Statins – Zocor (simvastatin), Lipitor (atorvastatin), Pravachol (pravastatin), Crestor (rosuvastatin), Lescol (fluvastatin), Mevacor (lovastatin), etc.

There is a genetic cause of angioedema which is in a category all by itself:

Hereditary angioedema is a condition that is genetic that will cause swelling episodes.  In this disorder, there is an inherited abnormal gene that causes a deficiency of a normal blood protein called “C1 esterase inhibitor.”  If an individual has this deficiency, they may have repetitive swellings which may last for 1 to 2 days in duration.  Hereditary angioedema usually begins to cause swelling episodes in patients after puberty.  These swelling episodes are not accompanied by hives (i.e., urticaria) whereas with allergic causes of angioedema, hives are quite commonly associated with the swelling episodes.   The episodes of swelling in individuals with hereditary angioedema can be spontaneous or they may be triggered by alcohol, physical or emotional stress, and/or hormonal factors.

If no cause of the angioedema can be identified, the individual is said to have idiopathic angioedema.  Idiopathic means that an unknown reason is causing the swelling episodes, however many causes have been ruled out as a cause.

The diagnosis of angioedema begins with a comprehensive history and physical examination.  Allergy testing and bloodwork may be necessary depending on the history and physical examination findings.  Allergy skin tests are often performed to rule out food, medication, insect sting, or latex, or allergies.  Blood testing is usually done if the swelling episodes become more chronic in nature, (more than 6 weeks), in order to rule out underlying conditions that may be causing the angioedema.

The treatment of angioedema depends on the severity and length of time of the swelling episodes.

In mild to moderate acute angioedema, taking an oral antihistamine and/or corticosteroid may be beneficial in curtailing and eliminating the swelling.  Alternatively, intramuscular administration of an injection of epinephrine can be performed along with an intramuscular injection of an antihistamine and/or a corticosteroid.

Severe acute angioedema is treated similarly, however, keeping the airway open is the main objective.  In order to maintain an open airway, intramuscular epinephrine is often used, particularly if the angioedema occurs in the throat or respiratory tract.  In such patients, a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, adrenaclick) should be prescribed and used if the throat or respiratory tract is involved.  The patient should also go immediately to the closest emergency room if the self-injectable epinephrine device is used.  The treatment of chronic recurrent angioedema often involves the use of oral antihistamines, leukotriene antagonists, H2-blockers, and/or corticosteroids.

Hereditary angioedema management typically involves the use of intravenous C1 inhibitor concentrate, the deficient enzyme causing the condition.  The C1 inhibitor concentrate can also be infused prophylactically about 1 hour before a surgical procedure in order to prevent swellings due to physical trauma.  It should be noted that hereditary angioedema generally does not respond well to antihistamines.  There are also various complement system blockers that can be used via injection to treat acute symptoms.  Newer medications such as Kalbitor (ecallantide) and Firazyr (icatibant) may also be used to treat this genetic condition.

The board certified allergy doctors at Black and Kletz Allergy have over 5 decades of experience in diagnosing and treating angioedema.  We treat both adult and pediatric patients.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC metropolitan area for many decades and we look forward to providing you with the utmost state-of-the-art allergy care in a friendly and professional environment.