Urticaria: Understanding Chronic Hives
Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health.
This week I had the pleasure of sitting down once again with Dr. Joni Sago, board-certified in internal medicine and dermatology, to talk about a condition that can be incredibly frustrating for patients: urticaria, or hives. It is one of those problems that may seem straightforward at first, but the more we understand about it, the more we realize there is often much more going on beneath the surface. We talked about what may actually be causing hives, how our understanding of the condition has changed, and some of the newer treatment options available for people dealing with chronic urticaria. As a primary care physician, I have seen how discouraging it can be for patients to hear that the cause is unknown or to assume it must simply be another allergy. Dr. Sago reminded us that hives are not always that simple, and thankfully, our understanding of them continues to grow.
We also talked about the difference between acute hives, which last less than six weeks, and chronic hives, which continue beyond six weeks. Naturally, most patients want to know exactly what is causing their symptoms. While triggers such as foods or medications may be easier to identify in children, we now know that many chronic cases in adults can have an autoimmune component, with the immune system mistakenly reacting against the body itself. Dr. Sago also explained how newer treatments, including Xolair, Dupixent, and Rapsodo, are giving physicians more options for patients who have struggled with chronic hives. Just as important, she emphasized the value of an ongoing partnership between the patient and physician, because sometimes finding the right answer and the right treatment takes time.
PODCAST NOTES
Acute urticaria is defined as hives that persist for less than six weeks, typically arising rapidly and causing intense itchiness, especially at night. Chronic urticaria, in contrast, lasts for more than six weeks, and the misery it brings can significantly disrupt quality of life by affecting sleep and daily activities. This distinction is key in shaping the patient’s diagnostic process and management plan.
Unlike acute urticaria—where a specific trigger such as a new food, medication, or infection is sometimes identifiable, especially in children—the majority of chronic hives cases in adults are now believed to be autoimmune in nature. In these instances, the body’s own immune system mistakenly mounts an attack on itself, resulting in persistent symptoms that are not always easy to trace back to a single, obvious cause.
Recent advances in immunology have revealed that some people with chronic urticaria create autoantibodies against their own proteins, such as interleukin-24. When this happens, normal immune signaling gets disrupted, causing mast cells to release histamine and perpetuate a cycle of itching and swelling—even in the absence of an external allergen.
It is crucial to rule out other potential causes and coexisting diseases in patients with chronic urticaria. Dr. Joni Sago emphasized the importance of checking basic bloodwork, including a complete blood count (CBC) to rule out blood disorders like leukemia or lymphoma; liver and kidney function tests; and a thyroid panel, since thyroid autoimmunity is often present in these patients, even if thyroid function is normal.
Laboratory findings such as elevated IgE levels and the presence of thyroid peroxidase (TPO) antibodies can offer important clues that a patient’s urticaria is likely autoimmune in nature. However, correcting underlying thyroid issues does not always resolve the hives—the presence of autoantibodies simply signals an underlying dysregulation of the immune system.
The role of gut health in triggering or sustaining immune responses that drive urticaria was also discussed. While the science is still evolving, there’s a growing recognition that things like leaky gut and exposure to food or bacterial particles may act as chronic irritants, further fueling autoimmunity. This is an area where further exploration and a multidisciplinary approach can be helpful.
Emerging therapies are now changing the outlook for sufferers of chronic urticaria, particularly those who do not respond to traditional treatments. Medications like Xolair (which acts as a "sponge" for IgE antibodies), Dupixent (which blocks certain interleukins involved in inflammation), and the new oral agent Rapsodo offer hope to patients with stubborn or severe disease, delivering targeted relief with fewer side effects.
The current recommended treatment strategy is to start with high, uptitrated doses of non-sedating antihistamines like Allegra and Claritin. Adjunctive therapies, including low-dose naltrexone (LDN), can provide additional benefit in difficult cases thanks to their anti-inflammatory properties. Thanks to new medications and a better understanding of the immune mechanisms at play, we can offer patients much more than a temporary fix—we can give them real, lasting relief.
To sum it up, if you or someone you love is dealing with hives that just won’t go away, don’t lose hope. We now know that many chronic cases may be connected to autoimmune processes rather than a simple allergy, and today we have more treatment options than ever before. If symptoms persist, it is worth taking a closer look, getting the right evaluation, and working with a knowledgeable provider like Dr. Joni Sago to find the best path forward. Stay informed, keep asking questions, and remember that as science continues to advance, so do our options for helping patients find relief.
Stay educated. Stay healthy.
Till next week.
