Chronic Hives Treatments

Treatment of chronic hives usually includes medicines and lifestyle changes. There is no cure for chronic hives. The goal of treatment is to reduce symptoms and improve quality of life. Doctors will usually follow a stepwise approach to treating chronic hives.^1,2

The cornerstone of treatment is non-drowsy antihistamines. These control symptoms for about half of people with chronic hives. When antihistamines do not control symptoms, doctors will add other medicines.^1-3

What are the goals of treatment for chronic hives?

The goals of chronic hives treatment are to:^1,2

• Relieve symptoms
• Reduce the burden on daily life
• Minimize side effects of medications
• Improve quality of life
• Reduce duration of the disease

Doctors will try to use as much medicine as you need, but as little as possible. They usually do this through a stepwise approach. This means they will increase or decrease your medicines based on how well symptoms are controlled. For chronic hives, the steps follow a sequence such as:^1,2

• Start with normal dosage of non-drowsy antihistamines
• If symptoms are not controlled, increase dosage (up to 2 to 4 times the original dose). Another antihistamine may also be added and increased at this step
• If symptoms are still not controlled, add omalizumab (Xolair®) or a drowsy antihistamine
• If symptoms are still not controlled, add cyclosporine or other anti-inflammatory or immune-suppressing drugs

What drugs are used to treat chronic hives?

H1 antihistamines

H1 antihistamines are the most common drug used to treat chronic hives. There are drowsy (first-generation) and non-drowsy (second-generation) versions. Doctors will start with non-drowsy H1 antihistamines, increasing the dose of a non-drowsy antihistamine up to 2-4 times the original dose, before suggesting drowsy versions.^1,3

All H1 antihistamines work by blocking a protein called the H1 receptor. This prevents histamine from activating the H1 receptor and causing allergy-like symptoms.¹

Examples of non-drowsy H1 antihistamines include:^1,4

• Cetirizine (Zyrtec®)
• Levocetirizine (Xyzal®)
• Fexofenadine (Allegra®)
• Loratadine (Claritin®, Alavert®)
• Desloratadine (Clarinex®)

Examples of drowsy H1 antihistamines include:¹

• Hydroxyzine (Vistaril®)
• Doxepin (Zonalon®), which is an antidepressant with antihistamine properties
• Cyproheptadine (Periactin®)

H2 blockers

Doctors may add H2 blockers if H1 antihistamines do not control symptoms. They work by blocking a protein called the H2 receptor. This may or may not have a beneficial effect on people with chronic hives. Examples of H2 blockers include:^1,5

• Famotidine (Pepcid®)
• Cimetidine (Tagamet HB®)

Leukotriene receptor antagonists

Doctors may add leukotriene receptor antagonists if H1 antihistamines do not control symptoms. These are asthma drugs that may reduce symptoms of chronic hives. They work by blocking the inflammatory action of a body chemical called leukotriene.¹

Examples of leukotriene receptor antagonists include:³

• Montelukast (Singulair®)
• Zafirlukast (Accolate®)

Steroids

Oral steroids like prednisone can reduce swelling, redness, and itching. They should only be used for a short time to control symptoms during an episode. Taking long-term corticosteroids has a higher risk for side effects.^1,6

Biologics

When antihistamines do not control symptoms, your doctor may suggest taking omalizumab (Xolair®). This is a biologic drug that blocks a protein involved in the allergic response, called immunoglobulin E (IgE). It is approved to treat people over age 12 with chronic hives that is not controlled with standard antihistamines. Xolair is given by injection under the skin (subcutaneously) every 4 weeks. About 65 percent of people who do not respond to antihistamines will respond well to omalizumab.^3,7

Immunosuppressants

If symptoms are still not controlled by antihistamines or omalizumab, your doctor may suggest drugs that suppress your immune system. Some options include:^3,7

• Cyclosporine (Gengraf®, Neoral®)
• Tacrolimus (Astagraft XL®, Prograf®, Protopic®)
• Mycophenolate (CellCept®, Myfortic®)
• Methotrexate (Otrexup®, Rasuvo®)

Skin creams

Skin creams, such as topical steroids, may reduce itching and swelling. However, talk to your doctor before using any topical creams. Experts do not suggest routine, long-term use of skin creams, such as topical steroids or antihistamines. Their effects are generally short-term, and they can cause unwanted side effects.^1,2

Other drugs

Doctors may try other therapies if none of the treatments listed above control symptoms. Many of these work by reducing inflammation. These drugs are approved for other conditions, and research is ongoing to determine effectiveness in chronic hives. Examples include:⁷

• Dapsone (Aczone®)
• Sulfasalazine (Azulfidine®)
• Hydroxychloroquine (Plaquenil®)
• Colchicine (Colcrys®, Mitigare®)
• Ligelizumab (QGE031)
• Dupilumab (Dupixent®)
• Benralizumab (Fasenra®)

Many other agents have been reported to treat chronic hives. However, they have major limitations. For example, intravenous immunoglobulin (IVIG) can only be used in specialized centers as a last option.^2,5

What lifestyle changes can help manage chronic hives?

Some studies have shown that certain lifestyle changes can help treat chronic hives. However, evidence for many of these methods is limited. Talk to your doctor before trying any lifestyle changes. They can suggest ways to do them safely.¹

Possible lifestyle changes include:^1,3

• Vitamin D supplementation
• Diet modifications, such as a low-histamine diet
• Relaxation and mindfulness techniques
• Avoiding triggers
• Wearing loose clothing
• Using certain types of soap and soothing skin products