Urticaria and angioedema are more than just itchy skin rashes. For many people, they’re sudden, scary, and sometimes life-threatening. You might wake up with raised, red welts all over your arms, or notice your lips swelling without warning. If you’ve had this happen more than once, you’re not alone - about 20% of people will experience hives at some point in their life. But when those hives stick around for months or years, or when the swelling goes deeper than the skin, it’s time to understand what’s really going on - and how to treat it properly.

What’s the Difference Between Urticaria and Angioedema?

Urticaria, commonly called hives, shows up as red, itchy, raised bumps on the skin. They come and go, often fading within hours. Angioedema is different - it’s swelling beneath the skin, usually around the eyes, lips, tongue, throat, hands, or feet. It doesn’t always itch. Sometimes, it just feels tight or painful. The two often happen together, but they can also occur alone.

Here’s the key: not all swelling is the same. Most hives and angioedema are caused by histamine - a chemical released by mast cells in your immune system. But about 20% of angioedema cases are caused by something else: bradykinin. This is important because antihistamines won’t help bradykinin-driven swelling. If your lips swell after taking an ACE inhibitor for blood pressure, that’s bradykinin. And giving you more antihistamines won’t fix it.

Acute vs. Chronic: How Long Do Symptoms Last?

Doctors divide these conditions by time. If your hives or swelling last less than six weeks, it’s acute. More than six weeks? That’s chronic. Acute cases often have clear triggers: a new antibiotic, shellfish, a bee sting, or even stress. Chronic cases are trickier. In fact, 75-80% of chronic hives have no obvious cause. This is called chronic spontaneous urticaria (CSU). The rest are triggered by things like pressure, cold, heat, or exercise - known as inducible urticaria.

Most acute cases clear up on their own within a day or two. But chronic hives can drag on for years. The good news? About 65-75% of people with chronic hives will see their symptoms fade completely within five years.

First-Line Treatment: Antihistamines Are the Foundation

For both acute and chronic hives, non-sedating antihistamines are the first and most important step. These include cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra), and desloratadine (Clarinex). They block histamine, the main driver of itching and swelling.

But here’s what most people don’t know: the standard dose often isn’t enough. For chronic hives, guidelines from the British Society for Allergy and Clinical Immunology (BSACI) and the NHS recommend increasing the dose up to four times the usual amount. That means:

• Cetirizine: 10mg → up to 40mg daily
• Fexofenadine: 180mg → up to 540mg daily (split into 360mg morning, 180mg evening)
• Loratadine: 10mg → up to 40mg daily

Studies show that at standard doses, antihistamines work for about 50-60% of people. At higher doses, that jumps to 70-80%. Many patients feel relief only after increasing their dose - not because the drug isn’t working, but because they weren’t taking enough.

When Antihistamines Aren’t Enough: What Comes Next?

If you’re still breaking out after four weeks of high-dose antihistamines, it’s time to add something else. The next step isn’t steroids - it’s adding another antihistamine. Some doctors combine an H1 blocker (like cetirizine) with an H2 blocker (like famotidine or ranitidine). This dual approach can help when histamine is still active despite H1 blockade.

Another option is montelukast (Singulair), a leukotriene receptor antagonist usually used for asthma. It’s not a first-line choice, but for people whose hives flare with NSAIDs like ibuprofen, it can help. One study showed that adding montelukast improved symptoms in about 30% of non-responders.

If none of that works, you may need biologic therapy. Omalizumab (Xolair) is an injectable medication that targets IgE, the antibody involved in allergic reactions. It’s approved for chronic spontaneous urticaria that doesn’t respond to antihistamines. Around 60-70% of patients see a major improvement within weeks. But it’s expensive - about £1,200 per month in the UK - and only available through specialist clinics.

Angioedema: Don’t Treat It Like Hives

This is where things get dangerous. If you have angioedema without hives - especially if there’s no itching - you might have bradykinin-mediated angioedema. This is not an allergy. It’s not histamine-driven. Giving you antihistamines or steroids won’t help. And it can be deadly if the swelling blocks your airway.

There are two main types:

• ACE inhibitor-induced: Caused by blood pressure meds like lisinopril or enalapril. Stopping the drug is the only cure. Swelling usually fades within 3-4 months.
• Hereditary angioedema (HAE): Rare, genetic, and caused by low C1 inhibitor levels. Requires specific drugs like icatibant or C1 esterase inhibitor concentrate.

For ACE inhibitor angioedema, the rule is simple: stop the drug immediately. Don’t switch to another ACE inhibitor. Even ARBs (like losartan) carry a 10% risk of triggering the same reaction. If you need blood pressure control after this, calcium channel blockers or diuretics are safer options.

For HAE, you need to see a specialist. Diagnosis starts with a blood test for C4 levels - low C4 is a red flag. If confirmed, you’ll need long-term prevention and emergency treatment plans.

When to Go to the Emergency Room

Most hives and even angioedema can be managed at home. But if you have any of these signs, call emergency services or go to the ER immediately:

• Difficulty breathing or wheezing
• Swelling of the tongue or throat
• Drooling or trouble swallowing
• Stridor (a high-pitched sound when breathing)
• Feeling like your airway is closing

For these cases, epinephrine (adrenaline) is the only life-saving treatment. It’s given as an injection - either in the thigh (EpiPen) or by a doctor. Antihistamines and steroids won’t stop airway swelling from bradykinin. But epinephrine can buy you time until you get to the hospital.

What to Avoid

Some common triggers make hives and angioedema worse - even if they don’t cause them.

• NSAIDs: Ibuprofen, naproxen, diclofenac - these can trigger or worsen hives in 20-30% of chronic cases.
• Alcohol: Can worsen itching and swelling.
• ACE inhibitors and Entresto: Never restart these if you’ve had angioedema.
• DPP4 inhibitors (gliptins): Diabetes drugs like sitagliptin can rarely cause angioedema.
• Stress: Doesn’t cause hives, but can make them flare.

Also, avoid long-term steroid use. Prednisone might help a severe acute flare, but using it for more than 10 days causes serious side effects - weight gain, bone loss, high blood sugar, mood swings. It doesn’t fix the root problem. Use it only for emergencies, and only under medical supervision.

Living With Chronic Hives

Chronic hives aren’t just a skin problem. They affect sleep, mood, work, and relationships. Many people feel anxious about the next flare-up. The good news: you can manage it.

Once your symptoms are under control for several months, you can start weaning off antihistamines. Reduce by one tablet every 6-8 weeks. If symptoms return, go back to the last dose that worked. Don’t rush the process.

Keep a symptom diary. Note what you ate, what meds you took, how much stress you had, and when the hives appeared. This helps your doctor spot patterns - even if they’re not obvious at first.

And remember: you’re not broken. Chronic hives are not your fault. They’re not contagious. And they’re not a sign of poor hygiene or diet. They’re a medical condition - one that’s treatable, even if it takes time.

Special Cases: Pregnancy and Breastfeeding

If you’re pregnant or breastfeeding, you still need treatment - but you need safe options. Cetirizine and loratadine are considered low-risk during pregnancy and breastfeeding. Avoid high-dose regimens unless absolutely necessary. Always talk to your doctor before changing anything.

For pregnant women with chronic hives, the goal is to use the lowest effective dose. Many women find their symptoms improve during pregnancy. Others don’t. Either way, you don’t have to suffer.

What Tests Do You Really Need?

Most people with acute hives don’t need blood tests. If you’ve had hives for less than six weeks and there’s a clear trigger (like a new medicine or food), testing isn’t helpful.

For chronic cases, doctors may check:

• Thyroid function (TSH) - up to 30% of chronic hives patients have autoimmune thyroid disease
• C3 and C4 levels - to screen for hereditary angioedema
• Complete blood count (CBC) - to rule out underlying infection or inflammation

But don’t expect a miracle test. In most cases, the diagnosis is clinical - based on your history and symptoms, not lab results.

Future Treatments on the Horizon

Omalizumab is the current gold standard for treatment-resistant chronic hives. But new drugs are coming. Lupuzor, litifilimab, and other biologics targeting different parts of the immune system are in clinical trials. Some may offer oral options instead of injections.

Research is also looking at gut health, microbiome changes, and the role of chronic infections. While nothing is proven yet, these areas may lead to better long-term management.

For now, the best approach remains simple: identify the type, use the right dose of antihistamines, avoid triggers, and know when to seek emergency help.