Urticaria: Symptoms, Types, Causes and Treatment

Urticaria, more commonly known as hives, is a frequent and often distressing skin condition that affects up to one in five people at some point in their lives. Characterized by itchy, red welts and sometimes deeper swelling (angioedema), urticaria can range from a brief nuisance to a chronic, life-altering disease. Understanding its symptoms, types, causes, and modern treatment options is essential for patients and healthcare providers alike. In this article, we provide an in-depth, evidence-based exploration of urticaria, synthesizing current research and expert guidelines.

Symptoms of Urticaria

When urticaria strikes, the symptoms are usually sudden and can be intensely uncomfortable. Recognizing these symptoms quickly can help individuals seek the right care and avoid unnecessary complications. While the skin signs are the most obvious, urticaria can sometimes involve deeper tissues or even systemic symptoms, making awareness crucial.

Symptom	Description	Duration/Pattern	Source(s)
Wheals	Raised, red or skin-colored welts; often itchy, can sting or burn; may have a pale center	Typically fade within hours (2–3h); migrate across skin	1,3,5,6
Angioedema	Deeper swelling, often in eyelids, lips, tongue, or throat; may be painful or burning	Can last longer than wheals; risk of airway involvement	1,3,5,6
Pruritus	Intense itching, sometimes severe	Accompanies wheals	2,3,5
Non-skin Symptoms	Fever, joint/muscle pain, malaise (mainly in chronic forms)	Episodic; linked to active disease	4

Table 1: Key Symptoms

Wheals: The Hallmark of Urticaria

Wheals, or hives, are the most recognizable symptom. They are raised, red or skin-colored plaques that appear suddenly and are intensely itchy. These lesions can range from a few millimeters to several centimeters, sometimes merging to form large patches. Wheals are transient—each typically disappears within hours, leaving the skin looking normal again. The pattern can be migratory, with new lesions appearing as old ones resolve, often leading to a “moving target” for the patient 1 3 5 6.

Angioedema: When Swelling Runs Deep

In some cases, urticaria causes angioedema—a deeper swelling of the skin and mucous membranes. This most often affects the eyelids, lips, tongue, or throat. Angioedema can be painful or cause burning sensations, and in severe cases, it can compromise the airway, making it a potential medical emergency 1 3 5 6. Unlike wheals, angioedema can last longer—sometimes up to 72 hours.

Itching and Discomfort

Pruritus (itchiness) is almost universal, and can be severe enough to disrupt daily activities and sleep 2 3 5. Some people experience stinging or burning sensations as well.

Non-Skin-Related Symptoms

Especially in chronic spontaneous urticaria, patients may also report symptoms like fever, joint or muscle pain, and malaise. These are less common but are associated with more active and uncontrolled disease 4.

Types of Urticaria

Urticaria is not a single disease but a spectrum of related disorders. Understanding these types is key to effective management, as each has unique triggers, durations, and responses to therapy.

Type	Definition/Features	Duration/Triggers	Source(s)
Acute Urticaria	Wheals/angioedema lasting ≤6 weeks; often with known trigger	<6 weeks; infections, drugs, food	1,2,3,6
Chronic Spontaneous Urticaria (CSU)	Recurrent wheals/angioedema >6 weeks, no clear trigger	>6 weeks; spontaneous episodes	1,6,7,13
Chronic Inducible Urticaria (CIndU)	Chronic urticaria with definite, identifiable triggers	>6 weeks; physical/environmental stimuli	1,6,7,9
Physical Urticarias	Urticaria triggered by physical factors (cold, pressure, heat, etc.)	After exposure to stimulus	8,9

Table 2: Types of Urticaria

Acute Urticaria

Acute urticaria is the most common form and typically resolves within six weeks. It is often triggered by infections, medications, or foods. The lesions appear suddenly and resolve completely within hours or days. In children, viral infections are a frequent cause, while in adults, medications and foods are more commonly implicated 1 2 3 6.

Chronic Spontaneous Urticaria (CSU)

CSU refers to hives that persist for more than six weeks without an obvious trigger. It is often idiopathic, but recent research suggests that up to half of cases may have an autoimmune basis, with antibodies targeting mast cell receptors or IgE 1 6 7 13. CSU can be particularly debilitating, affecting quality of life and even causing psychiatric distress 1 6.

Chronic Inducible Urticaria (CIndU)

CIndU, sometimes called physical urticaria, involves symptoms triggered by identifiable stimuli—such as pressure, temperature changes, sunlight, exercise, water, or vibration. Each subtype responds to its specific trigger, and management revolves around trigger avoidance and tailored therapy 1 6 7 9.

Physical and Special Forms

Physical urticarias include dermographism (hives after stroking or scratching the skin), cold urticaria, heat urticaria, cholinergic urticaria (triggered by sweating or heat), solar urticaria (triggered by sunlight), and others. There are also rare forms like urticarial vasculitis, which has distinct features and requires special attention 8 9.

Causes of Urticaria

The causes of urticaria are diverse, and identifying them can be challenging. In many cases, no cause is found, but understanding possible triggers and mechanisms helps guide treatment and prognosis.

Cause/Mechanism	Details/Examples	Common in Type(s)	Source(s)
Infections	Viral, bacterial (e.g., Helicobacter pylori)	Acute, sometimes chronic	1,2,11,12
Medications	NSAIDs, antibiotics, others	Acute, sometimes chronic	1,2,3
Foods	Nuts, shellfish, eggs, etc.	Acute	1,2,3
Autoimmunity	Autoantibodies to mast cell/IgE	Chronic spontaneous	1,10,13
Physical Stimuli	Pressure, cold, heat, sunlight, vibration	Chronic inducible	1,9
Idiopathic	Unknown cause	Chronic spontaneous	2,3,6

Table 3: Causes of Urticaria

Infections

Acute urticaria is often associated with infections—especially viral infections in children and bacterial infections, such as Helicobacter pylori, in adults. In some cases, successful treatment of the underlying infection leads to resolution of urticaria 1 2 11 12.

Medications and Foods

Common medications that can trigger urticaria include nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, and contrast agents. Foods such as nuts, shellfish, eggs, and certain food additives are also well-known triggers, particularly in acute cases 1 2 3.

Autoimmunity

In chronic spontaneous urticaria, up to 50% of cases are thought to have an autoimmune basis. Here, the immune system produces autoantibodies that activate mast cells, leading to the release of histamine and other mediators. This subgroup tends to have more severe and persistent symptoms 1 10 13.

Physical and Environmental Stimuli

Certain individuals develop urticaria in response to physical factors. Examples include:

• Dermographism: Raised wheals after scratching or pressure.
• Cold urticaria: Triggered by exposure to cold air, water, or objects.
• Cholinergic urticaria: Triggered by heat, exercise, or emotional stress.
• Solar urticaria: Triggered by sunlight.

Accurate identification of these triggers is essential for effective management 1 9.

Idiopathic Urticaria

In many chronic cases, no identifiable cause is found—these are termed “idiopathic.” Despite significant research, the underlying mechanisms remain elusive in a significant proportion of patients 2 3 6.

Treatment of Urticaria

Effective urticaria management aims for complete relief of symptoms. Treatment is guided by the type, severity, and chronicity of urticaria, as well as the patient’s response to previous therapies. Advances in understanding urticaria have led to new, targeted treatments for refractory cases.

Treatment	Use/Indication	Notes/Next Steps	Source(s)
Trigger Avoidance	All types, if trigger known	Essential first step	2,3
2nd-generation H1 Antihistamines	First-line in all forms	Can increase dose for chronic cases	1,2,3,6
1st-generation H1 Antihistamines	Adjunct; for sleep disruption	Sedating; limited use	2,3,8
H2 Antihistamines	Adjunct in resistant cases	Additive to H1 blockers	2,3,8
Leukotriene Receptor Antagonists	Adjunct in some cases	Montelukast, etc.	2,3,8
Systemic Corticosteroids	Short-term for severe flares	Not for chronic use	2,3,8
Omalizumab	Antihistamine-refractory CSU	Monoclonal anti-IgE; highly effective	1,2,14,15,16
Cyclosporine	Severe, refractory cases	Immunosuppressive; monitor closely	1,2,14,17
Novel Biologics/Agents	Under investigation	Future therapies	1,14

Table 4: Treatments for Urticaria

General Principles

The cornerstone of urticaria treatment is avoidance of triggering factors, when they can be identified. For many, however, no clear trigger exists, so medication becomes the mainstay 2 3.

Antihistamines: The Mainstay

Second-generation H1 antihistamines are the first-line therapy for most forms of urticaria due to their effectiveness and favorable safety profile. For chronic cases, doses can be increased up to fourfold if symptoms persist. First-generation (sedating) antihistamines may be added at night if itching disrupts sleep, but they are not recommended for routine daytime use due to sedation and anticholinergic effects 1 2 3 6 8.

Adjunctive Therapies

• H2 antihistamines (e.g., ranitidine) and leukotriene receptor antagonists (e.g., montelukast) can be considered as add-ons in resistant cases.
• Short courses of systemic corticosteroids may be used for severe flares or angioedema but should be avoided for long-term management due to side effects 2 3 8.

Advanced and Targeted Therapies

• Omalizumab: A monoclonal anti-IgE antibody, omalizumab is highly effective for patients with CSU who do not respond to high-dose antihistamines. Real-world data confirm its efficacy and safety, with most patients achieving partial or complete symptom control 1 2 14 15 16. Dose adjustments may be necessary for optimal results 16.
• Cyclosporine: An immunosuppressant used in severe, refractory cases. It requires close monitoring due to potential side effects 1 2 14 17.
• Novel Biologics and Agents: Therapies targeting new pathways—such as ligelizumab, dupilumab, and others—are under investigation and may represent the future of urticaria treatment 1 14.

Special Considerations

• Chronic Inducible Urticaria: Management focuses on identifying and avoiding triggers. Provocation testing can help confirm the diagnosis. Some patients benefit from physical desensitization or phototherapy 9.
• Non-skin Symptoms: In CSU with systemic symptoms, a multidisciplinary approach may be needed 4.

Conclusion

Urticaria is a common but complex condition with a wide spectrum of causes, types, and clinical presentations. While most cases are acute and resolve spontaneously, chronic forms can be profoundly disruptive. Advances in understanding the disease have led to more targeted and effective treatments, offering hope for those with persistent symptoms.

Summary of Key Points:

• Urticaria presents with itchy, transient wheals and sometimes deeper swelling (angioedema); non-skin symptoms are possible in chronic forms 1 3 4 5 6.
• The condition is classified as acute or chronic (spontaneous or inducible), with physical and special variants 1 6 7 8 9.
• Causes range from infections, medications, foods, and physical stimuli to autoimmunity; many chronic cases remain idiopathic 1 2 3 9 10 13.
• Treatment begins with trigger avoidance and antihistamines, escalating to advanced therapies such as omalizumab or cyclosporine for resistant cases; new biologics are on the horizon 1 2 3 6 14 15 16 17.

For patients and clinicians, understanding the full landscape of urticaria is the first step toward effective management and improved quality of life.