One of the most frustrating symptoms of chronic spontaneous urticaria (CSU) is undoubtedly the itchy hives that seemingly come out of nowhere.
“It’s called spontaneous because there’s nothing you’re doing to cause the hives to appear,” says Allen Kaplan, MD, a clinical professor of medicine at the Medical University of South Carolina in Charleston. “You could go to bed feeling fine, with no rash whatsoever, and wake up covered with hives.”
Hives from CSU usually last 12 to 24 hours at a time. In the meantime, there are ways to ease the itch. Keep reading to learn how.
What to Do When You Can’t Stop Scratching
With proper treatment from an allergist, dermatologist, or immunologist, plus the tips below, the itchy hives often dissipate.
1. Talk to Your Doctor About Medication
The first-choice treatment for CSU is a daily dose of an over-the-counter or prescription second-generation antihistamine. First-generation antihistamines are not recommended, because they can cause drowsiness and easily interact with other medications, says Dr. Kaplan.
Antihistamines, commonly used for allergies, tamp down the activity of histamine receptors that would otherwise ramp up to produce itchy, red welts on your skin. Almost half of people with CSU who take antihistamines notice an improvement, often within just two or three days, says Kaplan. They work best when taken consistently. Talk to your doctor about the best medication and dose for you. You can consider tapering off the medication once you’ve gone three to six months without breaking out in hives.
If antihistamines don’t take away the itch, says Kaplan, other options include omalizumab, an anti-inflammatory medication that’s delivered by injection every four weeks, and dupilumab, a biologic that helps halt inflammation.
Sometimes, an immunosuppressant medication called cyclosporine is prescribed off label for CSU, but it’s only used when other treatments have failed, says Kaplan. (This medication is used to help people with organ transplants avoid organ rejection.) It’s not a top choice, because it can raise blood pressure levels and interfere with kidney function.
2. Apply a Cool Compress to Your Skin
Run a clean washcloth under cold water, wring out the excess water, and place the cloth on your itchy skin. Leave it in place for about 10 to 20 minutes. This should help lower inflammation in the area, easing the itch. (But don’t do this if cold seems to trigger hives for you.)
3. Don’t Scratch Your Skin
As tempting as it is, try not to scratch the itchy area. It may only cause more irritation, which can worsen the outbreak. Some doctors recommend trimming your fingernails regularly, too, since short nails are less likely to harbor infection-causing bacteria.
4. Rethink Using Pain Relievers
Yes, the itch may hurt, but pain relievers may cause more harm than good. That’s because nonsteroidal anti-inflammatory pain relievers, such as aspirin and ibuprofen, can trigger hives in about 28 percent of people with CSU, possibly because the drug inhibits cyclooxygenase-1, an enzyme involved in inflammation. That begins a chain reaction of immune system events that can lead to hives for some people.
“Generally, it’s best to avoid NSAIDS, but if you know taking it does not affect the urticaria, it’s okay to use,” says Kaplan. If you have CSU along with another condition that causes chronic or occasional pain, ask your doctor about the best pain-relief options for you. For example, acetaminophen should not worsen hives, says Kaplan.
5. Consider Dietary Triggers
CSU isn't usually caused by diet. But if you get hives after eating specific foods, talk to your doctor about the possibility of food allergies.
While a few small studies suggest that following a low-histamine diet — one that restricts foods rich in histamine, such as cheese, chicken, fermented foods, and tuna — can help ease chronic hives, research is inconclusive overall. Discuss any concerns you have with your doctor. They might recommend testing a new dietary strategy for three to four weeks to see if it helps.
6. Try to Reduce Stress
About 1 in 3 people with CSU say stress aggravates the disease. More research is needed, but some scientific evidence suggests stress triggers the release of immune system chemicals that induce itchiness.
That said, Kaplan says it often goes the other way around: Hives often cause stress. “Nothing relieves the stress better than controlling the hives,” he says. If stress about hives is interfering with your ability to work or sleep, consider mental health counseling.
The Takeaway
Chronic spontaneous urticaria can trigger an intense itch that interferes with your quality of life.
Taking both over-the-counter and prescription medications can help keep hives at bay.
Other strategies, such as avoiding NSAIDs and lowering stress levels, can also help ease the itch.
EDITORIAL SOURCES
Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.
Zuberbier T et al. The International EAACI/GA²LEN/EuroGuiDerm/APAAACI Guideline for the Definition, Classification, Diagnosis, and Management of Urticaria. Allergy. March 2022.
Son JH et al. A Histamine-Free Diet Is Helpful for Treatment of Adult Patients With Chronic Spontaneous Urticaria. Annals of Dermatology. April 2018.
Bansal CJ et al. Stress, Pseudoallergens, Autoimmunity, Infection and Inflammation in Chronic Spontaneous Urticaria. Allergy, Asthma & Clinical Immunology. September 11, 2019.
Jon E. Stahlman, MD, has been a practicing allergist for more than 25 years. He is currently the section chief of allergy and immunology at Children’s Healthcare of Atlanta's Scottish Rite campus and the senior physician at The Allergy & Asthma Center in Atlanta. He served as the president of the Georgia Allergy Society, has been named a Castle Connolly Top Doctor, and was listed as a Top Doctor by Atlanta magazine. His research interests include new therapies for asthma and allergic rhinitis as well as the use of computerized monitoring of lung function.
He received his bachelor's and medical degrees from Emory University. He completed his pediatric residency at Boston Children’s Hospital and his fellowship in allergy and clinical immunology at Harvard University’s Boston Children’s Hospital and Brigham and Women’s Hospital. After his training, Dr. Stahlman conducted two years of clinical research at Boston Children’s Hospital and was part of the faculty at Harvard Medical School, where he taught medical students and allergy and immunology fellows.
Stahlman is board-certified and recertified in allergy and clinical immunology. He served as a principal investigator on phase 2 through 4 studies that are responsible for most of the U.S. Food and Drug Administration–approved therapies for allergies and asthma available today.
Outside of the office, he centers his interests around his wife and three daughters, coaching soccer for many years, and his hobbies include cycling and triathlons.
Julie Stewart is an author and editor with more than a decade of experience in health, science, and lifestyle writing. Her articles have appeared online for Men’s Health, Women’s Health, EatingWell, Vice, AARP The Magazine, and Shape.
