When you have chronic spontaneous urticaria (CSU), your hives may come and go. Or you might have flare-ups almost every day for months or even years. The intense itching can interfere with work, school, or sleep.
There’s no way to know how long you’ll have it, although there is about a 50/50 chance that your hives will go away within a year.
Your doctor probably isn’t sure why you have CSU, either. In 80% to 90% of cases, no clear cause is found. On top of that, you may be among the nearly 50% of people with CSU who also have angioedema, painful or tingly swelling in your throat, lips, and eyelids.
All of these things may make CSU tricky to manage. You and your doctor can try a number of types of medications to ease your symptoms. But there are plenty of other changes that might make a difference, too.
Setting a Treatment Plan
Most people with CSU take medications called antihistamines, and these usually control symptoms. But it’s crucial that you take them consistently, exactly as prescribed, says Jacquelyn Sink, MD, a dermatologist at Northwestern Medicine Regional Medical Group in Chicago. “Erratic, as-needed dosing or inconsistent use of antihistamines may contribute to breakthrough symptoms,” she says.
Even if you don’t take antihistamines, it’s important to follow the treatment plan your doctor recommends as closely as you can. If you don’t, it won’t be effective.
Talk With Your Dermatologist
Let your doctor know if your treatment plan isn’t working, especially when you’ve been following it to the letter. They might be able to make changes to improve your symptoms, says Ohara Aivaz, MD, a dermatologist at Cedars-Sinai Medical Group in Los Angeles.
For instance, if you’re taking an antihistamine, Aivaz says, your doctor can add another that works differently. If you’re still having problems, your doctor might have you take the antihistamine more than once a day. (With certain antihistamines, you can take up to four times the standard dose as needed to control symptoms, Sink says. But don’t change your dosage without talking to your doctor.)
If your symptoms still aren’t better, your doctor may prescribe a less common medication, such as:
- An oral corticosteroid like prednisone
- An H2 blocker like cimetidine (Tagamet), famotidine (Pepcid), or ranitidine (Zantac)
- A tricyclic antidepressant called doxepin (Silenor)
- A leukotriene modifier like montelukast
- An immunosuppressant such as cyclosporine (Gengraf, Neoral, Sandimmune), methotrexate (Rheumatrex, Trexall), mycophenolate (CellCept, Myfortic), or tacrolimus (Astagraft XL, Prograf, Protopic)
- An antibiotic such as dapsone (Aczone)
- A monoclonal antibody called omalizumab (Xolair)
Omalizumab targets immunoglobulin E (IgE), a protein that your immune system makes. It’s FDA-approved for people 12 and older who have CSU that isn’t controlled with antihistamines, Sink says. It’s injected under your skin every 4 weeks, either at your doctor’s office or at home. This is the medication doctors usually prefer, she says, because of effectiveness and safety.
Aivaz recommends adding any of these second-tier medications to the antihistamines you’re already taking, rather than replacing them.
One medical treatment that doesn’t involve drugs is narrow-band ultraviolet light therapy, also known as phototherapy. You stand in a booth “that emits a very specific wavelength of ultraviolet light for a few minutes, twice a week,” Aivaz explains. The UV light can help ease inflammation and relieve itchy skin.
Manage Side Effects
The most common side effect of antihistamines is drowsiness. Because of this, Sink says, it’s important to raise the dose slowly. This helps your doctor find the lowest dose you need to ease your symptoms.
You can also take your antihistamine at bedtime to keep from feeling quite so sleepy during the day, Sink says. This can be especially helpful if you’re taking sedating or first-generation antihistamines like diphenhydramine (Benadryl).
Once your symptoms have been under control for several months, Sink advises slowly tapering your dose (with your doctor’s supervision, of course).
In general, if you can handle the side effects of your medication, it’s best to stay on it. But if it’s seriously affecting your life or your health -- for example, if you’re so groggy that you can’t get anything done at work, or if you’re taking cyclosporine and develop high blood pressure or kidney damage -- you may need to stop taking it. But be sure to talk about it with your doctor first.
Beyond taking medications, one of the best things you can do when it comes to managing CSU is to avoid anything that seems to set off a flare. Sink says some common triggers that can make CSU worse include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin
- Friction or pressure on your skin, particularly from tight clothing, straps, or sitting
- Narcotics (pain medications)
- Lack of sleep
- Certain foods such as eggs, shellfish, or nuts
- Coloring or preservatives used in food, supplements, skin care products, spices, and other products
Home Remedies for CSU
There are plenty of things you can do at home to ease your itchy skin, such as:
- Keep your skin hydrated by slathering on moisturizer throughout the day (fragrance-free is best).
- Put an over-the-counter anti-itch cream such as calamine lotion or hydrocortisone on the affected areas.
- Try not to get overheated.
- Wear loose clothing made of cotton. Make sure it’s not scratchy or tight.
- Use a cool compress or wrap the area with moist bandages.
- Take a cool bath with colloidal oatmeal or baking soda.
- Use only mild soaps.
- Put on sunscreen before heading outside.
Change Your Diet
People with CSU often don’t want to be on medications for months or years, especially because of the side effects and risks, Aivaz says. Diet changes can be helpful. Some doctors recommend a low-pseudoallergen diet.
“Pseudoallergens are substances that induce hypersensitivity reactions that mimic allergic reactions and hives,” she explains. “They include food preservatives and dyes, substances containing histamine, and some fruits, vegetables, and spices.”
The list of foods to avoid on this diet is long but includes:
- Chewing gum and candy
- Spices and herbs, except salt and chives
- Many food colorings
- Smoked meats
- Vegetables such as peas, spinach, and sweet peppers
- Herbal tea
- Dried fruits
Talk to your doctor about whether this diet might be a good option for you to try.
Look Into Complementary Therapies
There is some evidence that other therapies may be helpful in treating the symptoms of CSU.
Acupuncture therapy is a common treatment for CSU in Asia. Many studies have shown that it helps ease chronic itchiness. Acupuncture also has minimal side effects. If you decide to try it, look for a certified acupuncture practitioner. Your doctor may even be able to give you a recommendation.
If stress is a trigger for you, try adding relaxation techniques into your day to help you unwind and calm down. These can include:
- Music and art therapy
- Deep breathing
- Progressive muscle relaxation
- Tai chi
Vitamin D supplements
Some research shows that vitamin D supplements could help CSU. A 2018 review of 17 studies noted that people with CSU were more likely to lack enough vitamin D. It also found that taking a high dose of vitamin D supplements for 4 to 12 weeks may improve CSU symptoms in some people. Talk to your doctor about whether this might work for you.
Sink recommends support groups as a great resource for people with CSU. These can be online discussion boards, social media groups, or local in-person groups. Not only can you connect with others who understand what you’re dealing with, but you can also gather helpful advice and tips on managing your condition.
CSU can be stressful “due to its unpredictable nature, lack of a clearly identifiable trigger, and disruption of work, school, and sleep,” Sink says. The condition may even be life-altering, she says, but CSU is rarely a sign of an underlying medical issue. Most people find ways to manage their symptoms over time. And for many, the symptoms will generally get better on their own.
Photo credit: MesquitaFMS / Getty Images
American Academy of Dermatology: “10 Ways to Get Relief from Chronic Hives.”
UpToDate: “Chronic spontaneous urticaria: Clinical manifestations, diagnosis, pathogenesis, and natural history,” “Chronic spontaneous urticaria: Standard management and patient education,” “Chronic spontaneous urticaria: Treatment of refractory symptoms.”
Mayo Clinic: “Chronic hives,” “Acupuncture,” “Stress management.”
Jacquelyn Sink, MD, FAAD, dermatologist, Northwestern Medicine Regional Medical Group, Chicago.
Ohara Aivaz, MD, dermatologist and internist, Cedars-Sinai Medical Group, Los Angeles.
Mayo Clinic News Network: “Home Remedies: Help with itchy hives,” “Home Remedies: Having chronic hives.”
BMJ Open: “Acupuncture for patients with chronic urticaria: a systematic review protocol,” “Acupuncture for patients with chronic pruritus: protocol of a systematic review and meta-analysis.”
Clinical and Translational Allergy: “Relationship between vitamin D and chronic spontaneous urticaria: a systematic review.”
American College of Allergy, Asthma & Immunology: “Hives.”
National Eczema Society: “Phototherapy.”
Medscape: “What is the role of H2 antihistamines in the treatment of urticaria (hives)?”
Allergy, Asthma & Clinical Immunology: “Leukotriene receptor antagonists for chronic urticaria: a systematic review.”