Bringing Hives Back to Dermatology
I can still remember my attending telling me, “Hives are the bane of the dermatologist’s existence,” as we were struggling to control hive patients with antihistamines and resorting to immunosuppressants like methotrexate to offer relief. Back when I was training, I agreed with his sentiment, but my opinion has evolved over time as therapies for hives have improved. Now I feel like a wizard of hives!
If you’ve ever had hives or know someone who has, the first thought anyone has is, “What am I allergic to?” While it’s true that acute allergic reactions can cause hives, most hives cases are idiopathic, meaning we don’t know the cause or should I say, the trigger. We do have a grasp on what’s happening with the immune system driving urticaria but the actual “Why did they start in the first place?” is often left unanswered. It’s human nature, right? We need to know the why. But this is one of those Jack Handy life lessons that we just must accept not knowing.
For years, hives, also known as urticaria, were viewed through an allergy-first lens, which led many to equate hives with allergy and then subsequent referrals to an allergist, shifting away from dermatology. This trend was reinforced when omalizumab came to the market and many dermatologists shied away from prescribing due to fears over side effects like anaphylaxis and turfed hive patients back to our allergy colleagues. Then add on the trend for elimination diets as the cure-all for all skin issues and anecdotal reports, especially on social media, of hive resolutions or improvement and—BOOM. Allergy evaluations became the first on the evaluation train, and dermatology was the runner up and often last place. The unintended consequence was patient frustration over not finding a direct cause and feeding the misconception that an allergy was the ultimate answer to hives.
If you think about it, urticaria truly illustrates the sheer power of the immune system in real time. When the main culprit, mast cells, burst and release histamine, they cause the wheals and itch on the skin. As a broad term, urticaria looks similar clinically, but there are many different types. It’s important to highlight that we categorize hives as acute or chronic, based on how long they have been present. Acute falls into a timeframe of less than 6 weeks, while chronic is longer than 6 weeks. It’s acute urticaria that may be the result of an allergy due to a food or medication or a reaction to a virus. An allergy evaluation might be useful with acute urticaria to help confirm or discover a potential cause. Once you enter the realm of going beyond 6 weeks, then you have chronic spontaneous urticaria or CSU. This is where we typically cannot find a cause and allergy referrals are of little benefit.
The goal here is not to disparage my allergy colleagues but to change the narrative from hives thought of as an allergy alone. Now it’s not usual for a hive patient to have environmental or contact allergies as well, but that doesn’t necessarily mean that they are clinically relevant to the hives themselves. They are simply united by a dysregulated immune system that can present with several different conditions like allergies, hives, asthma or atopic dermatitis. And unfortunately patients may have one, a few or all of those conditions.
So, yes, urticaria is a skin condition that dermatologists need to reclaim and take the lead on management. It goes without saying that we are experts in disease recognition and can distinguish urticaria from mimickers. We also have an understanding of disease severity and burden. And no disrespect to my allergy colleagues, but we need to break the cycle of automatically referring all urticaria patients to allergy. We also need broader education for the public and a shift in mindset from, “What am I allergic to?” to “How do we control my chronic hives?”
The biggest breakthrough in hives is not finding a trigger—it may be recognizing that for many patients there isn’t one to find. Once we accept that, we can focus on what matters most: controlling the disease and restoring quality of life.
Trotter’s Take: Dermatologists need to take back hives and reclaim it as a skin condition that we are experts in treating.
Still wanting answers and not triggers? Then continue the conversation with my podcast on hives with Dr. Walter Liszewski.
