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Dr. Zain Husain, MD with Heather and Courtney, breaks down hives (urticaria) from “inside and out,” explaining that hives are a common inflammatory skin reaction driven by histamine release that causes leaky blood vessels, swelling, and itch. They review typical features (raised pink welts that move and usually resolve within 24 hours) and less common presentations like bullous urticaria and urticarial vasculitis, noting they saw unusual hives during COVID. The episode covers triggers including foods (shellfish, nuts), medications (including NSAIDs like ibuprofen/naproxen), and infections (viral, bacterial, sometimes parasitic), and clarifies hives are not always allergic or contagious. They discuss when hives become serious (angioedema/airway symptoms, systemic concerns), first-line treatment with antihistamines (including higher dosing), limited steroid benefit, and newer options like Xolair, Dupixent, and the BTK inhibitor Rapsodo, plus EpiPen use for anaphylaxis risk and practical tips like photos, symptom diaries, trigger avoidance, and gentle skincare.
00:00 COVID Hives Surprise
00:14 Show Intro And Setup
00:40 What Are Hives
01:26 Urticaria Types And Clues
02:56 Common Triggers Explained
05:08 When Hives Are Serious
07:11 First Line Treatments
09:29 Biologics and EpiPen
11:40 Skincare And Tracking Flares
15:31 Myths And When To See Derm
17:27 Wrap Up And Takeaways
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
[00:00:00] Speaker: what I found interesting during the pandemic with like, with these patients with COVID, um, a lot of them developed hives and strange presentations of them. So that's something that I kind of kept seeing in my clinic over and over again.
Real skin, real science, real confidence with Dr. Zane Hussein. Welcome to.
[00:00:21] Speaker: Welcome to Skin Side Out. I'm your host, Dr. Zane, with Heather and Courtney. So today we're talking all about hives from the inside and out. Have you ever randomly broken out and welts and just didn't know why? Itchy, uncomfortable. So this is a condition that's super common, kind of confusing. So we'll delve right into it. So Heather, what are hives?
[00:00:42] Speaker 2: Hives are an inflammatory response to something.
It could be from. Um, an actual allergy. It could be, um, an infection. It could just be, um, like a physical trauma, cold heat exposure, lots of different things. But what happens is you get this inflammatory response and then, um, your body releases histamine, which actually causes your, um, blood vessels to leak a little bit of fluid, and then you get the swelling in the skin.
[00:01:14] Speaker: Got
[00:01:14] Speaker 2: it. And usually they're itchy.
[00:01:15] Speaker: Yeah. So we see this in response to many different things, often from the environment. Sometimes endogenous, like when we're taking like a medication. What is the scientific term for hives, Courtney, what do we call this in our clinic?
[00:01:30] Speaker 4: Urticaria and can you
[00:01:32] Speaker: say that again?
[00:01:33] Speaker 4: Urticaria. URTI know. Um, and sometimes if they are idiopathic, meaning that there is no, um, reason that these hives are occurring, um, you might hear something like, um. Chronic spontaneous urticaria, um, like I said, idiopathic. So it, there are different triggers for, for hives that we'll get into.
[00:01:55] Speaker 2: Yeah, usually they're raised little pink welts, like you mentioned.
Um, they can move around on the body. Oftentimes they're very quick to resolve, so most urticaria will last less than 24 hours. But there are some cases where they can last longer.
[00:02:14] Speaker: I mean, the transient nature is definitely something that's a hallmark feature of this condition. Um, and you can have some different presentations of urticaria.
So there are sometimes instances where we have hives that really have so much inflammation and fluid where you get blisters. So like a bolus urticaria, sometimes we see almost like bruised, like lesions within it. So it could be like a, an urticaria vasculitis, which can kind of, you know, head us down a different direction treatment.
But there are a variety of different, um, you know, ways that this can present. We talked a little bit about the triggers, so let's dive in a little bit more. Um, so let's talk about allergic triggers. What are the common ones that we see?
[00:03:03] Speaker 4: shellfish or nut allergies. So certain food allergies.
Um, I know we talked about a couple episodes back, just how you know, just because you have a rash doesn't always mean it's from food. But in this case, when someone has a true allergic reaction, um, they will have those hives, you know, across their body, usually in the upper. Body presentation. Mm-hmm.
[00:03:22] Speaker: Yeah.
So my daughter has, um, allergies to cashio and pistachio. So that is kind of what we saw visually when we first discovered this. Like she was developing hives, getting red, itchy. So that's something that you definitely want to let your physician know, especially like pediatrician, when you, when you have kids, um, it really can make a difference because, you know, we always want to be careful about something called anaphylaxis, which can be really serious and life threatening.
[00:03:51] Speaker 2: Yeah. We also see allergic triggers, um, from medications. So this is a common one. We do see it very often if you've started the medication recently, however, you can develop that allergic reaction. Anytime, like years after you've been on. 'cause a lot of people will always say, well, I've been on the same medication for years.
Mm-hmm. It doesn't matter unfortunately. Um, one surprising, one that I think most people don't know about is NSAIDs. Um, so like ibuprofen is a common one that can cause hives. Naproxen is another example of an nsaid.
[00:04:25] Speaker: What about infectious agents? I think that that is a very common one as well.
So what are the types of infections that we typically see hives associated with?
[00:04:34] Speaker 2: usually viral infections are very common. sometimes parasitic. But not as often.
[00:04:40] Speaker: Yeah. And even bacterial infections can lead to hives, so it's like a response to something that's foreign. So, um, you know, you could be reacting to a lot of different things.
Um, what I found interesting during the pandemic with like, with these patients with COVID, um, a lot of them developed hives and strange presentations of them. So that's something that I kind of kept seeing in my clinic over and over again.
[00:05:05] Speaker 2: Mm-hmm. And the vasculitis. Mm-hmm.
[00:05:06] Speaker: Yeah. Okay. So are most cases of hives actually dangerous?
[00:05:13] Speaker 4: No. No, but they're frustrating. Yeah.
[00:05:17] Speaker: Um, so, you know, that's a really key point. Like, you know, hives can be distressing, but oftentimes. You know, it can just burn out on its own. It can go away. Um, and aside from being itchy and, you know, sometimes visually unappealing, um, they typically don't cause too much of an issue.
[00:05:38] Speaker 2: Mm-hmm.
[00:05:39] Speaker: But it can be really annoying and it can impair your lifestyle as well. Um, people do get self-conscious of these hives that develop. Um, so. What we want to do is educate our patients about what they are and what triggers, um, they can identify and how we can treat it. So we'll dive into a little bit of that later, but when are hives actually serious?
[00:05:59] Speaker 2: When there's angioedema involved, which is, explain
[00:06:03] Speaker: what that is. Yeah.
[00:06:03] Speaker 2: Yeah. So it's swelling that you can get a lot deeper in the tissues. So especially around the face and the neck, it can cause like swelling of the tongue. It can, um, cause difficulties breathing. So very serious things, obviously.
[00:06:19] Speaker: Mm-hmm. what else? Anything else that you would be very concerned about with urticaria?
[00:06:26] Speaker 2: if it's lasting longer than 24 hours,
[00:06:30] Speaker: well, I mean, even if it's lasting longer than 24 hours, um, that's not really necessarily something dangerous. Yeah. But, um, I really, you know, do, get concerned, um, you know, like you said with any airway involvement with angioedema, but also, um, you know, making sure that there's else nothing else going on systemically.
[00:06:53] Speaker 2: Yeah.
[00:06:53] Speaker: Um. You know, sometimes you can develop strange rashes, um, in response to certain metabolic disorders, cancer. Um, so it's always good to get a full workup, especially if you don't know the origin, um, if you have any other symptoms associated with it. So that's something always, um, important to look into.
So now that you've developed hives, how do we treat this? So, the way that I think about it is we kind of classify hives into acute. And chronic, and typically we define that time period as under six weeks or greater than six weeks. So regardless of how long it's been going on, what is our first line therapy
[00:07:36] Speaker 2: antihistamines?
Um, so most commonly people start with over the counter. So like, Zyrtec, Claritin, Allegra, Zal. Um, there have been some studies showing that. Xal, which is Levocetirizine and Zyrtec, which is cetirizine, have been, um, a little bit more superior. And the nice thing is you can do up to like four times a day.
Mm-hmm. Um, especially with the Zelle.
[00:08:00] Speaker 4: Yeah. People are always shocked by that.
[00:08:02] Speaker 2: Mm-hmm. That they can do that. They're like, what? It's a 24 hour
What
[00:08:06] Speaker: about when we get the calls from the pharmacist?
[00:08:08] Speaker 4: Yeah,
[00:08:08] Speaker 2: yeah, yeah, yeah. But
[00:08:09] Speaker 4: you can do it safely up to four times a day.
[00:08:12] Speaker 2: Yeah. And then there's Benadryl, which I think a lot of people reach too.
Mm-hmm. Especially if they're having trouble sleeping. There is a prescription antihistamine. Um, a couple, um, hydroxyzine is very common one. Um, we also use doxepin for helping with hives, but, um, hydroxyzine doesn't. Necessarily like target the source of the hives. It kind of just makes you very drowsy too.
Um, but for people who are like really trouble or having a lot of trouble sleeping mm-hmm. It makes a big difference.
[00:08:45] Speaker: Yeah.
[00:08:46] Speaker 4: Yeah. They use hydroxyzine for anxiety too. Mm-hmm. And I feel like it's like, yeah. How can you be anxious when you're just sleepy? Just puts you to sleep.
[00:08:53] Speaker 2: Yeah.
[00:08:54] Speaker: do we use steroids for hives?
[00:08:57] Speaker 2: Not really. Mm-hmm. Um, maybe in desperate need.
[00:09:02] Speaker: Mm-hmm.
[00:09:02] Speaker 2: But, um, they haven't really been shown to be very helpful.
[00:09:07] Speaker: Yeah. I try to avoid steroids, especially systemic steroids because I've seen this phenomenon where the hives, um, it kind of gets hardened, like mm-hmm. You kind of get a slight suppression and then it kind of comes back with a rebound and it's.
Not really as effective as subsequent, um, you know, treatments with steroids. Mm-hmm. So, um, I tend to avoid them. Um, so luckily, um, we have some new treatments out there. Um. You know, let's elaborate on some of those. So, so let's talk about some biologics.
[00:09:39] Speaker 2: Yeah. There are a couple different options. Xolair is probably, um, the tried and true mm-hmm.
Treatment for, um, urticaria, especially once we get into classifying it as chronic, spontaneous urticaria. So meaning like chronic, so more than six weeks, um, spontaneous, or I guess another name would be like idiopathic. So you don't really have a known cause. Xolair is kind of tricky. Um, the injections have to be done in the office.
There's a little bit of monitoring that you have to do, It's kind of difficult for a lot of patients. Um, the next one that came on the market and got approved for, um, CSU was Dupixent or Dupilumab. Mm-hmm. it does work. I think it works really well, but we're also seeing some really good success with a newer one called Rapsodo.
Mm-hmm. Which, um, works very, very differently than the other two. And this one is a BTK inhibitor, which is a. Bruin tyrosine kinase inhibitor, which is really meant to focus on the true source of what's contributing to the urticaria or the hives from forming. And, um, it works really well. There are some side effects.
Very minimal though. Um, I think people are very nervous about like the bleeding side effect. Usually though it's like. Bruising. Mm-hmm. Um, it's not like, like they didn't see any brain bleeds or GI bleeds or anything with, um, the trials, but people kind of freak out when they see bleeding as a side effect.
[00:11:08] Speaker: Yep.
[00:11:08] Speaker 2: But obviously if you're on like a blood thinner, you, you know, it's up to your, you and your, um, dermatology provider to decide what's best.
[00:11:18] Speaker: Got it. And then also, like for patients who have urticaria associated with potential anaphylaxis. You should always carry an EpiPen. Mm-hmm. Um, because that can be life threatening.
So just always have that on hand and be prepared and just be very cautious. Um, especially when avoiding triggers. I think that's the key thing.
[00:11:39] Speaker 4: Mm-hmm.
[00:11:40] Speaker: All right, so let's talk about how this translates into skincare and what we counsel our patients to use on their skin, given that they get hives. So Courtney, what do you recommend to your patients?
[00:11:53] Speaker 4: Um, well, I think first thing, if someone. Thinks that they have hives because of the nature of hives about being so transient. I think it's always a really good idea to take a picture of your rash. I think it's really frustrating for both patients and providers when someone comes in and they're like, well, I have this rash, and it comes up sometimes, but like, it's not present today, but I had it last night.
So I think like the most helpful thing is just, taking pictures is really incredibly helpful for your provider to kind of take a look and see what they're looking for. Those like wheels and, mm-hmm. The, um, the ness of them, the distribution, all of those things. Um, but separate of that, like keeping, you know, also like a symptom diary can be helpful at home.
Um, like certain triggers or if you flare up one day thinking, okay, like writing down, this is what I ate this day, this is what I came into contact. Um, things like that just might. You find your flares more easily so that you can avoid them in the future. and then obviously just all of your sensitive skin, you know, skincare that we normally recommend with any kind of, um, sensitive patients, eczema patients, um, you know, hot showers that we talk about, probably every other podcast, but, um, fragrances and then, um, cool English lotions, things like that.
So just being mindful.
[00:13:04] Speaker 2: There are also some, um, specific types of urticaria that. May warrant certain things, so like cold or heat induced urticaria, um, pressure induced urticaria. So these are things that obviously are being triggered by certain things. So like, um, c cold induced urticaria is very common.
Um, usually it starts with the cold exposure, but then it actually gets worse as your body warms back up. and so, you know, trying to avoid. Those drastic changes in your environment. And then pressure urticaria. Um, we can see that a lot with like, like waistband, like tight pants for instance. Um, usually that takes a little bit longer to present, um, and then also takes a little bit longer to kind of fade, but just trying to avoid.
Those things like Courtney was mentioning, like trying to figure out what are your triggers.
[00:13:56] Speaker: Another thing that we haven't discussed yet is something called dermato graph.
[00:14:01] Speaker 2: Yeah.
[00:14:01] Speaker: So this is a condition where physical light trauma to the skin can elicit these hive like lesions. So, you know, typically we, I use the.
Back of a cotton tip applicator and just kind of stroke it along someone's skin, and then we wait. And then with that stimulation, those mast cells release histamine and cause this essential hive in that distribution. And with Dermato RAFs, that is something that we can use as a tool on our physical exam, especially if they don't have hives present.
Um, I know Courtney mentioned taking photographs. Not everyone does that, and sometimes they're just very transient, so it's another, you know, physical exam finding that we see. What is it called? Do you know what it's called?
[00:14:50] Speaker 2: Um, Darius. Yeah. Dairy air sign.
[00:14:52] Speaker: Sign. Yep. So something
[00:14:54] Speaker 2: that I was, I thought you were asking like what the term is called.
I was like, dermatographic. Me
[00:14:58] Speaker 4: too. That's why I thought
[00:14:59] Speaker: no, sorry, just posing you. No, it's fine. anything else that you would recommend for, um, or urticaria patients? It's from a lifestyle standpoint, besides trigger avoidance and gentle skincare.
[00:15:18] Speaker 2: This is a tricky question.
[00:15:20] Speaker: Mm-hmm.
[00:15:22] Speaker 2: Do you have anything?
[00:15:23] Speaker: No.
[00:15:24] Speaker 2: Yeah, I can't think of anything. Yeah, I think the diary's really helpful.
[00:15:28] Speaker: Okay.
[00:15:28] Speaker 2: Or photos.
[00:15:29] Speaker: So let's go some through. Some like true and falses. Okay. So urticaria or hives are always an allergy.
[00:15:39] Speaker 2: No. False. False.
[00:15:41] Speaker: Bingo. You must figure out the trigger.
[00:15:45] Speaker 2: Um, I think it's helpful, but it's not always doable.
[00:15:48] Speaker: Yeah.
[00:15:48] Speaker 4: Like idiopathic there.
[00:15:50] Speaker: Yeah.
[00:15:50] Speaker 4: Just is no trigger.
[00:15:51] Speaker 2: Just mm-hmm. Half of that is, and you can do like, um, lab tests and stuff like that to rule out other things, but
[00:15:58] Speaker: Yeah, half the time you don't know what's causing it.
[00:15:59] Speaker 2: Yeah.
[00:16:00] Speaker: Mm-hmm. And is urticaria contagious? Can you spread it? No. Can you give to someone?
[00:16:08] Speaker 2: No.
Okay,
[00:16:09] Speaker: cool. When should we see, um, you know, your board certified dermatologist or their team?
[00:16:15] Speaker 2: I think it's definitely important to see them if your hives are lasting longer than six weeks. Mm-hmm. So the chronic urticaria, um, and especially if you feel like you've tried something over the counter that hasn't helped.
[00:16:28] Speaker: Yeah.
[00:16:28] Speaker 2: Or if you're miserable, don't feel like you have to wait six weeks.
[00:16:31] Speaker: Absolutely.
[00:16:32] Speaker 4: Yeah. Most times if you know, you do consider those biologic options, they are going to want patients to try and fail the antihistamine. So it's always a good place to start and a safe. Place to start, I think, um, with something like a Zyrtec or Allegra, and even if you just start it once or twice a day, um, that's just what they're looking for is for you to try it.
[00:16:52] Speaker: You can also be co-managed with your allergist too. Um, you know, sometimes we use other medications, leukotriene inhibitors such as mantle, lcat, um, chromin, um, and few other potential options. So I often collaborate with my allergy colleagues and hopefully, you know, we can get these patients stabilized. Um, sometimes immunotherapy can be very helpful too with, um, you know, allergy shots.
Um, my daughter and Omni also get those, so that's also helped to reduce not only eczema, but also sometimes the hives that they get. All right. So I think this was a deep dive into hives and now that we know that hives are. Not necessarily harmful. They're very, very common and there are good ways to treat it.
So, you know, if you're suffering with hives and can't get under control with, you know, typical therapies, I think it is a good idea to seek help. Um, it can be very miserable and you know, it really can affect your quality of life, so you don't have to suffer in silence. We can help. Um, if you have any questions, comments, please drop us a line.
We're happy to help you guys out, but in the meantime, we'll see you next time. Skin side
[00:18:08] Speaker 3: out.