What are the best creams, ointments and antihistamines for urticaria?

Table of Content:
What are hives? | When should I see a doctor? | Do I need a prescription? | Over-the-counter (OTC) creams for hives | OTC antihistamines for hives | Prescription medications for urticaria | FAQ

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What is urticaria (hives)?

Hives, also known as urticaria, are a type of skin reaction that presents as red, itchy welts on the skin. These welts can vary in size and shape and can appear anywhere on the body. 

Urticaria is an immunological disease that can be inducible or spontaneous in nature. Inducible urticaria or hives are often caused by an allergic reaction to substances like food, medication, insect bites, or other irritants. Sometimes, they can also be triggered by stress, infections, temperature variation, or a sign of other underlying health conditions like thyroid disease. Spontaneous urticaria, on the other hand, is idiopathic in nature–without a known trigger or underlying cause.

The itchiness associated with urticaria can be particularly uncomfortable. In most cases, hives are temporary and resolve on their own or with the help of antihistamines, which reduce itching and swelling. However, chronic hives can persist for longer periods, and their cause is often more difficult to identify.

If hives are accompanied by more severe symptoms like difficulty breathing, and abdominal pain medical attention should be sought immediately, as it may indicate a more serious allergic reaction called anaphylaxis¹.

When to see a dermatologist for hives?

Dr. Mohta says you should also consult a dermatologist if your hives cover a large area, spread rapidly, persist for more than a few days, recur frequently, or are accompanied by other symptoms like fever, joint pain, or significant swelling. Chronic hives may indicate an underlying condition. If over-the-counter antihistamines do not relieve symptoms, or if hives significantly interfere with daily activities, a healthcare provider can offer further treatments.

Do I need a prescription for an urticaria treatment cream?

Dr. Mohta says that many cases, urticaria can be managed with over the counter creams. However, if you have chronic hives (which last six weeks or longer) you will probably need a prescription.

How to get prescription medication for hives?

You can a have a photo-consultation with a board-certified dermatologist affiliated with Miiskin, which only costs around $59. Once you submit the photo-consultation, they will send your treatment plan and prescription in less than 2 days.

What is the best cream for urticaria?

Dr. Mohta says that in many instances, when managing hives, the use of topical treatments can help alleviate the itching and discomfort, although oral antihistamines are more commonly recommended as the first line of defense. 

• Calamine lotion: This can help soothe the itching and discomfort caused by hives. It has a cooling effect that can be quite relieving.
• Antihistamine creams or gels: These can help to block the action of histamine (the chemical that causes hive symptoms) directly at the site of the rash. Examples include creams containing diphenhydramine.
• Pramoxine hydrochloride and menthol lotion: Pramoxine hydrochloride has been an FDA-approved anti-itch agent since 1953. Studies have validated its effectiveness in relieving itchiness. These provide a cooling effect and can numb the skin, which helps to relieve itching and irritation. 
• Aloe vera: Pure aloe vera gel can be soothing and has anti-inflammatory properties. It can help calm the skin and reduce redness and itching.
• Hydrocortisone cream: Over-the-counter 1% hydrocortisone cream can reduce inflammation and itching. However, it should be used sparingly, not over a large body area and only for a short period.

What are the best over the counter antihistamines for hives?

Dr. Mohta says that if topical over-the-counter creams and lotions are not enough, antihistamines are first-line treatment for hives due to their effectiveness and relative safety as they help to reduce or block the histamine release that causes the itching, redness, and swelling associated with hives. 

The choice of medication often depends on the severity of the symptoms, the frequency of outbreaks, and the presence of any side effects. It is important for patients to work with their healthcare provider to determine the best medication and dosage for their specific situation. 

Over-the-counter antihistamines for urticaria

• Zyrtec (Cetirizine): A second-generation antihistamine that is less likely to cause drowsiness. It provides 24-hour relief from hives.
• Allegra (Fexofenadine): Also a second-generation antihistamine, known for causing minimal sedation, making it a good choice for those who need to avoid drowsiness.
• Claritin (Loratadine): Another non-sedating, second-generation antihistamine that provides 24-hour relief from the symptoms of hives.

These antihistamines are generally preferred for their lower propensity to cause drowsiness compared to first-generation antihistamines, making them suitable for use during the daytime and for individuals who need to remain alert.

What are the best prescription antihistamines and oral medications for chronic hives?

If you have hives in a wide spread area of your body, your symptoms last longer than six weeks or you do not respond to over the counter antihistamines, there are some prescription medications that your dermatologist can prescribe for the treatment of severe or chronic hives such as prescription antihistamines, H2 Blockers, Leukotriene Receptor Antagonists, Oral corticosteroids, and Xolair (Omalizumab)¹⁰.

Antihistamines for chronic hives (H1 Blockers)

• Xyzal (levocetirizine): A more potent derivative of cetirizine, it’s available by prescription and is effective in treating skin reactions including hives¹¹. 
• Clarinex (Desloratadine): has similar benefits but is usually chosen for more severe cases¹².
• Atarax (Hydroxyzine): This is a first-generation antihistamine that is stronger and more sedating, often used for short-term management of severe hives, especially when symptoms disrupt sleep¹³.

H2 Blockers

When used for hives, H2 blockers are used as adjunct therapy to antihistamines.

• Zantac (Ranitidine): Previously one of the most popular choices, ranitidine has been withdrawn from many markets due to concerns about impurities linked to cancer risks.
• Pepcid (Famotidine): This is now the most frequently recommended H2 blocker for hives, due to its effectiveness and better safety profile compared to ranitidine.
• Tagamet (Cimetidine): Although less commonly used than famotidine, cimetidine is another option that can be effective for treating hives in combination with an antihistamine¹⁴.
• Axid (Nizatidine): Similar to the others, though less commonly used and available, it can be an option for treating hives.

Leukotriene Receptor Antagonists

• Singulair (Montelukast): Singulair is the most frequently prescribed LTRA for chronic urticaria when additional control beyond antihistamines is needed. It works by blocking leukotrienes, chemicals in the immune system that contribute to inflammation, swelling, and bronchoconstriction¹⁵. This medication should be used under medical supervision to monitor for potential side effects.

Oral corticosteroids

Oral corticosteroids are sometimes used for treating severe or persistent hives (urticaria), particularly when antihistamines and other standard treatments do not provide sufficient relief. 

• Prednisone, prednisolone and methylprednisolone: These are one of the most commonly prescribed corticosteroids for hives due to its effectiveness and relatively quick action. They are often used for short-term treatment to manage acute flare-ups of hives¹⁶.
• Dexamethasone: This corticosteroid is occasionally used for severe cases due to its strong anti-inflammatory properties. It is typically reserved for very brief treatment periods to minimize side effects¹⁷.

While oral corticosteroids are highly effective in managing hives, they are generally used for the shortest possible duration to control flare-ups because of the potential for serious side effects with long-term use, such as osteoporosis, weight gain, diabetes, cataract, hypertension and increased risk of infections. 

Xolair (Omalizumab)

Xolair is the first FDA-approved biologic treatment for chronic hives, when the cause is unknown. Xolair targets the underlying causes of symptoms, offering significant relief. Studies show that patients receiving treatment experienced a 67% reduction in both itch severity and hives, after 12 weeks of urticaria treatment¹⁸.

Can hives be diagnosed via a photo-consultation with a dermatologist?

Dr. Mota says that hives can often be diagnosed through photo-consultations with a dermatologist, especially when the characteristic appearance of the welts—red, raised, and often itchy patches that may change shape or size—is clear in the images. 

Get treatment for hives with Miiskin

Have a consultation with a board-certified dermatologist via Miiskin. You just need to take some high-resolution photos of your skin, answer the questions, enter your payment method and pay for the consultation. Miiskin dermatologists usually reply in 24 hours, but it can take up to 48 hours for them to respond. After that, you can collect your prescription at your pharmacy of choice.

What triggers hives?

Dr. Alpana Mohta, board-certified dermatologist, says that urticaria can be triggered by various factors that lead to the release of histamine and other chemicals from cells in the skin. These factors can be broadly categorized into allergic reactions, physical triggers, and other underlying conditions. Here are some common triggers of hives:

• Allergic reactions to foods (nuts, shellfish, eggs, milk, spicy food, etc.)
• Skin reaction to certain things (plants, pets, soaps, laundry detergents, etc.) 
• Medications (aspirin, non-steroidal anti-inflammatory drugs, penicillin, etc.)
• Emotional stress 
• Insect stings or bites
• Tight clothing
• Sun exposure 
• Extreme weather (cold, heat/sweat)
• Hormonal changes 
• Infections (viral and bacterial infections of any kind)^{2 3}
• Hepatitis⁴
• Mononucleosis⁵
• Autoimmune response for conditions like lupus⁶ or thyroid disease⁷
• Gastrointestinal disorders like celiac disease⁸ or inflammatory bowel disease⁹

What else can I do to minimize the itchiness caused by hives?

Dr. Mohta says that in addition to taking over the counter or prescription antihistamines  you can also use some home remedies to control the symptoms. 

Cool compresses

Applying a cool, wet cloth to the affected area can soothe the skin and help reduce the urge to itch. This can provide immediate, albeit temporary, relief.

Use a lotion or ointment for urticaria

Lotions containing calamine, menthol or pramoxine can soothe the skin and reduce itching. Ointments with menthol or pramoxine can also help numb the area, providing relief.

Loose clothing

Wear loose, light clothing to avoid irritation to the affected areas, and use natural fabrics such as cotton, avoid using synthetic fibers which can exacerbate the symptoms.

Stress management

Since stress can trigger or worsen hives, engaging in stress-reducing activities like deep breathing exercises, yoga, or meditation might be beneficial.

Hydration

Drinking plenty of fluids helps keep the skin hydrated and may aid in recovery.

Avoiding direct sun exposure

Sun exposure and high temperatures can trigger a form of urticaria called cholinergic urticaria. Therefore, practice strict sun protection and stay in cool shaded areas.

Frequently asked questions about hives and urticaria treatment

What is the difference between hives and chronic hives?

Dr. Mohta says that the difference between acute and chronic urticaria is that acute hives last less than six weeks and are often triggered by specific allergens like foods, medications, or insect bites, presenting as temporary red, itchy welts that resolve with or without treatment. In contrast, chronic hives persist for six weeks or more, frequently occurring without an identifiable trigger and may be linked to underlying conditions such as autoimmune disorders. Managing chronic urticaria often involves long-term treatment strategies, including prescription medications to alleviate persistent symptoms.

What other skin conditions or rashes can be mistaken for hives?

Several skin conditions can resemble urticaria and may sometimes be confused with them due to their similar appearance. Here are some of these conditions:

• Eczema (Atopic dermatitis): Eczema can cause itchy, red patches on the skin that may sometimes swell, somewhat like hives. However, eczema patches are usually more chronic and come with dry, scaly skin.
• Heat rash (Miliaria): This occurs when sweat ducts are blocked, and sweat is trapped under the skin, causing small, itchy bumps or blisters. Heat rash usually resolves when the skin cools and is primarily found in hot, humid environments.
• Insect bites: Bites from mosquitoes, fleas, and other insects often cause raised, red, and itchy welts that can be mistaken for hives.
• Contact dermatitis: This arises when the skin reacts to a substance it has touched, leading to red, itchy, and sometimes swollen patches. The reaction can look similar to hives but is generally localized to the contact area.
• Angioedema: Although related to hives, angioedema is a deeper swelling within the skin, often around the eyes and lips, and on the hands, feet, and throat. The swelling from angioedema can appear similar to hives but involves deeper layers of the skin.
• Pityriasis rosea: This skin condition presents as a large, scaly, pink patch on the skin, followed by additional patches. It has a distinct appearance but might initially be mistaken for hives.

How can you tell if hives are caused by stress?

Determining whether urticaria is caused by stress can be challenging because they can result from various triggers, including allergic reactions, infections, medications, and stress. However, there are a few considerations that can help determine if stress might be a contributing factor to your hives.

•  If outbreaks of hives coincide with periods of high stress, such as during major life changes, work deadlines, or personal crises, it might suggest a link between your stress levels and the hives.
• If common triggers such as foods, medications, or physical stimuli (like cold or pressure) have been ruled out through observation or medical testing, and if the hives appear during or after stressful periods, stress might be the cause.
• If you have chronic urticaria (lasting more than six weeks) and tests have not identified an allergen or another cause, stress could be a potential trigger. 
• Stress-related hives might also be accompanied by other symptoms of stress, such as anxiety, tension, headaches, or difficulty sleeping. If these symptoms also occur alongside the hives, it might indicate a stress-related cause.
• If you notice that hives recur in similar stressful situations, this pattern may indicate that stress is a trigger.

Does Benadryl help hives go away?

Yes, Benadryl (diphenhydramine) can be effective in helping hives go away, at least temporarily. Benadryl is an antihistamine that works by blocking histamine, a substance in the body that is released during allergic reactions and is responsible for many of the symptoms of hives, such as itching, swelling, and redness. However, it may cause drowsiness.

What do autoimmune hives look like?

Dr. Mohta says that autoimmune hives look similar to other types of hives. However this type often occurs without an obvious trigger and can persist for extended periods, sometimes becoming chronic. The hives may come and go, with flares often occurring unpredictably. Due to the autoimmune nature of the condition, these hives can be accompanied by other symptoms of autoimmune disorders, such as joint pain or fatigue, depending on the underlying cause.

How long do hives usually last?

Dr. Mohta says hives can vary widely in their duration. A single episode of hives usually disappears within 1-4 hours and wouldn’t usually last longer than 24 hours. Acute urticaria, which are the most common type, typically resolve within a few hours to a few days, usually not lasting more than six weeks. Chronic urticaria, on the other hand, persist for more than six weeks and can recur frequently, sometimes lasting for months or even years. 

Why do hives get worse at night?

Dr. Mohta says that urticaria often appears worse at night due to several factors. The body’s natural cortisol levels, which help suppress inflammation, decrease during nighttime, potentially exacerbating inflammation and symptoms. Histamine levels, which drive allergic reactions, naturally rise at night, worsening symptoms. Finally, lying down and the increased body temperature from bedding can also intensify itching and discomfort.

Can hives be a symptom of something serious?

Dr. Mohta says that hives can indeed sometimes signal more serious underlying health issues. They are a common symptom in severe allergic reactions known as anaphylaxis, which is life-threatening and requires immediate medical intervention. Chronic hives may also indicate autoimmune disorders like lupus or thyroid disease. Additionally, persistent hives can be linked to infections, such as viral hepatitis or bacterial infections like those caused by Helicobacter pylori. If your hives are persistent, recurrent, or accompanied by other symptoms seek medical guidance.

What autoimmune disease starts with hives?

Hives can be an initial symptom of several autoimmune diseases, although they are not the most common or definitive symptom for these conditions. Systemic Lupus Erythematosus (SLE) is one such autoimmune disorder where skin manifestations including hives can occur, although a butterfly-shaped facial rash is more characteristic. Hashimoto’s Thyroiditis might also present with skin issues such as hives, but it primarily leads to symptoms associated with thyroid dysfunction. Sjögren’s Syndrome and Celiac Disease.

What common illnesses cause hives?

There are several illnesses that can initially manifest as hives such as mononucleosis, hepatitis B and C, hand, foot, and mouth disease, and herpes (cold sores or genital herpes) can also trigger hives.

What virus starts with hives?

Many viral infections, such as the common cold, respiratory syncytial virus (RSV), Epstein-Barr virus (EBV, causing infectious mononucleosis), and coxsackievirus (responsible for hand, foot, and mouth disease), are known to cause hives. Bacterial infections, including strep throat, urinary tract infections, and sinus infections, can also lead to hives. Additionally, infections caused by the bacteria linked to stomach ulcers, may also trigger hives. Finally, parasitic infections, such as those caused by intestinal worms or scabies, can provoke an immune response manifesting as hives. 

Are hives contagious?

No, hives are not contagious. You cannot catch hives from someone else or pass them on to others. Hives are a reaction of the body’s immune system to certain triggers such as allergens, medications, infections, or stress. 

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