Antihistamines are the first-line treatment for chronic spontaneous urticaria (CSU). If antihistamines are unsuccessful, systemic therapies that suppress the immune system are the next option.
CSU is a type of chronic hives. It was formerly known as chronic idiopathic urticaria (CIU), with idiopathic meaning the cause is unknown. After experts learned that some chronic hives diagnoses involve autoimmune activity, CIU became known as CSU.
While many factors are linked to CSU, the cause is unknown. Treatment for CSU focuses on reducing the body’s release of histamine and preventing the immune system from overactivity.
If first-line CSU treatments do not work for you, a doctor can recommend changes to your treatment plan, such as different medications.
Urticaria, or hives, affects about
What causes chronic urticaria is unknown, or idiopathic, in 80% to 90% of cases.
Hives occur when the body releases histamine and other inflammatory mediators in response to an allergen or trigger. This response causes the red, itchy bumps of hives.
The goals of treatment are to relieve itching and clear up the hives completely. Options for treatment include reducing exposure to triggers and taking medication. While medication can’t cure hives, it can help reduce the immediate symptoms.
Most people with CSU will see symptom improvement or resolution within
Keeping a journal of urticaria flare-ups might help you identify allergens or triggers. Although it can be difficult to determine possible triggers, keeping a journal can help prevent future flare-ups. Some common triggers for chronic urticaria are:
- foods like eggs, shellfish, and peanuts
- foods like bananas, chestnuts, or mangos (some people with a latex allergy may also be allergic to these foods)
- colorings and preservatives in cosmetics, supplements, and foods
- medications like ibuprofen, aspirin, and antibiotics
- cold or heat
- ultraviolet light from tanning beds or natural sunlight
- adrenaline released from stress, exercise, and other causes
- skin pressure from tight clothes or other causes
Antihistamines are the
- cetirizine (Zyrtec)
- desloratadine (Clarinex)
- fexofenadine (Allegra)
- levocetirizine (Xyzal)
- loratadine (Claritin)
A doctor or allergist might recommend that you take a daily dose of one of these medications. If the first antihistamine you take doesn’t effectively address your symptoms, your dermatologist may increase the dose or add another antihistamine to your treatment plan.
A first-generation antihistamine like diphenhydramine (Benadryl) or hydroxyzine (Atarax) can also work. Because these medications can make you sleepy, doctors usually recommend that you take them at night.
With regular doses, these drugs may produce side effects, such as drowsiness, dry mouth, dizziness, and tinnitus. At higher doses, they might cause euphoria, problems with coordination, and delirium.
A 2016 study included in a
If antihistamines are not meeting your treatment goals for CSU, a doctor might recommend a
Examples of LRAs are montelukast (Singulair) and zafirlukast (Accolate). These are oral medications. Common side effects of montelukast include headache, cough, indigestion, stomach pain, and influenza infection.
Zafirlukast can also cause gastrointestinal upset, headaches, and upper respiratory infection.
One tricyclic antidepressant called
In a retrospective
Phototherapy involves exposing the skin to a controlled amount of light. The therapy is performed in a treatment center or doctor’s office.
People who have phototherapy usually also continue to take antihistamines. According to the American Academy of Dermatology (AAD), this combined therapy can lead to longer periods of remission than either of the therapies alone.
Phototherapy, or light therapy, has potential side effects, such as a temporary sunburn that lasts for about a day. With long-term use, phototherapy can cause skin aging and contribute to skin cancer risk.
Although it’s not known exactly how light therapy works for CSU,
Other systemic treatments for CSU include
Omalizumab (Xolair) is an immunosuppressant medication designed to help prevent the immune system from becoming overactive. It’s injected just under the skin and can take 4 to 6 months to clear chronic hives. Side effects include nausea, headache, cough, joint pain or soreness, colds, and respiratory infections.
Cyclosporine (Sandimmune) also reduces the immune system’s activity. Some doctors only recommend
Cyclosporine is taken orally. Besides hypertension, possible
Dupilumab (Dupixent) is a biologic medication that also works to reduce the immune system’s activity and to reduce inflammation. It’s injected under the skin. Dupilumab might
Other possible side effects include cold sores, eye redness, and eye itching. In rare cases, it can cause joint pain, shortness of breath, or wheezing.
Findings of a 2024 clinical trial showed that dupilumab reduced the itching and severity of hives in people who had never taken omalizumab and for whom antihistamines were unsuccessful.
A topical corticosteroid can help relieve itching caused by hives. A doctor might also prescribe a short course of an oral corticosteroid like prednisone, to be taken for 3 to 10 days. They will typically only prescribe this if symptoms are severe.
Long-term use of steroids can increase the risk of osteoporosis. Because of this, prednisone is not recommended for long-term use.
If hives last longer than 6 weeks or cover large parts of your body, see a doctor or dermatologist. They can recommend appropriate treatment options.
It’s also a good idea to follow up with your doctor if your current treatment plan isn’t working or if you’re experiencing unwanted side effects. They might be able to suggest changes to your current treatment.
Antihistamines are the first-line treatment for CSU. If antihistamines don’t help you reach your treatment goals, your doctor may recommend other therapies, such as medications that help address the immune system’s activity.
Identifying and avoiding triggers for hives can also help with ongoing management.
