Chronic spontaneous urticaria (CSU), hives (urticaria) that last 6 weeks or longer (chronic) and have an unknown cause (spontaneous), can have a significant impact on your life. The itchy hives can make you feel self-conscious. They can make it hard to sleep, leading to fatigue, and can make you irritable and depressed, leading to issues with relationships and at work. They can cause severe swelling in the lips, eyelids, hands, feet and other areas of the body.

And if you scratch at them, you could break the skin, which could lead to an infection. So, what can you do about CSU?

Find the right healthcare provider

Primary care physicians (PCPs) are usually your first stop if you develop hives, but if they’re not responding to treatment, it’s time to ask for a referral to a specialist — an allergist or a dermatologist. Allergists can do tests to rule out allergies or autoimmune diseases. They’re also the most up-to-date on the different types of antihistamines and other advanced medications used in allergy treatments.

Dermatologists, on the other hand, have experience prescribing immunosuppressant treatments, drugs that lower the immune system’s response, for many types of skin diseases.

Preparing for appointments to address chronic spontaneous urticaria

Regardless of which specialist you see, it’s important to be prepared for your appointments so you don’t leave and then realize there are things you didn’t discuss.

Track your symptoms: Using a calendar or journal app or paper, track when your hives come and go, where they appear, how long they last, and any triggers that might have caused them. Describe symptoms clearly and whether any treatments seemed to make them better.

Track your quality of life: As important as it is to track your hives, it’s also important that you track how they’re affecting you. You can show your healthcare provider (HCP) how the itching is keeping you awake, making you miss work or causing anxiety, for example.

Always bring a medication list to your appointments: You could either bring your own list of medications (including supplements, vitamins and any non-prescription skin creams) or ask your pharmacist to print out your latest medications.

Bring a list of questions: Before your first appointment and between appointments, keep a running list of questions so you can remember to ask them.

Treating chronic spontaneous urticaria

Since CSU is not caused by a specific allergy or external trigger, it doesn’t always respond to the same type of treatments that regular hives do. CSU is believed to be caused by an overactive immune system, meaning that the treatments may need to target more than the itchy hives.

There are several types of drugs that HCPs could use to treat CSU. You might need to try different medications to find what works for you, though. One of the questions you should ask your HCP when trying any new drug is, “How long will it take to see results from the medication?” This way you’ll know how long to wait, and you won’t get discouraged if it’s not working right away. You’ll also know if the medication isn’t working for you, and if you need to try a different option.

Treatment options for hives

Antihistamines

Antihistamines are usually the first treatment to try for CSU.

You can buy some antihistamines over the counter but others require a prescription. Antihistamines commonly used for CSU include:

• Cetirizine (Zyrtec)
• Desloratadine (Clarinex)
• Fexofenadine (Allegra)
• Levocetirizine (Xyzal)
• Loratadine (Claritin)

If these drugs work, they often take effect within a few days or weeks, sometimes after just one dose.

Steroids

Corticosteroids, like prednisone or prednisolone that are pills taken by mouth, can help get inflammation under control, which can reduce severe flares. However, they are a short-term solution and don’t treat the problem that caused the hives in the first place. These drugs aren’t used for long-term treatment because they have risks of serious side effects.

Steroids in creams or other preparations to put on the skin don’t work for CSU.

Asthma, allergy and eczema drugs

Researchers found that some drugs that are typically used to treat asthma, allergies or eczema might help manage CSU symptoms for people who aren’t getting relief from other drugs. Montelukast (Singulair) is one. It belongs to the drug family of leukotriene receptor antagonists. Your doctor might recommend it alongside antihistamines.

There isn’t a lot of research about how long it might take to work, but a few case studies showed some patients responded within a few weeks.

Dupilumab (Dupixent) and omalizumab (Xolair and Omlyclo) are biologics approved for treating CSU and are given monthly by injection. Some people using these drugs see their symptoms ease in a few weeks, but for others, it can take longer.

Immunosuppressants

Immunosuppressant drugs help treat illnesses where your body attacks itself. They’re used for many diseases, like multiple sclerosis, inflammatory bowel disease and rheumatoid arthritis. Some immunosuppressants can help with CSU, including:

• Acalabrutinib (Calquence)
• Azathioprine (Imuran)
• Cyclosporine (Gengraf, Neoral and Sandimmune)
• Hydroxychloroquine (Plaquenil)
• Methotrexate
• Mizorbine
• Mycophenolate mofetil
• Tacrolimus

Some patients see improvements in weeks, and for others, it can take months.

This educational resource was created with support from Regeneron and Sanofi.

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