Waking up covered in intensely itchy, burning red welts that reappear day after day is a deeply frustrating experience. When this cycle persists for six weeks or more, it’s rarely just “sensitive skin.” It’s likely Chronic Spontaneous Urticaria (CSU), defined as hives that occur without an identifiable external cause.
While research suggests only a small percentage of the population experiences CSU, that still translates to hundreds of thousands of people, with women being twice as likely as men to be affected. The unpredictability of CSU often leaves patients bouncing between specialists, but finding the right doctor and starting a focused diagnostic plan is the key to relief.
Finding the Right Specialist
When dealing with chronic hives, who should you see? Both Dermatologists and Allergists regularly treat CSU.
- Dermatologists often provide the initial assessment, especially if the patient initially suspects a rash like eczema.
- Allergists, like the experts at the Allergy & Asthma Center of Las Vegas, are highly qualified because they are also trained immunologists.
As Dr. Jason Bellak, an allergy immunotherapy physician in Las Vegas, notes, “Allergists are also trained immunologists and have experience with interpreting immune-related testing, as well as prescribing targeted medications for the immune system.”
To speed up your diagnosis, keep a detailed log of your symptoms: note how long the hives last, how frequently they appear, and if you experience swelling or breathing difficulties.
The Diagnostic Journey: Rarely About External Triggers
One of the biggest surprises for patients is that CSU is usually not caused by a simple contact or food allergy. Many spend weeks eliminating foods or switching detergents before learning that allergy testing is rarely the solution.
Dr. Bellak explains: “Generally speaking, allergy testing for environmental, and especially food, allergies isn’t helpful because an external trigger is rare.”
Instead, experts now believe a high percentage of CSU cases are autoimmune, where the body mistakenly attacks the cells that release histamine. Dr. Bellak estimates that “possibly up to 75 percent or more of CSU patients have an underlying autoimmune etiology.”
Your doctor’s detective work will focus on:
- Ruling Out Mimics: They will order basic blood work (like thyroid levels or inflammation markers) to ensure the hives aren’t symptoms of other conditions, such as lupus or vasculitis.
- Pattern Recognition: The most common diagnosis is based on the pattern: hives that appear and disappear daily (lasting less than 24 hours in one spot) and persist past the six-week mark.
Effective Treatment: Beyond Antihistamines
Fortunately, even without a clear cause, CSU is highly manageable and treatable.
- High-Dose Antihistamines: The initial treatment often involves increasing the dosage of second-generation antihistamines (like loratadine or cetirizine), sometimes up to four times the usual daily dose. Your doctor may also recommend H2 blockers, which have additional anti-histamine properties. Dr. Bellak confirms this, stating, “First-line treatment is high-dose antihistamines—both H1 and H2 receptor blockers.”
- Advanced Therapies (Biologics): For hives that persist despite high-dose antihistamines, biologics have been a “game-changer.”
- Omalizumab was the first FDA-approved injectable medication specifically for chronic hives that don’t respond to standard treatment. It works by blocking the IgE antibody, which is responsible for triggering histamine release.
- More recently, dupilumab was also approved for CSU, offering additional options for patients who have suffered for years.
Finding Relief and Reassurance
While it’s natural to want a definitive answer for the cause of your hives, Dr. Bellak stresses the most important message: “CSU is not life-threatening and is very treatable.”
The primary goal of the allergist is to use these advanced treatments to “decrease the burden so they feel normal, sleep normally, and are able to work and enjoy their hobbies.”
Relief is possible. Partner with a specialist who understands immunology, track your symptoms, and know that you are not alone in this journey.
For the full, detailed doctor’s plan on navigating chronic hives, including in-depth information on diagnosis and treatment options, please read the original article.
