Persistent Urticaria: When Hives Keep Coming Back
Persistent urticaria is a chronic condition when hives return repeatedly, often over weeks or months. These red or skin-colored welts appear suddenly, itch intensely, and typically fade within 24 hours, only to reappear elsewhere.
While most people assume hives are caused by allergies, recurrent urticaria usually isn’t triggered by external allergens. In fact, many patients with hives that keep coming back have no obvious allergy at all.
What Causes Persistent?
Most people think of hives as a short-lived skin reaction. Maybe you brushed up against something, ate something odd, or were just really stressed. The rash fades, and you move on.
But what if the hives come back again and again?
When standard allergy meds aren’t helping, you might be dealing with chronic urticaria and possibly something more complex going on underneath.
Possible contributing factors include:
- Autoimmune activity, where the immune system targets skin cells
- Viral or bacterial infections
- Chronic inflammation
- Hormonal fluctuations
- Physical stimuli like heat, cold, or pressure
In very few cases, recurring hives may be a symptom of rare diseases, such as:
Eosinophilic Granulomatosis with Polyangiitis
A rare form of vasculitis that can cause hives-like rashes, often with severe asthma, sinus issues and nasal polyps. In EGPA, the immune system attacks blood vessels, causing generalized inflammation. Early diagnosis is important to prevent serious organ damage.
👉 Learn more about Eosinophilic Granulomatosis with Polyangiitis.
Hypocomplementemic Urticarial Vasculitis Syndrome
An uncommon condition where the immune system causes inflammation in small blood vessels, leading to hives that last more than 24 hours. It’s linked to low levels of complement proteins in the blood. Some patients with HUVS also develop joint pain, kidney problems, or breathing issues.
Cryopyrin-Associated Periodic Syndromes
A group of rare genetic conditions where the body’s inflammation control system doesn’t work properly. CAPS symptoms include hives-like rash, fevers, joint pain, and eye problems. Attacks can be triggered by cold temperatures and often start in childhood.
Systemic Mastocytosis
A rare disorder where too many mast cells (a type of immune cell) build up in the body. These cells release chemicals like histamine, causing chronic hives, flushing, stomach issues, or even severe allergic reactions. Triggers can include certain foods, temperature changes, or stress.
Hereditary Alpha-Tryptasemia
A genetic condition where the body has extra copies of a gene that makes tryptase, a chemical released by mast cells. This can lead to hives, flushing, digestive problems, and sometimes dizziness or low blood pressure. Symptoms often run in families.
Schnitzler Syndrome
A very rare inflammatory disorder with chronic hives, fever, bone pain, and fatigue. It’s linked to a protein in the blood called monoclonal gammopathy. Without treatment, it can lead to more serious conditions like amyloidosis.
Autoimmune Thyroid Disease
Hashimoto’s and Grave’s Disease are conditions where the immune system attacks the thyroid gland. While they mainly affect energy, weight, and mood, some people also get long-lasting hives. Treating the thyroid issue can sometimes improve the skin symptoms.
This wide range of possibilities is why a careful medical evaluation is essential.
What Happens in the Body During Recurrent Urticaria?
Urticaria involves mast cells in the skin releasing histamine and other chemicals. This causes the typical symptoms:
- Swelling and redness
- Itching or burning
- Raised wheals or patches that appear and fade unpredictably
In chronic or autoimmune forms, mast cells can become hyperreactive, releasing histamine without a clear external trigger. In some patients, autoantibodies may even stimulate this release directly.
Recognizing the Symptoms
Recurrent urticaria often follows a recognizable but frustrating pattern. Patients commonly report:
- Red, swollen welts that appear suddenly
- Itching that worsens at night or with heat
- Hives lasting several hours, disappearing, then reappearing elsewhere
- Flare-ups without any clear reason
- Swelling of lips, eyelids, hands, or feet (angioedema)
These symptoms may persist almost daily for weeks or months, which can affect sleep, focus, and emotional well-being. If they appear alongside other unusual symptoms, a more in-depth evaluation may be warranted.
Types of Chronic Urticaria
Recurrent urticaria can be classified into two major categories:
1. Chronic Spontaneous Urticaria
- Occurs without a known trigger
- Often autoimmune in nature
- May persist for months or years
2. Chronic Inducible Urticaria
- Triggered by specific physical or environmental stimuli
- Common triggers include:
- Pressure or friction
- Cold or heat
- Exercise or stress
- Sunlight or water
In many cases, both types may overlap, which makes diagnosis and treatment more complex.
What Treatment Options Exist?
There is no universal cure for recurrent urticaria, but effective treatments exist. A structured, step-by-step approach is often used.
Standard treatment options include:
- Non-sedating antihistamines, sometimes at higher-than-usual doses
- Leukotriene receptor antagonists, often used in asthma treatment
- H2 receptor blockers, to complement antihistamines
- Biologic therapies such as omalizumab, especially effective in autoimmune forms
- Short-term corticosteroids, used cautiously during severe flares
- Immunosuppressive medications, if an autoimmune disease is confirmed
Choosing the right chronic urticaria medicine depends on the severity of symptoms, patient history, and presence of other immune-related conditions.
What Happens if Recurrent Urticaria Is Left Untreated?
While not life-threatening, untreated recurrent urticaria can significantly impact quality of life. Ongoing flare-ups may lead to:
- Persistent discomfort and lack of sleep
- Work or school disruptions
- Anxiety or emotional distress
- Missed diagnosis of serious underlying diseases
Early treatment and proper diagnosis can help reduce long-term impact and uncover related health concerns.
Take action
If you are experiencing hives that keep coming back, and standard treatments are not effective, it’s important to take the symptoms seriously. Persistent urticaria may be more than a skin reaction. It can be a signal from your immune system that something deeper is happening.