Infinite Itch: Learning to Live With Hives

PERSONAL HEALTH    

By JANE E. BRODY

The disorder, Mr. Brancaccio said, “exposes you to the limits of modern medicine.” The term “idiopathic” indicates that the cause is not known.

The name “makes it seem like the problem is solved,” he said. “But you’ve still got hives.”

Cause Unknown

Hives of one sort or another afflicts about one person in five at some time during their lives. For most, the problem is short-lived or “acute,” lasting less than six weeks. A specific cause, or trigger, can usually be identified.

Common triggers of acute urticaria include medications like antibiotics, aspirin and other Nsaids (nonsteroidal anti-inflammatory drugs), and opiates; foods like nuts, peanuts, fish and shellfish, wheat, eggs, milk and soybeans; infections of all kinds, including upper respiratory infections; insect stings, especially by bees and wasps; allergens like latex or pollen; and physical stimuli like cold, heat, exercise or sweat.

As I recall, a high school friend who was sensitive to cold air used to develop hives on her face going to and from school in winter. Dr. Vincent S. Beltrani, a dermatologist in Poughkeepsie, N.Y., noted that in patients whose symptoms have an identifiable cause, “the episode usually resolves spontaneously within hours after the trigger is removed.”

But the likelihood of finding a cause for chronic urticaria “is quite small,” Dr. Supriya Varadarajulu, allergist at the Park Nicollet Clinic in Minneapolis, said in an interview. In a few cases, a cause can be identified by taking a careful history, “but usually the condition remains idiopathic.”

Studies have indicated that up to 40 percent of patients with chronic urticaria, especially those more severely affected, have antibodies targeting the body’s own tissues circulating in their blood. These patients or their blood relatives may have other autoimmune disorders, like thyroid disease, diabetes or lupus.

About a quarter of patients with chronic urticaria have thyroid autoantibodies, and many of them are found to have thyroid dysfunction. Unfortunately, treating their thyroid condition does not eliminate the hives, Dr. Varadarajulu said.

Some people who get hives also have a related condition called angioedema, a swelling of tissues deep in the skin (hives develop at the skin’s surface). Although angioedema usually doesn’t cause itchiness, it can cause pain or a burning sensation.

It most often involves the lips, eyelids, face, arms and legs and genitalia. Dr. Varadarajulu said the swelling can show up suddenly and last for hours or days. A friend of mine who had angioedema of the face occasionally needed emergency treatment when the swelling of her tongue threatened to cut off her airway.

Treating Outbreaks

The duration of chronic hives varies widely. According to Dr. Beltrani, it disappears in 3 to 12 months in up to half of patients, but persists for up to five years in 20 percent of patients and for 20 or more years in 1.5 percent. Half of patients will have recurrences from time to time.

He and Dr. Varadarajulu emphasized that there was no magic bullet, or even a standard treatment, for chronic idiopathic urticaria. Rather, a series of antihistamines are commonly tried, both singly and in combination.

Dr. Varadarajulu said one of the newer nonsedating oral antihistamines is the treatment of first choice, though patients often need twice the standard dose, taking the drug every 12 hours rather than once a day.

Sometimes Zantac or Tagamet is added; though normally prescribed for heartburn, these drugs have antihistamine properties.

Another option, doxepin (brand name Sinequan), the drug that finally helped Mr. Brancaccio, is an antidepressant with both antihistamine properties and potent anti-itch action. It causes severe sedation and dry mouth, however, and is used only if less debilitating therapies fail to bring relief.

Still, chronic urticaria remains a challenge because “the extreme itchiness can drive people crazy,” Dr. Varadarajulu said, and no cause can be found in most cases.

Nonetheless, she said, “excellent disease control can be achieved with appropriate use of antihistamines until the disease spontaneously resolves over time.”

Mr. Brancaccio had to take doxepin for many weeks after his hives abated to keep them from recurring. Now 30, living and working in Manhattan, he has been in remission for years.

“I don’t know why, but I no longer react to cold water or bee stings,” he said.