Allergy & immunology · Cincinnati
Chronic hives and angioedema
Hives that last more than six weeks can disrupt sleep, work and daily life. Dr. David I. Bernstein sees many patients with chronic hives, has published research on their treatment and co-authored the national practice parameter on urticaria.
What chronic hives are
Hives (urticaria) are itchy, raised welts that come and go. When they continue for more than six weeks they are called chronic. Most chronic hives are spontaneous, meaning no outside allergen is found; in many patients the immune system itself is driving them. Others are inducible, set off by pressure, scratching, cold, heat or exercise.
About half of people with chronic hives also have angioedema, deeper swelling of the lips, eyelids, hands or feet. Chronic hives usually improve over time, and effective treatments are available now.
When to seek a specialist
- Hives most days for more than six weeks
- Antihistamines at standard doses are not enough
- You have needed repeated courses of oral steroids
- Swelling of the face, lips or tongue
- Swelling without hives, which needs a different evaluation
How chronic hives are treated
Treatment follows a stepwise approach set out in national guidelines.
Daily antihistamines
Long-acting, non-sedating antihistamines taken every day, often at higher than standard doses under a physician’s direction.
Biologic therapy
For hives that persist, injectable biologic medicines such as omalizumab, and newer approved options, control symptoms in many patients.
Other options
Medicines such as hydroxychloroquine or cyclosporine for selected patients, chosen with their side effects in mind.
Follow-up
Treatment is reduced step by step once hives are controlled, since many cases go into remission.
Hereditary angioedema
Swelling that occurs without hives and does not respond to antihistamines may be hereditary angioedema (HAE), a rare inherited condition, or angioedema caused by certain blood-pressure medicines (ACE inhibitors). These need specific blood tests and different treatment.
Dr. Bernstein co-authored the 2013 national practice parameter update on hereditary angioedema and acquired C1 inhibitor deficiency, and evaluates patients with suspected HAE.
Signs that suggest HAE
- Swelling without hives or itching
- Episodes of severe abdominal pain
- Swelling that lasts two to five days
- A family history of similar swelling
- No response to antihistamines or steroids
Common questions
What causes chronic hives?
In most people no outside allergen is found. Many cases are autoimmune, meaning the immune system activates the skin’s mast cells. Extensive allergy testing is usually not needed.
Will my hives go away?
Chronic hives often go into remission over months to years. Treatment controls symptoms in the meantime.
Are higher doses of antihistamines safe?
National guidelines support higher doses of non-sedating antihistamines for chronic hives under a physician’s direction.
Is swelling of the lips or tongue dangerous?
Swelling of the tongue or throat, or any trouble breathing or swallowing, is an emergency: call 911.
Dr. Bernstein’s work
Dr. Bernstein has studied antihistamine treatment of chronic hives since the 1980s and recently published a real-world study of hydroxychloroquine and omalizumab in chronic spontaneous urticaria. He was a co-author of the 2014 national practice parameter on acute and chronic urticaria.
Selected publications
- Khan N, Epstein TG, DuBuske I, Strobel M, Bernstein DI. Effectiveness of hydroxychloroquine and omalizumab in chronic spontaneous urticaria: a real-world study. J Allergy Clin Immunol Pract. 2022. PubMed · DOI
- Bernstein DI, et al. Efficacy of epinephrine nasal spray in the treatment of urticaria. J Allergy Clin Immunol Pract. 2026. PubMed · DOI
- Bernstein JA, Lang DM, Khan DA, et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014. PubMed · DOI
- Zuraw BL, Bernstein JA, Lang DM, et al. A focused parameter update: hereditary angioedema, acquired C1 inhibitor deficiency, and ACE inhibitor-associated angioedema. J Allergy Clin Immunol. 2013. PubMed · DOI
Hives or swelling that won’t go away?
Request a consultation. Dr. Bernstein reviews every request personally.