Integrative Dermatology Approach to Urticaria (Hives)

You may have experienced hives or urticaria if you have ever developed an itchy raised rash after eating food or coming into contact with a medication or something that you are allergic to. The inflammatory rash of urticaria appears as red or pink splotches on the skin that develop into raised welts or wheals due to the activation and degradation of skin mast cells, which release histamine and other mediators. These hives can be extremely itchy, burning, or stinging and often disrupt sleep. 

This type of rash is fairly common. About 20% of the world’s population will experience hives at least one time during their life, while around 1% to 3% of the population has chronic hives.

A conventional approach to hives usually involves antihistamines or steroids to tame the immune response. An integrative functional medicine approach evaluates underlying factors contributing to the development of hives and uses nutrition, lifestyle, and targeted supplementation to relieve itching and bring the body back into balance. 

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What is Urticaria (Hives)?

A urticaria rash usually starts as itchy patches that develop into welts (wheals) of various sizes. These welts can range from as small as a fingertip to as large as a dinner plate. In some cases, the smaller hives can coalesce and join together to form larger areas called plaques. On lighter skin, the rash is usually pink or reddish and may blanch or become pale in the center when pressed. 

Hives are usually due to swelling in the skin when the immune system reacts to something. While hives tend to arise and then fade at random as the reaction progresses, they may remain noticeable for several days or longer.

Urticaria can develop acutely when you are exposed to something or eat something that you are allergic to or persist more chronically. Acute hives usually resolve within one week, with fewer than 40% of cases becoming chronic. Chronic hives occur at least twice a week and last for more than six weeks. They commonly return over months or years. When chronic, the cause of urticaria is not always clear. 

In addition to patches of intensely itchy welts that can come and go anywhere on the body, with chronic hives, you may experience symptoms like painful swelling around your eyes, cheeks, or lips. This is known as angioedema and requires urgent medical attention. 

What Are The Possible Causes of Urticaria (Hives)?

Hives can be triggered when the immune system reacts to a trigger and releases mediators like histamine into the blood. Immune cells, known as mast cells, are found in the skin and other organs. When these cells are activated and triggered, they degranulate and release mediator chemicals, including histamine. These chemicals activate sensory nerves in the skin, cause dilatation of blood vessels and plasma to leak out of blood cells, and lead to the recruitment of inflammatory cells.

Flares of urticaria are commonly brought on by extremes of temperature (heat or cold), sunlight, exercise, vibration, pressure on the skin such as from tight clothing, emotional stress, foods (especially peanuts, eggs, nuts, and shellfish), medications (most commonly NSAIDs and antibiotics), or other substances to which you are allergic (pollen, dust mites, animal dander, insect bites/stings, latex, certain plants, etc.), or other medical conditions such as thyroid conditions, infections (especially upper respiratory tract infections like strep throat and urinary tract infections), or cancer. When hives are brought on by physical conditions like temperature extremes, vibration, or exercise, they are coined physical or inducible urticaria.

Allergic reactions are usually associated with acute hives. Hives are more likely to occur when the levels of histamine in your body exceed what you can break down and excrete at one time due to a variety of factors. This occurs due to exposure to foods, chemicals, stress, overexercise, hormonal shifts, and other environmental and lifestyle factors. In addition, some people are more sensitive to histamine due to genetic factors and/or gut health. For example, undiagnosed food allergies and dysbiosis can lead to chronically elevated histamine and IgE levels, while genetic single nucleotide polymorphisms (SNPs) in genes such as DAO, HMNT, and MTHFR influence how quickly and effectively your body can break down histamine.

Genetic factors seem to partly explain susceptibility to urticaria. In addition, people with medical conditions, including asthma, allergic rhinitis, and atopic dermatitis (eczema), are more likely to experience hives. 

On the other hand, chronic hives are less commonly caused by allergies. Instead, they may be associated with bacterial (especially Helicobacter pylori and focal bacterial infections), viral (including the common cold, infectious mononucleosis, and hepatitis), or parasitic infections or with medical conditions such as autoimmune diseases, most frequently Hashimoto’s thyroiditis, rheumatoid arthritis, vitiligo, autoimmune gastritis, and diabetes mellitus. Sometimes, chronic hives do not have a clearly identified cause. In this case, they are referred to as chronic spontaneous urticaria or chronic idiopathic urticaria.

Functional Medicine Labs to Test for Root Cause of Urticaria (Hives)

Functional medicine laboratory testing can help rule out differential diagnoses and evaluate underlying causes leading to the development of hives. 

Histamine 

Histamine can be measured in the blood or urine to get a sense of elevated levels of mast cell activation that may contribute to hives. In addition, tryptase may be added.

Comprehensive Gut Testing

An imbalance in the microbes within the gut (dysbiosis) can contribute to bacterial and parasitic infections and lead to elevated levels of systemic inflammation. Testing the balance of microbes along with markers of inflammation, immune function (secretory IgA), and leaky gut (zonulin) with the GI-MAP + Zonulin can provide insights into factors that may be contributing to histamine overload and hives. 

Food Allergy Testing

Food allergies and intolerances can be due to both IgE- and non-IgE-mediated reactions. Adding testing for food allergies and sensitivities to a comprehensive evaluation of gut health can help find root causes for elevated IgE-mediated urticaria. Precision Point's P88 Dietary Antigen Test uses a blood sample to evaluate IgE, IgG, IgG4, and C3d reactions to 88 of the most common foods to help identify food allergies and sensitivities.

Antibody Testing

Measurements of IgG anti-TPO and total serum IgE levels can be done to help in the diagnosis of autoimmune chronic spontaneous urticaria with elevated IgG anti-TPO levels suggesting concomitant autoimmune thyroiditis.

Genetic Testing

Genomic testing can uncover various genetic SNPs involved in how your body breaks down histamine. Evaluating genes like D-amino acid oxidase (DAO), which is an enzyme that metabolizes intestinal histamine, histamine N-methyltransferase (HMNT), which plays a key role in degrading histamine and in regulating the body’s response to histamine, and MTHFR can provide insights into biochemical pathways involved with the metabolism and clearance of histamine from the body to guide interventions that can support histamine metabolism.  

The 3x4 Genetics Test + Blueprint Report evaluates these and other genes to provide insights into an individual's overall histamine balance and tendency toward histamine overload.

Parasite Testing

Chronic spontaneous urticaria has been associated with parasitic infections. Patients with this condition more commonly have signs of infection with protozoa, toxocariasis, Anisakis simplex, fasciolosis, and Blastocystis hominis allele 34 (ST3) compared to control subjects. This Parasitology Test by Doctor’s Data can reveal if parasitic infections are present. 

Additional Labs To Test 

A skin examination and allergy testing are frequently used to diagnose acute hives and help determine their cause. A skin prick or scratch test involves applying different allergens to the skin and observing for a reaction. Blood testing may also be done to look for specific antibodies in your blood targeted against allergens.

Serum autoantibodies can be measured to help diagnose chronic autoimmune urticaria. This can be accomplished with in vivo autologous serum skin testing (ASST) or in vitro testing options such as a basophil histamine release assay and direct immunoassays like Western blotting, immunoprecipitation, enzyme-linked immunosorbent assay, and flow cytometry.

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Conventional Treatment for Urticaria (Hives)

Hives commonly resolve on their own. If needed, a conventional treatment approach to hives focuses on taming allergic reactions with allergy medications like antihistamines, allergy shots, and/or steroids. 

Antihistamines like diphenhydramine (Benadryl®) are used orally and/or topically to acutely block the effect of histamines, reducing itching and helping allergic reactions resolve. In cases of chronic allergic reactions, daily antihistamines may be prescribed, such as loratadine (Claritin®), fexofenadine (Allegra®), cetirizine (Zyrtec®,) or levocetirizine (Xyzal®). If hives persist, oral or topical steroids like prednisone are sometimes added to calm the allergic immune response. 

If medication does not resolve chronic hives, allergy shots or regular injections of drugs that block allergic reactions may be used to help block the immune system from making IgE antibodies in response to exposure to allergens.

Functional Medicine Treatment for Urticaria (Hives)

An integrative dermatology approach incorporating functional medicine treatment addresses symptoms of hives like itching while identifying and reducing potential triggers in the diet, lifestyle, and environment.

Nutritional Recommendations

Focusing on a nutrient-dense anti-inflammatory that eliminates high-histamine foods and any foods to which you are allergic and/or sensitive from your diet can help reduce the body’s histamine load and decrease hives. An anti-inflammatory diet focused on low-histamine fruits, vegetables, unsaturated fats, whole grains, legumes, herbs, and spices excludes foods that can contribute to inflammation like high-fat red and processed meats, ultra-processed foods, refined grains, sugary foods and beverages, and alcohol to help heal the gut and reduce overall inflammation that can contribute to hives.

A low-histamine limits foods high in histamine, often removing high-histamine foods for 30 days and reintroducing foods one at a time. Foods high in histamine include fermented dairy, soy, grains, and other products such as kombucha, vinegar, and sauerkraut; tomatoes, eggplant, spinach, and mushrooms; citrus fruit, banana, pineapple, avocado, and any overly-ripe fruits; cured meats like sausage, bacon, salami, and fermented ham; shellfish, tuna, mackerel, mahi-mahi, anchovy, sardines, herring, bluefish, amberjack, and marlin; bone broth and collagen; alcohol; yeast and yeast extracts; and artificial preservatives and food dyes. In addition, leftovers contain greater levels of histamine compared to freshly prepared foods since bacteria that produce histamines increase over time. 

Instead, individualizing a diet based on nutrient-dense, low-histamine foods that work for your body can help the body come back into balance. Fresh meat, freshly caught or frozen seafood that is low in histamines like cod and salmon, non-citrus fruits, fresh vegetables except for tomatoes, avocados, mushrooms, spinach, and eggplant, eggs, quinoa, rice, coconut milk, and olive oil are generally low in histamine.

Supplements & Herbs

In addition to a tailored anti-inflammatory diet focused on low histamine foods, targeted supplementation with options like vitamin C, DAO, quercetin, and probiotics may help reduce the severity and frequency of urticaria.

Vitamin C supports the degradation of histamine and can help to increase DAO levels. Look for vitamin C that is produced without fermentation.

Oral supplementation with diamine oxidase (DAO) before meals can improve histamine-related symptoms like hives by supporting the breakdown of histamine. 

Quercetin is a polyphenol flavonoid that is rich in antioxidants and has anti-allergic functions, inhibiting histamine production and pro-inflammatory mediators. In this way, it can help to stabilize the membranes of mast cells and reduce the release of histamine to reduce hives. ‍

Since gut balance plays an important role in the metabolism of histamine and overall inflammation in the body, restoring balance to the gut can help reduce urticaria. Probiotics focused on strains such as Bifidobacterium adolescentis, Bacteroides thetaiotaomicron, Bacteroides fragilis, and Lactobacillus rhamnosus help breakdown histamine and reduce the occurrence of chronic urticaria in animals. 

Complementary and Integrative Medicine for Urticaria (Hives)

Another crucial way to lower the body’s histamine load and reduce hives is to consider complementary and integrative medicine approaches like acupuncture and to look at environmental and lifestyle factors.  

Acupuncture

Studies suggest that acupuncture may be effective at reducing chronic hives. Some commonly used acupuncture points for hives include LI11 (Quchi), Sp10 (Xuehai), Sp6 (Sanyinjiao), and S36 (Zusanli).

Elimination of Causes and Avoidance of Triggers

When the trigger of urticaria can be identified, it is important to eliminate and avoid these factors as much as possible. For example, airborne allergens can be reduced using a high-quality HEPA home air filter. Removing your shoes and outerwear upon entering the house can also help to reduce the amount of pollens and molds brought inside.

In addition, many hive sufferers find it helpful to wear loose-fitting, lightweight clothing washed with gentle, non-chemical detergents and soaps without fragrances or dyes. Many people with hives also find it helpful to avoid extreme temperature changes.

Manage Stress

Since stress is associated with flares of hives, it is helpful to find meaningful stress management practices that help you relax and cope with daily life stressors. Incorporating these practices regularly into your life can help you minimize the impacts of chronic stress. Take breaks to avoid becoming overworked and burned out. 

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Summary

Urticaria causes very itchy raised wheals or welts known as hives that may appear on one part of the body, or spread across large areas. Hives occur when the immune system is triggered, and mast cells release chemical mediators, including histamine.

Acute urticaria is often due to an allergic reaction to a food, medication, or substance in the environment and resolves more quickly. Chronic urticaria persists longer than six weeks and can be due to unknown causes or from dysregulation of the immune system due to certain environmental exposures, mast cell issues, infections, physical stimulation like vibration, and/or genetic factors.  

Functional medicine testing can help uncover factors that increase histamine in the body so that these can be targeted with an individualized integrative medicine approach. An anti-inflammatory diet that eliminates high-histamine foods and any foods to which you are allergic or sensitive can help reduce the frequency and severity of urticaria. In addition, targeted supplements such as vitamin C, DAO, quercetin, and probiotics can reduce the body’s histamine load. Reducing environmental triggers in the environment, such as mold, dust, and pollen, can also help calm the body’s allergic response and reduce hives.