Episode 23: Chronic Hives
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Sick of the fatigue and fog? Fed up with the unpredictable flares? Hangry from the super restrictive diets?
Hello, and welcome to the Crunchy Allergist Podcast. A podcast empowering those who like me, appreciate both a naturally minded and scientifically grounded approach to health and healing.
Hi, I'm your host, Dr. Kara Wada, quadruple board certified pediatric and adult allergy immunology and lifestyle medicine, physician Sjogren's patient and life coach. My recipe for success combines, the anti-inflammatory lifestyle, trusting therapeutic relationships, modern medicine, and mindset to harness our body's ability to heal.
Now although I might be a physician, I'm not your physician and this podcast is for educational purposes only.
Welcome back everyone to this episode of the Crunchy Allergist Podcast.
I am so excited to welcome those returning listeners back. And for those of you who are new to the show, welcome in.
We talk about all things, allergy, autoimmunity, and anti-inflammatory living, and we are going to hit all of those topics today, as we talk about *Chronic Hives,* or as I like to use both words, *Urticaria* is the fancy word or the medical word to describe hives. Many times affecting our lives in many different ways and can be incredibly aggravating and scary.
We are going to demystify hives and hopefully provide you with some empowering education on what's going on with your body when your immune system is deciding that it's gonna misbehave a little bit.
So unfortunately, our family has dealt with hives in several different varieties. This is one thing that I would totally have been okay just empathizing with my patients rather than actually having that firsthand knowledge. Each of my three kiddos has dealt with hives for different reasons and or swelling, which we'll talk about called Angioedema, and I have dealt with hives on occasion as well.
So let's dig in what exactly are hives.
There's a lot of confusion, even amongst medical persons and professionals as to what hives actually are and what they look like.
They are red, raised, intensely itchy, swollen lesion, so they look like bug bites or welts, and they will move around on the body.
They typically will go up and down over the course of minutes to hours. Usually not staying in one place for more than a day. They can occur anywhere on the body but in particular areas of the body, they are going to be more prone to show up as intense swelling or angioedema.
In about half of people who have hives, especially hives on a chronic basis, they will have associated angioedema or swelling.
Areas of the body that will present more as swelling are the eyes, the lips and the mouth, the hands, the feet, and then the genital area.
In part, this is because those areas of the body are very vascular. There's a lot of blood vessels there, and there's a lot of room in that tissue than to hold fluid.
That can really result in some pretty disfiguring swelling in some cases. When allergy cells, which we're gonna talk about, get triggered.
That is the root as what is triggering these symptoms.
We have allergy cells called mast cells, M-A-S-T like the mast of a ship. They are located all over our body, but there are a lot of them in our skin.
Mast cells are immune system cells.
Their purpose, when we were cave people, we're to protect us from parasite type infection.
Intestinal worms and related type bugs that we would be exposed to when we were out trying to outrun the lions and hunt down a gazelle and all of those things.
Thankfully nowadays, we are not exposed to parasite infection. Especially in the US, not on a regular basis.
But these cells are still present and they still have their machinery that was really optimized to fight off these types of invaders.
Mast cells have in them preformed little packets or granules of substances that would help expel worms from our gut or fight off some of these larger invaders, parasite infection.
Those preformed packets contain things like histamine, tryptase, and a whole host, whole long list of other chemical mediators that when released make us red itchy sneezy.
In the case of mast cells in our gut, we'll try to purge out whatever was in there.
Either end, either through vomiting or through diarrhea. And in our skin will result in these big, raised red itchy, bumps, or swelling.
Although we call them allergy cells, now that was not their initial purpose and it's not the only way that they get triggered nowadays. It's just an easy way for us to set them apart from the rest of the immune system cells.
These particular cells especially in the setting of someone who's dealing with hives on a regular basis, akin to my middle child who had just turned four, but like a preschooler toddler who has not had a nap and a snack, they can get a little irritable and they can just be ready to like explode at drop of a hat.
Certain things though can move them closer to triggering or to releasing these inflammatory mediators that then cause the symptoms of mast cells.
So what can move them closer to triggering?
We know that one of those things is if we're allergic. They're allergy cells.
On the surface of these mast cells are receptors that hold our allergy proteins or allergy antibodies.
They look like the letter Y and they're hanging out there. If you are an allergic person trying to look for something that our body has deemed dangerous, which really isn't, but that didn't quite get the memo.
If you're someone who has peanut allergy and it sees that peanut allergen, it will essentially be a triggering mechanism to turn on those allergy cells. Thus throwing up your peanut or having a more systemic reaction. Right?
The other situation mast cells in our nose, see that Birch tree pollen, achoo! Itchy, sneezy, red, lots of clear mucus coming from the triggering of those mast cells.
The allergy protein on the surface is one way that those can get triggered and that's how they get their name.
Okay, so let's dig in, what are those other things that can move these mast cells closer to being triggered?
*One are certain types of medications*.
There are certain medications that we know have function through specific receptors on these mast cells and can in certain individuals make them more primed to triggering.
Non-steroidal anti-inflammatories. Things like aspirin, aleve a.k.a. naproxen, ibuprofen also known as Advil, things in that family can, for some individuals, increase the risk of reacting.
Another family of medications are the narcotic pain medicine. Those pain medicines you may get after surgery or broken bone or dental work.
The oral medications may be things like oxycodone or hydrocodone. Those are things in Percocet and Vicodin.
But also the IV versions you may get after a surgery. It's not uncommon to hear that someone got really itchy after getting a dose of morphine. This is part of that mechanism.
Infections can also increase the likelihood that these cells may get triggered.
*Another common cause of urticaria or hives is infection. *
Especially viral infection, which just tends to cause our immune system to go into hyperdrive or into this state of dysregulation where things are just off kilter and not functioning.
Quite normally, this is what has happened, especially in my middle child, Josephine, she as a little baby would get these bad daycare bugs. Tons of nasal drainage, little bit of fever, nothing that would set off total alarm bells, but she would get these huge welts. These itchy welts all over her bottom. She had puffy eyes, the angioedema on several occasions.
As my kiddo who also had hives from her egg allergy, this was hard to distinguish right in the setting. Thankfully we knew when her symptoms persisted outside of when she had eaten anything that she woke up with these symptoms.
Me as an allergist, I knew that this then, especially with her runny nose and everything going on, was related to viral infection. But when it first comes up, that can be incredibly scary for any parent to see their kiddo itchy, swollen, not looking like themselves.
Many times this will happen even in the setting of taking maybe an antibiotic.
Little kiddo has an ear infection. Ear infections can be viral and or can be bacterial.
Many times it's a viral infection that then transforms into a bacterial ear infection. We'll prescribe something like amoxicillin.
It is a great first line antibiotic for ear infections, kiddos taking the amoxicillin that bubblegum medicine and develops hives.
What is the first thing we think about? Is this an allergic reaction to the medication?
Interestingly, many times we're able to hindsight deduce that this is not. But that should be taken into discussion with your healthcare team and your kiddo's health history and everything as well.
But many times through taking a very careful history, we're able to help really delineate.
Was this allergy to the medication? Or was it maybe the illness itself?
Hopefully help take that allergy off your kiddo's list in the long term, but in the moment puts us into fight or flight. Puts us into protect our kiddo mode.
Even as a pediatrician, many times, we'll say, "yeah, let's stop that medicine just in case and come back to it later."
That is another instance of where our mast cells can get triggered.
There also is thought to be, especially in chronic hives.
Hives that are occurring on a regular basis for over six weeks in time, this is what's called *chronic hives,* or *chronic urticaria* and angioedema, it's the fancy long term for it.
In that instance, many times this is due to an autoimmune phenomenon.
We still don't have the code completely cracked but what we believe is happening is that there is some relationship between the receptor that is holding that allergy antibody in place.
Something going on with that receptor and that receptor getting turned on inappropriately.
In part, how we know this and how we're deducing this is in about 30% of folks who have chronic hives, they will have some blood proteins or antibodies that are specific for that receptor.
We know that there is a protein that is seeing that receptor is the danger signal, when it shouldn't be and that's, what's turning it on.
We also know that many of our patients, especially those who are not improving with our standard treatments, will really benefit from a medication called omalizumab also known as xolair.
These are month, typically monthly injections, that are directed to that particular receptor.
Those patients will tend to get better very quickly, sometimes within a dose or two, maybe three, and they are having really significant relief from their red itchy hives, their swelling.
We know that a mechanism at that receptor docking spot is implicated in many folks who have chronic hives.
We are still hard at work trying to understand the exact specific things that are going on that are causing and resulting in this state of immune dysregulation.
I have also seen, we were talking about infections and autoimmunity, there does tend to be some relationship at times between autoimmune thyroid or Hashimotos and chronic hives.
We know that these two conditions will tend to occur in the same folks a little more often. We're not sure exactly what that connection is just that there is that relationship.
True and related, true and unrelated.
This is still something that is up for discussion and up for improved study and understanding.
So what do we typically do about hives?
Typically if a patient comes to see me, they've been dealing with hives that have been occurring for a long term basis, more than a couple weeks may not even have hit that six mark, I'm already, the hamster wheel is the spinning, I'm already thinking about all of those different potential causes and all of those different potential exacerbating factors that may be playing a role.
One exacerbating factor that we haven't talked about yet is physical disruption of the cells.
These mast cells, as I mentioned, they're pretty twitchy, little buggers, and sometimes just the physical disruption of that cell wall will cause them to trigger.
And this can occur in many different ways.
It can occur from temperature change.
Some folks will have cold induced urticaria. They go out in the cold, then they come indoors, they warm up, have their hot cocoa and they get really itchy and have hives.
There are some folks who when they sweat, something called cholinergic urticaria, they will get these pinpoint little hives rashes all over.
There are some folks that pressure, wearing a heavy backpack, heavy purse that will induce hives in that area.
And then my favorite to talk about is something called dermatographism, writing on the skin.
This is a situation where it's the itch that rashes.
We have an itch, we scratch, that scratching turns on those mast cells even more, lo and behold, you end up with hives rashes where you are scratching.
This can make for some really fun images. If you do a Google search with people, taking advantage of this quirk that their bodies are experiencing and get quite artistic.
This is something I have been experiencing post COVID.
We can see sometimes in a post viral inflammation or post viral flare up of these symptoms that our immune systems can become a little more dysregulated and result in increase of these symptoms.
I'm doing my best not to scratch, but sometimes it is incredibly hard.
Me telling someone not to scratch their itch is not terribly helpful.
Though it can keep those cells from triggering even more, but many times that drive to scratch is primal.
We do it in our sleep.
Babies do it even starting as young as like under three months.
We'll start scratching at their skin if they are itchy.
So what are we going to do about it? What am I gonna talk to patient about in the office? We are going to dig into the history.
I put my Sherlock Holmes, detective hat on, and we go through everything.
When did it start? What was going on? Are you worried about any potential triggers? What have you tried? What has helped, what hasn't helped? What do you think is making it worse?
If anything, many times people are like, "I've rocked my brain. I can't find anything."
It's just going to the beat of its own drum and that is really assigned to me that many times this is more of an autoimmune type phenomenon. Something in that vein.
But we really dig in and I ask a lot of questions about those exacerbating factors, potentially triggering factors, and other conditions that may be associated with chronic hives.
Looking for other maybe autoimmune diagnoses that have been made or that I maybe suspicious of.
I'm doing a really good thorough review of systems, head to toe, what's going on with your body and trying to figure out if we need to do some additional workup to understand what might be going on.
Do we need to check your vitamin D? Do we need to make sure that their your blood counts are okay? Do we need to look for thyroid dysfunction?
A really thorough history and physical exam is gonna help direct specify what additional workup may be indicated. Many times we don't have to do any additional workup and that is great.
Then how are we going to help you feel better?
One thing that I love reassuring patients is, if their symptoms are more suggestive of this chronic hives, I can reassure them that they it's going to be extraordinarily rare that they would ever need an epinephrine pen or an EpiPen.
This condition just doesn't go to the voice box or cause a life threatening reaction.
Now I need to talk with someone, get a really thorough history and physical though, to make sure they're not dealing with something like a mast cell disorder, mastocytosis, mast cell activation.
All things I'm thinking about as we're talking with this patient.
Making sure it's not this new alpha gal or meat allergy situation that you can get from tick bites, more on that on a future episode.
These are all things that's really important to have a thorough evaluation and discussion with your allergist immunologist to make this diagnosis and to really make sure we're not missing anything.
We haven't missed anything and or we are working on working things up, but we wanna get you some relief.
Allergists on the whole, we do not like diphenhydramine or Benadryl, it's a little inside tip.
Only lasts about four to six hours, incredibly sedating or sleepy inducing. Results in increased falls, especially in those who are already at an increased risk of falling. And it dries us out, especially for anyone who's dealing with dryness at baseline.
What do we use instead of Benadryl?
We prefer long acting, less sedating antihistamines.
These are second generation antihistamines and third generations, too.
Which include things like loratadine a.k.a. Claratin, cetirizine a.k.a. zyrtec, fexofenadine which is Allegra. Those are the second generation.
Third generation are things like dust loratadine, clarinex, or levocetirizine which is xyzal.
Generally speaking, these third generations don't offer you that much additional benefit for the cost increase that you will see on their sticker price.
With these medications too many times, we'll need to push the doses up to higher doses than what you would read on the label.
Those doses are typically sufficient for stuffy noses, itchy, watery eyes, but not as sufficient to give you coverage for all of those mast cells all over your body.
Of course, you're gonna wanna do this in discussion with your personal healthcare professional. But this is something that you many times will hear us recommend.
These will close the front door of these mast cells, now we wanna close the back door.
Sometimes we'll use H2 blockers, which you may also known as stomach acid medicine. Like Famotidine, which is Pepcid that is gonna close the back door of these allergy cells.
In some instances, give us symptom control other medications that may come up for discussion something called singular montelukast this is called a leukotriene inhibitor.
It is a medication that blocks a different inflammation chemical family called Leukotrienes. And it is useful also in allergies and in mild asthma as well.
This medication is one we've used for many years, but it does have a black box warning on it. It can cause mood issues, decreased mood, depression, anxiety, bad dreams.
This is something to be conscientious of to watch out for and to stop if there's concern about.
But overall it is a very safe and useful medication for many of my patients.
Something that you should talk with your docs about, be conscientious of, and and just watch for any of those potential side effects.
Say our medication, these medications are not doing it. Then we have other tricks up our sleeves.
We have that omalizumab or xolair injection I talked about, but there are also many other medications that we used before xolair was available. Xolair's only been available for me the last 15, 20 years.
We have a good track record with it, but it may and it may not work for some people. Some folks may be a good candidate for it.
We do have other medications that we'll use things like cyclosporine, cephalexin, dapsone, hydroxychloroquine, tacrolimus, there's a whole list. Many of these medications, if you Google them, you are going to see some very scary side effects and potential things.
These are things we're trained to look out for, to screen for, to see what might be the best fit, given your other healthcare, other health diagnoses.
They many times will require some lab monitoring to watch out for side effects that can occur with these medications.
The good news is these medications have been around for decades, so we know what to look out for. That is one of the benefits of using, big pharma meds.
They of course have their disadvantages, right? They do have different side effects, but we know what they are and we know what to look out for and we are trained in those.
That is the one problem that will come up with certain supplements and other things that you'll find in the wellness market place is that we don't have a good way of keeping track of what these different side effects may be and knowing who might be more susceptible.
Who are they a good fit for? Who are they not a good fit for? And a way to report these suspected issues so that they are compiled somewhere.
That is one of the disadvantages of using something that is not within kind of that prescription or conventional kind of medication sphere.
Everything comes with pros and cons.
We don't like to ignore the gray area here on the Crunchy Allergist Podcast.
This is something we try our best to lean into because it is so important and there is so much that is lost when you avoid the nuance that is really important in medical practice. It's a practice. It is not a cookbook.
There are broad generalities, but we are all very unique in who we are as a human, our microbiome, our preferences, our backgrounds, we all walk through life with a different set of lenses.
On mine, typically are smudge from either rubbing my eyes or my kids fingers and I think that is just a really good analogy that we are all human.
We are all imperfect and we all have biases and it's really important to be aware of those.
To welcome them, to understand them, and to embrace all of our humanity.
I hope that you have learned a little something new about Chronic Hives today. If you were to have hives in a more acute setting eat something.
You're stung have a first dose of a medication, especially these are all situations where we would be more worried about an acute allergic reaction.
Anytime you're worried, we want you to reach out to us, reach out to your healthcare professional that is your doctor. I am not your doctor. This is just for educational purposes. They are going to know you best.
In an emergency situation, you want someone who in a perfect world knows you and/or knows how to handle the situation.
Thank you so much for joining me today. I look forward to seeing you again, next episode.
If you found this episode to be helpful, if you were able to gather some pearls and find something useful to take out into the rest of your day, I would love for you to hop over to Apple podcasts and leave us a five star review.
I would love for you to share this with your friends, your family, that is only gonna help us get the word out, to share this education, to share this resource and to make more episodes possible to help share all things, allergies, autoimmunity, and anti-inflammatory living in this intersection between things that are naturally minded and scientifically grounded.
Thank you so much for joining us this week. And I look forward to talking with you again next week.
