Urticaria (Hives) Treatment in Ankara, Turkey

Urticaria treatment aims to control allergic skin reactions characterized by itching, redness, and swelling. The treatment process begins with determining the underlying cause and selecting the appropriate medications. Antihistamines are generally used as first-line treatment and are effective in relieving symptoms.

Chronic urticaria management aims to eliminate triggering factors and achieve long-term symptom control. While creating a patient-specific treatment plan, possible causes such as stress, food allergens, or drug sensitivities are evaluated. If necessary, immunological factors are investigated with advanced tests.

In cases that do not respond to antihistamine treatment, corticosteroids or immunomodulatory agents may be used as second-line treatment. These medications reduce inflammation by suppressing the excessive response of the immune system. However, their long-term use should be monitored carefully.

Lifestyle modifications are also important in urticaria treatment. Paying attention to factors such as regular sleep, balanced nutrition, and stress management may reduce the frequency of attacks. In addition, individualized treatment plans maintained under dermatologist supervision provide long-term improvement.

What Is Hives (Urticaria)?

Hives, also called urticaria, is an allergic skin reaction characterized by itchy, raised, and red rashes that suddenly appear on the skin. It usually resolves spontaneously within a few hours, but some cases may last for days. Allergens, infections, stress, medications, or physical factors (cold, heat, pressure) may be triggers.

Symptoms of Hives:

• Itchy, raised, and clearly bordered rashes
• Burning or stinging sensation on the skin
• Frequent movement of the lesions
• In severe cases, swelling (angioedema) of the lips, eyelids, or throat

What Is the Difference Between Acute and Chronic Urticaria?

The only and most important difference between these two conditions is duration.

If hives attacks have been continuing for less than six (6) weeks, this condition is called Acute Urticaria. Acute urticaria is very common in society and is usually triggered by an infection, medication reaction, or a certain allergen (such as food), and most of the time it resolves on its own.

However, if the rashes and/or swellings have been recurring for longer than six weeks (almost every day or several times a week), this condition is defined as Chronic Urticaria (CU). Chronic urticaria is different from acute urticaria; it may have more complex causes and can seriously affect the patient’s quality of life (sleep, work/school performance, social life). Its treatment also requires a longer-term and different approach.

What Are the Types of Chronic Urticaria?

Chronic urticaria (CU) is divided into two main subgroups depending on how the symptoms occur. This distinction is very important in determining the diagnostic and treatment approach.

• Chronic Spontaneous Urticaria (CSU)
• Chronic Inducible Urticaria (CIndU)

Chronic Spontaneous Urticaria (CSU): This is the type seen in most patients. As its name suggests, the rashes appear “spontaneously,” that is, completely on their own without a clear external trigger (such as cold, heat, pressure, or sunlight). This may be very confusing for patients because they cannot predict when and why the rashes will appear.

Chronic Inducible Urticaria (CIndU): In this type, the rashes are always triggered by a specific and reproducible physical stimulus. After the stimulus is removed, the symptoms generally disappear within a short time (within 30 minutes to 2 hours). The urticaria types in this group are named according to their trigger.

What Is the Main Goal in Urticaria Treatment?

The primary and clearest goal in chronic urticaria treatment is to bring the disease completely under control. This means the complete elimination of itching, swellings, and edema.

To measure this goal objectively, international guidelines use a scoring system called “UAS7.” The ultimate aim of treatment is to reduce this UAS7 score to zero (UAS7=0). This means the patient lives a symptom-free life and regains quality of life. The treatment process is managed in a dynamic cycle of “evaluate, adjust, apply, and re-evaluate” until this goal is reached.

How Does Your Doctor Measure the Severity of Your Urticaria?

To understand how severe chronic urticaria is and to monitor whether the treatment is working, a patient diary system called “UAS7” (Urticaria Activity Score over 7 days / 7-Day Urticaria Activity Score) is used. This is the most important tool guiding treatment.

The patient is asked to score two main symptoms every day for 7 days:

• Number of Swellings (Rashes): (0: none, 1: mild [less than 20], 2: moderate [between 20-50], 3: many [more than 50])
• Severity of Itching: (0: none, 1: mild, 2: moderate, 3: severe)

Each day, these two scores are added together (the daily score can be a maximum of 6). The sum of the 7-day scores gives the weekly UAS7 score. This score ranges between 0 (no symptoms) and 42 (maximum severity).

According to this scoring, disease activity is classified as follows:

0 Points (Disease under control / Symptom-free)

• 1–6 Points (Well controlled)
• 7–15 Points (Mild severity)
• 16–27 Points (Moderate severity)
• 28–42 Points (Severe disease)

Treatment decisions are made according to this score. For example, if the score is above 7, this means the treatment is insufficient and it is necessary to move to the next treatment step.

Why Are Blood Tests Requested for Chronic Urticaria?

In chronic urticaria lasting longer than six weeks, your doctor requests some basic blood tests to exclude other systemic problems that may underlie the condition or to see whether there is an inflammatory state. This is generally not necessary in acute urticaria.

The routine basic tests requested include:

• Complete Blood Count (Hemogram)
• CRP (C-Reactive Protein)
• ESR (Erythrocyte Sedimentation Rate)
• TSH (Thyroid function test)

These tests are requested to check for infection or rheumatic inflammation in the body, anemia, and especially thyroid diseases known to be associated with urticaria (for example Hashimoto’s thyroiditis). These are not “allergy tests.”

Is It Necessary to Have an Allergy Test for Urticaria?

This is the most frequently asked question by these patients. The answer depends on the type of chronic urticaria.

In Chronic Spontaneous Urticaria (CSU): If there is no clear and repeated suspicion in the patient’s history that urticaria developed immediately after taking a certain food or substance (for example a medication), routine food or respiratory allergy tests (skin test or blood allergy test) are not recommended. This is because the vast majority of CSU cases (more than 90%) are not related to a typical allergy. Therefore, having broad allergy panels done is generally unnecessary and inconclusive.

In Chronic Inducible Urticaria (CIndU): Allergy tests are generally meaningless because the problem is not an allergen but a physical stimulus.

When Is Biopsy Necessary in the Diagnosis of Urticaria?

Biopsy (taking a small piece of skin) is not necessary for most urticaria cases. The diagnosis is made based on the patient’s history and the clinical appearance of the rashes.

However, if a rash stays in the same place for longer than 24 hours, leaves a purple or brown mark as it disappears, or appears atypical, other diagnoses such as “urticarial vasculitis” (a condition involving vascular inflammation that mimics urticaria) are suspected. A biopsy is taken only in these suspicious cases to make a differential diagnosis.

Why Is the Autologous Serum Skin Test (ASST) Important in the Diagnosis of Urticaria?

In a significant portion of Chronic Spontaneous Urticaria (CSU) patients (between 35% and 58%), the condition may have an “autoimmune” basis. This means that the body’s immune system mistakenly develops a reaction against its own structures (in this case, antibodies that stimulate mast cells).

The Autologous Serum Skin Test (ASST) is a simple screening test used to investigate this autoimmune tendency.

During the test, the patient’s own blood is taken. This blood is centrifuged and the “serum” part (the liquid of the blood) is separated. Then this serum is injected into the patient’s own forearm with a small needle, into the skin. For control, saline (negative control) is injected next to it.

If after 30 minutes a larger swelling and redness (that is, a hives rash) forms at the site where the serum was injected than at the site where the saline was injected, the test is considered positive.

A positive ASST indicates that there are factors in the patient’s bloodstream (probably autoantibodies) capable of stimulating their own mast cells. A positive result generally indicates that the disease may be more severe and longer-lasting and may serve as a guide for the doctor in treatment planning.

How Is Physical (Inducible) Urticaria Diagnosed?

The diagnosis of Chronic Inducible Urticaria (CIndU) is made with “provocation (triggering) tests” to confirm the patient’s history. In these tests, the suspected physical stimulus is applied to the skin in a controlled manner and the reaction is observed.

Some common CIndU types and their tests are:

• Dermographism: (The most common type). Formation of swelling along the line when the skin is scratched with a blunt object (such as a tongue depressor).
• Cold Urticaria: Applying an ice pack or a special cooling device to the arm for 5-10 minutes. Formation of swelling in that area while the skin is warming after the ice is removed.
• Cholinergic Urticaria: (Triggered by exercise, hot showers, stress). The patient is made to exercise for 15-20 minutes (treadmill, bicycle) or is placed in a hot bath to raise body temperature. Small, itchy swellings are expected to appear together with sweating.
• Delayed Pressure Urticaria: Applying a fixed weight (such as a bag strap) to the shoulder or back for a certain period (for example 15-20 minutes). Symptoms appear 4-8 hours after the test.
• Solar (Sun) Urticaria: It is tested by applying controlled doses of UVA, UVB, and visible light sources to different areas of the skin.
• Aquagenic (Water) Urticaria: It is tested by applying water (generally at room temperature) to the skin.

What Can Worsen Hives (Urticaria) Attacks?

Regardless of the underlying cause, it is very important for chronic urticaria patients to avoid some general triggers that may worsen their symptoms. Even if you are receiving medication treatment, paying attention to these factors increases the success of treatment.

Main factors to avoid or be careful about:

• Some painkillers (NSAID group; ibuprofen, naproxen, diclofenac, etc.)
• Aspirin
• Excessively hot environments such as hot baths, Turkish baths, and saunas
• Tight clothing that compresses and puts pressure on the skin (belts, tight pants)
• Intense physical and emotional stress
• Alcohol consumption
• Flu infections or other febrile illnesses

In addition, scratching the rashes creates a vicious cycle. Scratching mechanically stimulates mast cells and leads to more histamine release, meaning more itching and swelling. Applying a cold compress or moisturizing the skin instead of scratching is more beneficial.

How Should Urticaria Medications (Antihistamines) Be Used?

This is one of the most critical points in this treatment. Antihistamine medications used in chronic urticaria treatment (especially second-generation ones) are used to “suppress” symptoms, not to “cure” them.

The most common mistake is taking the medication only when itching or swelling starts, that is, “as needed.”

In chronic urticaria, the correct approach is to take these medications regularly every day even if you have no symptoms. The aim is to keep the receptors that histamine acts on in the skin continuously occupied, even if histamine is released from mast cells, thus preventing the rashes from forming from the very beginning. Continuous use has been proven to be much more effective than as-needed use.

What Is the First Step in Urticaria Treatment?

The first-line treatment recommended by international guidelines in chronic urticaria treatment is the use of modern allergy medications known as “Second-Generation H1-Antihistamines” (sgAH) at the standard (licensed) dose.

Unlike first-generation (old-type) antihistamines (hydroxyzine, diphenhydramine, etc.), the greatest advantage of second-generation medications is that they pass into the brain much less. Therefore, they have a much lower risk of causing side effects such as significant drowsiness, grogginess, dry mouth, or impaired concentration. This allows the patient to be treated without impairing daily quality of life.

Some of the most commonly used second-generation antihistamines in this group are:

• Cetirizine
• Fexofenadine
• Levocetirizine
• Desloratadine
• Bilastine
• Ebastine
• Rupatadine

In the first step, one of these medications is selected and the response is evaluated after regular use for 2 to 4 weeks (using the UAS7 score).

What Is Done If the Standard Dose Urticaria Medication Is Insufficient?

Unfortunately, approximately 50-60% of chronic urticaria patients do not respond fully to the first-step standard-dose antihistamine treatment (that is, the UAS7 score does not fall below 7).

If the disease is still not under control despite 2-4 weeks of regular standard-dose treatment, Step Two is initiated.

Step Two is increasing the dose of the current second-generation antihistamine. International guidelines recommend increasing the standard doses of these medications up to four (4) times. (For example, increasing Bilastine taken once daily at 20 mg to 20 mg four times daily.)

Patients are generally concerned about increasing the dose this much, but clinical studies have shown that these second-generation medications remain quite safe even at fourfold doses (especially in terms of cardiac toxicity) and do not lead to a significant increase in the risk of serious side effects.

Which Urticaria Medications Are Preferred During Dose Increase?

When choosing a medication in Step Two (dose increase), safety and quality of life are as important as effectiveness. The goal is not to suppress symptoms by making the patient sleepy or groggy but to control symptoms without impairing quality of life.

For this reason, medications that cause the least drowsiness (sedation) and cognitive impairment even at high doses are preferred first.

Fexofenadine and Bilastine stand out as the most advantageous options in this regard. Both medications are known for not causing significant drowsiness or affecting cognitive performance even at high doses (Fexofenadine 540 mg/day, Bilastine 80 mg/day).

Cetirizine and Levocetirizine are also effective options, but in some patients, especially when the dose is increased, they may have a slightly higher potential to cause drowsiness or fatigue compared to the others.

Your doctor will determine the most suitable one among these options according to your individual response and tolerance.

What Is “Resistant Urticaria” and How Is It Treated?

If the patient is still not under control despite using Step Two treatment regularly for 1 to 4 months (that is, up to four times increased antihistamine dose) (if the UAS7 score persistently remains above 7), this condition is called “Resistant (Refractory) Chronic Urticaria.”

At this point, in addition to the current antihistamine treatment, it is necessary to proceed to Step Three treatment.

There are two main options in Step Three:

• Omalizumab (Biological Agent)
• Cyclosporine A (Immunosuppressant / Immune Suppressant)

Generally, Omalizumab is preferred first because it is a targeted (smart drug) treatment and has a much better safety profile.

How Does Omalizumab (Injection Treatment) Work in Urticaria Treatment?

Omalizumab is a modern treatment option known as a “biological agent” or “smart drug.” It is a specially produced “anti-IgE antibody” developed in the laboratory.

It targets one of the basic mechanisms underlying chronic urticaria. It finds the “IgE” molecules responsible for allergic reactions in the body and binds to them like a shield. By binding to IgE, it renders it ineffective and prevents it from binding to mast cells, which start the main alarm.

This action reduces the number of IgE receptors on mast cells and prevents mast cell stimulation (degranulation), that is, histamine release. As a result, it radically suppresses the main mechanism causing urticaria.

Omalizumab is administered once a month in the form of a subcutaneous injection at a dose of 300 mg (sometimes 150 mg). Response is generally obtained within the first few months and is closely monitored with UAS7 scores. This treatment has an extremely high success rate in patients who do not respond to antihistamines.

When Is Cyclosporine Treatment Used for Urticaria?

Cyclosporine A (CsA) is actually a very powerful “immune system suppressant” (immunosuppressant) medication used in organ transplant patients to prevent organ rejection.

In urticaria treatment, it is an option reserved in Step Three for very severe and resistant cases that do not respond to both maximum-dose antihistamines and Omalizumab treatment (or cannot use Omalizumab).

Cyclosporine works by suppressing the T cells (fighter cells) of the immune system and directly preventing histamine release from mast cells. It is generally used at doses between 200-300 mg per day and may be effective in resistant cases.

Why Does Cyclosporine Treatment Require Close Monitoring for Urticaria?

Cyclosporine is not a targeted or safe medication like Omalizumab or antihistamines. Since it suppresses the entire immune system and has the potential for serious systemic side effects, it requires very close medical monitoring.

The decision to use this treatment is made in cases where the potential benefits outweigh the serious risks.

The risks particularly monitored during this treatment are:

• Deterioration in Kidney Function (Nephrotoxicity): This is its most important risk. It may cause kidney damage in long-term use.
• Increase in Blood Pressure (Hypertension): This is a common side effect.
• Decrease in Blood Magnesium Levels
• Other Electrolyte Imbalances
• Increase in infection risk

For this reason, it is mandatory for patients receiving Cyclosporine treatment to have regular blood tests (especially kidney function tests such as creatinine, eGFR, and magnesium levels) and blood pressure measurements.

What Is the Most Important Message in Urticaria Treatment?

Chronic urticaria (hives) is an irritating and quality-of-life-reducing but manageable condition. Treatment is not a “quick fix” but an evidence-based, step-by-step process.

The most important thing in this process is to be patient and to be in full cooperation with your doctor. Taking your medications regularly as instructed, avoiding triggers, and honestly keeping your UAS7 diary are critical for treatment success. Even if you do not respond to standard treatments today, thanks to modern biological agents such as Omalizumab, it is now possible to achieve full symptom control (UAS7=0) in the great majority of patients.