Hives (urticaria) are raised, itchy welts that appear suddenly, last minutes to hours, and move around the body. Acute hives last less than six weeks and are usually triggered by an infection, food, or medication. Chronic spontaneous urticaria (CSU) is hives that recur most days for more than six weeks without an identifiable external trigger; it affects about 1 percent of people, is twice as common in women, and often comes with swelling of the lips, eyelids, or hands (angioedema). CSU is an immune condition, not an allergy, and it is highly treatable.

What causes hives?

Mast cells in the skin release histamine and other chemicals, producing the welt. In acute hives the trigger is often a viral infection, a food, or a drug such as an antibiotic or NSAID. In chronic spontaneous urticaria, the immune system activates mast cells directly, in about half of patients through autoantibodies. Physical triggers (pressure, cold, heat, exercise, sunlight) cause inducible urticaria. Extensive allergy testing rarely finds a cause in chronic hives and is not routinely recommended.

What are the symptoms?

Pink or skin-colored welts of any size that itch, blanch when pressed, and resolve within 24 hours without leaving marks, only to appear elsewhere. Swelling of the face, lips, or hands with or without welts. Hives that last longer than 24 hours in one spot, bruise, or are painful rather than itchy need evaluation for urticarial vasculitis. Hives with trouble breathing or throat tightness are an emergency.

How are hives treated?

Second-generation antihistamines (cetirizine, fexofenadine, levocetirizine) are first-line and are safely increased to four times the standard dose under guidance. For chronic hives not controlled by antihistamines, omalizumab (Xolair) injections control symptoms in most patients within weeks; dupilumab is also approved for CSU, and remibrutinib, an oral BTK inhibitor, is a newer option. Short steroid courses are used only for severe flares. Most patients with CSU eventually go into remission, and treatment is stepped down as they do.

How Tono treats hives

Tono's board-certified dermatologists see patients with hives within days, not months, by video visit in 33 states and in person at Tono clinical centers. Chronic hives are diagnosed on history and examination and managed well by telehealth: antihistamine titration, prescribing and prior authorization for omalizumab or dupilumab, and follow-up with a symptom diary and photos. We coordinate with allergy when an inducible or allergic component is suspected. Your visit ends with a written plan, prescriptions sent to your pharmacy, and follow-up scheduled with the same dermatologist. Most insurance is accepted and no referral is required.

When should I see a dermatologist for hives?

See a dermatologist if hives have recurred for more than six weeks, if standard-dose antihistamines are not controlling them, if you are having facial swelling, or if welts last more than a day or leave bruises. Seek emergency care for hives with difficulty breathing or swallowing.