Hives, known medically as urticaria, are raised itchy patches of skin that can come up within minutes and usually fade within a day. For most people they are a one-off reaction to a food, medicine, insect bite or infection. For others the rash keeps returning for weeks or months with no obvious trigger. That long-lasting form is called chronic urticaria, and it is managed very differently from the acute kind.

Acute versus chronic

Acute urticaria lasts less than six weeks and is often linked to an identifiable trigger: a new food, an antibiotic, a viral infection or a bee sting. It usually settles on its own.

Chronic urticaria is defined as hives occurring on most days for six weeks or more. In roughly half of cases no cause is ever found; this is called chronic spontaneous urticaria. Some people have a physical trigger such as pressure, cold, heat, sunlight or exercise, which is called chronic inducible urticaria. It is not the same as an allergy, and standard allergy tests are usually normal.

What pharmacies can offer

The first-line treatment for any urticaria is a non-sedating antihistamine taken regularly, not just when the rash appears. Most are available to buy.

• Cetirizine 10 mg once a day. Widely available, cheap, a small chance of drowsiness.
• Loratadine 10 mg once a day. Rarely causes drowsiness.
• Fexofenadine 120 mg or 180 mg once a day. Available without prescription at pharmacy supervision level since its reclassification.

Older sedating antihistamines such as chlorphenamine (Piriton) help some people sleep through severe itching but are not first-line for daily control because of next-day drowsiness.

Why dose sometimes needs to go up

National guidance from the British Association of Dermatologists accepts that some adults with chronic urticaria need up to four times the standard licensed dose of a non-sedating antihistamine to control symptoms. That off-label escalation must be directed by a GP or dermatologist, not self-initiated. A pharmacist will not supply a four-times dose off the shelf.

Red flags that need urgent care

Call 999 or go to A&E if hives come with:

• Swelling of the face, lips, tongue or throat.
• Difficulty breathing, wheeze or a tight chest.
• Feeling faint, fast heartbeat, or collapse.

These are signs of anaphylaxis, not ordinary urticaria.

When to see a GP rather than self-manage

Book a routine GP appointment if:

• Hives have been present on most days for more than six weeks.
• Standard doses of a non-sedating antihistamine are not controlling the itch.
• The rash is accompanied by joint pain, fever or weight loss.
• The same medicine seems to set it off each time.
• The patches leave bruises or take more than 24 hours to fade — this can indicate urticarial vasculitis, which needs investigation.

Specialist treatments for chronic urticaria that does not respond to antihistamines include montelukast, ciclosporin and the biologic omalizumab. These are hospital-initiated.

Managing flares at home

Cool showers, loose cotton clothing and avoiding known physical triggers can help. Keeping a simple symptom diary for two to four weeks, noting foods, medicines, stress and weather, gives a GP useful information even when no single trigger is identified.

Finding a pharmacy

A community pharmacist is a good first stop for advice about which antihistamine to try, how long to take it for, and whether it is safe alongside other medicines. Use PharmSee's pharmacy directory to find one with late or weekend opening.

Sources

• NICE Clinical Knowledge Summaries: Urticaria
• British Association of Dermatologists: Urticaria and angioedema patient information leaflet
• British National Formulary: cetirizine, loratadine, fexofenadine
• NHS: Hives