If urticarial symptoms—redness, hives, and itching—persist much longer than 6 weeks, it is called chronic spontaneous urticaria. Discomfort can persist for several months or years, sometimes even for decades. Angioedema can also occur, especially in the facial area or on the hands and feet, and in the genital area. Now it is time to investigate the causes more thoroughly, and in this connection the doctor and patient need not adhere slavishly to the six-week limit. It depends not least on the severity of the discomfort.
Urticarial discomfort is always basically caused by the activation of mast cells. Therefore, discomfort can occur anywhere in the body where mast cells are present. Mast cells are found mainly in the skin and the mucous membranes of the respiratory and gastrointestinal tract. The activation of mast cells in the mucous membranes of the respiratory tract can lead to dysphagia and dyspnea, while the activation of mast cells in the gastrointestinal tract may cause abdominal pain, nausea, and diarrhea. Many patients also report indisposition, fatigue, headache, and joint pain that may occur during a severe urticaria attack.
Among the identified causes of such chronic spontaneous urticaria, in connection with which hives/angioedema may occur daily, weekly, or less frequently, are chronic infections or inflammatory processes (such as Helicobacter pylori), non-allergic hypersensitivity reactions to foods, food additives, and drugs (pseudo-allergies) and autoreactivity including autoimmune reactions (reactions caused by autoantibodies). That is, the body\’s immune system provides antibodies (immunoglobulins) against its own proteins. These are attacked by the defensive antibodies as if these antibodies were dealing with dangerous intruders such as bacteria. The body, as it were, fights itself. Therefore, we call such defense antibodies against “oneself” autoantibodies.
The search for the trigger (or triggers) is often detective work. The elimination of the underlying cause must be the goal of treatment of chronic urticaria. In the case of infection urticaria, then, the infection should be eliminated, and in the case of intolerance urticaria-inducing substances should be avoided. If such a treatment approach is not possible or not successful, a symptomatic treatment is used (see Therapy graphic in the section Therapy of Urticaria).
The pragmatic approach is therefore to maintain a symptom diary and to watch closely: Where do the wheals/angioedema occur? What time of day? In connection with certain activities, such as when showering or during walks in the winter? Is there a connection with work time and leisure time or with certain foods, activities, hobbies or diseases?
Where foods or food additives are suspected as the cause, a three-week elimination diet may be helpful. One can start, for example, with tap water, black tea, rusks and then continue with potatoes and rice etc.: if the symptoms disappear in this time, new foods can be gradually introduced until one comes across those that trigger an urticaria attack.
What kinds of discomfort are caused by urticaria?
Have you—perhaps when you were a child—ever gotten into stinging nettles? Then you surely still remember the itching and burning and the feeling of having to scratch. Usually, itching is the most unpleasant and agonizing symptom of urticaria. Affected patients can be “driven up the wall” and often do not sleep. Incidentally, the itching (in contrast to the itching associated with atopic eczema/neurodermatitis, for example) provokes rubbing and not scratching, that is, skin scratched raw by fingernails is seldom seen. Almost always, the affected skin is perceived as over-heated and after resolution of an episode as dry. Occasionally patients also report a burning of the skin; rarely, outright pain in the affected skin areas is reported. In patients with urticaria the wheals often occur all over the body, and not just once, but often several times a day and every day for months, years, and even decades.
During an urticaria attack, headaches or joint pain may occur. In such cases, it should first be established whether the hives, itching, or swelling are a consequence of the treatment of pain and have been triggered, for example, by the use of acetylsalicylic acid (ASA, e.g. in aspirin) or other chemically related drugs. We know that many medications can cause hives. Patients suffering from hives should take less problematic painkillers such as paracetamol instead of acetylsalicylic acid. In about one tenth of urticaria patients nausea, indigestion, or other breathing difficulties occur. In extreme cases, so-called anaphylactic shock may also occur in connection with cases of urticaria. However, pain may also be an indication of an inflammation, and it is known that chronic inflammation, i.e., inflammation that persists over a long period, can cause urticaria to persist.
Quality of life
It is not surprising that urticaria can have a negative effect on the quality of life of those affected. The effects of urticaria go far beyond the physical symptoms and can also have serious consequences with regard to the well-being and quality of life of those affected. The frequent failure of efforts to identify an underlying cause of urticaria, the unpredictable symptoms, and the significant burden represented by the disease very often lead to frustration among those affected.
The discomfort caused by urticaria can lead to sleep disturbances and lethargy. Itching and sleep disorders can have a negative impact on the careers. Many patients feel limited in everyday life. The disease also often leads to a restriction of social contacts and, subsequently, to isolation and loneliness. Not uncommonly, anxiety and depression occur. Sometimes, those affected are therefore plagued by thoughts of suicide. Urticaria is also a great burden on a partnership, and family life is strongly influenced.