Hives

 


A common presenting complaint, do not simply pass off these individuals as a hypersensitivity reaction or benign condition without ruling out the multiple causes of hives precipitation.  It’s best to isolate them into 5 broad categories…

Infectious

Environmental

Physical

Malignant

Autoimmune
Pharyngitis Heat/cold exposure Pregnancy (PUPPP) Lymphoma Rheumatoid arthritis
URI/GI/GU infx Food allergies Stress Leukemia SLE
Fungal/parasitic infx Dust, molds, pollens, danders Exercise Other carcinoma Polymyositis
Virus (coxsackie, hepatitis, EBV, etc) Sulfites, tartrazine, benzoates

Vasculitides
Mycoplasma Water exposure

Amyloidosis
Syphillis Sun exposure

Sarcoidosis
Malaria


Hyperthyroid

 

  • Workup
    • Physical exam
      • HEENT: pharyngitis? thyroid dz? Lymphadenopathy
      • CV/Resp: URI? axial lymph nodes
      • Abd: Signs of liver dz?
      • Skin: Signs of autoimmune dz, check feet for fungemia
    • Definition of a “Hive”
      • Well-circumscribed, raised, blanching lesion w/ erythematous borders and central pallor
      • Linear, circular, or serpiginous; tend to be migratory and transient
  • Labs
    • If acute, not needed
    • If chronic (>1wk), consider CBC, CMP, ESR, CRP, CXR
      • Eosinophilia? Leukocytosis? LFT elevation? Inflammation?
  • Treatment
  1. Antihistamines
    1. First-line, should be initial treatment of choice
      1. Hydroxyzine, Benadryl, brompheniramine, loratadine, fexofenadine, certrazine
    2. For cold urticaria, cyproheptadine (2-4mg bit/tid) might be best
    3. For cholinergic urticaria (exercise/stress/heat) , hydroxyzine might be best
  2. Steroids
    1. Second-line, employ only if antihistamines fail