Urticaria and angioedema are more than just itchy skin or puffy lips-they’re signals your body is reacting in ways that can be harmless, alarming, or even life-threatening. If you’ve woken up with raised, red welts that come and go, or noticed your lips or eyes swelling without warning, you’re not alone. About 20% of people will experience hives at least once in their life. For 1 in 100, those hives stick around for months or years. And in up to 1 in 5 of those cases, the swelling goes deeper-into the skin and tissue beneath-becoming angioedema. The big problem? Most people treat them the same way, and that’s where things go wrong.

What’s the Difference Between Hives and Angioedema?

Urticaria, or hives, shows up as raised, red, itchy bumps on the skin. They look like mosquito bites but can join together into large, angry patches. They come and go within hours, often fading without a trace. Angioedema, on the other hand, isn’t itchy. It’s deep swelling-usually around the eyes, lips, tongue, throat, hands, or feet. It feels tight, warm, and sometimes painful. You won’t see a raised bump. You’ll just notice your face looks different.

Both are caused by mast cells releasing chemicals, but the key difference is which chemical is driving the reaction. In most hives and some angioedema, it’s histamine. In other cases-especially when there’s no itching-it’s bradykinin. And this distinction changes everything about treatment.

Acute Urticaria and Angioedema: What to Do Right Away

If this is your first time dealing with hives or swelling that started suddenly, you’re likely dealing with acute urticaria or angioedema-symptoms lasting less than six weeks. The trigger? Often something clear: a new medication, a food allergy, a bug bite, or a viral infection.

First rule: Stop any ACE inhibitor if you’re taking one. Drugs like lisinopril, enalapril, or ramipril are the #1 drug cause of angioedema. If you’ve started one in the last few months and now have swelling, stop it immediately. Don’t wait. Don’t call your doctor tomorrow-stop it today. Symptoms usually fade over 3 to 4 months after stopping, but the swelling can get worse before it gets better.

If you’re having trouble breathing, your tongue is swelling, or you’re drooling or using your neck muscles to breathe, this is an emergency. Epinephrine is the only thing that can stop this from becoming fatal. Call an ambulance. Use an EpiPen if you have one. Antihistamines won’t help here. Steroids won’t help here. Only epinephrine buys you time.

If you’re not in immediate danger but still have hives or swelling, start with a non-sedating antihistamine: cetirizine (10mg), loratadine (10mg), or fexofenadine (180mg). Take it once daily. Most people see improvement within hours. If it doesn’t help after a day, double the dose. Yes, double it. Guidelines from the British Society for Allergy and Clinical Immunology and NICE support using up to four times the standard dose for stubborn cases. Cetirizine at 40mg a day is not unusual for chronic cases-and it’s safe.

Chronic Hives: The Long Game

Chronic spontaneous urticaria (CSU) means hives or swelling lasting six weeks or longer with no clear trigger. It’s not allergies. It’s not stress. It’s your immune system mistakenly attacking your own skin cells. About 75% of chronic cases fall into this category. And yes-it can last for years.

First-line treatment is still antihistamines. But here’s the catch: standard doses only work for about half of people. The other half need higher doses. Don’t give up after one pill. Try cetirizine 20mg. Then 30mg. Then 40mg. That’s four times the normal dose. Studies show this boosts success rates from 50% to over 80%.

Still not working? Add a second antihistamine. Some people respond better to loratadine in the morning and fexofenadine at night. Others need H2 blockers like famotidine (20mg twice daily) added in. This isn’t off-label magic-it’s backed by the NHS and BSACI guidelines.

Next step: montelukast. This asthma drug blocks leukotrienes, another inflammatory chemical. It’s especially helpful if you also get hives after taking NSAIDs like ibuprofen. Take 10mg at night. It’s not a cure, but it can reduce flare-ups.

If you’ve tried all that and still have hives daily? Omalizumab. It’s an injection given every four weeks. It’s expensive-around £1,200 a month-but it works for 60-70% of people who’ve failed everything else. It’s not a steroid. It doesn’t weaken your immune system. It just calms down the overactive mast cells. You need a specialist to prescribe it, but it’s the most effective long-term option for chronic hives.

Angioedema Without Hives: Don’t Treat It Like Hives

This is where most people get it wrong. If you have swelling-especially around the lips, tongue, or throat-but no itching, no redness, no hives, it’s likely bradykinin-mediated angioedema. This includes cases caused by ACE inhibitors, hereditary angioedema (HAE), or sometimes even unknown triggers.

Antihistamines? Useless. Epinephrine? Doesn’t help. Steroids? Waste of time and risky. Giving these to someone with bradykinin angioedema doesn’t just do nothing-it exposes them to side effects like weight gain, high blood pressure, or mood swings for no benefit.

What does help? Airway monitoring. If you’re not struggling to breathe, the best thing you can do is wait. Swelling from ACE inhibitors usually goes down on its own within 24 to 72 hours. Keep your head elevated. Avoid alcohol, spicy foods, or anything that might worsen swelling. Stay calm.

If you’re having trouble breathing, you need hospital care. Intubation may be needed. But don’t expect antihistamines or steroids to fix it. For true bradykinin angioedema, specific drugs like icatibant or C1 esterase inhibitor concentrate are required. These aren’t available in most GP offices. They’re reserved for specialists and emergency departments.

What to Avoid

There are hidden traps that make hives and swelling worse. First: NSAIDs. Ibuprofen, naproxen, diclofenac-they trigger or worsen hives in 20-30% of chronic cases. Switch to paracetamol if you need pain relief.

Second: ACE inhibitors. If you’ve had angioedema once, you can’t take them again. Not even if you’re told it’s “safe.” The risk of recurrence is too high. If you need blood pressure control, ARBs like losartan are safer-but still carry a 10% risk of angioedema. Monitor closely.

Third: steroids for the long term. Yes, doctors sometimes prescribe prednisone for severe flare-ups. And yes, it works fast. But using it for more than 5 to 10 days increases your risk of diabetes, osteoporosis, cataracts, and adrenal suppression. It’s not a cure. It’s a band-aid. Never use it for chronic hives.

Fourth: unnecessary testing. Most people with chronic hives don’t need allergy tests. You’re not allergic to your own skin. Blood tests for food allergies in CSU patients rarely find anything useful. Focus on medication review and symptom tracking instead.

When to See a Specialist

You don’t need to see an allergy specialist for every case of hives. But you should if:

• Your hives last longer than six weeks
• You have swelling without itching
• Antihistamines at high doses don’t help
• You’ve had angioedema more than once
• You have a family history of swelling episodes
• You’re pregnant or breastfeeding and need safe treatment

Specialists can test for hereditary angioedema by checking C4 levels. Low C4 means you need a different treatment plan entirely. They can also prescribe omalizumab, evaluate for autoimmune causes, or rule out rare conditions like mastocytosis.

Living With Chronic Hives

Chronic urticaria is exhausting. You never know when the next flare will hit. You might cancel plans because your skin is burning. You might avoid certain foods or clothes just in case. But here’s the good news: most people go into remission within 5 years. Studies show 65-75% of chronic hives cases resolve on their own.

Track your symptoms. Note what you ate, what meds you took, stress levels, sleep, and weather. You might spot patterns. Some people flare with heat, exercise, or pressure from tight clothing. If you have inducible urticaria, avoiding triggers can cut flares by half.

When symptoms improve, don’t stop antihistamines cold turkey. Taper slowly. Reduce by one tablet every 6 to 8 weeks. Stopping too fast can cause a rebound flare. Patience matters.

What’s New in Treatment

The biggest shift in recent years is understanding that angioedema without hives isn’t an allergy. It’s a different disease. That’s why treatments that work for hives fail for swelling.

Research is now looking at other biologics beyond omalizumab. Drugs like ligelizumab and teprotumumab are in trials and show promise for people who don’t respond to current options.

Also, doctors are getting better at spotting drug triggers. DPP4 inhibitors (gliptins) for diabetes, like sitagliptin, can cause angioedema in 1 in 500 users. If you’ve started one and got swelling, it’s worth discussing.

And for breastfeeding mothers: cetirizine and loratadine are still the safest choices. They pass into breast milk in tiny amounts. No need to switch to sedating antihistamines.

Bottom Line

Urticaria and angioedema aren’t one condition. They’re two faces of the same problem-with different causes, different treatments, and different risks. Treat hives with antihistamines. Treat angioedema without itching like a medical emergency-not an allergy. Stop ACE inhibitors. Avoid steroids long-term. Don’t waste time on useless tests. And know that chronic hives aren’t a life sentence. Most people get better. You just need the right approach.