Chronic urticaria, commonly known as chronic hives, affects thousands of people who experience recurrent episodes of itchy wheals, swelling, and discomfort that can persist for months or years. Until recently, both patients and doctors approached the condition as an allergy that required identifying and avoiding triggers. However, current research has changed this understanding significantly. Chronic urticaria, particularly chronic spontaneous urticaria (CSU), is now recognised as long-term immune-mediated disorder that needs sustained treatment and monitoring.
Identifying immune-driven diseases
According to Jyothsna Dasararaju, senior consultant dermatologist and cosmetologist, Kauvery Hospital, Vadapalani, Chennai, chronic urticaria was earlier treated as a persistent allergic reaction. “The earlier medical approach focused heavily on identifying triggers such as food, environmental allergens, infections, or stress. However, current research shows that the disease can continue without any contact with external triggers,” she explains.
Katheeja Nasika, consultant, department of dermatology, Rela Hospital, Chennai, adds that CSU is now recognised as an immune-mediated condition in which mast cells in the skin become chronically activated, often due to autoimmune mechanisms.
Pushpa Gnanaraj, senior consultant dermatology, Apollo Speciality Hospitals, Vanagaram, Chennai, notes that this shift has changed how clinicians manage the disease. “Instead of endlessly searching for triggers, the focus is now on long-term disease control, similar to how asthma and other chronic inflammatory disorders are treated,” she says.
Investigating the triggers
Doctors still recommend a basic evaluation that includes a detailed medical history, clinical examination, and essential tests to rule out infections, systemic illnesses, or drug reactions. However, specialists warn that excessive investigations can delay treatment.
“If urticaria persists beyond six weeks and routine tests fail to show infection, systemic disease, or medication-related problems, further investigations rarely provide useful information,” says Dr. Nasika. She points out that continuing extensive testing may increase patient stress and delay relief.
Dr. Gnanaraj also emphasises that repeated investigations often add anxiety and financial burden without improving outcomes, particularly when there are no warning signs of underlying disease.
At this stage, dermatologists recommend adopting a treatment-focused approach that prioritises symptom control and quality of life.
Types of chronic urticaria
Chronic urticaria is broadly classified into chronic spontaneous urticaria and chronic inducible urticaria, and understanding the distinction is essential for treatment.
Chronic spontaneous urticaria occurs without any identifiable or reproducible trigger. Its symptoms can appear unpredictably and cannot be reliably recreated during testing. Patients with CSU often require continuous medical management because avoidance strategies alone are ineffective.
Chronic inducible urticaria, on the other hand, occurs in response to specific physical stimuli such as heat, cold, pressure, exercise, or friction. Doctors use controlled testing methods to identify these triggers. However, specialists say that even when triggers are identified, patients may continue to experience episodes.
“Unintentional exposure during daily activities is common, which is why treatment requires medication in addition to avoidance measures,” says Dr. Dasararaju. Dr. Nasika adds that patients with inducible urticaria may still have multiple flare-ups before effective medical intervention is achieved.
Experts emphasise that frequent flare-ups despite avoiding suspected triggers usually indicate that the disease itself is not adequately controlled rather than poor patient compliance.
Emotional burden
Chronic urticaria can have a significant impact on mental health and daily functioning. Patients often experience sleep disturbances, reduced work productivity, and emotional stress caused by unpredictable symptoms.
“The medical community needs to move from repeatedly asking ‘why is this happening?’ to evaluating ‘how well is the disease being controlled?’,” says Dr. Dasararaju.
Dermatologists recommend structured follow-up visits that include standardised symptom assessments and regular medication adjustments based on individual patient needs.
Counselling also plays an important role. Dr. Gnanaraj says patients must be reassured that chronic urticaria might not be dangerous, nor progressive,“The absence of a clear trigger does not mean a poor prognosis. The condition is highly manageable and treatable,” she explains.
Treatment needs and approaches
Doctors decide to intensify treatment based on the severity and impact of symptoms rather than how long the disease has persisted. Patients who continue to experience hives, swelling, or sleep disturbances despite standard antihistamine therapy may require advanced treatment options.
Modern management strategies also include targeted therapies such as biologic agents, which help control disease activity by addressing specific immune pathways.
Dr. Nasika explains that escalation of therapy is considered when conventional treatment fails to provide adequate symptom relief. “These therapies are evidence-based and aim to restore normal quality of life,” she says.
Addressing concerns about long-term medication, specialists stress that advanced treatments help stabilise the disease and do not create dependence. According to Dr. Gnanaraj, chronic urticaria often enters remission over time, and treatment plans are regularly reviewed to assess whether medications can be reduced or stopped.
“Escalating treatment should not be seen as a failure. It is a proactive step that helps patients live comfortably while the disease settles,” she says.
The current medical approach to chronic urticaria focuses on continuous monitoring, individualised treatment plans, and long-term management strategies.
As research continues to refine treatment strategies, dermatologists highlight that early diagnosis, consistent follow-up, and patient education remain key to managing chronic urticaria effectively.
Published – February 11, 2026 04:37 pm IST