Hives or urticaria are common allergic reactions. They are itchy, elevated, red blotches of varying size that appear suddenly and disappear mysteriously after hours to days. Hives may be associated with dramatic swelling reactions; swelling of the lips, eyes, and ears can suddenly and grotesquely alter the appearance of an allergy victim. Marked swelling especially of facial tissues is referred to as angioedema and is often associated with urticaria. Swelling of the lips and tongue may occur immediately after eating a food and may be life-threatening because of airway obstruction.

Stephen Gislason MD

Foods and drugs are the common causes of hives. Some patients get hives occasionally only when they ingest a specific food or food additives. Other get hives as a chronic problem which can go-on for years. Most studies of chronic hives suggest a very low  % of food allergy causes usually because diet revision attempts were inadequate to reveal the hidden food causes.

Acute Urticaria is Immediate Hypersensitivity

The type I version of urticaria tends to occur in acute discrete attacks and may follow the ingestion of specific foods, over-the counter medications, or prescription drugs. Atopic children with eczema and rhinitis are prone to urticaria from food. Hives are associated with high IgE and occur usually as acute food reactions. Hives also occur as a feature of anaphylactic reactions. The itchy, erythematous welts, typical of acute urticaria can occur in any distribution in the body.  Infants may develop facial wheals on contact with food. Adults often have a single bout of  hives when they encounter an unusual or seasonal food or take a drug. Hives following a strawberry feed in the summer or after a eating prawns at a sea-food restaurant are typical examples.

Treatment of acute hive attack may requires antihistamine for a few days. An injection of adrenaline can stop the hives in minutes and can be life saving if the hives are associated with swelling, wheezing, and shortness of breath. Drug therapy for UR involves antihistamines both H1 and H2 blockers may reduce the activity. If hive activity is recurrent or becomes chronic then prednisone will produce the most dramatic remission of symptoms, but the urticaria often flare after the dose of prednisone is reduced below a threshold level - in adults usually below 10 mg per day. Complete diet revision should be undertaken to remove food causes if the hives recur frequently or become chronic.

Delayed Hypersensitivity

Chronic urticaria is a different disease, occurring in a continuous or continuously intermittent series of skin eruptions, often associated with other symptoms. Most patients are not aware of the source of the hives. Although most patients' symptoms can be controlled with drug therapy, many suffer from symptoms for years. Numerous factors have been suggested for causing this disease such as allergy to foods, azo dyes, food preservatives, candida in the gut and traces of penicillin in dairy products. Occasional patient may benefit with elimination of single foods, but often, the cause of the disease remains obscure and multiple factors are likely to be involved.

Charlesworth stated (1) " Urticaria and angioedema are frustrating for patients as they go from one physician to another in hope of finding that extraordinary physician who will be able to identify the cause, eliminate the culprit and thus cure their hives. Physicians treating hives are equally frustrated...."

Both patient and physician would be less frustrated if they used the Alpha Nutrition Program - a standardized method of eliminating  the culprit and redesigning the diet to avoid hive recurrence.

Chronic urticaria should be classified as a delayed hypersensitivity disease and fits into the type III pattern of food allergy. There is no necessary association with Atopy, IgE, and skin tests are not helpful to locate the culprit (s). Hive may be the most obvious expression of an underlying food allergy (delayed pattern) which causes other symptoms but the connection may not be recognized.

Urticaria associated with CICs occurs with drug reactions and with infections such as hepatitis B. Chronic urticaria may be associated with a perivascular lymphocyte and mononuclear cell infiltrates and sometimes merges with more serious inflammatory skin lesions such as erythema multiforme, urticaria pigmentosa, dermatitis herpetiformis and bullous pemphigoid.

Investigations should be carried out to rule out hidden diseases, although seldom are these investigations helpful - complete blood counts; a stool sample for ova and parasites, liver and kidney function tests can be done if there is concern about underlying disease.. Skin prick test and intradermal skin tests may be positive but have limited utility in predicting which substances cause the hives. Challenge tests with food coloring agents and preservatives may be helpful, but are not definitive and do not replace adequate diet revision.Chronic urticaria may be slow to clear and a selective elimination diet often fails because of reactions to retained foods.

Tolerance to antihistamine therapy may develop in a patient whose symptoms are previously under control. This tolerance cannot be overcome by increasing the dosage or by changing the antihistamine. The cause of tolerance is thought to be due to the down regulation of the H1 receptors. Ketotifen and oral sodium cromoglycate have been used with some success.

Urticaria and Vasculitis

A leukocytoclastic vasculitis such as Henoch-Schonlein purpura can be associated with urticaria. A purpuric rash develops over the lower extremities, buttocks and forearms. Joints and kidneys may be involved. The lesions of urticarial vasculitis tend to be flatter erythematous patches that hurt rather than itch and last longer than the more typical itchy wheals that clear in a matter of hours. Occasionally, these sore, red patches will persist and grow slowly in size. Arthralgias are commonly associated. A punch biopsy will reveal the vasculitis. Chronic inflammatory infiltrates are found around venules with deposits of immunoglobulins and complement. This picture is consistent with an Arthus mechanism initiated by circulating immune complexes entering the tissue through blood vessel walls. Although vasculitis is commonly associated with hypersensitivity reactions to drugs or infections, unexplained cases may be due to food antigens; the possibility may at least be considered.

The Solution -Alpha Nutrition

Complete diet revision is essential to solve the problems of chronic urticaria since many food antigens  and foodborne chemicals may be involved. There is no reliable test to identify them. Serious hives require serious efforts to fix them.

• Usually a very slow track on the Alpha Nutrition Program with the option of supportive medication for the first few weeks of recovery - antihistamines and optional prednisone if the problem is bad enough.
• A proper evaluation of the role of food as the antigen source usually requires starting with a 10-day  food holiday on Alpha ENF.
• If the hive triggers were in the food supply, the hives should diminish and then disappear.
• Slow food reintroduction is then required to screen returning foods for allergic activity.

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Paganelli et al investigated 24 patients with urticaria-angioedema; 16 responded well to an oligoantigenic diet consisting of rice, horse meat, rabbit, potato, lettuce, apples, pears, olive oil, salt, sugar, tea, and spring water. 10 of 13 patients with arthralgias improved; measurement of their gut permeability to milk protein (bovine lactoglobulin) showed that permeability was significantly increased.

(1) Charlesworth E.N. Urticaria and angioedema: a clinical spectrum. Ann Allergy 76:6, 1996 484-506

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