My son joined the #football team this year. As a #homeschooler, this has never been an option before, for any of my kids, but Samuel is especially athletic, so I made the decision to transfer him to the local government school so he could participate. The second week into playing, I picked him up from practice and his face was significantly swollen and pink. He shared they had to do a lot of up/downs because another kid on the team had demonstrated some poor behavior during a prior game. He was aggravated and didn't want to talk. It was 90 degrees outside. He was flushed and exhausted. I gave him his space after encouraging him to hydrate. Once we got home, I realized his left eye was also swollen and he pointed out his ear was as well.
My kids have had almost no #allergic responses, ever. No #asthma in any of us, and no #eczema. Samuel has never even had #antibiotics. I had little cause for concern about #anaphylaxis unlike a mother of a child with peanut allergies or asthma. Appreciating this history and recognizing the streaks of pink puffiness on his face, I was confident we had a classic case of #hives.
We certainly aren't immune to hives in the Lane household. My oldest daughter gets hives on a regular basis from any level of excitement, nerves, anger, embarrassment. She may be talking as cool as a cucumber but she can't hide her nerves as you'll see hives begin to appear on her chest, working their way up her neck and onto her face. Its become a little comical, I suppose for me more-so than her.
Urticaria & Angioedema
Urticaria is a skin reaction that creates raised, red, itchy welts which may be small spots to large blotches several inches in diameter. These welts may seem to get more intense at times and at other times fade a bit as the reaction runs its course. Typically this is less than 24 hours, but it can certainly be longer especially with repeat exposure to the underlying trigger. Hives are a #histamine response, so there is generally a cause and once that cause is identified and eliminated, the hives will self-resolve. Mom can almost always manage these at home.
As a #clinician, hives is one of the more simple office visits we manage. It really does come down to investigative work, which of course, moms do best. What has the child been exposed to which may be different than before? There are times too that our immune systems are a little bit more active and responsive, so we may have a reaction to something they've been familiar with before without issue. Stress can do this. Heat and extreme cold can do this. Pregnancy can also create more histamine responses so while #inflammation seems to improve during pregnancy, histamine responses can be more frequent.
Hives are generally very acute and without any intervention what-so-ever, they typically self-resolve. Depending on their severity, if they are especially itchy or on the face, Benadryl may certainly be helpful. Practitioners will define hives as acute if it lasts less than six weeks, and chronic if more than six weeks in duration. Several years ago I had a client who had hives almost six weeks. We discussed the potential for any new exposures: detergents, soaps, bedsheets and even washed everything she was being exposed to while also utilizing Benadryl with little relief. Then she realized she had begun taking #chromium to help with her blood sugar levels and as soon as she stopped, they resolved. This client was a metal worker so potentially she was just getting a little too much exposure.
Angioedema is related to urticaria. This is a deeper swelling in the skin around the eyes and lips. It doesn't often itch but its duration lasts a little longer, often for a day or two. Certainly swelling in these areas is much more concerning and may indicate the onset of anaphylaxis which may require epinephrine so unless you are beyond confident your child is not having an allergic reaction, as I recognized with my son, seek medical attention. In these cases, prednisone may also be administered.
Hives is also an IgE response, although there are other mechanisms as well, so Benadryl really is the best remedy. Keep in mind, they may require thirty minutes to take effect. These lesions do not bruise. In fact, they don't leave any lasting marks.
Identifying the Trigger
Ultimately the larger challenge is to identify the trigger with episodic urticaria. Generally when this is food related, the exposure would have been within the last two hours. Nuts, shellfish, kiwi, egg whites, milk, soy, and strawberries are common offenders. Exercise plus a specific food combination is also common. Interestingly, dogs can lick your child and cause hives as can laying in ragweed or on a wool blanket.
Your primary care provider can refer the child for skin prick testing to better identify the #allergen but these are only helpful about half the time and there is no effective or safe immunotherapy available for food allergies. Epinephrine is our primary response.
When these cases become more consistent, like waves of hives, we tend to think about viruses or strep as the underlying cause. Drug reactions may also be to blame. These cases often last a week or two and are not generally IgE mediated. Your clinician will likely order a rapid strep/culture, evaluate liver functioning tests, and test for #hepatitis. It may be that they refer for drug allergy testing as well, if your child has been treated recently with penicillin. This is not typically very accurate beyond penicillin however. Antihistamines and potentially steroids are the most common treatment plan, along with identifying and removing the trigger.
When urticaria becomes chronic, lasting even for years, one then considers causes such as heat or cold, even vibrations, pressure, and water. The onset is within minutes of exposure typically and there is a fairly short duration. This can be challenge tested, but history really is key. Avoidance is the main therapy but for some, daily antihistamines is necessary.
These chronic hives though can be much more involved. The underlying issue may be autoimmune, neuroimmunological, or related to anti-IgE, interleukins, or histamine releasing factors. It may also be related to parasites, thyroid disease, food dye allergy, or even cancer or liver disease. Clients will be encouraged to avoid fever and illness, heat and exercise, #alcohol ingestion, emotional #stress, and aspirin. Females will likely be encouraged to utilize hormonal contraception to eliminate menses. This is non-fatal. Chronic hives is generally not food related and typically resolves after about two years, but for some, it does last longer than five years.
Hives in the Littlest of Littles
Benadryl can not be given to little ones younger than two years of age, so connect with your primary care provider in these scenarios. Hives certainly does occur in the littles because their immune systems are fairly underdeveloped and especially triggered. To reduce itching, oatmeal baths are great, cool washrags, nettles tea, a humidifier in their room, and lots of time at the breast. Certainly, if your littles are members in my practice, I would love to connect with you during these times, but hives in itself, is typically not an urgent or life-threatening scenario. It generally doesn't advance to anaphylaxis, is self-resolving, and responds well to anti-histamines.