Rashes and Hives

Causes of Chronic Urticaria and Angioedema in Autoimmune Diseases

Feb 4, 2007

Persons with autoimmune disorders, especially thyroid disorders, lupus and Sjogren's, are at risk for rashes, hives and urticarial vasculitis.

Rashes and hives, which are technically referred to as urticaria and angioedema, are common occurrences in people with allergies and autoimmune diseases. Urticaria is defined by rashes that are characterized by a raised swelling of the skin with itching that typically lasts no longer than 24-48 hours. Angioedema presents as a deeper, nondependent swelling without itching. In certain types of urticaria and angioedema, the underlying cause is autoimmunity related to the presence of thyroid antibodies or an acquired C1 inhibitor deficiency.

The cumulative lifetime incidence of urticaria is estimated to be as high as 20 percent in the general population. The most common cause is IgE mediated (allergic) reactions to food or drugs. The cause is mast cell degeneration with release of histamine caused by the formation of IgE antibodies. When the offending trigger is identified and removed the urticaria resolves.

When the solution isn’t as simple and urticaria persists for longer than 6 weeks, the condition is known as chronic urticaria. Approximately 50 percent of patients with chronic urticaria also have conditions of angioedema. When both conditions are present the condition is seldom related to allergy and it is known as chronic idiopathic urticaria/angioedema.

The Role of Thyroid Antibodies

Several groups of researchers have described a relationship between chronic urticaria and thyroid disease, primarily Hashimoto’s thyroiditis and to a lesser extent Graves’ disease. These patients typically have levels thyroid peroxidase antibodies. In general, these patients had severe chronic urticaria/angioedema and no other signs of thyroid disease although some patients had a slight goiter. Treatment with levothyroxine caused improvement in the urticaria and angioedema. When treatment was stopped the symptoms returned and then subsided with the continuation of treatment. In the patients without evidence of thyroid antibodies, levothyroxine had no effect. The pathogenic relationship between thyroid antibodies and the chronic urticaria hasn’t yet been determined.

Anti-FceRIα antibodies

Another group of patients with chronic urticaria were found to have autoantibodies to FceRIα. These patients reacted to serum from normal subjects with wheals and flares.

Urticarial Vasculitis

Chronic urticaria may also be associated with a leukocytoclastic (white blood cell-mediated) vasculitis confined to skin or to a wider area of connective tissue. Palpable purpura (small purplish bruises) and urticaria of long duration are typically seen in urticarial vasculitis. Urticarial vasculitis often occurs in systemic lupus, polymyositis, mixed cryoglobulinemia, and Sjogren’s disease and tends to be associated with low levels of C1q.

C1 Inhibitor Deficiency

Patients with C1 inhibitor deficiency often have recurrent attacks of angioedema. C1 inhibitor is a multifunctional serine protease inhibitor that inhibits the immune system’s complement system. Complement represents a number of immune system chemicals. In patients with autoimmune diseases, C1 inhibitor may be catalyzed at an accelerated rate, causing an acquired C1 inhibitor deficiency and resulting angioedema. These patients generally have anti-idiotypic autoantibodies, which are thought to activate complement and lead to the C1 inhibitor deficiency.

Resources:

Bruce Zaraw, Urticaria, Angioedema, and Autoimmunity, Progress and Controversies in Autoimmune Disease Testing, Clinics in Laboratory Medicine, Philadelphia: W.B. Saunders, 1997.

Dreyfus, DH, Steroid-resistant chronic urticaria associated with anti-thyroid microsomal (peroxidase) antibodies in a 9-year old boy, Journal of Pediatrics, 1996; 128.

The copyright of the article Rashes and Hives in Autoimmune Disease is owned by Elaine Moore. Permission to republish Rashes and Hives in print or online must be granted by the author in writing.

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Feb 9, 2009 7:01 PM

Guest :

hello! I have had 2 -3 episodes of angioedema per year for the last 15 years (I am 60, female, post menopausal, have both celiac and sjogren's diseases). Our rescue dog had to begin treatment for severe pulmonary hypertension and damaged valves with a combination of an ace inhibitor (Enalopril), a bronchodilator (Theophylline), and a vasodilator (Pimobendan). When I began administering these meds, I had 6 episodes of angioedema within 5 weeks (throat, tongue, feet, hands). I can only presume that handling these drugs (or just the Enalopril) is as reactive as ingesting them myself! Has anyone else observed a similar reaction? (I now use gloves + a dust mask when giving our dog his meds.)
Regards,
Susan

Feb 10, 2009 9:45 AM

Elaine Moore :

Hi,
If the gloves take care of the problem it likely is the enalapril. I had a similar reaction to anafranil. Best, Elaine

Mar 4, 2009 8:29 AM

Guest :

Have had hives daily for 3 months now. thyroid antibodies are elevated and was diagnosed with Hashimotos thyroiditis yesterday. But Dr. didn't want to treat yet, saying eventually it would turn into hypothyroidism and he will treat that. So for now, I guess I have to live with the hives.

Mar 4, 2009 8:30 AM

Guest :

Mar 5, 2009 8:14 AM

Elaine Moore :

Hi,
I'm surprised your doctor hasn't started treatment. When thyroid antibodies are present, thyroid hormone is often started. Other treatments used for hives include diphenhydramine (Benadryl), hydroxyzine (Atarax), corticosteroids, vitamin A, and Zantac. I hope some of the topical preparations bring your relief. Perhaps you can get a referral to see a dermatologist. Best, Elaine

Mar 7, 2009 11:06 PM

Guest :

I have had urticaria vasculitis for 12 years now.In the first few years medications didnt seem to work.When I went unmedicated is when I started to seperate side effects from symptoms.I react to a variety of things(ice,sun,foods,medications,presure against my skin & most of all stress)so to keep away from these things has been more benifical than anything.There are times breakouts occure & meds are needed but you must identify what your triggers are.I am now having problems with gut pain & headaches & I cant seem to get my Dr. to see it could be the Urtcaria Vasculitis.I have only been using benadril & ibuprophin for years because I grow ammune to other meds so fast & I know there will come a day they have to work to save my life.How do you explain to a Dr. Urticaria Vasculitis?

Mar 9, 2009 10:18 AM

Elaine Moore :

Hi,
You're doing a great job of keeping symptoms in line. Avoiding triggers is so important.
Over time, ibuprofen can cause gut pain. I know some of the doctors at National Jewish are using a combination of Zantac, Zyrtec and thyroid hormone (if thyroid antibodies are present).
You might want to see if there's an immunologist in your area. Best, Elaine

Mar 16, 2009 10:57 AM

Guest :

For the guest - FIND ANOTHER DOCTOR. Thyroid hormone was the only thing that helped my 12 year old duaghter with chronic hives, who had normal thyroid function, but elevated anitbodies. Her thryroid eventually became underactive, but we still needed periodic increases of thyroid hormone to contol the hives. Thankfully, after 6 years of bouts of hives, she has been hive-free for almost 6 years. We also saw doctors at National Jewish who specialized in the immune system. Don't give up - hive is a "four letter word" for sure!

Apr 7, 2009 9:20 AM

Guest :

I've just been diagnosed with Hashimoto's thyroiditis after suffering with hives and angioedema for two months. I first went to an allergist who determined the cause was not a food allergy but elevated TPO sent me to an endo. He has me on small doses of synthroid. I'm wondering if I continue with the allergy medication (Zyzol, Zantac, hydroxyzine) and the hives clear up, how will I know if the synthroid is what worked or the allergy meds? I hate the idea of taking medication but don't like suffering either. Any ideas are appreciated.
~Dee

Apr 7, 2009 9:28 AM

Elaine Moore :

Hi,
Since you've been diagnosed with Hashimoto's thyroiditis, you probably need to be on thyroid replacement hormone to keep your levels in an optimal range. This will also slow your gland's activity down and help reduce thyroid antibody production. The other meds will help inhibit the allergic reaction.

Most people I know who have the same problem as you are on thyroid hormone, zantac, and either zyrtec or claritin. Over time, they've been able to reduce the antihistamine, using it only at night or as needed.

You'll probably need to continue on the replacement hormone, and as your symptoms abate discuss with your doctor the possibility of cutting back on or stopping the other meds. Best, Elaine

Apr 7, 2009 3:02 PM

Guest :

Apr 14, 2009 11:45 AM

Guest :

Elaine,
I have suffered from chronic hives since I was 16; I am now 29 and having outbreaks of hives again. I usually have an outbreak every 3 to 5 years. I was diagnosed with Hashimotos thyroiditis several years ago and have been on levothyroxin since. My thyroid level was tested when this recent outbreak occured and my levels are fine. My doctor has me on a combination of Zyrtec and Doxpin, but the hives are still happening. Are there any other medications that help hives? Should I see another doctor?

Apr 14, 2009 12:24 PM

Elaine Moore :

Hi,
Your thyroid hormone levels may well be within the normal range, but they still may be too low for your body's needs, especially if your doctor is measuring you with TSH alone. When FT4 and or/FT3 are too low, the immune system produces more thyroid antibodies as it speeds up its activities trying to fix the problem. This increased thyroid antibody production is what seems to cause the hives.
Most doctors who treat this use zantac, zyrtec, hydroxyzine, or claritin, nasal steroids and adequate thyroid hormone. I hope it's not doxepin your doctor is using. This is an antidepressant and wouldn't be useful.
It'd be good if you could see an immunologist who's familiar with this or a good dermatologist. Best, Elaine

Apr 14, 2009 10:18 PM

Guest :

Hi, I have had cronic hives 4 months now recently had a blood test which came up positive for autoimmune problem with all other functions normal. For a while I was holding the hives at bay with a single antihistimine a day now two of the same give no relief. The doctor claims it is likely to go away eventually. Am I doing more harm by not medicating and just putting up with the hives as long as I can or should I start taking heavier meds?

Apr 15, 2009 5:13 AM

Elaine Moore :

Hi,
It's probably more of a case of needing the right medications than more medications. Often, hives are caused by reactions to foods and medications or they can be due to an autoimmune thyroid condition, which doesn't necessarily cause a thyroid disease. It would be good to see an allergist or immunologist who can run the correct tests and determine the best treatment. Take care, Elaine

May 22, 2009 8:57 AM

Elaine Moore :

Hi,
I'm sorry to hear about your 4-week episode of urticaria. There's a clear association between thyroid antibodies and urticaria, and thyroid antibodies increase dramatically after RAI.
You might also want to read this article, autoimmunedisease.suite101.com/article.cfm/thyroid_peroxidase_antibodies

In general, patients are put on Zantac, antihistamines like Zyrtec, and sufficient thyroid replacement hormone. After RAI, TSH levels are usually falsely decreased so it's important to look at FT4 and FT3 levels. Having adequate thyroid hormone and avoiding environmental triggers such as excess dietary iodine will help reduce your thyroid antibody levels. Best, Elaine

Jun 3, 2009 3:11 PM

Elaine Moore :

Hi,

Because you mentioned your bottom, dermatitis herpetiformis comes to mind. This is a condition that can occur in gluten sensitivity, thyroid conditions and other autoimmune conditions. You may want to read my articles on chronic urticaria in thyroid disease and dermatitis herpetiformis and also this one on tpo antibodies:
autoimmunedisease.suite101.com/article.cfm/thyroid_peroxidase_antibodies< br />
Let me know what you think. Best, Elaine

Jun 3, 2009 6:50 PM

Elaine Moore :

Hi,
Your doctor may have tested you for thyroid function with TSH, FT4 and FT3 tests but he may not have tested you for thyroid antibodies. It's important to have tests for TPO antibodies since they're associated with both angioedema and miscarriages.
see autoimmunedisease.suite101.com/article.cfm/thyroid_peroxidase_antibodies

One of the most common causes of multiple miscarriages is antiphosholipid syndrome
See autoimmunedisease.suite101.com/article.cfm/antiphospholipid_syndrome_ aps
This is also an autoimmune disorder in which antibodies cause the blood to clot too soon. Although you mentioned one miscarriage, it might be good to test for APS while having tests for TPO antibodies. Best, Elaine

Jun 4, 2009 10:04 AM

Guest :

Guest:
I am a thirty year old male. Some two and a half months back, while I was sleeping, I felt a bit of itching sensation in my inner palms and hands. At that time I concluded that it was an insect bite and did not give it much importance. Then the itching grew more intense with every passing night. One night I felt a bit of itching sensation on the rim of my lower lip and when I scratched, after some time, one side of my lip got swelled and till morning it had migrated to the other side of my lip. After taking citrazine the condition faded away till midday. But after that, I repeatedly used to get these swellings and red spot at different locations of the body. The areas most affected include lips, hands, fingers, eyes. Once or twice my private parts also got involved. I consulted a couple of doctors who diagnosed me with chronic urticaria/angioedema and prescribed levocitrazine. After taking the drug, i do get relief but once i discontinue the drug the condition reoccurs. The condition is getting more and more worse day by day. I also tried to identify the allergin but in vain.

Jun 4, 2009 7:49 PM

Elaine Moore :

Hi,
I could see where the citrizine meds would help if you had a response to a bug bite. But angioedema and hives often start with itching in the hands. It would be good to have tests for thyroid antibodies to see if you might be having a thyroid antibody mediated response. Best, Elaine

Jun 12, 2009 12:25 PM

Guest :

I was diagnosed w/ Hashimotos thyroiditis about 3 years ago & have had hives for about 6 weeks, my endo. sent me to an allergist, she ran some blood test but I haven't gotten the results yet. In the mean time she perscribed Allegra but that doesn't help at all, the only thing that helps is Benedryl but it makes me so sleepy, any suggestions?

Jun 13, 2009 7:54 PM

Elaine Moore :

Hi,
I'm sorry to hear about your hives.
Hives are often caused by allergies to food and/or medications and they can occur when thyroid hormone levels are low in people with TPO antibodies. These antibodies are typically seen in Hashimoto's thyroiditis. If no allergies show up in your tests you might want to ask about the role of thyroid antibodies. Best, Elaine

Jun 30, 2009 5:31 PM

Elaine Moore :

Hi,
Childbirth can cause some significant immune system changes. Women occasionally develop thyroid antibodies, specifically TPO antibodies, although they don't necessarily develop thyroid disorders. These antibodies can be associated with rashes. Although you don't want skin tests, there are blood tests such as RAST tests for allergens, and tests for TPO antibodies that could help with your diagnosis. Congratulations on your new baby! Best, Elaine

Jul 15, 2009 4:05 PM

Elaine Moore :

Hi,
Chronic idiopathic urticaria can be accompanied by vasculitis. Best, Elaine

Aug 24, 2009 5:53 PM

Elaine Moore :

Hi,
I'd see a rheumatologist experienced in vasculitis rather than a dermatologist for your condition. It would be a good idea to have tests for thyroid antibodies. If they're present thyroid replacement hormone may be needed. Best, Elaine

Aug 24, 2009 5:58 PM

Elaine Moore :

Hi,
I think it's best to find out the cause of your rash and swelling rather than use constant medication to control symptoms. I've had a similar problem that was caused by cooked celery, bee pollen, soy, and a few other foods. I would have never figured this out if I hadn't seen a good allergist/immunologist. Doxepin is a tricyclic antidepressant that can help reduce the stress response. Best, Elaine

Aug 29, 2009 7:53 PM

Elaine Moore :

Hi,
Your allergist should realize the importance of your high IgE. Hives can be from allergies to foods and medications. This can result in a high IgE. Some seemingly innocuous medications, like blood pressure meds and innocent foods like tomatoes, can cause hives.
I'd see if you can find the articles on thyroid antibodies and urticaria and see if you can have tests for thyroid antibodies. But still, you should have a complete workup for allergens. Allergic reactions can increase thyroid antibody production causing a vicious cycle of rashes and hives. Best, Elaine

Sep 30, 2009 1:49 PM

Guest :

Hello. I am a 29 year old female diagnosed with Hashimotos Thyroiditis. I have had chronic hives, which have become progressively worse, over 3 yrs. I have a multinodular goiter. Dx by allergist. My new endocrine doc has me on synthroid, xyzal, zantac and claritin. This seemed to work for 6 months, now hives are back with periods of relief. Levels are "normal". I have to take courses of steroids to function at work and those have their own problems. Any other otc supplements that can help? Do I continue with steroids, ask for an increase in Synthroid, or consult an ENT for thyroidectomy?...kinda desperate for relief.
thanks,
karen

Sep 30, 2009 2:43 PM

Elaine Moore :

Hi Karen,

Often, increasing Synthroid, using your FT4 level as a guide and making sure it's not higher than the high end of the range, can help. Vitamin A and vitamin D also may help.
If you're allergic to any medication or food avoiding it is necessary. Even seemingly innocuous substances like BHA and BHT used as food preservatives can trigger hives.
Avoid any immune system triggers like vaccines as well. Low dose naltrexone (LDN) may also offer benefits since it modulates the immune system. See my articles on LDN and on adaptogens too. Best to you, Elaine

Oct 9, 2009 1:36 AM

Guest :

I am 30 years old and I have the hives and angioedema every day for the last 16 years. I have been put on every allergy drug available and they work for a while then my body becomes tolerant and they stop working not to mention some are very expensive. Also I've had this so long that doctors don't believe me when I give my history to a new doc. I have been on steroids and in the first year using them I gained almost 70 pounds, and they stop working after the first week and I have to switch to a new one as well. Sometimes I swell up so bad I can't walk, move my fingers or hands, my face begins to develop big hard lumps, my eyes swell shut and my lips swell up to about 3 times the normal size. I have had to take so much benedryl I have also developed high blood pressure. I'm in so much pain most of the time all I can do is cry. After the hives and swelling go away my entire body feels like I've been beaten and I am sore and bruised it hurts in some places like my fingers and knees right down into the joint. I have been to every kind of specialist available to me and they had no answers and I know it is not an outside allergen. The docs I've seen have to be missing something or they just don't want to deal with it, I don't know, but I am at the end of my rope. I would just like yo know what I have so I can treat it. I have lost jobs because of this and I am so far in debt because of medical problems as well I can't afford to go in circles with the specialists and tests and so on. If anybody has any answers please post them. Thank you, Amy

Oct 9, 2009 6:17 AM

Elaine Moore :

Hi,
You haven't mentioned being tested for thyroid antibodies. They can be the cause of chronic urticaria and angioedema. Treatment is with thyroid replacement hormone.
Ask about having tests for these antibodies and see if you can find the articles listed in the resource section of this article. Best, Elaine

Oct 14, 2009 3:51 PM

Guest :

I was recently put on Synthroid after discovering I had a slightly elevated TPO-Ab level (130-149) and a TSH level between 4.79-5.01. My TSH has come down to the 1.0 range (my medication was adjusted after it dipped too low and I was having some anxiety), but my TPO-Ab have stayed about the same. I have also suffered from hives on my face and neck since 1992 or 1993. I had no idea that the TPO-Ab could be related to the hives. I have also had at least two miscarriages (which is why the thyroid tests were done). I'm now trying to get pregnant again after about 5 months on Synthroid. Is there something else I should be taking to lower my TPO-Ab level? The hives seem to be lessening, although I have outbreaks around ovulation and when I get my period (some months worse than others). I'm wondering if my hives and TPO-Ab were caused by an allergic reaction to penicillin or perhaps exposure to TB? (I took INH for 6 months after a positive TB skin test in 1993.) I have had hive outbreaks while dusting and after eating spicy foods or shellfish, but not in every situation. Stress also seems to make them worse. I have never been tested for allergies. Every time I think I know the cause of the hives, it seems my theory is wrong. I have been treating the hives with topical hydrocortisone for years and hope it isn't doing more harm than good. (I got too sleepy taking benadryl tablets, even the children's strength, and claritin and zyrtec only worked for a little bit.) At this point I am most concerned about getting and staying pregnant, but would also love to find a cure for the hives. I'm hoping the thyroid meds will do the trick, but any other advice you have would be appreciated.
Thanks, Valerie

Oct 15, 2009 9:29 AM

Elaine Moore :

Hi Valerie,
One recent study showed that taking adequate selenium (200 mcg daily) can help lower thyroid antibodies. Selenium is needed for proper thyroid hormone metabolism. I wrote an article on this that you can find on suite101.

Many of us with hives find that stress and even exercise can trigger hives if we've eaten certain foods. For me, it's cooked celery, bee pollen, and a few other things. Having allergy tests can help.

Being on Synthroid should also help lower your TPO abs as your gland can settle down. In hypothyroidism (TSH higher than 3.0) the gland works to try to correct the problem and all activiities, including thyroid antibody production, increase. Best, Elaine

Oct 16, 2009 7:46 AM

Guest :

Hello, I have had hives (urticarial vasculitis) for the past 11 years. At first I was on every antihistamine made but they did nothing. The only
medication that helped me was prednisone. I had every blood test under the sun done and all were normal including thyroid. I break out every other year or so and the hives stay for at least a year. My rheumotologist put me on 400mg of plaquenil (hydroxychloriquine) daily and once in my system I am hive free. But only while on this med am I hive free. I just wanted to mention this because I did not read that anyone else has tried this. The only other time I am hive free is when I am pregnant!! I just wish someone would find a reason WHY all of a sudden I woke up one day with hives and now they never go away!

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