How to Resolve Chronic Hives – Audience Question

Today I answer an audience question regarding hives, aka urticaria.  We’ll discuss what causes urticaria and how it can be treated both naturally and with medications. There is a gut and autoimmune component to urticaria, and the treatments are applicable to many other gut and autoimmune conditions.

Dr. R’s Fast Facts

Urticaria, also known as hives

What causes it?

  • There are a few theories as to the cause; autoimmune might be the best supported theory out there
  • Is there a gut connection?
    • Yes, some studies have found gut imbalances, like Blastocystis hominis, to be present


 One of our patient stories

Deep dive into the histamine component

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How to Resolve Chronic Hives – Audience Question

Dr. Michael Ruscio: Hi, this is Dr. Ruscio, and let’s discuss an audience question about urticaria or hives. And let me read this question here from Maria.

“Hi, doctor. There is one topic that I’ve never heard any functional doctors talk about, and that is chronic urticaria. There is very little known about what causes this condition and how to treat it effectively. Thanks.”

Sure. So, urticaria, also known as hives. There are different types of urticaria. There are different causes of urticaria. I would like to provide you with a few broad strokes in terms of simple and foundational things that I have found to be helpful.

So again, urticaria/hives and some people will experience hives randomly, some will experience hives from activity, from stress, from hot or cold exposure, from eating certain foods. And these all have different levels of heat-induced, cold-induced urticaria, contact urticaria, what have you. And when we boil it all down, let’s talk about what may be one of the predominant fundamental causes of urticaria and then what you can do about it.

Now, again, there are many theories as to the cause of urticaria. But I think the one that holds the most promise and the most potential is the autoimmune component, meaning that urticaria might be autoimmune or it might be associated with the immune system and/or other autoimmune conditions.

So this is why we may see an increase of urticaria potentially in patients that have hypothyroidism. Luckily though, speculation aside, what’s nice about the autoimmune theory is that it gives us a lot to potentially work with or to modulate. And so, there’s two different angles that we can come at this through. One would be conventional medicine and one would be more integrated medicine. From the integrated perspective, there is definitely some promise in gut-directed therapies because—and probably no surprise—that the gut has a fairly sizable impact on the immune system. Now, this is likely why at least one study that I know of has found a higher prevalence of certain, using the term loosely, infections in the intestines associated with urticaria. And more importantly, treatment of those infections was shown to reduce the severity and duration of urticaria outbreaks.

One study in particular looked at various types of infections. And again, I use that term loosely because not all these things are technically infections. But Blastocystis hominis was the one found to be the most prevalent. Now, Blastocystis hominis is not considered an infection or a strict pathogen. Some circles consider it benign. Some circles consider it pathogenic. And I think the most reasonable approach is if you find Blastocystis hominis in someone with symptoms treat that. So, we have some at least preliminary evidence showing the association and the causal link by treatment that Blastocystis hominis and potentially other gut imbalances may be involved with urticaria and may allow alleviation of urticaria. So, that is very good news.

Now, there are other things that you can do, which would be dietary changes. Dietary changes that help to improve gut health would also stand to reason to be able to benefit. And I think there’s a decent amount of anecdotal evidence to support this. So something like a Paleo diet or standard elimination diet, where you cut out foods that are oftentimes problematic for people, seems to be a reasonable recommendation to make. There also maybe aid garnered through the low FODMAP diet. And the low FODMAP diet kind of transitions us into the topic of how more conventional medicine comes at this, which is with histamine blocking agents, H1 or H2, histamine1, histamine2 antagonists, to try to block histamine, which is part of the immune response, and more so part of the allergy response, using that term loosely.

And remember that allergy and autoimmunity share this fundamental underpinning of the immune system status, so either being a well-calibrated immune system or potentially an overzealous or mal-calibrated immune system.

So conventional medicine typically administers various types of H1, H2 histamine antagonists, histamine blockers, and those can be effective. However, the low FODMAP diet has been shown to cause an eight-fold reduction in histamine according to one study. So a low FODMAP diet may do the same thing as these drugs. And given, they’re over-the-counter drugs and fairly benign, but it may achieve this from a dietary perspective.

Now, there’s also the low histamine diet specifically, which could also be helpful, which reduces dietary histamine. The low FODMAP diet deprives foods that feed bacteria that likely produce histamine and a low histamine diet reduces the amount of actual histamine in the food. So someone can even go as far as to go on a low FODMAP and low histamine diet if they really wanted to go at this aggressively.

Now, also treating any other gut infections could be helpful. Some of these histamine blockers could be helpful. But all that together, if you improve your diet, either an elimination diet, like a Paleo diet or a low FODMAP or low histamine diet, in addition to addressing any imbalances in the gut, and this may be achieved by taking a probiotic. I don’t know of any evidence showing that probiotics help with urticaria. And it may be there and I’m just not aware of it. But it would certainly stand to reason that a treatment of imbalances in the gut can improve urticaria. And if probiotics help to improve the health of the gut, then a probiotic may help with urticaria, but it’s speculative.

But by going through all these steps to optimize your diet, optimize your gut health, I think you have a fairly good probability of coming out with a good response to the urticaria. Now, I’ll also share in the post here, one of our patients who had good results with urticaria, and then also, if you wanted to get really deep into this immune histamine angle, an interview with Dr. Lawrence Afrin, who is a researcher essentially in histamine intolerance, or as it’s also termed mast cell activation syndrome.

So there are definitely some very good options for urticaria. And to Maria’s point, yes, it’s not something that you hear a lot about. But for someone who’s suffering with hives, it can certainly be frustrating and maybe, at times, a little bit embarrassing. And while there are some simple options of over-the-counter antihistamines, there are also some more natural and fundamental treatments that may help you feel better.

Now, as a quick example, if someone was to derive benefit for urticaria from a low FODMAP diet, there’s a very good chance that they’ll also see other improvements. Potentially, they’ll be less bloated or have better formed stools, potentially less brain fog, better energy or less irritability. All these things can be achieved from rectifying the levels of histamine in your body. One way of which you can do that is through a low FODMAP diet.

So, again, urticaria or hives is something that can be problematic. But again, Maria, yes, you’re right, this is a condition that’s not often talked about. But fortunately, there are some very helpful therapies that come back to this philosophy of starting with your gut. And if you do that, I think you have a good probability of coming out on top.

So, this is Dr. Ruscio. And I hope this information helps you get healthy and get back to your life. Thanks.

What do you think? I would like to hear your thoughts or experience with this.

Dr. Ruscio is your leading functional and integrative doctor specializing in gut-related disorders such as SIBO, leaky gut, Celiac, and IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco Bay area and distance patients via phone and Skype.


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