Nutritional considerations for chronic urticaria

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By Kellie Blake, RDN, LD, IFNCP

Many of my patients have experienced hives at some point, but fortunately for most, resolution is quick with no long-lasting effects. When hives become chronic in nature, they can be very difficult to treat, leaving patients feeling frustrated and hopeless.

By the time I met with Melissa, she had stopped her daily walk for exercise due to the painful hives on her feet. Despite trying numerous medications and diet-related strategies to treat her hives, they always seemed to return. Her quality of life had been significantly affected and she desperately wanted to know how to keep her symptoms at bay.

Chronic urticaria (CU), or hives that occur on most days of the week for greater than six weeks, affects approximately one percent of the population in the U.S. and Europe. While this may seem like a relatively insignificant figure, the effect of CU on quality of life for these patients is immeasurable. There are two recognized types of CU, spontaneous (CSU) and inducible (CIU). Whereas CSU has no discernable external cause and is usually associated with autoimmunity, CIU can have numerous identifiable triggers. Physical stimuli such as heat, cold, humidity, exercise, sweating, vibration, water, and sunlight, stress, drugs including non-steroidal anti-inflammatories, and foods such as peanuts, eggs, chocolate, and alcohol, can spark the mast cell response in CIU.

In both types of CU, mast cells release mediators like histamine, prostaglandins, and cytokines causing vasodilation and increased vascular permeability, leading to the formation of wheals that can last from 30 minutes to 24 hours. In CSU, autoimmunity is considered to be the main factor underlying this mechanism and up to 50 percent of patients with CSU have autoantibodies leading to the degranulation of mast cells.

In addition to the hallmark wheals, patients with CU can experience fatigue, headaches, arthritis, flushing, wheezing, palpitations, nausea, and abdominal pain. Conventional therapy includes the use of antihistamines, but the addition of nutrition therapy can provide powerful relief for some patients.

Food allergies rarely cause CU, but there are three known food allergic causes to investigate with patients including gaclactose-α-1,3-galactose allergy, or meat allergy, resulting from a tick bite, hypersensitivity to a fish nematode from eating raw fish, and gluten ingestion by celiac patients. More common in CU are food sensitivities causing a non-IgE release of histamine from mast cells. For example, pseudoallergens such as additives, fruits, some vegetables, preservatives, flavorings, dyes, spices, acetyl salicylic acid, histamine, and nitric oxide have been implicated in CU.

Removing these foods for a short period of time and then reintroducing can help uncover possible trigger foods.  As reported in Dermatology Practical & Conceptual, patients who followed a three-week pseudoallergen elimination diet reported a substantial reduction in medication usage, improved quality of life, and had a significant decrease in leukotriene E4 levels. 

A sample three week elimination food plan might include:

• Seafood: all except fresh caught and frozen fish that has been well-cooked
• Meat: aged sausages, smoked meats, and processed meats
• Dairy: fermented dairy products
• Vegetables: tomatoes, spinach, eggplant, avocado, fermented vegetables, and overripe vegetables
• Fruit: all fruit and fruit juices
• Beverages: alcohol and herbal tea
• Other: fermented foods, food additives, spices and herbs, chocolate, chewing gum, and candy

In addition to the pseudoallergen elimination diet, vitamin D supplementation should be considered. CU patients have a higher incidence of vitamin D deficiency—serum 25-hydroxyvitamin D < 20ng/dL—as compared to healthy controls and supplementing to improve vitamin D levels has been shown to significantly improve CU symptoms.

Case Study

Melissa is a 35-year-old female diagnosed with CSU and has a history of livedo reticularis, asthma, sinusitis, and migraines. She sought nutrition counseling to improve her symptoms related to CSU, but she also desired to improve significant gastrointestinal symptoms. Melissa was already avoiding eggs, mushrooms, peas, corn, and some high histamine fruits. Her initial medications included loratadine, fexofenadine, ranitidine, vitamin D3 4,000 international units daily, alprazolam l-theanine, progesterone, botox, and sumatriptan.

She had a history of frequent antibiotic and proton pump inhibitors use and reported food allergies to mushrooms, peas, and red dye. She had very limited physical activity due to the hives on her feet and reported excess stress related to work and social situations. She said she wanted to feel better, have energy, stop taking naps, and improve focus. She wanted her hives to stay away.

Increased intestinal permeability and adrenal dysfunction were suspected root causes of some of her symptoms, so the initial nutrition plan included:

1. Full elimination diet for six weeks, excluding gluten, dairy, soy, corn, eggs, red meat, pork, shellfish, additives, inflammatory oils, chocolate, caffeine, sugar, and sugar substitutes.
2. Salivary cortisol testing indicated early phase 1 adrenal dysfunction, so a multivitamin, vitamin C 2,000 milligrams, stress resistance complex, and a B vitamin complex were recommended.
3. Stool analysis recommended, but patient declined.
4. Stress management, including practicing 10 minutes of meditation twice daily and increasing to goal of 20 minute twice daily.
5. Physical activity, including walking for 10 minutes after meals, if able.
6. Continue current vitamin D supplementation.

After four months of nutrition therapy, Melissa’s symptoms significantly improved. She reported feeling great and stated she gets a few hives occasionally, but typically occur when she consumes certain foods, such as spicy dishes. However, the hives are less painful and shorter in duration.

In addition to the improved CSU, Melissa has lost weight, is more energetic, experiences no joint or muscle pain, and has far less migraines, anxiety, and reflux. Her livedo reticularis is much improved and she now has normal bowel movements.

Melissa’s maintenance nutrition plan is plant-based, gluten- and corn-free, limited in sugar and dairy, and avoids trigger foods. She has continued the multivitamin and stress resistance complex. She plans to try yoga as an additional stress management technique.

CU can be difficult to treat, but ruling out food allergy-related causes and targeting any suspected external cause can be an effective approach. With regard to CSU where there is no apparent external cause, a personalized approach to improve gut function, determine possible trigger foods, and address vitamin D status can help patients achieve significant symptom relief. 

References

Frasher, K., and Robertson, L., (2013). Chronic urticaria and autoimmunity. Skin Therapy Letter. Retreived from: https://www.skintherapyletter.com/urticaria/autoimmunity/

Hon, K., Leung, A., Ng, W., and Loo, S. (2019). Chronic Urticaria: An Overview of Treatment and Recent Patents.  Recent Patents on Inflammation & Allergy Drug Discovery. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6751347/

Jaros, J., Shi, V., and Katta, R. (2020). Diet and Chronic Urticaria: Dietary Modification as a Treatment Strategy. Dermatology Practical & Conceptual. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936629/