Hives on the Face: Urticaria, Angioedema and When It's an Emergency

Hives on the face are itchy, raised welts or patches that appear suddenly and usually fade within a day, though new ones can keep coming. They look pink or red on lighter skin and may be skin-colored or slightly darker on brown and black skin. Deeper swelling of the lips, eyelids or cheeks is called angioedema, and swelling of the lips, tongue or throat with trouble breathing is a medical emergency.

Pori does not diagnose skin conditions. The selfie scans and photo diary in Pori can help you keep dated photos of welts that are often gone by the time you see a doctor, and see whether treatment is working.

Below we explain what hives look like on different skin tones, how they differ from angioedema, what sets them off, how they're treated, and exactly which signs mean you should call 911.

What do hives on the face look like?

Hives are raised bumps or patches with clear edges. They itch, and some people feel stinging or burning. The American Academy of Dermatology (AAD) says hives often look pink or red on lighter skin, while on darker skin they can closely match the skin tone and be harder to spot. The NHS also notes that the color can be harder to see on brown and black skin. Feeling for raised, swollen skin and watching for welts that move around helps on any skin tone.

The key feature is how fast they change. The AAD says a single welt usually fades within 24 hours, while new ones can appear elsewhere. Welts can merge into larger patches, and they blanch (go pale) when pressed, according to the American College of Allergy, Asthma and Immunology (ACAAI). Hives are common: the ACAAI says they affect about 20 percent of people at some point in life.

Acute vs chronic hives

Most episodes last a few days to a few weeks. When hives keep appearing for 6 weeks or more, they are called chronic hives. Chronic hives often have no trigger that can be found, which doctors call chronic spontaneous urticaria.

What is the difference between hives and angioedema?

Hives sit in the top layers of the skin. Angioedema is swelling deeper under the skin. MedlinePlus describes it as "swelling that is similar to hives, but the swelling is under the skin instead of on the surface". It usually affects the eyes and lips, and can also involve the hands, feet and throat.

The two can happen together or separately. Angioedema without hives deserves a doctor's visit even when it settles, because some causes, such as certain blood pressure medicines and the rare inherited form, need different treatment.

When are hives on the face an emergency?

Call 911 or go to the emergency room right away if hives or facial swelling come with any of these. The NHS and the AAD list them as signs of a serious allergic reaction:

• Sudden swelling of the lips, mouth, tongue or throat
• Trouble breathing, wheezing, very fast breathing or a tight throat
• Trouble swallowing
• Feeling lightheaded, faint, confused or drowsy, or a racing heart
• Skin, lips or tongue turning blue, gray or pale

The AAD says swelling in the face, mouth or throat always needs immediate care. If you have an epinephrine auto-injector, use it. The ACAAI calls epinephrine the only treatment for anaphylaxis and advises going to the emergency room even after using one. Antihistamines do not stop anaphylaxis.

Swelling of the eyelids or lips without any breathing or swallowing problems is less urgent, but it should still be checked by a doctor promptly; the NHS lists swelling under the skin as a reason to get medical advice.

What causes hives on the face?

Hives happen when cells in the skin release histamine and other chemicals. The AAD and the NHS list these common triggers:

• Foods: MedlinePlus says hives are usually triggered by an allergic reaction to a drug or food; the AAD also notes that hives hours after eating red meat can point to alpha-gal syndrome.
• Medicines: including antibiotics and pain relievers such as NSAIDs. MedlinePlus adds that ACE inhibitors, a type of blood pressure medicine, can cause angioedema.
• Infections: colds, strep throat and urinary tract infections.
• Insect bites and stings.
• Physical triggers: cold, heat, sweating, exercise, pressure, scratching and, rarely, sunlight or water.
• Contact: plants, animals, latex or chemicals touching the skin.
• Stress, which both the NHS and MedlinePlus list as a trigger.

Often no cause is found. That is frustrating, but it is common, and it does not mean something serious is being missed. The AAD suggests thinking about what you ate, took or did in the few hours before the hives appeared. A short note with a photo each time makes patterns easier to spot.

Hives are not contagious. The AAD says "you cannot catch hives", though an infection that triggered them may be.

Can skincare or makeup cause hives on the face?

It can, though it is less common than a slower, itchy contact rash. The FDA notes that allergic reactions to cosmetics most often cause an itchy red rash, and that other symptoms can include hives, flaking skin and facial swelling. Fragrances, preservatives, hair dyes, natural rubber latex and metals are the main culprits it lists. If welts appear within minutes to hours of applying a new product, wash it off with plain water, stop using it, and note the product name. If the reaction is a rash that builds over a day or two and stays where the product went, read our guide to contact dermatitis on the face, since a patch test may help find the ingredient. Any swelling of the lips or tongue after a product is an emergency, as described above.

Could it be something other than hives?

For other causes of a red face, see why is my face red.

How are hives on the face treated?

At home

For mild hives, the AAD suggests a non-drowsy, 24-hour antihistamine. Follow the label, and ask a pharmacist first if you take other medicines, are pregnant or are treating a child. Other steps that help:

• Avoid any trigger you have identified.
• Use cool compresses on itchy or swollen areas.
• Skip hot showers, tight clothing and scratching, which can make welts worse.
• Keep facial skincare simple and fragrance-free until the skin settles, and avoid starting new products during a flare.

What a doctor may prescribe

If one antihistamine is not enough, the AAD says a dermatologist may raise the dose or add another; don't do this on your own. A short course of oral steroids may be used for severe swelling. For chronic hives that don't respond to antihistamines, the AAD lists omalizumab (Xolair), dupilumab (Dupixent) and remibrutinib (Rhapsido), along with options such as phototherapy and cyclosporine. The AAD notes omalizumab can take time to work, sometimes 4 to 6 months.

People who have had a severe reaction are usually prescribed an epinephrine auto-injector and referred to an allergist to identify the trigger.

How long do hives on the face last?

The NHS says hives usually get better within a few days. Each welt fades within a day, so a rash that stays in the same place for several days is probably something else. MedlinePlus says angioedema that does not affect breathing usually clears within a few days.

When should you see a doctor about hives?

Outside the emergency signs above, see a doctor if:

• Hives haven't improved after 2 days, are spreading or keep coming back (the NHS threshold)
• You have a fever or feel unwell
• You get facial swelling, even mild, for the first time
• Hives keep returning for 6 weeks or more
• Welts last longer than a day in one spot, leave bruising or dark marks, or burn more than they itch
• You started a new medicine shortly before the hives began

For chronic hives, a dermatologist or allergist is the right specialist; you can find a dermatologist near you. Photos of the welts with the date and time are useful, since they may be gone by the appointment.