The Healthy Skin Show 003: What's Causing My Chronic Itchy Hives? w/ Dr. Kara Fitzgerald

Sometimes I have clients who are losing their minds because they can’t figure why they keep getting hives. They’ve had allergy testing but just can’t figure out what to do. These chronic, itchy, bumpy conditions have solutions as my guest today tells us all about.


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Dr. Kara Fitzgerald is a mentor, a teacher, and a brilliant practitioner. She not only sees patients but also teaches clinicians. With a postdoc in nutritional biochemistry and laboratory science, Dr. Kara is the author and editor for case studies in integrative and functional medicine.

She’s the co-author of the e-book the Methylation Diet and Lifestyle, she’s on the faculty at the Institute of Functional Medicine and has her own practice in Connecticut.

As Dr Kara explains, hives are caused high histamine, which is often the result of an allergic reaction, but not always.

We discuss identifying the most common allergies so you can eliminate those. We also examine non-allergic factors of hives, like autoimmune disease, and how to mitigate those. There are steps you can take to counter the histamines that flood your system and cause these uncomfortable reactions.

What steps do you take to deal with your hives? Let me know in the comments!


In this episode

  • Problems with Medications (like Dupixent) Used On Your Skin
  • What hives are and why it’s so bothersome
  • Common resolutions to hives
  • What mast cell activation is and how it leads to hives
  • What you can do to help lower your histamine load in the face of a hives outbreak
  • Labs to ask your doctor to run if you have chronic hives



“It’s up to us to figure out two things. One – we want to figure what the triggers are, and two – we want to balance the immune system so we stop having those reactions altogether.” [3:45]

“A low histamine diet is probably going to be the best for someone who’s got some gut disturbance.” [8:08]

“As soon as you go on a good supplement, a good antihistamine immune balancing supplement protocol and work on your diet, you’ll be able to step away from relying on those medications.” [14:04]

“Treating your gut, taking botanical antihistamines, lowering overall inflammation, and changing your diet. If you respond to those, that’s your diagnosis and your cure.” [16:05]



Find Dr. Kara Fitzgerald online

Follow Dr. Kara Fitzgerald on Instagram | Twitter | Facebook

Methylation Diet and Lifestyle

Institute of Functional Medicine

The Healthy Skin Show 003: What's Causing My Chronic Itchy Hives? w/ Dr. Kara Fitzgerald

003: What's Causing My Chronic Itchy Hives? w/ Dr. Kara Fitzgerald FULL TRANSCRIPT

Dr. Fitzgerald:                    Hi everyone. Welcome back. Today I have what I would consider a mentor, a teacher as well as a really brilliant practitioner who not only sees patients but she also teaches clinicians which is really fascinating and an amazing at the same time. Her name is Dr Kara Fitzgerald and she's completed a post-doctorate training in nutritional biochemistry and laboratory science under the direction of Richard Lord at Metametrix Laboratory. She authored and edited case studies and integrative and functional medicine and was a contributing author to laboratory evaluations for integrated functional medicine, the Institute for functional medicine's textbook for functional medicine and co- author the ebook, the Methylation Diet and Lifestyle, which by the way guys is a very good.

Dr. Fitzgerald:                    Thank you.

Jennifer:                              She has been in numerous peer reviewed peer reviewed journals, blogs and podcasts regularly for professionals and consumers at drkarafitzgerald.com and she's also on faculty at the Institute for Functional Medicine and maintains a functional medicine practice in Sandy Hook Connecticut. Thank you for joining us, Dr. Fitzgerald.

Dr. Fitzgerald:                    I am thrilled to be with you again, Jen. It's always great to see you.

Jennifer:                              Likewise. Well today I wanted to jump into this topic on people who have chronic hive, the type issues. So getting all these itchy bumps all over the place and they're taking Benadryl all the time. This can happen sometimes with people that seem to have eczema, for example, and other skin conditions. Sometimes I've even had clients who cannot figure out what they ate. They're going nuts. They think it's related. They're not sure they've had allergy tests, they just don't know what to do and they can't make it stop. So can you explain to us a little bit about what hives are and why they might be, why they might be continuing to bother you, essentially?

Dr. Fitzgerald:                    Yeah, yeah, yeah. Right. So it's basically just a little swollen spot on the skin. There's a little bit of fluid accumulation and then, you know, it actually presents in the skin and it's caused by some type of an allergic reaction. And it's mediated by histamine. So people respond by taking Benadryl, which is the classic anti-histamine.I guess the challenge with hives, is, you know, what the heck caused this? This experience, it can be, I mean, it's just horrible. It can be very itchy. I mean, you know, if you've got, I've had patients who've got total body hives and they're just covered and they're itchy and they can't sleep. And you know, they're uncomfortable and it's, it's, if you can't pinpoint it or if you don't get much relief from Benadryl, it's just, it's a disaster. So it's on the allergic continuum.

Dr. Fitzgerald:                    Hives, the react, the Hyde reaction is, and it's mediated by histamine. So what the heck is causing this reaction? And that's where the sleuthing comes in. And it can be, you know, well actually I say that it's on the allergic continuum, so let's talk about that. Cause there are also non allergic reasons that we could have high histamine. So I'm going to the, we're gonna just talk about these two buckets and just make sure that I do Jen. So allergic continuum is, you know, when there was a lot of, immunological reactivity to, to antigens or compounds in the environment or in our diet. We have a lot of IGE, which is the immunoglobulin produced by B cells in the body that's responsible for that whole allergic cascade. Anything. So allergies are, you know, hay fever or you know, reacting to seasons, all other seasonal, inhalants or dust mites or you know, we can be allergic to foods, say peanut and have actual anaphylaxis, which you know, is also similarly a swelling.

Dr. Fitzgerald:                    You know, the tissues was up in our tongue and our throat and our lips, and elsewhere on the body. So it's almost like anaphylatic reaction is almost like a really severe case of hives kind of deeper but in the face. And anyway, so that's the allergic, that's the allergic hives presentation. And it's up to us to figure out, well, two things. One, we want to figure out what those triggers are. And then two, we want to blunt and balance the immune system. So we stop having those reactions all together. Is it food? Clearly we're going to be asking that and looking carefully. If somebody comes to a functional medicine practice such as myself or, or you know, or if they work with you, you can enact an elimination diet. Sometimes we our standard elimination diet pulls out the top best known problem foods like, egg, dairy, soy, wheat , nuts, fish or shellfish.

Dr. Fitzgerald:                    And so we pull out those top foods and sometimes that's all we need to do to resolve somebody's hives and it's one of those foods. And then when you reintroduce, you can figure out what food caused the hives. Or conversely you could do a lab test to see what foods you're positive to. Hives can actually also be caused by certain environmental exposures or maybe compounds we're putting on the body. And we'll look at that as well. So what things might, what, what, what soaps might somebody be using or what kind of exposures might might be present in their, in their environment that could cause a reaction. And then we'll look at eliminating those as well.

Dr. Fitzgerald:                    So what would be in that non allergic bucket?

Dr. Fitzgerald:                    And that is probably where the missing part of the missing pieces to when someone's going to a more traditional or conventional doctor or they're just kind of looking at, Oh, you're sensitive to something in your immediate environment that's really quite important.

Dr. Fitzgerald:                    Well, you know, we can become, there's a, there's this sort of emerging condition. It's actually, you know, I think it's been around for a while. Actually. Anything related to histamine seems to be on a rise. They like, we know allergies aren't a rise on the rise and so forth, but there's a condition that a lot of us are gaining awareness of both clinically and you know, regular people. And that's called mass cell activation. So mass cells are the big histamine releasers in the body. So mass cells are clearly turned on and in allergic disease, but they're also turned on in not by non allergic triggers. Mass cell activation can happen with, disruption of the gastrointestinal track. It can happen when we're unable to actually, well, we can have higher histamine when we're unable to actually adequately, break histamine down because we've had some gut damage.

Dr. Fitzgerald:                    Mass cells, interestingly enough, can be activated in non. So classically we think about muscle activation with regard to allergies, but other immune conditions can be associated with mass cell activation. Autoimmune conditions might have as a, might have some mass cell activation as, as, as a secondary problem. Interestingly enough, there's research on lime disease, you know, as, as exposure to that to, the lime, bacteria is being able to turn on mass cell activation interest in being able to just cause this histamine dump. And you can have classic allergies or potentially hives as a result of the lime exposure. So non immunological hives can come from lots of gut damage, inability to actually adequately break down histamine, immunological, can happen from allergies. But then, you know, other non allergic conditions that we think of might have mass cell activation as a component.

Dr. Fitzgerald:                    What else am I thinking about with regard to this to mean? Probably actually. Okay. So there was one more thought I had. I just wanted to go in there and pull it out. So there's actually, there's a, there's an autoimmune disease that can result in chronic urticaria where there are auto antibodies produced towards the cells that generate histamine or turn on IGE response. So there's an autoimmune disease in and of itself that can result in hives and that would be somebody who's got, you know, really a chronic high presentation that hasn't been responsive as at all. We might think about that. It's less common. But it's out there. So, you know, as I'm walking myself through the various triggers and the potential causes, there are really quite a few. Most commonly though, we're looking at allergies and we're looking at something that has to be, or some things that have to be figured out in the environment.

Dr. Fitzgerald:                    And so for somebody if they are in the category of mass cell activation with something like a low histamine diet. And most of the time people's first steps are like what can I change in my diet and they will try things like a low histamine diet at some point, what about that, would that be a helpful step?

Dr. Fitzgerald:                    Potentially potentially a low histamine diet is probably going to be the best for someone who's got some gut disturbance, small intestinal bacterial overgrowth, super common, you know, IBS, which we see a lot in as causing SIBO.

Dr. Fitzgerald:                    Any, you know, even some of the autoimmune like inflammatory bowel disease, Crohn's disease are all sort of colitis, you know, might cause damage to the gastrointestinal track where that, you know, precious and enzyme diamine oxidase is actually not adequately produced. And diamine oxidase is how we break down histamine in our gut. So if there's chronic gut inflammation or whatever, cause we can damage the production of diamine oxidase. In fact, you know, really when we're thinking about people with intestinal permeability and, you know, any reason for gut damage diamine oxidase may be in low supply. And therefore when we eat histamine containing foods, we can, we need to be able to break it down and we can't. And then that can, that can result in a hives presentation for people, for some people, not all people. Some, some people get like, you know, I was talking to a patient yesterday who has, histamine intolerance and he presents with like hot flashes or red skin, but some people can actually show up with eczema or frank hives on their body.

Dr. Fitzgerald:                    And so that would be a histamine intolerance, you know, GI mediated and a low histamine diet would, you know, for sure be beneficial while you're working on, you know, building gut health and restoring gut integrity. So the body is able to, you know, make diamine oxidase. Again, incidentally, our microbiome can support, either inhibiting or breaking down our histamine exposure or actually promoting it. So a dysbiotic gut can be a problem in histamine intolerance. So even if you have enough guy mean oxidase or you actually overwhelming your ability, your, you know, your ability to break it out, break it down by a really dysbiotic gut. So gut health is something that we would want to look at, as well.

Jennifer:                              And something that just came to mind as you said that is that certain probiotics. Like some people go oh I'm going to take probiotics, as they are really good for my gut but if you have an issue with histamines, I guess the message here is that you need to be careful what probiotics you buy.

Dr. Fitzgerald:                    Potentially, you know, potentially I would say, you know, as a rule we're not introducing, the quantity of probiotic as compared to our two pounds of gut bugs is relatively small.

Dr. Fitzgerald:                    So the, the heavy lifting is going to be in changing the makeup of that microbiome through diet and lifestyle interventions. You know, you and I were just talking about repairing intestinal permeability and some of the protocols we're using there. And so we want to really think about big picture, but you know, we could be mindful around probiotics too, but the heavy lifting is going to be in that deeper work. So initially avoiding histamine foods while you heal and repair and then doing a challenge and re-introduction process where you see if you've repaired enough where your body can then handle a lifetime of histamine food exposures shouldn't be necessary. You should be able to turn that around.

Jennifer:                              For somebody who is dealing with this like when you are in the middle like literally in the middle of an itchy situation and you have got to go out or any number of things

Dr. Fitzgerald:                    Yeah, it's tough

Jennifer:                              I would really love to stop taking Benadryl. Is there anything that, are there any botanicals or anything that somebody could do to help lower the histamine load that might be potentially serious or blocking out reaction in some way.

Dr. Fitzgerald:                    Yeah, so we have a pretty good arsenal of botanical anti-histamines and you know, again, it's, if you want to think about it two fold. So it's an inflammatory process. So you want to think about generally reducing inflammation in the body. If we're thinking about diet, as I know you do with your clients all the time, you want to lower sugar, you want to lower processed foods, you want to lower additives, you want to lower all that, you know, kaka in our diet that could promote inflammation. You want to increase Omega threes. So you want to do that really basic good balancing, increase the antioxidants, increase, you know, flavonoid, rich foods, all our fruits and vegetables and so on and so forth. So you want to do that. Also find foundationally, and then above and beyond that we can think about our anti histamine interventions.

Dr. Fitzgerald:                    Of course, quercetin is a heavy lift, or, I mean, I use that in my practice all of the time. With quercetin, you can't just, you're not going to get a lot of benefit by just taking some quercetin as a one off and expecting to see it act as a Benadryl does. You need to do a loading period with quercetin at an adequate therapeutic dose. I go up to in my, I go up to five grams or 5,000 milligrams for a short period of time to really get the histamine under control and then you can drop back to a maintenance dose of maybe a 500 to a thousand milligrams. So quercetin is a really amazing nutrient. Luteolin is another potent anti histamine, that I use in practice quite a bit. Interestingly, reishi, I actually just learned this.

Dr. Fitzgerald:                    Reishi mushrooms have a, a compound in them that have anti-histamine properties. So it's a fat soluble, triterpenoid it's called that actually has some anti histamine property. Yeah, it is really cool. So you might think about adding reishi or taking reishi mushroom extract, as an anti histamine. Other interventions I use Bus Walia quite a bit. So one of the other pathways that's, impacted in this sort of heightened immune response or heightened allergic type response, is called, well, Leukotriene pathways or some of these Leukotriene compounds can really promote, the hive picture and you know, myriad other things. So, fatty acids there would be good Omega threes there will help blunt the production of leukotrienes. Also an herb called Bus Walia is really fabulous and may help with the hive presentation. So in, you know, in the short term people might need to lean on Benadryl while you're doing this work, but as soon as you start on a good supplement, a good anti-histamine, you know, immune balancing, supplement protocol, you know, and work on your diet, you'll be able to step away from relying on those medications.

Jennifer:                              So like in a wrap around a case has a lot of histamine like issues and any particular like ask their doctor for one.

Dr. Fitzgerald:                    Well, histamine itself has a really, it's broken down in the body almost immediately. So it's, it's difficult to get an accurate histamine picture unless you get your blood drawn. Right at the time I've been of an attack. So if your doctor were to measure histamine, you want to go there when you're actually really symptomatic. There's another compound that behaves similarly called tryptase and sometimes we measure that. But again, it's really hard to see a positive. So you might see if you, so you could ask for histamine, you could ask for tryptase, but they're not that great. Probably what I would do is look for, do IGE and IGG testing on foods and inhalants. That can be really useful. So if you've got hives due to allergies, you can nail down what they are and you can start to build your protocol out around that. There are some really new next generation tests that we can consider, but I would go to your functional medicine provider for those.

Dr. Fitzgerald:                    Actually I did a, a podcast recently on mass cell activation and we'll be releasing that. So if you kind of stay tuned on my web on my website or if you get my newsletter and you grab it, you'll see mass cell activation coming down the pike soon. It's one of the most dense, scientifically dense podcasts ever. But if you hang in there, we talk a lot about labs. Probably the rubber meets the road with seeing how you respond to these anti histamine approaches that we've talked about today. So it's really a clinical diagnosis with a clinical solution, treating your gut, taking the botanical anti-histamines, lowering overall inflammation and changing your diet. If you respond to those, you know, that's your diagnosis and your cure.

Jennifer:                              Very cool and we know everybody listening to this sometimes one's journey is longer and more complex then others

Jennifer:                              I can tell there's a bunch of different avenues to get down here.

Dr. Fitzgerald:                    Sometimes we can just bang it out, we can treat hives really quickly and just turn it around. And other times, you know, we have to ask, is this autoimmune urticaria or is this urticaria, is the medical term for hives or are we looking at, you know, urticaria triggered by, you know, exposure to, Lime disease. You know, and so sometimes we have to go a little bit deeper into our, differential into what we're thinking the cause is.

Jennifer:                              Well, doctor Kara, I so much appreciate your time and all of the knowledge that you've raised, not just to the patients out there, but also to the practitioners who want to learn and educate themselves. So that we can help. I know that you've got number one, everybody listening. So if you're a practitioner, Dr Fitzgerald has an amazing podcast, which I even listened to and learn a ton from, but as a patient, you can certainly tune it. It might be a little bit over your head at times, but that's okay. But she does have fantastic articles all over her website on a bunch of different topics that even, I agree. Yeah, you can find it.

Dr. Fitzgerald:                    Thank you. I know you've got a lot, you know, we're inundated with stuff to read, so the fact that you actually pause and read mine is great.

Jennifer:                              I do and you can find her over at drkarafitzgerald.com and she has a really great guide. If you're interested. It's called the Healthy Skin Guide, which will put a link in the show notes as well as to all of our social media and depending on when this is released, if that mass cell activation podcast is up, I'll put that link in the show notes as well to make it really easy for all of you to find it. Dr Cara, thank you so much for joining us.

Dr. Fitzgerald:                    My pleasure. Thanks Jen.

Jennifer Fugo, MS, CNS

Jennifer Fugo, MS, CNS is an integrative Clinical Nutritionist and the founder of Skinterrupt. She works with women who are fed up with chronic gut and skin rash issues discover the root causes and create a plan to get them back to a fuller, richer life.

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