A woman came to us with a three year history of hives. For over 1,000 days and nights she has seen and felt her skin itch, turn red, stretch and swell in lumps, bumps, and welts. All this would slowly recede within a day without a trace, only to be followed by new hives without rhyme or reason. Hers was not a rare disease. Indeed, several million people in our country suffer from this chronic urticaria. Hers was a common disease but, as it turned out, the cause was so rare it had never been previously described.

Chronic hives calls for courage and patience on the part of the victim as well as the doctor. No disease has a more daunting and diverse set of causes. There is no quick fix. The cause must be found and eliminated. Otherwise, there is only the search for relief with a variety of antihistamines. These, in turn, have their own side effects, and their own drug interactions, a few having turned fatal. Likewise, the new cutting edge therapies with intravenous immunoglobulin, the immunosuppressant, cyclosporine, or “washing” the blood with plasmapheresis, provide only temporary relief.

Chronic hives calls for the best in Sherlock Holmesian medical detection. Before searching for the criminal, it is wise to review the anatomy of the crime. Although our patient had “chronic” urticaria, every bump and lump was really “acute.” Only the daily succession of acute attacks made it chronic urticaria. What is urticaria?