Chronic urticaria (hives) is often misunderstood as primarily an allergic condition, when in reality most cases have no identifiable trigger. While acute hives may be linked to allergies, infections, or medications, chronic spontaneous urticaria is typically driven by immune system dysregulation rather than a specific allergen. Advances in treatment have transformed management, shifting the focus from an often-fruitless search for triggers to effective disease control. Dermatologists are uniquely positioned to diagnose, manage, and improve quality of life for patients with chronic hives, making urticaria a condition that should remain firmly within the scope of dermatologic care.