Chronic urticaria and infections

Chronic urticaria: assessment of current treatment

Chronic urticaria is heterogenous, long-persisting and has a severe impact on quality of life and daily work. Effective treatment is essential but remains a confounding problem. This review summarizes available treatment strategies for chronic urticaria and their strength of evidence. Besides treatment of identified triggering factors such as chronic persistent bacterial infections (e.g., with Helicobacter pylori, streptococci, staphylococci or yersinia), standard treatment consists of nonsedating H1-antihistamines. Most patients require increasing (off-label) dosages that should be taken daily and regularly, however, this still fails in a third of cases. Reliable alternatives in the world literature are rare and the level of evidence is low. Certain subgroups may display benefit from additional treatment with cyclosporine A, cysteinyl leukotriene receptor antagonists, chloroquine, dapsone or other alternatives. A practicable step-wise treatment approach is given to optimize and individualize the treatment of patients with chronic urticaria.

Identification of the etiologies of chronic urticaria in children: a prospective study of 94 patients

The etiologies of chronic urticaria (CU) in childhood remains incompletely understood because of limited data in children. The objective of this study was to examine some of the possible etiologies of CU in children by focusing on the functional autoantibody to FcepsilonRIalpha and IgE, thyroid autoimmunity, urticarial vasculitis, parasitic infestation and food allergy. Children 4-15 yr of age with CU were investigated for complete blood count, erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), CH(50), free-T4 (FT(4)), thyroid stimulating hormone (TSH), anti-thyroglobulin and anti-microsomal antibody, autologous serum skin test (ASST), skin prick tests (SPT) for foods, food challenges, and stool examination for parasites. Ninety-four children who met the criteria for CU were recruited. Patients with physical urticaria were excluded. Eosinophilia and elevated ESR were found in 23% and 13%, respectively. High ANA titers were found in 2%. None of these patients had clinical features of urticarial vasculitis, abnormal CH(50) level, abnormal TSH and FT(4). Anti-thyroglobulin and anti-microsomal antibodies were not detected. Positive ASST was found in 38%. There were no differences in medication requirement and CU remission between patients with positive and negative ASST. Parasites were found in 5% without clinical correlation. SPT to foods was positive in 35%. Positive food challenges were found in six/nine patients with positive history of food allergy and two/seven patients with negative history. Food avoidance was beneficial to the subgroup of patients with positive history of food allergy only.

Increased levels of serum IL-31 in chronic spontaneous urticaria

IL-31 represents a novel cytokine involved in pruritic skin diseases including atopic dermatitis (AD). We, therefore, aimed at investigating IL-31 levels in chronic spontaneous urticaria (CU). We included 46 patients with CU, 26 non-atopic skin healthy subjects as negative and 28 patients with AD as positive controls. IL-31 serum levels were analysed using commercial ELISA kit. IL-31 serum levels were higher in patients with CU compared to healthy controls (P < 0.001), but lower compared to patients with AD (P < 0.001). There was no difference in IL-31 serum levels in autologous serum skin test positive or negative CU patients and patients with infectious trigger factors including helicobacter pylori infection. IL-31 serum levels may play a role in the pathophysiology of CU. This is supported by the finding that not all patients with CU respond to antihistamine treatment but to the treatment with immunosuppressive drugs.

Urticaria and infections

Urticaria is a group of diseases that share a distinct skin reaction pattern. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear. In spontaneous acute urticaria there is no doubt for a causal relationship to infections and all chronic urticaria must have started as acute. Whereas in physical or distinct urticaria subtypes the evidence for infections is sparse, remission of annoying spontaneous chronic urticaria has been reported after successful treatment of persistent infections. Current summarizing available studies that evaluated the course of the chronic urticaria after proven Helicobacter eradication demonstrate a statistically significant benefit compared to untreated patients or Helicobacter-negative controls without urticaria (p < 0.001). Since infections can be easily treated some diagnostic procedures should be included in the routine work-up, especially the search for Helicobacter pylori. This review will update the reader regarding the role of infections in different urticaria subtypes.

Etiologic aspects and prognostic factors of patients with chronic urticaria: nonrandomized, prospective, descriptive study

BACKGROUND

Studies investigating etiologic factors in chronic urticaria are based on small populations of a few hundred patients. In addition, data on prognostic factors of the disorder are scarce.

OBJECTIVE

To investigate the etiologic and prognostic factors of chronic urticaria on a large population referred to tertiary specialized hospital departments.

METHODS

The study investigated 2,523 patients with chronic urticaria and a negative autologous serum skin test using anamnesis, and the literature suggested laboratory tests for etiologic factors of the disorder. The patients were prescribed cetirizine 10 mg daily plus treatment of any underlying disorders illuminated by the laboratory investigation. The rescue medicine was loratadine 10 mg. The patients were evaluated every 3 months. Comparative statistical methods were used to evaluate the prognostic factors having an impact on the duration of the disorder until resolution of symptoms.

RESULTS

Etiologic factors of chronic urticaria-angioedema were identified in 38.7% of the patients. Physical urticarias had a prevalence of 17.1% in the population under study. Other common etiologic factors identified included infection (7.7%) and autoimmune thyropathy (7.3%). Multiple regression analysis showed that female gender, long duration of the disorder at the initial examination, the presence of angioedema, and physical urticarias are associated with worse prognosis of the disorder, whereas increased self-reported stress and psychiatric disease had no impact on the course of the disorder.

CONCLUSION

A detailed medical history and selective laboratory tests can illuminate etiologic factors in less than 40% of patients with chronic urticaria. Prognostic factors identified to impact the natural history of the disorder could be helpful when designing studies assessing the efficacy of therapeutic agents for chronic urticaria.

EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria

This guideline, together with its sister guideline on the management of urticaria [Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: Management of urticaria. Allergy, 2009; 64:1427-1443] is the result of a consensus reached during a panel discussion at the 3rd International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO). Urticaria is a frequent disease. The life-time prevalence for any subtype of urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria do not only cause a decrease in quality of life, but also affect performance at work and school and, as such, are members of the group of severe allergic diseases. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors, and pathomechanisms. In addition, it outlines evidence-based diagnostic approaches for different subtypes of urticaria. The correct management of urticaria, which is of paramount importance for patients, is very complex and is consequently covered in a separate guideline developed during the same consensus meeting. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria

This guideline, together with its sister guideline on the classification of urticaria (Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: definition, classification and diagnosis of urticaria. Allergy 2009;64: 1417-1426), is the result of a consensus reached during a panel discussion at the Third International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO). As members of the panel, the authors had prepared their suggestions regarding management of urticaria before the meeting. The draft of the guideline took into account all available evidence in the literature (including Medline and Embase searches and hand searches of abstracts at international allergy congresses in 2004-2008) and was based on the existing consensus reports of the first and the second symposia in 2000 and 2004. These suggestions were then discussed in detail among the panel members and with the over 200 international specialists of the meeting to achieve a consensus using a simple voting system where appropriate. Urticaria has a profound impact on the quality of life and effective treatment is, therefore, required. The recommended first line treatment is new generation, nonsedating H(1)-antihistamines. If standard dosing is not effective, increasing the dosage up to four-fold is recommended. For patients who do not respond to a four-fold increase in dosage of nonsedating H(1)-antihistamines, it is recommended that second-line therapies should be added to the antihistamine treatment. In the choice of second-line treatment, both their costs and risk/benefit profiles are most important to consider. Corticosteroids are not recommended for long-term treatment due to their unavoidable severe adverse effects. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Chronic urticaria as a presenting symptom of Crohn's disease

Clinical presentation of Crohn's disease (CD) may be variable according to the location and the intensity of the inflammation. Some patients may have atypical symptoms which could delay the diagnosis. We report the first case of chronic urticaria related to a subclinical, complicated CD. Although the pathologic mechanism of this association was unclear in our patient, this case suggests that in patients with unexplained chronic urticaria it is opportune to investigate for a possible CD, even if there are no or few specific symptoms of intestinal inflammatory disease.

Chronic urticaria as a presenting symptom of Crohn's disease

Clinical presentation of Crohn's disease (CD) may be variable according to the location and the intensity of the inflammation. Some patients may have atypical symptoms which could delay the diagnosis. We report the first case of chronic urticaria related to a subclinical, complicated CD. Although the pathologic mechanism of this association was unclear in our patient, this case suggests that in patients with unexplained chronic urticaria it is opportune to investigate for a possible CD, even if there are no or few specific symptoms of intestinal inflammatory disease.

Helicobacter pylori infection in patients with chronic urticaria: correlation with pathologic findings in gastric biopsies

BACKGROUND

Chronic urticaria is a persistent urticaria lasting longer than 6 weeks, affecting 20% of the general population. Various infectious agents have been reported as causes of urticaria, including Helicobacter pylori, which is a common worldwide bacterial infection. Its role in inducing allergic conditions, such as chronic urticaria, has been suggested in some reports and ignored in others.

AIMS

To assess the prevalence of H. pylori infection in patients with chronic urticaria and to explore the possible etiopathogenetic link between them.

METHODS

Thirty-five patients suffering from chronic urticaria and 10 normal control individuals were subjected to upper endoscopic gastric biopsies to assess and semiquantify H. pylori infection and to address other pathologic abnormalities, using routine hematoxylin and eosin staining and Giemsa staining.

RESULTS

Forty percent of control subjects and 57% of patients were positive for H. pylori infection, but the difference did not reach statistically significant levels (P = 0.47). The severity of urticarial symptoms was greater in the H. pylori-positive than in the H. pylori-negative group (P = 0.019). Heavy bacterial colonization (P = 0.008) and intense gastric inflammation (P < 0.0001) were associated significantly with severe clinical manifestations. Eighty percent of the H. pylori-positive urticaria group experienced complete remission after receiving eradication therapy for H. pylori.

CONCLUSIONS

Helicobacter pylori may have a role in the exacerbation of urticarial symptoms, even though it is not involved directly in its etiology, and its eradication may lead to symptom improvement in a considerable number of infected urticaria patients. The severity of symptoms is dependent on the density of bacterial infection and the intensity of inflammatory infiltrate in the gastric biopsy.

Management of difficult urticaria

Chronic urticaria, a major health problem causing patient's distress, induces often physicians' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.

Urticaria : a review

Urticaria is often classified as acute, chronic, or physical based on duration of symptoms and the presence or absence of inducing stimuli. Urticarial vasculitis, contact urticaria, and special syndromes are also included under the broad heading of urticaria. Recent advances in our understanding of the pathogenesis of chronic urticaria include the finding of autoantibodies to mast cell receptors in nearly half of patients with chronic idiopathic urticaria. These patients may have more severe disease and require more aggressive therapies. Extensive laboratory evaluation for patients with chronic urticaria is typically unrevealing and there are no compelling data that associate urticaria with chronic infections or malignancy. Pharmacologic therapy consists primarily of the appropriate use of first- and second-generation histamine H(1) receptor antihistamines. Additional therapy may include leukotriene receptor antagonists, corticosteroids, and immunomodulatory agents for severe, unremitting disease. Despite our greater understanding of the pathogenesis of urticaria, the condition remains a frustrating entity for many patients, particularly those with chronic urticaria.

A case report of double-filtration plasmapheresis for the resolution of refractory chronic urticaria

A 29-year-old Chinese female was diagnosed with chronic urticaria. Dexamethasone and gamma globulin initially resolved the illness; however, when dexamethasone was decreased and gamma globulin was withdrawn, urticaria emerged again and could not be controlled by any of the medications used. The diagnosis of refractory chronic urticaria was made and double-filtration plasmapheresis (DFPP) was performed. The symptoms were relieved during the first DFPP procedure and the disease resolved shortly thereafter. DFPP theoretically removes medium to large molecular substances such as IgG and IgE from circulation, and therefore may prove to be an effective treatment for refractory chronic urticaria.

Association of specific IgE to staphylococcal superantigens with the phenotype of chronic urticaria

It has been well established that bacterial superantigens lead to the induction and aggravation of chronic inflammatory skin diseases. We investigated the clinical significance of serum specific immunoglobulin E (lgE) to the staphylococcal superantigens staphylococcal enterotoxin A (SEA), staphylococcal enterotoxin B (SEB), and toxic shock syndrome toxin (TSST)-1 in patients with chronic urticaria (CU), focusing on the differences in these prevalences between aspirin-intolerant CU (AICU) and aspirin-tolerant CU (ATCU) patients. Aspirin sensitivity was confirmed by oral aspirin provocation test. There were 66 patients AICU and 117 patients ATCU in the study. Serum IgE antibodies specific for SEA, SEB, and TSST-1 were measured by the ImmunoCAP test and the patients were compared with 93 normal controls (NC). The prevalences of serum specific IgE to staphylococcal superantigens were significantly higher in CU than in NC patients (IgE to SEA, 13.7% vs. 5.4%; IgE to SEB, 12.0% vs. 4.3%; IgE to TSST-1, 18.0% vs. 6.5%; p<0.05, respectively). The patients with specific IgE to SEA, SEB, and TSST-1 had higher serum total IgE levels and higher rates of atopy. Significant associations were noted between the prevalence of specific IgE to SEA and SEB and the HLA DQB1*0609 and DRB1*1302 alleles in the AICU group. We confirmed that a sub-population of patients with CU possesses serum IgE antibodies to SEA, SEB, and TSST- 1. Particularly, the IgE immune response to TSST-1 is associated with aspirin sensitivity in CU patients.

Urticaria: its history-based diagnosis and etiologically oriented treatment

INTRODUCTION

The term "urticaria" refers to any of a group of distinct skin conditions that are characterized by itchy, wheal-and-flare skin reactions (hives). In spontaneous urticaria, the most common type, the hives seem to arise without provocation.

METHODS

Selective review of the literature, including current guidelines.

RESULTS

Spontaneous urticaria is divided into acute (lasting less than six weeks) and chronic types. The pathognomonic itching, hives, and angioedema arise by the same mechanism--cutaneous mast cell activation and release of histamine and other mediators of inflammation--in both acute and chronic urticaria, but these two disorders have different etiological profiles. The underlying cause of acute urticaria cannot be identified in about half of all cases. Chronic urticaria, which is much rarer, is usually caused by autoreactivity, chronic infection, or intolerance to food additives. If the condition persists after the underlying cause has been treated or eliminated, non-sedating antihistamines are the agents of first choice for symptomatic treatment.

DISCUSSION

Unlike acute urticaria, which is self-limited and should be treated symptomatically, chronic urticaria should be treated by the identification and elimination of underlying causes, which is usually curative.

First attack of acute urticaria in pediatric emergency department

BACKGROUND

Management of a first attack of acute urticaria in children is dependent on the etiology of the disease. Knowledge of the various etiologies of urticaria will help primary physicians to perform appropriate clinical assessments. In this study, we analyzed the etiologies and their prevalence in first-attack acute urticaria in infants, children and adolescents in central Taiwan.

METHODS

This was a retrospective study of 953 children who were admitted to the emergency department (ED) with a first attack of acute urticaria from January 2000 to December 2006. All patients were followed in the ED or outpatient department until their symptoms subsided. Patient demographics and detailed etiologies of the first attack of acute urticaria were analyzed. Furthermore, the prevalence of various etiologies in different age groups, as well as the etiologic trends of acute urticaria in children during the previous 7 years, was determined.

RESULTS

The most common etiologies of a first attack of acute urticaria in children were various infections (48.4%), foods (23.5%), idiopathic causes (13.2%), and medications (11.5%). Among the three major etiologies above, upper respiratory tract infections (nasopharyngitis), seafood (shrimp) and nonsteroidal anti-inflammatory drugs (ibuprofen) were the most frequent causes. Moreover, the etiologies differed significantly with patient age (p < 0.001). Overall, infections were the major cause in infants (56.5%), whereas food (36.6%) and medications (26.8%) were the most common etiologies in adolescents. The prevalence of various infections dropped as the age of the children increased (56.5% in infants, 51.2% in preschool-aged children, 42.1% in school-aged children and 17.1% in adolescents). The etiologies of foods and medications were more prevalent in adolescents than in younger children.

CONCLUSION

Detailed etiologies of first-attack urticaria in children in central Taiwan were analyzed. Most importantly, we found that there was a decrease in the prevalence of various infections as causative factors as the age of the children increased. The etiologies of foods and medications were more prevalent in adolescents than in younger children.

Pathophysiology of chronic urticaria

OBJECTIVE

To review the literature on the pathogenesis of chronic urticaria (excluding physical urticaria).

DATA SOURCES

PubMed was searched using the keywords urticaria and either chronic or autoimmune or pathogenesis for articles published from January 1972 to June 2007. All searches were limited to the English language. References from review articles on chronic urticaria were also considered for inclusion in this review.

STUDY SELECTION

The authors selected relevant and current sources for inclusion in this review.

RESULTS

No concise pathogenic mechanism has been identified for all cases of chronic urticaria, although evidence for a serologic mediator that may be autoimmune in nature has been identified in many cases. The activation of basophils and/or mast cells is a central feature in any theory proposed to explain this troubling disease.

CONCLUSION

Further research is needed to better define the mechanism or mechanism(s) responsible for the development of chronic urticaria. Such research will lead to more effective and possibly even curative treatments.

Candida spp. colonization and serum anticandidal antibody levels in patients with chronic urticaria

BACKGROUND

The role of Candida infections in the pathogenesis of chronic urticaria (CU) is debatable. Objective. In this study, we investigated the role of Candida spp. colonization and infection in patients with CU.

METHODS

In total, 38 patients with CU and a control group of 42 healthy individuals consented for inclusion in the study. Stool and oral specimens from all participants were cultured and evaluated quantitatively. Candida albicans ELISA IgG/IgM/IgA test kits were used for the detection of antibodies against C. albicans in the sera of patients and controls.

RESULTS

Yeasts were isolated from the stools of 60.5% of the patients and 50.0% of the controls (P = 0.78, Student's t-test) and from oral specimens in 47.4% and 42.9% (P = 0.85, Student's t-test), respectively. Colony counts in the positive specimens of both groups were not significantly different. IgG, IgM and IgA antibodies were positive in 36.8%, 23.8% and 5.3% of the patients and in 42.9%, 19.1% and 4.8% of the controls, respectively. The qualitative and quantitative results of the antibodies were not significantly different between the two groups (chi2 test).

CONCLUSION

Intestinal and oral colonization of Candida spp. and serological evidence of Candida infections were not significantly different between patients with CU and controls. Claims of triggering of CU by Candida spp. should be explored in studies that measure allergic reactivity to Candida, and also in those that include eradication therapy.

The frequency of nasal carriage in chronic urticaria patients

OBJECTIVE

Chronic urticaria is characterized by oedema of the skin and mucous membranes. Although many agents have been implicated, aetiology is unknown in 70 to 75% of patients. Infections and foci of chronic infections are most commonly held responsible for chronic urticaria. In this study, the frequency of nasal carriage as the occult focus of infection and sensitivity to antimicrobials are explored in patients with chronic urticaria.

MATERIAL AND METHOD

Ninety-four patients with chronic urticaria and 30 controls participated in the study, which was carried out at the Ege university medical faculty, department of dermatology between January 2004 and January 2005. Nasal swab specimens were taken from the patients and controls and incubated at 37 degrees C degrees for 48 h, and inoculated on standard bacterial medium (blood agar). Antimicrobial susceptibility of a growth from isolates of the nasal swab specimens was conducted. Data were analysed statistically using chi-square and Mann-Whitney U-tests.

RESULTS

Ninety-four patients with chronic urticaria (72.3% female and 27.7% male) and 30 controls (63.3% female and 36.7% male) comprised the study group. Mean age of the patients and controls were 42.6 and 33.8 years, respectively. Staphylococcus aureus was detected in swab specimens from the nasal cavity in 50 of the 94 patients (53.2%) with chronic urticaria and four of the 30 controls (13.3%). Testing revealed that the most susceptible antibiotics were cefaclor, ceftriaxone, amoxycillin-clavulanic acid, amikacin, netilmicin, and fucidic acid.

CONCLUSION

Growth on cultures prepared from nasal swab specimens of chronic urticaria patients was statistically higher than the control group. We detected resistance to growth against mupirocin, an antibiotic frequently used in nasal carriage. High nasal carriage of Staphylococcus aureus in patients with chronic urticaria compared to controls suggests that nasal carriage as a focus of infection should be kept in mind as aetiology.

[Parasites as a cause of urticaria. Helminths and protozoa as triggers of hives?]

Urticaria is one of the most prevalent disorders in dermatological practice. The disease can be incapacitating. There are clear pathophysiological and epidemiological hints that helminths and protozoa are rare but treatable causes of acute and chronic urticaria. Doctors and patients are often not aware that parasitic diseases are increasingly common even in industrialized countries due to a steep rise in migration and international travel. This review presents the most important parasitic causes of urticaria and provides relevant details regarding personal history, clinical presentation, diagnosis and therapy.

Chronic idiopathic urticaria: prevalence and clinical course

The purpose of our study was to assess the prevalence and clinical course of patients with chronic idiopathic urticaria (CIU), as well as possible causes or associated findings, laboratory findings and the duration of the disease in patients with chronic urticaria (CU). We retrospectively reviewed the 450 case record forms of patients with CU and/or angioedema who attended the Department of Dermatology, Siriraj Hospital, during the period 2000-2004. Of 450 patients with CU, 337 patients (75%) were diagnosed as CIU. Forty-three patients (9.5%) had physical urticaria, while 17 patients (3.8%) had infectious causes. Other possible causes were food, thyroid diseases, atopy, drugs, dyspepsia and collagen vascular diseases. In eighty-nine percent of patients, no abnormalities were detected at the time of physical examination. The most common abnormal laboratory finding was minimal elevation of the erythrocyte sedimentary rate (42%). In 61 patients, autologous serum skin tests had been done. Fifteen patients (24.5%) had positive results i.e. autoimmune urticaria. Anti-thyroglobulin and anti-microsomal antibodies were positive in 16 % and 12% of CIU patients respectively. After 1 year from the onset of the symptoms, 34.5% of CIU patients were free of symptoms and after 1.2 years from the onset of the symptoms, 56.5% of autoimmune urticaria patients were free of symptoms. The median disease duration of CIU and autoimmune urticaria were 390 days and 450 days respectively. Our study provided an overview of CU and CIU in a large series of Thai patients, based on etiological aspects and clinical courses.

Moderne Diagnostik und Therapie der Urtikaria

The different urticaria subtypes represent a common diagnostic and treatment challenge for the dermatologist. Usually, acute urticaria is treated symptomatically with modern H1 antihistamines and, if needed, short courses of glucocorticosteroids. In acute urticaria which is often induced by an acute infection no further diagnostic procedures are recommended. In contrast, a targeted work-up followed by specific therapy is required for chronic urticaria, physical urticaria and special urticaria types, because many of these subtypes are characterized by their persistence for several years and have a profound impact on the quality of life. This article elucidates the management of urticaria by presenting five characteristic case reports of patients managed in a special urticaria consulting hour.

EAACI/GA2LEN/EDF guideline: management of urticaria

This guideline is the result of a consensus reached during a panel discussion at the second International Consensus Meeting on Urticara, Urticaria 2004, a joint initiative of the EAACI Dermatology Section and GA2LEN. Urticaria has a profound impact on the quality of life, and effective treatment is therefore required. The recommended first line treatment are nonsedating H1 antihistamines. They have proven to be effective in double-blind controlled studies, but dosages increased up to fourfold over the recommended doses may be necessary. However, for different urticaria subtypes and in view of individual variation in the course of the disease and response to treatment, additional or alternative therapies may be required. Immunosuppressive drugs like cyclosporin A and corticosteroids are not recommended for long-term treatment due to unavoidable severe adverse effects. This guideline was, in addition, accepted by the European Dermatology Forum (EDF) and formally approved by the European Union of Medical Specialists (UEMS).

EAACI/GA2LEN/EDF guideline: definition, classification and diagnosis of urticaria

This guideline is the result of a consensus reached during a panel discussion at the 2nd International Consensus Meeting on Urticaria, Urticaria 2004, a joint initiative of the European Academy of Allergology and Clinical Immunology Dermatology Section and the European Union (EU)-funded network of excellence, GA2LEN. It covers the definition and classification of urticaria, taking into account the recent progress in identifying causes, eliciting factors and pathomechanisms of this disease. We have outlined useful diagnostic approaches for different subtypes of urticaria. This guideline was, in addition, accepted by the European Dermatology Forum (EDF) and was formally approved by the European Union of Medical Specialists (UEMS).

Aktuelle Positionsbestimmung zur Bedeutung von Nahrungsmittelallergien und -unverträglichkeiten bei der Urtikaria

Foods are usually the first suspect as the cause of urticaria. However, a causal relationship is found only in special subtypes of urticaria. IgE-mediated food allergy should be clearly separated from non-allergic hypersensitivity (pseudoallergic reactions). The former may play a role in acute urticaria, particularly in patients with atopic dermatitis. The responsible food proteins vary with age. IgE-mediated sensitization can apply to food-dependent exercise-induced urticaria/anaphylaxis but more often the combination of food intake (irrespective of which type) plus exercise results in symptoms. In chronic urticaria, IgE-mediated sensitization to food is normally irrelevant while pseudoallergic reactions to food additives and perhaps also to biogenic amines may be involved. Another urticaria subtype that may be caused by food is contact urticaria which is mostly found in the context of occupational food handling. Very rarely anisakiasis and nickel may cause food-induced urticaria. Aspirin is able not only to exacerbate and aggravate urticaria but can also enhance food-dependent urticaria.

Cost Effectiveness of Levocetirizine in??Chronic Idiopathic Urticaria

BACKGROUND

Chronic idiopathic urticaria is a distressing condition that severely affects patients' quality of life. The overall costs associated with this disease, both for the healthcare payer and society, are unknown. The objective of this study was to evaluate the cost effectiveness of levocetirizine, a first-line treatment for urticaria.

METHODS

Data were collected from two placebo-controlled trials and from official French databases. The effectiveness of the treatment was assessed by the mean number of pruritus-free days experienced by the patient within a 30-day period (PFD30). Direct cost parameters were medications used, medical procedures and hospitalisations for urticaria or treatment of adverse events. Productivity cost parameters were the workdays lost, defined as absenteeism and/or presenteeism, resulting from urticaria. The costing was performed using a French societal perspective. Costs were reported in euro (2002 values) and were standardised to a 30-day month. Whenever possible, incremental cost-effectiveness ratios (ICERs) were derived from these data.

RESULTS

The pooled sample contained 294 patients. Compared with placebo, patients in the levocetirizine group experienced an additional mean 6.5 (95% CI 3.8, 9.3) pruritus-free days per month (p < 0.001). Considering only direct medical costs, the incremental cost of treatment with levocetirizine was totally offset by the reduction in other medical costs (i.e. reduced cost of additional medications, medical procedures and hospitalisations). From the perspective of society, treatment with levocetirizine was cost saving, with a net gain of Euro 91.93 per patient per month.

CONCLUSION

Treating chronic idiopathic urticaria with levocetirizine is a dominant strategy for society since it is more effective (in terms of pruritus-free days gained) and less costly than placebo.

Basophils and mast cells in chronic idiopathic urticaria

Chronic idiopathic urticaria (CIU) is diagnosed in patients when urticarial eruptions recur for more than 6 weeks, and no specific cause is determined. Given that urticaria resembles the lesions induced by injection of histamine or allergen into the skin, a role for mast cells or basophils has been proposed in the generation of localized urticarial lesions. However, currently, the exact mechanisms governing regional mast cell or basophil activation are unknown. In the past decade, there has been mounting interest in viewing CIU as an autoimmune disease, given the presence of circulating autoantibodies to IgE or the alpha subunit of the high-affinity IgE receptor (FceRI) in a subset of patients. In this review, we propose that in addition to autoantibodies, specific differences in the expression of FceRI-signaling molecules in the basophils or mast cells of CIU patients may contribute to the generation of urticarial eruptions.