[Chronic urticaria. Prevalence, course, prognostic factors and impact]

The challenges of chronic urticaria part 2: Pharmacological treatment, chronic inducible urticaria, urticaria in special situations

This is Part 2 of an updated follow-up review of the World Allergy Organization (WAO) position paper on the diagnosis and treatment of urticaria and angioedema. Since that document was published, new advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics in patients with severe refractory disease, mainly omalizumab, have been gained. For these reasons, WAO decided to initiate an update targeted to general practitioners around the world, incorporating the most recent information on epidemiology, immunopathogenesis, comorbidities, quality of life, clinical case presentations, and the management of chronic spontaneous and chronic inducible urticaria, and urticaria in special situations such as childhood and pregnancy. A special task force of WAO experts was invited to write the different sections of the manuscript, and the final document was approved by the WAO Board of Directors. This paper is not intended to be a substitute for current national and international guidelines on the management of urticaria and angioedema, but to provide an updated simplified guidance for physicians around the world who have to manage patients with this common ailment.

An observational study on the efficacy of single injection of omalizumab in the treatment of chronic spontaneous urticaria

Chronic Spontaneous Urticaria (CSU) is one of the most challenging therapeutic problems faced by dermatologists. Omalizumab is a third line drug for CSU which is currently recommended as monthly injections for 6 months. To study the efficacy of single injection of Omalizumab in the treatment of CSU. This was a prospective single center observational study. Single dose of injection Omalizumab 300 mg was administered to 30 patients of CSU on double the dose of tablet Fexofenadine 180 mg with Urticaria Activity Score (UAS-7) more than 15 and their response was assessed using UAS-7 up to 6 months. The mean duration of response of early and late responders were analyzed. Of the 30 patients who completed the study, 29 patients (96.7%) were responders and one (3.3%) was nonresponder. Of the 29 responders, 21 (70%) were early responders and eight (26.7%) late responders. The mean total symptom free durations amongst early and late responders were analyzed and were found significant. The prolonged symptom free intervals in early responders after single injection of Omalizumab followed by antihistamines not only prevented over treatment with Omalizumab but was also cost saving in the long-term management of these cases. With careful monitoring of UAS7 scores an individualized, cost-effective approach can be adopted in the treatment of CSU. This study provides a basis for larger studies and may eventually determine a new standard of care with respect to limiting the doses of a biologic.

Urticaria: recommendations from the Italian Society of Allergology, Asthma and Clinical Immunology and the Italian Society of Allergological, Occupational and Environmental Dermatology

BACKGROUND

Urticaria is a disorder affecting skin and mucosal tissues characterized by the occurrence of wheals, angioedema or both, the latter defining the urticaria-angioedema syndrome. It is estimated that 12-22% of the general population has suffered at least one subtype of urticaria during life, but only a small percentage (estimated at 7.6-16%) has acute urticaria, because it is usually self-limited and resolves spontaneously without requiring medical attention. This makes likely that its incidence is underestimated. The epidemiological data currently available on chronic urticaria in many cases are deeply discordant and not univocal, but a recent Italian study, based on the consultation of a national registry, reports a prevalence of chronic spontaneous urticaria of 0.02% to 0.4% and an incidence of 0.1-1.5 cases/1000 inhabitants/year.

METHODS

We reviewed the recent international guidelines about urticaria and we described a methodologic approach based on classification, pathophysiology, impact on quality of life, diagnosis and prognosis, differential diagnosis and management of all the types of urticaria.

CONCLUSIONS

The aim of the present document from the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC) and the Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA) is to provide updated information to all physicians involved in diagnosis and management of urticaria and angioedema.

Prevalence of chronic urticaria in children and adults across the globe: Systematic review with meta-analysis

BACKGROUND AND OBJECTIVES

Urticaria is a frequent skin condition, but reliable prevalence estimates from population studies particularly of the chronic form are scarce. The objective of this study was to systematically evaluate and summarize the prevalence of chronic urticaria by evaluating population-based studies worldwide.

METHODS

We performed a systematic search in PUBMED and EMBASE for population-based studies of cross-sectional or cohort design and studies based on health insurance/system databases. Risk of bias was assessed using a specific tool for prevalence studies. For meta-analysis, we used a random effects model.

RESULTS

Eighteen studies were included in the systematic evaluation and 11 in the meta-analysis including data from over 86 000 000 participants. Risk of bias was mainly moderate, whereas the statistical heterogeneity (I² ) between the studies was high. Asian studies combined showed a higher point prevalence of chronic urticaria (1.4%, 95%-CI 0.5-2.9) than those from Europe (0.5%, 0.2-1.0) and Northern American (0.1%, 0.1-0.1). Women were slightly more affected than men, whereas in children < 15 years we did not find a sex-specific difference in the prevalence. The four studies that examined time trends indicated an increasing prevalence of chronic urticaria over time.

CONCLUSIONS

On a global level, the prevalence of chronic urticaria showed considerable regional differences. There is a need to obtain more sex-specific population-based and standardized international data particularly for children and adolescents, different chronic urticaria subtypes and potential risk and protective factors.

Sex in Respiratory and Skin Allergies

A bulk of literature demonstrated that respiratory allergy, and especially asthma, is prevalent in males during childhood, while it becomes more frequent in females from adolescence, i.e., after menarche, to adulthood. The mechanisms underlying the difference between females and males are the effects on the immune response of female hormones and in particular the modulation of inflammatory response by estrogens, as well as the result of the activity of various cells, such as dendritic cells, innate lymphoid cells, Th1, Th2, T regulatory (Treg) and B regulatory (Bregs) cells, and a number of proteins and cytokines, which include interleukin (IL)-4, IL-5, IL-10, and IL-13. As far as sexual dimorphism is concerned, a gender difference in the expression profiles of histamine receptors and of mast cells was demonstrated in experimental studies. A critical phase of hormone production is the menstrual cycle, which often is associated with asthma deterioration, as assessed by worsening of clinical symptoms and increase of bronchial hyperresponsiveness. In asthmatic woman, there is a high risk to develop more severe asthma during menstruation. The higher prevalence of asthma in females is confirmed also in the post-menopause age, but the underlying mechanisms are not yet understood. In pregnancy, asthma may worsen but may also improve or remain unchanged, with no significant difference in frequency of these three outcomes. For allergic rhinitis, the available studies indicate, likewise asthma, a male predominance in prevalence in childhood that shifts to a female predominance in adolescence and adulthood, but further investigation is needed.

Chronic urticaria in a health maintenance organization of Buenos Aires, Argentina - new data that increase global knowledge of this disease

BACKGROUND

In spite of the frequency of chronic urticaria, there are no epidemiological studies on its prevalence in Argentina.

OBJECTIVE

The objective of this study was to define the prevalence and epidemiological characteristics of chronic urticaria patients in Buenos Aires.

METHODS

The population studied were the members of the Italian Hospital Medical Care Program, a prepaid health maintenance organization located in the urban areas around the Autonomous City of Buenos Aires, Argentina. All patients with diagnosis of chronic urticaria members of the Italian Hospital Medical Care Program, and with at least 12 months of follow up were included in the study. All medical records obtained between January 1st, 2012 and December 31, 2014 were analyzed. The prevalence ratio for chronic urticaria per 100,000 population with 95% CI for December 31, 2014 was calculated. The prevalence rate for the entire population and then discriminated for adults and pediatric patients (less than 18 years old at diagnosis) was assessed.

RESULTS

158,926 members were analyzed. A total of 463 cases of chronic urticaria were identified on prevalence date (68 in pediatrics, 395 in adults), yielding a crude point prevalence ratio of 0.29% (CI 95% 0.26-0.31%). The observed prevalence of chronic urticaria in the adult population was 0.34 % (95% CI 0.31-0.38%), while in pediatrics it was 0.15 % (95% CI 0.11-0.20%).

STUDY LIMITATIONS

the main weakness is that the results were obtained from an HMO and therefore the possibility of selection bias.

CONCLUSIONS

chronic urticaria is a global condition. Its prevalence in Buenos Aires is comparable with other countries.

Review of Physical Urticarias and Testing Methods

PURPOSE OF REVIEW

This review aims to update the information available on the prevalence, clinical picture, diagnostic methods, and treatment of urticarias induced by external physical stimuli.

RECENT FINDINGS

Physical urticarias are present in up to 5% of the general population, and in 10 to 50% of patients with chronic urticaria. Recent investigations have provided evidence that the presence of physical urticaria alone or when comorbid with chronic spontaneous urticaria is associated with a worse prognosis and duration. Most frequent subtypes of physical urticaria are dermographism and delayed pressure urticaria. The diagnosis is established through specific provocation tests and the management encompasses avoidance measures, pharmacologic therapy with nonsedating antihistamines, and alternative medications in refractory cases.

CRP relevance in clinical assessment of chronic spontaneous urticaria Tunisian patients

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common dermatological condition defined by the sudden occurrence of daily wheals and pruritus for at least six weeks. Multifactorial origin is suggested such as oxidative stress. This latter may play a double role as a trigger and remnant agent.

OBJECTIVES

The first aim of this study is to investigate antioxidant status, inflammatory proteins, hematologic counts and clinical assessment in CSU patients. The second aim is to evaluate the effect of a first-line treatment: desloratadine 5 mg/d on these different parameters.

PATIENTS AND METHODS

This study enrolled 30 CSU patients and same number of controls. We assessed the urticaria activity score (UAS), total antioxidant status (TAS), glutathione S-transferase (GST), superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase (CAT), albumin, alpha1, alpha2, beta1 beta2, gamma globulins, c-reactive protein (CRP) and hematologic numeration.

RESULTS

At baseline alpha1, alpha2, beta1, beta2, gamma globulins, CRP, SOD activity, leukocytes and basophils were significantly higher in patients versus controls (p < 0.05). TAS, GST, CAT, GPx and albumin were significantly low in patients versus controls (p < 0.05). After treatment, TAS, GST and GPx were significantly increased in patients versus patients before treatment (p < 0.001). SOD, alpha1, alpha2, beta1, beta2, gamma globulins, CRP, albumin, leukocytes and basophils were significantly decreased after treatment versus before treatment (p < 0.05). A significant correlation between CRP and UAS (r = 0.3; p = 0.011) was noted. UAS assessment revealed the efficacy of 30 d-antihistaminic treatment.

CONCLUSIONS

Desloratadine exerted anti-inflammatory and antioxidant effects on CSU patients revealed by CRP. Patients' remission was synergistic to CRP attenuation emphasizing CRP relevance for CSU clinical assessment.

Factors linked to disease severity and time to remission in patients with chronic spontaneous urticaria

Biomarkers useful for the evaluation and management of patients with chronic spontaneous urticaria (CSU) are not currently available. A review of various clinical and laboratory markers that have been studied to assess their value for determining the severity or predicting the evolution of disease in adult patients with CSU was carried out. A search of the medical literature on PubMed and MEDLINE including the terms urticaria, chronic urticaria, chronic idiopathic urticaria, CSU, severity, prognosis and treatment was performed. Based on our review of the literature, among the clinical markers studied, higher age at onset, being female, long disease duration and aspirin/NSAID hypersensitivity may be linked to both severe CSU and a long time to spontaneous remission. In addition, a positive autologous serum skin test (ASST) may be associated with severe CSU, and comorbidity of inducible urticaria and concomitant recurrent angio-oedema may be linked to longer CSU duration. Potential biomarkers of CSU severity and/or duration include basophil numbers and susceptibility to activation, inflammatory markers, markers of activation of the extrinsic coagulation pathway, immunoglobulin E and vitamin D. Although the described markers are promising, further studies on representative and well-characterized patient populations are needed to determine the value of these clinical and biological markers for predicting the severity and course of disease in patients with CSU.

Management of urticaria: not too complicated, not too simple

In spite of being an old disease and apparently easy to diagnose, chronic spontaneous urticaria (CSU) is still perceived as an uncontrollable and difficult to manage disease. The perception of the patient is that his/her condition is not well understood and that is suffering from a disorder with hidden causes that doctors are not able to tackle. Sometimes patients go through a number of clinicians until they found some CSU expert who is familiar with the disease. It is surprising that myths and believes with no scientific support still persist. Guidelines are not widely implemented, and recent tools to assess severity are infrequently used. European and American recent guidelines do not agree in several key points related to diagnosis and treatment, which further contributes to confusion. With the aim to clarify some aspects of the CSU picture, a group of allergists and dermatologists from the Spanish Dermatology and Allergy societies developed a Frequent Asked Questions leaflet that could facilitate physicians work in daily practice and contribute to a better knowledge of common clinical scenarios related to patients with CSU.

Diagnosis and treatment of urticaria and angioedema: a worldwide perspective

: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.

Quality of life in chronic urticaria: a survey at a public university outpatient clinic, Botucatu (Brazil)

OBJECTIVE

To evaluate the impact of chronic urticaria on quality of life of outpatients through the university questionnaire Dermatology Life Quality Index (DLQI).

METHODS

Survey of the impact on quality of life caused by chronic urticaria, using the DLQI questionnaire validated for the Portuguese language. Patients were interviewed during visits to a specialized outpatient clinic between May 2009 and May 2010 at a Brazilian public service (Botucatu-SP). DLQI scores were analyzed according to the following subgroups: age, gender, education, disease duration, and presence of angioedema.

RESULTS

We interviewed 100 patients with chronic urticaria. There was a female predominance (86%), mean age 41.8 years, mean disease duration of 6 years, and angioedema occurrence in 82% of patients. The mean DLQI score was 13.5, characterized by serious impact on quality of life, higher than Hansen's disease, psoriasis, atopic eczema, and basal cell carcinoma. The presence of angioedema was associated with higher scores: 14.5 x 9.9 (p < 0.01). Female patients reported greater impact on clothing, while male patients reported treatment interference with work and study (p < 0.05).

CONCLUSION

Chronic urticaria seriously compromises the quality of life of patients evaluated at a university service in Brazil, particularly of patients with angioedema.