The Burden of Chronic Urticaria from Brazilian Patients' Perspective

Quality of life measurement in urticaria: Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient-Oriented Outcomes and Urticaria and Angioedema

The European Academy of Dermatology and Venereology (EADV) Task Forces on quality of life (QoL) and patient-oriented outcomes and on urticaria and angioedema recommendations for the assessment of Health-related (HR) QoL in all patients with urticaria in research and practice are as follows: to use the DLQI for adults and the CDLQI for children as dermatology-specific and the CU-Q2oL as a disease-specific HRQoL instruments in urticaria; to use generic instruments to provide comparison of data on urticaria with non-dermatologic diseases, or to compare with healthy volunteers or the general population; to select validated HRQoL instruments with appropriate age limits; to present exact numeric data for HRQoL results; correct title of any HRQoL instrument should be used, along with its correct abbreviation and the reference to its original publication, where possible. The EADV TFs discourage the use of non-validated HRQoL instruments and modified HRQoL instruments that have not undergone standard validation.

Global, regional, and national levels and trends in burden of urticaria: A systematic analysis for the Global Burden of Disease study 2019

Background

Urticaria places a significant burden on individuals and society due to its widespread nature. The aim of this study was to evaluate the burden of urticaria in different regions and nations by analysing data from the Global Burden of Disease study 2019 (GBD 2019), with the goal of providing information to health care policymakers.

Methods

By utilising data from the GBD 2019 database, this study analysed metrics such as incidence, prevalence, disability-adjusted life years (DALYs), age-standardised rate (ASR), and estimated annual percentage changes (EAPC) globally and across 204 countries and regions. The data was further stratified by age, sex, and sociodemographic index (SDI).

Results

In 2019, global incidence cases, prevalence cases, and overall disease burden as measured by DALYs all increased. The distribution of the burden exhibited marked geographical heterogeneity. At the regional level, the burden is highest in Central and Eastern Europe and Central Asia, with the strongest growth in South Asia, compared with a decline in the high-income Asia Pacific. At the country level, Nepal reports the highest burden of urticaria, while Portugal has the lowest. Gender and age analyses showed that the burden of urticaria is higher in females than in males, with urticaria cases declining with age, especially in children, and picking up among the elderly. The study also finds a correlation between the burden of urticaria and the SDI, with the central part of the SDI showing a consistent increasing trend.

Conclusion

This study found that the global burden of urticaria has risen from 1990 to 2019. Factors like geographic location, gender, and SDI influenced the urticaria burden. Overall, these results offer a resource to guide public health strategies seeking to reduce the burden of urticaria.

Burden of and Trends in Urticaria Globally, Regionally, and Nationally from 1990 to 2019: Systematic Analysis

BACKGROUND

Urticaria presents a significant global health challenge due to its sudden onset and potential for severe allergic reactions. Past data on worldwide prevalence and incidence is inconsistent due to differing study methodologies, regional differences, and evolving diagnostic criteria. Past studies have often provided broad ranges instead of specific figures, underscoring the necessity for a cohesive global perspective to inform public health strategies.

OBJECTIVE

We aimed to assess the global burden of urticaria using the 2019 Global Burden of Disease (GBD) study data and systematically analyze urticaria prevalence, incidence, and disability-adjusted life years (DALYs) at global, regional, and national levels, thereby informing more effective prevention and treatment strategies.

METHODS

We analyzed the global, regional, and national burden of urticaria from 1990 to 2019 using the 2019 GBD study coordinated by the Institute for Health Metrics and Evaluation. Estimations of urticaria prevalence, incidence, and DALYs were derived using DisMod-MR 2.1, a Bayesian meta-regression tool. The Socio-demographic Index (SDI) was used to correlate development status with health outcomes. The GBD's division of the world into 21 regions and 204 countries and territories facilitated a comprehensive assessment. Age-standardized estimated annual percentage changes were generated for urticaria metrics to quantify temporal trends, with age standardization adjusting for potential confounding from age structure.

RESULTS

From 1990 to 2019, the global age-standardized prevalence, incidence, and DALY rates of urticaria showed marginal changes. In 2019, 65.14 million individuals were affected, with a prevalence rate of 841.88 per 100,000 population. The DALY rate was 50.39 per 100,000 population. Compared to 1990, the global age-standardized prevalence, incidence, and DALY rates saw increases of 2.92, 4.84, and 0.31 per 100,000 population, respectively. Women persistently had higher rates than men. At a regional level in 2019, low-middle SDI regions exhibited the highest age-standardized metrics, whereas high SDI regions reported the lowest. Central Europe showed the highest rates, contrasting with Western Europe's lowest rates. Nationally, urticaria prevalence in 2019 varied dramatically, from a low of 27.1 per 100,000 population in Portugal to a high of 92.0 per 100,000 population in Nepal. India reported the most DALYs at 749,495.9, followed by China, Pakistan, and the United States. Agewise data showed higher rates in younger age groups, which diminished with age and then experienced a slight resurgence in the oldest populations. This pattern was pronounced in women and younger populations, with the largest rises seen in those aged less than 40 years and the smallest in those aged more than 70 years.

CONCLUSIONS

Urticaria remains a significant global health issue, with considerable variation across regions, countries, and territories. The increased burden among women, the rising burden in younger populations, and the regional differences in disease burden call for tailored interventions and policies to tackle this emerging public health issue.

Causal relationship between gut microbiota and urticaria: a bidirectional two-sample mendelian randomization study

Background

Cumulative evidence showed an association between gut microbiota and urticaria, but the causal relationship between them is unclear. We aimed to verify whether there is a causal relationship between the composition of gut microbiota and urticaria and explore whether the causal effect was bidirectional.

Methods

We obtained genome-wide association studies (GWAS) summary data of 211 gut microbiota and urticaria from the most extensive available GWAS database. A bidirectional two-sample mendelian randomization (MR) study was used to test the causal relationship between the gut microbiota and urticaria. The MR analysis was primarily performed with the inverse variance weighted (IVW) method, and MR-Egger, weighted median (WM), and MR-PRESSO were performed as sensitivity analyses.

Results

The Phylum Verrucomicrobia (OR 1.27, 95%CI 1.01 to 1.61; p = 0.04), Genus Defluviitaleaceae UCG011 (OR 1.29, 95%CI 1.04 to 1.59; p = 0.02), and Genus Coprococcus 3 (OR 1.44, 95%CI 1.02 to 2.05; p = 0.04) was a risk effect against urticaria. And Order Burkholderiales (OR 0.68, 95%CI 0.49 to 0.99; p = 0.04) and Genus Eubacterium xylanophilum group (OR 0.78, 95%CI 0.62 to 0.99; p = 0.04) were negatively associated with urticaria, suggesting a protective effect. At the same time, urticaria had a positively causal effect on gut microbiota (Genus Eubacterium coprostanoligenes group) (OR 1.08, 95%CI 1.01 to 1.16; p = 0.02). These findings showed no influence by heterogeneity or horizontal pleiotropy. Moreover, most sensitivity analyses showed results consistent with those of IVW analysis.

Conclusion

Our MR study confirmed the potential causal relationship between gut microbiota and urticaria, and the causal effect was bidirectional. Nevertheless, these findings warrant further examination owing to the unclear mechanisms.

Urticaria: A Narrative Overview of Differential Diagnosis

Urticaria is an inflammatory skin disorder that may occur in isolation or associated with angioedema and/or anaphylaxis. Clinically, it is characterized by the presence of smooth, erythematous or blanching, itchy swelling, called wheals or hives, which greatly vary in size and shape and last less than 24 h before fading to leave normal skin. Urticaria is the consequence of mast-cell degranulation that can be caused by immunological or non-immunological mechanisms. From a clinical point of view, many skin conditions can mimic urticaria and their recognition is mandatory for a correct management and therapeutic approach. We have reviewed all of the main relevant studies which addressed differential diagnosis of urticarial, published until December 2022. The National Library of Medicine PubMed database was used for the electronic research. The present review offers a clinical narrative overview, based on the available literature, of the principal skin disorders that can be misdiagnosed as urticaria (mainly autoinflammatory or autoimmune disorders, drug-induced reactions, and hyperproliferative diseases). The aim of this review is to provide clinicians a useful tool for correctly suspecting and identifying all of these conditions.

Acupuncture and Related Therapies for Chronic Urticaria: A Critical Overview of Systematic Reviews

Background. Chronic urticaria (CU) can severely impair the quality of life. Acupuncture and related therapies have been widely used in the treatment of CU in China. This study aimed to summarize and critically evaluate the methodological and reporting quality of relevant systematic reviews (SRs) and present objective and comprehensive evidence on the effectiveness and safety of acupuncture and related therapies for CU. Methods. Eight electronic databases were searched from inception to October 2021 for SRs examining acupuncture and related therapies for CU, and gray literature was manually searched. Two authors independently identified SRs and extracted data. The methodological and reporting quality of these SRs were assessed by the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) tool and preferred reporting items for SRs and meta-analyses (PRISMA, 2020), respectively. In addition, the risk of bias in systematic reviews (ROBIS) was used to evaluate the risk of bias. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was applied to evaluate the quality of evidence for outcome measures. Results. In total, 23 SRs, including a total of 11 outcome indicators, were published before October 2021. The AMSTAR-2 results showed that the methodological quality of all SRs was critically low; items 2, 3, 7, 9, 10, and 16 were found to have particularly low quality. For PRISMA, the reporting quality of the included SRs was unsatisfactory, and major reporting flaws were observed in the search strategy, synthesis method, certainly assessment, reporting biases, registrations, and financial support of the included SRs. For ROBIS, 22 SRs (95.65%) had a high risk of bias. Among the 55 outcomes assessed using the GRADE framework, there were 3 (5.45%) outcomes with moderate-quality evidence, 6 (10.91%) outcomes with low-quality evidence, and 46 (83.64%) outcomes with very low-quality evidence. We found the moderate quality of evidence indicating that the total effective rate and curing rate of the acupuncture group were higher than those of the western medicine group, and the recurrence rate was lower than that of the western medicine group. Conclusions. Acupuncture and related therapies for the treatment of CU are supported by low-quality evidence-based medicine. However, considering the poor quality of these SRs, we suggest that studies with more rigorous designs, larger sample sizes, and higher methodological and reporting quality are necessary to provide stronger evidence. Registration. The protocol for this study has been registered (PROSPERO registration number: CRD42021259131).

Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review

Purpose

Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU.

Patients and methods

Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results

Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H₁-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU.

Conclusion

Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H₁- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.

Prospective analysis of clinical evolution in chronic urticaria: Persistence, remission, recurrence, and pruritus alone

Background

Population and study's methodology heterogenicity became clinical evolution of chronic spontaneous urticaria (CSU) highly variable.

Objective

In a prospective cohort, we evaluated the different pathways of clinical evolution of CSU and identified possible risk factors.

Methods

A total of 685 CSU patients (>12 years) were prospectively followed over 5 years. Diagnosis and follow-up of urticaria were based on medical evaluation and photographic records. Remission was defined as at least 6 months without symptoms (hives, angioedema, or pruritus) and medication. The follow-up included at least 2 visits per year, with photographic registration and clinical evaluation. Predefined clinical and paraclinical variables were included in the regression analyses.

Results

We identified four clinical evolution pathways; The cumulative prevalence of remission at 5 years was 59.1%, recurrence was 17.1%, persistence was 11.6%, and chronic pruritus without hives or angioedema was 12.2%. The probability of persistence increased with hypothyroidism diagnosis (HR 0.425, 95% CI 0.290-0.621) and each point in the UAS7 (HR 0.931 95% CI 0.918-0.945).

Conclusion

Chronic urticaria has different evolutions. Disease activity and hypothyroidism predict persistence and remission. Recurrence and chronic pruritus phenotypes require further study to evaluate their causality and prognosis.

Prevalence of Helicobacter pylori Infection Among Rosacea and Chronic Spontaneous Urticaria Patients in a Tertiary Hospital in Riyadh, Saudi Arabia

BACKGROUND

The multifactorial nature of rosacea and chronic spontaneous urticaria (CSU) pathogenesis complicates the achievement of satisfactory treatment outcomes. 13C urea breath test (UBT) has been identified as an accurate, non-invasive, and quick procedure to detect the presence of Helicobacter pylori (H. pylori) with high sensitivity and specificity.

OBJECTIVE

In this study, we aim to assess the correlation between H. pylori infection and rosacea and CSU patients.

METHODS

A cross-sectional, observational study was conducted on patients with rosacea and CSU in the dermatology clinic at King Khalid University Hospital in Riyadh, Saudi Arabia. History and physical examination were performed by a dermatologist. H. pylori 13C-UBT detection was performed in all subjects.

RESULTS

In total, 114 patients were included in this current study, with 41 rosacea and 73 urticaria patients. The vast majority of our subjects were females (96.5%). The mean (±SD) age was 42.3 (±12.7). More than half (58.8%) of the examined samples were positive for 13C-UBT; however, positive results were significantly higher in the rosacea patients (73.2%) compared to the urticaria group (50.7%), with a p-value of 0.019.

CONCLUSION

Our findings underline the significant association of H. pylori with rosacea and CSU regardless of the presence or absence of gastrointestinal symptoms. We thus recommend the inclusion of H. pylori testing in the routine workup of CSU and rosacea patients.

Epidemiology, comorbidities, and healthcare utilization of patients with chronic urticaria in Germany

BACKGROUND

Comprehensive data on the epidemiology and comorbidities of chronic urticaria (CU) in Germany are either limited, or not contemporary.

OBJECTIVES

To investigate the epidemiology of CU, overall comorbidities and healthcare resource utilized by patients with CU in Germany, using an anonymized statutory health insurance (SHI) database.

METHODS

Anonymized SHI claims research database of the Institute for Applied Health Research, Berlin [InGef] (01 January 2015-30 September 2018) was used to analyse insured individuals with a confirmed diagnosis of CU (ICD-10-GM codes). Twelve-month diagnosed prevalence and incidence, comorbidities (vs. atopic dermatitis and psoriasis), and healthcare utilization by patients with CU were investigated.

RESULTS

Of 4 693 772 individuals of all ages listed in the database, 3 538 540 were observable during 2017. Overall, 17 524 patients (˜0.5%) were diagnosed with CU; chronic spontaneous urticaria (CSU: 71.2%), chronic inducible urticaria (CIndU: 19.7%), CSU+CIndU (9.1%). Females, vs. males, had higher diagnosed prevalence (0.62% vs. 0.37%) and diagnosed incidence (0.18% vs. 0.11%) of CU among all patients. Patients most frequently visited general practitioners (41.3% of total visits). Hypertensive diseases (43.5%), lipoprotein metabolism disorders (32.1%) and affective disorders (26.0%) were the most frequently reported comorbidities of special interest. Rates of most comorbidities of special interests were similar to atopic dermatitis and psoriasis patients, and all higher vs. overall population. More than half (54.1%) of all CU patients were not prescribed any treatment. Second-generation H₁ -antihistamines were the most commonly prescribed medication for adult (17.9%) and paediatric (27.9%) patients. Patients with CIndU (paediatric, 15.5%; adult, 7.8%) were more often hospitalized versus patients with CSU (paediatric, 9.9%; adult, 4.6%).

CONCLUSIONS

In Germany, prevalence of CU along with multiple comorbidities may pose increased burden on the healthcare system. Awareness of adhering to treatment guidelines, and aiming for complete control of urticaria, needs to be driven and may improve outcomes.

What lessons can we learn? Clinical and epidemiological retrospective analysis of 267 patients with urticaria in a Brazilian tertiary center

BACKGROUND

There are few epidemiological studies of urticaria, published in the indexed literature (PubMed/Medline).

OBJECTIVE

The study aimed to evaluate the epidemiological and clinical data among patients with urticaria/angioedema attending a reference clinic in Brazil.

METHODS

Two hundred sixty-seven patients were evaluated retrospectively considering demographic data, time course of the disease, triggering symptoms, the presence of angioedema, complementary laboratory tests including total blood count, reactive-C protein, erythrocyte sedimentation rate, IgE serum levels, and other, as necessary.

RESULTS

The most commonly diagnosed type of urticaria was chronic spontaneous urticaria (56.93%). Angioedema was associated with chronic urticaria in 108 patients (40.08%).

STUDY LIMITATIONS

Unicentered and retrospective.

CONCLUSION

Some relevant findings in this study are the observation of a female prevalence of cases (4-females: 1-man), a result more elevated than demonstrated in previous studies in Europe and Asia, the median age was 43-years old and the delay of time between the diagnosis of urticaria and the admission for treatment in a specialized center was approximately 2-years. Other multicenter studies can better establish these differences in Brazilian patients.

Treatment satisfaction in chronic urticaria during guideline-based therapy

BACKGROUND AND OBJECTIVES

Patients with chronic urticaria are often unsatisfied with their treatment. We aimed to assess patient satisfaction, chronic urticaria control, treatment goals, self-treatment competence, knowledge, and factors influencing treatment satisfaction.

PATIENTS AND METHODS

Eighty-seven adult patients with chronic urticaria who were previously insufficiently treated with oral antihistamines received guideline-based care for six months and completed questionnaires.

RESULTS

This study included patients with chronic spontaneous (80 %) and/or inducible urticaria (CIndU, 32 %). Significant median improvements were observed with the urticaria control test (UCT, from 7 to 11), the urticaria activity score for patients with chronic spontaneous urticaria (from 19 to 10), and treatment satisfaction (from 5.2 to 8.4). Six significant, independent factors of treatment satisfaction after six months of treatment were identified (negative: male sex, CIndU, sleep disturbances; positive: UCT, baseline treatment satisfaction, perceived competence of the study physician). Adequate urticaria control (UCT ≥ 12) was achieved in 19 % of patients with CIndU and 61 % of patients without CIndU.

CONCLUSIONS

In patients with chronic urticaria who were previously insufficiently treated with antihistamines, six months of guideline-based therapy significantly improved disease control and treatment satisfaction. Adequate control requires several consultations for many patients and is considerably more difficult to achieve for CIndU.

Hormonal Effects on Urticaria and Angioedema Conditions

Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.

A Systematic Review and Meta-Analysis of Health Utility Estimates in Chronic Spontaneous Urticaria

Background: Chronic spontaneous urticaria (CSU) is a common recurrent skin disease that adversely affect patient's quality of life condition to treat. Economic evaluations of health care often include patient preferences for health outcomes using utilities.

Objectives: The study aimed to determine pooled estimates of utility-based quality of life in patients with CSU.

Methods: We conducted a systematic review, meta-analysis, and meta-regression of peer-reviewed articles and conference papers that published from database inception to 31 April 2019 that reported utility estimates in patients with CSU. Scores reported with the EQ-5D, SF-6D, SF-12, and SF-36 instruments were converted to utilities using published mapping algorithms. Meta-analysis was used to calculate the pooled and meta-regression was used to examine the effects of possible factors.

Results: The pooled utility estimate for CSU was 0.68 [95% confidence interval (CI): 0.67–0.70]. The pooled utility estimate that converted from SF-36 or SF-12 was 0.66 (95% CI: 0.58–0.74), 0.72 (95% CI: 0.70–0.74) for EQ-5D, and 0.65 (95% CI: 0.63–0.67) for SF-6D, respectively. According to the meta-regression, higher proportion of female patients was significantly associated lower utility estimates (p = 0.013).

Conclusions: The study provides evidence-based utility estimates to inform health-related burden analysis of CSU and reference for the follow-up cost-effectiveness evaluation of chronic spontaneous urticaria intervention. These results highlight differences in common utility-based instruments and need to be cognizant of the specific instruments used when comparing the results of outcome studies.

Association between Chronic Urticaria and Helicobacter pylori Infection among Patients Attending a Tertiary Hospital in Tanzania

BACKGROUND

Chronic urticaria (CU) is a common skin disease; however, its etiology is rarely recognized. Infection due to Helicobacter pylori (H. pylori) has been shown in some studies to play a significant role in the pathogenesis of CU.

OBJECTIVE

This study was conducted to determine the association between CU and H. pylori infection among patients attending the Regional Dermatology Training Center, Northern Tanzania, from October 2018 to April 2019. Methodology. A matched case-control study that included 55 cases and 55 controls matched by age and sex was conducted. Data were collected through direct interviews, and the results of laboratory investigations were recorded in the extraction sheet. An enzyme-linked immunosorbent assay test was used to detect H. pylori antigen in the stool samples. Conditional logistic regression was used to measure the association between CU and H. pylori.

RESULTS

The total number of participants in this study was 110 patients (55 cases and 55 controls), whereby the median age was 31 (IQR 27-45) among controls versus 34 (IQR: 22-46) years among the cases. Both cases and controls had the same number of females and males. There was no significant association between CU and baseline characteristics of the participants. There was an association between CU and H. pylori infection, such that subjects with CU had a higher number of positive H. pylori test (15/55 = 27%) versus controls (6/55 = 10.1%) (p = 0.0225). The adjusted odds of CU among patients who were positive for H. pylori were sixfolds higher (OR = 6.9; CI: 1.3-36.2; p = 0.021) than those of patients who were negative for H. pylori.

CONCLUSION

There was a strong and significant association between CU and H. pylori infection. We recommend investigating for H. pylori in all cases of CU and conducting further trials on H. pylori eradication.

Natural history, prognostic factors and patient perceived response to treatment in chronic spontaneous urticaria

Background

Although the diagnosis and management of chronic spontaneous urticaria (CSU) is well documented in the literature, some aspects of the disease remain unclear. We aimed to further describe the natural history, prognostic factors, humanistic burden and uptake of traditional and alternative therapies in patients with CSU.

Methods

This was a prospective, cross-sectional analysis at a single centre. We reviewed patient medical records and conducted a survey in patients with CSU.

Results

72 patients participated in the study with a median duration of CSU of 48 months. 30% of patients had symptoms that resolved in under 2 years with these patients trending towards an older age of onset of CSU (48 ± 17 years). 16% of patients had symptoms lasting 10 years or longer with these patients trending towards a younger age of onset (22 ± 16 years). Patients with a relapsing/remitting disease course (31%) and those with co-existing angioedema (57%) trended towards a longer median duration of CSU (96 and 50 months respectively) and were observed to have a higher proportion of patients reporting CSU duration of 10 years or longer (33% and 25%, p = 0.033 and p = 0.036 respectively). Patients with co-existing autoimmune/thyroid disease (19%) trended towards a shorter median duration of CSU (37 months). 54 patients (75%) reported sleep disturbance and 29 patients (43%) required emergency room visit(s) for symptomatic control. 84% of patients who trialed second generation antihistamines reported a response to treatment, while 73% of patients who trialed omalizumab reported a response to treatment. Patients using alternative medicine such as acupuncture, traditional Chinese medicine and naturopathic medicine had lower reported response rates (20–29%) to treatment.

Conclusions

The natural history of CSU may be longer than previously reported with our study finding a median duration of symptoms of nearly 4 years with one-third of patients reporting a relapsing/remitting disease course. Younger age of onset, a relapsing/remitting disease course and angioedema may predict a longer duration of CSU, whereas older age of onset and co-existing autoimmune/thyroid disease may predict a shorter duration of CSU. Reported symptomatic benefit was higher from guidelines based pharmacologic therapy versus various alternative medicines.

A Meta-Analysis of Observational Studies on the Association of Chronic Urticaria With Symptoms of Depression and Anxiety

Background: Chronic urticaria (CU) is a frequently occurring skin condition associated with many psychological factors, but the effect size of associations varied in literature.

Objectives: To perform a systematic review and meta-analysis on the associations of CU with the symptoms of depression and anxiety.

Methods: According to a pre-specified protocol, we systematically searched articles published in PubMed, Web of Science, CNKI, and CQVIP databases between January 2000 and January 2019. Pooled estimates in terms of odds ratios (ORs) or standardized mean differences (SMDs) were calculated according to outcome measures. Subgroup analysis by disease subtypes and tool of measurement, and sensitivity analysis were performed. Risk of bias and quality of studies were evaluated.

Results: Twelve studies were selected for the systematic review. The ORs were 3.99 [95% confidence interval (CI): 3.24–4.91, P < 0.001] for anxiety and 2.94 (95% CI: 2.42–3.58, P < 0.001) for depression. The SMDs of severity were 0.98 for anxiety (95% CI: 0.76–1.200, P < 0.001) and 0.84 for depression (95% CI: 0.59–1.10, P < 0.001). Subgroup analysis by disease subtypes and tool of measurement showed variations in effect size, where chronic spontaneous urticaria showed greater effects on anxiety (OR = 6.62, 95% CI: 3.67–11.95, P < 0.001) and depression (OR = 6.13, 95% CI: 2.31–16.31, P < 0.001). Sensitivity analysis demonstrated consistent results.

Conclusion: CU is associated with higher risks of anxiety and depression.

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.

Health-Related Utility of EQ-5D in Korean Adults With Chronic Urticaria: Mapping From Urticaria Outcome Measures

Purpose

A need for useful measures reflective of the socio-economic burden of chronic urticaria (CU) has arisen. To obtain utility estimates for CU, we investigated EuroQol-5-Dimension (EQ-5D) indices according to urticaria control status and urticaria severity.

Methods

In this prospective observational study, we administered patient-oriented questionnaires on EQ-5D and urticaria outcomes, including Urticaria Activity Score over 7 days (UAS7), Urticaria Control Test (UCT), and CU-specific quality of life (CU-QOL). EQ-5D utility index scores were compared according to urticaria control status and disease severity. Conditional process analysis (CPA) was used to map EQ-5D utility scores from UAS7 and UCT.

Results

Greater EQ-5D utility values were obtained in patients with better urticaria control (0.91 ± 0.10 for well controlled CU, 0.84 ± 0.12 for partly controlled, 0.77 ± 0.14 for uncontrolled, P < 0.001). According to CU severity, mean utility values were ranged from 0.746 (severe, UAS7 ≥ 28) to 0.860 (moderate), 0.878 (mild), and 0.953 (urticaria free). CPA suggested that UAS7 was directly correlated with UCT (regression coefficient, −0.251; 95% confidence interval [CI], −0.278, −0.223; P < 0.001) and EQ-5D utility (−0.002; 95% CI, −0.003, −0.001; P = 0.007) after controlling for age, sex, urticaria duration, and combined allergic diseases.

Conclusions

EQ-5D values increased with improvement in urticaria control and decreased with urticaria severity. A predictive model mapping EQ-5D utility from UAS7 and UCT scores suggested that EQ-5D can be useful for the pharmacoeconomic evaluation of individualized treatments for CU patients.

The role of patient-reported outcomes in the management of chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a debilitating condition that can substantially affect patients' quality of life (QoL), mental health and ability to perform daily tasks. International guidelines on the management of CSU, jointly developed by the European Academy of Allergy and Clinical Immunology (EAACI), Global Allergy and Asthma European Network (GA²LEN), European Dermatology Forum (EDF) and World Allergy Organization (WAO), recommend a treat-to-target strategy until symptom control or remission is achieved. This may mean stepping up or down in the treatment algorithm according to the course of CSU and re-evaluating the need for continued/alternative drug treatment. Utilising patient-reported outcome (PRO) tools in daily clinical practice will create a gold standard for care in CSU, aiding the treat-to-target strategy, increasing patient wellbeing and reducing healthcare costs through optimal treatment and management of patients with CSU. This article outlines PRO tools recommended by EAACI/GA²LEN/EDF/WAO guidelines for assessment of CSU symptom control, severity and QoL.

Therapeutic effect of Bacillus Calmette-Guerin polysaccharide nucleic acid on mast cell at the transcriptional level

Background

Chronic spontaneous urticaria (CSU) is a common and recurrent autoimmune-related disease with unclear pathogenesis. Dysfunction of immune cells, such as T cells, mast cells, and basophils, is involved. Bacillus Calmette-Guerin polysaccharide nucleic acid (BCG-PSN), an immunomodulator partially extracted from BCG, can be used in the combined treatment of CSU with an unknown mechanism.

Methods

To study the therapeutic effect and mechanism of BCG-PSN on CSU, we initially assessed the clinical efficacy in 110 enrolled CSU patients of 4-week antihistamine monotherapy vs. antihistamine plus BCG-PSN combined therapy. Subsequently, to explore the further mechanism of BCG-PSN, the mast cell line RBL-2H3 pretreated with BCG-PSN was used to evaluate the transcriptional expression profiles via lncRNA sequencing. Real time PCR was conducted to validate the candidate gene expression.

Results

We found no significant difference in treatment efficacy between the BCG-PSN group (71.7%) and the monotherapy group (71.9%). However, the average time of complete relief in the BCG-PSN group was significantly shorter than that in the monotherapy group (36.77 ± 17.33 vs. 51.27 ± 16.80, p = 0.026). In vitro experiments showed that BCG-PSN inhibited β-hexosaminidase release rates in IgE-sensitized RBL-2H3 cells (p < 0.001). Sequencing data revealed the expression profiles of functional genes, including a significant decrease in Erb-B2 receptor tyrosine kinase 4, which can be regulated by the nuclear factor kappa B (NF-κB) pathway.

Discussion

CSU is a chronic, recurrent disease with complex pathogenesis. Mast cells and basophils are the primary target cells of the disease. BCG-PSN decrease the β-HEX release rates and regulated IgE-mediated mast cell activation in RBL-2H3 cells by mediating immune-related gene expression including ERBB4. These findings suggest that BCG-PSN may mediate ERBB4 expression via the NF-κB pathway and may have value in the treatment of CSU.

Efficacy and safety of acupuncture for patients with chronic urticaria: study protocol of a randomized, sham-controlled pilot trial

Background

Chronic urticaria (CU) is a refractory skin disease with long duration and a high recurrence rate. Acupuncture has been widely used for the treatment of CU in clinical practice in China. However, until now, there has been no appropriately designed randomized controlled trial (RCT) to provide explicit evidence about the effectiveness of acupuncture for the treatment of CU worldwide. Therefore, we plan to conduct a pilot study to explore its effectiveness and safety and determine the feasibility of studying acupuncture in a future, full-scale, RCT of CU.

Methods/design

This randomized, sham-controlled, participant-blinded and assessor-blinded pilot trial is underway in China. A total of 60 participants with CU will be randomly assigned to two groups in a 1:1 ratio: one treated with real acupuncture and the other with sham acupuncture, for 10 sessions over 2 weeks. The experimental group will receive acupuncture on a fixed prescription of acupoints, whereas the control group will receive sham acupuncture, namely minimal acupuncture on non-acupuncture points. The primary outcome will be the urticaria activity score (UAS). The secondary outcomes will include a visual analogue scale (VAS) score for itching intensity, the Dermatology Life Quality Index (DLQI), the Hamilton Depression Scale (HAMD), the Hamilton Anxiety Scale (HAMA), the humoral immunity index, serum total IgE, and adverse events. The UAS, VAS for itching and the DLQI will be conducted at baseline and at 1, 2, 3, and 4 weeks after randomization. The HAMD, HAMA, humoral immunity index, and serum total IgE will be assessed at baseline and at 2 weeks after randomization. Adverse events will be summarized at 1 week and 2 weeks after randomization.

Discussion

The pilot study mainly aims to investigate trial feasibility, and confirm basic information about its effects and safety. Results of this trial will help clarify whether the acupuncture treatment is beneficial for symptom improvement in patients with CU. The finding of this study will provide preliminary evidence on the effectiveness and safety of acupuncture for CU.

Trial registration

Acupuncture-Moxibustion Clinical Trial Registry, AMCTR-ICR-18000190. Registered on 19 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3433-1) contains supplementary material, which is available to authorized users.

Acupoint catgut embedding for patients with chronic urticaria: A systematic review protocol

BACKGROUND

The purpose of this paper is to evaluate the effectiveness and safety of acupoint catgut embedding in the treatment of chronic urticaria (CU).

METHODS

We will electronically search PubMed, Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, and Wan-Fang Database from their inception to March 2019. In addition, we will manually retrieve other resources including the reference lists of identified publications, conference articles, and gray literature. The clinical randomized controlled trials or quasi-randomized controlled trials related to acupoint catgut embedding for the treatment of CU will be included in the study. The language is limited to Chinese and English. Research selection, data extraction, and research quality assessment will be independently completed by 2 researchers. Data were synthesized by using a fixed effect model or random effect model depend on the heterogeneity test. The total effective rate was the primary outcomes. Skin disease quality of life index scores, adverse events, and recurrence rates will also be assessed as secondary outcomes. RevMan V.5.3 statistical software will be used for meta-analysis. If it is not appropriate for a meta-analysis, then a descriptive analysis will be conducted. Data synthesis will use the risk ratio and the standardized or weighted average difference of continuous data to represent the results.

RESULTS

This study will provide a high-quality synthesis to assess the effectiveness and safety of acupoint catgut embedding for patients with CU.

CONCLUSION

This systematic review will provide evidence to judge whether acupoint catgut embedding is an effective intervention for patients with CU.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019129459.

Eczema and Urticaria in the Adult Population in Portugal: A Prevalence Study

BACKGROUND AND AIMS

Eczema and urticaria are both inflammatory skin diseases. The prevalence of both diseases varies worldwide and the reasons are unknown. We aimed to investigate the eczema and urticaria prevalence in the Portuguese adult (≥16 years-old) population.

MATERIALS AND METHODS

A telephone interview survey was performed in the last quarter of 2017. To calculate the prevalences, subjects should have been previously diagnosed with eczema/urticaria by a health professional, be aged ≥16 years-old, and reside in Portugal. The sample had a proportion that was approximately representative by population, region, gender, and age group. Odds ratios were performed to measure associations with prevalences. SPSS statistics and values of p<0.05 with 95% confidence intervals were considered statistically significant.

RESULTS

5,000 phone calls were analysed. The prevalence of eczema and urticaria in Portugal is 4.4% and 3.4%, respectively. Algarve is the region with the highest prevalence for both diseases. Being a female is the factor that most influenced these diseases with an OR=1.99 (p<0.001; CI 1.49-2.66) for eczema and 1.73 (p=0.001; CI 1.25 - 2.40) for urticaria, with also higher prevalences (5.7% and 4.2%, respectively).

CONCLUSIONS

The prevalences found are higher than in previous studies in Portugal and comparable to results from other countries. Comparisons among prevalence of eczema are affected by several obstacles. Regarding urticaria, our results seem to be in the same line as others. Being female with eczema and urticaria is more common and represents a higher risk factor than male subjects. According to Harrop et al., 2007, in Europe, atopic eczema is 0.14-0.60% of general eczema. In this way, we can estimate that prevalence of atopic eczema in Portugal is around 0.61-2.64%.

Systematic reviews of pharmacological and nonpharmacological treatments for patients with chronic urticaria: An umbrella systematic review

A wide range of pharmacological and nonpharmacological interventions for chronic urticaria (CU) have been evaluated in systematic reviews (SRs). We conducted an umbrella review of SRs of the effectiveness and safety of pharmacological and nonpharmacological interventions for CU, which allow the findings of separate reviews to be compared and contrasted and thereby provide decision makers in healthcare with the evidence they need.We included SRs evaluating pharmacological and nonpharmacological interventions for CU. Comprehensive searches were conducted in 7 bibliographic databases, relevant journals up to July 2018. Two reviewers independently assessed the studies' relevance and quality. The assessment of multiple systematic reviews tool and grading of recommendations assessment, development and evaluation method was used to assess the methodological quality of the SRs and classify the quality of the outcomes.In total, 41 SRs were included. Thirty-seven reviews performed quantitative research syntheses, and 4 reviews performed qualitative research syntheses. The majority of SRs evaluated interventions based on combination therapies, antihistamines, traditional Chinese medicines, autohemotherapy, omalizumab, acupuncture, cyclosporine, and leukotriene receptor antagonist. Positive intervention outcomes were reported in the majority (75.32%) of the reviews. However, the methodological quality and evidence quality of the reviews were generally poor.There is some evidence to support a variety of interventions for CU. However, there was much heterogeneity in evidence quality among SRs. Many of the SRs had methodological weaknesses that make them vulnerable to bias. Moreover, there remained little information on the relative effectiveness of one intervention compared with another. Therefore, further SRs that adherence to strict scientific methods are necessary, and primary studies make comparisons between the different treatment options directly.

Prevalence estimates for chronic urticaria in the United States: A sex- and age-adjusted population analysis

BACKGROUND

Disease burden in chronic urticaria (CU) is poorly understood.

OBJECTIVE

To estimate standardized overall and sex-, age-, and race-specific prevalence estimates for CU among adults in the United States.

METHODS

A cross-sectional analysis with electronic health records data for a demographically heterogeneous population-based sample of >55 million patients across all 4 census regions.

RESULTS

The overall CU prevalence was 0.23%, or 230 CU cases/100,000 adults. The adjusted prevalence in women was 310 (95% confidence interval [CI] 307-312) cases/100,000 adults, more than twice that of men (146 [95% CI 143-148] cases/100,000 adults, P < .001). CU prevalence was highest among patients aged 40-49 years (256 [95% CI 252-261] cases/100,000 adults) and 50-59 years (246 [95% CI 242-251] cases/100,000 adults) compared with all other age groups (P < .0001). Adjusted prevalences for black (292 [95% CI 285-298] cases/100,000 adults) and other (331 [95% CI 323-338] cases/100,000 adults) patients were higher than that for white patients (262 [95% CI 260-264] cases/100,000 adults; P < .001).

LIMITATIONS

Use of administrative data has the potential to underestimate burden.

CONCLUSION

There are >500,000 people estimated to have CU in the United States, most of whom are women or adults ≥40 years of age.