Urticarial vasculitis: a retrospective study of 15 cases

A novel histopathological scoring system to distinguish urticarial vasculitis from chronic spontaneous urticaria

Background

Urticarial vasculitis (UV) is defined by long‐lasting urticarial lesions combined with the histopathologic findings of leukocytoclastic vasculitis. As one of the major unmet needs in UV, diagnostic criteria are rather vague and not standardized. Moreover, there seems to be considerable overlap with chronic spontaneous urticaria (CSU), particularly for the normocomplementemic variant of UV. Therefore, this study aimed to develop a diagnostic scoring system that improves the histopathologic discrimination between UV and CSU.

Methods

Lesional skin sections of patients with clinical and histopathologic diagnosis of UV (n = 46) and CSU (n = 51) were analyzed (blinded to the diagnosis) for the following pre‐defined criteria: presence of leukocytoclasia, erythrocyte extravasation, fibrin deposits, endothelial cell swelling, ectatic vessels, blurred vessel borders, dermal edema, intravascular neutrophil, and eosinophil numbers and numbers of dermal neutrophils, macrophages and mast cells.

Results

The greatest differences between UV and CSU samples were observed for leukocytoclasia (present in 76% of UV vs. 3.9% of CSU samples; p < 0.0001), erythrocyte extravasation (present in 41.3% of UV vs. 2.0% of CSU samples; p < 0.0001), and fibrin deposits (present in 27.9% of UV vessels vs. 9.7% of CSU vessels; p < 0.0001). Based on these findings, we developed a diagnostic score, the urticarial vasculitis score (UVS), which correctly assigned 37 of 46 cases of UV and 49 of 51 cases of CSU to the previously established diagnosis.

Conclusion

Our results suggest that the UVS, a combined quantitative assessment of the three criteria leukocytoclasia, fibrin deposits and extravasated erythrocytes, distinguishes UV from CSU in skin histopathology. The UVS, if validated in larger patient samples, may help to improve the diagnostic approach to UV.

Normocomplementemic Urticarial Vasculitis Associated with A/H1N1 in a Child. Case Report

Urticarial vasculitis is an entity characterized by urticarial rashes that are typically pruritic and painful, associated with angioedema and purpura. Influenza viruses are common respiratory pathogens that can cause seasonal infections and global human morbidity/mortality. A 4.5-year-old girl presented with fever and painful urticarial skin lesions leaving post-inflammatory hyperpigmentation. The nasal specimens showed a positive for influenza A/H1N1. On the basis of these findings, a diagnosis of urticarial vasculitis associated with A/H1N1 was concluded. Taking the results together, we suggest that urticarial vasculitic lesions can be considered to the list of cutaneous manifestations during the seasonal flu.

Clinicopathological Profile and Outcome of Childhood Urticaria Vasculitis: An Observational Study

Background Urticaria is a type III hypersensitivity reaction usually triggered by an infection, medication, or food item. It usually subsides within 24 hours without any residual lesion and does not have any systemic manifestation. Urticaria vasculitis (UV) is a clinicopathological condition defined by the presence of an urticarial lesion lasting for >24 hours or recurrent episodes of urticaria associated with histopathological features of leukocytoclastic vasculitis. Methods This retrospective study was conducted in a tertiary care teaching institute in Eastern India over a period of 2 and ½ years. Children presenting with urticaria lesions for a duration of > 24 hours that did not subside either spontaneously or with anti-histamines were admitted for further workup and management. Results During the study period (July 2015 to December 2017), a total of 20 children with urticaria needed admission for symptom control and further workup. There were 16 boys and 4 girls. The mean (SD) age of presentation was 6.5 years (±2.4). Besides urticaria in all, pain abdomen was present in 13 (65%) and fever in 6 (30%) children. Only one had arthritis. Skin biopsy performed in these children was suggestive of leukocytoclastic vasculitis. One child was ANA (anti-nuclear antibody) positive with low C3. All except three children required systemic steroid for symptom control along with other medications (anti-histamines). None had suffered any complication or relapse.  Conclusions Urticaria vasculitis (most common cause being idiopathic) remains underdiagnosed because of the need of confirmation by biopsy, which might not always be attempted in every case. Though anti-histamines remain the main stay of treatment, adding short course oral steroid shortens the course once infection is ruled out.

Clinical characteristics and treatment outcomes in patients with urticarial vasculitis

OBJECTIVE

Urticarial vasculitis (UV) is an uncommon disease clinically presenting with pruritic urticarial plaques of the skin. The disease is classified as normocomplementic and hypocomplementemic types according to their complement levels. We aimed to evaluate demographic characteristics, laboratory findings, and response to treatment of patients diagnosed as UV in our clinic.

METHODS

Between January 2015 and January 2019, the files of the patients were retrospectively reviewed. Demographic data, clinical features, laboratory findings, suspected triggering factors, disease course, treatment modalities, and treatment results of the patients were recorded.

RESULTS

A total of 16 patients (nine males [56.25%], seven females [43.75%]) were included in the study.The mean age at diagnosis was 45.2±10.4 years and the duration of the disease was 72.1±62 months. Twelve (75%) patients had angioedema and two (12.5%) patients had residual hyperpigmentation. The most common extracutaneous finding was arthralgia (43.7%). No hypocomplementemia was detected in the patients. The most common abnormal laboratory findings were CRP elevation (37.5%) and ANA positivity (n=4/15, 26.7%). Analgesic and antibiotic drugs use were the most common possible triggering factors for the disease (n=9, 56%). Oral antihistamines, oral corticosteroids, azathioprine, colchicine, dapsone, hydroxychloroquine, doxepin, and omalizumab were among the treatments given to the patients. Complete remission was achieved in three patients.

CONCLUSION

Compared with other studies, we found that angioedema was more frequent, postinflammatory hyperpigmentation was lower and long-term treatment was needed to control UV attacks. There are a few studies on UV and we think that more and larger patient groups are needed for standardization of treatment.

Omalizumab as a Succesfull Therapy in Normocomplementemic Urticarial Vasculitis: A Series of Four Patients and Review of the Literature

Urticarial vasculitis is an eruption characterized by inflamed itchy or painful red papules or plaques that resemble urticaria but last longer than 24 hours and heal with residual pigmentation or purpura. Histopathologically, urticarial vasculitis presents as leukocytoclastic vasculitis with perivascular infiltrate and fibrin deposits. The treatment options are oral antihistamines, oral corticosteroids, dapsone, colchicine and hydroxychloroquine. We report four cases with normocomplementemic urticarial vasculitis who were treated with omalizumab and a brief review of the literature on the use of omalizumab in normocomplementemic urticarial vasculitis.

Patient-reported outcomes in urticarial vasculitis treated with omalizumab: case report

Background

Despite the current knowledge of UV, there is a lack of consensus among diagnostic criteria and management. In general, antihistamine therapy is regularly used for the symptomatic management of pruritus but does not control inflammation or alter the course of the disease. Monoclonal antibodies such as omalizumab (anti-IgE) have been proposed as a potential treatment for urticarial vasculitis. A few studies have reported the benefits of omalizumab in patient-reported outcome measures (PROMs). Herein we describe a female patient with urticarial vasculitis who was treated with omalizumab. We discuss the response to treatment and possible implications of PROMs in guiding the management of the disease.

Case presentation

We describe the case of a 57-year-old woman with a diagnosis of urticarial vasculitis. Due to lack of response to first-line treatment and the severity of the disease, treatment with omalizumab was initiated. Omalizumab 150 mg was administered every four weeks for three months. Second-generation antihistamines were used as needed. Both CU-Q2oL and UAS 7 improved. After three-month therapy with omalizumab, disease severity improved from moderate severity (UAS7 = 19) to well controlled (UAS7 = 6). However, 5 months after the last administration of omalizumab, the patient complained of worsening symptoms and active disease with quality of life impairment. A single dose of omalizumab (150 mg) was prescribed with corticosteroids. Thereafter, the patient presented a disease activity and quality of life with a fluctuating pattern that was controlled with additional doses of omalizumab.

Conclusion

In chronic urticaria, patient-reported outcome measures (PROMs) are important for assessing disease status and the impact of symptoms on patients’ lives. However, to our knowledge, there is no validated tool to measure such outcomes in UV patients. Although UAS7 and CU-Q2oL were not designed for UV assessment, they might be useful in the clinical setting as objective measures to determine treatment efficacy. However, some domains in the CU-Q2oL questionnaires do not correlate well with UAS7, which might serve as a relative indication to continue treatment despite disease severity improvement. Based on our observations, we believe omalizumab 150 mg might be a feasible therapeutic alternative when first-line treatment is unsuccessful.

Urticaria vasculitis in a child: a case report and literature review

Annular urticarial lesions in a child must establish a main differential diagnosis with urticaria multiforme, common urticaria, acute hemorrhagic edema of infancy, erythema marginatum, erythema annulare centrifugum, annular erythema in childhood, erythema multiforme, Sweet's syndrome, Schönlein‐Henoch purpura, erythematosus lupus, several systemic vasculitis, and serum sickness.