Risk of comorbidities in patients diagnosed with chronic urticaria: A nationwide registry-study

Global Prevalence of Anxiety, Depression, and Stress Among Patients with Skin Diseases: A Systematic Review and Meta-analysis

The changes in human lifestyle over the past few decades have impacted the prevalence of skin diseases within different societies. Skin diseases may result in various physical and mental disorders. The most common mental disorders observed among the patients are stress, anxiety, and depression. This study aims to investigate the global prevalence of anxiety, depression, and stress in patients with skin diseases. In this Systematic Review and Meta-Analysis study, the PubMed, Scopus, Science Direct, Embase, Web of science, and Google Scholar repositories were searched without a lower time limit. Heterogeneity among the identified studies was examined using the I2 index, and accordingly random effects model was adopted for analysis. Data analysis was conducted within the Comprehensive Meta-Analysis software (v. 2). In total, 113 studies were included for the final analysis. The overall pooled prevalence of stress, depression, and anxiety in skin disease patients was found to be 39.4%, 27.2% and 28.8%, respectively. Among patients with psoriasis, acne, vitiligo or atopic dermatitis diseases, the highest number of patients suffering from stress was related to patients with acne (75.7%). The highest prevalence of depression, and anxiety was reported in patients with vitiligo (38.3%) and acne (36.5%), respectively. Considering the high prevalence of mental disorders among patients with skin diseases and recognising the impacts of mental health challenges on patients' well-being, the findings of this study provide valuable insights for identifying specific populations that require targeted interventions for the diagnosis, treatment, and prevention of mental illnesses. Accordingly, healthcare policymakers should incorporate psychological treatment and support measures as integral components of comprehensive care strategies for patients with skin diseases.

A Retrospective Cohort Study on the Comorbidity in 19,264 Chinese Patients of Different Ages with Urticaria

To examine the prevalence of comorbidities in Chinese urticaria patients and assess medication use patterns across different ages (6-11 years, 12-17 years, above 18 years), a retrospective cohort study was performed in 192,647 urticaria patients within the Health Database. After 1:1 propensity score matching, 166,921 people were divided into the urticaria group and the control group, and the follow-up data were collected within 2 years. During the 12-month and 24-month follow-up period, significant comorbidities identified included allergic rhinitis and asthma, with distinct patterns observed across age groups. Chronic urticaria patients often have complications, such as allergic rhinitis, upper respiratory infection, oropharyngeal infection, and dental caries. The study underscores the need for age-specific treatment strategies in urticaria management.

A comparative analysis of chronic inducible urticaria in 423 patients: Clinical and laboratory features and comorbid conditions

BACKGROUND

Chronic inducible urticaria (CIndU) is a subtype of chronic urticaria (CU) which require specific physical or non-physical triggers to occur. They may be isolated or may coexist with chronic spontaneous urticaria (CSU). Despite their frequent appearance in dermatology clinics, there is scarce information on the distinguishing features among the most common subtypes of CIndU as well as isolated CIndU versus CSU plus CIndU.

OBJECTIVES

To compare clinical and laboratory characteristics, and comorbid conditions among the most common CIndU types and isolated CIndU versus CSU plus CIndU.

METHODS

We retrospectively analysed CIndU patients and compared patients' demographic, clinical and laboratory characteristics across isolated CIndU, CSU plus CIndU, symptomatic dermographism (SD), cold urticaria (ColdU) and cholinergic urticaria (ChoU).

RESULTS

A total of 423 patients (~70% isolated CIndU, ~30% CSU plus CIndU, ~5% mixed CIndU subtypes) were included in the study. The most frequent CIndU subtypes were SD (68.6%; 290/423), ColdU (11.4%; 48/423) and ChoU (10.9%; 46/423). Isolated CIndU patients were younger than CSU plus CIndU (33.74 ± 12.72 vs. 37.06 ± 11.84, p = 0.010). Angioedema, emergency referrals, need for systemic steroids, comorbid systemic disorders were more frequent and baseline urticaria control test scores were lower in CSU plus CIndU patients (vs. CIndU, p < 0.001, p = 0.008, p < 0.001, p = 0.031, p = 0.036, respectively). Among CIndU subtypes, ChoU patients were younger (24.9 ± 12.2 vs. 34.47 ± 12.12 vs. 31.38 ± 14.95; p < 0.001) and had male predominance (p < 0.001) while SD patients had no angioedema (p < 0.001) and had higher frequency of increased total IgE levels (p = 0.006).

CONCLUSIONS

Isolated CIndU and CSU plus CIndU seems to be different endotypes of CU where CSU plus CIndU presents a more severe and refractory course. There are distinctive features of each CIndU subtype. These suggest involvement of different pathomechanistic pathways in these subtypes that need to be clarified in future studies.

Dupilumab as Add-on Therapy for Management of Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is characterized by pruritus, urticaria and associated with substantial patient burden. Emerging clinical trial data suggest dupilumab, an anti-IL-4Rα biologic indicated for several Type-2 inflammatory diseases, may have clinical utility for CSU. Here we present real world clinical data evaluating dupilumab as add-on therapy for CSU. We queried our tertiary academic center electronic health record for all patients with an ICD-9/10 code for urticaria with a history of dupilumab use (1/1/2010-6/30/2022). Retrospective chart review was performed to confirm CSU diagnosis, dupilumab use, patient demographics, medical history, treatments, and outcomes. Data were evaluated using summary and descriptive statistics, paired t-test, and Fisher's exact test. A total of 199 patients were identified: 39 had active CSU at time dupilumab initiation; six were excluded due to limited follow up. The most common indication for dupilumab prescription was atopic dermatitis (57.6%), followed by asthma (27.3%). Mean length of dupilumab therapy was 23 months. Following dupilumab, there was a significant reduction in number of patients on daily H1 antagonists (pre: 27 [81.8%]; post: 20 (60.1%); p=0.03), as well as total daily number of antihistamines (pre: 1.95±2.0; post: 0.13±0.2; p=0.01). For patients with moderate/severe vs. mild disease, there was greater improvement in disease control as assessed by physicians global impression of change (77% vs. 30%, p=0.02). In this real-world study, when used as add-on therapy for patients with CSU, dupilumab was associated with improved disease control and decreased H1 blocker use, suggesting a future for dupilumab as an approvedbiologic therapy for the treatment of CSU.

Cognitive, neuropsychiatric and neurological alterations in mastocytosis: A systematic review

BACKGROUND

Mastocytosis manifests with multisystemic symptoms, often involving the nervous system. Numerous cognitive, neuropsychiatric and neurological alterations have been reported in multiple observational studies.

METHODS

We performed a qualitative systematic literature review of reported data consulting the electronic databases Medline, Scopus, Web of Science, Cochrane, and BASE until June 2023.

RESULTS

We selected 24 studies in which the majority showed that a high proportion of mastocytosis patients suffer cognitive, neuropsychiatric and neurological alterations. The most common disorders and estimated ranges of frequency observed in adults were depression (68%-75%), anxiety, high stress or irritability (27%-54%), cognitive impairment (27%-39%, primarily affecting memory skills), and headaches (55%-69%). Attention challenges and learning difficulties were reported in children at a rate of 13%, while neurodevelopmental disorders occurred at rates of 8%-12%. Frequent white abnormalities in mastocytosis patients with concomitant psychocognitive symptoms have been reported although neuroimaging studies have been performed rarely in this population.

CONCLUSION

Further studies with more comprehensive and homogeneous evaluations and neuroimaging and histological analysis should be performed for a better understanding of these manifestations. An earlier detection and proper management of these symptoms could greatly improve the quality of life of these patients.

Occurrence and risk factors of mental disorders in patients with chronic urticaria

This study aimed to evaluate the prevalence and risk factors of mental disorders in patients with chronic urticaria (CU) in a cohort of adult outpatients. Mental disorders occurred in almost one-sixth of the patients with CU, depression (9.7%), and anxiety (5.0%) being the most prevalent conditions. Furthermore, a significant difference in impairment of quality of life was seen between patients with mental disorders compared to patients without. Although, the prevalence of mental disorders in patients with CU is high, larger clinical studies are needed to investigate and understand the association and risk factors of mental disorders in patients with CU.

Chronic spontaneous urticaria: new evidences on the role of autoimmunity

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the recent advancements and relevance of the autoimmune theories in chronic spontaneous urticaria (CSU).

RECENT FINDINGS

Two primary types of autoimmunity, Type I and Type IIb, have emerged as major contributors to CSU, characterized by immunoglobulin E (IgE) and immunoglobulin G (IgG) autoantibodies, respectively. Genetic evidence supports the notion that CSU shares more similarities with other autoimmune diseases rather than atopic diseases. Novel autoallergens such as FcεRI and tissue transglutaminase have been identified, contributed to our understanding of autoimmune mechanisms. Furthermore, the potential overlap between Type I and Type IIb autoimmunity has been recognized. Evaluating the autoimmune status of CSU patients through biomarkers and understanding their clinical implications is vital for effective management. For instance, CSU patients with Type IIb autoimmunity, with or without coexisting Type I autoimmunity, may exhibit resistance to H1-antihistamines and omalizumab treatment but could potentially respond well to cyclosporine or Bruton's tyrosine kinase inhibitors.

SUMMARY

Further investigations are needed to explore new autoallergens and autoantibodies in CSU, establishing their connection to the development of autoimmunity. The efficacy of novel drugs targeting different mechanisms should be examined to determine their responses in both autoimmune CSU and nonautoimmunity-related CSU.

Biomarkers for Monitoring Treatment Response of Omalizumab in Patients with Chronic Urticaria

Chronic urticaria (CU) is a debilitating skin disease affecting around 1% of the population. CU can be subdivided into chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU). Different pathophysiological mechanisms have been proposed to play a role in the development of CU, and these are also being investigated as potential biomarkers in the diagnosis and management of the disease. As of now the only assessment tools available for treatment response are patient reported outcomes (PROs). Although these tools are both validated and widely used, they leave a desire for more objective measurements. A biomarker is a broad subcategory of observations that can be used as an accurate, reproducible, and objective indicator of clinically relevant outcomes. This could be normal biological or pathogenic processes, or a response to an intervention or exposure, e.g., treatment response. Herein we provide an overview of biomarkers for CU, with a focus on prognostic biomarkers for treatment response to omalizumab, thereby potentially aiding physicians in personalizing treatments.

Increased Risk of Systemic Lupus Erythematosus in Patients with Chronic Urticaria: A Systematic Review and Meta-analysis

Introduction

The association between systemic lupus erythematosus (SLE) and chronic urticaria (CU) has been suggested in the literature although the amount of evidence is still relatively limited. We aimed to combine all available studies on this association using systematic review and meta-analysis technique.

Methods

Potentially eligible studies were identified from Medline and EMBASE from inception to February 2023 using search strategy that comprised of terms for "chronic urticaria" and "systemic lupus erythematosus". The eligible study must consist of one group of patients with CU and another group of comparators without CU and must compare the prevalence of SLE in each group and report effect size with 95% confidence intervals (95% CIs). We extracted such data from each study to calculate a pooled odds ratio using the generic inverse variance method with random-effect model. Funnel plot was used to evaluate publication bias. Newcastle-Ottawa Scale was used to appraise the methodological quality of the included studies.

Results

A total of 5,155 articles were identified. After two rounds of independent review by four investigators, five studies met the eligibility criteria and were included in the meta-analysis. The meta-analysis found an increased prevalence of SLE among patients with CU compared with individuals without CU with the pooled odds ratio of 5.03 (95% CI, 2.57-9.85, I2 of 93%).

Conclusion

This systematic review and meta-analysis found that patients with CU had a significantly increased risk of SLE compared to individuals without CU.

Prevalence of Autoimmune and Autoinflammatory Diseases in Chronic Urticaria: Pathogenetic, Diagnostic and Therapeutic Implications

Chronic spontaneous urticaria (CSU) is defined as the almost daily occurrence of widespread wheals, angioedema, or both, for more than 6 weeks. It affects 1-2% of the general population, with a higher prevalence in female patients, and is more frequent patients over 20 years of age. More than half of all cases of chronic idiopathic urticaria are thought to occur due to an autoimmune mechanism, specifically the production of autoantibodies against the high-affinity immunoglobulin E (IgE) receptor (FcεRI). The quality of life in these patients is often greatly compromised, also due to the onset of comorbidities represented by other autoimmune diseases, such as thyroid disease, rheumatoid arthritis, systemic lupus erythematosus, Sjögren's syndrome, celiac disease, and type 1 diabetes, among others. This review aimed to analyze the close correlation between CSU and some autoimmune and autoinflammatory diseases, in order to encourage a multidisciplinary and multimorbid approach to the patient affected by CSU, which allows not only control of the natural course of the disease, but also any associated comorbidities.

Comorbidities in Patients with Vitiligo: A Systematic Review and Meta-Analysis

Vitiligo has been reported to be associated with a variety of diseases, but it has not been systematically reviewed. Therefore, we aimed to identify prevalent diseases in patients with vitiligo and quantify their associations compared with those in healthy controls. A comprehensive search of MEDLINE and EMBASE from the inception to June 2022 was conducted. Observational studies on prevalent diseases in patients with vitiligo compared with those in healthy controls were included, whereas studies limited to pediatrics or providing only laboratory results were excluded. A total of 78 studies were eligible for analyses. Patients with vitiligo showed higher risks of having comorbid autoimmune and connective tissue diseases, including alopecia areata (OR = 2.63, 95% confidence interval [CI] = 2.50‒2.78), discoid lupus erythematosus (OR = 2.54, 95% CI = 1.74‒3.72), Sjogren's syndrome (OR = 2.50, 95% CI = 1.98‒3.16), myasthenia gravis (OR = 2.30, 95% CI = 1.74‒3.02), systemic lupus erythematosus (OR = 1.96, 95% CI = 1.52‒2.52), and rheumatoid arthritis (OR = 1.82, 95% CI = 1.55‒2.15). Thyroid diseases, diabetes mellitus, metabolic syndrome, sensorineural hypoacusis, and ophthalmic abnormalities were also more prevalent in patients with vitiligo. In conclusion, vitiligo is associated with various systemic diseases. Physicians should evaluate and manage potential comorbid conditions in patients with vitiligo.

Comorbidities of Chronic Urticaria: A glimpse into a complex relationship

Chronic Urticaria (CU) is a chronic inflammatory, predominantly mast cell-driven disease, characterized by the development of wheals and/or angioedema for more than 6 weeks. It affects approximately 1%-5% of the total population worldwide and imposes a substantial burden on health-related quality of life, significantly affecting patients' daily life. The economic impact on the health system is also not negligible, with an estimated cost per patient per year of approximately 2.000 $ in the United States. Although the underlying pathophysiology is not fully explored, autoimmune mechanisms have been proposed, including type I ("autoallergy" by means of autoantibodies to self-antigens) and type IIb (autoimmunity). Atopic, autoimmune, and psychiatric disorders are prevalent comorbidities in both children and adults with Chronic Spontaneous Urticaria (CSU). Although malignancies, cardiovascular diseases and other comorbidities have also been reported as associated diseases in patients with CSU, data remain scarce. It is still unknown whether the aforementioned comorbidities share common pathophysiological mechanisms with specific endotypes of CSU. The current review aims to overview current data on comorbidities of CU, and furthermore to comment on the potential linked pathways underlying these diseases.

Prevalence, predictors, and clinical relevance of α-gal sensitization in patients with chronic urticaria

Background

Little is known about α‐gal (galactose‐α‐1,3‐galactose) sensitization in patients with chronic urticaria (CU). The aim of this study was to examine the prevalence, predictors and clinical relevance of α‐gal sensitization in patients with CU.

Methods

Two consecutive cohorts of newly referred patients with CU from a primary care allergology practice and a tertiary hospital dermatology department, plus a control group with allergic disease, but not CU, from the allergology practice, were interviewed and screened for α‐gal sensitization (serum specific‐IgE ≥0.35 KU/L).

Results

Of 733 patients included, 21 (5.6%) and 11 (3.9%) of CU patients from private practice and hospital, respectively, were α‐gal sensitized. In total, 8 patients (38.1% of sensitized patients, and 2.1% of all CU patients) from private practice, and 2 patients (18.2% of sensitized patients, and 0.7% of all CU patients) from hospital, had clinically relevant α‐gal allergy. In private practice, male sex (47.6 vs. 24.7%), p = 0.020, obesity (33.3 vs. 23.6%), p = 0.302, and frequency of angioedema (61.9 vs. 51.4%), p = 0.350; and in hospital, male sex (72.7 vs. 27.9%), p = 0.003, and high total immunoglobulin E (median 168 vs. 70.5 KU/L), p = 0.022 were associated with α‐gal sensitization.

Conclusion

α‐gal sensitization is observed in a small fraction of CU patients with only few patients experiencing clinically relevant sensitization. Certain patients, particularly from primary care, may constitute a relevant population for aimed testing.

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.

A Meta-Analysis of Randomized Clinical Trials of Runzao Zhiyang Capsule in Chronic Urticaria

Chinese herbal medicine has many advantages in the treatment of chronic urticaria (CU). Herein, we evaluated the efficacy and safety of the Runzao Zhiyang (RZZY, Chinese patent herbal medicine capsule) capsule for CU through a meta-analysis of randomized clinical trials (RCTs). This meta-analysis included 17 RCTs involving 1,760 patients. RZZY capsule combined with conventional drugs showed a better clinical total effective rate (risk ratio (RR) = 1.20, 95% confidence interval (CI) (1.15, 1.24), $P<0.00001$ ), significantly reduced the adverse reaction rate [RR = 0.68, 95% CI (0.50, 0.92), $P=0.01$ ] and recurrence rate [RR = 0.29, 95% CI (0.18, 0.46), $P<0.00001$ ], and improved the life quality of patients (mean difference (MD) = −2.95, 95% CI (−4.32, −1.57), $P=0.0001$ ). Meanwhile, the serum Interleukin-4 (IL-4) (MD = −13.83, 95% CI (−23.45, −4.20), $P=0.005$ ) and immunoglobulin E (IgE) (MD = −22.99, 95% CI (−31.48, −14.50), $P<0.00001$ ) of patients in the intervention group decreased more significantly. In all, the RZZY capsule has potential therapeutic advantages and is relatively safe for CU. However, we are cautious about the conclusion, which needs to be further confirmed by more large samples, multicenter, and high-quality research in the later stage.

From Skin Barrier Dysfunction to Systemic Impact of Atopic Dermatitis: Implications for a Precision Approach in Dermocosmetics and Medicine

: Atopic dermatitis (AD) affects up to 20% of children and is considered the starting point of the atopic march with the development of food allergy, asthma, and allergic rhinitis. The heterogeneous phenotype reflects distinct and/or overlapping pathogenetic mechanisms with varying degrees of epidermal barrier disruption, activation of different T cell subsets and dysbiosis of the skin microbiome. Here, we review current evidence suggesting a systemic impact of the cutaneous inflammation in AD together with a higher risk of asthma and other comorbidities, especially in severe and persistent AD. Thus, early therapy of AD to restore the impaired skin barrier, modified microbiome, and target type 2 inflammation, depending on the (endo)phenotype, in a tailored approach is crucial. We discuss what we can learn from the comorbidities and the implications for preventive and therapeutic interventions from precision dermocosmetics to precision medicine. The stratification of AD patients into biomarker-based endotypes for a precision medicine approach offers opportunities for better long-term control of AD with the potential to reduce the systemic impact of a chronic skin inflammation and even prevent or modify the course, not only of AD, but possibly also the comorbidities, depending on the patient’s age and disease stage.

Sex differences in the efficacy of omalizumab in the treatment of chronic spontaneous urticaria

Background

Omalizumab is shown to be effective in the treatment of chronic spontaneous urticaria (CSU), a disease with high personal and social impact. Sex differences in CSU are recognized with women more frequently affected. Scarce is the knowledge about response to omalizumab between sex groups. We sought to identify any differences based on the sex of patients receiving omalizumab.

Methods

We evaluated data of patients diagnosed with CSU refractory to high-dose second-generation H1 antihistamines and treated with 300 mg omalizumab every 4 weeks for 6 months and then at relapse.

Results

Discussion: All patients, regardless of sex, age, or any other factor, achieved the clinical remission of the disease after the first 3 doses with a reduction of the disease activity indices and impact on the quality of life. Recurrences predominate in men, two months after the suspension of the drug. Respect to sex and recurrence we did not find any correlation with age, body mass index, peripheral eosinophil counts, total IgE levels, D-dimer, plasma prothrombine level or C-reactive protein. We found no sex differences in tolerability and safety. CSU in girls may persist longer and have worse prognosis, but no one has so far noted sex differences in response to omalizumab.

Conclusions

Although there are no certainties on the mechanism of action of omalizumab in CSU, the noticeable difference in response between males and females lead us to suppose a role of the hormonal balance both on the pathogenesis of the CSU and on the efficacy of OmAb.

Clinical and laboratory characteristics of chronic spontaneous urticaria with connective tissue diseases: A cross-sectional study

Objectives: The aim of this study was to investigate the frequency of connective tissue diseases (CTDs) in patients with chronic spontaneous urticaria (CSU) and to evaluate clinical and laboratory characteristics of CSU accompanied by CTDs.

Patients and methods: Between January 2017 and December 2020, a total of 390 CSU patients (120 males, 270 females; mean age: 38.9±13.7 years; range, 18 to 78 years) were included in the study. Clinical and laboratory characteristics of CSU in patients with and without CTD were analyzed.

Results: A total of 6.4% patients (n=25) with CSU had CTD, and the rate was found to be 8.9% in female patients (n=24). In these patients, Sjögren syndrome (SS) was seen in 15 (5.5%), rheumatoid arthritis in five (1.85%), undifferentiated connective tissue disease in three (1.11%), and systemic lupus erythematosus in one (0.37%). Anti-thyroglobulin antibody, rheumatoid factor, anti-cyclic citrullinated peptide antibody, antinuclear antibody positivity, low complement 4 level, and erythrocyte sedimentation rate were significantly different between CSU patients with and without CTD (p=0.013, p<0.001, p<0.001, p<0.001, p=0.0182, p<0.001, respectively).

Conclusion: Our study results suggest that CSU is associated with CTDs, particularly with Sjögren syndrome. Every patient diagnosed with CSU should be questioned about rheumatic symptoms, particularly female patients and those having later-onset CSU.

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.

Predictive features associated with chronic spontaneous urticaria recurrence

When chronic spontaneous urticaria (CSU) is resolved, patients are often apprehensive about the likelihood of recurrence, and want to know if we can predict this using clinical or laboratory markers. This question is crucial because CSU is frequently accompanied by a high incidence of stressful comorbidities, and the fear of experiencing this again can be devastating to the patient. This study was designed with the aim of focusing on the prevalence and characteristics of the recurrence of CSU. We used our CSU patient registry that includes data on 180 patients who are followed periodically. In 23 (13%) patients, CSU was resolved during the first year. In 47 (26%) patients, CSU lasted more than 5 years. The recurrence of CSU was recorded in 21% of our patients after having experienced a full remission anywhere between 1 to 10 years (mean ± 2.9 years). While investigating predictive clinical or laboratory markers, we noticed that bronchial asthma existed in 10/25 (40%) of patients in whom CSU recurred as compared with 45/180 (25%) in the general CSU population (p = 0.049). In addition, increased levels of total immunoglobulin (Ig)E were found in 10/25 (40%) of the recurrence group as compared with 34/150 (23%) of the general CSU group (p = 0.04). Anti-thyroid peroxidase antibodies were also found in 11/25 (44%) of the recurrence group as compared with 32/160 (20%) of the general group (p = 0.003). The prevalence of CSU recurrence after a full remission is significantly higher among patients with existing bronchial asthma, increased levels of total IgE, and autoimmunity. Further studies are required in order to substantiate this important issue.

Urticaria and increased risk of rheumatoid arthritis: a two-sample Mendelian randomisation study in European population

BACKGROUND

In recent years, a growing body of observational studies suggest that urticaria is associated with a higher risk of rheumatoid arthritis (RA). However, the causal association between urticaria and RA remains unknown.

OBJECTIVE

To investigate the causal relationship of urticaria and RA in European populations by Mendelian randomisation (MR) approach.

METHODS

We conducted two-sample MR analyses. Eleven single-nucleotide polymorphisms associated with urticaria were used as instrumental variables. The summary data on urticaria were derived from FinnGen Data Freeze 2. The summary data on RA were obtained from a published meta-analysis using European samples. Four MR methods were applied to the MR estimates. Three heterogeneity tests, including Cochran's Q test, single variant analysis, and leave-one-out variant analysis, were used. The pleiotropy and horizontal pleiotropy among instrumental variables were assessed with MR-Egger regression intercept, MR pleiotropy residual sum and outlier global test, and PhenoScanner.

RESULTS

The MR analysis suggested that urticaria was causally associated with RA (odds ratio = 1.114, 95% confidence interval = 1.024-1.211, p = .011). No genetic pleiotropy or horizontal pleiotropy was revealed by MR-Egger regression intercept and MR pleiotropy residual sum and outlier global test. The sensitivity analysis results were relatively robust.

CONCLUSIONS

The MR analysis suggested there was sufficient evidence to indicate urticaria is the cause of RA.

The challenges of chronic urticaria part 1: Epidemiology, immunopathogenesis, comorbidities, quality of life, and management

This is Part 1 of an updated follow-up review of a World Allergy Organization (WAO) position paper published in 2012 on the diagnosis and treatment of urticaria and angioedema. Since 2012, there have been advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics, such as omalizumab, in patients with severe refractory disease. For these reasons, the 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, including 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 manage patients with this common ailment.

[Treatment of simultaneously occurring urticaria and atopic dermatitis with dupilumab]

Our 21-year-old woman presented with symptoms of chronic spontaneous urticaria with angioedema and of cholinergic urticaria as well as of atopic dermatitis. Treatment with the IgE antibody omalizumab resulted in an improvement of urticaria; however, relapses of the atopic dermatitis occurred. The use of the monoclonal IL-4/13 receptor antibody dupilumab resulted in complete healing of the atopic dermatitis, complete remission of the chronic spontaneous urticaria with angioedema, and the satisfactory control of cholinergic flare ups over a follow-up period of 26 weeks.

Autoimmune Diseases Are Linked to Type IIb Autoimmune Chronic Spontaneous Urticaria

PURPOSE

Patients with chronic spontaneous urticaria (CSU) have an increased risk for comorbid autoimmune diseases. In this retrospective multicenter study of CSU patients, we evaluated clinical and laboratory features of CSU associated with a higher risk of comorbid autoimmune diseases.

METHODS

We analyzed records of CSU patients (n = 1,199) for a history or presence of autoimmune diseases. Patients were diagnosed with type IIb autoimmune CSU (aiCSU) if all 3 tests were positive: autologous serum skin test (ASST), basophil histamine release assay (BHRA) and/or basophil activation test (BAT), and IgG autoantibodies against FcεRIα/IgE detected by immunoassay.

RESULTS

Twenty-eight percent of CSU patients had at least 1 autoimmune disease. The most prevalent autoimmune diseases were Hashimoto's thyroiditis (HT) (≥ 21%) and vitiligo (2%). Two percent of CSU patients had ≥ 2 autoimmune diseases, most frequently HT plus vitiligo. Comorbid autoimmune diseases, in patients with CSU, were associated with female sex, a family history of autoimmune diseases, and higher rates of hypothyroidism and hyperthyroidism (P < 0.001). Presence of autoimmune diseases was linked to aiCSU (P = 0.02). The risks of having autoimmune diseases were 1.7, 2.9 and 3.3 times higher for CSU patients with a positive ASST, BHRA and BAT, respectively. In CSU patients, markers for autoimmune diseases, antinuclear antibodies and/or IgG anti-thyroid antibodies were associated with non-response to omalizumab treatment (P = 0.013).

CONCLUSIONS

In CSU, autoimmune diseases are common and linked to type IIb autoimmune CSU. Our results suggest that physicians assess and monitor all adult patients with CSU for signs and symptoms of common autoimmune diseases, especially HT and vitiligo.

Refractory chronic urticaria in adults: clinical characterization and predictors of severity

Background

Chronic urticaria (CU) is defined as recurrent urticaria lasting for more than 6 weeks.

Objectives

We aimed to characterize the phenotypes of patients with CU refractory to standard dose anti-H1 antihistamine treatment and search for clinical predictors of poor disease control.

Methods

Retrospective collection of data regarding clinical characteristics, comorbidities, treatment, and disease control of all adult refractory CU patients presenting to the Allergy and Immunology Department during 1 year.

Results

Sixty-one adult patients were included, 74% females, average age 44.5 years (18 to 84 years old). Most patients (78.7%) had initiated CU less than 1 year before enrolment. Chronic spontaneous urticaria (CSU) accounted for 55.7% of the patients, CSU associated with chronic inducible urticaria (CIndU) as a comorbidity for 44.3%, and angioedema was present in 55.7%. Medically-confirmed psychiatric disorders were present in 78.7%. Complementary diagnostic tests were performed in cases with more severe presentation (UAS7 ≥ 28 and/or UCT < 12) or with longer evolution (> 1 year), corresponding to 42 tested patient. Evidence for autoimmunity (positive anti-thyroid peroxidase antibodies, anti-nuclear antibodies or autologous serum test) was found in 45.2% (n = 19/42), and high C-reactive protein was present in 14.3% (n = 6/42), half of these also had positive antinuclear antibodies. Forty-six patients (75.4%) had at least one significant exacerbation, requiring medical appointment, emergency room, hospitalization or job absenteeism. The number of exacerbations correlated with the presence of angioedema (p = 0.022), with a recent diagnosis (< 1 year), and with higher UAS7 severity (p = 0.006). Although ClndU was associated with poor symptom control (p = 0.022), it was also associated with less exacerbations requiring medical observation or hospitalization (p = 0.015). All patients were using antihistamines and 21.3% (n = 13) of them were also under treatment with omalizumab, ciclosporine or montelukast for disease control.

Conclusions

Autoimmunity can affect about half of the patients with severe or long-term CU. UAS7 and angioedema are associated with disease exacerbations. UAS7 and UCT presented unequal accuracy, with UAS7 better associating with the occurrence of exacerbations and treatment doses. Patients with refractory CU frequently present psychiatric disorders. Accurate diagnostic tests, namely autoimmune parameters and inflammatory markers, should be recommended in some individual cases.

Association between atopic dermatitis and autoimmune diseases: a population-based case-control study

Background

Atopic dermatitis (AD) is a common chronic skin disorder and is well known to be associated with other atopic conditions. There is increasing evidence for an association also with nonatopic conditions, including autoimmune diseases, but data are limited about several autoimmune diagnoses.

Objectives

To investigate the association between AD and autoimmune diseases.

Methods

This case–control study used Swedish national healthcare registers. The source population comprised the entire Swedish population aged ≥ 15 years from 1968 to 2016. Cases, including all those with an inpatient diagnosis of AD (from 1968) and/or a specialist outpatient diagnosis of AD (from 2001), were matched by sex and age to healthy controls (104 832 cases of AD, 1 022 435 controls).

Results

AD was significantly associated with one or more autoimmune diseases compared with controls – adjusted odds ratio (aOR) 1·97, 95% confidence interval (CI) 1·93–2·01 – and this association was significantly stronger in the presence of multiple autoimmune diseases compared with only one. The association was strongest for autoimmune disorders involving the skin (aOR 3·10, 95% CI 3·02–3·18), the gastrointestinal tract (aOR 1·75, 95% CI 1·69–1·82) or connective tissue (aOR 1·50, 95% CI 1·42–1·58). In the overall analysis, men with AD had a stronger association with rheumatoid arthritis and coeliac disease than did women with AD. In subanalyses, the findings remained stable in multivariable analyses after adjustment for smoking and parental autoimmune disease.

Conclusions

This large population‐based study indicates significant autoimmune comorbidity of adults with AD, especially between AD and autoimmune dermatological, gastrointestinal and rheumatological diseases. Having multiple autoimmune diseases resulted in a stronger association with AD than having only one autoimmune disease.

What is already known about this topic?

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases.

Some studies have shown that AD is associated with some autoimmune diseases, such as Crohn disease, ulcerative colitis, coeliac disease, alopecia areata and vitiligo, but data are limited for several major autoimmune diagnoses.

What does this study add?

In this study, AD was associated with several autoimmune diseases, especially those involving the skin, the gastrointestinal tract or connective tissue.

The association was stronger for individuals with multiple autoimmune comorbidities.

Linked Comment: J.I. Silverberg. Br J Dermatol 2021; 185:243–244.

Plain language summary available online

Allergic diseases do not impair the cognitive development of children but do damage the mental health of their caregivers

This study aimed to investigate whether children with atopic diseases exhibited different neurodevelopment function from healthy controls and whether their caregivers had differential parental stress. In total, we recruited 109 patients with atopic diseases (mean age 6.8 years, 54.1% male) and 82 healthy children (mean age 6.3 years, 54.9% male). Based on the children’s age, they underwent developmental, cognitive evaluations and attention deficit/hyperactivity disorder (ADHD) symptoms. The parenting stress of children’s caregivers was evaluated using the Chinese Health Questionnaire (CHQ-12) and Family APGAR. Of the children with atopic diseases, 87.2%, 74.3%, 29.4%, and 8.3% of them had allergic rhinitis, asthma, atopic dermatitis, and urticaria, respectively. None of these conditions were associated with children’s cognitive profiles or ADHD symptoms. However, the caregivers of patients who had asthma suffered from higher CHQ-12 scores than those of patients without asthma. Furthermore, the number of atopic diseases had a dose–response effect on caregivers’ CHQ-12 scores. In conclusion, allergic diseases did not impair the cognitive development of children. However, caregivers of patients with asthma or multiple atopic diseases may suffer a greater mental health burden with regard to caring for their children. Such caregivers may require support to effectively fulfill their parenting roles.