Clinical and aetiological aspects in urticaria and angio-oedema

Acute urticaria and cardiovascular diseases

BACKGROUND

Acute urticaria (AU), characterized by sudden skin wheals, has been associated with various triggers. While chronic urticaria's cardiovascular comorbidities have been studied, AU's associations remain largely unexplored.

OBJECTIVE

This study aimed to identify prevalent cardiovascular comorbidities in AU patients and assess their clinical significance.

METHODS

A retrospective cohort study used data from Leumit Health Services, matching AU patients with controls. Demographic, clinical, and laboratory data were analyzed. Statistical analyses included Fisher's Exact Test and Mann-Whitney U test.

RESULTS

The AU group (72,851 individuals) showed no sex/ethnic distribution differences from controls (291,404 individuals). Systolic blood pressure, weight, BMI, glucose, hemoglobin A1c, C-reactive protein, eosinophil counts, total IgE levels were higher in AU (p < 0.001). Several cardiovascular comorbidities showed significant associations with AU, including valvular heart diseases (aortic regurgitation, mitral regurgitation, and pulmonary valve stenosis), cardiac arrhythmias (atrial fibrillation and others), deep vein thrombosis, diseases of capillaries, peripheral artery disease, cerebrovascular disease, coronary artery disease, and inflammatory heart diseases (pericarditis, heart failure, and hypertension) (p < 0.05). Medications, including antihistamines and glucocorticoids, were more prevalent in the AU group (p < 0.001).

CONCLUSION

This study's findings underscore the importance of recognizing cardiovascular comorbidities in AU patients and considering their implications for management. The observed associations provide insight into potential shared mechanisms between AU and cardiovascular diseases, though further research is needed to validate and expand upon these findings.

[What are the main symptoms of urticaria and how are they systematically recorded?]

Wheals or angioedema or both are the main symptoms of urticaria. The small number of the symptoms usually makes diagnosis easy. What is not trivial, however, is the comprehensive systematic recording and assessment of these symptoms and, above all, their sequelae, which affect many areas of the patient's life. Disease activity, quality of life and disease control can and should be measured before and during treatment in order to optimally adapt therapeutic measures. The instruments developed for this purpose have become easier and more convenient to use in recent years thanks to user-friendly platforms such as mobile health apps.

A survey on subtypes and clinical characteristics of 1061 patients with urticaria in the primary care institutes in Japan

The prevalence of urticaria has been reported mostly in Europe and North America. However, precise information regarding its subtypes and clinical characteristics in primary care practice, especially in Asian countries, are scant. Patients with urticaria and/or angioedema who visited nine primary clinics of accredited dermatologists and allergologists in Japan were recruited from October to November 2020. The information of age, sex, disease duration, urticaria control test (UCT), and concomitant urticaria subtypes were collected. A total of 1061 patients participated. The number of patients was high in the 20 to 50 age groups with a peak in the 40s. The most frequent urticaria subtype was chronic spontaneous urticaria (CSU) followed by dermographism, acute spontaneous urticaria (ASU), angioedema, and cholinergic urticaria (CholU) (66.8%, 22.7%, 18.9%, 14.1% and 5.7% in all patients with urticaria). CSU development increased with age from the 20s to 50s, especially in females. Dermographism had a peak in the 40s. ASU had bimodal peaks in childhood and in the 30s. CholU was common in males in the 10-20s. Most angioedema patients were female with an increase in their 30s. Angioedema was solely present in 14 of 1061 participants (1.3%), while 136 (12.8%) had angioedema concomitant with urticaria. UCT showed poorly controlled urticaria with lower scores in patients with concomitant CSU and other subtypes than in those with CSU alone. Urticaria tends to develop in young to middle-aged females. The most common urticaria subtype is CSU, while the number of patients with CholU is high and that of angioedema is low in Japan.

Urticaria in a Pediatric Population: A Portuguese Single-Center Cohort Report

Background

Urticaria typically involves the skin and mucosa and is characterized by the development of wheals, angioedema, or both. According to the temporal evolution of the lesions, urticaria is classified as acute (AU) or chronic (CU), depending on whether the episodes last for fewer or more than six weeks, respectively. This study aimed to characterize a group of children and adolescents with urticaria and describe its subtypes, associated comorbidities, treatment, and evolution.

Methodology

This retrospective, observational study included patients aged <18 years who were diagnosed with urticaria in a tertiary teaching hospital in Portugal, and followed up in a Pediatric Allergy Unit, between January 2019 and December 2021.

Results

A total of 43 patients, aged nine months to 16 years were included. Of these, 22 (51%) were males. AU was identified in 12 (28%) cases, chronic spontaneous urticaria in 21 (63%), and physical urticaria (to cold) in four (9%). Autoantibodies were detected in four patients with spontaneous urticaria. In 6% of patients with CU, the episodes were associated with angioedema. Most CU episodes were successfully managed with the recommended or double the recommended dose (48%) of H1 antihistamines. Three patients requiring fourfold higher than the recommended dose of H1 antihistamines remained unresponsive and were started on omalizumab. Associated autoimmune thyroiditis was diagnosed in four patients.

Conclusions

In this cohort of patients, urticaria was equally distributed between the genders and the first-line therapy was second-generation antihistamines, consistent with current guidelines. Universal screening for autoimmune diseases in patients with chronic spontaneous urticaria revealed four cases of thyroiditis, which supports the relevance of this approach when managing CU.

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

BACKGROUND

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

METHODS

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

CONCLUSIONS

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

Clinical characteristics and epidemiology of chronic urticaria: a nationwide, multicentre study on 1091 patients

Introduction

Urticaria is one of the most common skin diseases. Depending on the length of symptoms, acute (lasting less than 6 weeks) and chronic urticaria (CU) (> 6 weeks) are distinguished. According to the current European guidelines, CU is divided into inducible urticaria (IU) and chronic spontaneous urticaria (CSU).

Aim

To assess the epidemiology and clinical characteristics of CU in Poland.

Material and methods

This was a nationwide, multicentre, cross-sectional, questionnaire-based study performed under the auspices of the Polish Dermatological Society. A total of 102 physicians (dermatologists and allergists) recruited 1091 patients suffering from CU.

Results

Among 1091 adults with CU, IU was found in 35.1% (n = 383) of patients and CSU was responsible for 61.1% (n = 667) of CU cases. The remaining patients (n = 41, 3.8%) suffered from both, IU and CSU. Persons with CSU were twice more likely to report family history of urticaria than those with IU (12.1% vs. 6.0%, p = 0.001). Generalized eruptions of wheals predominated in CSU (generalized wheals: 57.9%, localized wheals: 42.1%), whereas wheals localized in particular body areas were found more commonly in IU (generalized wheals: 45.2%, localized wheals: 54.8%, p < 0.001). The CU was the cause of absenteeism in almost every fifth patient suffering from this disease.

Conclusions

The CSU is about twice as frequent cause of CU as compared to IU. The treatment of CU is a major challenge for physicians of various specialties and the treatment choice is closely associated with the specialist knowledge of current treatment guidelines.

Dermatological diseases in the geriatric age group: Retrospective analysis of 7092 patients

AIM

The aim of the present study was to retrospectively investigate the dermatological diseases seen in geriatric patients, and their distribution according to age, sex and season, making a significant contribution to the few previous prevalence studies.

METHODS

Data from 7092 geriatric patients examined at our dermatology clinic from 1 January to 31 December 2017 were retrospectively analyzed. The data were analyzed according to age, sex and seasons.

RESULTS

The seven most frequently occurring diseases were eczematous dermatitis, fungal infections, pruritus, precancerous and malignant neoplasm, xerosis cutis, benign neoplasms, and papulosquamous diseases, respectively. In the youngest group, the most frequent disease was eczematous dermatitis, whereas in the older group it was precancerous and malignant neoplasms. The most common disease for both men and women was eczematous dermatitis. Eczematous dermatitis, pruritus, xerosis cutis, rash and general drug eruptions, and papulosquamous diseases were most frequent in the winter, but less in the summer (P < 0.01). Fungal diseases were frequent in the spring and summer (P < 0.01). Pigmentation disorders were frequent in the summer (P < 0.01).

CONCLUSIONS

The present study, which is the largest prevalence study in the literature with 7092 geriatric patients, will raise awareness regarding the pattern and nature of dermatological diseases in geriatric patients. Geriatr Gerontol Int 2019; 19: 582-585.

Acute-phase response and its biomarkers in acute and chronic urticaria

Introduction

Since urticaria is a persisting inflammatory disease it is important to establish the prognostic factors for the duration and severity of the disease.

Aim

To evaluate serum concentrations of selected acute-phase proteins (APP) in patients with various forms of urticaria as compared to healthy volunteers and also to analyze these concentrations in different types of urticaria. Additionally, to evaluate the correlation between serum levels of selected APP and disease activity.

Material and methods

Serum concentrations of C-reactive protein (CRP), α₁-acid glycoprotein (AGP), α₁-antichymotrypsin (ACT), α₁-antitrypsin (AT), ceruloplasmin (Cp), transferrin (Tf), α₂-macroglobulin (α₂M) and haptoglobin (Hp) were measured. Quantitative measurement was conducted using the rocket immunoelectrophoresis. Disease activity was assessed with the use of total symptom score.

Results

Analysis of serum APP concentrations revealed statistically higher serum concentrations of CRP, AGP and ACT in the entire group of patients with urticaria in comparison with the control group. In the entire group of patients with urticaria, CRP, AGP, ACT, Cp and Hp correlated positively with disease activity, intensity of pruritus and the number and size of urticarial wheals. Statistically lower serum concentrations of CRP, ACT, Cp and Hp were detected in the group of patients with acute urticaria (AU) and angioedema together, compared to the patients suffering from AU only.

Conclusions

Patients with symptoms of various forms of urticaria present a distinct profile of serum APP concentrations. A significant correlation observed between CRP, AGP, ACT, Cp, Hp and clinical activity score points to the potential role of APP as markers of the urticarial activity.

C-reactive protein is linked to disease activity, impact, and response to treatment in patients with chronic spontaneous urticaria

BACKGROUND

Elevated levels of C-reactive protein (CRP), a sensitive marker of inflammation, have been consistently reported in chronic spontaneous urticaria (CSU). Here, we retrospectively analyzed data from 1253 CSU patients from 2 centers to answer the following questions: (i) What is the prevalence of elevated levels of CRP in CSU? (ii) Why do CSU patients show elevated levels of CRP? (iii) Are elevated CRP levels relevant?

METHODS

Serum levels of CRP were measured by the nephelometric method. We collected information regarding various laboratory tests including ESR, CBC with differential, D-dimer, fibrinogen, C3, C4, IL-6, etc. For most patients, we also collected data on age, gender, duration of CSU, presence of angioedema, activity (UAS at the time of blood sampling and for 7 days), quality of life (CU-Q2oL and/or DLQI), comorbidities and possible causes of CSU, and autologous serum skin test (ASST) response. The efficacy of second-generation antihistamines was evaluated on the day of blood collecting.

RESULTS

One-third of CSU patients had elevated levels of CRP. Higher levels of CRP were associated with ASST positivity (P = .009) and arterial hypertension (P = .005), but not with other possible causes or comorbidities of CSU. C-reactive protein correlated with urticaria activity (P < .001), quality of life impairment (P = .026), and inflammatory and coagulation markers (P < .001). C-reactive protein levels were significantly higher in nonresponders to antihistamines as compared to responders (P < .001).

CONCLUSION

Elevated levels of CRP are common and relevant in CSU patients. The assessment of CRP levels may help to optimize the management of patients with CSU.

Autoimmune comorbidity in chronic spontaneous urticaria: A systematic review

BACKGROUND AND OBJECTIVE

Numerous autoimmune diseases (AIDs) have been linked to chronic spontaneous urticaria (CSU). Here, we provide the first extensive and comprehensive evaluation of the prevalence of AIDs in patients with CSU and vice versa.

METHODS

A Pubmed and Google Scholar search was performed to identify studies reporting the prevalence of various AIDs in CSU and vice versa published before April 2017.

RESULTS

The prevalence of individual AIDs in CSU is increased (≥1% in most studies vs ≤1% in the general population). AIDs with relatively high prevalence in the general population are also quite common in CSU patients, whereas those with low prevalence remain a rare finding in CSU. The rates of comorbidity in most studies were ≥1% for insulin-dependent diabetes mellitus, rheumatoid arthritis (RA), psoriasis and celiac disease (CD), ≥2% for Graves' disease, ≥3% for vitiligo, and ≥5% for pernicious anemia and Hashimoto's thyroiditis. Organ-specific AIDs are more prevalent in CSU than systemic (multiorgan or non organ-specific) AIDs. >2% of CSU patients have autoimmune polyglandular syndromes encompassing autoimmune thyroid disease (ATD) and vitiligo or pernicious anemia. Antithyroid and antinuclear antibodies are the most prevalent AID-associated autoantibodies in CSU. >15% of CSU patients have a positive family history for AIDs. The prevalence of urticarial rash in AID patients is >1% in most studies. This rash is more prevalent in eosinophilic granulomatosis with polyangiitis, ATD, systemic lupus erythematosus, RA and CD.

CONCLUSIONS

CSU patients have an increased risk of AIDs, especially adult female patients and those with a positive family history and a genetic predisposition for AIDs, who should be screened for signs and symptoms of AIDs.

Comorbidity of chronic spontaneous urticaria and autoimmune thyroid diseases: A systematic review

Patients with chronic spontaneous urticaria (CSU) are widely held to often have other autoimmune disorders, including autoimmune thyroid disease. Here, we systematically evaluated the literature on the prevalence of thyroid autoimmunity in CSU and vice versa. There is a strong link between CSU and elevated levels of IgG antithyroid autoantibodies (AAbs), with most of a large number of studies reporting rates of ≥10%. Levels of IgG against thyroid peroxidase (TPO) are more often elevated in CSU than those of other IgG antithyroid AAbs (strong evidence). Levels of IgG antithyroid AAbs are more often elevated in adult patients with CSU than in children (strong evidence). Patients with CSU exhibit significantly higher levels of IgG antithyroid AAbs (strong evidence) and IgE-anti-TPO (weak evidence) than controls. Elevated IgG antithyroid AAbs in CSU are linked to the use of glucocorticoids (weak evidence) but not to disease duration or severity/activity, gender, age, or ASST response (inconsistent evidence). Thyroid dysfunction rates are increased in patients with CSU (strong evidence). Hypothyroidism and Hashimoto's thyroiditis are more common than hyperthyroidism and Graves' disease (strong evidence). Thyroid dysfunction is more common in adult patients with CSU than in children (strong evidence) and in female than in male patients with CSU (weak evidence). Urticaria including CSU is more prevalent in patients with thyroid autoimmunity than in controls (weak evidence). CSU can improve in response to treatment with levothyroxine or other thyroid drugs (strong evidence). Pathogenic mechanisms in CSU patients with thyroid autoimmunity may include IgE against autoantigens, immune complexes, and complement.

Increased Risk of Chronic Spontaneous Urticaria in Patients With Autoimmune Thyroid Diseases: A Nationwide, Population-based Study

There was no previous population-based study on the comparison of the risk of chronic spontaneous urticaria (CSU) between autoimmune thyroid diseases (AITD) and age- and gender-matched controls. The primary objective of this study was to evaluate the risk of CSU after diagnosis of AITD using national registry data from Korea. The secondary objective was to evaluate other risk factors of CSU. Based on the disease code diagnoses in 2003-2005, we composed an AITD group (n=3,659) and an age- and gender-matched control group (n=18,295). Each patient was tracked for whether CSU occurs or not until 2013. After adjusting for demographic differences and comorbidities, patients with AITD had a significantly higher rate of CSU compared to the control group (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25-1.70; P<0.001). Among the AITD patients, the adjusted HR for CSU was higher in patients with Hashimoto's thyroiditis (HR, 1.50) than in those with Grave's disease (HR, 1.33), although the difference was not statistically significant (P=0.368). Analysis of CSU patients associated with AITD showed that female patients had a significantly higher risk of CSU compared to male ones (HR, 1.34; P=0.001) and that those with allergic rhinitis (HR, 1.51; P<0.001), atopic dermatitis (HR, 2.44; P<0.001), and asthma (HR, 1.50; P<0.001) had a significantly higher risk of CSU compared to patients without respective diseases. Our results demonstrated that AITD could be significantly associated with an increased risk of CSU.

Phototherapy using narrowband ultraviolet B and psoralen plus ultraviolet A is beneficial in steroid-dependent antihistamine-refractory chronic urticaria: a randomized, prospective observer-blinded comparative study

BACKGROUND

Literature on the efficacy of phototherapy in steroid-dependent antihistamine-refractory chronic urticaria (CRU) is limited.

OBJECTIVES

To assess and compare the efficacy of psoralen plus ultraviolet A (PUVA) and narrowband ultraviolet B (NB-UVB) in steroid-dependent CRU.

METHODS

In this randomized, prospective observer-blinded comparative study, 50 patients with steroid-dependent CRU (6 months of spontaneous urticaria with no response after 3 consecutive months of antihistamines and steroid dependence) were administered either PUVA (group A) or NB-UVB (group B) for 90 days, with a post-treatment follow-up of 90 days. The treatment efficacy was assessed using the average urticaria activity score 7 (aUAS7) and outcome scoring scale (OSS) every 2 weeks.

RESULTS

The mean values of aUAS7 progressively decreased from 4·9 ± 0·8 and 5·0 ± 0·7 at baseline to 1·9 ± 0·7 and 1·4 ± 0·7 in groups A and B, respectively, by day 90. This further decreased to 1·5 ± 0·8 and 1·4 ± 1·0 at day 180 in both groups. The values of OSS progressively increased from baseline (1·6 ± 0·5 in group A and 1·3 ± 0·5 in group B) to 3·9 ± 0·3 and 4·0 ± 0·3 in groups A and B, respectively, by day 90, and 3·9 ± 0·5 and 4·0 ± 0·6 by day 180. NB-UVB fared statistically better than PUVA at different time points. Adverse events encountered were minimal and did not warrant treatment discontinuation.

CONCLUSIONS

Phototherapy, especially NB-UVB, is an effective, safe and affordable therapeutic modality for steroid-dependent CRU and should be tried prior to third-line treatment options such as omalizumab, ciclosporin and other immunosuppressants.

Chronic spontaneous urticaria and internal parasites--a systematic review

Chronic spontaneous urticaria (CSU) is defined as persistent wheals, angioedema, or both lasting for >6 weeks due to known or unknown causes. Some epidemiological studies and case reports suggest that internal parasite infections (PI) can cause CSU. Here, we provide a systematic overview of published findings on the prevalence and relevance of PI in CSU and we discuss possible pathomechanisms. The prevalence of PI in CSU was investigated by 39 independent studies and comorbidity reportedly ranged from 0 to 75.4% (two-thirds of these studies reported infection rates of 10% or less). The prevalence of PI in adult and pediatric CSU patients ranged from 0% to 75.4% and from 0% to 37.8%, respectively. CSU patients were more often diagnosed with protozoa and had a significantly higher risk of toxocariasis seropositivity and Anisakis simplex sensitization when compared to healthy controls. Patients with chronic urticaria more frequently had seropositivity of fasciolosis, Anisakis simplex sensitization, and the presence of Blastocystis hominis allele 34 (ST3) as compared with control subjects. In 21 studies, efficacy of treatment with antiparasitic drugs ranged from 0 to 100% (35.7% of 269 CSU patients benefitted). In 9 (42.8%) of 21 studies, more than 50% of efficacy was observed. The reported rate of urticaria comorbidity in PI patients in 18 independent studies is 1-66.7%. Urticaria including CSU might be a quite common symptom of strongyloidiasis and blastocystosis. Pathogenic mechanisms in CSU due to PI may include specific IgE, Th2 cytokine skewing, eosinophils, activation of the complement, and the coagulation systems.

Transient improvement of urticaria induces poor adherence as assessed by Morisky Medication Adherence Scale-8

Poor adherence to medication is a major public health challenge. Here, we aimed to determine the adherence to oral and topical medications and to analyze underlying associated factors using the translated Japanese version of Morisky Medication Adherence Scale-8 regarding urticaria treatment. Web-based questionnaires were performed for 3096 registered dermatological patients, along with a subanalysis of 751 registered urticaria patients in this study. The adherence to oral medication was significantly associated with the frequency of hospital visits. Variables that affected the adherence to topical medication included age and experience of drug effectiveness. The rate of responses that "It felt like the symptoms had improved" varied significantly among the dermatological diseases treated with oral medications. Dermatologists should be aware that adherence to the treatment of urticaria is quite low. Regular visits and active education for patients with urticaria are mandatory in order to achieve a good therapeutic outcome by increasing the adherence.

Anaphylaxis and urticaria

Anaphylaxis and urticaria are common presenting allergic complaints. Affecting up to 2% of the population, anaphylaxis is a serious, life-threatening allergic reaction. Although not life-threatening, urticaria is a rash of transient, erythematous, pruritic wheals that can be bothersome and affects up to 25% of the population. All cases of anaphylaxis warrant thorough clinical evaluation by the allergist-immunologist, although most cases of urticaria are self-limited and do not require specialist referral. This article offers an overview of our current knowledge on the epidemiology, pathogenesis, triggers, diagnosis, and treatment of anaphylaxis and urticaria.

Evaluation of D-dimer serum levels among patients with chronic urticaria, psoriasis and urticarial vasculitis

BACKGROUND

It has been demonstrated that neutrophils, eosinophils and monocytes, under appropriated stimulus, may express tissue factor and therefore, activate the extrinsic pathway of coagulation. We performed a transversal and case-control study of patients with chronic urticaria and patients with psoriasis, in our outpatient clinic to evaluate the production of D-dimer.

OBJECTIVE

To evaluate D-dimer serum levels in patients with chronic urticaria and its possible correlation with disease activity.

PATIENTS AND METHODS

The study was conducted from October 2010 until March 2011. We selected 37 consecutive patients from our Allergy Unit and Psoriasis Unit, and divided them into three groups for statistical analysis: (i) 12 patients with active chronic urticaria (CU); (ii) 10 patients with chronic urticaria under remission and (iii) 15 patients with psoriasis (a disease with skin inflammatory infiltrate constituted by neutrophils, lymphocytes and monocytes). Another five patients with urticarial vasculitis were allocated in our study, but not included in statistical analysis. The serum levels of D-dimer were measured by Enzyme Linked Fluorescent Assay (ELFA), and the result units were given in ng/ml FEU.

RESULTS

Patients with active chronic urticaria had the highest serum levels of D-dimer (p<0.01), when compared to patients with CU under remission and the control group (patients with psoriasis).

CONCLUSIONS

Patients with active chronic urticaria have higher serum levels of D-dimer, when compared to patients with chronic urticaria under remission and patients with psoriasis. We found elevated serum levels of D-dimer among patients with urticarial vasculitis.

Efficacy and safety of sulfasalazine in patients with chronic idiopathic urticaria

BACKGROUND

There are limited data regarding alternative treatments for antihistamine refractory chronic idiopathic urticaria (CIU). Patients with recalcitrant skin disease often cannot gain satisfactory symptom control with standard therapies and may require prolonged courses of oral corticosteroids. There is a lack of information describing the degree and duration of sulfasalazine's efficacy, the frequency and nature of adverse reactions, and the appropriate safety monitoring parameters.

OBJECTIVE

To present a case series detailing the efficacy and safety of sulfasalazine therapy in patients with CIU.

METHODS

A retrospective chart review was conducted of 39 patients with sulfasalazine-treated CIU evaluated at Johns Hopkins Asthma and Allergy Center from October 2007 to March 2012. Eight patients were excluded from the final analysis.

RESULTS

Twenty-six patients (83.9%) showed an improvement in symptoms within the first 3 months, with 51.6% of patients (n = 16) becoming asymptomatic within the first 6 months of starting sulfasalazine. Eleven patients (35.4%) achieved complete relief of symptoms after tapering off sulfasalazine therapy. Five of the 31 patients (16.1%) failed treatment, defined as worsening symptoms and pursuit of an alternative therapy. Six of 31 patients (19.4%) had a modified course of sulfasalazine therapy owing to abnormal hematologic parameters. Serious adverse events leading to drug discontinuation occurred in 6.5% of patients (n = 2) and included a patient with drug-induced leukopenia and one with rhabdomyolysis.

CONCLUSION

Sulfasalazine is a highly effective treatment for patients with antihistamine resistant CIU. The frequency of adverse events leading to an alteration of sulfasalazine treatment supports the need for close monitoring of these patients.

The general characteristics of acute urticaria attacks and the factors predictive of progression to chronic urticaria

BACKGROUND

The natural history of progression from acute urticaria (AU) to chronic urticaria (CU) remains poorly understood. This study aimed to investigate the potential triggers of AU attacks and factors associated with their duration, as well as the factors which may be predictive of progression to CU.

METHODS

The study included 281 AU patients (AU group). Data were obtained from 207 AU patients retrospectively and from 74 AU patients prospectively. The CU group consisted of 953 patients, whose data were previously published.

RESULTS

According to the medical history, the most common potential triggers of AU attacks were drugs (38.1%); infections (35.2%); stress (24.7%); and foods (17.8%). Attack duration was shorter in cases in which food (p=0.04) or infection (p=0.04) was the suspected trigger. Patients with a history of rhinitis (p=0.04) and food allergy (p=0.04), and positive skin prick test results for pollens (p=0.02) and dog (p=0.02) also had attacks of shorter duration. Patients with asthma had attacks of longer duration (p=0.01). Based on history and/or provocation test results, the prevalence of non-steroidal anti-inflammatory drug hypersensitivity (NSAIDH) was significantly higher in the CU group than the AU group (24.9% vs. 4.3%, respectively, (p<0.01)), as was antibiotic hypersensitivity (10.6% vs. 4.6%, respectively, (p<0.01)) and food allergy (18.3% vs. 3.9%, respectively, (p<0.01)).

NSAIDH (OR

7.97; 95%CI: 4.33-14.66; p<0.01) and food allergy (OR: 5.17; 95%CI: 2.71-9.85; p<0.01) were observed to be independent factors associated with CU.

CONCLUSIONS

As NSAIDH and food allergy were associated with CU, their presence should be carefully evaluated in patients with AU in order to predict progression to CU.

Comparison of CD63 Upregulation Induced by NSAIDs on Basophils and Monocytes in Patients with NSAID Hypersensitivity

Background. An in vitro basophil activation test, based on the detection of CD63 upregulation induced by NSAIDs, has been described. Its clinical significance remains controversial. Objectives. In patients with a history of nonallergic NSAID hypersensitivity, stratified according to the severity of the symptoms, to assess with NSAIDs the predictive value of basophil (BAT) and monocyte (MAT) activation tests. Patients/Methods. Sixty patients who had NSAIDs-induced or exacerbated urticaria/angiooedema and 20 controls was included. After incubation with NSAIDs or acetaminophen, leukocytes were analysed for CD63 upregulation. Results. With aspirin, the sensitivity (37%) and specificity (90%) of BAT agree with already published results. In contrast, when patients had had cutaneous and visceral reactions, the frequency of positive BAT 14/22 (64%, P < 0.001) or MAT 10/22 (46%, P < 0.01) were increased. Conclusions. Positive tests were more frequent among patients having a severe hypersensitivity contrasting with the other patients who had results similar to controls.

Six cases of antihistamine-resistant dermographic urticaria treated with oral ciclosporin

BACKGROUND

Dermographic urticaria (DU) is characterized by strong itch and wheals induced by mechanical scratching. H(1)-receptor antagonists may reduce symptoms of DU to some extent, but other treatments being used for chronic spontaneous urticaria, such as H(2)-receptor antagonists and corticosteroids, are not usually effective for DU.

CASE SUMMARY

We here report six cases of antihistamine-resistant DU treated with oral ciclosporin. Four cases suffering from severe itches that spontaneously occurred before the appearance of wheals in response to scratching were substantially improved by use of ciclosporin for 21, 16, 32, and 8 months, and one of them reached complete remission. Two cases did not obtain a benefit from the treatment, because of insufficient effects and/or side effects.

DISCUSSION

Oral ciclosporin may be of value as a potential treatment of anti-histamine-resistant DU.

Cyclosporin-A efficacy in chronic idiopathic urticaria

Common drugs in the therapy of chronic idiopathic urticaria (CIU) include antihistamines alone or combined with corticosteroids, but severe unresponsive patients require alternative treatments. This retrospective study aims to evaluate clinical response and safety of low-dose and long-term oral Cyclosporin-A (CyA) in unresponsive patients. One hundred and ten CIU patients, unresponsive to a previous treatment (antihistamines plus prednisone 0.2 mg/kg/day), received additional oral CyA 1–3 mg/kg/day for 6 months. The patients were subdivided into three groups (A, B, C) according to the different CyA doses. Parameters of clinical efficacy including pruritus, and size and number of wheals were evaluated at baseline, after three and six months. All adverse events were recorded. The mean total symptom severity score decreased by 63% in Group A, 76% in Group B, and 85% in Group C after 6 months. Total disappearance of the symptoms was recorded in 43 patients (39.1%): 7 (28%) of Group A; 12 (37.5%) of Group B and 24 (45%) of Group C. After a mean of 2 months from CyA suspension, 14 patients (11%) had recurrence of symptoms. Minor side effects were noted in 8 patients (7%). Our study indicates that low-dose, long-term CyA therapy is efficacious and safe in severe unresponsive CIU.

Cyclosporine-A in severe chronic urticaria: the option for long-term therapy

BACKGROUND

The treatment of severe chronic urticaria (CU) remains a difficult goal to achieve. Many patients do not respond to anti-histamine therapy, even when off-label doses are given. Thus, cyclosporine-A (CsA) becomes a good therapeutic option for severe patients and for some, long-term therapy is required. We evaluated the effectiveness and safety of low-dose CsA, when treatment cannot be discontinued and long-term CsA therapy is needed to maintain severe CU in remission.

METHODS

Among 2000 patients with CU who were referred to our outpatient clinic, 120 patients who suffered from a very severe CU began treatment with CsA 3 mg/kg. A clinical and laboratory followup was performed during this period of treatment.

RESULTS

In 20 patients, CsA was discontinued within 2-15 days after initiation because of side-effects. Among 62 of the remaining 100 patients (62%), CsA was administered for a period of 3 months with a highly beneficial outcome. In another 20 patients (20%), CsA was considered beneficial; however, it was required for a longer period of time, 5-10 years for some of the cases. In all cases, CsA was well tolerated and most important, it was safe. For 18 patients (18%), CsA therapy was reported as failed.

CONCLUSION

A low dose of CsA is a good option for patients who suffer from especially severe CU. In most cases, this therapy regimen is considered effective and safe. For a small group of patients, long-term therapy is needed, and until now it is considered safe.

Chronic urticaria: assessment of current treatment

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

The inflammasome, an innate immunity guardian, participates in skin urticarial reactions and contact hypersensitivity

Urticarial rash, one of the clinical manifestations characteristic of cryopyrin-associated periodic syndrome (CAPS), is caused by a mutation in the gene encoding for NLRP3 (nucleotide-binding oligomerization domain, leucine-rich repeats containing family, pyrin domain containing 3). This intracellular pattern recognition receptor and its adaptor protein, called apoptosis associated speck-like protein containing a caspase-recruitment and activating domain (ASC), participate in the formation of a multi-protein complex termed the inflammasome. The inflammasome is responsible for activating caspase-1 in response to microbial and endogenous stimuli. From the analysis of cellular mechanisms of urticarial rash in CAPS, we have traced caspase-1 activated IL-1beta in CAPS to a surprising source: mast cells. Recently, two groups have generated gene-targeted mice that harbored Nlrp3 mutations. These mice had very severe phenotypes, with delayed growth and the development of dermatitis, but not urticaria. The reason for the differences in the skin manifestations observed with CAPS and these knock-in mice relates to the findings that the inflammasome also plays a role in contact hypersensitivity, and that IL-18, another cytokine involved with inflammasome-activation of caspase-1, may be a major player in dermatitis development.

Mast cells mediate neutrophil recruitment and vascular leakage through the NLRP3 inflammasome in histamine-independent urticaria

Urticarial rash observed in cryopyrin-associated periodic syndrome (CAPS) caused by nucleotide-binding oligomerization domain-leucine-rich repeats containing pyrin domain 3 (NLRP3) mutations is effectively suppressed by anti-interleukin (IL)-1 treatment, suggesting a pathophysiological role of IL-1beta in the skin. However, the cellular mechanisms regulating IL-1beta production in the skin of CAPS patients remain unclear. We identified mast cells (MCs) as the main cell population responsible for IL-1beta production in the skin of CAPS patients. Unlike normal MCs that required stimulation with proinflammatory stimuli for IL-1beta production, resident MCs from CAPS patients constitutively produced IL-1beta. Primary MCs expressed inflammasome components and secreted IL-1beta via NLRP3 and apoptosis-associated speck-like protein containing a caspase recruitment domain when stimulated with microbial stimuli known to activate caspase-1. Furthermore, MCs expressing disease-associated but not wild-type NLRP3 secreted IL-1beta and induced neutrophil migration and vascular leakage, the histological hallmarks of urticarial rash, when transplanted into mouse skin. Our findings implicate MCs as IL-1beta producers in the skin and mediators of histamine-independent urticaria through the NLRP3 inflammasome.

[Assessment of association between autoimmune thyroid disease and chronic urticaria]

Several studies found a higher prevalence of Autoimmune Thyroid Disease (ATD) in patients with Chronic Urticaria (CU). This relationship may be due to the possible autoimmune etiology in up to one third of the cases of Chronic Idiopathic Urticaria (CIU). However, the frequency of ATD ranged from 1.14% to 28.6%. The study began by determining whether there is an association between ATD and CU, in a population seen at the same clinic. We compared the frequency of anti-thyroid antibodies and thyroid dysfunction in 49 patients with CIU (group 1) and 112 controls (group 2). In order to support the result found, we studied the prevalence of CIU in 60 patients with ATD (group 3) and compared with 29 patients who had non-immune thyroid disease (NITD) (group 4). We did not find a statistical difference for the presence of anti-thyroid antibodies or thyroid dysfunction between groups 1 and 2 (12.24% x 9.82% and 12.24% x 7.14%, respectively). The same occurred for the presence of CIU among groups 3 and 4 (3.33% x 3.44%). In our study it was not possible to demonstrate a relationship between ATD and CIU, which means that different populations may present a higher or lower degree of association between these illnesses.

Chronic idiopathic urticaria: prevalence and clinical course

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

Chronic urticaria--which clinical parameters are pathogenetically relevant? A retrospective investigation of 339 patients

BACKGROUND

Urticaria is a clinical reaction pattern triggered by many factors causing liberation of vasoactive substances such as histamine, prostaglandins and kinins. It presents as transient itching wheals which are either limited to the local stimulus area or more widespread. Urticaria is classified according to its duration into acute (duration > or = 6 weeks) and chronic (duration 6 weeks) forms. Various clinical investigations may be initiated to diagnose the cause. This study critically evaluates the relevance of frequently performed laboratory investigations and searches for infectious foci, as well as the results of physical provocation testing and oral provocation with food additives.

PATIENTS AND METHODS

The laboratory and clinical data of 339 patients who had been treated for urticaria at the Christian-Albrechts-University in Kiel over a period of four years were collected in a data entry form and statistically evaluated. Nominal values were analyzed by their relative and absolute quantities, quantitative parameters with the help of statistical data such as minimum, maximum, median and 25th and 75th percentiles.

RESULTS

Chronic recurrent urticaria was most common, accounting for 52% of cases. Women were affected 1.8 times more often than men. One-third of the patients also had angioedema. The medians of all laboratory parameters evaluated were within normal values. Only rarely were elevated antinuclear antibody titers, abnormal thyroid function tests or active infections such as hepatitis B or borreliosis detected. The search for infectious foci identified tonsillitis or sinusitis in almost 50% of analyzed patients. Positive reactions to physical testing occurred in 30% of patients and in 11% to oral provocation with various food additives.

CONCLUSIONS

This study of a large patient group stresses the relevance of individually-tailored evaluations in patients affected with urticaria rather than an expensive initial broad diagnostic testing. More specific searches should be based on individual clues.

Angioedema

Although first described more than 130 years ago, the pathophysiology, origin, and management of the several types of angioedema are poorly understood by most dermatologists. Although clinically similar, angioedema can be caused by either mast cell degranulation or activation of kinin formation. In the former category, allergic and nonsteroidal anti-inflammatory drug-induced angioedema are frequently accompanied by urticaria. Idiopathic chronic angioedema is also usually accompanied by urticaria, but can occur without hives. In either case, an autoimmune process leading to dermal mast cell degranulation occurs in some patients. In these patients, histamine-releasing IgG anti-FcepsilonR1 autoantibodies are believed to be the cause of the disease, removal or suppression by immunomodulation being followed by remission. Angiotensin-converting enzyme inhibitor-induced angioedema is unaccompanied by hives, and is caused by the inhibition of enzymatic degradation of tissue bradykinin. Hereditary angioedema, caused by unchecked tissue bradykinin formation, is recognized biochemically by a low plasma C'4 and low quantitative or functional C'1 inhibitor. Progress has now been made in understanding the molecular genetic basis of the two isoforms of this dominantly inherited disease. Recently, a third type of hereditary angioedema has been defined by several groups. Occurring exclusively in women, it is not associated with detectable abnormalities of the complement system. Angioedema caused by a C'1 esterase inhibitor deficiency can also be acquired in several clinical settings, including lymphoma and autoimmune connective tissue disease. It can also occur as a consequence of specific anti-C'1 esterase autoantibodies in some patients. We have reviewed the clinical features, diagnosis, and management of these different subtypes of angioedema.

LEARNING OBJECTIVE

After completing this learning activity, participants should be aware of the classification, causes, and differential diagnosis of angioedema, the molecular basis of hereditary and non-hereditary forms of angioedema, and be able to formulate a pathophysiology-based treatment strategy for each of the subtypes of angioedema.

Drug-induced urticaria

Urticaria is characterised by transient swellings of the skin, which fluctuate over hours. Deeper swellings of the subcutaneous and submucosal tissue are known as angio-oedema. Drug-induced urticaria has been reported with a wide range of drugs and vaccines. NSAIDs and antibiotics are the drugs most commonly associated with urticaria, although reliable data from prospectively controlled studies is scarce. Spontaneous reports of drug-induced urticaria to the Committee on Safety of Medicines, UK, over a 40-year period also implicate bupropion, selective serotonin re-uptake inhibitor antidepressants, angiotensin-converting enzyme inhibitors (ACEI), H2 and H1 antihistamines, and systemic antifungals. New evidence suggests that selective COX-2 inhibitors may be tolerated in patients with aspirin-sensitive urticaria. The safety of angiotensin II receptor antagonists in patients with angio-oedema induced by ACEI has not yet been established.

Autoimmune progesterone dermatitis in a parturient for emergency caesarean section

A parturient with a 14-year history of autoimmune progesterone dermatitis presented in labour at 36 weeks' gestation. She had suffered recurrent episodes of angioedema over a long period and had been scheduled for elective caesarean hysterectomy and bilateral oophorectomy at 37 weeks' gestation. In most cases surgical oophorectomy provides prolonged relief from the recurrent angioedema and dermatological manifestations that are typical of autoimmune progesterone dermatitis. Spinal anaesthesia was chosen in order to avoid airway manipulation, a factor frequently implicated in the development of angioedema. Delivery was uneventful and the obstetricians proceeded to hysterectomy and oophorectomy. Forty minutes after delivery the patient experienced an attack of angioedema, she was markedly hypotensive and was given fluids, ephedrine and phenylephrine with good effect. As she remained normotensive, she was given intramuscular rather than intravenous epinephrine to provide a slower release. She recovered well and stabilised without the need for intubation or ventilation. This case reinforces the rationale for regional anaesthesia in these patients and demonstrates how intramuscular epinephrine contributed towards a positive outcome.

Chronic Urticaria

Chronic urticaria is a common condition that can be very disabling when severe. A cause for chronic idiopathic urticaria (CIU) is only infrequently identified. Potential causes include reactions to food and drugs, infections (rarely) and, apart from an increased incidence of thyroid disease, uncomplicated urticaria is not usually associated with underlying systemic disease or malignancy. About one-third of patients with CIU have circulating functional autoantibodies against the high affinity IgE receptor or against IgE, although it is not known why such antibodies are produced, or how the presence of such antibodies alters the course of the disease or response to treatment. There are only a few publications relating to childhood urticaria, but it is probably similar to the adult form, except that adult urticaria is more common. The diagnosis is based on patient history and it is vital to spend time documenting this in detail. Extensive laboratory tests are not required in the vast majority of patients. Chronic urticaria resolves spontaneously in 30-55% of patients within 5 years, but it can persist for many years. Treatment is aimed firstly at avoiding underlying causative or exacerbating factors. Histamine H1 receptor antagonists remain the mainstay of oral treatment for all forms of urticaria. The newer low-sedating antihistamines desloratadine, fexofenadine, levocetirizine and mizolastine should be tried first. Sedating antihistamines have more adverse effects but are useful if symptoms are causing sleep disturbance. Low-dose dopexin is effective and especially suitable for patients with associated depression. There is controversy as to whether the addition of an histamine H2 receptor antagonist or a leukotriene antagonist is helpful. For CIU, second-line agents include ciclosporin (cyclosporine) [which is effective in approximately 75% of patients], short courses of oral corticosteroids, intravenous immunoglobulins and plasmapheresis, although the last two were found to be beneficial in small trials only. Treatments for CIU with only limited or anecdotal supportive evidence include sulphasalazine, methotrexate, stanazol, rofecoxib and cyclophosphamide. The efficacy of photo(chemo)therapy is controversial. Physical urticarias may respond to H1 receptor antagonists, although in delayed pressure urticaria, and cold, solar and aquagenic urticaria, the response may be disappointing. Second-line agents for physical urticarias vary depending on the urticaria and most have limited supportive evidence. The potential for spontaneous resolution, the variation in the disease activity and the unpredictable nature of the disease makes the efficacy of treatments difficult to assess.