Chronic urticaria

Comparative efficacy and safety of the treatment by Omalizumab for chronic idiopathic urticaria in the general population: A systematic review and network meta-analysis

BACKGROUND

Omalizumab is the only licensed drug that serves as a third-line treatment for chronic idiopathic urticaria (CIU). The optimum doses of omalizumab remain controversial. Therefore, this study aims to estimate the efficacy and safety of different doses of omalizumab in the treatment of CIU patients.

MATERIALS AND METHODS

Four databases were searched from the database's creation to April 8, 2023. Several keywords such as omalizumab and urticarias were used to retrieve related studies. The meta-analytical outcomes were analyzed in R 4.2.1 software and Stata 15.1 software. Cochrane risk-of-bias tool Ver. 2 was used to evaluate the risk of bias in randomized controlled trials (RCTs).

RESULTS

In total, 2331 patients were included. Five indexes were employed to assess, including weekly Itch Severity Score (ISS7), weekly Hive Severity Score (HSS7), weekly Urticaria Activity Score (UAS7), Dermatology Life Quality Index (DLQI), and adverse events (AE). A 300 mg dose of omalizumab was the optimum dose to treat CIU, followed by the 150 mg dose. Furthermore, 600 mg of omalizumab only showed a significant difference from the placebo in HSS7. No significant statistical difference was observed in AE. Meta-regression analysis revealed that time, as a covariate, was statistically significant in the comparison of omalizumab 150 mg with placebo.

CONCLUSION

300 mg of omalizumab was the optimum dosage to treat CIU patients, with a 150 mg dose also exhibiting good efficacy. Further studies are required to explore the efficacy and safety of different doses of omalizumab in the treatment of CIU patients.

Type 3 autoimmune polyglandular syndrome (APS-3) or type 3 multiple autoimmune syndrome (MAS-3): an expanding galaxy

BACKGROUND

The number of recognised distinct autoimmune diseases (AIDs) has progressively increased over the years with more than 100 being reported today. The natural history of AIDs is characterized by progression from latent and subclinical to clinical stages and is associated with the presence of the specific circulating autoantibodies. Once presented, AIDs are generally chronic conditions. AIDs have the tendency to cluster and co-occur in a single patient. Autoimmune thyroid diseases (AITD) are the most prevalent of AIDs in the world population, and about one-third of the AITD patients also present with a non-thyroid AID during their life-span. Furthermore, patient with non-thyroid AIDs often presents with a form of AITD as a concurrent condition. Many of the clusters of AIDs are well characterized as distinctive syndromes, while some are infrequent and only described in case reports.

PURPOSE

In this review, we describe the wide spectrum of the combinations and the intricate relationships between AITD and the other AIDs, excluding Addison's disease. These combinations are collectively termed type 3 Autoimmune Polyglandular Syndrome (APS-3), also called type 3 Multiple Autoimmune Syndrome (MAS-3), and represent the most frequent APS in the world populations.

CONCLUSIONS

Numerous associations of AITD with various AIDs could be viewed as if the other AIDs were gravitating like satellites around AITD located in the center of a progressively expanding galaxy of autoimmunity.

Atypical Presentation of Sjogren’s Syndrome With Chronic Urticaria: A Case Report and Literature Review

We present a case of a 26-year-old female with a history of 6-8 months of recurrent severe allergic reactions with anaphylaxis who presented with bilateral shoulder arthralgia and inflammatory arthritis of the right hand involving metacarpophalangeal joints (MCP). Physical examination was significant for tenderness in shoulder and knee joints, swelling, warmth, and tenderness involving MCP joints of the right hand. Schirmer's test was positive in both eyes. Further workup revealed positive antinuclear antibody (ANA) (speckled pattern), anti-Ro antibodies, and elevated inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The patient was diagnosed with Sjogren's syndrome and was started on methotrexate once weekly and hydroxychloroquine with significant improvement in the symptoms. Also, we review the literature describing the association between chronic urticaria and rheumatological diseases. This case highlights the varied presentation of rheumatological diseases.

S3 Guideline Urticaria. Part 1: Classification and diagnosis of urticaria - German-language adaptation of the international S3 Guideline

The lifetime prevalence of urticaria, a severe allergic disease, is almost 20%. It not only limits the quality of life of those affected, but also their general performance at work and in their daily activities. This publication is the first section of the Urticaria Guideline. It covers the classification and diagnosis of urticaria, taking into account the major advances in research into its causes, triggering factors and pathomechanisms. It also addresses strategies for the efficient diagnosis of the different subtypes of urticaria. This is crucial for individual, patient-oriented treatment, which is covered in the second part of the guideline, published separately. This German-language guideline was developed according to the criteria of the AWMF on the basis of the international English-language S3 guideline with special consideration of health system characteristics in the German-speaking countries. This first part of the guideline describes the classification of urticaria, distinguishing spontaneously occurring wheals (hives) and angioedema from forms of urticaria with inducible symptoms. Urticaria is defined as sudden onset of wheals, angioedema, or both, but is to be distinguished from conditions in which wheals occur as a short-term symptom, such as anaphylaxis. The diagnosis is based on (a limited number of) laboratory tests, but especially on medical history. In addition, validated instruments are available to measure the severity, activity and course of the disease.

Metformin and the Risk of Chronic Urticaria in Patients with Type 2 Diabetes

We conducted this study to determine the effect of metformin use on the risk of new-onset chronic urticaria in patients with type 2 diabetes (T2D). In total, 24,987 pairs of metformin users and nonusers were identified with propensity score-matching from Taiwan's National Health Insurance Research Database from 1 January 2000, to 31 December 2017. Multivariable Cox proportional hazards models were used to compare the risks of chronic urticaria development, severe chronic urticaria, and hospitalization for chronic urticaria between metformin users and nonusers. Compared with metformin nonuse, the aHRs (95% CI) for metformin use in chronic urticaria development, severe chronic urticaria, and hospitalization for chronic urticaria were 1.56 (1.39-1.74), 0.40 (0.12-1.30), and 1.45 (0.82-2.56), respectively. The cumulative incidence of chronic urticaria development was significantly higher in metformin users than in nonusers (p < 0.0001). A longer average cumulative duration of metformin use was associated with higher risks of new-onset and hospitalization for chronic urticaria than metformin nonuse. This nationwide cohort study showed that metformin use was associated with a significantly higher risk of chronic urticaria development. A longer average cumulative duration of metformin use was associated with a higher risk of outcomes. More prospective studies are needed to verify our results.

Immunological signature of chronic spontaneous urticaria (Review)

Chronic urticaria (CU) is a condition characterized by intensely pruritic, edematous, erythematous papules lasting for more than 6 weeks. Over half of the cases have concomitant swelling of deeper tissues, known as angioedema. The socio-economic burden of the disease is significant. Unfortunately, patients with severe CU, refractory to conventional treatment, have limited and expensive therapeutic options. The pathogenesis of CU is not yet completely understood. Therefore, elucidating the pathophysiological mechanisms involved would potentially identify new therapeutic targets. It has been accepted in recent years that mast cells and their activation, followed by excessive degranulation represent the key pathophysiological events in chronic spontaneous urticaria (CSU). The triggering events and the complexity of the effector mechanisms, however, remain intensely debated topics with conflicting studies. One pathogenetic mechanism incriminated in chronic spontaneous urticaria is the response mediated by the high-affinity receptor for IgE (FcεRI) expressed on mast cells. Increasing recognition of chronic spontaneous urticaria as an autoimmune disease linked to the cytokine-chemokine network imbalance resulting from alteration of innate immune response is another pathogenetic explanation. It is likely that these different pathological mechanisms are more interconnected, both acting synergistically, rather than separately, to produce the clinical expression of CU. The discovery and understanding of pathogenic mechanisms represent the premise for the development of safe and effective immunomodulators and targeted biological treatment for severe, refractory CU.

The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria

This update and revision of the international guideline for urticaria was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA²LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), the European Dermatology Forum (EDF; EuroGuiDerm), and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology with the participation of 64 delegates of 50 national and international societies and from 31 countries. The consensus conference was held on 3 December 2020. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease that presents with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous or inducible urticaria is disabling, impairs quality of life, and affects performance at work and school. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Effects of Serum Vitamin D Levels and Vitamin D Supplementation on Urticaria: A Systematic Review and Meta-Analysis

(1) Backgrounds: Several studies have shown that the level of 25-hydroxyvitamin D (25(OH)D) could affect urticaria. The association of Vitamin D (VitD) with urticaria has not been well established. (2) Methods: The up-to-date meta-analysis was performed to synthesize the new findings. We performed a systematic search in PubMed, EMBASE, Web of Science, and Cochrane Database. We included the observational studies with the comparisons of 25(OH)D between urticarial populations and controls and clinical studies with the clinical severity of urticaria records. (3) Results: A meta-analysis of seventeen studies of urticaria group vs. controls revealed a mean difference of −9.35 ng/mL (95% CI −12.27 to −6.44). There was also an association of urticaria with VitD deficiency. In the subgroup analysis of age and disease type, significant effects of 25(OH)D were found among adult and chronic urticarial populations. Six VitD supplementation trials showed a significant reduction in clinical urticarial score on intervention with VitD with the standard mean difference of −3.63 and −1.54 among randomized control studies and repeated measure trials, respectively. (4) Conclusions: The urticarial population, especially the adult chronic urticarial patients, may be associated with a high risk for lower serum 25(OH)D. VitD supplementations could result in a reduction of urticarial clinical symptoms.

Retrospective Study of Clinico-Aetiological Factors of Chronic Urticaria Among Children Attending a Tertiary Care Paediatric Centre in Eastern Province of Sri Lanka

Introduction: Chronic urticaria is one of the growing problems worldwide and the prevalence is increasing. Around 2% of children have been shown to be affected with chronic urticaria.

Objectives: To evaluate demographic, clinical and aetiological factors related to chronic urticaria in children and to assess investigations and treatment.

Method: A retrospective study was done from January 2018 to December 2019 on 40 children aged 1-14 years who presented with chronic urticaria to the paediatric clinic, University Paediatric Unit, Batticaloa Teaching Hospital. Detailed information including demographic factors, duration of illness, main reasons for clinic attendance, treatment received from the out-patient department, caregiver reported allergens, family history of atopy and complications such as secondary bacterial infection were retrieved from clinic-based records. Information regarding laboratory investigations was also retrieved. Data were analysed using SPSS version 19.0 (IBM Corp., Armonk, NY).

Results: Forty children were available for the analysis. The most common age category was four to eight years and 25 (62.5%) were females. Seventy percent of children had urticaria for one or more years. Thirty-six (90%) children had a family history of allergies such as allergic rhinitis, eczema, food allergies, medication allergies and bronchial asthma. The common precipitating factors were foods in 12 (30%) cases and insect bites in 10 (25%) cases. The main reasons for seeking medical advice were severe itchiness in 40 (100%) and sleep disturbances in 24 (60%). Only a limited number of investigations had been performed and they included white cell counts (differential eosinophil counts) and thyroid functions. Almost all had normal thyroid functions whilst 45% had eosinophilia.

Conclusions: The majority of children with chronic urticaria had symptoms for over the one-year duration and reported a family history of allergy. All children reported severe itchiness as the main symptom and sleep was disturbed in the majority. The common precipitating factors were food and insect bites.

Approach to Children with Hives

Urticaria (or hives) is a pruritic and erythematous skin rash. Angioedema commonly occurs with urticaria. The term "chronic urticaria" is used when hives are present for more than 6 weeks. Acute urticaria is common in children, whereas chronic urticaria is rare. Causes of urticaria can be identified in many cases of acute urticaria with a thorough medical history. Laboratory evaluation may be needed to confirm the etiology of acute urticaria. Chronic urticaria is often idiopathic. Clinicians should avoid universal allergy testing for food allergens or aeroallergens in chronic urticaria as it usually does not help in identifying the cause, can lead to false-positive results, and unnecessary avoidance of allergens or foods. Urticarial vasculitis should be considered for lesions that are painful, present for more than 48 hours, leave scars/hyperpigmentation, or present with systemic symptoms such as fever, weight loss, and arthritis. Skin biopsy should be considered for suspected urticarial vasculitis. [Pediatr Ann. 2021(5):e191-e197.].

Systematic evaluation of nine monogenic autoinflammatory diseases reveals common and disease-specific correlations with allergy-associated features

BACKGROUND

Monogenic autoinflammatory diseases (AID) are caused by mutations in innate immune genes. The effects of these mutations on allergic inflammation are unknown.

OBJECTIVES

We investigated allergic, immunological and clinical phenotypes in FMF (familial Mediterranean fever), CAPS (cryopyrin-associated periodic syndrome), TRAPS (tumour necrosis factor receptor-associated periodic syndrome), HIDS (hyper-IgD syndrome), PAPA (pyogenic arthritis, pyoderma gangrenosum and acne), DADA2 (deficiency of adenosine deaminase 2), HA20 (haploinsufficiency of A20), CANDLE (chronic atypical neutrophilic dermatosis, lipodystrophy, elevated temperature) and SAVI (STING-associated vasculopathy of infancy).

METHODS

In this cross-sectional study, clinical data were assessed in 425 patients with AID using questionnaires and chart reviews. Comparator data were obtained from public databases. Peripheral blood mononuclear cells obtained from 55 patients were stimulated and CD4⁺ cytokine production assessed.

RESULTS

Clinical laboratory features of Type 2 immunity were elevated in CAPS but reduced in most AID, particularly DADA2. Physician-diagnosed allergic diseases were prevalent in multiple AID, including CAPS and DADA2. T helper 2 (Th2) cells were expanded in CAPS, TRAPS and HIDS; Th9 cells were expanded in HA20.

CONCLUSIONS

CAPS is characterised by an enhanced Type 2 signature, whereas FMF and CANDLE are associated with reduced Type 2 responses. DADA2 is associated with reduced Type 2 responses but a high rate of physician-diagnosed allergy. Therefore, NLRP3-driven autoinflammation may promote Type 2 immunity, whereas AID like DADA2 may manifest clinical phenotypes that masquerade as allergic disorders. Further investigations are needed to determine the contribution of autoinflammation to allergic clinical and immunological phenotypes, to improve the treatment of patients with AID.

Blastocystis, urticaria, and skin disorders: review of the current evidences

Blastocystis is one of the most common intestinal protozoan parasites worldwide, which is linked to cutaneous lesions and urticaria. In a setting of systematic review, the data on the association of Blastocystis infection with cutaneous lesions were searched in order to summarize the main clinical symptoms, diagnostic methods, treatment, and outcome of the patients. The search identified 28 eligible articles, including 12 cross-sectional studies and 16 case reports/case series (including 23 cases). A diverse spectrum of skin symptoms, mainly urticaria, rash, and itching, was reported from the studies. Of the 23 infected cases with the skin symptoms, gastrointestinal symptoms were reported from the 16 cases, whereas 7 cases with urticaria had asymptomatic infection. The most frequent subtypes were ST1, ST2, and ST3, respectively. Metronidazole, paromomycin, and tinidazole were the most prescribed drugs in patients with single Blastocystis infection. Notably, urticaria and other cutaneous symptoms of all treated patients were resolved after treatment. In conclusion, this study indicates that Blastocystis infection can be a neglected cause of urticaria and skin disorders. Since the treatment of Blastocystis infection is simple, screening and treatment of this infection should be considered in patients with urticaria and other skin disorders.

Systematic review and meta-analysis: Effect of Helicobacter pylori eradication on chronic spontaneous urticaria

BACKGROUND

Helicobacter pylori (HP) infection is considered to play a role in the pathogenesis of chronic spontaneous urticaria (CSU). However, the efficacy of HP eradication therapy on CSU symptom improvement has not been well established. This meta-analysis was conducted to estimate the association between HP infection and CSU and to evaluate whether HP eradication therapy benefits patients with CSU.

MATERIAL AND METHODS

In October 2018, we searched databases for studies investigating the efficacy of HP eradication therapy for patients with CSU. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using random effects models.

RESULTS

The meta-analysis included 22 studies with a total of 1385 patients with CSU. When comparing the spontaneous remission of urticarial symptom in patients with HP-positive to HP-negative patients, HP-negative patients showed significantly higher spontaneous remission of urticarial symptoms. (risk ratio 0.39; 95% confidence interval: 0.19-0.81). Among HP-positive CSU patients, remission of CSU was more likely shown in HP eradication therapy group compared to untreated group, aside from achieving HP elimination (risk ratio 2.10; 95% confidence interval: 1.20-3.68). However, there was no significant difference in the remission of CSU whether antibiotic therapy was successful in eradication of HP or not (risk ratio 1.00; 95% confidence interval: 0.65-1.54).

CONCLUSIONS

The results of this meta-analysis show that HP might be associated with the occurrence and persistence of CSU. The effectiveness of HP eradication therapy in suppressing CSU symptoms was significant. Interestingly, we found that resolution of CSU was not associated with successful eradication of HP infection. CSU Patients who were undergone antibiotic therapy for HP eradication showed significant higher CSU remission with or without HP eradication. Further studies are recommended to evaluate the mechanisms associated with relation of HP with CSU.

Benefits and Harms of Omalizumab Treatment in Adolescent and Adult Patients With Chronic Idiopathic (Spontaneous) Urticaria: A Meta-analysis of "Real-world" Evidence

Importance

Omalizumab is indicated for the management of chronic idiopathic urticaria (CIU) (also known as chronic spontaneous urticaria) in adolescents and adults with persistent hives not controlled with antihistamines. The effectiveness of omalizumab in the real-world management of CIU is largely unknown.

Objective

To quantitatively synthesize what is known about the benefits and harms of omalizumab in the real-world clinical management of CIU regarding urticaria activity, treatment response, and adverse events.

Data Sources

Published observational studies (January 1, 2006, to January 1, 2018) and scientific abstracts on the effectiveness of omalizumab in CIU were identified using PubMed, Embase, Web of Science, and Cochrane search engines; references were searched to identify additional studies.

Study Selection

Included studies were observational in design and included at least 1 outcome in common with other studies and at a concurrent time point of exposure to omalizumab. A total of 67 articles (35.2% of those screened) were included in the analysis.

Data Extraction and Synthesis

PRISMA and MOOSE guidelines were followed; independent selection and data extraction were completed by 2 observers. Random-effects meta-analyses were performed.

Main Outcomes and Measures

Main outcomes were change in weekly Urticaria Activity Score (UAS7; range, 0-42), change in Urticaria Activity Score (UAS; range 0-6) (higher score indicating worse outcome in both scales), complete and partial response rates (percentages), and adverse event rate (percentage).

Results

Omalizumab therapy was associated with an improvement in UAS7 scores (-25.6 points, 95% CI, -28.2 to -23.0; P < .001; 15 studies, 294 patients), an improvement in UAS scores (-4.7 points, 95% CI, -5.0 to -4.4, P < .001; 10 studies, 1158 patients), an average complete response rate of 72.2% (95% CI, 66.1%-78.3%; P < .001; 45 studies, 1158 patients) with an additional average partial response rate of 17.8% (95% CI, 11.7%-23.9%; P < .001; 37 studies, 908 patients), and an average adverse event rate of 4.0% (95% CI, 1.0%-7.0%; P < .001; any level of severity, 47 studies, 1314 patients).

Conclusions and Relevance

Benefits and safety of omalizumab in the real-world treatment of CIU meet or exceed results gleaned from clinical trials. These real-world data on omalizumab in CIU may help inform both clinical treatment expectations and policy decision making.

Omalizumab for chronic spontaneous urticaria in "complex" patients: data from real-life clinical practice

Introduction

Omalizumab is a recombinant humanized anti-IgE monoclonal antibody, approved for patients affected by chronic spontaneous urticaria resistant to antihistamines. Although the clinical benefit of omalizumab has been established in several clinical trials, there are very little data about long-term treatment with this drug and real-life reports regarding its use in patients affected by comorbidities other than urticaria are lacking.

Objectives

To assess omalizumab efficacy and safety in a heterogeneous population of patients affected by chronic spontaneous urticaria and several comorbidities in a real-world setting.

Materials and methods

Patients affected by chronic spontaneous urticaria with weekly urticaria activity score >16 resistant to antihistamines were treated with omalizumab 300 mg injection as add-on to H1-antihistamines administered every 4 weeks for 6 months. Clinical assessment of weekly urticaria activity score, dermatology life quality index and blood tests were performed at baseline, 12, 24 and 52 weeks of treatment. Response was assessed based on reduction weekly urticaria activity score.

Results

Thirty-two patients (22F; 10M) with a mean age of 52.4 years (range 27-72) affected by chronic spontaneous urticaria were enrolled. Comorbidities affecting our study population were divided into 6 categories: cardio-metabolic (77%), oncologic (19%), infectious (16%), allergic (45%) immunologic (41%) and others (18%). Omalizumab determined a satisfactory reduction of symptoms of chronic spontaneous urticaria and an amelioration of quality of life within our population. No relevant alterations regarding patients' underlying conditions were encountered. This is the first study regarding the use of omalizumab for chronic spontaneous urticaria in a population of adult patients affected by several comorbidities, eg, cardio-metabolic, oncologic, infectious, allergic, immunologic and psychiatric diseases. Real-life data represent a valuable source of information about a drug's safety and efficacy profile, especially in patients affected by different comorbidities that are widely diffused in Western countries.

Brain histamine H1 receptor occupancy after oral administration of desloratadine and loratadine

Some histamine H1 receptor (H1R) antagonists induce adverse sedative reactions caused by blockade of histamine transmission in the brain. Desloratadine is a second-generation antihistamine for treatment of allergic disorders. Its binding to brain H1Rs, which is the basis of sedative property of antihistamines, has not been examined previously in the human brain by positron emission tomography (PET). We examined brain H1R binding potential ratio (BPR), H1R occupancy (H1RO), and subjective sleepiness after oral desloratadine administration in comparison to loratadine. Eight healthy male volunteers underwent PET imaging with [11C]-doxepin, a PET tracer for H1Rs, after a single oral administration of desloratadine (5 mg), loratadine (10 mg), or placebo in a double-blind crossover study. BPR and H1RO in the cerebral cortex were calculated, and plasma concentrations of loratadine and desloratadine were measured. Subjective sleepiness was quantified by the Line Analogue Rating Scale (LARS) and the Stanford Sleepiness Scale (SSS). BPR was significantly lower after loratadine administration than after placebo (0.504 ± 0.074 vs 0.584 ± 0.059 [mean ± SD], P < 0.05), but BPR after desloratadine administration was not significantly different from BPR after placebo (0.546 ± 0.084 vs 0.584 ± 0.059, P = 0.250). The plasma concentration of loratadine was negatively correlated with BPR in subjects receiving loratadine, but that of desloratadine was not correlated with BPR. Brain H1ROs after desloratadine and loratadine administration were 6.47 ± 10.5% and 13.8 ± 7.00%, respectively (P = 0.103). Subjective sleepiness did not significantly differ among subjects receiving the two antihistamines and placebo. At therapeutic doses, desloratadine did not bind significantly to brain H1Rs and did not induce any significant sedation.

Epidemiology of urticaria including physical urticaria and angioedema in Korea

BACKGROUND/AIMS

Despite the high burden and frequency of urticaria, its epidemiology is not well known. We investigated the epidemiology of various type of urticaria in Korea and changes in its annual prevalence over 5 years.

METHODS

We used data from the 2010 to 2014 Health Insurance Review and Assessment database, which covers the claims of 97.0% of the South Korean population. Patients aged > 10 years old were included in this study. The presence of urticaria was identified on physician-certified diagnoses using the International Classification of Diseases 10th Revision (ICD-10) codes that include various type of urticaria (L500-L509) and angioedema (T783). Epidemiology of all type of urticaria, physical urticaria and angioedema were investigated.

RESULTS

The prevalence of all-type urticaria over the 5 years was 4.5% with a peak in individuals, especially females, aged 30 to 59 years. The age-specific prevalence of all-type urticaria increased with age from the 10- to 19-year age group to the 70- to 79-year age group. The prevalence of dermographism, cholinergic urticaria, and angioedema were 0.12%, 0.025%, and 0.027%, respectively. Cholinergic urticaria was most prevalent in those aged 10 to 29 years with male predominance. The annual prevalence of all-type urticaria, dermographism, and angioedema increased over the 5 years.

CONCLUSION

The prevalence of urticaria has increased annually in Korea. Cholinergic urticaria showed unique distribution in its age and gender, and angioedema showed remarkable increases in annual prevalence, although the prevalence estimation is still exploratory and diagnosis of urticaria based on ICD-10 codes need to be validated.

Higher Levels of Depression and Anxiety in Patients with Chronic Urticaria

Background

Chronic urticaria (CU) is a common disease, characterized by the development of wheals, angioedema, or both. CU reduces quality of life and can also cause emotional distress. Studies addressing depression and anxiety in such patients are rare in the literature. The aim of this study was to determine the relationship between urticaria symptoms and depression and anxiety in patients with CU.

Material/Methods

The Hospital Anxiety-Depression Scale (HADS) was used to evaluate depression and anxiety in patients with CU. We included 50 patients with CU and a control group of 60 healthy volunteers. Urticaria activity score, medications, age, sex, comorbidities, occupation, and income of patients were recorded. Depression and anxiety scores were evaluated between the patient and the healthy groups.

Results

The HADS questionnaire showed that 24 (48%) subjects in the patient group had depressive symptoms and 24 (48%) had anxiety, and both of these conditions were significantly more frequent than in controls (p=0.002 and p=0.001). The mean anxiety and depression scores ±SD were 10.82±4.29 and 7.74±4.49 in the patient group and 6.42±3.02 and 4.85±3.26, in the control group respectively (p=0.001). The mean score of the UAS ±SD was 23.14±13.40 and a significant positive correlation between UAS and the anxiety and depression scores was observed (r=0.400; p=0.004 and r=0.373; p=0.004, respectively).

Conclusions

Our data demonstrated that depression and anxiety symptoms are more common in patients with CU than in the control group. Therefore, we should pay attention to the potential of mental comorbidities while managing patients with CU.

Impact of chronic urticaria on systemic lupus erythematosus: A nationwide population-based study in Taiwan

Chronic urticaria (CU) may be closely pathogenically related to systemic lupus erythematosus (SLE). This study aims to investigate the association between CU and SLE patients in Taiwan. A nationwide population-based cohort study from 1997 to 2013 was conducted. Investigated subjects were selected from the Taiwan National Health Insurance Research Database using the International Classification of Disease, Ninth Revision code. Participants consisted of 13 845 subjects newly diagnosed with CU from 2003 to 2013. We estimated the incidence risk of SLE among patients with CU by time-to-event analysis. Patients with CU were more likely to be female, and had a significant difference in urbanization and length of hospital stays (P < 0.0001). The incidence rates of SLE for the CU and control groups were 3.55 and 1.68, respectively. The crude hazard ratio of SLE among subjects with CU was 2.113 compared with the non-urticarial control group. After adjusting the demographic, length of hospital stay and comorbidity, the adjusted hazard ratio (aHR) of SLE was still significantly higher in the CU group (aHR = 2.113) compared with the control group. The use of non-steroidal anti-inflammatory drugs or corticosteroids may decrease the risk of SLE in patients with CU (P = 0.0216 and 0.0120, respectively). In conclusion, CU is associated with a higher risk of incidental SLE in this population-based, nationwide, cohort study. Inflammation and immune dysregulation are considered two potential mechanisms. Clinically, patients with urticaria should be carefully evaluated for risk of future SLE.

The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Critical appraisal of the unmet needs in the treatment of chronic spontaneous urticaria with omalizumab: an Italian perspective

PURPOSE OF REVIEW

The humanized anti-IgE antibody omalizumab has been available for patients with chronic spontaneous urticaria (CSU) in Italy since 2015. This review summarizes the unresolved issues and unmet therapeutic needs associated with omalizumab and discusses practical recommendations for its use in the management of CSU.

RECENT FINDINGS

Although modern second-generation H1-antihistamines are the standard of care for patients with CSU, adjunctive treatments (including omalizumab) may be required for effective control of symptoms in many patients. Evidence from clinical trials and experience from daily clinical practice suggest that the use of omalizumab in patients with CSU who have inadequate response to H1-antihistamines remains challenging.

SUMMARY

Based on current international guidelines, omalizumab labelling information and our experience in clinical practice, we provide treatment recommendations regarding the use of omalizumab in patients with CSU. These include: optimal treatment duration, the use of concomitant antihistamine therapy, the definition and management of disease relapse after treatment, and the management of patients with late or no response to treatment.

Associations of chronic urticaria with atopic and autoimmune comorbidities: a nationwide population-based study

BACKGROUND

Most cases of chronic urticaria (CU) are idiopathic. Circumstantial evidence suggests that some CU cases have an autoimmune pathogenesis. Previous research indicates that a substantial percentage of patients with CU have an atopic background.

OBJECTIVES

This study aims to examine the association between CU, and atopic and autoimmune diseases.

METHODS

This population-based retrospective cohort study identified 9,332 patients with CU and 37,328 controls matched for age, sex, and number of dermatological clinic visits from the Taiwan National Health Insurance Research Database for 2004-2009. Using multiple logistic regression, we estimated odds ratios (OR) and 95% confidence intervals (CI) for associations of CU with atopic and autoimmune diseases.

RESULTS

CU was most strongly associated with Kawasaki disease (modified OR, 2.76; 95% CI 1.15-6.63), followed by Henoch-Schönlein purpura (HSP), atopic dermatitis (AD), systemic lupus erythematosus (SLE), allergic rhinitis (AR), autoimmune thyroid diseases, Sjögren syndrome, inflammatory bowel disease (IBD), and asthma, which had the lowest adjusted OR (1.11; 95% CI 1.01-1.22) among comorbidities significantly associated with CU. The associations varied in relation to age, group, and sex. Among women, CU was significantly associated with AD, AR, autoimmune thyroid diseases, SLE, vitiligo, and HSP. Among men, CU was significantly associated with AD, AR, autoimmune thyroid diseases, Kawasaki disease, and IBD.

CONCLUSION

CU is associated with atopic/autoimmune diseases. Increased awareness of atopic and autoimmune comorbidities may be warranted for patients with CU.

Management of Pediatric Urticaria with Review of the Literature on Chronic Spontaneous Urticaria in Children

There are substantial knowledge gaps related to diagnosis and management of pediatric cases of chronic urticaria, and in particular chronic spontaneous urticaria (CSU). In this article we aimed to review the diagnosis and management of chronic urticaria in children and CSU in particular. We conducted a systematic review of articles published in English and French on pediatric CSU management in the last 10 years. We included experimental studies (eg, randomized controlled trials), other experimental designs (eg, nonrandomized methods of assignment, controlled before-after studies, and interrupted time series), and observational studies (eg, prospective or retrospective cohort studies, cross-sectional studies, case-control studies, and case reports). Our findings highlight the efficacy of second-generation antihistamines for the treatment of CSU in children and supports the use of omalizumab for more severe cases. However, our study also reveals severe knowledge gaps related to the best management strategy in children with more severe/refractory cases of CSU. Future studies are required to establish the beneficial effect of high doses of second-generation antihistamines as well as the effectiveness and safety of omalizumab and other biologics in young children.

Whole Exome Sequencing and Molecular Modeling of a Missense Variant in TNFAIP3 That Segregates with Disease in a Family with Chronic Urticaria and Angioedema

Chronic urticaria is a common condition characterized by recurrent hives lasting several weeks or months and is usually idiopathic. Approximately half of the individuals with chronic urticaria will present with episodes of angioedema that can be severe and debilitating. In this report, we describe a 47-year-old Hispanic male who presented initially for an evaluation of chronic hives following hospitalization due to hive-induced anaphylaxis. The individual had a history significant for urticaria and angioedema beginning in his early 30s. Interestingly, both the individual's 41-year-old sister and 12-year-old daughter were also affected with chronic urticaria and severe angioedema. Whole exome sequencing of the proband and several family members revealed a heterozygous variant of uncertain significance in exon 2 of TNFAIP3, denoted as c.65G>A (p.R22Q), in all affected members. Variants in TNFAIP3 have been associated with multiple autoimmune diseases, susceptibility to allergy and asthma, and periodic fever syndromes, suggesting that this variant could potentially play a role in disease.

Consensus Statement for the Diagnosis and Treatment of Urticaria: A 2017 Update

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab.

Evaluating Comorbidities, Natural History, and Predictors of Early Resolution in a Cohort of Children With Chronic Urticaria

Importance

Chronic urticaria (CU) affects 0.1% to 0.3% of children. Most cases have no identifiable trigger and are classified as chronic spontaneous urticaria (CSU). At least half of patients with CSU may have an autoimmune etiology that can be determined in vitro using the basophil activation test (BAT). While 30% to 55% of CU cases resolve spontaneously within 5 years in adults, the natural history and predictors of resolution in children are not known.

Objective

To assess the comorbidities, natural history of CU, and its subtypes in children and identify predictors of resolution.

Design, Setting, and Participants

We followed a pediatric cohort with chronic urticaria that presented with hives lasting at least 6 weeks between 2013 and 2015 at a single tertiary care referral center.

Exposures

Data were collected on disease activity, comorbidities, physical triggers, BAT results, complete blood cell count, C-reactive protein levels, thyroid-stimulating hormone levels, and thyroid peroxidase antibodies.

Main Outcomes and Measures

We assessed the rate of resolution (defined as absence of hives for at least 1 year with no treatment) and the association with clinical and laboratory markers.

Results

The cohort comprised 139 children younger than 18 years old. Thirty-one patients (20%) had inducible urticaria, most commonly cold induced. Six children had autoimmune comorbidity, such as thyroiditis and type 1 diabetes. Autoimmune disorders (24 patients [17%]) and CU (17 patients [12%]) were common in family members. Positive BAT results (CD63 levels > 1.8%) were found in 58% of patients. Patients with positive BAT results (CD63 level >1.8%) were twice as likely to resolve after 1 year compared with negative BAT results (hazard ratio [HR], 2.33; 95% CI, 1.08-5.05). In contrast, presence of basophils decreased the likelihood of resolution (HR, 0.40; 95% CI, 0.20-0.99). No correlation with age was found. Chronic urticaria resolved in 43 patients, with a rate of resolution of 10.3% per year. Levels of CD63 higher than 1.8% and absence of basophils were associated with earlier disease resolution.

Conclusions and Relevance

Resolution rate in children with CU is low. The presence of certain biomarkers (positive BAT result and basophil count) may help to predict the likelihood of resolution.

Omalizumab substantially improves dermatology-related quality of life in patients with chronic spontaneous urticaria

Background

Chronic spontaneous/idiopathic urticaria (CSU/CIU) has substantial detrimental effects on health‐related quality of life (HRQoL) with an effect comparable to or worse than many other skin diseases.

Objective

To assess the effect of omalizumab on CSU patients' HRQoL, measured by the Dermatology Life Quality Index (DLQI) in three phase III studies ASTERIA I, ASTERIA II and GLACIAL.

Methods

A post hoc analysis examined changes in DLQI scores, distribution of patients across DLQI bands and the proportion reaching minimal clinically important difference (MCID) following omalizumab vs. placebo.

Results

Omalizumab 300 mg significantly improved total DLQI scores vs. placebo, with a mean decrease from baseline to week 12 of −10.3 vs. −6.1 (P < 0.0001) in ASTERIA I, −10.2 vs. −6.1 (P = 0.0004) in ASTERIA II and −9.7 vs. −5.1 (P < 0.0001) in GLACIAL. A significant shift from high disease impact on life at baseline towards less impact at week 12 was seen with omalizumab 300 mg vs. placebo (P < 0.001; all studies). The proportion of patients where change in mean total DLQI score from baseline to week 12 reached an MCID of ≥4 was 74.1%, 76.0% and 77.2% in ASTERIA I, II and GLACIAL, respectively (P < 0.01; all studies).

Limitations

Maximum duration of omalizumab treatment was 24 weeks.

Conclusion

This additional analysis assessed the impact of CSU and benefit of treatment with omalizumab by exploring different facets of DLQI data by treatment arm at multiple assessment points. The original aspects of analysis included applying the concept of the recently validated score for the MCID of the DLQI, changes in DLQI domain scores and in the distribution of subjects based on validated total DLQI score bands. It showed consistently that omalizumab provides significant and clinically relevant improvements in many aspects of HRQoL that are important to patients with CSU. These results contribute to a better understanding of the impact of CSU and its treatment on patients and can support clinical decision‐making in routine medical practice.

The Advantage of Cyclosporine A and Methotrexate Rotational Therapy in Long-Term Systemic Treatment for Chronic Plaque Psoriasis in a Real World Practice

Background

Psoriasis is a chronic inflammatory disease. In the treatment of psoriasis, cyclosporine is commonly prescribed systemic agents. However, long-term use of cyclosporine is not recommended because of side effects such as nephrotoxicity or hypertension.

Objective

To ascertain the improved safety of rotational therapy using cyclosporine and methotrexate, we investigated the frequency of abnormal results in laboratory test after long term rotational therapy using cyclosporine and methotrexate.

Methods

From January 2009 to June 2014, patients who were treated with cyclosporine or methotrexate were enrolled. The clinical data and usage of medications were reviewed. Laboratory tests were conducted before starting the treatment and regularly follow-up. The occurrences of any laboratory abnormalities during the treatments were investigated.

Results

A total of 21 psoriatic patients were enrolled. The mean of medication period and cumulative dose of cyclosporine and methotrexate were 497.81±512.06 days and 115.68±184.34 g in cyclosporine and 264.19±264.71 days and 448.71±448.63 mg in methotrexate. Laboratory abnormalities were found in total two patients after rotational therapy: two patients (9.5%) in aspartate aminotransferase/alanine aminotransferase and one patient (4.8%) in uric acid. No laboratory abnormalities were found in renal function test.

Conclusion

We found that the rotational approaches using cyclosporine and methotrexate reduced the possibility of the development of nephrotoxicity. In addition to other advantage such as quick switching from one agent to another, the rotational therapy using cyclosporine and methotrexate can minimize the adverse events during the systemic treatment of chronic plaque psoriasis.

Prevalence and Risk Factors of Urticaria With a Focus on Chronic Urticaria in Children

Purpose

Limited data is available on the prevalence and risk factors of acute and chronic urticaria in children. Our purpose was to determine the prevalence and identify the risk factors of acute and chronic urticaria in Korean children.

Methods

This population-based study examined 4,076 children (age 4 to 13 years) who were enrolled in the 2015 prospective Seongnam Atopy Project (SAP 2015) in Korea. The parents completed an urticaria questionnaire that included questions regarding the duration, severity, and triggering factors of urticaria. Blood sampling (n=464) was performed to measure vitamin D, total eosinophil count (TEC), and total IgE levels, and skin prick tests (n=503) were done.

Results

The prevalences of the life-time, acute, and chronic urticaria were 22.5%, 13.9%, and 1.8% (chronic continuous urticaria, 0.7%; and chronic recurrent urticaria, 1.1%), respectively. Acute urticaria was significantly associated with allergic diseases and parental history of allergy (P<0.001), but chronic urticaria was not associated with these clinical factors. There was no significant difference in the 25-hydroxyvitamin D level between subjects with chronic urticaria and controls (P=0.124). Chronic continuous urticaria was associated with living in a new residence (aOR=2.38, 95% CI=1.02-5.54, P=0.044) and belonging to a family with a high income (aOR=4.24, 95% CI=1.24-14.56, P=0.022).

Conclusions

A total of 1.8% of children were found to have chronic urticaria. Living in a new residence and belonging to a family with a high income increased the risk of chronic continuous urticaria.

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.

FLG single nucleotide polymorphisms in chronic idiopathic urticaria

BACKGROUND

Filaggrin (FLG), which is formed from profilaggrin protein during epidermal terminal differentiation, is a prerequisite to squame biogenesis and thus for perfect formation of the skin barrier. Yet, the relationship between genetic polymorphisms of FLG and chronic idiopathic urticaria (CIU) has not been investigated.

METHODS

The study population consisted of 93 CIU patients and 93 healthy control subjects without a history of allergic, autoimmune or any other systemic disease. Five single nucleotide polymorphisms (SNPs) of FLG were investigated: rs2485518, rs3126065, rs2786680, rs3814300, and rs3814299.

RESULTS

For all the investigated polymorphisms, 100% of both CIU patients and control subjects exhibited one given allele and consequently one given genotype as following: A/A genotype for two SNPs, rs3126065 and rs2786680, C/C genotype for two SNPs, rs2485518 and rs3814300, and G/G genotype for one SNP rs3814299 of FLG, and hence no association was found between either allele frequencies or genotype distributions of FLG SNPs and CIU in an Iranian population.

CONCLUSIONS

The present study examined the possible relationship between SNPs of FLG and CIU for the first time, and demonstrated that none of five investigated SNPs (rs2485518, rs3126065, rs2786680, rs3814300, and rs3814299) are correlated with CIU in an Iranian population. Further investigations are required to address whether ethnicity/race impacts on relationship between SNPs of FLG and CIU.

Particularities of allergy in the Tropics

Allergic diseases are distributed worldwide and their risk factors and triggers vary according to geographical and socioeconomic conditions. Allergies are frequent in the Tropics but aspects of their prevalence, natural history, risk factors, sensitizers and triggers are not well defined and some are expected to be different from those in temperate zone countries. The aim of this review is to investigate if allergic diseases in the Tropics have particularities that deserve special attention for research and clinical practice. Such information will help to form a better understanding of the pathogenesis, diagnosis and management of allergic diseases in the Tropics. As expected, we found particularities in the Tropics that merit further study because they strongly affect the natural history of common allergic diseases; most of them related to climate conditions that favor permanent exposure to mite allergens, helminth infections and stinging insects. In addition, we detected several unmet needs in important areas which should be investigated and solved by collaborative efforts led by the emergent research groups on allergy from tropical countries.

Diagnostic and Therapeutic Iter in Chronic Urticaria Patients

We describe a diagnostic and therapeutic protocol for the management of chronic urticaria. It is derived from an extensive review of current literature, with a cost-effective evaluation of laboratory investigations and therapeutic approaches. Our protocol may not represent a cornerstone for chronic urticaria: much has in fact to be clarified on pathogenetic mechanisms and aetiological factors. Nevertheless, its application should be able, in our opinion, to identify what is useful or not in the everyday management of chronic urticaria patients.

Serum Clusterin as a Prognostic Marker of Chronic Spontaneous Urticaria

A substantial proportion of patients with chronic spontaneous urticaria (CSU) are refractory to antihistamines. However, identifying the subpopulation whose urticaria is not completely controlled by antihistamines remains difficult. The response of autologous serum skin test (ASST), a clinical test for the detection of basophil histamine-releasing activity upon autoantibodies or autoreactive stimulation, has been suggested as a potential predictor in the control of urticaria. We sought to identify proteins that were differentially expressed in the sera of patients with positive and negative ASST results and to investigate their association with urticaria control.Proteomics analysis was performed using sera from 3 CSU patients with positive ASST results compared with those showing negative ASST results. Seven upregulated and 5 downregulated proteins were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in the ASST-positive group compared with the ASST-negative group.Proteins that were differentially expressed according to the ASST results in CSU patients were classified into 6 groups: apolipoproteins, glycoproteins, modified albumin, haptoglobulin, plectin, and others. Among these, apolipoprotein J or clusterin was validated using an enzyme-linked immunosorbent assay. Clusterin levels in 69 ASST-positive patients were significantly higher than those in 69 ASST-negative patients and in 86 healthy controls (231.2 ± 44.0 vs 210.2 ± 36.1 vs 118.7 ± 71.9 μg/mL, P < 0.001). Furthermore, clusterin levels differed significantly between patients with responsive and refractory responses to antihistamine treatment within 3 months (231.0 ± 39.1 vs 205.1 ± 40.4 μg/mL, P < 0.001). ASST results and serum clusterin levels can predict 92.7% of CSU patients whose urticaria would be refractory to antihistamines. Serum clusterin can be a prognostic marker to determine the responsiveness to antihistamine treatment in patients with CSU.

Idiopathic histaminergic angioedema without wheals: a case series of 31 patients

Idiopathic histaminergic acquired angioedema (IH-AAE) is a common cause of recurrent angioedema without wheals. It is a mast cell-mediated disease thought to belong to the same clinical entity as chronic urticaria (CU). The objective of this study was to describe the clinical and epidemiological characteristics of IH-AAE patients. From 2014 to 2015, 534 patients were seen at our national reference centre for angioedema and/or urticaria. Among them, we identified 31 patients with idiopathic histaminergic acquired angioedema without wheals (IH-AAE). Thirty-one patients (15 men and 16 women) with a mean age of 50 years met the criteria for IH-AAE. The average delay in diagnosis was 6·3 years. A history of allergy was found in 12 patients (38·7%), nine suffering from allergic rhinitis. The mean duration of attacks was 28·1 h. The AE attack was located in the upper respiratory tract in 54·8% of cases (17 patients). A lingual location was found in 29% of patients. Men were more likely than women to have an upper airway involvement. No intubations or admissions to intensive care units were reported. The dosage of anti-histamines to control the symptoms was onefold the recommended dose in 51·6% of patients (16 patients), twofold in 32% (10 patients) and three-fourfold in 16·1% (five patients). IH-AAE is characterized by an important delay in diagnosis, a frequent involvement of the upper airway and a benign course during attacks. As in CU, a trial of up to fourfold dose of H1-anti-histamines may be necessary to control symptoms.

Comparative Study of Positive Versus Negative Autologous Serum Skin Test in Chronic Spontaneous Urticaria and its Treatment Outcome

Background:

Chronic urticaria (CU) is defined as urticaria persisting daily or almost daily for more than 6 weeks and affecting 0.1% of the population. Mast cell degranulation and histamine release are of central importance in the pathogenesis of CU. About 40-50% of the patients with chronic idiopathic urticaria (CIU) or chronic spontaneous urticaria (CSU) demonstrates an immediate wheal and flare response to intradermal injected autologous serum. This led to the concept of autoimmune urticaria (AIU).

Aims:

To determine the occurrence, clinical features, associated clinical conditions, comorbidities of AIU, and to compare this with CSU. This study aimed to find the frequency of autologous serum skin test (ASST)-positive patients among patients with CSU and to identify the clinical and laboratory parameters associated with positive ASST and to compare the treatment outcome.

Materials and Methods:

A prospective correlation study in 110 patients with CSU was conducted, after screening 200 CU patients attending the outpatient Department of Dermatology during from January 2012 to May 2013. Patients were subjected to ASST, complete blood counts, urine routine examination, liver function tests, renal function tests, thyroid function tests (T3, T4, and TSH), and urine analysis.

Results:

Out of 200 CU patients screened, 90 patients had excludable causes based on detailed history and skin prick test, and the remaining 110 patients were considered to have CSU. These 110 patients were further subjected to ASST, serum immunoglobulin E (IgE), and peripheral blood eosinophilia. ASST was positive in 48 patients and negative in 62 patients. Frequency of urticarial attacks and associated diseases such as abnormal thyroid function tests in both ASST-positive and ASST-negative patients did not show any statistical significance. Only attacks of angioedema in ASST-positive individuals were higher and were statistically significant. In the ASST-positive group, 31 (81.25%) patients showed improvement with first-line antihistamines, along with oral prednisolone and injection Histaglobulin and 10 (10.41%) patients did not show any improvement. Thirty-three (43.54%) patients in the ASST-negative group showed improvement while 13 (30.62%) patients did not show improvement.

Conclusion:

ASST is considered a screening test for AIU, which decreases the rate of diagnosis of idiopathic form of CU. ASST-positive patients in addition to antihistamines, were treated with short course of oral steroids and weekly Histaglobulin injections for 5 weeks followed by the 3^rd and 6^th months.

Effects of Helicobacter pylori Eradication in Chronic Spontaneous Urticaria: Results from a Retrospective Cohort Study

BACKGROUND AND OBJECTIVE

Helicobacter pylori (Hp) infection has been hypothesised to play a major role in the pathogenesis of chronic spontaneous urticaria (CSU). Despite only weak evidence from Hp eradication studies, screening for Hp infection is still recommended in several CSU guidelines. The aim of this study was to investigate the effect of Hp eradication in combination with standard CSU treatment in Hp-positive compared with Hp-negative patients, applying the latest guidelines for both diseases.

METHODS

138 consecutive patients with CSU were enrolled in this retrospective cohort study. All patients underwent gastroscopy and Hp status was determined by urease testing and histologic examination. Seventy-five patients were diagnosed as Hp negative and 47 patients fulfilled criteria for definite Hp infection, 45 of whom received eradication therapy. Sixteen patients who received eradication therapy without an appropriate indication served as the medication control. All patients received symptomatic treatment with antihistamines and/or glucocorticoids regardless of Hp status. Partial response (PR) was defined as subjective amelioration of CSU symptoms; patients returning for further CSU treatment within 6 months were considered non-responders/relapsers (NRs).

RESULTS

The prevalence of Hp infection was comparable with Hp seroprevalence data reported for healthy western populations. Standard treatment of CSU led to relief of symptoms independent of Hp status. Hp eradication by standard triple therapy had no additional effect on PR (p = 0.32) or NR (p = 0.50).

CONCLUSIONS

Hp eradication has no discernible effect on CSU beyond that of standard CSU therapy. Therefore, Hp eradication should only be initiated in accordance with currently accepted indications of Hp treatment guidelines.