Chronic urticaria serum induces histamine release, leukotriene production, and basophil CD63 surface expression--inhibitory effects ofanti-inflammatory drugs

A Comparative Study of Sex Distribution, Autoimmunity, Blood, and Inflammatory Parameters in Chronic Spontaneous Urticaria with Angioedema and Chronic Histaminergic Angioedema

BACKGROUND

Recurrent idiopathic histaminergic angioedema is currently classified as a subtype of angioedema, as well as a subtype of chronic spontaneous urticaria (CSU), based on the fact that both are mast cell-mediated and respond to the same treatments.

OBJECTIVE

In the present work, we sought to verify whether chronic histaminergic angioedema (CHA) is an entity distinct from CSU or represents a CSU subtype that lacks hives.

METHODS

We performed a prospective study comparing 68 CHA patients, angioedema without hives, with 63 CSU patients, with hives and angioedema, from whom we collected demographic and clinical data, as well as blood and serum markers.

RESULTS

We found key pathogenic features that differentiate CHA from CSU: gender distribution, basophil number, and antibodies against the IgE receptor. The male/female ratio in CHA was 0.78, whereas in CSU it was 0.36 (P = .0466). Basopenia was more often seen in CSU (n = 13 [20%]) than in CHA (n = 5 [7%]). Finally, 31.15% of CSU sera induced basophil activation, whereas no CHA sera were able to activate normal basophils. By contrast, nonspecific inflammation or immune markers, for example, erythrocyte sedimentation rate, C-reactive protein, or IgG antithyroid antibodies, were very similar between both groups. IgE anti-IL-24 could not be assessed because a control population did not differ from CSU.

CONCLUSIONS

Inclusion of CHA as part of the spectrum of CSU is an assumption not evidence-based, and when studied separately, important differences were observed. Until there is further evidence, CHA and CSU should not necessarily be considered the same disorder, and it is our opinion that review articles and guidelines should reflect that possibility.

Management of Pediatric Chronic Spontaneous Urticaria: A Review of Current Evidence and Guidelines

Chronic urticaria (CU) is associated with debilitating symptoms such as pruritic wheals and/or angioedema, which can significantly affect patients’ sleep, productivity and quality of life. Chronic spontaneous urticaria (CSU) is defined in cases in which no triggering factor is identified. Various guidelines directing the optimal management of CU in the adult population were published and updated over the recent years with the most accepted and widely used being the EAACI/GA²LEN/EDF/WAO 2017 guidelines. Meanwhile, guidelines specific to the pediatric population are scarce, mainly due to the fact that high quality evidence is lacking for many treatment options in this age group. The objective of this article is to review and synthesize the existing literature regarding the management of pediatric CSU. Our review highlights evidence supporting the EAACI/GA²LEN/EDF/WAO 2017 treatment guidelines with non-sedating second-generation antihistamines (sgAHs) as the mainstay of treatment for pediatric CSU, considering their demonstrated efficacy and reassuring safety profile. Additionally, the use of omalizumab in adolescents is well supported by the current literature. There is limited data available regarding the updosing of sgAHs, omalizumab in children with CSU under 12 years of age and the treatment with cyclosporine and leukotriene receptor antagonists (LTRAs) in pediatric patients of all ages. However, the results from currently available case series and case reports are promising for omalizumab and cyclosporine use in children with CSU, although large and well-designed randomized control trials (RCTs) assessing these treatment options are needed in order to formulate strong recommendations for their use. First-generation antihistamines (fgAHs) remain commonly used in pediatric CSU treatment despite a lack of studies assessing their efficacy and safety in the pediatric population and their widely known inferior safety profile compared to sgAHs.

Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H₁ antihistamines alone or in combination with other classes of medications, including H₂ antihistamines, leukotriene receptor antagonists, or first-generation H₁ antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H₁ antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).

Gene Polymorphism of Aspirin-Induced Urticaria in Children With Kawasaki Disease

Objective: To investigate the distribution of the single nucleotide polymorphism (SNP) of LTC4S A-444C in children with Kawasaki disease in northern China and determine whether LTC4S A-444C SNP is associated with aspirin-induced urticaria (AIU). Methods: The clinical data of children with Kawasaki disease hospitalized in our center from April 2015 to November 2017 were collected, and fluorescence in situ hybridization was used to detect the LTC4S A-444C. According to the genotype, the subjects were divided into three groups: AA genotypes, AC genotypes, and CC genotypes. The incidence of AIU in the three groups was calculated and the relationship between LTC4S A-444C SNP and AIU was analyzed. Results: (1) A total of 574 children with Kawasaki disease were enrolled in the study. The allele frequencies for A, C were 980 (85.4%), 168 (14.6%). (2) Twenty-five cases of AIU in AA genotypes, with a positive rate of 6%, 11 cases of AIU in AC genotypes, with a positive rate of 7.5%, 2 cases of AIU in CC genotypes, with a positive rate of 18.2%. CC genotypes had higher incidence of AIU than that of AA and AC genotypes. However, there was no significant difference among the three groups (P > 0.05). Conclusion: The proportion of CC genotypes of LTC4S A-444C in children with Kawasaki disease in northern China is lower than that of AA genotypes and AC genotypes, and the incidence of AIU of CC genotypes is higher than that of AC genotypes and AA genotypes.

Basophil Activation Test: Old and New Applications in Allergy

PURPOSE OF REVIEW

The basophil activation test (BAT) using flow cytometry has supplanted traditional methods of measuring basophil degranulation using histamine and other mediator release, and can be used for clinical applications as well as to explore the immune mechanisms of effector cell response to allergen. This review discusses the advancements made in clinical, diagnostic and laboratory research of allergy utilizing an ever-evolving BAT.

RECENT FINDINGS

Being an in vitro surrogate of the allergic reaction that happens in vivo in the sick patient, the BAT can be used to support the diagnosis of various allergic conditions, such as food, drug, respiratory and insect venom allergies, and the assessment of clinical response to allergen-specific immunotherapy and other immunomodulatory treatments. The BAT can also be used for research purposes to explore the mechanisms of allergy and tolerance at the level of the basophil, for instance by manipulating IgE and IgG and their receptors and by studying intracellular signalling cascade in response to allergen. This review covers the applications of the BAT to the clinical management of allergic patients and the increased understanding of the mechanisms of immune response to allergens as well as technological advancements made in recent years.

Omalizumab efficacy in cases of chronic spontaneous urticaria is not explained by the inhibition of sera activity in effector cells

Omalizumab (OmAb) is a humanized anti-IgE antibody approved for the treatment of chronic spontaneous urticaria (CSU). OmAb's mechanism of action is known to include actions on free IgE and on pre-bound IgE. However, OmAb is equally and rapidly effective against autoimmune and non-autoimmune urticaria where IgE involvement is not clear, suggesting the involvement of additional mechanisms of action. In this study, we sought to investigate the ability of OmAb to inhibit mast cell and basophil degranulation induced by sera from CSU patients. For this purpose, we performed a comparison between the in vitro incubation of sera from CSU patients treated with OmAb and the in vivo administration of OmAb in a clinical trial. We found that OmAb added in vitro to sera from CSU patients did not modify the ability of the sera to induce cell degranulation. Similarly, the sera from patients treated with OmAb in the context of the clinical trial who had a good clinical outcome maintained the capacity to activate mast cells and basophils. Thus, we conclude that the beneficial activity of OmAb does not correlate with the ability of patient sera to induce cell degranulation.

Chronic urticaria: a focus on pathogenesis

Chronic urticaria is a spontaneous or inducible group of diseases characterized by the occurrence of wheals (and, in about half of cases, angioedema) for more than 6 weeks. These are rather frequent conditions that may severely affect patients’ quality of life and sometimes represent a challenge for doctors as well. The causes of chronic urticaria are still poorly defined, although there is growing evidence that different biologic systems including immunity, inflammation, and coagulation may take part in the pathomechanism eventually leading to mast cell and basophil degranulation and hence to wheal formation. This review will discuss the main findings that are (slowly) shedding light on the pathogenesis of this disorder.

Basophil markers for identification and activation in the indirect basophil activation test by flow cytometry for diagnosis of autoimmune urticaria

Background

The indirect basophil activation test using flow cytometry is a promising tool for autoimmune urticaria diagnosis. We aimed to identify better donor basophils (from atopic vs. non-atopic donors and interleukin-3 primed vs. unprimed basophils) and improve basophil identification and activation markers (eotaxin CC chemokine receptor-3 [CCR3] vs. CD123 and CD63 vs. CD203c).

Methods

Donor basophils were obtained from non-atopic and atopic group O donors. Positive control sera were artificially prepared to simulate autoimmune urticaria patients' sera. Patient sera were obtained from nine children with chronic urticaria. Assay sensitivity was compared among each variation by using positive control sera (n=21), applying cutoff values defined from negative control sera (n=20).

Results

For basophil identification, a combination of CCR3 and CD123 markers revealed a higher correlation with automated complete blood count (r=0.530) compared with that observed using CD123 (r=0.498) or CCR3 alone (r=0.195). Three activation markers on the atopic donor basophils attained 100% assay sensitivity: CD203c on unprimed basophils, CD63+CD203+ or CD63 alone on primed basophils; however, these markers on the non-atopic donor basophils attained lower assay sensitivity.

Conclusions

For basophil identification markers, a combination of CD123 and CCR3 is recommended, while CD123 alone may be used as an alternative. Donor basophils should be obtained from an atopic donor. For basophil activation markers, either CD203c alone on unprimed basophils or CD203c and CD63 on primed basophils are recommended, while CD63 alone on primed basophils may be used as an alternative.

Basophil Activation Test identifies the patients with Chronic Spontaneous Urticaria suffering the most active disease

Introduction

The basophil activation test showing CD63 up regulation could be a specific and sensitive in vitro complementary text to the in vivo autologous serum skin test for the activity assessment of the patients suffering autoimmune chronic spontaneous urticaria. The aim of this study is to define the basophil activation test as a useful tool in clinical practice in order to identify those patients with more active disease.

Methods

We screened 139 patients (96 women) diagnosed of chronic spontaneous urticaria using simultaneously autologous serum skin test and basophil activation test and their relationship with disease activity.

Results

Positive autologous serum skin test was found in 56.8%; from them, 31.6% were basophil activation test positive. Negative autologous serum skin test result was found in the 43.2% of the sample that showed negative CD63 expression results in all cases, except one. Patients with positive autologous serum skin test and positive CD63 by basophil activation test showed significant higher Urticaria Activity Score of 7 days (P = 0.004) and of 3 weeks (P = 0.001) than patients with positive autologous serum skin test and negative CD63 (mean ± standard deviation [SD] 26.57 ± 10.56 versus 18.40 ± 12.05 for the Urticaria Activity Score of 7 days and 56.47 ± 23.78 versus 39.88 ± 25.44 for the Urticaria Activity Score of 3 weeks).

Conclusions

The CD63 expression on basophils appears as a reliable in vitro marker, useful in clinical practice in combination with autologous serum skin test to define chronic spontaneous urticaria patients with the highest urticaria activity that impairs a normal life.

The clinical utility of basophil activation testing in diagnosis and monitoring of allergic disease

The basophil activation test (BAT) has become a pervasive test for allergic response through the development of flow cytometry, discovery of activation markers such as CD63 and unique markers identifying basophil granulocytes. Basophil activation test measures basophil response to allergen cross-linking IgE on between 150 and 2000 basophil granulocytes in <0.1 ml fresh blood. Dichotomous activation is assessed as the fraction of reacting basophils. In addition to clinical history, skin prick test, and specific IgE determination, BAT can be a part of the diagnostic evaluation of patients with food-, insect venom-, and drug allergy and chronic urticaria. It may be helpful in determining the clinically relevant allergen. Basophil sensitivity may be used to monitor patients on allergen immunotherapy, anti-IgE treatment or in the natural resolution of allergy. Basophil activation test may use fewer resources and be more reproducible than challenge testing. As it is less stressful for the patient and avoids severe allergic reactions, BAT ought to precede challenge testing. An important next step is to standardize BAT and make it available in diagnostic laboratories. The nature of basophil activation as an ex vivo challenge makes it a multifaceted and promising tool for the allergist. In this EAACI task force position paper, we provide an overview of the practical and technical details as well as the clinical utility of BAT in diagnosis and management of allergic diseases.

Indirect Immunofluorescence for the Detection of Autoimmune Urticaria

BACKGROUND

An autoimmune basis is believed to be responsible for about half of chronic spontaneous urticaria (CSU) cases. The autologous serum skin test is used as a possible indicator, but there is currently no test that directly indicates an autoimmune etiology. In this study, an indirect immunofluorescence was used to identify patients with autoantibodies directed at mast cells.

METHODS

Two substrates were used including paraffin embedded sections of skin biopsies from an infant with bullous mastocytosis and cord blood-derived mast cells (CBMC). Sera from 76 patients with CSU were incubated with substrates and conjugated with human IgG.

RESULTS

Using the bullous mastocytosis preparations, positive indirect immunofluorescence was found in 46% (n = 76), while the CBMC substrate was positive in 39% (n = 70).

CONCLUSION

The IgG autoantibodies directed at mast cells could be detected in about half the patients with CSU. Indirect immunofluorescence should be considered as an indicator of the autoimmune form of CSU.

Immunological events in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a highly debilitating skin disease associated with systemic features. We have made significant progress in several aspects relating to this condition. However, the exact physiopathology remains unknown. There is mounting evidence for an autoimmune basis, demonstrated by the CSU serum ability to activate healthy donors skin mast cells and blood basophils. However, it is only seen among 35–40% of patients. Mast cells and basophils play an important role in this skin condition. Both cells in CSU patients have unique features that differentiate them from basophils and mast cells from healthy donors. In the case of basophils, basopenia is typically found in CSU patients. Basophils from CSU patients also tend to be hyporesponsive to stimuli that act through the IgE receptor, responsive to other stimuli as MCP-1 or C5a, and hyperesponsive when incubated with sera. Eosinophils are also present in CSU skin biopsies, yet their exact role has not yet been defined. Likewise, endothelial cells also play a function, as indirectly demonstrated by an increase of vasoactive peptides in skin and plasma of CSU patients’ samples. All these facts orchestrate a systemic inflammation response producing a significant increase of several inflammatory markers. Unfortunately, we lack a unitary model that could explain the exact role of each of these players. In this review, we will describe the history and discover the pathway to the present knowledge on the immunological facts of this disease.

Interleukin-6 and tumor necrosis factor-alpha gene polymorphisms in chronic idiopathic urticaria

BACKGROUND

This study was performed to evaluate association of gene polymorphisms among proinflammatory cytokines and susceptibility to chronic idiopathic urticaria (CIU).

METHODS

Ninety patients with prolonged urticaria more than 6 weeks were included as case group. Single nucleotide polymorphisms (SNPs) of IL-6 (G/C -174, G/A nt565) and TNF-α (G/A -308, G/A -238) were evaluated, using polymerase chain reaction (PCR); and the results were compared to the control group.

RESULTS

G allele was significantly higher in the patients at locus of -238 of promoter of TNF-α gene (p<0.001). Frequency of following genotypes were significantly lower in patients with CIU, compared to controls: AG at -308 and GA at -238 of TNF-α gene (p<0.05 and p<0.001, respectively), CG at -174 and GG at +565 of IL-6 gene (p<0.05). Additionally, following genotypes were more common among patients with CIU: GG at -308 and -238 of TNF-α gene (p<0.05 and p<0.001, respectively), GG at -174 and GA at +565 of IL-6 gene (p<0.05).

CONCLUSIONS

Pro-inflammatory cytokine gene polymorphisms can affect susceptibility to CIU. TNF-α promoter polymorphisms as well as IL-6 gene polymorphisms are associated with CIU.

A rapid method of detecting autoantibody against FcεRIα for chronic spontaneous urticaria

Background

Chronic spontaneous urticaria (CU) is a common skin disorder, with an estimated prevalence of 0.5–1.8% in most populations. Around 30–50% of CU patients have an autoimmune etiology, with autoantibodies (autoAbs) against IgE, FcεRIα, and FcεRII/CD23. Although the in vivo autologous serum skin test (ASST) and in vitro histamine release/activation assay are the most frequently used screening methods, these two have many limitations and do not directly measure susceptible autoAbs. This study aimed to establish an in vitro rapid screening test using recombinant autoantigen FcεRIα(rFcεRIα) to improve the diagnosis of autoimmune urticaria.

Methods

Forty patients with CU and 20 healthy individuals were enrolled. After PCR-based cloning and the production of extracellular fragments of the FcεRIαprotein using the E. coli expression system, serum autoAb to rFcεRIαwas evaluated using in-house ELISA and rapid immunodot test.

Results

In ELISA-based detection, 14 out of 20 CU-ASST(+) patients exhibited anti- FcεRIαresponses, whereas five of the 20 CU-ASST(-) and two of the 20 non-CU patients showed autoantibody background in the assay. For the immunodot test, 55% (11/20) of the CU-ASST(+) sera exhibited anti-FcεRIαreactivity. There was no false positive among the CU-ASST(-) and non-CU groups. Using clinical urticaria plus ASST(+) as the gold standard, in-house ELISA had 70% sensitivity, 82.5% specificity, and positive likelihood ratio of 4, while immunodot had 55% sensitivity, 100% specificity, and positive likelihood ratio >55.

Conclusions

This study has developed a rapid immunodot method with high specificity for detecting autoAb to FcεRIαin patients with CU. Preliminary data indicates that this immunodot technique has the potential to be a routine diagnostic assay for autoimmune CU.

Basophil activation test with food additives in chronic urticaria patients

The role of food additives in chronic urticaria (CU) is still under investigation. In this study, we aimed to explore the association between food additives and CU by using the basophil activation test (BAT). The BAT using 15 common food additives was performed for 15 patients with CU who had a history of recurrent urticarial aggravation following intake of various foods without a definite food-specific IgE. Of the 15 patients studied, two (13.3%) showed positive BAT results for one of the tested food additives. One patient responded to monosodium glutamate, showing 18.7% of CD203c-positive basophils. Another patient showed a positive BAT result to sodium benzoate. Both patients had clinical correlations with the agents, which were partly determined by elimination diets. The present study suggested that at least a small proportion of patients with CU had symptoms associated with food additives. The results may suggest the potential utility of the BAT to identity the role of food additives in CU.

The role of focal infections in the pathogenesis of psoriasis and chronic urticaria

INTRODUCTION

The Focal Infection Theory, originally presented at the beginning of the 20(th) century, postulates that systemic diseases can be caused by microorganisms that arise from the focus of infection. Foci of infections have been described as sinuses, adenoids, tonsils, teeth, genitourinary tract, gall bladder and kidneys. A focus of infection is defined as the area that can occur in any part of the body, contains a pathogen (microorganism) and is usually asymptomatic. There are discordant opinions about the role of focal infections in the pathogenesis of psoriasis and urticaria.

AIM

To establish whether there is a higher incidence of focal infections in patients with chronic urticaria and psoriasis.

MATERIAL AND METHODS

We retrospectively reviewed 129 patients with a history of psoriasis and chronic urticaria: 58 women and 71 men treated in the Department of Dermatology of the Jagiellonian University Medical College in Krakow.

RESULTS

In the analyzed group, 11 patients had a dental consultation, 58 - laryngological consultation and 29 women had a gynecological consultation. The most common examples of focal infection were tonsillitis, upper respiratory tract infections, sinusitis, dental caries and genitourinary tract infections. Aggravating factors were similar to previously described.

CONCLUSIONS

A high incidence of focal infections in patients with psoriasis and urticaria suggests that infections may play a significant role in the pathogenesis of these skin disorders. Treatment of infection foci may play the key role in the remission of skin changes.

EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria

An autoimmune subset of chronic spontaneous urticaria is increasingly being recognized internationally, based on laboratory and clinical evidence that has accrued over the last 20 years. This evidence has been reviewed by a taskforce of the Dermatology section of the European Academy of Allergy and Clinical Immunology. Functional autoantibodies in chronic urticaria (CU) patient sera have been demonstrated against IgE and FcεRIα by basophil and mast cell histamine release assays and by basophil activation assays. Antibody specificity has been confirmed by immunoassay, but there is a poor correlation between functionality and immunoreactivity. Approximately 25% of CU patients have a positive basophil histamine release assay and show autoreactivity (a positive autologous serum skin test), whereas 50% are negative regarding both. Functionality of CU sera appears to be complement dependent on mast cells but not exclusively on basophils. Basophil activation by CU sera is predominantly restricted to IgG1 and IgG3 subclasses. Circumstantial evidence for CU being an autoimmune disease comes from an observed association with other autoimmune diseases, a strong association between serum functionality and HLA-DR4 haplotype and the good response of CU patients to immunotherapies. It was proposed that a study should be undertaken to prospectively validate potentially relevant clinical criteria (from the history, examination and routinely available clinical investigations) against a new 'gold standard' for the diagnosis of ACU (positive autoreactivity, functional bioassay and immunoassay) to define preliminary criteria sets for the diagnosis of ACU based on clinical and laboratory features with highest individual sensitivity and specificity.

Add-on montelukast in antihistamine-resistant chronic idiopathic urticaria

BACKGROUND

Antihistamines (AH) alleviate pruritus and decrease the incidence of hives in patients with chronic idiopathic urticaria (CU). However, some patients do not respond completely to this therapy. We hypothesized that some of them might benefit from the addition of leukotriene receptor antagonists (LA).

METHODS

We screened patients diagnosed and treated for CU and selected those that had symptoms despite antihistamine treatment. In a double-blind crossover study, patients took the leukotriene antagonist montelukast (10 mg per day) or placebo. Efficacy was assessed by a symptom score.

RESULTS

In a group of 22 patients, the symptom score was not significantly different between periods using montelukast (48.8; 0-214) or placebo (68.5; 0-230). However in the subgroup of five patients with the most severe urticaria, defined as patients with symptom scores in the upper quartile at inclusion in the study, montelukast (41; 11 214) was superior to placebo (95.5; 48 230; p < 0.05), but only when using an in-house symptom score questionnaire and not when using a validated urticaria activity score questionnaire.

CONCLUSIONS

We showed that in patients with antihistamine-resistant CU the addition of montelukast significantly diminished symptoms in only a small minority of patients. However, response to add-on montelukast was seen in the subgroup of patients with particularly severe disease. To confirm this observation, a study with a larger group of patients is warranted.

[Cellular in-vitro assays. Applicability in daily routine]

Cellular in-vitro assays are able to detect antigen-dependent cellular processes without any risk for the patient. After antigen stimulation, both the cellular antigen stimulation test assessing sulfidoleukotriene production in leukocyte suspension, and flow cytometric basophil activation assays determining surface activation markers (CD63, CD203c), represent accepted models for in-vivo mast cell stimulation particularly in IgE-dependent reactions of immediate type. The value of these assays should be estimated considering the type of antigen and further diagnostic options. Most studies can not be compared due to different allergen concentrations, conditions of stimulation, methods, and defined cut-offs. Therefore, it is difficult to evaluate published evidence. Because of the logistic effort, cellular assays are often available only in specialized laboratories. However, in daily routine they are important in cases with clear-cut history but negative conventional allergy diagnostic procedures, in case of rare allergens (drugs, exotic food), as well as contraindications for skin and/or provocation test (hymenoptera venom allergy, anaphylaxis).

Are chronic urticaria, analgesic intolerance and seasonal rhinitis markers of different severities and phenotypes of the asthma they accompany?

BACKGROUND

Asthma is a heterogeneous disease that presents with different clinical phenotypes. We aimed to compare the patients with asthma diagnosis alone with the patients, who, in addition to their asthma had accompanying analgesic intolerance (AI), chronic urticaria (CU) or seasonal rhinitis (SR) if there are any distinctions and specific characteristics of these defined patient groups.

METHODS

Eighty-four asthma patients diagnosed with SR, 46 with CU, 75 with AI and 71 patients with asthma alone were enrolled to the study retrospectively. The reference group for the comparisons was the group with asthma diagnosis alone.

RESULTS

The mean age of all patients was 37.2±13 (15-80) and 70.7% of them were females. Asthma patients with SR had a significantly earlier onset of asthma (age: 27.4±10.8 and 34.5±15.9; respectively, p<0.01), significantly better pulmonary function tests and were significantly more atopic (92.9% and 28.8%; p<0.001). Moderate-to-severe asthma significantly correlated with older age at the time of diagnosis, older age of asthma onset, higher body mass index, less atopy and fewer pollen sensitivity. Asthma severity of patients with SR was significantly milder than the reference group (OR: 0.6, 95% CI 0.5-0.8). Asthma with AI tended to be more severe although the relation was insignificant (OR:1.6 95% CI:0.8-3.5).

CONCLUSIONS

Asthma patients with SR have significantly milder and earlier onset of asthma, better pulmonary function tests and are significantly more atopic while asthma with AI tends to be more severe. Asthma with CU does not show a specific phenotypic characteristic.

The employment of leukotriene antagonists in cutaneous diseases belonging to allergological field

Leukotrienes (LTs) are potent biological proinflammatory mediators. LTC4, LTD4, and LTE4 are more frequently involved in chronic inflammatory responses and exert their actions binding to a cysteinyl-LT 1 (CysLT1) receptor and a cysteinyl-LT 2 (CysLT2) receptor. LTs receptor antagonists available for clinical use demonstrate high-affinity binding to the CysLT1 receptor. In this paper the employment of anti-LTs in allergic cutaneous diseases is analyzed showing that several studies have recently reported a beneficial effects of these agents (montelukast and zafirlukast as well as zileuton) for the treatment of some allergic cutaneous related diseases-like chronic urticaria and atopic eczema although their proper application remains to be established.

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.

Increased levels of serum IL-31 in chronic spontaneous urticaria

IL-31 represents a novel cytokine involved in pruritic skin diseases including atopic dermatitis (AD). We, therefore, aimed at investigating IL-31 levels in chronic spontaneous urticaria (CU). We included 46 patients with CU, 26 non-atopic skin healthy subjects as negative and 28 patients with AD as positive controls. IL-31 serum levels were analysed using commercial ELISA kit. IL-31 serum levels were higher in patients with CU compared to healthy controls (P < 0.001), but lower compared to patients with AD (P < 0.001). There was no difference in IL-31 serum levels in autologous serum skin test positive or negative CU patients and patients with infectious trigger factors including helicobacter pylori infection. IL-31 serum levels may play a role in the pathophysiology of CU. This is supported by the finding that not all patients with CU respond to antihistamine treatment but to the treatment with immunosuppressive drugs.

Urticaria and infections

Urticaria is a group of diseases that share a distinct skin reaction pattern. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear. In spontaneous acute urticaria there is no doubt for a causal relationship to infections and all chronic urticaria must have started as acute. Whereas in physical or distinct urticaria subtypes the evidence for infections is sparse, remission of annoying spontaneous chronic urticaria has been reported after successful treatment of persistent infections. Current summarizing available studies that evaluated the course of the chronic urticaria after proven Helicobacter eradication demonstrate a statistically significant benefit compared to untreated patients or Helicobacter-negative controls without urticaria (p < 0.001). Since infections can be easily treated some diagnostic procedures should be included in the routine work-up, especially the search for Helicobacter pylori. This review will update the reader regarding the role of infections in different urticaria subtypes.

C5a-induced in vitro basophil activation in patients with chronic urticaria: a pilot study

BACKGROUND

Complement component 5a (C5a) might be involved in the formation of wheals in patients with chronic urticaria (CU). We sought to compare the in vitro responsiveness of basophils to C5a in patients with CU and in a control group.

METHODS

Basophil surface expression of activation marker CD63 induced by C5a, anti-FcepsilonRI mAb or anti-IgE pAb was measured using flow cytometry in 17 patients with CU and in 10 healthy controls.

RESULTS

Patients with CU showed significantly greater basophil CD63 surface expression induced by C5a (median [interquartile range]; 16.4% [13-25.1]; P = 0.011) than the group of healthy controls (10.7% [7.2-16.8]). In contrast, basophil CD63 response to anti-IgE and anti-FcepsilonRI was lower in the CU group (12.3% [6-36.3]; 25.9% [12.5-60.5]) than in the control group (51.7% [6.7-84.3]; 62.1% [9.7-89.2]), although not statistically significant.

CONCLUSION

Results of this pilot study suggest that patients with CU might have an enhanced basophil response to stimulation with C5a, indicating that further studies in CU basophil responsiveness are needed.

Contact urticaria: present scenario

Immunological contact urticaria is a hypersensitivity reaction that appears on the skin following contact with an eliciting substance. Recent advances in our understanding of the molecular mechanism and pathogenesis of this reaction have altered its classification, diagnosis, and treatment. We discuss classification, epidemiology, diagnosis, testing, and treatment options that are available to patients with contact urticaria.

Leukotriene receptor antagonists in monotherapy or in combination with antihistamines in the treatment of chronic urticaria: a systematic review

In vitro and in vivo clinical and experimental data have suggested that leukotrienes play a key role in inflammatory reactions of the skin. Antileukotriene drugs, ie, leukotriene receptor antagonists and synthesis inhibitors, are a class of anti-inflammatory drugs that have shown clinical efficacy in the management of asthma and in rhinitis with asthma. We searched MEDLINE database and carried out a manual search on journals specializing in allergy and dermatology for the use of antileukotriene drugs in urticaria. Montelukast might be effective in chronic urticaria associated with aspirin (ASA) or food additive hypersensitivity or with autoreactivity to intradermal serum injection (ASST) when taken with an antihistamine but not in mild or moderate chronic idiopathic urticaria [urticaria without any possible secondary causes (ie, food additive or ASA and other NSAID hypersensitivity, or ASST)]. Evidence for the effectiveness of zafirlukast and the 5-lipoxygenase inhibitor, zileuton, in chronic urticaria is mainly anecdotal. In addition, there is anecdotal evidence of effectiveness of antileukotrienes in primary cold urticaria, delayed pressure urticaria and dermographism. No evidence exists for other physical urticarias, including cholinergic, solar and aquagenic urticarias, vibratory angioedema, and exercise-induced anaphylaxis.

Effects of a new nutraceutical ingredient on allergen-induced sulphidoleukotrienes production and CD63 expression in allergic subjects

Allergic diseases represent conditions affecting millions of individuals across the world. The objective of this study was to investigate the potential anti-allergic effects of a new nutraceutical ingredient, Pantescal (Bionap, Italy), contained in different food supplements. Pantescal is a mixture of plant extracts, such as Capparis spinosa, Olea europaea, Panax Ginseng and Ribes nigrum. The study was a randomized, double-blind, placebo controlled design. 60 patients allergic to common aeroallergens were chosen. Allergic patients were divided into two groups: one group was supplemented by Pantescal and the other, using a placebo formulation. Two in vitro tests were performed on blood samples taken from patients before and at 2 h, 2, 3 and 10 days after supplementation: cellular antigen stimulation test (CAST) was used to analyze the amount of sulphidoleukotrienes (SLT) production and flow-cytometric antigen stimulation test (FAST) to measure expression of basophil degranulation marker (CD63) was also performed. CAST showed that after 2 and 3 days, a slight decrease of SLT production was evident but only after 10 days did it become significant with a percentage of inhibition (P.I)=43.3%. FAST revealed that there were no statistical differences for the first 2 days after supplementation although there was an inhibitory trend in the supplemented patients. CD63 expression was significantly reduced after 10 days (P.I.=64.8%). This study suggests that Pantescal is effective in reducing allergic biomarkers such as CD63 protein and SLT in atopic subjects. The higher inhibitory effect on CD63 expression compared to SLT production allows us to hypothesize cell membrane stabilization as the main potential mechanism to explain the observed Pantescal protective effects.

Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1

OBJECTIVE

To evaluate the use of alternative therapies for chronic urticaria refractory to first-line treatments in an evidence-based manner.

DATA SOURCES

MEDLINE searches were performed cross-referencing urticaria with the names of multiple therapies. Articles were then reviewed for additional citations. Articles published after 1950 were considered.

STUDY SELECTION

All articles, including case reports, were reviewed for soundness and relevance.

RESULTS

Experience has been reported for a wide variety of alternative therapies in the treatment of chronic idiopathic and physical urticarias. Evidence for most agents is limited to anecdotal reports. The second-line therapies reviewed are also categorized based on criteria of safety, efficacy, convenience, and cost, in relation to the first-line antihistamines.

CONCLUSIONS

Alternative agents should be considered in patients with chronic urticaria who are both severely affected and unresponsive to antihistamines. Although monitoring for toxicity is important in management with many alternative agents, safety is favorable compared with corticosteroids.

Urticaria

Urticaria and angioedema are common and, if chronic, often persist for years with significant impact on quality of life and occupational ability. To achieve a better understanding of disease etiology and pathogenesis and to compare clinical trials, there is a clear need for cross-specialty and international agreement of the nomenclature and diagnostic classification of urticaria and angioedema. At least in part this has been achieved by two recently published European guidelines. After the urticaria subtype is defined, potential triggers should be sought including persistent bacterial infections (Helicobacter pylori, streptococci, staphylococci, Yersinia, parasites) pseudoallergic reactions (acetylsalicylic acid, rarely food additives) and/or autoreactive mechanisms (autologous serum test). Identified trigger factors should be avoided or eradicated, as this is the most successful therapeutic approach. Treatment of most urticaria subtypes is difficult and besides H1 antihistamines neither standardized nor evidence-based. Low-sedating H1 antihistamines represent the mainstay of treatment, as they have a better therapeutic index and pharmacodynamic properties than older agents. In severe cases their dose has to be increased which is off-label use. The evidence base for treatment alternatives is totally insufficient and the risk-benefit profile of each off-label used drug should be carefully considered.

Effect of stress on basophil function in chronic idiopathic urticaria

BACKGROUND

Chronic idiopathic urticaria (CIU) is a distressing skin condition involving recurrent itchy hives lasting 6 weeks or longer. The mechanism involves mast cell and basophil degranulation, which releases inflammatory mediators including histamine. In our clinical practice, we have observed that the onset of CIU is often preceded by a major life event.

OBJECTIVE

To investigate the role of the hormones of the hypothalamic-pituitary-adrenal (HPA) axis in the link between psychological stress and CIU.

METHODS

Thirty people with CIU and 30 normal controls were recruited. A flow cytometric CD63 expression assay was used to quantify basophil activation, and serum cortisol concentrations were measured as an indication of stress.

RESULTS

Both corticotrophin releasing factor (CRF) and adrenocorticotrophic hormone (ACTH) were shown to activate basophils. There was no significant difference between numbers of CIU patients and normal controls responding to CFR, ACTH or cortisol. However, the responses in the CIU patients were stronger than those in normal controls. There was also a trend towards higher serum cortisol concentrations in CIU patients. The basophil response to CRF and ACTH correlated with the serum cortisol concentration in normal controls, but not in CIU patients.

CONCLUSIONS

Although our data have not supported the hypothesis that stress makes a major contribution to CIU, the heightened basophil response to CFR and ACTH and higher levels of serum cortisol do suggest a derangement of the HPA axis in CIU.

Moderne Diagnostik und Therapie der Urtikaria

The different urticaria subtypes represent a common diagnostic and treatment challenge for the dermatologist. Usually, acute urticaria is treated symptomatically with modern H1 antihistamines and, if needed, short courses of glucocorticosteroids. In acute urticaria which is often induced by an acute infection no further diagnostic procedures are recommended. In contrast, a targeted work-up followed by specific therapy is required for chronic urticaria, physical urticaria and special urticaria types, because many of these subtypes are characterized by their persistence for several years and have a profound impact on the quality of life. This article elucidates the management of urticaria by presenting five characteristic case reports of patients managed in a special urticaria consulting hour.

Chronic unremitting urticaria: is the use of antihistamines above the licensed dose effective? A preliminary study of cetirizine at licensed and above-licensed doses

Recently, several authors have suggested an off-label increase of antihistamine dosage should be given to patients with chronic urticaria (CU) not responding to the usual, recommended doses, in order to gain better control of the disease. However, this recommendation is not evidence-based. The objective of this study was to assess the effectiveness of increased doses of antihistamines in patients with CU showing poor control at recommended doses. In total, 22 adult patients with moderate/severe CU not controlled with the usual antihistamine doses were studied. These subjects recorded urticaria severity on a visual analogue scale (range 0-10) for 2 weeks. During the first week, they were treated with cetirizine at the licensed dose (10 mg/day), and with a three-fold increased dose (10 mg x 3/day) during week 2. Only 1 patient (5%) responded satisfactorily to the increased dosage of antihistamine; in the remaining 21 subjects, urticaria scores did not change, and these patients had to be treated with steroids, ciclosporin, and in 1 case with cyclophosphamide. Disease control was eventually gained in all cases. This study suggests that the proportion of patients with severe CU that may gain a better control of their disease with high, off-label doses of antihistamines is probably small, and that most patients will eventually have to undergo more aggressive treatments.

Flow-assisted allergy diagnosis: current applications and future perspectives

Physicians predominantly rely upon quantification of serum-specific immunoglobulin E (IgE) and/or skin test to confirm clinically suspected IgE-mediated allergy. However, for various reasons, identification of the offending allergen(s) and potentially cross-reactive structures is not always straightforward. Flow-assisted allergy diagnosis relies upon quantification of alterations in the expression of particular basophilic activation markers. Actually, upon challenge with a specific allergen, basophils not only secrete quantifiable bioactive mediators but also upregulate the expression of different markers which can be detected efficiently by flow cytometry using specific monoclonal antibodies. Currently, the technique has been applied in the investigation of IgE-mediated allergy caused by classical inhalant allergens, food, Hevea latex, hymenoptera venoms and drugs. It is also appreciated; the technique proves valuable in the diagnosis of non-IgE-mediated (anaphylactoid) reactions such drug hypersensitivity and the detection of autoantibodies in certain forms of chronic urticaria. This review will not address immunologic features, characteristics and general pitfalls of flow-assisted analysis of in vitro-activated basophils as summarized elsewhere. After a recapitulation of the principles and some specific technical issues of flow-assisted analysis of in vitro-activated basophils, we principally focus on the current clinical and research applications of the basophil activation tests. Personal experience of both research groups is provided, where appropriate. Finally, a viewpoint on how the field might evolve in the following years is provided.

Serum-induced basophil CD63 expression by means of a tricolour flow cytometric method for the in vitro diagnosis of chronic urticaria

BACKGROUND

Functional autoantibodies against the alpha-chain of the high-affinity IgE receptor (FcepsilonRIalpha) identify a subset of patients with chronic urticaria (CU) due to autoreactivity, as assessed by an in vivo positive response to autologous serum skin test (ASST). We performed a study to standardize the serum-induced basophil activation assay by flow cytometry (FCM) using a new tricolour method, assessing the diagnostic performance of this test in discriminating between ASST+ and ASST- CU patients.

METHODS

Sera of 64 CU patients (22 ASST+ CU and 42 ASST- CU) and 10 healthy subjects were tested for their ability to induce basophil CD63 expression when incubated with whole blood of both atopic (DA) and non-atopic donors (DNA). Using a triple-labelled strategy with anti-CD123, anti-HLA-DR and anti-CD63 antibodies, CD63+ basophils were identified on a selected population of CD123+ HLA-DR- cells. In 3 ASST+ CU patients who underwent cyclosporine therapy, the assay was performed before and after treatment.

RESULTS

The ASST+ CU sera resulted in a significant higher induction of basophil CD63 expression compared with ASST- CU and healthy donors sera; when whole blood from DA was used, sensitivity and specificity of the assay were 95.5% and 90.5% respectively. ASST+ CU serum activity was significantly decreased during cyclosporine A treatment, in parallel with clinical remission.

CONCLUSIONS

Chronic urticaria serum-induced CD63 expression assay performed on DA whole blood by means of our tricolour FCM method could be the most useful tool for identification of a subset of patients with autoimmune CU and may become a promising tool also for monitoring treatment efficacy.