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Choi JH, Lee DH, Song WJ, Choi M, Kwon JW, Kim GW, Kim MH, Kim MA, Kim MH, Kim BK, Kim S, Kim JS, Kim JE, Kim JY, Kim JH, Kim HJ, Kim HO, Kim HB, Roh JY, Park KH, Park KY, Park HK, Park H, Bae JM, Byun JY, Song DJ, Ahn YM, Lee SE, Lee YB, Lee JS, Lee JH, Lim KH, Youn SW, Chang YS, Jeon YH, Jeon J, Jue MS, Choi SH, Hur GY, Lim DH, Ye YM, Park YM. The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 2. Management of H1-Antihistamine-Refractory Chronic Urticaria. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:750-770. [PMID: 32638557 PMCID: PMC7346997 DOI: 10.4168/aair.2020.12.5.750] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023]
Abstract
Quite a few patients with chronic spontaneous urticaria (CSU) are refractory to H₁-antihistamines, even though the dose of H₁-antihistamines is increased up to 4-fold. CSU that is not controlled with H₁-antihistamines results in increased disease burden. Several immunomodulators have been used to manage these patients. The guidelines reported herein are connected to Part 1 of the KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children, and aimed to provide evidence-based recommendations for the management of H₁-antihistamine-refractory CSU. Part 2 focuses on the more commonly used additional treatment options for refractory CSU, including omalizumab, cyclosporine, leukotriene receptor antagonist, dapsone, methotrexate, and phototherapy. The evidence to support their efficacy, dosing, safety, and selection of these agents is systematically reviewed. To date, for patients with refractory CSU, the methodologically sound data to evaluate the use of omalizumab has been growing; however, the evidence of other immunomodulators and phototherapy is still insufficient. Therefore, an individualized stepwise approach with a goal of achieving complete symptom control and minimizing side effects can be recommended. Larger controlled studies are needed to elevate the level of evidence to select a rational therapeutic agent for patients with refractory CSU.
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Affiliation(s)
- Jeong Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong Hun Lee
- Department of Dermatology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mira Choi
- Department of Dermatology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Jae Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Gun Woo Kim
- Department of Internal Medicine, St. Carollo General Hospital, Suncheon, Korea
| | - Myung Hwa Kim
- Department of Dermatology, Dankook University College of Medicine, Cheonan, Korea
| | - Mi Ae Kim
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Min Hye Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Byung Keun Kim
- Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Joung Soo Kim
- Department of Dermatology, Hanyang University Guri Hospital, Guri, Korea
| | - Jung Eun Kim
- Department of Dermatology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Young Kim
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Joo Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyun Jung Kim
- Institute for Evidence-based Medicine, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hye One Kim
- Department of Dermatology, Hallym University College of Medicine, Seoul, Korea
| | - Hyo Bin Kim
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Joo Young Roh
- Department of Dermatology, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Kyung Hee Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kui Young Park
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Han Ki Park
- Department of Allergy and Clinical Immunology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyunsun Park
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jung Min Bae
- Department of Dermatology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Ji Yeon Byun
- Department of Dermatology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Dae Jin Song
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Young Min Ahn
- Department of Pediatrics, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Division of Pulmonology and Allergy, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Bok Lee
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joong Sun Lee
- Department of Dermatology, School of Medicine, Eulji University, Daejeon, Korea
| | - Ji Hyun Lee
- Department of Dermatology, Seoul St. Mary's Hospital, Brain Korea 21 PLUS Project for Medical Science, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Sang Woong Youn
- Department of Dermatology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoon Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - You Hoon Jeon
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jiehyun Jeon
- Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Mihn Sook Jue
- Department of Dermatology, Veterans Health Service Medical Center, Seoul, Korea
| | - Sun Hee Choi
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Hyun Lim
- Department of Pediatrics, School of Medicine, Inha University, Incheon, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
| | - Young Min Park
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Liang SE, Hoffmann R, Peterson E, Soter NA. Use of Dapsone in the Treatment of Chronic Idiopathic and Autoimmune Urticaria. JAMA Dermatol 2019; 155:90-95. [PMID: 30476976 DOI: 10.1001/jamadermatol.2018.3715] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The first-line treatment for patients with chronic spontaneous urticaria (CSU), which is divided into idiopathic and autoimmune subtypes, consists of H1-antihistamines. However, limited evidence guides the treatment of CSU after maximal therapy with antihistamines fails. Two randomized clinical trials suggest that dapsone may be a successful second-line therapy. Objective To evaluate the efficacy and safety of dapsone therapy in patients with CSU. Design, Setting, and Participants This retrospective medical record review included 79 patients with CSU treated with dapsone who presented to the tertiary care academic medical center at the New York University School of Medicine, New York, New York, from January 1, 2005, through April 15, 2017. Follow-up was completed on February 28, 2018. Data were analyzed from March 1 through May 31, 2018. Exposures Treatment with oral dapsone for CSU. Main Outcomes and Measures Efficacy of dapsone therapy for CSU was evaluated as improvement, complete response, and remission. Results Seventy-nine patients (65% women; mean [SD] age, 49.8 [16.1] years [range, 20-79 years]) were included in the analysis. Forty-five patients had chronic idiopathic urticaria and 34 had chronic autoimmune urticaria. Improvement in CSU was observed in 62 patients (78%) (36 [80%] with idiopathic and 26 [76%] with autoimmune disease) with dapsone. Mean (SD) time to improvement was 1.1 (1.0) months. A complete response was achieved in 29 (47%) of these 62 patients (16 [44%] with idiopathic and 13 [50%] with autoimmune disease). Mean (SD) time to complete response was 5.2 (5.2) months. Dapsone therapy was tapered in 21 patients after a mean (SD) of 2.4 (2.2) months and discontinued in 18. Ten patients experienced remission with no subsequent flares, even after dapsone therapy was discontinued with follow-up of 0.3 to 10.0 months. Sixteen patients experienced mild adverse effects. Two serious adverse effects were reported. Conclusions and Relevance Results of this study suggest that dapsone is a useful and well-tolerated second-line therapy for patients with CSU in whom antihistamines and other first-line agents have failed.
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Affiliation(s)
- Sydney E Liang
- currently a medical student at New York University School of Medicine, New York, New York
| | - Rachel Hoffmann
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Erik Peterson
- currently a medical student at New York University School of Medicine, New York, New York
| | - Nicholas A Soter
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
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Vestergaard C, Deleuran M. Chronic spontaneous urticaria: latest developments in aetiology, diagnosis and therapy. Ther Adv Chronic Dis 2015; 6:304-13. [PMID: 26568807 PMCID: PMC4622315 DOI: 10.1177/2040622315603951] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic urticaria is a debilitating disease characterized by itching and hives with or without angioedema lasting for more than 6 weeks. The disease carries a significant emotional and economic burden for the patient and often results in an odyssey between doctors of different specialities. Patients suffering from chronic urticaria are considered more difficult to satisfy, treat and to have a bigger emotional burden than the average patient in dermatology, paediatric and general practice settings. A joint initiative under the Dermatology section of the European Academy of Allergy and Clinical immunology (EAACI), the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) has resulted in recently published guidelines for the diagnosis, classification and treatment of chronic urticarial: these guidelines are clinically useful and have a high success rate when followed in daily clinical practice. The treatment of choice for chronic urticaria is still nonsedating antihistamines although other treatments are available, with omalizumab (humanized IgG anti IgE antibodies) as the newest therapy. The pathogenesis of urticaria is poorly understood but autoimmunity is considered as one of the major underlying causes for this disease, although other theories exist.
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Affiliation(s)
| | - Mette Deleuran
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
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Greenberger PA. Chronic urticaria: new management options. World Allergy Organ J 2014; 7:31. [PMID: 25383135 PMCID: PMC4223736 DOI: 10.1186/1939-4551-7-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 09/30/2014] [Indexed: 11/16/2022] Open
Abstract
Chronic urticaria is defined as episodic or daily hives lasting for at least 6 weeks and impairs quality of life. Two main subtypes include chronic idiopathic (spontaneous) urticaria and inducible (physical) urticaria, but some patients have urticarial vasculitis. “Autoimmune chronic urticaria” implies the presence of histamine releasing or mast cell activating autoantibodies to IgE or FcϵRI, the high affinity receptor on mast cells and basophils. In patients not readily controlled with labeled dosages of second generation H1 receptor antagonists (antihistamines), there is evidence for reduction of urticaria using up to 4 fold increases in labeled dosages. The biologic modifier, omalizumab, helps to reduce lesions of chronic urticaria within 1–2 weeks.
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Affiliation(s)
- Paul A Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 676 N. St. Clair Street, # 14108, 60611 Chicago, IL USA
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Morgan M, Cooke A, Rogers L, Adams-Huet B, Khan DA. Double-blind placebo-controlled trial of dapsone in antihistamine refractory chronic idiopathic urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:601-6. [PMID: 25213055 PMCID: PMC4165520 DOI: 10.1016/j.jaip.2014.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 05/18/2014] [Accepted: 06/11/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Management of antihistamine refractory chronic idiopathic urticaria (CIU) has poorly defined therapeutic options. OBJECTIVE To evaluate the efficacy of dapsone (4,4'-diaminodiphenylsulfone) in antihistamine refractory CIU compared with placebo. METHODS Twenty-two patients with antihistamine refractory CIU were randomly assigned to 100 mg of dapsone daily or placebo for 6 weeks in a 14-week double-blind, placebo-controlled crossover trial. End points were measured from a daily diary that reflected the weekly hive score, the weekly itch score, and a visual analog scale (VAS) score. Secondary to a carryover effect, the first period results were analyzed as a parallel design that compared placebo with dapsone directly by using repeated-measures analysis. RESULTS After 6 weeks, the patients in the dapsone arm showed mean improvement over baseline in VAS (2.3 [95% CI, 0.6-4.1], P = .01), urticaria score (-3.5 [95% CI, -6.2 to -0.9], P = .01), and itch score (-4.8 [95% CI, -7.6 to -2.1], P = .001), whereas the placebo arm showed no improvement over baseline for VAS, urticaria, or itch scores. Dapsone showed greater improvement compared with placebo for itch (P = .047) and VAS (P = .04). Of the 22 patients, 3 showed complete resolution of hives and itch with dapsone, whereas 31% and 41% had ≥ 50% resolution of hives and itch, respectively. No serious adverse effects were observed with dapsone. CONCLUSION To our knowledge, this is the first double-blind, placebo controlled study of dapsone in CIU and indicates that dapsone has efficacy in patients with antihistamine refractory CIU.
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Affiliation(s)
- Matt Morgan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Allergy, Asthma, and Immunology of North Texas, McKinney, Texas
| | - Andrew Cooke
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laura Rogers
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Chicago Lake Shore Allergy and Asthma, Chicago, Ill
| | - Beverley Adams-Huet
- Division of Biostatistics, Department of Clinical Sciences, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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Wozel G, Blasum C. Dapsone in dermatology and beyond. Arch Dermatol Res 2013; 306:103-24. [PMID: 24310318 PMCID: PMC3927068 DOI: 10.1007/s00403-013-1409-7] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 07/30/2013] [Accepted: 08/19/2013] [Indexed: 12/21/2022]
Abstract
Dapsone (4,4′-diaminodiphenylsulfone) is an aniline derivative belonging to the group of synthetic sulfones. In 1937 against the background of sulfonamide era the microbial activity of dapsone has been discovered. Shortly thereafter, the use of dapsone to treat non-pathogen-caused diseases revealed alternate antiinflammatory mechanisms that initially were elucidated by inflammatory animal models. Thus, dapsone clearly has dual functions of both: antimicrobial/antiprotozoal effects and anti-inflammatory features similarly to non-steroidal anti-inflammatory drugs. The latter capabilities primarily were used in treating chronic inflammatory disorders. Dapsone has been investigated predominantly by in vitro methods aiming to get more insights into the effect of dapsone to inflammatory effector cells, cytokines, and/or mediators, such as cellular toxic oxygen metabolism, myoloperoxidase-/halogenid system, adhesion molecules, chemotaxis, membrane-associated phospholipids, prostaglandins, leukotrienes, interleukin-8, tumor necrosis factor α, lymphocyte functions, and tumor growth. Moreover, attention has been paid to mechanisms by which dapsone mediates effects in more complex settings like impact of lifespan, stroke, glioblastoma, or as anticonvulsive agent. Additionally, there are some dermatological investigations in human being using dapsone and its metabolites (e.g., leukotriene B4-induced chemotaxis, ultraviolet-induced erythema). It could be established that dapsone metabolites by their own have anti-inflammatory properties. Pharmacology and mechanisms of action are determining factors for clinical use of dapsone chiefly in neutrophilic and/or eosinophilic dermatoses and in chronic disorders outside the field of dermatology. The steroid-sparing effect of dapsone is useful for numerous clinical entities. Future avenues of investigations will provide more information on this fascinating and essential agent.
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Affiliation(s)
- Gottfried Wozel
- Study Centre for Clinical Trials, Dermatology, Gesellschaft für Wissens- und Technologietransfer der Technischen Universität Dresden mbH, Blasewitzer Str. 43, 01307 Dresden, Germany
| | - Christian Blasum
- Private Practice of Dermatology, Marktplatz 25, 73728 Esslingen, Germany
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Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, Gower R, Kahn DA, Kaplan AP, Katelaris C, Maurer M, Park HS, Potter P, Saini S, Tassinari P, Tedeschi A, Ye YM, Zuberbier T. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J 2012; 5:125-47. [PMID: 23282382 PMCID: PMC3651155 DOI: 10.1097/wox.0b013e3182758d6c] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.
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Affiliation(s)
- Mario Sánchez-Borges
- Department of Allergy and Clinical Immunology, Centro Médico-Docente La Trinidad, Caracas, Venezuela
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno-Dugnano, Milan, Italy
| | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quirón Bizkaia, Bilbao, Spain
| | - Ilaria Baiardini
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section University of Cincinnati, Cincinnati, OH
| | - G Walter Canonica
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Richard Gower
- Department of Medicine, University of Washington, Spokane, WA
| | - David A Kahn
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Allen P Kaplan
- Division of Pulmonary and Critical Care Medicine and Allergy and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Connie Katelaris
- Department of Allergy and Immunology, University of Western Sydney and Campbelltown Hospital, Sydney, Australia
| | - Marcus Maurer
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Paul Potter
- Allergy Diagnostic & Clinical Research Unit, University of Cape Town Lung Institute, Groote Schuur, South Africa
| | - Sarbjit Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Paolo Tassinari
- Immunology Institute, Faculty of Medicine, Universidad Central de Venezuela, Caracas, Venezuela
| | - Alberto Tedeschi
- U.O. Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Torsten Zuberbier
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
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Maurer M, Altrichter S, Ardelean E, Krause K, Magerl M, Metz M, Siebenhaar F, Weller K, Zuberbier T. [Therapeutic alternatives for antihistamine-refractory urticaria]. Hautarzt 2011; 61:765-9. [PMID: 20711555 DOI: 10.1007/s00105-010-1934-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with chronic spontaneous urticaria, the most frequent non-acute form of urticaria, generally exhibit a clinical picture of persistent disease, a high degree of disease activity, considerable impairment of quality of life, and poor response to treatment. More than half of the patients continue to develop symptoms despite standard therapy with non-sedating antihistamines. In these cases, the antihistamine dose should be increased (up to four times the daily dose). If this approach also does not result in symptom control, the high-dose antihistamine should be combined with a leukotriene antagonist and if necessary an H2 blocker. If the patient does not respond to this combination therapy, cyclosporin A, dapsone, or omalizumab should be administered.
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Affiliation(s)
- M Maurer
- Klinik für Dermatologie, Venerologie und Allergologie, Allergie-Centrum-Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin.
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9
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Abstract
Chronic urticaria, a major health problem causing patient's distress, induces often physicians' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.
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Affiliation(s)
- Sudha Yadav
- From the Departments of Skin, Veneral Disease, and Leprosy, M.L.N. Medical College, Allahabad, UP, India.
| | - A K Bajaj
- From the Departments of Skin, Veneral Disease, and Leprosy, M.L.N. Medical College, Allahabad, UP, India.
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Bingham CO. Immunomodulatory approaches to the management of chronic urticaria: an immune-mediated inflammatory disease. Curr Allergy Asthma Rep 2008; 8:278-87. [PMID: 18606079 DOI: 10.1007/s11882-008-0046-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although commonly encountered in clinical practice, chronic urticaria (CU) remains difficult to treat. In contrast to acute urticaria, neither exogenous triggers nor specific immunoglobulin E are identified in most chronic cases. A body of evidence suggests that CU is represented within the spectrum of immune-mediated inflammatory diseases (IMID). Our understanding of the CU disease pathogenesis now recognizes a role for T cells, B cells, and autoantibodies, and intrinsic abnormalities of histamine-releasing effector cells, thus providing new targets of intervention beyond the current mainstay of often inadequate symptomatic treatment directed against histamine receptors and steroids, with their attendant morbidities. Agents previously used to treat other autoimmune and inflammatory diseases have demonstrated efficacy in CU. Newer biologic and nonbiologic immunomodulatory agents approved for other indications and in clinical development provide potential options for this often severe disease.
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Affiliation(s)
- Clifton O Bingham
- Divisions of Rheumatology and Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
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