Chronic urticaria and infections

Impact of autoimmune gastritis on chronic urticaria in paediatric patients - pathophysiological point of views

We would like to provide an updated comprehensive perspective and identify the components linked to chronic spontaneous urticaria (CSU) without specific triggers in autoimmune atrophic gastritis (AAG). AAG is an organ-specific autoimmune disease that affects the corpus-fundus gastric mucosa. Although we lack a unified explanation of the underlying pathways, when considering all paediatric patients reported in the literature, alterations result in gastric neuroendocrine enterochromaffin-like (ECL) cell proliferation and paracrine release of histamine. Several mechanisms have been proposed for the pathogenesis of CSU, with much evidence pointing towards AAG and ECL cell responses, which may be implicated as potential factors contributing to CSU. The excessive production/release of histamine into the bloodstream could cause or trigger exacerbations of CSU in AAG, independent of Helicobacter pylori; thus, the release of histamine from ECL cells may be the primary modulator.

CONCLUSION

Considering the understanding of these interactions, recognising the respective roles of AAG in the pathogenesis of CSU may strongly impact the diagnostic workup and management of unexplained/refractory CSU and may inform future research and interventions in the paediatric population.

WHAT IS KNOWN

• Autoimmune atrophic gastritis is a chronic immune-mediated inflammatory disease characterised by the destruction of the oxyntic mucosa in the gastric body and fundus, mucosal atrophy, and metaplastic changes. • Autoimmune atrophic gastritis in paediatric patients is important because of the poor outcome and risk of malignancy and possibly underestimated entities primarily reported in single-case reports.

WHAT IS NEW

• Upper gastrointestinal inflammatory disorders, independent of H. pylori, have been implicated as potential inducing factors in the development of chronic spontaneous urticaria. • If a paediatric patient presents with symptoms such as anaemia, reduced vitamin B12 levels, recurrent urticaria with no other detectable aetiology, positive anti-parietal cell antibodies, and elevated gastrin levels, autoimmune atrophic gastritis should be considered a possible cause of chronic urticaria.

Evaluation of Pediatric Chronic Urticaria with Emphasis on Clinical and Laboratory Characteristics and Treatment Response to Omalizumab: A Real-Life Experience from a Tertiary Allergy Center

Pediatric data on the clinical and etiologic features, treatment response, and use of omalizumab for chronic urticaria (CU) are quite limited. The aim of this study was to evaluate the clinical and demographic characteristics, laboratory findings, and response to treatment of CU in children. Children with a diagnosis of CU between 2019 and 2023 were included in the study. Information on demographic characteristics, clinical features, laboratory tests, provocation tests for inducible urticaria, urticaria activity scores (UAS7), and treatment responses were obtained from patients' medical records. A total of 150 children (50.7% male) with CU were enrolled in the study. A total of 14 (9.3%) patients had autoimmune diseases of which 11 (7.3%) had autoimmune thyroiditis. Overall, 97 (64.7%) patients had chronic spontaneous urticaria (CSU) and 53 (35.3%) had chronic inducible urticaria. A total of 16 patients who remained symptomatic despite high-dose antihistamines were treated with omalizumab, with a good response in 13 (81.3%) and a partial response in 3 (18.7%) patients. CSU accounts for the majority of pediatric CU, with the etiology being in part related to an autoimmune background. This study provides an overview of CU in children and demonstrates the safety and efficacy of treatment with omalizumab.

Time Course of Priming Effect of TF Inducers on Synergistic TF Expression and Intra-Cellular Gap Formation of Human Vascular Endothelial Cells via the Extrinsic Coagulation Cascade

Chronic spontaneous urticaria (CSU) is characterized by daily recurring wheal and flare with itch for more than 6 weeks. The extrinsic coagulation system has been shown to be activated in correlation with CSU severity. We have reported that tissue factor (TF), a trigger of the extrinsic coagulation cascade, is synergistically expressed on vascular endothelial cells by simultaneous stimulation with TF inducers (TFI), followed by activation of the extrinsic coagulation cascade and hyper permeability in vitro. However, vascular endothelial cells are not likely to be simultaneously stimulated by multiple TFIs under physiological conditions. Therefore, in order to know whether sequential, rather than simultaneous, stimuli with interval may induce synergistic activation of TF, we investigated the time course of the priming effects of each TFI for synergistic TF expression in vascular endothelial cells (HUVECs). We stimulated HUVECs with a TFI (first stimulation) and then stimulated cells with another TFI at indicated time points (second stimulation) and detected TF expression and activity. The TF expression induced by simultaneous stimulation diminished in a few hours. However, both synergistic enhancement of TF expression and activation level of the coagulation cascade were detected even when the second stimulation was added 18 or 22 h after the first stimulation. Thus, the priming effect of TFI for synergistic TF expression may persist for a half day or longer.

Chronic Urticaria and Angioedema: Masqueraders and Misdiagnoses

Chronic urticaria is a common condition presenting with intensely pruritic wheals. Although individual lesions resolve within 24 hours, by definition, chronic urticaria lasts for a duration of at least 6 weeks. Both spontaneous and inducible forms exist. In the spontaneous variant, chronic urticaria occurs in the absence of clearly identifiable triggers. In chronic inducible urticaria, specific triggers may include dermatographism, cholinergic (heat), cold, exercise, delayed pressure, and solar. Extensive laboratory evaluation for chronic spontaneous urticaria is not required unless indicated by clinical history or physical examination. Angioedema describes sudden onset of localized edema involving the deep layers of the skin and submucosal tissues. It can be seen in isolation or in conjunction with chronic urticaria. Angioedema typically resolves slower than wheals, taking up to 72 hours or longer. Histamine- and bradykinin-mediated forms exist. Both chronic urticaria and angioedema have many mimics, and a broad range of differential diagnoses should be considered. Importantly, an incorrect diagnosis may have significant implications for the additional investigation, treatment, and prognosis of the affected patient. The aim of this article is to discuss the characteristics of chronic urticaria and angioedema, and an approach to the investigation and diagnosis of their mimics.

How Infection and Vaccination Are Linked to Acute and Chronic Urticaria: A Special Focus on COVID-19

Since more than a century ago, there has been awareness of the connection between viral infections and the onset and exacerbation of urticaria. Our knowledge about the role of viral infection and vaccination in acute and chronic urticaria improved as a result of the COVID-19 pandemic but it has also highlighted knowledge gaps. Viral infections, especially respiratory tract infections like COVID-19, can trigger the onset of acute urticaria (AU) and the exacerbation of chronic urticaria (CU). Less frequently, vaccination against viruses including SARS-CoV-2 can also lead to new onset urticaria as well as worsening of CU in minority. Here, with a particular focus on COVID-19, we review what is known about the role of viral infections and vaccinations as triggers and causes of acute and chronic urticaria. We also discuss possible mechanistic pathways and outline the unmet needs in our knowledge. Although the underlying mechanisms are not clearly understood, it is believed that viral signals, medications, and stress can activate skin mast cells (MCs). Further studies are needed to fully understand the relevance of viral infections and vaccinations in acute and chronic urticaria and to better clarify causal pathways.

Urticaria and HIV Infection: A Case Report

Urticaria is a common skin rash, which can be acute or chronic. It can be idiopathic or associated with various disorders and infections, but rarely human immunodeficiency virus (HIV). We report a case of an adult male presenting with a new onset of chronic urticaria. Its workup revealed newly diagnosed HIV. The frequency and severity of urticaria wheals improved significantly with HIV treatment.

Natural History and Influencing Factors of Chronic Urticaria in Children

Purpose

Chronic urticaria (CU) can reduce the quality of life of children and their parents, but there are only a few studies on the course of CU in children. This study aimed to investigate the natural course of CU in children and identify the factors that influence its prognosis.

Methods

We evaluated 77 children diagnosed with CU, who were monitored for at least 48 months. Subjects were classified as either chronic spontaneous urticaria (CSU) or other CU, and the clinical features were compared. Remission was defined as having no symptoms without treatment for more than 1 year. The remission rate was analyzed, and the factors influencing the prognosis were investigated.

Results

The average age of the study population was 5.96 ± 4.06 years, and 64 (83.1%) patients had CSU. The remission rates at 6 months, 1 year, 2 years, 3 years, and 4 years after symptom onset were 22.1%, 40.3%, 52.0%, 63.7%, and 70.2%, respectively, for children with CU. For children with CSU, these values were 23.4%, 43.7%, 56.2%, 68.7%, and 75.0%, respectively. The total serum immunoglobulin E (IgE) levels were positively correlated with disease duration (r = 0.262, P = 0.021); no other factors were associated with the duration of the disease.

Conclusions

A high proportion of children with CU were classified as CSU. No indicators, except for total IgE were found to predict the timing of spontaneous remission. The CU remission rate identified in this study is expected to be used as one of the reference data for the progress of CU in patients.

Epidemiology, comorbidities, and healthcare utilization of patients with chronic urticaria in Germany

BACKGROUND

Comprehensive data on the epidemiology and comorbidities of chronic urticaria (CU) in Germany are either limited, or not contemporary.

OBJECTIVES

To investigate the epidemiology of CU, overall comorbidities and healthcare resource utilized by patients with CU in Germany, using an anonymized statutory health insurance (SHI) database.

METHODS

Anonymized SHI claims research database of the Institute for Applied Health Research, Berlin [InGef] (01 January 2015-30 September 2018) was used to analyse insured individuals with a confirmed diagnosis of CU (ICD-10-GM codes). Twelve-month diagnosed prevalence and incidence, comorbidities (vs. atopic dermatitis and psoriasis), and healthcare utilization by patients with CU were investigated.

RESULTS

Of 4 693 772 individuals of all ages listed in the database, 3 538 540 were observable during 2017. Overall, 17 524 patients (˜0.5%) were diagnosed with CU; chronic spontaneous urticaria (CSU: 71.2%), chronic inducible urticaria (CIndU: 19.7%), CSU+CIndU (9.1%). Females, vs. males, had higher diagnosed prevalence (0.62% vs. 0.37%) and diagnosed incidence (0.18% vs. 0.11%) of CU among all patients. Patients most frequently visited general practitioners (41.3% of total visits). Hypertensive diseases (43.5%), lipoprotein metabolism disorders (32.1%) and affective disorders (26.0%) were the most frequently reported comorbidities of special interest. Rates of most comorbidities of special interests were similar to atopic dermatitis and psoriasis patients, and all higher vs. overall population. More than half (54.1%) of all CU patients were not prescribed any treatment. Second-generation H₁ -antihistamines were the most commonly prescribed medication for adult (17.9%) and paediatric (27.9%) patients. Patients with CIndU (paediatric, 15.5%; adult, 7.8%) were more often hospitalized versus patients with CSU (paediatric, 9.9%; adult, 4.6%).

CONCLUSIONS

In Germany, prevalence of CU along with multiple comorbidities may pose increased burden on the healthcare system. Awareness of adhering to treatment guidelines, and aiming for complete control of urticaria, needs to be driven and may improve outcomes.

The Role of Coagulation and Complement Factors for Mast Cell Activation in the Pathogenesis of Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is a common skin disorder characterized by an almost daily recurrence of wheal and flare with itch for more than 6 weeks, in association with the release of stored inflammatory mediators, such as histamine, from skin mast cells and/or peripheral basophils. The involvement of the extrinsic coagulation cascade triggered by tissue factor (TF) and complement factors, such as C3a and C5a, has been implied in the pathogenesis of CSU. However, it has been unclear how the TF-triggered coagulation pathway and complement factors induce the activation of skin mast cells and peripheral basophils in patients with CSU. In this review, we focus on the role of vascular endothelial cells, leukocytes, extrinsic coagulation factors and complement components on TF-induced activation of skin mast cells and peripheral basophils followed by the edema formation clinically recognized as urticaria. These findings suggest that medications targeting activated coagulation factors and/or complement components may represent new and effective treatments for patients with severe and refractory CSU.

Treatment satisfaction in chronic urticaria during guideline-based therapy

BACKGROUND AND OBJECTIVES

Patients with chronic urticaria are often unsatisfied with their treatment. We aimed to assess patient satisfaction, chronic urticaria control, treatment goals, self-treatment competence, knowledge, and factors influencing treatment satisfaction.

PATIENTS AND METHODS

Eighty-seven adult patients with chronic urticaria who were previously insufficiently treated with oral antihistamines received guideline-based care for six months and completed questionnaires.

RESULTS

This study included patients with chronic spontaneous (80 %) and/or inducible urticaria (CIndU, 32 %). Significant median improvements were observed with the urticaria control test (UCT, from 7 to 11), the urticaria activity score for patients with chronic spontaneous urticaria (from 19 to 10), and treatment satisfaction (from 5.2 to 8.4). Six significant, independent factors of treatment satisfaction after six months of treatment were identified (negative: male sex, CIndU, sleep disturbances; positive: UCT, baseline treatment satisfaction, perceived competence of the study physician). Adequate urticaria control (UCT ≥ 12) was achieved in 19 % of patients with CIndU and 61 % of patients without CIndU.

CONCLUSIONS

In patients with chronic urticaria who were previously insufficiently treated with antihistamines, six months of guideline-based therapy significantly improved disease control and treatment satisfaction. Adequate control requires several consultations for many patients and is considerably more difficult to achieve for CIndU.

The impact of COVID-19 pandemic on the management of patients with chronic urticaria: An observational two-center study from Turkey

The Coronavirus Disease 2019 (COVID‐19) outbreak significantly affected the clinical practice in hospitals and the management of many diseases. The aim of this study was to evaluate the effect of pandemic‐related factors on the severity and course of chronic urticaria (CU). A total of 194 CU patients who were on regular follow‐up, were enrolled in the study. The disease activity was assessed by means of the weekly urticaria activity score (UAS7) and urticaria control test (UCT). Patients were divided into two subgroups according to their disease aggravation as “aggravated” and “non‐aggravated”. Two groups were compared in terms of demographic, clinical, COVID‐19‐associated parameters, and parameters related with the effect of COVID‐19 pandemic on CU management. The omalizumab use was statistically higher (P = .017), and the systemic corticosteroid use was statistically lower (P = .025) in the “aggravated” group. Adherence to quarantine was significantly lower in the “aggravated” group (P = .027). 173 patients (89.2%) were unable to contact a dermatologist during the pandemic. Among 186 patients who received treatment for CU before the pandemic, 48 (25.8%) did not continue the existing treatment during the pandemic. CU aggravated in one patient with COVID‐19 and remained stable in the other. This study showed that CU patients, especially those on omalizumab therapy, had difficulties in attending medical care and even in the maintenance of their existing therapies during the pandemic. Creating novel follow‐up and treatment models as well as the increased use of teledermatology might be beneficial in the management of this life‐disturbing condition.

The association of chronic spontaneous urticaria (CSU) with anxiety and depression: a nationwide cohort study

Chronic spontaneous urticaria (CSU) is a dermatological disease associated with significant impairment of overall quality of life as well as psychological distress. Previous studies have demonstrated significant comorbidity between CSU and a wide range of mental illnesses. In this study we aimed to focus on the association between CSU and anxiety and depression, using an optimized matched controlled design. A nationwide matched control study was conducted using the Clalit Health Services (CHS) database. The study included 12,539 CSU patients and 60,510 age and sex matched controls. Three multiple logistic regression models were conducted to assess the association between CSU and anxiety and depression, while adjusting for age, sex, socioeconomic status (SES), diabetes, obesity, hypertension, and smoking status. A higher frequency of anxiety and depression was found in CSU patients compared to that in controls (anxiety frequency of 9.6% vs. 5.7%, p < 0.001; depression frequency of 11% vs 7.9%, p < 0.001, respectively) after adjustment for demographic and clinical factors. The association of CSU with anxiety was the strongest in the 18-29 age group, and in the high SES group, while the association of CSU with depression was the highest in the 50-69 age group, and in the low SES group. Chronic spontaneous urticaria is associated with anxiety and depression. In light of the clinical implications of a comorbid mental disorder, dermatologists should consider employing mental health screening procedures, especially for patients from specific risk groups.

Impact of mycoplasma pneumonia infection on urticaria: A nationwide, population-based retrospective cohort study in Taiwan

Mycoplasma pneumonia (MP) infection might be pathogenically closely related to urticaria. This study is a nationwide population-based cohort study from 1997 to 2013, which investigated the association between MP infection and urticaria in Taiwan. A total of 1,175 patients were included for the study group, and 2,350 for the control group. Multivariate Cox regression analysis was performed to estimate the adjusted hazard ratio (aHR) for urticaria. Result showed that 254 patients with new-onset urticaria were involved in the study group and 465 incident cases in the control group. The incidence rates (per 100,000 person-months) of urticaria were 37.2 and 32.5 in the study and control groups, respectively. The relative risk is 1.1 (95% CI = 1.0–1.3) indicating no significant correlation between MP and urticaria. The multivariate analysis revealed that the risk of urticaria with MP infection (aHR = 1.1, P = 0.1058) had no statistically significance difference compared to the control group. However, the risk of urticaria in MP-infected patients aged between 20 and 59 years old was found to have increased (aHR = 1.6, 95% CI = 1.1–2.2) prior to a diagnosis.

Increased risk of psoriasis in patients with chronic rhinosinusitis without nasal polyps: a longitudinal follow-up study using Korean national sample cohort

PURPOSE

Focal chronic inflammation or infection is thought to be one of the causes of psoriasis. Few reports on the association between chronic rhinosinusitis (CRS) and psoriasis exist, thus it is poorly defined. This study seeks to investigate the incidence of psoriasis in patients with CRS with reference to a matched control group.

METHODS

This national cohort study relies on data from Korean Health Insurance Review and Assessment Service-National Sample Cohort (HIRA-NSC), which were entered from 2002 to 2013. A total of 34,219 patients with CRS without nasal polyps was matched with 136,976 controls. The Cox proportional hazard model was used to analyze the crude (simple) and adjusted hazard ratios (HRs) of psoriasis. For subgroup analysis, participants were grouped by age and sex.

RESULTS

The risk of psoriasis was higher in the CRS group than in the control group (adjusted HR 1.28, 95% CI 1.12-1.47, P < 0.001). Children, adolescents below 19 years regardless of sex, and old adult men above 60 years are at significantly higher risk for subsequent psoriasis after CRS diagnosis.

CONCLUSION

CRS may increase the risk of psoriasis.

Chronic spontaneous urticaria and the extrinsic coagulation system

Chronic spontaneous urticaria (CSU) is a common skin disorder characterized by daily or almost daily recurring skin edema and flare with itch. Recently, the activation of the blood coagulation cascade has been suggested to be involved in CSU, but the trigger of the coagulation cascade remains unclear. In this article, we review recent understanding of the relationship between the pathogenesis of CSU and extrinsic coagulation reactions. In CSU, vascular endothelial cells and eosinophils may play a role as TF-expressing cells for activating the extrinsic coagulation pathway. Moreover, the expression of TF on endothelial cells is synergistically enhanced by the activation of Toll-like receptors and histamine H₁ receptors. The activated coagulation factors may induce plasma extravasation followed by degranulation of skin mast cells and edema formation recognized as wheal in CSU. Molecules involved in this cascade could be a target for new and more effective treatments of urticaria.

Checklist for a complete chronic urticaria medical history: an easy tool

BACKGROUND

Existing guidelines do not offer a quick, efficient alternative to the patient's recollection of relevant clinical features during anamnesis and physical examination for chronic urticaria (CU). This study aimed to identify specific items reflecting the main characteristics of CU that should be included in a comprehensive medical history for patients with CU. We also aimed to clarify possible eliciting factors for CU to support accurate diagnosis of the disease.

METHODS

A panel of postgraduate dermatologists conducted a literature search for relevant studies on CU using Medline, the Cochrane database, and PubMed.

RESULTS

We identified82 articles from which we drew a collection of items to inform development of an easy-to-use checklist and collection of items that should be included in a correct medical history. The final version of the checklist included42 items across two areas: essential clues for anamnesis and diagnosis of CU; and typical symptoms/parameters or characteristics according to subtype, etiology, and laboratory findings. Items included time of disease onset; duration, shape, size, color, and distribution of wheals; associated angioedema; atopy; and triggering factors.

CONCLUSIONS

Our guide provides an easy-to-use tool to support clinicians to focus, orient themselves, and save time in medical consultations for CU, allowing better diagnosis and management of this disease.

Taiwanese Dermatological Association consensus for the definition, classification, diagnosis, and management of urticaria

BACKGROUND/PURPOSE

This report describes the 2014 consensus of the Taiwanese Dermatological Association regarding the definition, classification, diagnosis, and management of urticaria. This consensus is distributed to practices throughout Taiwan to provide recommendations for diagnostic and therapeutic approaches for common subtypes of urticaria, in order to improve the quality of life of urticaria patients. The consensus, thus, serves as an important reference for dermatologists throughout Taiwan.

METHODS

All the consensus contents were voted on by the participating dermatologists, with approval by no less than 75% being required for inclusion. The consensus provides a comprehensive overview of urticaria, including recent advances in identifying its causes and the processes by which it develops.

RESULTS

All the consensus meeting attendees agreed to a definition of urticaria, which states that it is characterized by the sudden appearance of wheals (also known as hives), angioedema, or both. Most of the experts (16 out of 19, or 84.2%) agreed that chronic urticaria is defined as the sudden occurrence of wheals and/or angioedema for a period of ≥ 6 weeks. In addition, the consensus attendees also approved the Urticaria Activity Score system or the Urticaria Activity Score for 7 days system as the recommended method for assessing disease activity in spontaneous urticaria.

CONCLUSION

It was also determined that the treatment goal for patients with any form of urticaria should be complete cessation of suffering from all urticaria symptoms. The recommended treatment algorithms for chronic spontaneous urticaria and acute urticaria were finally proposed and approved by 100% (19/19) and 84.2% (16/19) of the consensus attendees, respectively.

Role of nidi of infection in various skin diseases

Reviewed scientific publications that define the location of foci of chronic infections in dermatology. Indicated by the currently existing problematic issues and their solutions.

A neglected cause for chronic spontaneous urticaria in children: Helicobacter pylori

BACKGROUND

The aetiology of chronic urticaria is usually considered idiopathic. There is a paucity of research both on the prevalence of Helicobacter pylori infection in the aetiology of chronic spontaneous urticaria (CU) in children and also on which patients H. pylori should be investigated.

METHODS

All paediatric and adult patients who presented to the allergy outpatient clinic due to CU between January 2011 and July 2012 were included in this prospective, randomised study. Stool samples from all patients were examined for the H. pylori antigen. Paediatric and adult patients who had a positive stool test for the H. pylori antigen were reassessed following eradication therapy.

RESULTS

Thirty-two children with CU and 35 adults with CU were enrolled in the study. Ten of the 32 (31.2%) children and 18 of the 35 (51.4%) adults were H. pylori positive (p=0.09). All children with positive-H. pylori were older than eight years of age. There was a significant positive correlation between age and the frequency of H. pylori infection (p<0.001; r=0.61). The presence of H. pylori was not significantly associated with the presence of GI (gastrointestinal) symptoms (p>0.05). Following H. pylori eradication, urticarial symptoms recovered in 15 of the adults (83.3%) and 10 of the paediatric (100%) patients (p=0.172).

CONCLUSION

In the current study we found that H. pylori is common among children with CU, particularly after eight years of age. We suggest that CU patients with an unknown aetiology should be routinely screened for H. pylori even if they do not present with GI symptoms and that those with H. pylori-positive results may receive treatment.

Relationship between Helicobacter pylori and idiopathic chronic urticaria: effectiveness of Helicobacter pylori eradication

INTRODUCTION

Chronic urticaria (CU) is defined as the presence of urticaria on most days of the week for a period of 6 weeks or longer. Some studies have reported an association between CU and Helicobacter pylori (H. pylori) infection.

AIM

To determine the prevalence of H. pylori infection using the stool antigen test in patients with idiopathic CU and to investigate the infected patients with CU following eradication of H. pylori.

MATERIAL AND METHODS

One hundred patients with idiopathic CU and 100 healthy controls were referred to our clinic between May 2012 and June 2013 and were tested for H. pylori antigen. The patients infected with H. pylori received quadruple therapy for 2 weeks. To assess eradication efficacy, a repeated H. pylori stool antigen test was performed in each patient 6 weeks after the end of anti-H. pylori therapy. The effectiveness of eradication therapy on CU was assessed 3 months after treatment.

RESULTS

Thirty-six percent patients with idiopathic CU were infected with H. pylori while 23% of the controls were infected. Response to eradication therapy was evident in 33 (91.67%) patients in whom H. pylori was eradicated while 3 (8.33%) patients showed no response despite eradication of H. pylori. Clinical follow-up of 33 successfully treated patients 3 months later revealed complete remission of urticaria in 54.5%, partial remission in 18.2%, and no improvement in 27.3%.

CONCLUSIONS

The results of our study suggest that H. pylori infection should be included in diagnostic workup of patients with no response to habitual treatment for CU or symptomatic gastrointestinal patients. For the diagnosis of H. pylori infection, one should consider the costs and accessibility of the population to the HpSA(®) stool antigen test and Urea breath test (UBT).

Positive associations between infections of Toxoplasma gondii and seropositivity with Anisakis simplex in human patients suffering from chronic urticaria

Toxoplasma gondii is a food-borne and orofecal microorganism which produces chronic infection, and attempts have been made to prove its negative association with atopy in the context of the hygiene hypothesis. Anisakis simplex is a fish parasite associated with chronic urticaria (CU) in endemic regions. We analysed the relationship between both infectious agents in CU. We included 42 patients with chronic urticaria (18 patients with CU associated with A. simplex sensitization and 24 not sensitized CU patients). Patients were assessed for atopy by a skin prick test (SPT) against common aeroallergens and for respiratory symptoms. Anisakis simplex sensitization was assessed by SPT and specific IgE by CAP fluoro-enzyme immunoassay (CAP-FEIA). Anti-T. gondii IgG levels were measured by enzyme-linked immunosorbent assay (ELISA). CU patients were analysed with respect to T. gondii seropositivity, A. simplex sensitization, atopy and immigrant status. The seroprevalence of T. gondii was 40.5% in CU patients and 42.1% in the control group. Immigrants were more frequently infected by T. gondii (41.2% versus 12%; P =0.036). Anti-T. gondii IgG antibodies were associated with past A. simplex parasitism (odds ratio 6.73; P =0.03) and independently with atopic sensitization (odds ratio 5.85; P =0.04). In CU patients, T. gondii has no protective effect on atopic sensitization or A. simplex sensitization.

The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update

This guideline is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The life-time prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria do not only cause a decrease in quality of life, but also affect performance at work and school and, as such, are members of the group of severe allergic diseases. 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. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Herpesvirus-associated acute urticaria: an age matched case-control study

Background

Acute and recurrent acute urticaria are often associated with multiple factors including infections and recent data suggest a role for herpesviruses.

Objective

To test the null hypothesis, that is, there is no association of herpesvirus infections with urticaria.

Methods

Thirty-seven patients between one month and 15 years of age were age matched to 37 controls who were healthy or had mild acute respiratory infections but without urticaria. Patients and controls were followed for 1 to 6 years. Diagnostic studies included DNA detection by real-time PCR for herpes simplex virus (HSV) types 1 and 2, Epstein-Barr virus (EBV), cytomegalovirus (CMV) and human herpesvirus-6 (HHV-6). Tests for other infections included adenovirus, parvovirus B 19, respiratory syncytial virus, influenza A, Group A streptococci, rotavirus, and parasites.

Results

Specific infections were diagnosed in 26 of 37 cases and among 9 of 37 control children (P=0.0002). Single or concomitant herpesvirus infections occurred in 24 cases and in 4 controls (65% vs 11 %, p=0.0003). Cases had 10 HHV-6 infections, 8 CMV infections, 5 EBV infections, and 4 HSV-1 infections.

Conclusion

Herpesvirus infections are associated with acute or recurrent acute urticaria.

Disease activity only moderately correlates with quality of life impairment in patients with chronic spontaneous urticaria

BACKGROUND

The impact of chronic spontaneous urticaria (CSU) on health-related quality of life (HRQoL) is widely held to be mainly influenced by disease activity and comorbidities.

OBJECTIVE

To assess the correlation between disease activity and HRQoL impairment by using validated disease-specific instruments.

METHODS

The Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) was translated into Greek and subsequently applied to 110 CSU patients along with the Dermatology Life Quality Index and the Urticaria Activity Score. After the validity and reliability of the Greek CU-Q2oL had been determined, we assessed the relation between disease activity and HRQoL impairment by computing correlations as well as by performing multiple regression analysis.

RESULTS

Exploratory factor analysis revealed a six-scale structure of the Greek CU-Q2oL that explained 67.9% of its total variance. The internal consistency was satisfactory with Cronbach's α >0.7. Disease activity was the only predictor of quality of life impairment, but it only moderately correlated with the CU-Q2oL total score (r = 0.40, p < 0.0001).

CONCLUSION

Our results suggest that there are additional factors to disease activity that are responsible for the pronounced reduction of HRQoL in CSU, and this supports the recommendation to assess and monitor both disease activity and quality of life in CSU patients.

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.

Streptococcal tonsillitis as a cause of urticaria: tonsillitis and urticaria

BACKGROUND

The primary role of infections in chronic urticaria (CU) is controversial. We hypothesised that streptococcal tonsillitis (ST) could be a primary cause of CU or acute recurrent urticaria (ARU).

METHODS

Retrospective study of 14 outpatients observed between January 2000 and December 2009, with CU/ARU and clinical and/or laboratorial suspicion of an aetiopathogenic link with ST. Clinical history, objective examination and laboratorial study were looked for. Three groups were defined: spontaneous resolution of urticaria, resolution after tonsillectomy, and still symptomatic.

RESULTS

In these patients, a causal relationship between ST and urticaria is supported by: markers of streptococcal infection, the perception of a clinical relationship between tonsillitis and urticaria, the decrease of urticaria severity with early antibiotherapy to tonsillitis and urticaria resolution after tonsillectomy.

CONCLUSIONS

Our study encourages the investigation of tonsillitis in these otherwise idiopathic patients, especially until young adulthood and even in the absence of any symptoms.

Chronic urticaria following acute hepatitis A

Urticaria has a documented association with the prodromal phases of hepatitis A, B and, although still contentious, likely hepatitis C. Despite the documented association there are few actual reported cases of urticaria occurring with hepatitis A infection and in all of the cases reported so far the urticaria preceded the diagnosis of hepatitis A and was acute rather than chronic. We describe a case of urticaria occurring following acute infection with hepatitis A, which persisted beyond 6 weeks and therefore was by definition chronic. Although chronic urticaria has been reported to be associated with other forms of viral hepatitis, to the best of our knowledge this has not been reported previously with hepatitis A.

Screening of hepatitis C virus genotypes in urticaria patients in Saudi Arabia

OBJECTIVE

The main objective of this study was to estimate the prevalence of hepatitis C virus (HCV) infection and to determine the HCV genotypes in urticaria patients of Saudi Arabia.

METHODS

After thorough clinical examination by a consultant dermatologist, urticaria patients and individual healthy controls were enrolled. Venous blood collected from subjects was analyzed for LFT (aspartate transaminase [AST], alanine transaminase [ALT], albumin, and bilirubin), hepatitis B surface antigen (HBsAg), and HCV antibodies--HCV-RNA-PCR screening and genotyping.

RESULTS

Upon enzyme immunoassay (EIA) screening for HCV infection, 5/70 (7.1%) urticaria patients and none among the controls tested positive for the presence of anti-HCV antibodies (p=0.005). Genotyping analysis revealed that HCV belongs to types 3 and 4 with subtypes 3a, 4a, and 4c. No significant variations were seen in the mean serum levels of ALT, AST, albumin, and bilirubin between the patients based on their HCV sero-positivity status.

CONCLUSION

This prospective study indicated that HCV infection plays a significant role in urticaria. However, larger studies in different ethnicities could ascertain the association between different HCV genetic variants and the urticaria.

A Summary of the New International EAACI/GA(2)LEN/EDF/WAO Guidelines in Urticaria

Urticaria is a heterogeneous group of disorders, especially acute urticaria and angiooedema can be a medical emergency. This paper summarizes the EAACI/GA(2)LEN/EDF/WAO guidelines, the most recent international guidelines from 2009. Patients with urticaria are often not diagnosed and treated appropriately and the guidelines state that clinicians should always aim to provide complete symptom relief. The mainstay of urticaria treatment is the use of modern nonsedating antihistamines, if required up to 4-fold of standard doses.

Comorbidities between nose and skin allergy

PURPOSE OF REVIEW

This review focuses on comorbidities between nose and skin allergies. For this purpose, allergic rhinitis and chronic rhinosinusitis (CRS) were selected as examples of nasal disorders and atopic dermatitis and urticaria as examples of allergic skin disorders and the individual entities of both localizations were evaluated and compared in relation to their prevalence and coincidence, underlying pathophysiological mechanisms, genetic data and shared therapy options.

RECENT FINDINGS

The inter-relationships between atopic dermatitis and allergic rhinitis are the best studied, but even for the other comorbidities it was possible to demonstrate comparable pathomechanisms in addition to a high prevalence and coincidence, particularly in the case of atopically assisted forms. In this context, the interactions of IgE, mast cells and eosinophils play a special role, but genetic issues, the significance of epithelial barrier defects and colonization with Staphylococcus aureus are also important sharing issues.

SUMMARY

Allergic skin disorders such as atopic dermatitis and urticaria are frequently associated with comorbidities of the nose as well as allergic rhinitis and CRS. By contrast, different manifestations of these diseases involve the nose and the skin. These are not separate diseases but are linked by complex and currently unclear/insufficiently defined inter-relationships.

A Summary of the New International EAACI/GALEN/EDF/WAO Guidelines in Urticaria

Urticaria is a heterogeneous group of disorders, especially acute urticaria and angiooedema can be a medical emergency. This paper summarizes the EAACI/GALEN/EDF/WAO guidelines, the most recent international guidelines from 2009. Patients with urticaria are often not diagnosed and treated appropriately and the guidelines state that clinicians should always aim to provide complete symptom relief. The mainstay of urticaria treatment is the use of modern nonsedating antihistamines, if required up to 4-fold of standard doses.

Evidence-based evaluation and management of chronic urticaria in children

Urticaria affects nearly 25% of the population at some time in their lives. In a subset of children, urticaria will develop into a chronic condition that can greatly affect quality of life. Although numerous causes and triggers are proposed for chronic urticaria (CU) in children, ranging from infections, allergens, and medications to physical factors and autoimmune disease, the exact etiology is not always identifiable. Accordingly, a large subset of cases are designated "chronic idiopathic urticaria." Because of the clinical complexities of CU, as well as the confusing literature on this topic, we have developed a conceptual framework based on the cumulative evidence to assist with the categorization, clinical evaluation, and treatment of CU in children.

Chronic urticaria

Chronic urticaria (CU) is a disturbing allergic condition of the skin. Although frequently benign, it may sometimes be a red flag sign of a serious internal disease. A multitude of etiologies have been implicated in the causation of CU, including physical, infective, vasculitic, psychological and idiopathic. An autoimmune basis of most of the 'idiopathic' forms is now hypothesized. Histamine released from mast cells is the major effector in pathogenesis and it is clinically characterized by wheals that have a tendency to recur. Laboratory investigations aimed at a specific etiology are not always conclusive, though may be suggestive of an underlying condition. A clinical search for associated systemic disease is strongly advocated under appropriate circumstances. The mainstay of treatment remains H1 antihistaminics. These may be combined with complementary pharmacopeia in the form of H2 blockers, doxepin, nifedipine and leukotriene inhibitors. More radical therapy in the form of immunoglobulins, plasmapheresis and cyclophosphamide may be required for recalcitrant cases. Autologous transfusion and alternative remedies like acupuncture have prospects for future. A stepwise management results in favorable outcomes. An update on CU based on our experience with patients at a tertiary care centre is presented.

Different serum cytokine levels in chronic vs. acute Anisakis simplex sensitization-associated urticaria

The knowledge on immune mechanisms of chronic urticaria (CU) at the cytokine level is widely scarce. We compared pro- and anti-inflammatory as well as Th1- and Th2-associated serum cytokine levels in two phenotypes of CU: associated with (CU+) and without (CU⁻) sensitization against Anisakis simplex, a ubiquitous fish parasite, that has been associated with acute urticaria in gastro-allergic anisakiasis (GAA) and with CU+. Thirteen CU+ and 19 CU⁻ patients were compared with 13 GAA patients and 15 control subjects for cytokines, measured by cytometric bead array. Urticaria activity score was positively correlated with IL-6 in CU⁻. Serum levels of IL-10 were lower in CU+ and CU⁻ with respect to the control group. Median IFN-γ was lower in all urticaria groups. Patients with previous parasitism by A. simplex displayed higher TGF-β levels than subjects without previous parasitism. The main finding was lower levels of IL-17 in CU+ with respect to GAA or controls, with a further tendency to even lower levels in CU⁻. Different urticaria phenotypes are associated with distinct serum cytokine levels.

Chronic urticaria: etiology and natural course in children

BACKGROUND

Chronic spontaneous urticaria (CSU) in childhood is infrequent, and information about the disease in children is limited. We attempted to investigate its etiologic factors, natural course, and predictors of prognosis.

METHODS

All children aged ≤ 18 years followed for CSU during an 8-year period were analyzed retrospectively, and the final outcomes were queried via a telephone interview.

RESULTS

One hundred patients (male/female ratio 1.27) with a median age of 9.2 years (range 0.7-17.2) at symptoms onset were evaluated. The median follow-up was 2.5 years (range 0.2-18.1). An autologous serum skin test was positive in 46.7% of the subjects (n = 45), with a female predominance (71.4%) (p = 0.023). In 13.8% of the children, ANA titers were over 1/100. Food allergy (n = 1), thyroid autoantibodies (n = 3), possible collagen disease (n = 1), and drug usage (deferoxamine) (n = 1) were found to be associated factors. Infections could not be confirmed as the cause of CSU. Recovery was seen in 16.5, 38.8, and 50.0% of the children after 12, 36, and 60 months, respectively. Though in multivariate analysis none of the factors, including age, gender, autologous serum skin test positivity, the presence of angioedema, or other allergic diseases, appeared to predict the prognosis, in univariate analysis being female and being older than 10 years of age predicted an unfavorable prognosis.

CONCLUSION

The etiology of CSU in children is mainly related to an autoreactive background, as in adults. CSU has a favorable prognosis, and resolution is seen in half of the children within 5 years. Girls older than 10 years may have an unfavorable prognosis.

Urticaria and thyroid autoimmunity

BACKGROUND

Chronic urticaria is a common clinical condition whose etiology, in about 75% of cases, is unknown and is therefore called chronic idiopathic urticaria (CIU). A link between CIU and autoimmune thyroid diseases was proposed several decades ago. Here we review this topic.

SUMMARY

Several studies have been performed to determine if and to what degree there is an association between CIU and autoimmune thyroid diseases, particularly autoimmune thyroiditis. Many of these studies were not well controlled, however. Approximately one-fourth of CIU patients have serological evidence of thyroid autoimmunity, suggesting that these two disorders are associated. The mechanisms for the apparent association between CIU and serological evidence of thyroid autoimmunity are not clear. There are no data regarding the correlations between CIU and histological features of autoimmune thyroiditis or hypothyroidism. Despite this, there are anecdotal reports regarding L-thyroxine administration in patients with CIU.

CONCLUSIONS

Screening for thyroid autoimmunity is probably useful in patients with CIU. More solid evidence, based on still lacking well-conducted controlled studies, is desirable to determine if there is a therapeutic role for L-thyroxine treatment in ameliorating the skin manifestations of urticaria.

Chronic urticaria is associated with a differential helminth-arthropod-related atopy phenotype

The relationship between atopic sensitization and chronic urticaria is still controversial. In this study, we aimed to compare the prevalence of aeroallergen sensitization in chronic urticaria patients with (CU/As+) and without (CU/As-) sensitization against Anisakis simplex. Forty-nine CU/As+ and 80 CU/As- patients were studied and skin prick tests (SPT) were performed against aeroallergens. We assessed sensitization in a subgroup of patients with allergic rhinoconjunctivitis and/or bronchial asthma (RCBA) and compared the prevalence with a control group of 522 non-urticaria patients with RCBA. Forty-five percent of CU/As- and 60.4% of CU/As+ patients displayed positive SPT to at least one aeroallergen. CU/As+ patients had a higher prevalence of sensitization against pollen, mould or dander (PMD) (52.2% vs 29.1%, P < 0.01), whereas the prevalence of house dust mite (HDM) sensitization was not statistically different (26.3% in CU/As- and 36.7% in CU/As+). However, in chronic urticaria patients with RCBA, 53.8% of CU/As- and 57.9% of CU/As+ patients differed in the prevalence of HDM sensitization compared to the control group (33.5%, P = 0.03), whereas no difference could be stated for PMD sensitization. Compared to RCBA patients, both CU/As+ and CU/As- patients have a higher clinically relevant sensitization rate against HDM, thus displaying a differential atopy phenotype.

Chronic spontaneous urticaria in children: itching for insight

While there is increasing information about the pathogenesis and treatment of chronic spontaneous urticaria (csU) in adults, there is little published information about csU in children. Consequently, most of the recommendations contained in current guidelines for the prevention and treatment of csU in infants and children is based on extrapolation of data obtained in adults. To rectify this, this review points out critical gaps in our knowledge and suggests strategies which may help us to improve our understanding of this condition. How common is csU in children? What do we know about its clinical presentation and the presence of useful biomarkers? What are its common underlying causes? What is the course of csU in children? How does csU affect the everyday life of children? What treatment options are available for children? To answer these questions, two separate types of information are required. The first is information about the prevalence of the condition in the community at large and how csU affects the everyday life of both the child-patient and the parent or carer. Because most csU cases in infants and children do not come to specialists but are treated by general practitioners or by parents using over-the-counter medications, these questions may be answered only by general population surveys or schools programmes. The second is clinical information including family history and disease presentation, the presence of biomarkers and comorbidities, objective measures of severity, frequency and duration of exacerbations, the response to therapy and the time to remission. Targeted questionnaires need to be developed and validated for these investigations. This has already begun in Germany with the establishment of the CU-KID Netzwerk (Email address: cu-kid@charite.de), the aim of which is to identify clinical centres and colleagues who treat children with urticaria and to initiate the information gathering described above.

Practical management of antibiotic allergy in adults

This review looks at the main issues around immediate hypersensitivity and the role and limitations of testing. The majority of literature on antibiotic hypersensitivity relates to β-lactam antibiotics, mainly because of the heavy usage of this class of drugs. Concerns around cross-reactivity always worry clinicians, particularly in the emergency situation. Reasonable data now exist in relation to β-lactam antibiotics and derivatives, which enable appropriate risk management to be undertaken. The available literature for other classes of antibiotics is also discussed.

Significant factors associated with severity and outcome of an initial episode of acute urticaria in children

The aim of this study was to determine the predictive factors of severity and duration of an initial episode of acute urticaria in children. This was a retrospective study of 1120 children of <18 yr who presented to the emergency department (ED) with an initial episode of acute urticaria during the period January 1, 2001, to December 31, 2007. These patients were followed in the ED or outpatient department (OPD) until their symptoms subsided. Variables comprising mild, moderate, and severe urticaria were compared to determine the predictors of severity. The relationships between duration of urticaria and clinical features, including physician-diagnosed causes and treatment modalities, were also analyzed. Significant predictive factors of severity of an initial episode of acute urticaria in children included age, physician-diagnosed causes of urticaria, clinical presentation, coexistent pyrexia or angioedema, and personal allergic history (all p < 0.001). The duration of urticaria was dependent on the physician-diagnosed causes and treatment. Inhalants and unknown causes were predictive of longer duration, while contact materials were associated with shorter duration of urticaria (p < 0.001). Combination treatment comprising an oral plus injectable form of antihistamine or corticosteroid significantly shortened the duration of urticaria compared to single treatment (p < 0.001), especially in children receiving short-term aggressive treatment in the pediatric observation unit (POU) of the ED.

Treatment strategies in urticaria

Urticaria is a common group of disorders encountered in dermatology and in a variety of other fields. In particular, acute urticaria and angiooedema are common medical emergencies, which are treated in the first instance in the Accident and Emergency Department, whereas chronic urticaria poses a challenge in the long-term treatment. This review presents the latest evidence about the treatment for urticaria and is based on the most recent international guidelines (GA(2)LEN, Global Allergy and Asthma Network, 2009). Patients with acute and chronic urticaria are often not treated appropriately and this review provides a guide for any clinician to treat the underlying cause as well as the symptoms of this disorder according to the latest evidence. Many new therapies are available to patients with urticaria refractory to common therapies and it is important to consider second- and third-line therapies.