Update on chronic urticaria: focusing on mechanisms

Secondary Syphilis Presentation and Urticarial Eruption After Moderna COVID-19 Vaccination

The diversity of the cutaneous manifestations of syphilis and the ability of the spirochete to evade diagnosis have been well documented by medical literature. However, what triggers the onset of secondary syphilis is not yet clear because of difficulties studying the bacterium. Our case describes the onset of a heterogeneous rash (or coexisting rashes) that presented the day after vaccination with the Moderna mRNA-1273 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. The potential etiologies of the patient's rash: A vaccine reaction, reactivation of chronic spontaneous urticaria, or a physical sign of syphilis itself are then reviewed. The potential for the Moderna coronavirus disease 2019 (COVID-19) vaccine to be the catalyst of this patient's cutaneous manifestations of his immune system responses is also hypothesized.

REMOVED: Plasma Steroids and Endocannabinoids Used as Biomarkers to Assess the Pruritus Severity of Patients With Prurigo Nodularis

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the first author and the approval of all of the co-authors. After publication, the author contacted the journal regarding errors affecting the statistical analysis: the incorrect identification of patients in the part of clinical information and biomarker's levels led to incorrect conclusions of the study. The data is lacking experimental verification due to data loss and errors. The editor in chief accepted the retraction. The authors offer their apologies.

REMOVED: Plasma Steroids and Endocannabinoids Used as Biomarkers to Assess the Pruritus Severity of Patients With Prurigo Nodularis

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the first author and the approval of all of the co-authors. After publication, the author contacted the journal regarding errors affecting the statistical analysis: the incorrect identification of patients in the part of clinical information and biomarker's levels led to incorrect conclusions of the study. The data is lacking experimental verification due to data loss and errors. The editor in chief accepted the retraction. The authors offer their apologies.

Association among stress, hypocortisolism, systemic inflammation, and disease severity in chronic urticaria

BACKGROUND

Chronic urticaria (CU) is an immune-mediated disease characterized by wheals for at least 6 weeks. The role of stress and the correlation of stress, hypocortisolism, and inflammatory markers are not well understood.

OBJECTIVES

To estimate C-reactive protein (CRP), interleukin (IL)-18, and cortisol levels in patients with CU and to explore their association with disease severity and stress.

METHODS

Forty-five patients with CU and 45 age- and sex-matched healthy controls were recruited for this cross-sectional study. Disease severity was assessed by the urticaria activity score (UAS) and stress by Presumptive Stressful Life Events (PSLE) and Daily Hassles and Uplifts Scale-Revised (DHUS-R) scoring. IL-18 and high-sensitivity CRP (hs-CRP) were estimated using enzyme-linked immunosorbent assay kits and cortisol levels by chemiluminescence.

RESULTS

We observed significant systemic inflammation (increased hs-CRP and IL-18 levels) and stress scores, whereas there was a lowering of basal cortisol levels in patients with CU compared with controls. This finding was more pronounced with increasing disease severity and autoimmune disease, except for stress scores, which did not vary between patients with positive and negative autologous plasma skin test results. We further observed that patients with CU with hypocortisolism had higher levels of hs-CRP and IL-18 and higher PSLE and DHUS-R scores compared with those without hypocortisolism. The hs-CRP level, IL-18 level, PSLE score, DHUS-R score, and duration of the symptoms are significantly positively correlated with UAS, whereas the cortisol level is significantly negatively correlated with UAS. Cortisol has a significant negative correlation with PSLE score, DHUS-R score, and the duration of the disease.

CONCLUSION

CU is associated with systemic inflammation and stress, along with a significant lower basal cortisol, especially with severe disease and autoimmune urticaria. Thus, chronic stress may precipitate the vicious cycle in the pathogenesis of CU.

Gene expression profiles in chronic idiopathic (spontaneous) urticaria

BACKGROUND

The pathophysiology of chronic idiopathic (spontaneous) urticaria (CIU) is poorly understood.

OBJECTIVE

We hypothesized that a study of gene expression in active lesions from patients with CIU would uncover unexpected associations.

METHODS

We enrolled eight patients with CIU and six healthy controls, and obtained 4 mm punch biopsy specimens of active lesions and unaffected skin of patients with CIU and of skin from normal controls. Routine histologic evaluation was performed, RNA was isolated, and gene expression data were assessed. Due to technical reasons, the final evaluation included six samples of lesional skin, six samples of nonlesional skin, and five samples of normal skin.

RESULTS

As expected, lesional skin had more inflammatory cells per high-powered field (mean ± SE, 96 ± 6) than did samples from nonlesional skin of the subjects with CIU (17 ± 2) (p < 0.01). Lesions of CIU showed significant upregulation of 506 genes and reduced expression of 51 genes. Those most upregulated were predominantly involved in cell adhesion (e.g., selectin E [SELE]), cell activation (e.g., CD69), and chemotaxis (e.g., CCL2). Twelve independent canonical pathways with p ≤ 0.001 were identified (including intracellular kinase pathways (RAs-related nuclear protein [RAN] and Janus activated kinase/interferon), cytokine signaling pathways (IL-9, IL10, and IFN), a strong inflammatory response (interferon, IL-9, IL-10, inducible nitric oxide synthase and glucocorticoid pathways) and increased cell proliferation (RAN signaling, cell cycle control, and tRNA charging).

CONCLUSIONS

This preliminary study describes a method to study gene activation in urticarial lesions and demonstrated a strong inflammatory response with a large variety of activated genes that are distinct from those reported with other dermatologic conditions.

How Effective is Autologous Serum Therapy in Chronic Autoimmune Urticaria

Background:

Chronic autoimmune urticaria (CAU) is one of the most challenging therapeutic problems faced by a dermatologist. Recently, weekly autologous serum injections have been shown to induce a prolonged remission in this disease.

Aim:

To evaluate the efficacy of repeated autologous serum injections in patients with CAU.

Materials and Methods:

Seventy patients of CAU were prospectively analyzed for the efficacy of nine consecutive weekly autologous serum injections with a post-intervention follow-up of 12 weeks. Total urticaria severity score (TSS) was monitored at the baseline, at the end of treatment and lastly at the end of 12 weeks of follow up. Response to treatment was judged by the percentage reduction in baseline TSS at the end of treatment and again at the end of 12 weeks-follow-up.

Results:

Out of the 70 patients enrolled, 11 dropped out of the injection treatment after one or the first few doses only. Among the rest of 59 patients, only 7 patients (12%) went into a partial or complete remission and remained so over the follow-up period of 12 weeks. Forty patients (68%) did not demonstrate any significant reduction in TSS at the end of the treatment period. Rest of the 12 patients showed either a good or excellent response while on weekly injection treatment, but all of them relapsed over the follow-up period of 12 weeks.

Conclusion:

Autologous serum therapy does not seem to lead to any prolonged remission in patients of CAU.

Platelet and other hemostatic characteristics in patients with chronic urticaria

Several publications have pointed out the importance of coagulation and fibrinolysis in the occurrence of chronic urticaria (CU), but only a few indicated the direct role of platelets. We assessed platelet aggregation and evaluated parameters of coagulation and fibrinolysis in patients with CU. Patients (n = 34) diagnosed as having CU and 36 healthy controls were enrolled. Platelet aggregation was assayed using an impedance aggregometer and adenosine diphosphate, arachidonic acid, thrombin receptor-activating peptide (TRAP), and ristocetin as agonists. In patients with CU, significantly decreased platelet aggregation to some agonists (ristocetin and TRAP) was observed. The D-dimer levels were elevated, mean platelet volume was decreased, but no alteration was observed in other coagulation assays. Elevated D-dimer levels indicated that coagulation and fibrinolysis are activated in the patients with CU. Evaluation of platelet function may contribute to identify the role of these cells in the pathogenesis of CU.

Evaluation of autologous serum skin test and skin prick test reactivity to house dust mite in patients with chronic spontaneous urticaria

Background

Chronic spontaneous urticaria (CSU) is a common skin disorder with etiology that is not well understood.

Methods

In this study, we evaluated the prevalence of autologous serum skin test (ASST) and skin prick testing (SPT) to house dust mite (HDM) in 862 CSU cases in China. Clinical features, courses and treatment responses were also recorded.

Results

The prevalence of positive ASST was 46.3%, and patients aged 30–39 years had the highest positive rate (52.1%). Positive SPT to HDM was seen in 153 patients (17.7%) with the highest positive rate (34.2%) in patients aged 20 or less. Patients with positive ASST had higher urticaria activity scores (UAS) (4.18±0.65 vs. 3.67±0.53) but lower positive rates of HDM (24.6% vs. 37.6%), as compared with those with negative ASST (odds ratio (OR) 1.84, 95% CI 1.38–2.47). Patients could be categorized into four groups based on the results of ASST and SPT to HDM and patients with positive ASST and positive SPT to HDM had the highest disease activity scores, experienced higher frequencies of angioedema, diseases duration, and required higher dosage of loratadine every month, compared with other subgroups (P<0.0001).

Conclusions

Patients with CSU showed varied responses of positive ASST and varied sensitivity to HDM, Patients with positive ASST and/or positive SPT had more disease activity compared with patients with negative ASST and/or negative SPT. Further classification can be made based on the result of SPT and ASST.

[Selected psychosomatic aspects of dermatologic practice]

In recent years, mental disorders and diseases have moved more and more into the focus of public attention and play an increasingly larger role in clinical practice. Dermatologists are familiar with the relationship between psyche and skin, but they not are only confronted with patients whose mental illness afflicts the skin, but also by those with problems of coping with serious and/or stigmatizing skin diseases. Furthermore, there are psychological influences on the course of various dermatologic diseases. The present article provides an overview over the complex interactions between mental and cutaneous disease and presents treatment options.

Urticaria and angioedema

Urticaria and angioedema are common disorders that can severely impair the quality of a patient's life and can be extremely difficult to treat. Symptoms can persist for years to decades. The causes of urticaria and angioedema are varied and may be immunologic, nonimmunologic, or idiopathic. This article reviews the literature and provides primary care physicians with up-to-date information of the epidemiology, basic pathophysiology, diagnosis, and management of this common and often debilitating condition. Additionally, clinical manifestations of acute and chronic urticaria, hereditary and acquired angioedema, as well as the physical urticarias will be discussed.

Chronic urticaria: a comparison of management guidelines

INTRODUCTION

Chronic urticaria is characterized by recurring episodes of spontaneous transient dermal wheals and pruritus, with or without angioedema, which can persist for ≥ 6 weeks. Chronic urticaria impairs quality of life, emphasizing the need for effective treatments. Professional societies and clinical experts have issued evidence-based recommendations for the management of chronic urticaria, including recommending the use of second-generation antihistamines as a first-line therapy.

AREAS COVERED

A Medline search was conducted from 2000 to 2011 using the following terms, alone or in combination: 'chronic urticaria', 'management guidelines', 'consensus guidelines' and 'expert opinions'. Ten management guidelines/expert opinions met the inclusion criteria.

EXPERT OPINION

There was a universal agreement among the articles reviewed, that low-sedating, second-generation antihistamines should be prescribed as a first-line treatment of chronic urticaria. For refractory urticaria, however, recommendations varied and included dose escalation of second-generation antihistamines and adjunctive treatments with other agents of the same class, such as sedating antihistamines or leukotriene receptor antagonists. More research into effective second-line treatments and consistent implementation of current guidelines is needed, to ensure that treatment is based on clinical evidence.

Mast cells as cellular sensors in inflammation and immunity

Mast cells are localized in tissues. Intense research on these cells over the years has demonstrated their role as effector cells in the maintenance of tissue integrity following injury produced by infectious agents, toxins, metabolic states, etc. After stimulation they release a sophisticated array of inflammatory mediators, cytokines, and growth factors to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, but they have also been shown to regulate other infiltrating immune cell functions. Research in recent years has revealed that the outcome of mast cell actions is not always detrimental for the host but can also limit disease development. In addition, mast cell functions highly depend on the physiological context in the organism. Depending on the genetic background, strength of the injurious event, the particular microenvironment, mast cells direct responses ranging from pro- to anti-inflammatory. It appears that they have evolved as cellular sensors to discern their environment in order to initiate an appropriate physiological response either aimed to favor inflammation for repair or at the contrary limit the inflammatory process to prevent further damage. Like every sophisticated machinery, its dysregulation leads to pathology. Given the broad distribution of mast cells in tissues this also explains their implication in many inflammatory diseases.

IgE mediated autoallergy against thyroid peroxidase--a novel pathomechanism of chronic spontaneous urticaria?

BACKGROUND

Chronic spontaneous urticaria (csU), which is characterized by recurrent episodes of mast cell-driven wheal and flare-type skin reactions, is often associated with elevated total IgE levels and thyroid autoimmunity. We speculate that some csU patients express IgE autoantibodies against thyroid antigens such as thyroid peroxidase (TPO), which could bind to skin mast cells and induce their activation.

METHODS

We developed and used a site-directed human IgE capture ELISA to quantify IgE-anti-TPO. We used this assay and investigated csU patients (n = 478) and healthy control subjects (n = 127) for IgE-anti-TPO and then assessed IgE-anti-TPO-positive and -negative csU patients for clinical and serological differences.

PRINCIPAL FINDINGS

CsU patients were found to express more than 2fold higher IgE-anti-TPO serum levels as compared to healthy control subjects (p<0.001). 54% of csU patients had serum levels higher than the cut off ( = 5 IU/ml). By distribution analyses we identified two distinct subpopulations of csU patients: 1) IgE-anti-TPO(low) ( = 39%, IgE-anti-TPO: median 2.17 interquartile range 0.86-5.44,  =  comparable to healthy controls) and 2) IgE-anti-TPO(high) ( = 61%, IgE-anti-TPO: median 6.67, interquartile range 5.39-8.24). IgE-anti-TPO-positive and -negative csU patients had very similar distributions of age and gender as well as disease activity and duration. IgE-anti-TPO-positive csU patients exhibited significantly higher IgG-anti-TPO levels and lymphocyte counts as well as decreased C4 complement levels.

CONCLUSION

Our findings show that a sizeable subgroup of csU patients expresses IgE antibodies against thyroid peroxidase. These autoantibodies could cause "autoallergic" mast cell activation, a novel pathomechanism of chronic spontaneous urticaria.

Clinical evaluation and treatment of chronic urticaria

Chronic urticaria is a common disease characterized by recurrent pruritic wheals with surrounding erythema for >6 weeks. It is associated with a significant health care burden and affects patient quality of life. The etiology of chronic urticaria is often difficult to elucidate; however, known etiologies include autoimmune urticaria, physical urticarias (eg, cold, cholinergic, and delayed pressure urticaria), and idiopathic urticaria. The etiology is unknown in many patients, leading to a diagnosis of chronic idiopathic urticaria. The diagnosis of chronic idiopathic urticaria can be challenging for the primary care physician because of the disease's chronic symptoms. Diagnosis requires a detailed patient history and comprehensive physical examination, with additional testing tailored to the patient's history. Effective treatments include antihistamines, leukotriene receptor antagonists in combination with antihistamines, and oral immunomodulatory drugs, including corticosteroids, cyclosporine, dapsone, hydroxychloroquine, and sulfasalazine. Newer experimental therapies include intravenous immunoglobulin and omalizumab. This article reviews the pathophysiology, diagnosis, and treatment of chronic urticaria.