Effectiveness of Helicobacter pylori eradication in chronic urticaria: evidence-based analysis using the Grading of Recommendations Assessment, Development, and Evaluation system. Curr Opin Allergy Clin Immunol. 2010;10:362-369. [PMID: 20610979 DOI: 10.1097/aci.0b013e32833c79d7]

[Which augmentation and trigger factors are relevant in urticaria?]

The aim of this review is to present relevant trigger as well as augmentation factors that can induce or exacerbate urticaria on the basis of a current, PubMed-based literature search. In addition to a brief description of relevant influencing factors in acute and chronic inducible urticaria, the focus will be on chronic spontaneous urticaria. In particular, the aggravating role of medication, stress, food, psychological and metabolic comorbidities, infections and inflammation as well as hormonal processes will be discussed.

Potential Therapeutic Approaches for Chronic Urticaria: Beyond H1-Antihistamines and Biologics

Chronic urticaria is a disease that can significantly impact a patient's quality of life and ability to function. There are effective treatment options, such as nonsedating antihistamines or biologics, but some patients do not respond to these therapies, or the therapies are not available or affordable to all patients. This review aims to summarize potential treatment strategies for patients (1) who do not respond to antihistamines and (2) cannot readily access or do not respond to biologics. The review emphasizes the importance of sound clinical practice, including correct diagnosis of chronic urticaria phenotypes, treatment of associated comorbidities, and consideration of add-on pharmacological and nonpharmacological approaches. Although some treatments may lack high-quality evidence, they may still be justifiable in certain cases, provided that there is shared decision-making, regular reassessment, and early recognition of adverse events.

Management of Allergic Skin Disorders in Pregnancy

The safe management of allergic skin disorders during pregnancy is essential to maternal and fetal health. Poorly controlled allergic skin disease affects the health of mother and child. This article reviews the disease course and treatment of atopic dermatitis, chronic urticaria, and allergic contact dermatitis in pregnancy. It focuses on topical and systemic therapies in the context of pregnancy and breastfeeding. Because disease activity may vary in pregnancy, prescription stewardship is imperative; a balance among disease control, minimum effective dosing, and medication safety profiles should be maintained. Secondary complications and risks to maternal or infant health should also be avoided.

S3 Guideline Urticaria. Part 2: Treatment of urticaria - German-language adaptation of the international S3 guideline

This publication is the second part of the German-language S3 guideline on urticaria. It covers the management of urticaria and should be used together with Part 1 of the guideline on classification and diagnosis. This publication was prepared according to the criteria of the AWMF on the basis of the international English-language S3 guideline with special consideration of health system conditions in German-speaking countries. Chronic urticaria has a high impact on the quality of life and daily activities of patients. Therefore, if causal factors cannot be eliminated, effective symptomatic treatment is necessary. The recommended first-line treatment is to administer new generation, non-sedating H1 antihistamines. If the standard dose is not sufficiently effective, the dose should be increased up to fourfold. For patients who do not respond to this treatment, the second-line treatment in addition to antihistamines in the treatment algorithm is omalizumab and, if this treatment fails, ciclosporin. Other low-evidence therapeutic agents should only be used if all treatments in the treatment algorithm agreed upon by the guideline group fail. Both the benefit-risk profile and cost should be considered. Corticosteroids are not recommended for long-term treatment due to their inevitable severe side effects.

Acupuncture for gastrointestinal urticaria: A protocol for systematic review and network meta-analysis

Introduction

The purpose of this review is to evaluate the effectiveness and safety of acupuncture in the treatment of patients with gastrointestinal urticaria (GU) and to provide a clinician's guide to GU treatment options.

Methods and analysis

We plan to search multiple databases (i.e., PubMed, EMBASE, Springer, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database and Wanfang Database) for studies published before September 1, 2022. We will electronically search for all relevant studies concerning clinical acupuncture treatments of GU, including unpublished conference articles and other gray literature. The language limit of this systematic review is Chinese and English. Any reports of clinical randomized controlled trials of acupuncture for the treatment of GU will be included in the study. Two researchers will perform independent data extraction to increase the quality of the data extraction. The primary outcome was the Urticaria Activity Score 7 (UAS7). Abdominal visual analog scale (VAS) for abdominal pain, dermatological life quality index (DLQI), the total effective rate, recurrence rate, and occurrence of adverse events were secondary outcomes. We will use RevMan V.5.3 statistical software for pairwise meta-analysis and ADDIS V.1.16.8 software for Bayesian network meta-analysis. If feasible, meta-regression and subgroup analyses will also be performed to address the potential causes of inconsistency and heterogeneity. We will conduct a GRADE assessment of the quality of evidence for the interventions included in this review.

Discussion

This study may validate acupuncture as an alternative therapy for the effective treatment of GU.

Trial registration number

PROSPERO CRD42022333977.

Urticaria

Urticaria is an inflammatory skin disorder that affects up to 20% of the world population at some point during their life. It presents with wheals, angioedema or both due to activation and degranulation of skin mast cells and the release of histamine and other mediators. Most cases of urticaria are acute urticaria, which lasts ≤6 weeks and can be associated with infections or intake of drugs or foods. Chronic urticaria (CU) is either spontaneous or inducible, lasts >6 weeks and persists for >1 year in most patients. CU greatly affects patient quality of life, and is linked to psychiatric comorbidities and high healthcare costs. In contrast to chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU) has definite and subtype-specific triggers that induce signs and symptoms. The pathogenesis of CSU consists of several interlinked events involving autoantibodies, complement and coagulation. The diagnosis of urticaria is clinical, but several tests can be performed to exclude differential diagnoses and identify underlying causes in CSU or triggers in CIndU. Current urticaria treatment aims at complete response, with a stepwise approach using second-generation H1 antihistamines, omalizumab and cyclosporine. Novel treatment approaches centre on targeting mediators, signalling pathways and receptors of mast cells and other immune cells. Further research should focus on defining disease endotypes and their biomarkers, identifying new treatment targets and developing improved therapies.

Pediatric chronic spontaneous urticaria: a brief clinician's guide

INTRODUCTION

Chronic urticaria (CU) appears with daily or intermittent/recurrent wheals with/without angioedema for more than six weeks. When no specific eliciting factors are found, chronic urticaria is defined as spontaneous (CSU). Up to 50% of patients with CSU do not respond to therapy, leading to a prolonged disease course and the need for expensive therapies, impacting the quality of life (QoL) and healthcare resources.

AREAS COVERED

: Diagnosis of CSU is made when other potential causes of chronic urticaria are excluded. CSU therapy aims to achieve complete control of symptoms and normalization of QoL. Current treatment options for urticaria aim to target mast cell mediators such as histamine, or activators, such as autoantibodies. Guidelines recommend starting with second generation antihistamines (sgAHs) and adding omalizumab therapy if symptoms are not controlled. This review aims to provide a practical guide for CSU in the pediatric population.

EXPERT OPINION

: Treatment options for pediatric CSU are primarily based on adult data that have been extrapolated for children. Current guidelines should be re-evaluated based on pediatric data, new biological treatments, and the COVID-19 pandemic. Future research is needed to investigate strategies to personalize current treatments and identify potential predictive biomarkers.

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

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

Chronic Urticaria: Advances in Understanding of the Disease and Clinical Management

Chronic urticaria (CU) is a common skin condition characterized by the recurrence of wheals, with or without angioedema, which lasts for at least 6 weeks. Owing to its pruritus and incurability, this disease adversely affects the patients' physical and mental health and diminishes the quality of life. CU is generally classified into two subtypes based on the relevance of eliciting factors: chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU), the latter of which is further divided into several subtypes. To improve the understanding and clinical management of this highly heterogeneous disorder, the EAACI/GA²LEN/EDF/WAO guideline was developed and published in 2018 based on evidence and expert consensus. The diagnostic and treatment algorithms proposed by the guideline have largely facilitated dermatologists in clinical practice. However, several questions remained unsolved and have been widely investigated in the recent years. First, a better understanding of the association between chronic urticaria and its potential underlying causes or eliciting factors such as autoimmunity, infections, coagulation aberrance, and vitamin D deficiency is warranted. This would lead to updates in the diagnostic and treatment procedures of different subtypes of chronic urticaria. Secondly, treatment for recalcitrant cases, especially those resistant to or intolerant of second-generation antihistamines and (or) omalizumab, calls for novel therapeutic measures or strategies. In the present review, we summarized recent advances in the understanding and management of both CSU and CIndU, with special emphasis on their underlying causes or eliciting factors, pathogenic mechanisms, potential targets for intervention, and advances in treatment strategies.

The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

BACKGROUND

In chronic spontaneous urticaria (CSU), the guidelines recommend very limited diagnostic procedures during the routine workup, although additional investigations might be indicated in some patients with CSU. For physicians treating patients with CSU, it is often difficult to decide which diagnostic tests are useful.

OBJECTIVE

To provide recommendations on what diagnostic tests should be performed on which patients with CSU.

METHODS

We performed an extensive literature search on the respective topics and identified relevant questions that should prompt diagnostic procedures based on the published evidence and expert consensus among all authors.

RESULTS

We provide questions, diagnostic testing, where appropriate, and recommendation that should be included when assessing the history of a patient with CSU, to explore and rule out differential diagnoses, to assess patients for underlying causes and modifying conditions, to explore patients for comorbid diseases and consequences of having CSU, and to assess patients for CSU components that can help to predict their disease course and response to treatment.

CONCLUSIONS

Here, we provide physicians treating patients with CSU with information about which clues should lead to which tests and why.

Role of Helicobacter pylori Eradication in Chronic Spontaneous Urticaria: A Propensity Score Matching Analysis

Objective

To investigate the role of Helicobacter pylori (HP) eradication in chronic spontaneous urticaria (CSU) treatment.

Methods

Retrospective analysis was performed on the clinical data of 522 patients with CSU who underwent a HP breath test in Hangzhou Third People’s Hospital between January 2018 and December 2019. The CSU-HP(+) group consisted of patients with CSU and HP infection, who were treated with antihistamines combined with HP eradication therapy. The CSU-HP(-) group consisted of patients with CSU alone, who were treated with antihistamines. Propensity score matching (PSM) analysis, using the nearest neighbor matching method on a 1:1 basis, was performed to ensure the characteristics of the CSU-HP(+) and CSU-HP(-) groups were similar. Factors, including age, gender, white blood cells, red blood cells, platelets, alanine transaminase, creatinine, immunoglobulin E, and pre-treatment urticaria activity score (UAS), were matched to obtain a balanced cohort of patients in each group. Therapeutic effects were compared after matching. t-tests, Χ² test, and McNemar’s test were used for comparison between the two groups before and after matching.

Results

Patients in the CSU-HP(+) group reported significantly more gastrointestinal symptoms than those in the CSU-HP(-) group. UAS scores in the second week of treatment were significantly different between the two groups. After 3 months, the recurrence rate in the CSU-HP(+) group was lower than in the CSU-HP(-) group.

Conclusion

Eradication of HP infection in patients with CSU helps relieve gastrointestinal symptoms, improves the therapeutic effect of CSU within 2 weeks, and reduces the recurrence rate 3 months after treatment.

The Effects of Antibiotics for Helicobacter pylori Eradication or Dapsone on Chronic Spontaneous Urticaria: A Systematic Review and Meta-Analysis

Background: Chronic spontaneous urticaria (CSU) is a disease with wheals and/or angioedema. Some drugs, especially antibiotics for Helicobacter pylori (H. pylori) eradication and the sulfone antibiotic dapsone, may be candidates for treating CSU. The present study assessed the efficacy of these antibiotic therapies for CSU. Methods: Databases (MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal and ClinicalTrials.gov) were searched until October 2020. Study selection, data abstraction and quality assessments were independently performed using the Grading of Recommendations Assessment, Development and Evaluation approach. The outcomes were the remission of CSU-related symptoms, activities and adverse events due to antibiotics for H. pylori eradication or dapsone. Results: Nine randomized controlled trials (RCTs; 361 patients) were included. The antibiotics for H. pylori eradication increased the remission rate (risk ratio (RR) = 3.99, 95% confidence interval (CI) = 1.31 to 12.14; I² = 0%), but dapsone did not (RR = 1.15, 95% CI = 0.74 to 1.78). Antibiotics for H. pylori eradication (standard mean difference (SMD) = 1.49, 95% CI = 0.80 to 2.18; I² = 69%) and dapsone (SMD = 7.00, 95% CI = 6.92 to 7.08; I² = 0%) improved symptoms. The evidence of certainty was moderate. Dapsone was associated with mild adverse events, whereas H. pylori eradication was not. Conclusion: Antibiotics, especially those for H. pylori eradication, improved the remission rate and symptoms of CSU with few adverse events. Further studies are needed.

Urticaria: recommendations from the Italian Society of Allergology, Asthma and Clinical Immunology and the Italian Society of Allergological, Occupational and Environmental Dermatology

BACKGROUND

Urticaria is a disorder affecting skin and mucosal tissues characterized by the occurrence of wheals, angioedema or both, the latter defining the urticaria-angioedema syndrome. It is estimated that 12-22% of the general population has suffered at least one subtype of urticaria during life, but only a small percentage (estimated at 7.6-16%) has acute urticaria, because it is usually self-limited and resolves spontaneously without requiring medical attention. This makes likely that its incidence is underestimated. The epidemiological data currently available on chronic urticaria in many cases are deeply discordant and not univocal, but a recent Italian study, based on the consultation of a national registry, reports a prevalence of chronic spontaneous urticaria of 0.02% to 0.4% and an incidence of 0.1-1.5 cases/1000 inhabitants/year.

METHODS

We reviewed the recent international guidelines about urticaria and we described a methodologic approach based on classification, pathophysiology, impact on quality of life, diagnosis and prognosis, differential diagnosis and management of all the types of urticaria.

CONCLUSIONS

The aim of the present document from the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC) and the Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA) is to provide updated information to all physicians involved in diagnosis and management of urticaria and angioedema.

Management of chronic urticaria in children: a clinical guideline

The aim of this guidance is to provide recommendations to clinicians and other interested parties on chronic urticaria in children. The Italian Society for Pediatrics (SIP), the Italian Society for Allergy and Immunology (SIAIP), the Italian Society for Pediatric dermatology (SIDerP) convened a multidisciplinary panel that prepared clinical guidelines for diagnosis and management of chronic urticaria in childhood. Key questions on epidemiology, natural history, diagnosis, and management were developed. The literature was systematically searched and evaluated, recommendations were rated and algorithms for diagnosis and treatment were developed. The recommendations focus on identification of diseases and comorbidities, strategies to recognize triggering factors, improvement of treatment by individualized care.

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

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

Eradication of Helicobacter pylori, as add-on therapy, has a significant, but temporary influence on recovery in chronic idiopathic urticaria: a placebo-controlled, double blind trial in the Polish population

Introduction

The infectious factor like Helicobacter pylori (HP) has been thought to trigger the vicious circle of chronic idiopathic urticaria (CIU), therefore its eradication could modify the course of the disease.

Aim

To reveal the influence of HP eradication on CIU clinical course.

Material and methods

Sixty-four CIU patients, receiving fexofenadine, as the basic treatment, took part in the research, divided into 3 groups: HP patients treated by eradication, HP patients receiving placebo, and patients without bacteria. Gastroscopy, urease test and histopathology were done to detect HP. Patients with HP were randomized and received eradication treatment or placebo. The efficacy of eradication was checked after 6 weeks by means of another gastroscopy, urease test and histopathology. In the 6^th week and in the 4^th and 6^th month after eradication, the symptoms were evaluated basing on the score symptom scale.

Results

Helicobacter pylori did not occur more frequently in CIU patients than in the healthy population. A statistically significant clinical improvement of CIU symptoms was observed in the 6^th week after eradication as compared to the group receiving placebo (p = 0.02) and patients who were not infected (p = 0.02). Further observation in the eradicated patients group revealed the rebound phenomenon – worsening of the clinical state (p = 0.001), which in the 4^th month did not differ from the patients not infected or patients receiving placebo.

Conclusions

Although HP occurs as frequently in CIU patients as in the healthy population, eradication, added to basic antihistaminic treatment, has a significant influence on CIU patients’ recovery parallel to the reduction of stomach inflammation features.

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

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

ACG Clinical Guideline: Treatment of Helicobacter pylori Infection

Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.

A 21-35 kDa Mixed Protein Component from Helicobacter pylori Activates Mast Cells Effectively in Chronic Spontaneous Urticaria

BACKGROUND

Helicobacter pylori (H. pylori) seem to involve in the etiology of chronic spontaneous urticaria (CSU). But studies of the pathogenic mechanism are very little.

METHODS

In this study, we detected the serum-specific anti-H. pylori IgG and IgE antibodies in 211 CSU and 137 normal subjects by enzyme-linked immunosorbent assay (ELISA), evaluated the direct activation effects of H. pylori preparations and its protein components on human LAD₂ mast cell line in vitro, and analyzed the specific protein ingredients and functions of the most effective H. pylori mixed protein component using liquid chromatography-mass spectrometry and ELISA assay.

RESULTS

In CSU patients, the positive rate of anti-H. pylori IgG positive rate was significantly higher than that in normal controls, and the anti-H. pylori IgE levels had no statistical difference between H. pylori-infected patients with and without CSU. Further studies suggested that H. pylori preparations can directly activate human LAD₂ mast cell line in a dose-dependent manner and its most powerful protein component was a mixture of 21-35 kDa proteins. Moreover, the 21-35 kDa mixed protein component mainly contained 23 kinds of proteins, which can stimulate the release of histamine, TNF-a, IL-3, IFN-γ, and LTB4 by LAD₂ cells in a dose-dependent or time-dependent manner.

CONCLUSIONS

A 21-35 kDa mixed protein component should be regarded as the most promising pathogenic factor contributing to the CSU associated with H. pylori infection.

Helicobacter pylori: A significant and treatable cause of chronic urticaria and angioedema

Two outpatient medical offices evaluated 204 patients with chronic urticaria during 2012. This article presents a retrospective study showing that 10% of patients with chronic urticaria may be infected with H. pylori. Furthermore, eradication of infection can be followed by remission of urticaria, reduced morbidity from gastric ulcers, and cancer.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between Helicobacter pylori and extra-gastric diseases

Helicobacter pylori (H. pylori) is confirmed to be associated with many diseases such as gastric cancer, peptic ulcer, gastritis and mucosa-associated lymphoid tissue lymphoma. Recent studies found that H. pylori is associated with many extra-gastric diseases. The underlying mechanism involves autoimmunity, inflammation and oxidative stress. Here we review the association between H. pylori and extra-gastric diseases.

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.

Association between Helicobacter pylori Infection and Chronic Urticaria: A Meta-Analysis

Background. Some studies have shown the possible involvement of Helicobacter pylori (H. pylori) infection in chronic urticaria, but the relationship remains controversial. The aim of this meta-analysis was to quantitatively assess the association between H. pylori infection and chronic urticaria. Methods. Observational studies comparing the prevalence of H. pylori infection in patients with chronic urticaria and control subjects were identified through a systematic search in MEDLINE and EMBASE up to July 2014. H. pylori infection was confirmed by serological or nonserological tests. For subgroup analyses, studies were separated by region, publication year, and H. pylori detection method to screen the potential factors resulting in heterogeneity. Results. 16 studies involving 965 CU cases and 1235 controls were included. Overall, the prevalence of H. pylori infection was higher in urticarial patients than in controls (OR = 1.66; 95% CI: 1.12–2.45; P = 0.01). This result persisted in subanalysis of nine high-quality studies (OR = 1.36; 95% CI: 1.03–1.80; P = 0.03). Subgroup analysis showed that detection method of H. pylori is also a potential influential factor for the overall results. Conclusions. Our present meta-analysis suggests that H. pylori infection is significantly, though weakly, associated with an increased risk of chronic urticaria.

Anaphylaxis and urticaria

Anaphylaxis and urticaria are common presenting allergic complaints. Affecting up to 2% of the population, anaphylaxis is a serious, life-threatening allergic reaction. Although not life-threatening, urticaria is a rash of transient, erythematous, pruritic wheals that can be bothersome and affects up to 25% of the population. All cases of anaphylaxis warrant thorough clinical evaluation by the allergist-immunologist, although most cases of urticaria are self-limited and do not require specialist referral. This article offers an overview of our current knowledge on the epidemiology, pathogenesis, triggers, diagnosis, and treatment of anaphylaxis and urticaria.

Recurrence of chronic urticaria caused by reinfection by Helicobacter pylori

OBJECTIVE

To describe a case of chronic urticaria in a female adolescent associated with Helicobacter pylori infection, confirmed in two different occasions, with improvement of urticaria after the antibacterial treatment.

CASE DESCRIPTION

A 13-year-old female patient sought medical care with chronic urticaria and epigastric pain unresponsive to medical treatment. Laboratorial tests for further investigation were normal except for the upper gastrointestinal endoscopy with biopsy showing moderate chronic active gastritis associated with Helicobacter pylori. After specific and appropriate treatment, the patient had remission of the symptoms. A new upper gastrointestinal endoscopy to control the treatment after nine months was normal. After five years, the patient returned with recurrence of urticaria and epigastric pain. She was taking antihistamines, without any improvement. It was again submitted to screening protocol for chronic urticaria with normal results. She was submitted to upper gastrointestinal endoscopy, which showed positive urease test. The patient started a new treatment for Helicobacter pylori with disappearance of chronic urticaria and epigastric pain within seven days.

COMMENTS

The reported case suggests a causal relationship between the positive diagnosis of Helicobacter pylori and the occurrence of chronic urticaria, showing the remission of symptoms after the institution of effective therapy for this agent. Chronic urticaria is a disease of complex etiology, and although controversial, there is growing evidence of Helicobacter pylori involvement with extraintestinal diseases, including chronic urticaria.

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).

Helicobacter pylori and skin autoimmune diseases

Autoimmune skin diseases are characterized by dysregulation of the immune system resulting in a loss of tolerance to skin self-antigen(s). The prolonged interaction between the bacterium and host immune mechanisms makes Helicobacter pylori (H. pylori) a plausible infectious agent for triggering autoimmunity. Epidemiological and experimental data now point to a strong relation of H. pylori infection on the development of many extragastric diseases, including several allergic and autoimmune diseases. H. pylori antigens activate cross-reactive T cells and induce autoantibodies production. Microbial heat shock proteins (HSP) play an important role of in the pathogenesis of autoimmune diseases because of the high level of sequence homology with human HSP. Eradication of H. pylori infection has been shown to be effective in some patients with chronic autoimmune urticaria, psoriasis, alopecia areata and Schoenlein-Henoch purpura. There is conflicting and controversial data regarding the association of H. pylori infection with Behçet’s disease, scleroderma and autoimmune bullous diseases. No data are available evaluating the association of H. pylori infection with other skin autoimmune diseases, such as vitiligo, cutaneous lupus erythematosus and dermatomyositis. The epidemiological and experimental evidence for a possible role of H. pylori infection in skin autoimmune diseases are the subject of this review.

Helicobacter pylori and autoimmune disease: Cause or bystander

Helicobacter pylori (H. pylori) is the main cause of chronic gastritis and a major risk factor for gastric cancer. This pathogen has also been considered a potential trigger of gastric autoimmunity, and in particular of autoimmune gastritis. However, a considerable number of reports have attempted to link H. pylori infection with the development of extra-gastrointestinal autoimmune disorders, affecting organs not immediately relevant to the stomach. This review discusses the current evidence in support or against the role of H. pylori as a potential trigger of autoimmune rheumatic and skin diseases, as well as organ specific autoimmune diseases. We discuss epidemiological, serological, immunological and experimental evidence associating this pathogen with autoimmune diseases. Although over one hundred autoimmune diseases have been investigated in relation to H. pylori, we discuss a select number of papers with a larger literature base, and include Sjögrens syndrome, rheumatoid arthritis, systemic lupus erythematosus, vasculitides, autoimmune skin conditions, idiopathic thrombocytopenic purpura, autoimmune thyroid disease, multiple sclerosis, neuromyelitis optica and autoimmune liver diseases. Specific mention is given to those studies reporting an association of anti-H. pylori antibodies with the presence of autoimmune disease-specific clinical parameters, as well as those failing to find such associations. We also provide helpful hints for future research.

Chronic urticaria can be triggered by eradication of Helicobacter pylori

BACKGROUND

Participation of Helicobacter pylori (HP) in the pathogenesis of chronic spontaneous urticaria (CU) is subject to dispute, although its eradication proved to be effective for some patients.

AIMS

To investigate the cases of CU following eradication of HP.

METHODS

The cases of patients in whom CU was diagnosed following triple therapy for HP eradication were retrospectively reviewed. The identified patients underwent follow-up examination to exclude drug hypersensitivity and repeated autologous serum skin test (ASST) was done.

RESULTS

From 831 patients with CU, 9 (1.08%) cases of CU related to triple therapy for HP eradication have been detected. In 8 (88.9%) patients CU was associated with positive ASST.

CONCLUSIONS

CU can be triggered by eradication of HP. The pathophysiological mechanisms of CU development following HP eradication are far from being clear, but it could be speculated that the systemic effects of HP eradication may involve some kind of immunomodulation, activating autoimmune mechanisms of CU.

Diagnosis and treatment of urticaria and angioedema: a worldwide perspective

: 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.

Possible benefit from treatment of Helicobacter pylori in antihistamine-resistant chronic urticaria

BACKGROUND

Some patients with chronic spontaneous urticaria (CU) are resistant to conventional doses of antihistamine (AH) medications. Some research groups have reported an association between CU and Helicobacter pylori infection.

AIM

To determine whether H. pylori eradication can reverse AH resistance in CU.

METHODS

We retrospectively reviewed cases of patients with CU, and recorded their Urticaria Activity Score (UAS) and results of a (13)C-urea breath test ((13)C-UBT) for H. pylori infection. Patients without improvement in CU despite a full 8 weeks of AH treatment at four times the initial dose comprised the resistant CU group, while the patients who did respond comprised the responsive CU group. Patients with resistant CU and a positive (13)C-UBT (n = 46) were offered a 14-day treatment with amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily and omeprazole 20 mg twice daily. The effect of H. pylori eradication on CU was evaluated by the UAS, measured at baseline and at 8, 16, and 28 weeks after triple therapy.

RESULTS

Of the 46 patients with resistant CU, 29 (63%) had a positive (13)C-UBT result. Treatment eradicated H. pylori in 18 of the 29 patients (subgroup A), and 11 patients refused the triple therapy (subgroup B). The remaining 17 patients had a negative (13)C-UBT result, (subgroup C). In subgroup A, baseline UAS reduced from 5.29 ± 0.94 to 3.62 ± 0.96 (P = 0.03) at week 8; to 1.43 ± 0.41 (P < 0.001) at week 16, and to 1.17 ± 0.32 (P = 0.04) at week 28. Five of the patients (27.8%) in this group were completely free of symptoms at week 28, whereas none of the untreated patients achieved complete remission.

CONCLUSION

Some patients with resistant CU might benefit from H. pylori eradication.

Histamine H2-receptor antagonists for urticaria

BACKGROUND

Urticaria is a common skin disease characterised by itching weals or hives, which can occur almost anywhere on the body. There are a number of different subtypes and a range of available treatment options. There is lack of agreement on the efficacy of H2-receptor antagonists used in the treatment of urticaria.

OBJECTIVES

To assess the safety and effectiveness of H2-receptor antagonists in the treatment of urticaria.

SEARCH METHODS

We searched the following databases up to 7 October 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2011, Issue 4), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of H2-receptor antagonists in people with a clinical diagnosis of urticaria of any duration or of any subtype. Studies including H1-antihistamines for chronic urticaria are the topic of a separate Cochrane review; thus, they were not included in this review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted and analysed data.

MAIN RESULTS

Four studies of a relatively small size, involving 144 participants, were included in this review. A combination of ranitidine with diphenhydramine was more effective at improving the resolution of urticaria than diphenhydramine administered alone (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.07 to 2.36). Although there was a similar improvement in itching, weal size, and intensity, cimetidine provided no statistically significant greater overall improvement in symptoms of urticaria when compared to diphenhydramine. However, a combination of these medications was more effective than diphenhydramine alone (RR 2.02, 95% CI 1.03 to 3.94). Adverse events were reported with several of the interventions, i.e. ranitidine and diphenhydramine, causing drowsiness and sedation, but there was no significant difference in the level of sedation from baseline with either famotidine or diphenhydramine.

AUTHORS' CONCLUSIONS

The very limited evidence provided by this review was based on a few old studies of a relatively small size, which we categorised as having high to unclear risk of bias. Thus, at present, the review does not allow confident decision-making about the use of H2-receptor antagonists for urticaria. Although some of these studies have reported a measure of relief of symptoms of urticaria and rather minimal clinical improvement in some of the participants, the evidence was weak and unreliable. We have emphasised the lack of precision and limitations in the reported data where appropriate in this review.

Acute-phase response in chronic urticaria

The patterns of acute-phase response (APR) biomarkers differ upon various inflammatory conditions. Little information is available on the systemic inflammatory response in urticaria/angio-oedema. It has been shown that concentrations of circulating APR biomarkers, IL-6 and C-reactive protein (CRP), are elevated more in severe chronic urticaria (CU) than in patients showing milder urticarial symptoms. It is not clear whether the increase of IL-6 and CRP is merely an epiphenomenon or may contribute to the pathogenesis of CU. It is tempting to speculate that mediators of APR may enhance urticarial inflammation. In addition, there is some association between APR and activation of coagulation/fibrinolysis in CU. It is well known that even slight elevation in CRP baseline concentration is enough to produce significant increase in cardiovascular risk. In this light, one should ask whether CU patients, in particular those showing stronger systemic inflammatory response and long-lasting course are more vulnerable to the cardiovascular events. Apart from highly troublesome symptoms and low quality of life, CU may then involve some remote, serious systemic consequences. Taken together, CU can be identified as a mast cell- and basophil-dependent inflammatory disorder of the skin, which is accompanied by APR. Characterization of APR in CU may appear essential for an insight into the activity of this disease and for assessment of the inflammation degree. Moreover, measurement of these biomarkers might be particularly relevant while assessing CU patients demanding an anti-inflammatory or immunosuppressive therapy. This review summarizes information regarding APR in the course of urticaria/angio-oedema.