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Chu AWL, Rayner DG, Chu X, Chen L, Dong AYH, Waserman S, Baker DR, Sheikh J, Moellman J, Lang DM, Ben-Shoshan M, Mathur SK, Beck LA, Khan DA, Oliver ET, Asiniwasis RN, Chan J, Cole EF, Trayes KP, Frazier WT, Runyon L, Wheeler KE, Eftekhari S, Gardner DD, Winders T, Bernstein JA, Saini SS, Chu DK. Topical corticosteroids for hives and itch (urticaria): Systematic review and Bayesian meta-analysis of randomized trials. Ann Allergy Asthma Immunol 2024; 133:437-444.e18. [PMID: 38901542 DOI: 10.1016/j.anai.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Topical corticosteroids are widely used as a treatment for itch and wheals (urticaria), but their benefits and harms are unclear. OBJECTIVE To systematically synthesize the benefits and harms of topical corticosteroids for the treatment of urticaria. METHODS We searched MEDLINE, EMBASE, and CENTRAL from database inception to March 23, 2024, for randomized trials comparing topical corticosteroids with placebo for patients with urticaria (either chronic spontaneous or inducible urticaria or acute urticaria elicited from skin/intradermal allergy testing). Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects meta-analyses addressed urticaria severity, itch severity (numeric rating scale; range 0-10; higher is worse), and adverse events. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed certainty of evidence ratings. PROSPERO registration: CRD42023455182. RESULTS A total of 19 randomized controlled trials enrolled 379 participants with a median of mean age of 30.1 (range 21.1-44.0) years. Compared with placebo, topical corticosteroids may reduce wheal size (ratio of means 0.47, 95% CI 0.38-0.59; low certainty) and itch severity (mean difference -1.30, 95% CI -5.07 to 2.46; very low certainty). Topical corticosteroids result in little to no difference in overall adverse events (94 fewer patients per 1000, 95% credible intervals 172 fewer to 12 more; high certainty). CONCLUSION Compared with placebo, topical corticosteroids may result in a reduction of wheal size and little to no difference in overall adverse events. Topical corticosteroids may reduce itch severity, but the evidence is very uncertain. Future large, randomized trials addressing the use of topical corticosteroids would further support optimal urticaria management.
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Affiliation(s)
- Alexandro W L Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
| | - Daniel G Rayner
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Xiajing Chu
- Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lina Chen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
| | - Audrey Y H Dong
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Diane R Baker
- Department of Dermatology, Oregon Health & Sciences University, Portland, Oregon
| | - Javed Sheikh
- Department of Clinical Immunology and Allergy, Southern California Permanente Medical Group, Los Angeles, California
| | - Joseph Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology and Dermatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Sameer K Mathur
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Lisa A Beck
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric T Oliver
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel N Asiniwasis
- Division of Dermatology, Department of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Jeffrey Chan
- Emergency Medicine, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Emily F Cole
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Kathryn P Trayes
- Department of Family and Community Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Winfred T Frazier
- Department of Family Medicine, UPMC St. Margaret, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Lauren Runyon
- Division of Allergy and Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kathryn E Wheeler
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Sanaz Eftekhari
- Asthma and Allergy Foundation of America, Arlington, Virginia
| | | | - Tonya Winders
- Global Allergy & Airways Patient Platform, Vienna, Austria
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sarbjit S Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; The Research Institue of St. Joe's Hamilton, Hamilton, Ontario, Canada.
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Kelso JM. Application of topical corticosteroids to sites of positive immediate-type allergy skin tests to relieve itching: results of a double-blind, placebo-controlled trial. Ann Allergy Asthma Immunol 2007; 98:182-4. [PMID: 17304888 DOI: 10.1016/s1081-1206(10)60694-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In many allergy clinics topical corticosteroid cream is applied to sites of positive skin tests in an attempt to alleviate itching. OBJECTIVES To determine whether or not this practice is effective. METHODS Patients with 5 or more positive skin test results were randomly assigned to 1 of 3 groups after skin test result reading: application of 2.5% hydrocortisone in moisturizing cream, moisturizing cream alone, or no topical application. Immediately after the skin test results were read (baseline) and at 5, 15, and 30 minutes, patients rated their itching on a 100-mm visual analog scale. RESULTS Average itch scores for all groups combined were 44, 33, 22, and 12 at 0, 5, 15, and 30 minutes, respectively. No differences were found among the groups at any time point. No correlation was found between the baseline itch scores and age, sex, number of positive skin test results (> or = 3-mm wheals), or number of large positive skin test results (> or = 15-mm wheals). CONCLUSIONS The application of corticosteroid cream to sites of positive immediate-type allergy skin tests does not provide relief of itching; therefore, this practice should be abandoned. Instead, patients should be informed that any itching they may be experiencing will substantially resolve during the next 30 minutes and that application of such topical treatment will not hasten the relief of itching.
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Affiliation(s)
- John M Kelso
- Allergy Division, Naval Medical Center, San Diego, California, USA.
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Abstract
Chronic urticaria is a common condition that can be very disabling when severe. A cause for chronic idiopathic urticaria (CIU) is only infrequently identified. Potential causes include reactions to food and drugs, infections (rarely) and, apart from an increased incidence of thyroid disease, uncomplicated urticaria is not usually associated with underlying systemic disease or malignancy. About one-third of patients with CIU have circulating functional autoantibodies against the high affinity IgE receptor or against IgE, although it is not known why such antibodies are produced, or how the presence of such antibodies alters the course of the disease or response to treatment. There are only a few publications relating to childhood urticaria, but it is probably similar to the adult form, except that adult urticaria is more common. The diagnosis is based on patient history and it is vital to spend time documenting this in detail. Extensive laboratory tests are not required in the vast majority of patients. Chronic urticaria resolves spontaneously in 30-55% of patients within 5 years, but it can persist for many years. Treatment is aimed firstly at avoiding underlying causative or exacerbating factors. Histamine H1 receptor antagonists remain the mainstay of oral treatment for all forms of urticaria. The newer low-sedating antihistamines desloratadine, fexofenadine, levocetirizine and mizolastine should be tried first. Sedating antihistamines have more adverse effects but are useful if symptoms are causing sleep disturbance. Low-dose dopexin is effective and especially suitable for patients with associated depression. There is controversy as to whether the addition of an histamine H2 receptor antagonist or a leukotriene antagonist is helpful. For CIU, second-line agents include ciclosporin (cyclosporine) [which is effective in approximately 75% of patients], short courses of oral corticosteroids, intravenous immunoglobulins and plasmapheresis, although the last two were found to be beneficial in small trials only. Treatments for CIU with only limited or anecdotal supportive evidence include sulphasalazine, methotrexate, stanazol, rofecoxib and cyclophosphamide. The efficacy of photo(chemo)therapy is controversial. Physical urticarias may respond to H1 receptor antagonists, although in delayed pressure urticaria, and cold, solar and aquagenic urticaria, the response may be disappointing. Second-line agents for physical urticarias vary depending on the urticaria and most have limited supportive evidence. The potential for spontaneous resolution, the variation in the disease activity and the unpredictable nature of the disease makes the efficacy of treatments difficult to assess.
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Affiliation(s)
- Martina M A Kozel
- Department of Dermatology, Red Cross Hospital, Beverwijk, The Netherlands.
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Barlow RJ, Macdonald DM, Black AK, Greaves MW. The effects of topical corticosteroids on delayed pressure urticaria. Arch Dermatol Res 1995; 287:285-8. [PMID: 7541190 DOI: 10.1007/bf01105080] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Six patients with delayed pressure urticaria (DPU) applied clobetasol propionate (0.05%) ointment or its base to predetermined test sites on the right and left thigh as part of a randomized, double-blind study. A pressure challenge was administered to each test site at the initial visit and repeated after 3 days and 6 weeks of treatment and at between 4 and 8 weeks after treatment. The areas of pressure-induced weals were measured 6 h after each challenge. At the 6-week visit, a 4-mm punch biopsy was taken from pressure-challenged skin on each test site. Sections were stained for mast cells and immunohistochemical labelling was used to demonstrate neutrophils (neutrophil elastase), eosinophils (eosinophil cationic protein), monocytes/macrophages (EBM 11), cells expressing the beta-2 integrins (CD11/18) and the vascular adhesion molecules, E selectin and intercellular adhesion molecule-1 (ICAM-1). In the steroid-treated sites, there was a significant decrease (P < 0.05, Wilcoxon's matched-pairs test) in the size of the pressure weals compared with baseline at 3 days, 6 weeks and at follow-up. Demonstrable mast cells were significantly decreased (P = 0.059) in the pressure-challenged areas in the steroid-treated sites compared with the base-treated sites. The histological response to pressure was minimal in both sites perhaps demonstrating an active pharmacological effect of the ointment base. In conclusion, the application of potent topical steroids significantly reduced the clinical response to pressure in patients with DPU, possibly through a reduction in mast cells.
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Affiliation(s)
- R J Barlow
- St John's Institute of Dermatology, UMDS, St Thomas Hospital, London, UK
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