BSACI guidelines for the management of chronic urticaria and angio-oedema

Chronic Urticaria in Children: A Single-Center Retrospective Study From Turkey

The studies on childhood chronic urticaria (CU) are limited. We aimed to investigate the epidemiological and etiological factors of children with CU. Demographic characteristics, laboratory findings, and etiological factors of patients diagnosed with CU younger than the age of 18 were retrospectively evaluated. Of the 124 participants, 68 (54.8%) were aged 12 and older. Angioedema accompanied 18.5% of the patients. Chronic spontaneous urticaria (CSU) was found in 75%, while 24.2% had chronic inducible urticaria. Symptomatic dermographism (16.1%) was the most common among chronic inducible urticaria, followed by cholinergic urticaria (4.8%). No etiological factor could be detected in 56.5% of the children. Infections (29.8%) were the most common etiological factor, followed by drugs (8%). Dental problems (16.9%) were the primary infections associated with CU. Chronic urticaria prevalence in children increased with age, with CSU being the most common type. Infections played a significant role in childhood CU.

A Prospective Randomized Non-Blinded Study of Safety and Efficacy of Bilastine Up-Dosing (40 mg) Versus Combination of Bilastine 20 mg With Levocetirizine 5 mg in the Treatment of Chronic Spontaneous Urticaria

Introduction

Chronic spontaneous urticaria (CSU) is the most commonly diagnosed skin condition in dermatology outpatient departments. Second-generation antihistamines are shown to be effective in the control of CSU. As per the guidelines, a combination of antihistamines is less recommended due to the lack of synergistic effect, though used widely. Exploring effective treatment options are crucial, given the challenges posed by CSU.

Aims and Objectives

To assess the safety and efficacy of Bilastine up-dosing versus combination of 20 mg Bilastine with 5 mg Levocetirizine in the treatment of CSU.

Materials and Methods

This prospective randomized non-blinded comparative trial involved 62 patients, with 32 in group A and 30 in group B. Group A received Tablet Bilastine 20 mg bd, while Group B received a combination of Tablet Bilastine 20 mg and Tablet Levocetirizine 5 mg. Urticarial Activity Score 7 was performed at baseline and follow-up visits (every 2 weeks for 6 weeks).

Results

Both groups had a higher number of male patients in the 20-30 years age group. Angioedema was present in 15.6% of group A and 23.3% in group B. After 6 weeks, both the groups showed a significant improvement in UAS 7 scores (P value <0.05). Group A demonstrated a remarkable reduction in UAS 7 from 19.4% to 0.03% with minimal side effects.

Conclusion

Bilastine up-dosing proved to be efficient, secure, and well tolerated when compared to the combined dose of Levocetirizine 5 mg and Bilastine 20 mg, suggesting that up-dosing of Bilastine could be a valuable addition to the current medication arsenal with the minimal side effects.

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.

Dapsone-induced methemoglobinemia and hemolysis in a woman without G6PD deficiency presenting with idiopathic urticaria

BACKGROUND

The appearance of bite cells associated with methemoglobinemia can be caused by oxidizing drugs such as dapsone in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency or high drug serum levels. Bite cells are often pathognomonic for oxidant injury in patients with G6PD deficiency and suggest active hemolysis.

CASE PRESENTATION

We report a case of a woman with no prior history of G6PD deficiency who presented with anemia, methemoglobinemia and bite cells on peripheral blood smear after dapsone therapy for new onset idiopathic urticaria. Laboratory tests for G6PD, blood count and liver function were within normal limits prior to initiation of therapy. During the patient's hospital course, moderate methemoglobinemia and anemia were identified despite mildly increased serum G6PD level. These pathologies were reversed upon stopping dapsone therapy.

CONCLUSION

This case highlights the potential for therapeutic levels of dapsone to induce side effects in patients without G6PD deficiency and highlights the importance of routine blood monitoring for anemia and hemolysis during the course of drug therapy.

Chemometrics assisted untargeted metabolomic analysis to explore metabolic alterations in chronic urticaria via LC/Q-TOF/MS/MS

Chronic urticaria (CU) is a common disease characterized by the development of recurrent itchy blisters and/or angioedema lasting longer than 6 weeks. The evidence-based diagnosis of CU is described in the most recent urticaria guideline. Metabolomics has the potential to offer diagnostic biomarkers for the detection and prognosis of diseases and predict the efficacy and safety of pharmaceutical interventions. Determining the variation in metabolites found in the plasma of CU patients (n = 20) and 20 controls has therefore been the goal of this investigation. Samples were analyzed using liquid chromatography quadrupole time-of-flight mass spectrometry after applying acetonitrile precipitation. For the purpose of identifying and characterizing metabolites, the METLIN database was utilized. According to results, 21 metabolites were found to be significantly (VIP score > 0.7, p < .05 and fold analysis >1.5) altered. Differentiations between each group were successful via both OPLS-DA and ROC analysis. While plasma allantoate, homogentisate, indole acetate, proline, phenylalanine levels decreased in CU patients compared to healthy subjects, tryptophan, spermidine, phenyl pyruvate, oleic acid, lysine, valine, ornithine, histidine, glutamate, leucine, kynurenine, hypoxanthine, tyrosine, glucose, creatine and cortisol levels were significantly increased. Diagnosis of CU could be achieved by evaluating the metabolic profile of patients.

Chinese version of the chronic urticaria quality of life questionnaire: cultural adaptation, factor analysis, assessment of reliability and validity

Chronic urticaria is a common skin disorder that contributes profound impact on patients' quality of life (QoL). However, the cause of the disease is not clear, and the treatment still faces challenges. To better evaluate the effectiveness of treatment, an effective questionnaire survey on quality of life is needed. For the first time in Italy, a new questionnaire for chronic spontaneous urticaria, the chronic urticaria quality of life questionnaire (CU-Q2oL), has been developed. The purpose of this study was to develop and verify the Chinese version of the chronic urticaria quality of life questionnaire (CU-Q2oL). Three hundred and twenty-eight chronic urticaria patients were prospectively recruited and evaluated by the translated Chinese version of CU-Q2oL along with the Dermatology Life Quality Index (DLQI). Factor analysis, internal consistency, convergent validity, sensitivity to change and known-group validity were determined. Multiple linear regressions were used to determine the predicting factors of CU-Q2oL results. Factor analysis revealed a six-dimensional structure, and five of the six scales showed good internal consistency. Convergent validity and know-group validity showed good correlations. It was found to distinguish well between patients with different levels of urticaria activity and those to be sensitive to change in the Chinese CU-Q2oL. Disease severity was highly significantly predictive of the CU-Q2oL score on all scales. The CU-Q2oL Chinese version is a valid, reliable and sensitive instrument. It can be widely adopted to evaluate treatment outcomes and be applied in clinical research in Chinese patients.

Chronic urticaria and thyroid autoimmunity: a meta-analysis of case-control studies

PURPOSE

Autoimmunity has been implicated in some patients with idiopathic chronic urticaria (CU). Because of the frequency of autoimmune thyroid diseases, their association with CU deserves special attention. We tested both the existence and the extent of an association between thyroid autoimmunity and CU.

METHODS

A thorough search of PubMed, Scopus, Web of Science, and Cochrane databases was performed. Studies reporting the positivity rate for anti-thyroperoxidase antibodies (TPOAbs) in people with (cases) and without CU (controls) were included. Quality of the studies was assessed by the Newcastle-Ottawa Scale. Between-study heterogeneity was assessed by Cochrane Q and I2 tests, and the odds ratio (OR) for TPOAbs positivity was combined using random-effects models.

RESULTS

Nineteen studies provided information about TPOAbs positivity on 14,351 patients with CU and 12,404 controls. The pooled estimate indicated a more than fivefold increased risk of exhibiting TPOAbs positivity in the group with CU (pooled OR 5.18, 95% CI 3.27, 8.22; P < 0.00001). Correction for publication bias had a negligible effect on the overall estimate (pooled adjusted OR: 4.42, 95% CI 2.84, 6.87, P < 0.0001). Between‑study heterogeneity was established (I2 = 62%, Pfor heterogeneity = 0.0002) and when, according to meta‑regression models, a sensitivity analysis was restricted to the 16 studies with the highest quality scores, the OR for TPOAbs positivity rose to 6.72 (95% CI 4.56, 9.89; P < 0.00001) with no significant heterogeneity (I2 = 31%, Pfor heterogeneity = 0.11).

CONCLUSIONS

Patients with CU have a five-to-nearly sevenfold higher risk of displaying TPOAbs positivity. All patients with CU may well be offered a screening for thyroid autoimmunity.

Insights into urticaria in pediatric and adult populations and its management with fexofenadine hydrochloride

OBJECTIVE

The present narrative review provides a comprehensive update of the current knowledge on urticaria, both in adult and pediatric populations, and on the safety and efficacy of fexofenadine hydrochloride (HCl) as a treatment option.

DATA SOURCE

A literature search was conducted on Embase and Medline.

STUDY SELECTION

Clinical studies published in English and published between 1999 and 2020 were selected.

RESULTS

Although the exact pathogenesis of urticaria is not fully understood, multiple pathways of mast cell activation are discussed to explain the existence of phenotypically different clinical manifestations of urticaria. An overview of the worldwide prevalence of chronic urticaria, including disease burden and patient's quality of life is provided. The impact of urticaria on patient's life differs on the basis of whether its form is acute or chronic, but pharmacological approaches are most often needed to control the disabling symptoms. A summary of the current management of urticaria recommended by different guidelines across countries (Global; European; American; Australian; Asian; Japanese) is presented. Non-sedating, second-generation H₁-antihistamines are the preferred choice of treatment across several guidelines worldwide. Herein, the efficacy and safety of fexofenadine HCl, a representative second-generation H₁-antihistamine approved for the treatment of urticaria, is discussed. The occurrence of urticaria manifestations in COVID-19 patients is also briefly presented.

CONCLUSION

The burden of acute and chronic urticaria is high for patients. Second generation anti-histamines such as fexofenadine HCl can help managing the symptoms.

Development of the Cold Urticaria Activity Score

BACKGROUND

Cold urticaria (ColdU) is a form of inducible urticaria where cold induces wheals and/or angioedema. The burden of disease is high and linked to trigger thresholds, exposure, and avoidance. There are presently no validated patient-reported outcome measures (PROMs) to assess and monitor disease activity. Our objective was to develop a disease-specific activity score for ColdU that is easy to administer and evaluate.

METHODS

A Cold Urticaria Activity Score (ColdUAS) questionnaire was developed, directed by PROM developing guidelines. After the generation of a conceptional framework, the item generation phase included the literature research on ColdU signs and symptoms and on comparable tools for similar diseases and 47 ColdU patient interviews. Subsequently, an impact analysis for content validity was performed. The final selection of items underwent expert review for face validity and cognitive debriefing.

RESULTS

The ColdUAS, a self-administered questionnaire for the prospective assessment of disease activity in patients with ColdU, consists of 4 items: 1. the frequency and severity of the signs (wheals and/or angioedema), 2. the frequency and severity of the symptoms (e.g., itch and burn), 3. the exposure to specific triggers, and 4. the avoidance of these triggers. The recall period for each item is the last 24 h.

CONCLUSIONS

The ColdUAS is the first disease-specific PROM to assess ColdU disease activity. It may help to better assess patients' disease status in routine clinical practice as well as in clinical trials. Anchor-based approaches are currently used to validate the ColdUAS.

A Comparative, Three-Arm, Randomized Clinical Trial to Evaluate the Effectiveness and Tolerability of Bilastine vs Fexofenadine vs Levocetirizine at the Standard Dose and Bilastine vs Fexofenadine at Higher Than the Standard Dose (Up-Dosing) vs Levocetirizine and Hydroxyzine (in Combination) in Patients with Chronic Spontaneous Urticaria

Introduction

Though second-generation antihistamines (SGAH) are first-line drugs in chronic spontaneous urticaria (CSU), 50% of patients do not respond to them. In such patients, guidelines recommend either up-dosing of SGAH or combination of different antihistamines. However, the studies comparing these treatment regimens are limited.

Methods

In this comparative, three-arm study, CSU patients were randomized to receive standard dose of either bilastine, fexofenadine, or levocetirizine for 2 weeks. After 2 weeks of treatment, non-responders received double dose of either bilastine or fexofenadine, while hydroxyzine 25 mg once daily was added in the levocetirizine group. Patients were primarily evaluated for improvement in CSU, quality of life, and somnolence.

Results

A total of 110 patients with CSU were recruited. At the end of 4 weeks, 33/39, 26/35, and 22/36 patients in the bilastine, fexofenadine, and levocetirizine groups showed improvement in urticaria symptoms. At week 2, there was no statistical difference in urticaria activity score (UAS7) improvement between any of the groups; however, at week 4, there was a statistical difference between the bilastine and levocetirizine groups (p<0.05). Somnolence was significantly lower in the bilastine group (p<0.05). Bilastine was statistically significant (p<0.05) in the improvement of quality of life as compared to both groups. No major adverse events were reported during study period; however, bilastine was associated with significantly lower levels of AEs compared to levocetirizine (p<0.05).

Conclusion

Two-fold up-dosing of bilastine improves CSU symptoms without compromising safety as compared to two-fold up-dosing of fexofenadine and combination of first- and second-generation antihistamines.

Cetirizine for the treatment of allergic diseases in children: A systematic review and meta-analysis

OBJECTIVE

The global prevalence of allergic diseases has led to a negative and extensive impact on the health and lives of a large population of children. This study investigates the efficacy, acceptability, and safety of cetirizine (CTZ) for treating allergic diseases in children and provides evidence-based assertions for decision-making.

METHODS

PubMed, Embase, the Cochrane Library, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and the European Union Clinical Trials Register were systematically searched from inception to April 21, 2022. Randomized controlled trials (RCTs) or quasi-RCTs of children with allergic diseases receiving CTZ compared with those receiving placebo or other drugs were included without language limitations. Two investigators independently identified articles, extracted data, conducted meta-analyses, assessed the Cochrane risk of bias of individual studies, and evaluated the evidence certainty using the Grading of Recommendations Assessment, Development, and Evaluation approach; any discrepancies were resolved by consulting with a third investigator. Primary outcomes included scales that evaluated the recovery of allergic conditions in AR, such as the total symptom score (TSS). Secondary outcomes included laboratory test changes, safety (adverse events, AEs), and quality of life (QOL). Data were pooled using the Cochrane Review Manager 5.4, and a fixed-effects model was used if heterogeneity was evaluated as low (I ² < 50%); otherwise, a random-effects model was adopted.

RESULTS

A total of 22 studies (5,867 patients) were ultimately included [eight with perennial AR, six with seasonal AR, four with atopic dermatitis (AD), and four with other allergic diseases], most of which had a low or unclear risk of bias. Moderate certainty evidence showed that CTZ was found to benefit allergic symptom control [mean difference (MD) of TSS at 1 week: MD, -0.32 (-0.52, -0.12); at 2 weeks: MD, -0.25 (-0.35, -0.14); at 4 weeks: MD, -4.07 (-4.71, -3.43); at 8 weeks: MD, -4.22 (-4.73, -3.72); at 12 weeks: MD, -5.63 (-6.14, -5.13); all P-values were less than 0.05] and QOL [at 12 weeks: MD, -23.16 (-26.92, -19.39); P < 0.00001] in children with AR. It had similar efficacy compared with other antihistamines (AHs) or montelukast, without showing better control of AD severity in children. Moderate-to-low certainty evidence demonstrated that CTZ was well tolerated and did not increase the risk of severe and overall AEs, cardiotoxicity, damage to the central nervous and digestive systems, or other systems in children, except for the risk of somnolence [risk ratio, 1.62 (1.02, 2.57); P = 0.04, compared with placebo].

CONCLUSION

Moderate-to-low certainty evidence revealed that CTZ could improve clinical improvement and QOL in children with AR and have comparable efficacy with other AHs. CTZ is well tolerated in the pediatric population, except for an increased risk of somnolence.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021262767].

Clinical and aetiologic profile of patients with chronic urticaria at the outpatient clinic of a tertiary hospital in Lagos, Nigeria: a cross-sectional observational study

Chronic urticaria is a condition characterized by recurrent wheals associated with itching lasting longer than six weeks. The condition tends to run a chronic course with significant morbidity. Several factors have been explored in the cause, yet the aetiology is still uncertain. We documented the clinical profile and assessed the possible aetiologic factors in patients with chronic urticaria. Clinical profile of sixty consecutive patients with chronic spontaneous urticaria was assessed with possible precipitants identified using a structured questionnaire. The complete blood count with erythrocyte sedimentation rate, antithyroid peroxidase (antiTPO), hepatitis B surface antigen (HBsAg), antihepatitis C virus screening (AntiHCV), stool for ova and parasites and helicobacter pylori were carried out. Controls without a history of urticaria were recruited in a 1: 1 ratio for stool for parasites and H. pylori because of the high prevalence rates reported in this environment. Data analysis was carried out with Statistical Packages for Social Sciences (SPSS) version 22. Sixty patients with chronic urticaria and sixty age and sex matched controls were enrolled in the study. Females presented more often with urticaria with a M: F ratio of 1: 2.5. The mean age of onset of urticaria was in the third decade of life. Precipitants were identified in close to a third of patients. The investigated antigenic aetiology was not found to play a role. The presentation and clinical profile of patients in this environment is similar to previously documented studies. History still remains the cornerstone of management as precipitants and triggers may be identified. Management of patients should therefore be individualized.

Trends in office visits and treatment for urticaria in children in the United States, 1998-2016

BACKGROUND/OBJECTIVES

Urticaria is a common condition with an estimated prevalence of up to 23% in the pediatric population. Studies characterizing visits and treatments for urticaria in the pediatric population are unavailable. Understanding visit and treatment trends for urticaria in the pediatric population may help inform care for patients with urticaria.

METHODS

A total of 108 278 outpatient records from the National Ambulatory Medical Care Survey representing 3.4 billion visits by patients of age 18 and younger were analyzed. This study included the calendar years 1998 through 2016.

RESULTS

Pediatricians saw the largest proportion of all visits (52.7%). Male and female patients accounted for approximately equal proportions of all visits for urticaria. There was a slight male predominance in visits to pediatricians (53.7%), whereas dermatologists saw female patients more frequently (63.3%). Most visits for urticaria were by non-Hispanic (78.1%) and White (78.2%) patients. H1 antihistamines were the most commonly prescribed treatment (70.3%), whereas topical corticosteroids were prescribed least frequently (4.9%). Topical corticosteroids were most frequently prescribed by dermatologists (7.7%). Non-H1 antihistamine and non-corticosteroid therapy were prescribed in 9.7% of all visits and in 4.5% of visits to pediatricians. Most visits for urticaria were to physicians in metropolitan areas (88.8%). Pediatricians saw the highest number of non-metropolitan area visits (56.3%).

CONCLUSIONS

H1 antihistamines were the most commonly used therapy (70%), consistent with established treatment guidelines. Male and female pediatric patients present equally often for urticaria, but sex differences were seen with visit frequencies to certain specialties.

In vitro effects of histamine receptor 1 antagonists on proliferation and histamine release in canine neoplastic mast cells

Canine mastocytomas (MCTs) are characterized by rapid proliferation of neoplastic mast cells (MCs) and clinical signs caused by MC-derived mediators. In dogs suffering from MCT, histamine receptor 1 (HR1) antagonists are frequently used to control mediator-related clinical symptoms. Previous studies have shown that the HR1 antagonists loratadine and terfenadine exert some growth-inhibitory effects on neoplastic MCs. We examined whether other HR1 antagonists used in clinical practice (desloratadine, rupatadine, cyproheptadine, dimetindene, diphenhydramine) affect proliferation and survival of neoplastic MCs. Furthermore, we analysed whether these HR1 antagonists counteract IgE-dependent histamine release from a MC line harbouring a functional IgE-receptor. HR1 antagonists were applied on two canine MC lines, C2 and NI-1, and on primary MCs obtained from three MCT samples. The HR1 antagonists desloratadine, rupatadine and cyproheptadine were found to be more potent in decreasing proliferation of C2 and NI-1 cells when compared with dimetindene and diphenhydramine. Similar effects were seen in primary neoplastic MCs, except for diphenhydramine, which exerted more potent growth-inhibitory effects than the other HR1 antagonists. Drug-induced growth-inhibition in C2 and NI-1 cells was accompanied by apoptosis. Loratadine, desloratadine and rupatadine also suppressed IgE-dependent histamine release in NI-1 cells. However, drug concentrations required to elicit substantial effects on growth or histamine release were relatively high (>10 µM). Therefore, it remains unknown whether these drugs or similar, more potent, HR1-targeting drugs can suppress growth or activation of canine neoplastic MCs in vivo.

Long-term follow-up effect of omalizumab in chronic spontaneous urticaria and its association with serum C-reactive protein levels

This study aims to determine the efficacy of omalizumab, a humanized monoclonal anti-immunoglobulin E antibody, in patients with chronic spontaneous urticaria (CSU) refractory to conventional therapy, together with the evaluation of serum CRP levels. All the patients with a diagnosis of CSU who were continuously treated with omalizumab (300 mg/mo) for at least 3 months between June 2016 and July 2019 were included in this study. Urticaria activity score (UAS-7) was used for assessment of disease activity. Serum CRP levels were also retrospectively analyzed. When UAS-7 scores before the initiation of therapy were compared to the week 4, 12, 24, and 36 scores after the treatment, each were significantly different from the pretreatment results (P < .01). CRP level prior to treatment was found to be strongly correlated with baseline UAS scores of the patients' (P = .00). At the 12th week of treatment, decline of CRP level was positively and strongly correlated with the decline of UAS (P = .037). In this study, mean UAS decreased, mean rescue medication use declined, and overall therapeutic response improved with omalizumab treatment. Additionally, significant correlation between the decline of CRP levels and treatment response was found.

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.

Psychological Stress and Chronic Urticaria: A Neuro-immuno-cutaneous Crosstalk. A Systematic Review of the Existing Evidence

PURPOSE

It has been observed that certain patients with chronic spontaneous or idiopathic urticaria (CSU/CIU) have a personal history of a significant stressor before urticaria onset, while the prevalence of any psychopathology among these patients is significantly higher than in healthy individuals. Research has confirmed that skin is both an immediate stress perceiver and a target of stress responses. These complex interactions between stress, skin, and the nervous system may contribute to the onset of chronic urticaria. This systematic review investigated the association between CSU/CIU and neuroimmune inflammation with or without evidence of co-existing psychological stress from in vivo and ex vivo studies in human beings.

METHODS

PubMed and Scopus were searched to September 2019 for reports in human beings describing neuroimmune inflammation, stress, and CSU/CIU. A comprehensive search strategy was used that included all the relevant synonyms for the central concept.

FINDINGS

A total of 674 potentially relevant articles were identified. Only 13 satisfied the predefined inclusion criteria and were included in the systematic review. Five of these 13 studies evaluated the correlation between CSU/CIU, stress, and neuro-immune-cutaneous factors, while the remaining 8 focused on the association between CSU/CIU and these factors without examining any evidence of stress.

IMPLICATIONS

The complex neuro-immune-cutaneous model that involves numerous neuropeptides and neurokinins, inflammatory mediators and cells, hypothalamic-pituitary-adrenal axis hormones, and the skin may better explain the underlying pathophysiological mechanisms involved in the onset of urticaria. In addition, the elevated psychological stress level that has been closely related to CSU/CIU could be attributed to the imbalance or irregularity of this neuro-immune-cutaneous circuit. It is still unclear and must be further investigated whether any psychological stress results in or triggers CSU/CIU onset on top of a preexisting neuroimmune dysregulation. Nevertheless, new psycho-phenotypic or neuro-endotypic CSU/CIU subsets should be considered as the era of personalized treatment strategies emerges. A better understanding of CSU/CIU pathophysiology and consideration of the patient as a whole is vital for identifying targets for new potential treatment options.

Urticaria and silent parasitism by Ascaridoidea: Component-resolved diagnosis reinforces the significance of this association

Urticaria remains a major problem in terms of aetiology, investigation, and management, and although parasitic diseases are considered potential causes, the absence of a consistent link between parasitic infections and skin allergy symptoms leads to the need for a deeper study of parameters that support this association. The objectives of this study were to analyse a possible relationship between parasitism by Ascarididae (Toxocara canis and Anisakis simplex) and the clinical expression of urticaria and to identify possible parasitic molecular markers for improving the diagnosis of unknown urticaria aetiology. The prevalence of Toxocara and Anisakis infestations was evaluated by measuring the levels of specific IgG (sIgG) and IgE (sIgE) antibodies against crude extracts and isolated components from whole larvae of Anisakis simplex (Ani s 1, Ani s 3 and Ani s 7) and Toxocara canis (TES-120, TES-70, TES-32 and TES-26) using immunologic and molecular diagnostic methods. A cross-sectional study was performed in a group of 400 individuals. The study group consisted of 95 patients diagnosed with urticaria (55 with chronic urticaria and 40 with acute urticaria). A control group consisted of 305 subjects without urticaria (182 diagnosed with respiratory allergy and 123 without allergy). Statistically significant differences were demonstrated in the seroprevalence of specific IgG and IgE antibodies between the urticaria patients and the healthy general population when isolated ascarid antigens were evaluated. The prevalence of IgG antibodies against Ani s 1, IgE antibodies against TES-120 and IgE antibodies against TES-70 were significantly different between the control individuals (healthy general population) and patients with urticaria. Moreover, the urticaria patient group demonstrated a higher seroprevalence of antibodies (sIgE and sIgG) against Anisakis simplex larva whole extract than the control group but just with statistically diferences when sIgE was evaluated. The presence of IgE and/or IgG antibodies against Ani s 3 (tropomyosin) can help to discriminate between patients with and without urticaria. Both ascarids seem to be associated with urticaria, although in our region, Anisakis seems to have greater involvement than Toxocara in this relationship. Molecular diagnostics can be used to associate urticaria with parasite infestations. Tropomyosin and Ani s 1 were the most relevant markers to demonstrate the association between urticaria and the most relevant Ascarididae parasites in our region.

Angioedema - Our Experience Focused On Socio-Demographic, Etiological and Clinical Characteristics of the Condition and Its Management

BACKGROUND:

Angioedema (AE) is acute oedema of the skin and mucous surfaces, involving the respiratory and gastrointestinal tracts. AE could be a life-threatening medical condition. Regardless of its growing clinical importance, many aspects of its aetiology and pathogenesis remain poorly understood. Its incidence, demographic characteristics, diagnosis and therapy, need further investigation.

AIM:

This study reports our experience with angioedema concerning its social and demographic characteristics, aetiology, clinical features, diagnosis and treatment outcomes. Study design: Eighty-eight patients with AE were enrolled. The study is a retrospective analysis of patients treated in our Clinics.

METHODS:

All participants were asked on a voluntary basis to fill out a specially designed questionnaire on the day of their discharge. Other important data sources included: patients’ history and notes during the hospital stay, information from previous admissions, etc. Parametric and non-parametric statistical methods were used for data processing. Data analysis was performed using SPSS (SPSS Inc., IBM SPSS Statistica) version 20.0

RESULTS:

Based on our results, AE affects more frequently patients over 50 years of age, regardless of their sex. Urban residents prevail, among them - more commonly working women. Non-steroidal anti-inflammatory drugs (NSAIDs), hormones and antibiotics were among the most common triggers – in 8%, 4.5% and 11.4% of the cases respectively. In 9.09% of the patients, food-induced AE was seen, the most common foods reported, were – nuts, eggs and egg products. The common sites of involvement were periorbital area and lips. In only 9.1% of the patients, oedema progressed to spread to the upper respiratory tract. Cardiac conditions were the most frequent underlying disorders – 33%, of the patients, auto-immune thyroiditis was the second most common-14.8%, followed by musculo- skeletal disorders (10.2%) and diabetes (4.5%) Family history of allergy was seen in 8.4% of the patients, the most frequent allergic disorder, reported, was asthma. In patients with HAE, family history was present in 2.9% of the patients.

CONCLUSIONS:

All patients received therapy with steroids and antihistamines, resulting in resolution of symptoms and no invasive procedures were necessary. Based on our results, the diagnosis of AE is often difficult and delayed and requires specialist evaluation. If recognised on time and adequately treated, the outcomes are favourable.

[Omalizumab for the treatment of chronic urticaria: Real-life findings]

OBJECTIVE

Assessment of the efficacy and safety of omalizumab in chronic urticaria refractory to conventional treatment (H1-antihistamines at high dosage and montelukast) in real-life practice.

PATIENTS AND METHODS

A retrospective, descriptive, single-centre study was performed of the data for all patients presenting refractory chronic spontaneous urticaria or inducible urticaria and receiving omalizumab (300mg every four weeks) from November 2012 to June 2016.

RESULTS

In all, 23 patients were included. Omalizumab led to complete or significant remission in 19 patients (83%) with chronic urticaria, with remission in 9 patients (47%) occurring within 72hours of the first injection. One patient had a partial response and 3 (13%) showed no response. Only 2 patients (9%) in complete remission stopped their treatment at 1 and 3 years. 52% of patients presented non-serious adverse events, which in one case resulted in treatment withdrawal.

CONCLUSION

Omalizumab exhibited good real-life efficacy in a small series of chronic urticaria patients in France.

Altered Gut Microbiota Diversity and Composition in Chronic Urticaria

BACKGROUND

The pathogenesis of chronic urticaria (CU) is closely related to imbalances in immunity. The gastrointestinal microflora provides a vast and continuous stimulation for the immune system. However, the composition and diversity of gut microflora in CU patients are rarely reported.

METHODS

10 CU patients and 10 healthy individuals were selected in this study, and their intestinal microbiome was detected by 16S rRNA sequencing. The data were analyzed using R language software.

RESULTS

392 bacterial OTUs were common in the CU and healthy groups, but there were 159 OTUs particularly existing in the CU group, while 87 OTUs only were observed in healthy individuals. The bacterial diversity was reduced in CU patients compared with healthy individuals. The principal component analysis (PCA) and principal coordinate analysis (PCoA) revealed that the bacterial cluster in CU patients and the healthy controls were divided into different branches. Pathogenic strains including Escherichia coli were significantly higher in CU, while Faecalibacterium prausnitzii, Prevotella copri, and Bacteroides sp. were significantly lower in CU when compared with the healthy controls. CU patients with a high abundance of Escherichia coli had no ideal effect for probiotic therapy.

CONCLUSION

Our results demonstrated that the microbial composition was significantly different between CU patients and the healthy individual, which may be the reason leading to the various outcomes of probiotic treatment.

Real life management of chronic urticaria: Multicenter and cross sectional study on patients and dermatologists in Iran

Recently, advances in understanding the etiology of urticaria and updates of diagnostic and therapeutic management guidelines have drawn attention to chronic urticaria (CU) morbidity. The present study aimed to evaluate Iranian dermatologists' practice and real life management of CU patients. A total of 35 dermatologists and 443 patients were included in the study. Number of female patients was 321 (72.5%). Mean (standard deviation) age of the study patients was 38 (13) years and the median (inter quartile range) of disease duration was 12 (6-48) months. Severity of patients' symptoms was mild for 32.1%, moderate for 38.7%, severe for 18.8%, and 10.4% of them had no evident signs or symptoms. The most common diagnostic methods were physical examination (96.6%), differential blood count (83.5%), erythrocyte sedimentation rate (77.4%), and C-reactive protein (62.8%). The number of dermatologists prescribed nonsedating antihistamines (nsAH) in regular dose and high dose mono therapy were 26 (74%) and 6 (17%), respectively. About 66% of dermatologists were familiar with British Association of Dermatologists (BAD) guideline. The most common first-line treatment for CU by Iranian dermatologists was nonsedating antihistamines in regular or high doses. The real-life management of patients with CU in Iran was in accordance with the available practice guidelines.

Thyroid diseases and skin autoimmunity

The skin is the largest organ of the body, at the boundary with the outside environment. Primarily, it provides a physical and chemical barrier against external insults, but it can act also as immune organ because it contains a whole host of immune-competent cells of both the innate and the adaptive immune systems, which cooperate in eliminating invading pathogens following tissue injury. On the other hand, improper skin immune responses lead to autoimmune skin diseases (AISD), such as pemphigus, bullous pemphigoid, vitiligo, and alopecia. Although the interplay among genetic, epigenetic, and environmental factors has been shown to play a major role in AISD etiology and progression, the molecular mechanisms underlying disease development are far from being fully elucidated. In this context, epidemiological studies aimed at defining the association of different AISD with other autoimmune pathologies revealed possible shared molecular mechanism(s) responsible for disease progression. In particular, over the last decades, a number of reports have highlighted a significant association between thyroid diseases (TD), mainly autoimmune ones (AITD), and AISD. Here, we will recapitulate the epidemiology, clinical manifestations, and pathogenesis of the main AISD, and we will summarize the epidemiological evidence showing the associations with TD as well as possible molecular mechanism(s) underlying TD and AISD pathological manifestations.

Evaluating and managing chronic idiopathic urticaria in adults

Chronic idiopathic urticaria (CIU), also known as chronic spontaneous urticaria, is characterized by the presence of hives on most days of the week, for 6 weeks or longer, and without an identifiable or consistent cause. Evaluation is clinical and based on the presence of episodic urticarial lesions. Although patients are subject to overtesting during the diagnosis of CIU, guidelines suggest starting with three basic laboratory tests. Treatment is a stepwise approach, involving second-generation antihistamines, histamine2 antagonists, leukotriene receptor antagonists, first-generation antihistamines, and potent antihistamines. Refractory CIU requires adding alternative agents such as omalizumab, anti-inflammatory agents, and immunosuppressants.

Efficacy and safety of Tripterygium wilfordii hook F for chronic urticaria: a systematic review and meta-analysis

Background

The first-line agents comprising antihistamines for chronic urticaria, are not completely satisfactory. Tripterygium wilfordii Hook F (TwHF), a Chinese herb, has been developed into several Tripterygium agents and have definite effects on autoimmune and inflammatory diseases. In chronic urticaria, however, their values of practical application remain unclear. The aim of this study was to investigate the efficacy and safety of TwHF in patients with chronic urticaria.

Methods

Several databases were systematically searched including PubMed, Embase, Cochrane Central Register of Controlled Trials, China Network Knowledge Infrastructure, Chinese Scientific Journals Database, Wan Fang Database, and Chinese Biomedicine. Randomized controlled trials comparing antihistamines with TwHF or Tripterygium agents in combination with antihistamines were included. Revman5.3 was utilized to calculate risk ratios (RR) with 95% confidence intervals (CI). This study was registered with PROSPERO, number CRD42018091595.

Results

Twenty-one trials with 2565 participants were included in this analysis. Meta-analysis showed that, when antihistamines were combined with TwHF and Tripterygium agents, the curative effect in cases of chronic urticaria was superior to that of antihistamines alone (RR: 1.40; 95% CI: 1.33–1.46). The incidence rates of gastrointestinal disorder (RR: 2.91; 95% CI: 1.70–4.99) and menstrual disorder (RR: 6.00; 95% CI: 1.79–20.13) in drug combination groups were higher than those in controls, while other adverse events were similar between the two groups. After treatment, Dermatology Life Quality Index (RR: 1.23; 95% CI: 1.09–1.40), quality of sleep (RR: 1.50; 95% CI: 1.07–2.12), and daily activity (RR: 1.49; 95% CI: 1.25–1.78) were all improved. Furthermore, drug combination groups demonstrated less relapse (RR: 0.34; 95% CI: 0.25–0.45).

Conclusions

TwHF and Tripterygium agents, in combination with antihistamines, appear to be more effective than antihistamines alone. Nevertheless, adverse events cannot be ignored. Large sample, multi-center, high-quality clinical studies are needed to verify the exact effects and safety of TwHF and Tripterygium agents in treatment of chronic urticaria.

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2305-7) contains supplementary material, which is available to authorized users.

Solar urticaria in 145 patients: Assessment of action spectra and impact on quality of life in adults and children

BACKGROUND

Solar urticaria (SU) is a rare chronic inducible urticaria triggered via uncharacterized chromophores. We detail responses of a large patient series to monochromator phototesting and broadband ultraviolet radiation (UVR); relationship to life quality is explored.

METHODS

Retrospective review of all SU patients undergoing standardized diagnostic photoinvestigation at a specialist centre during 2000-2016. From 2011, patients completed dermatology life quality index (DLQI) questionnaires for the past week and year.

RESULTS

In 145 patients (mean: 35.8, range: 3-69 years; 18 aged <18 years; 100 female), combined phototesting with broadband UVR and monochromator sources successfully provoked 74.5% patients, with 65.6% provoked by broadband UVR alone and 57.9% by monochromated radiation alone. The narrow wavebands most frequently eliciting wheal and flare response were between 370 and 400 nm, with 25% patients at 300 ± 5 nm, 53.6% at 320 ± 10 nm, 66.7% at 330 ± 10 nm, 77.4% at 350 ± 20 nm, 83.3% at 370 ± 20 nm, 86.9% at 400 ± 20 nm, 44% at 500 ± 20 nm and 17.8% at 600 ± 20 nm. In 62 patients, the DLQI revealed 56.1% had very to extremely large impact in the past week (all patients: mean score: 11.1, range: 0-29) rising to 69.8% for the past year (12.5, 0-30); adults and children were similarly affected. Patients with positive photoprovocation had higher DLQI score than those who were negative (DLQI for past week: mean: 12.6 ± SEM 1.1 vs 4.6 ± 1.4, P < .01).

CONCLUSION

SU is predominantly provoked by longer UVA-shorter visible radiation, which penetrates window-glass and where sunscreens are less effective; impact on life quality is considerable. Photoprotective agents effective against this spectrum are needed.

Chronic Pruritus in the Geriatric Population

Chronic pruritus (>6 week's duration) in the geriatric population (≥65 years old), is an increasing health care problem. The pathophysiologic predisposing factors are abnormalities of the epidermal barrier, immune system, and nervous system. Causes can be dichotomized into histaminergic and nonhistaminergic pruritus. Topical treatments are generally safe. Systemic treatments are chosen depending on the condition, comorbid diseases, and drug interactions. Treatment options are limited. Progress has been made in identifying itch-selective mediators over the last decade. Numerous new medications are currently undergoing clinical trials and they are anticipated to enter the clinics in the near future.

Management of Pediatric Urticaria with Review of the Literature on Chronic Spontaneous Urticaria in Children

There are substantial knowledge gaps related to diagnosis and management of pediatric cases of chronic urticaria, and in particular chronic spontaneous urticaria (CSU). In this article we aimed to review the diagnosis and management of chronic urticaria in children and CSU in particular. We conducted a systematic review of articles published in English and French on pediatric CSU management in the last 10 years. We included experimental studies (eg, randomized controlled trials), other experimental designs (eg, nonrandomized methods of assignment, controlled before-after studies, and interrupted time series), and observational studies (eg, prospective or retrospective cohort studies, cross-sectional studies, case-control studies, and case reports). Our findings highlight the efficacy of second-generation antihistamines for the treatment of CSU in children and supports the use of omalizumab for more severe cases. However, our study also reveals severe knowledge gaps related to the best management strategy in children with more severe/refractory cases of CSU. Future studies are required to establish the beneficial effect of high doses of second-generation antihistamines as well as the effectiveness and safety of omalizumab and other biologics in young children.

A preliminary study on efficacy of rupatadine for the treatment of acute dengue infection

Currently there are no specific treatments available for acute dengue infection. We considered that rupatadine, a platelet-activating factor receptor inhibitor, might modulate dengue-associated vascular leak. The effects of rupatadine were assessed in vitro, and in a dengue model, which showed that rupatadine significantly reduced endothelial permeability by dengue sera in vitro, and significantly inhibited the increased haematocrit in dengue-infected mice with dose-dependency. We conducted a randomised, placebo-controlled trial in 183 adult patients in Sri Lanka with acute dengue, which showed that rupatadine up to 40 mg daily appeared safe and well-tolerated with similar proportions of adverse events with rupatadine and placebo. Although the primary end-point of a significant reduction in fluid leakage (development of pleural effusions or ascites) was not met, post-hoc analyses revealed small but significant differences in several parameters on individual illness days - higher platelet counts and lower aspartate-aminotransferase levels on day 7 in the rupatadine group compared to the placebo group, and smaller effusions on day 8 in the subgroup of patients with pleural effusions. However, due to the small sample size and range of recruitment time, the potential beneficial effects of rupatadine require further evaluation in large studies focused on recruitment during the early febrile phase.

Etiology of chronic urticaria: the Ecuadorian experience

Background

The purpose of this study was to identify chronic urticaria (CU) etiologies and treatment modalities in Ecuador. We propose that the sample distribution fits the expected one, and that there is an association between the etiology and its treatment.

Methods

We performed a retrospective study involving 112 patients diagnosed with CU using a Checklist for a complete chronic urticaria medical history. Demographic and clinical variables were collected. The etiology of CU was classified using the EAACI/GA2LEN/EDF/WAO guideline. Descriptive analyses were performed for demographical and clinical variables. Chi square tests were applied to analyze the fit of distribution and the independence of variables. P values less than 0.05 were considered significant.

Results

Among all the patients, 76.8% were diagnosed with chronic spontaneous urticaria (CSU), of which 22.3% had a known etiology or possible exacerbating condition. Food allergy was identified as the most common accompanying condition in patients with CSU (10.7%) (p < 0.01).. On the other hand, 23.2% inducible urticarias (CIndU) were indentified; dermographism was the most common (10.7%) (p < 0.01).

Regarding treatment regimens, sg-H1-antihistamines alone represented the highest proportion (44.6%). The combination of any H1-antihistamine plus other drug was a close second (42.0%) (p < 0.01). Almost 48% of CSUs of unknown etiology were treated with any antihistamine plus another drug. In patients with known etiology, sg-antihistamines alone (44.0%) was the most common management. In addition, 53.8% of CIndUs were treated with sg-antihistamines alone. Though, these associations were not statistically significant.

Conclusion

CSU is the most frequent subtype of CU. Modern non-sedating antihistamines in licensed doses are the drug of choice. Nevertheless, a great proportion of patients require the addition of another type of medication.

Long-term management of chronic spontaneous urticaria with omalizumab

BACKGROUND

Clinical trials have shown the efficacy of omalizumabs efficacy in refractory chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU), but real-life management strategies are lacking.

AIM

To assess the long-term efficacy and safety of omalizumab, and to identify predictive factors and optimum dosage regimens.

METHODS

This was a prospective study of 13 patients (11 women, 2 men) with severe CSU [weekly urticaria activity score (UAS7) > 28] resistant to anti-H1 antihistamines. Patients were started on omalizumab 150 mg subcutaneously every 4 weeks. Dose and interval between administrations were adjusted according to clinical response (189 administrations; treatment duration range 2-38 months).

RESULTS

Mean UAS7 was 36.3 ± 5.4. Of the 13 patients, all had experienced angio-oedema, while in addition, 7 had delayed pressure urticaria (DPU) and 1 had solar urticaria (SU). After omalizumab treatment, 4 (30.8%) of the 13 patients had complete response (CR), and the remaining 8 (61.5%) had partial response. CR was achieved with a dose of 150 mg every 4 (n = 2 patients) or 5 (n = 2) weeks. One of these patients remained disease-free after stopping treatment. Partial responses were achieved with 150 mg every 4 weeks (n = 4) and with 300 mg (n = 4) at intervals of 5 weeks (n = 1), 4 weeks (n = 2) or 3 weeks (n = 1). Only one patient (7.7%) did not show significant improvement, despite a dose of 300 mg every 4 weeks. There were no significant differences in epidemiological, clinical and laboratory data between the different response groups. Only two adverse events were observed: one was mild headache and the other was severe angio-oedema and aggravation of urticaria within 6 h of omalizumab administration.

CONCLUSION

Omalizumab dose and interval between administrations could be individualized for long-term management of CSU.

Efficacy and safety of bilastine in Japanese patients with chronic spontaneous urticaria: A multicenter, randomized, double-blind, placebo-controlled, parallel-group phase II/III study

BACKGROUND

Bilastine, a novel non-sedating second-generation H₁-antihistamine, has been widely used in the treatment of allergic rhinoconjunctivitis and urticaria with a recommended dose of 20 mg once daily in most European countries since 2010. We evaluated its efficacy and safety in Japanese patients with chronic spontaneous urticaria (CSU).

METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled phase II/III study (trial registration No. JapicCTI-142574). Patients (age, 18-74 years) were randomly assigned to receive bilastine 20 mg, 10 mg or placebo once daily for 2 weeks. The primary efficacy endpoint was the change from baseline (Day -3 to 0) in total symptom score (TSS) at 2 weeks (Day 8-14), consisting of the itch and rash scores.

RESULTS

A total of 304 patients were randomly allocated to bilastine 20 mg (101 patients), bilastine 10 mg (100 patients), and placebo (103 patients). The changes in TSS at 2 weeks were significantly decreased by bilastine 20 mg than did placebo (p < 0.001), demonstrating the superiority of bilastine 20 mg. Bilastine 10 mg also showed a significant difference from placebo (p < 0.001). The TSS changes for the bilastine showed significant improvement from Day 1, and were maintained during the treatment period. The Dermatology Life Quality Index scores were also improved in bilastine than in placebo. The bilastine treatments were safe and well tolerated.

CONCLUSIONS

Two-week treatment with bilastine (20 or 10 mg) once daily was effective and tolerable in Japanese patients with CSU, demonstrating an early onset of action.

Allergic Dermatoses

The purpose of this article is to review the current available material pertaining to atopic dermatitis, contact dermatitis, urticaria, and angioedema. This article focuses on each disease process's clinical presentation, diagnosis, and management. Although atopic dermatitis and contact dermatitis are similar, their development is different and can affect a patient's quality of life. Urticaria and angioedema are also similar, but the differentiation of the two processes is crucial in that they have significant morbidity and mortality, each with a different prognosis.

Current and future therapies for the treatment of histamine-induced angioedema

INTRODUCTION

Angioedema, a sudden, self-limited swelling of localized areas of any part of the body that may or may not be associated with urticaria, is thought to be the result of a mast-cell mediated process versus a bradykinin etiology. Understanding the mechanism is key in determining the proper treatment. Areas Covered: Clinical presentation of varying angioedema types may be similar; however, the appropriate treatment algorithm is dependent upon clinicians' knowledge of the underlying pathophysiology and classification of angioedema. Literature review of recent guidelines, available medications, and alternative therapies was completed to provide an overview of options.

CONCLUSION

There are no formal guidelines for treatment of acute or chronic histamine-mediated angioedema, and therefore, algorithms for the treatment of acute and chronic urticaria should be followed until such information becomes available. Differentiating histamine-mediated versus bradykinin mediated angioedema is essential, as treatments and treatment responses are quite different. Further research is needed to better understand idiopathic angioedema that is unresponsive to H1/H2 antagonists, LTMAs, or medications designed to treat bradykinin-mediated angioedema.

Prevalence and Risk Factors of Urticaria With a Focus on Chronic Urticaria in Children

Purpose

Limited data is available on the prevalence and risk factors of acute and chronic urticaria in children. Our purpose was to determine the prevalence and identify the risk factors of acute and chronic urticaria in Korean children.

Methods

This population-based study examined 4,076 children (age 4 to 13 years) who were enrolled in the 2015 prospective Seongnam Atopy Project (SAP 2015) in Korea. The parents completed an urticaria questionnaire that included questions regarding the duration, severity, and triggering factors of urticaria. Blood sampling (n=464) was performed to measure vitamin D, total eosinophil count (TEC), and total IgE levels, and skin prick tests (n=503) were done.

Results

The prevalences of the life-time, acute, and chronic urticaria were 22.5%, 13.9%, and 1.8% (chronic continuous urticaria, 0.7%; and chronic recurrent urticaria, 1.1%), respectively. Acute urticaria was significantly associated with allergic diseases and parental history of allergy (P<0.001), but chronic urticaria was not associated with these clinical factors. There was no significant difference in the 25-hydroxyvitamin D level between subjects with chronic urticaria and controls (P=0.124). Chronic continuous urticaria was associated with living in a new residence (aOR=2.38, 95% CI=1.02-5.54, P=0.044) and belonging to a family with a high income (aOR=4.24, 95% CI=1.24-14.56, P=0.022).

Conclusions

A total of 1.8% of children were found to have chronic urticaria. Living in a new residence and belonging to a family with a high income increased the risk of chronic continuous urticaria.

Therapy of antihistamine-resistant chronic spontaneous urticaria

INTRODUCTION

Chronic urticaria affects up to 1-3% of the general population and contributes to significant direct and indirect medical costs as well as decreased quality of life, which has a significant economic impact on our health care system. Areas covered: Given the prevalence of this condition on a large sector of the population, finding lasting relief for refractory cases is essential and is the focus of this review. Expert commentary: The choice of appropriate therapy in chronic refractory urticaria is not a 'one-size fits all' approach. Treatment should take multiple factors into consideration including the chronicity of hives, presence of physical urticaria, type of cellular infiltrate on skin histopathology, patient age, concomitant comorbid conditions, as well as patient preference and cost.

Vitamin D in atopic dermatitis, chronic urticaria and allergic contact dermatitis

Vitamin D influences allergen-induced pathways in the innate and adaptive immune system, and its potential immunomodulatory role in allergic skin disorders has been explored. This comprehensive review article provides an overview of the role of vitamin D in three common dermatologic conditions: atopic dermatitis (AD), chronic urticaria, and allergic contact dermatitis (ACD). Whereas the literature regarding vitamin D and AD has resulted in mixed findings, several studies have described an inverse relationship between vitamin D levels and AD severity, and improvement in AD with vitamin D supplementation. Similarly, several studies report an inverse relationship between vitamin D levels and severity of chronic urticaria. Although current research in humans remains limited, an increased likelihood of ACD has been demonstrated in vitamin D-deficient mice. Additional well-designed clinical trials will be necessary to determine whether vitamin D supplementation should be recommended for prevention or adjuvant treatment of these common dermatologic conditions.

A stepwise approach in the management of chronic spontaneous urticaria in children

Background

There is limited literature in the management of chronic urticaria in children. Treatment algorithms are generally extrapolated from adult studies.

Objective

Utility of a weight and age-based algorithm for antihistamines in management of chronic spontaneous urticaria (CSU) in childhood. To document associated factors that predict for step of control of CSU and time taken to attain control of symptoms in children.

Methods

A workgroup comprising of allergists, nurses, and pharmacists convened to develop a stepwise treatment algorithm in management of children with CSU. Sequential patients presenting to the paediatric allergy service with CSU were included in this observational, prospective study.

Results

Ninety-eight patients were recruited from September 2012 to September 2013. Majority were male, Chinese with median age 4 years 7 months. A third of patients with CSU had a family history of acute urticaria. Ten point two percent had previously resolved CSU, 25.5% had associated angioedema, and 53.1% had a history of atopy. A total of 96.9% of patients achieved control of symptoms, of which 91.8% achieved control with cetirizine. Fifty percent of all the patients were controlled on step 2 or higher. Forty-seven point eight percent of those on step 2 or higher were between 2 to 6 years of age compared to 32.6% and 19.6% who were 6 years and older and lesser than 2 years of age respectively. Eighty percent of those with previously resolved CSU required an increase to step 2 and above to achieve chronic urticaria control.

Conclusion

We propose a weight- and age-based titration algorithm for different antihistamines for CSU in children using a stepwise approach to achieve control. This algorithm may improve the management and safety profile for paediatric CSU patients and allow for review in a more systematic manner for physicians dealing with CSU in children.

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.

The opioid effects of gluten exorphins: asymptomatic celiac disease

Gluten-containing cereals are a main food staple present in the daily human diet, including wheat, barley, and rye. Gluten intake is associated with the development of celiac disease (CD) and related disorders such as diabetes mellitus type I, depression, and schizophrenia. However, until now, there is no consent about the possible deleterious effects of gluten intake because of often failing symptoms even in persons with proven CD. Asymptomatic CD (ACD) is present in the majority of affected patients and is characterized by the absence of classical gluten-intolerance signs, such as diarrhea, bloating, and abdominal pain. Nevertheless, these individuals very often develop diseases that can be related with gluten intake. Gluten can be degraded into several morphine-like substances, named gluten exorphins. These compounds have proven opioid effects and could mask the deleterious effects of gluten protein on gastrointestinal lining and function. Here we describe a putative mechanism, explaining how gluten could "mask" its own toxicity by exorphins that are produced through gluten protein digestion.

Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines

Urticaria can present acutely and be self-limiting or become chronic and persist for weeks, months, or years. In either case, the condition may have a significant impact on the patient's quality of life. Two major consensus groups, the EAACI/WAO and the AAAAI/ACAAI Joint Task Force, have written guidelines on the diagnosis and management of urticaria. While both agree on most points regarding the definition, general evaluation, and treatment, there are some differences which exist. The guidelines, which are written to assist both primary practitioners and specialists in managing their patients with urticaria, have been developed based on scientific evidence, and when insufficient evidence is available, then recommendations are based on expert consensus opinion. The majority of the differences between the two guidelines pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these two groups, highlighting the key similarities and differences.

Management of allergy to penicillins and other beta-lactams

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.