EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria

Biologic therapy for chronic spontaneous urticaria in pediatrics and adolescents: current landscape, challenges, and future perspectives

INTRODUCTION

Chronic spontaneous urticaria (CSU) poses significant challenges, especially in pediatric and adolescent patients, impacting physical, emotional, and social well-being. Recent biologic breakthroughs offer promise, however, data on safety and efficacy in this population remain limited.

AREAS COVERED

This review examines current biologic treatments in pediatrics and adolescents with CSU and explores the rapidly emerging landscape.

EXPERT OPINION

Despite omalizumab's approval for allergic asthma in children since 2009, its delayed approval for CSU raises questions. Ligelizumab, a next-generation anti-IgE mAb, showed effectiveness in adults but lacks pediatric studies. CT-P39, a biosimilar to omalizumab, demonstrates promise, yet adolescent-specific outcomes are undisclosed. Dupilumab's recent approval for atopic dermatitis in children from 6 months onwards signifies progress. Expert opinion underscores the scarcity of controlled trials in pediatric and adolescent CSU, emphasizing the need for comprehensive studies. Age-specific data and collaboration are crucial for addressing research gaps and expanding indications for pediatric CSU treatment. The recently validated UAS7 parameter in children marks a milestone for prospective clinical trials. Despite challenges, the biology therapy outlook for pediatric and adolescent CSU is promising. Importantly, studies indicate that pediatric CSU is at least as prevalent as in adults, highlighting the need for approved treatments in this population.

Different doses and courses of omalizumab for patients with chronic spontaneous urticaria: A systematic review with meta-analysis and trial sequential analysis

Background

The stability, efficacy, and safety of omalizumab at different doses and regimens for chronic spontaneous urticaria (CSU) are yet to be studied.

Objective

A systematic review (SR) with meta-analysis (MA) and trial sequential analysis (TSA) was performed to assess the efficacy and safety of omalizumab in CSU.

Methods

Randomised controlled trials (RCTs) of administering omalizumab versus placebo for CSU were searched. Random-effects MAs were performed using planned subgroup analyses. TSA was performed to control for the risk of random errors and assess the stability of our MA results. Publication bias was visually assessed using a contour-enhanced funnel plot and the trim-and-fill method. The quality of RCTs was assessed using the Cochrane Risk of Bias Tool 2.

Results

Twelve studies met the inclusion criteria. Omalizumab had remarkable effects on the patient percentage of the weekly urticaria activity score is zero (UAS = 0) [RR 4.64, 95% CI (3.38, 6.37)], percentage of no angioedema-burdened days [MD 3.15, 95% CI (0.10, 6.19], patient percentage of UAS ≤6 [RR 3.05, 95% CI (2.46, 3.78)], and patient percentage of the weekly itch severity score minimally important difference (ISS7 MID) [RR 1.50, 95% CI (1.36, 1.66)]. Omalizumab was well tolerated across studies [RR 0.98, 95% CI (0.90, 1.08)]. TSA confirmed the above results, except for "the percentage of no angioedema-burdened day".

Conclusion

Among the different doses and courses assessed, omalizumab (300 mg, 12 weeks) can be recommended as an effective treatment for patients with CSU. However, whether omalizumab improves angioedema requires further investigation. The clinical management of angioedema accompanying CSU requires further attention.

Methimazole-induced urticaria in hyperthyroid patients: A safe re-administration protocol

PURPOSE

The safety profile of methimazole (MMI) seems to be better than propylthiouracil in the management of hyperthyroidism. It is therefore advisable to use IMM as the first choice in Graves' patients. It is important to keep this drug in patients regardless of minor side effects. We report a case series of MMI-induced urticaria and provide a stepwise protocol for the safe re-administration of MMI.

METHODS

It was a retrospective case series including all patients having manifested urticaria following MMI intake for hyperthyroidism; notified to the Pharmacovigilance Unit of the Clinical Pharmacology Department (March 2013-January 2022).

RESULTS

We have included 11 patients (SR: 0.22). The median time interval between the start of MMI and the onset of urticaria averaged 14.5 days. The median daily dose of MMI was 40mg. MMI was interrupted in all patients. Urticaria has progressively resolved after drug interruption and antihistamine intake. Reintroduction of MMI was performed in 10/11 patients as follows: one quarter of the daily dose on the first day, half of the daily dose on the 4th day, the three quarters of the daily dose on the 7th day, to reach the scheduled total dose on the 10th day. Cetirizine was added at the time of reintroduction and withdrawn 2 weeks later. All the patients were successfully controlled.

CONCLUSION

Given the importance of this drug in the management of hyperthyroidism, MMI should not be withdrawn in cases of urticaria. After the resolution of urticaria, a gradual reintroduction of MMI should be attempted with concomitant antihistamine therapy.

Managing hyperglycemia and rash associated with alpelisib: expert consensus recommendations using the Delphi technique

Hyperglycemia and rash are expected but challenging adverse events of phosphatidylinositol-3-kinase inhibition (such as with alpelisib). Two modified Delphi panels were conducted to provide consensus recommendations for managing hyperglycemia and rash in patients taking alpelisib. Experts rated the appropriateness of interventions on a 1-to-9 scale; median scores and dispersion were used to classify the levels of agreement. Per the hyperglycemia panel, it is appropriate to start alpelisib in patients with HbA1c 6.5% (diabetes) to <8%, or at highest risk for developing hyperglycemia, if they have a pre-treatment endocrinology consult. Recommend prophylactic metformin in patients with baseline HbA1c 5.7% to 6.4%. Metformin is the preferred first-line anti-hyperglycemic agent. Per the rash panel, initiate prophylactic nonsedating H1 antihistamines in patients starting alpelisib. Nonsedating H1 antihistamines and topical steroids are the preferred initial management for rash. In addition to clinical trial evidence, these recommendations will help address gaps encountered in clinical practice.

Embryonic-stem-cell-derived mesenchymal stem cells relieve experimental contact urticaria by regulating the functions of mast cells and T cells

Contact urticaria (CU) is an inflammatory skin disorder triggered by specific substances upon skin contact, leading to immediate acute or chronic manifestations characterized by swelling and redness. While mesenchymal stem cells (MSCs) are increasingly recognized for their therapeutic potential in immune diseases, research on the efficacy and mechanisms of stem cell therapy for urticaria remains scarce. This study investigates the regulatory role of embryonic-stem-cell-derived multipotent MSCs (M-MSCs) administered in a CU mouse model. Therapeutic effects of M-MSC administration were assessed in a Trimellitic anhydride-induced contact urticaria model, revealing significant inhibition of urticarial reactions, including ear swelling, itchiness, and skin lesion. Moreover, M-MSC administration exerted control over effector T cell activities in major lymphoid and peripheral tissues, while also suppressing mast cell degranulation in peripheral tissues. Notably, the inhibitory effects mediated by M-MSCs were found to be TGF-β-dependent. Our study demonstrates the capacity of M-MSCs to regulate contact urticaria in a murine model, harmonizing the activation of inflammatory T cells and mast cells. Additionally, we suggest that TGF-β derived from M-MSCs could play a pivotal role as an inhibitory mechanism in contact urticaria.

Comparative study on the efficacy and safety of bepotastine besilate versus levocetirizine in chronic spontaneous urticaria: A randomised, open-label, parallel study

Background Urticaria is a common skin disease which often causes impairment in the quality of life. The ideal drug for chronic urticaria would have antihistaminic and anti-inflammatory actions. Bepotastine besilate is a recently approved novel anti-allergic agent with multiple mechanisms of action; levocetirizine is a potent and selective second-generation H1 receptor antagonist used in the treatment of urticaria. Aim To compare the efficacy and safety of bepotastine besilate versus levocetirizine in patients with chronic spontaneous urticaria. Methods The study design is a randomised, open-label, parallel-group, prospective interventional study. The study subjects were randomly assigned to either of the two groups a and b, each group had 50 patients with chronic urticaria. Statistical analyses were performed using (SPSS, version 18) for all the variables. Chi-square test was used for comparison between categorical variables. An unpaired student's t-test was done for quantitative variables. Results There was a significant decrease in mean urticaria activity score (P < 0.001), chronic urticaria quality of life (P < 0.001) and clinical global improvement (P < 0.001) in both the treatment groups but this improvement was higher in the bepotastine than in the levocetirizine group. There was no significant difference in the mean of absolute eosinophil count, C-reactive protein, aspartate transaminase, alanine transaminase from baseline to 4th week between the two study groups. Visual analogue scale showed statistically significant improvement from baseline to 4th week (P < 0.001) of follow-up but this increase was higher in levocetirizine group (0.64-4.24) than in bepotastine group (0.56-2.56) Limitations Blinding was not done. To assess the efficacy and safety of bepotastine, a larger study can be planned. Conclusion This study found that bepotastine is superior to levocetirizine and showed a statistically significant reduction in mean urticaria activity score 7, improved quality of life and clinical global improvement in patients with urticaria.

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.

PK/PD modeling to characterize placebo and treatment effect of omalizumab for chronic spontaneous urticaria

The pharmacokinetic (PK) characteristics of omalizumab and its pharmacodynamic (PD) effect in patients has yet to be fully characterized in chronic spontaneous urticaria, which could elucidate its pathogenesis and treatment response. This study has two objectives; (1) characterize the population PK of omalizumab and its PD effect on IgE, and (2) develop a drug effect model of omalizumab in urticaria (via change in weekly itch severity score). The target-mediated population of PK/PD model incorporating omalizumab-IgE binding and turnover adequately described PK and PD of omalizumab. The effect compartment model and linear drug effect and additive placebo response adequately described placebo and treatment effects of omalizumab. Several baseline covariates were identified for PK/PD and drug effect models. The developed model has the potential to aid in understanding variability in PK/PD as well as response to omalizumab treatment.

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.

Case series of chronic spontaneous urticaria following COVID-19 vaccines: an unusual skin manifestation

BACKGROUND

Urticaria following the COVID-19 vaccine was rarely reported and had a short self-limited resolution. However, there has been relatively little literature published on CSU induced by COVID-19 vaccines.

PURPOSE

We describe a case series of patients who experienced CSU after SARS-CoV-2 vaccination.

METHODS

A retrospective case series of 10 patients referred to the Department of Clinical Pharmacology of the University of Monastir (January 2021-January 2022) and included for evaluation of urticaria after COVID-19 vaccination.

RESULTS

The median age was 31 years and patients were mostly female. Atopy was presented in 3 patients and urticaria was accompanied by angioedema in 6 patients. The median time interval between vaccination and the onset of urticaria was 28.5 h. The offended dose was the first one in 8 patients. The resolution of the eruption was observed at least 2 months later, despite the regular use of a full dose of antihistamine in nine patients. Polynuclear leucocytosis was identified in 5 patients. Anti-TPOAb was positive in one patient after receiving the BNT162b2 vaccine. Total serum IgE was elevated in 4 patients. Skin tests for the suspected vaccine as well as the vaccine excipient were negative.

CONCLUSION

We add to the medical literature ten new cases of chronic spontaneous urticarial reactions following COVID-19 vaccines uncontrolled with high-dose first-generation H1 antihistamines.

Effectiveness of Hydroxychloroquine and Omalizumab in Chronic Spontaneous Urticaria: A Real-World Study

BACKGROUND

Chronic spontaneous urticaria (CSU) not controlled by optimized doses of antihistamines is referred to as refractory CSU. Add-on therapies recommended by guidelines include omalizumab, immunosuppressive, and anti-inflammatory agents.

OBJECTIVES

The objective of the study was to assess the real-world effectiveness of different add-on treatment options for refractory CSU in 2 large clinical practices.

METHODS

A retrospective chart review was conducted in 264 patients with refractory CSU not adequately controlled for ≥6 weeks with optimized doses of second-generation histamine-1 blockers. Omalizumab and hydroxychloroquine were the most frequently prescribed add-on therapies, allowing comparisons of clinical outcomes for these 2 agents. Complete response included absent or infrequent urticaria and patient satisfaction with treatment. Partial response was reduced hives, but requiring a second add-on therapy. Sustained response was complete response to an add-on therapy for ≥1 year.

RESULTS

Omalizumab add-on treatment was significantly more likely to be associated with a complete response versus hydroxychloroquine. Complete sustained response at 1 year was observed in 82% (111 of 134) of patients on omalizumab and 66% (73 of 111) on hydroxychloroquine as the first add-on therapy (P < .01). Patients with thyroid disease had a poorer response to add-on treatments (45% responded vs 63%; P = .03). In patients with incomplete responses to first add-on interventions (n = 45), 65% and 62% subsequently had complete responses to omalizumab and hydroxychloroquine, respectively.

CONCLUSIONS

Although omalizumab was superior, hydroxychloroquine achieved a complete response in two-thirds of treated patients. Given a favorable safety profile, hydroxychloroquine should be considered as an add-on treatment for refractory CSU.

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.

New markers to predict the response to omalizumab in chronic spontaneous urticaria

Omalizumab has high treatment efficacy in patients with chronic spontaneous urticaria (CSU) who do not respond to high doses of antihistamines. Systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI) were described as novel inflammatory and prognostic biomarkers. The present study aimed to evaluate the effectiveness of SII and SIRI in patients with CSU who receive omalizumab therapy. A total of 124 patients with severe urticaria who had an Urticaria Activity Score over 7 days (UAS-7) ≥28 were included in the study. UAS-7, C-reactive protein (CRP), SII, and SIRI values ​​were recorded before and after omalizumab treatment. Patients with UAS-7 ≤ 6 at week 12 and/or week 24 of omalizumab treatment were considered responders. Three months after omalizumab treatment, significant decreases were observed in SII, SIRI, CRP, and UAS-7 compared to pre-treatment values ​​(p:0.003, p < 0.001, p:0.006, and p < 0.001, respectively). At the third and sixth months of treatment, baseline SII and SIRI levels of the omalizumab responder group were significantly higher than the non-responder group (p < 0.001). However, there was no difference in baseline CRP and UAS-7 levels between responders and non-responders (p˃0.05). After adjusting for confounding factors, only pre-treatment SII (OR: 1.002, 95% CI: 1.000-1.004, p: 0.036) and SIRI (OR: 4.334, 95% CI: 1.751-10.726, p:0.002) values were independently associated with response to omalizumab at 3 months in multivariate regression analysis. SII and SIRI could be effectively used to predict the response to omalizumab therapy. More comprehensive studies are needed to validate and elaborate on this relationship.

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.

High-dose non-sedating antihistamines are used insufficiently in chronic urticaria patients treated with omalizumab

BACKGROUND

The lifetime prevalence of chronic urticaria (CU) is 0.5%-1%. In some patients with CU, symptomatic control is not achieved with non-sedating second-generation H1 antihistamines (nsAH1) alone, even with quadrupled standard doses as recommended in international guidelines. In these cases, biological treatment with omalizumab can be added. Since omalizumab is expensive compared to antihistamines, lack of adherence to guidelines for high dose nsAH1 (up to four-fold standard dose per day) may be associated with substantial unnecessary costs. The aim was to measure the use nsAH1 before and during omalizumab use for the first time in an omalizumab treated CU population.

METHODS

We identified all Danish patients with CU who initiated omalizumab from March 2014 to December 2018 and evaluated new and ongoing nsAH1 treatments using the Danish nationwide registries.

RESULTS

A total of 955 CU patients initiated treatment with omalizumab within the study period (median age 40 years [IQR 28-50], 74.5% females). During the 12 months prior to omalizumab initiation, 95.6% of the patients filled at least one prescription with nsAH1 at some point, while 84.7% filled at least one prescription during the three months before omalizumab. From 3 months before omalizumab initiation till 3 months after, the proportions of users of high-dose nsAH1 was maximum 31.1%.

CONCLUSIONS

Omalizumab was usually administered before sufficient nsAH1 treatment was tried. In despite of the labelling that omalizumab should be co-administered with high dose nsAH1, this does not happen This may lead to substantial unnecessary costs.

Efficacy and Safety of Non-brain Penetrating H1-Antihistamines for the Treatment of Allergic Diseases

H₁ receptor antagonists, known as H₁-antihistamines (AHs), inactivate the histamine H₁-receptor thereby preventing histamine causing the primary symptoms of allergic diseases, such as atopic dermatitis, pollinosis, food allergies, and urticaria. AHs, which are classified into first-generation (fgAHs) and second-generation (sgAHs) antihistamines, are the first line of treatment for allergic diseases. Although fgAHs are effective, they cause adverse reactions such as potent sedating effects, including drowsiness, lassitude, and cognitive impairment; anticholinergic effects, including thirst and tachycardia. Consequently, the use of fgAHs is not recommended for allergic diseases. Today, sgAHs, which are minimally sedating and, therefore, may be used at more effective doses, are the first-line treatment for alleviating the symptoms of allergic diseases. Pharmacologically, the use of sedating fgAHs is limited to antiemetics, anti-motion sickness drugs, and antivertigo drugs. The use of histamine H₁-receptor occupancy (H₁RO) based on positron emission tomography (PET) has been developed for the evaluation of brain penetrability. Based on the results of the H₁RO-PET studies, non-brain-penetrating AHs (nbpAHs) have recently been reclassified among sgAHs. The nbpAHs are rapidly acting and exhibit minimal adverse reactions and, thus, are considered first-line drugs for allergic diseases. In this review, we will introduce recent topics on the pharmacodynamics and pharmacokinetics of AHs and make recommendations for the use of nbpAHs as first-line treatment options for allergic diseases.

Clinical difference between single subtype and mixed subtype chronic urticaria: A retrospective study

BACKGROUND

The subtypes of chronic urticaria share a common clinical expression, but may show differences phenotypically. Meanwhile, two or more different subtypes of chronic urticaria can coexist in any given patient which may involve different phenotypes.

AIMS

The study aims to compare the two phenotypes in terms of demographics, clinical profile and treatment response.

METHODS

In this retrospective study, 2678 chronic urticaria patients were divided into the single subtype chronic urticaria group and mixed subtype chronic urticaria group as was appropriate.The differences in the clinical features, possible causes, urticaria activity score of seven days, dermatology life quality index score, laboratory investigations and response to treatments were evaluated among the two groups.

RESULTS

An obvious female predominance was detected in chronic urticaria, especially in mixed subtype chronic urticaria patients. Of the 2678 chronic urticaria patients, there were 837(31.25%) mixed subtype chronic urticaria. Chronic spontaneous urticaria combined with symptomatic dermographism was the most common group in the mixed subtype chronic urticaria. Patients with mixed subtype chronic urticaria were more likely to have associated chest tightness/shortness of breath and showed greater urticaria activity. In patients with single subtype chronic urticaria, the positive rate of family history with allergic rhinitis, asthma or urticaria was lower. Based on evaluation of the treatment, control with second-generation antihistamines at licensed doses was achieved in only 38.83% of mixed subtype chronic urticaria patients, compared with 56.32% of patients with single subtype.

LIMITATIONS

First, this study was a single-center design retrospective study. Second, omalizumab treatment was not included. Third, the differences between different subtypes of mixed subtype chronic urticaria were not discussed in detail.

CONCLUSION

This study showed that mixed subtype chronic urticaria had some distinct features. Comprehensive knowledge about it may help us define effective therapeutic strategies and improve symptom control and the quality of life for chronic urticaria patients.

Contact Urticaria

This article discusses contact urticaria syndrome definition, history, epidemiology, occupational relevance, mechanisms, clinical manifestations, diagnostic tools, agents responsible, and how to prevent and treat the patients affected. Contact urticaria syndrome is often misdiagnosed because it is not well known or recognized by physicians. Commonly the patient recognizes the cause of the clinical symptom, but the cause can be exceptional or new. Triggers include proteins, chemical compounds, agricultural chemicals, metals, plants, foods, and other substances. The objective of this article is to help dermatologists, toxicologists, and immunologists by providing diagnostic tools to avoid the culprit agent and treat the patients.

The challenges of chronic urticaria part 2: Pharmacological treatment, chronic inducible urticaria, urticaria in special situations

This is Part 2 of an updated follow-up review of the World Allergy Organization (WAO) position paper on the diagnosis and treatment of urticaria and angioedema. Since that document was published, new advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics in patients with severe refractory disease, mainly omalizumab, have been gained. For these reasons, WAO decided to initiate an update targeted to general practitioners around the world, incorporating the most recent information on epidemiology, immunopathogenesis, comorbidities, quality of life, clinical case presentations, and the management of chronic spontaneous and chronic inducible urticaria, and urticaria in special situations such as childhood and pregnancy. A special task force of WAO experts was invited to write the different sections of the manuscript, and the final document was approved by the WAO Board of Directors. This paper is not intended to be a substitute for current national and international guidelines on the management of urticaria and angioedema, but to provide an updated simplified guidance for physicians around the world who have to manage patients with this common ailment.

Case Report: Refractory Chronic Spontaneous Urticaria Treated With Omalizumab in an Adolescent With Crohn's Disease

Chronic spontaneous urticaria (CSU) is a mast cell-driven disease that is often associated with autoimmune or autoinflammatory conditions. Omalizumab is recommended in the treatment of refractory CSU in patients over 12 years of age who do not respond to four standard doses of antihistamines. Omalizumab blocks the mast cells’ degranulation, thus interrupting the resulting inflammatory cascade driven by T-helper 2 (Th2) cytokines. The efficacy of omalizumab in controlling CSU and possible associated diseases has been studied in few patients so far. In particular, some case reports describe adults with CSU and concomitant inflammatory bowel diseases (IBD), such as Crohn’s disease (CD) or ulcerative colitis (UC). Although the treatment of CD with anti-tumor necrosis factors-α (TNF-α) seems to be effective in controlling CSU, no cases of the utility of omalizumab in patients with both conditions have been described so far. At the moment, there is no evidence that the pathogenetic mechanisms underlying CD are linked to the same pathways that are inhibited by omalizumab for the treatment of CSU. We present the first pediatric case of refractory CSU and CD in which omalizumab led to CSU remission, even if the follow-up period was limited. In conclusion, our experience shows how CSU could be associated with CD and successfully treated with the monoclonal anti-IgE antibody in a patient on immunosuppressive therapy. However, more data is needed from a larger population.

Evaluation of serum levels of C-reactive protein, D-Dimer and Autologous Serum Skin Test in patients with Chronic Spontaneous Urticaria in a Brazilian tertiary center : a cross-sectional study

Background

The pathophysiology of urticaria is still poorly understood. Recent studies demonstrate that the activation of coagulation is correlated with the clinical activity of Chronic Spontaneous Urticaria. Coagulation and inflammation are strongly linked.

Objectives

To correlate the severity and activity of Chronic Spontaneous Urticaria with the levels of D-dimer, C-reactive protein, and autologous serum test in patients with Chronic Spontaneous Urticaria.

Methods

The study included 55 patients diagnosed with chronic spontaneous urticaria. D-dimer levels were measured using enzyme-linked fluorescent assay and C-reactive protein levels were measured using the nephelometric method; autologous serum testing was performed on patients who discontinued antihistamine therapy. The severity of the disease was assessed using the urticaria activity score.

Results

patients with severe, spontaneous, and difficult-to-control chronic urticaria had elevated serum levels of D-dimer, as well as a positive autologous serum test. Little correlation was demonstrated between the severity of chronic spontaneous urticaria and the levels of C-reactive protein.

Conclusion

The authors concluded that patients with severe Chronic Spontaneous Urticaria showed signs of activated fibrinolysis. Most patients with high clinical scores had high D-dimer values. Patients with positive results for the autologous serum test also had more severe Chronic Spontaneous Urticaria and needed more drugs to control the disease. Finally, little correlation was found between C-reactive protein levels and disease severity.

Study limitations

The main limitation was the small sample of patients. In the present patients, it was demonstrated that serum D-dimer levels and the autologous serum test can act as predictive markers of severity and activity of Chronic Spontaneous Urticaria.

Omalizumab Updosing in Chronic Spontaneous Urticaria: an Overview of Real-World Evidence

Chronic spontaneous urticaria (CSU) is defined as the spontaneous development of itchy hives and/or angioedema due to known or unknown causes that last for at least 6 weeks. At any given time, CSU is believed to affect 0.5–1% of the global population. Omalizumab (a recombinant, humanized anti-immunoglobulin-E antibody) is the only approved treatment for antihistamine refractory CSU. However, ~ 30% of patients remain symptomatic at licensed doses of omalizumab 150 mg and 300 mg, even after a treatment period of over 6 months. In the recent years, there have been several studies on updosing of the drug, suggesting that the individualized approach for urticaria treatment with omalizumab is useful. In this article, we provide an overview of these studies and the real-world data on omalizumab updosing as it became necessary to obtain complete CSU symptom control in a proportion of patients. Published observational studies (from June 2003 to October 2019) on the updosing of omalizumab in CSU were identified using PubMed and Ovid databases. Reports mainly show that updosing/dose adjustment evaluated with the assessment of disease activity (Urticaria Activity Score) and control (Urticaria Control Test) achieves better clinical response to omalizumab with a good safety profile in a pool of patients with CSU. These real-world data will provide an overview of updosing of omalizumab in CSU and aid in setting informed clinical practice treatment expectations.

Clinical characteristics of patients with chronic urticaria and adherence to management guidelines by postgraduate students in dermatology: A retrospective single center study

Background:

Chronic urticaria is a heterogenous skin disorder representing one of the important reasons for consultation with a dermatologist. Dermatology post-graduate students play an importanrt role in the treatment of patients with chronic urticaria.

Objective:

The objective of the study was to describe clinical characteristics of patients with chronic urticaria and assess adherence to the guidelines by postgraduate students in the department of dermatology of a tertiary care center.

Materials and Methods:

In this retrospective study, prescriptions of patients with chronic urticaria and/or angioedema presenting to the outpatient department for 5 months were analyzed. Percentage of prescriptions adhering to international urticaria management guidelines was calculated. Urticaria Activity Score, percentage of patients receiving second-generation antihistamines, first-generation antihistamines, and other drugs was recorded. Comorbidities in patients with chronic urticaria were also noted.

Results:

A total of 60 patients (mean age 32.1 years; 58.3% male) were included in. Mean (SD) duration of urticaria at the time of study was 4.7 (2.7) months. Demographism and history of allergy to drugs was present in 45 (75%) and 4 (6.7%) patients. Mean (SD) Urticaria Activity Score was 12.5 (6.5). A total of 12 (20%) patients had comorbidities. Mean number of drugs received per patient was 1.7 (0.5). A total of 47 (78.3%) patients received second-generation antihistamines, whereas 11 (18.3%) received first-generation antihistamines. Two (3.3%) patients received combination of first-generation and second-generation antihistamines. Fexofenadine, levocetirizine, bilastine, and cetirizine was prescribed to 24 (40%), 26 (43.3%), 18 (30%), and 14 (23.3%) patients. There was no significant difference in male and female patients receiving fexofenadine (P = 0.59) or levocetirizine (P = 0.13).

Conclusion:

Adherence to urticaria management guidelines by resident doctors in dermatology department in our institute was satisfactory.

Real-Life Experience of Efficacy and Safety of Bilastine in the Refractory Cases of Chronic Spontaneous Urticaria and its Effect on the Quality of Life of Patients

Introduction:

Second-generation H1-antihistamines (SGAHs) are the mainstay of treatment of chronic spontaneous urticaria (CSU). Bilastine, newer non-sedating SGAHs, was recently introduced in India after the approval of the Drugs Controller General of India. There is a paucity of evidence about the long-term efficacy and safety of Bilastine in Indian patients. We undertook this study to find the long-term efficacy and tolerability of Bilastine in patients with CSU in India.

Materials and Methods:

This retrospective chart analysis was conducted by analyzing electronic medical records from May 1, 2019, to March 20, 2020, to identify patients of CSU who were prescribed Bilastine. Adult patients, with CSU >6 months were included, who had an unsatisfactory response as per Urticaria Activity Score 7 (UAS7) to previous antihistamine therapies, and who continued treatment for at least 6 months were included. Treatment effectiveness was determined by retrospectively reviewing their UAS7 scores from their medical records and evaluating their scores at weeks 4, 8, 12, 16, 20, and 24. Also, DLQI was assessed and compared at baseline and week 24.

Result:

Forty-nine patients were found to fulfill the criteria and included in the study. At the end of 24 weeks, 51% of patients (n = 25) achieved complete treatment response (UAS = 0), whereas 49% of patients (n = 24) were labeled as well-controlled urticaria (UAS<6). At 24 weeks, the mean UAS7 score (1.35 ± 1.61) was statistically significant compared to the baseline score (20.2 ± 5.73). The mean score of DLQI was also reduced to 1.63 ± 1.18 at 24 weeks from 8.39 ± 2.49 at baseline (P-value <0.001).

Conclusion:

The study showed that in patients who had an inadequate response with commonly used antihistamines at a double dose or combined use, switching over to Bilastine resulted not only in relieving the symptoms of CSU but also improved the quality of life of the patients with CSU.

High-Density Lipoprotein (HDL) in Allergy and Skin Diseases: Focus on Immunomodulating Functions

From an evolutionary perspective, lipoproteins are not only lipid transporters, but they also have important functions in many aspects of immunity. High-density lipoprotein (HDL) particles are the most abundant lipoproteins and the most heterogeneous in terms of their composition, structure, and biological functions. Despite strong evidence that HDL potently influences the activity of several immune cells, the role of HDL in allergies and skin diseases is poorly understood. Alterations in HDL-cholesterol levels have been observed in allergic asthma, allergic rhinitis, atopic dermatitis (eczema), psoriasis, urticaria, and angioedema. HDL-associated apolipoprotein (apo) A-I, apoA-IV, and apoC-III, and lyso-phosphatidylcholines potently suppress immune cell effector responses. Interestingly, recent studies provided evidence that allergies and skin diseases significantly affect HDL composition, metabolism, and function, which, in turn, could have a significant impact on disease progression, but may also affect the risk of cardiovascular disease and infections. Interestingly, not only a loss in function, but also, sometimes, a gain in function of certain HDL properties is observed. The objective of this review article is to summarize the newly identified changes in the metabolism, composition, and function of HDL in allergies and skin diseases. We aim to highlight the possible pathophysiological consequences with a focus on HDL-mediated immunomodulatory activities.

Mesenchymal Stem Cells: a Potential Treatment Approach for Refractory Chronic Spontaneous Urticaria

The etiopathogenesis of chronic spontaneous urticaria (CSU) is not fully elucidated, and almost 30-40% of patients are resistant to treatments; therefore, there is still a need for the development of new and effective treatments. This study aimed to develop experimental cellular therapy for CSU patients resistant to current treatment options. Autologous adipose tissue mesenchymal stem cells (MSC) were administered to 10 refractory CSU patients who were then followed up for six months. The efficacy of treatment was evaluated according to the weekly urticaria activity scores (UAS7) and drug use scores (DUS7). To observe the effect of treatment on immune cells, CD4⁺ T cell subsets were analyzed by flow cytometry, and the serum IFN-γ, TNF-α, IL2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17a, IL-21, IL-22, TGF-β1, PGE2, IDO and anti-FcεRI levels were measured using the Luminex and ELISA methods. The values obtained were compared with 10 control refractory CSU patients and five healthy controls. We found that the T cell subsets and inflammatory molecules were not affected by MSC treatment during the follow-up period. In control patients, a significant decrease was detected only at the Th2 subset, TGF-β1, PGE2, IDO and anti-FcεRI levels on the 14th day of treatment. The UAS7 and DUS7 values of the MSC-treated patients significantly decreased during the follow-up period, but in control patients, a significant but temporary decrease was seen. According to our findings, unlike conventional treatment, MSC therapy resulted in longer and more effective recovery. Our data indicate that MSCs may be an alternative and effective approach for treatment-resistant CSU patients. Graphical Abstract.

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.

Current and Potential Biologic Drugs for the Treatment of Chronic Urticaria

This article reviews biologic treatments that are currently applied for the treatment of severe chronic urticaria. Monoclonal anti-immunoglobulin E (omalizumab) is effective and safe in many patients, but accessibility and cost constitute barriers to its wider use. Questions on the optimal duration of the treatment and possible symptom recurrences after discontinuing the drug are still raised. A discussion is presented about several other biologics currently under investigation with potential to be incorporated in the near future in patients with severe chronic urticaria.

How "benign" is cutaneous mastocytosis? A Danish registry-based matched cohort study

BACKGROUND

There are limited estimates of the incidence rates (IRs) of mastocytosis, and only a few studies have addressed the long-term consequences of living with these diagnoses. Previous reports have shown that systemic mastocytosis is associated with leukemic transformations and an increased risk of death as opposed to cutaneous mastocytosis (CM) and indolent systemic mastocytosis (ISM), which have benign diagnoses with life expectancy rates similar to those of the background population.

OBJECTIVE

This study aimed to analyze the incidence and mortality of mastocytosis.

METHODS

A population-based matched cohort study of patients with mastocytosis between 1 January 1, 1977 and 31 December 31, 2014 was identified from the Danish National Health Registries. IRs of CM, ISM, and pediatric mastocytosis were highlighted. Survival estimates were compared with those of a healthy background population, using a Cox proportional hazard model.

RESULTS

A total of 1461 patients with mastocytosis were identified. The annual IR of overall mastocytosis was 1.1 per 100,000 person years (95% confidence interval [CI], 1.0-1.2). Among children, the IR was 1.8 per 100,000 person years (95% CI, 1.6-2.1). The prevalence of any comorbidity was twice as high among patients with mastocytosis compared with the population without mastocytosis (odds ratio: 2.1; 95% CI, 1.8-2.5). The Charlson Comorbidity Index-adjusted mortality among adult patients with mastocytosis was HRCutaneous Mastocytosis 1.2 (95% CI, 0.8-1.9), HRIndolent Systemic Mastocytosis 1.9 (95% CI 1.4-2.5), and HRSystemic Mastocytosis 4.2 (95%, CI 1.9-9.4), respectively.

CONCLUSION

Based on an entire nation, with free health care at the point of access, we estimated an annual IR of mastocytosis and its subgroups. We discovered that patients with ISM had an increased risk of death compared with the general population. Our data supported the overall benign nature of CM diagnosed after age 2 years.

Assessment of thiol/disulphide homoeostasis and ischaemia-modified albumin and their relationship with disease severity in children with chronic urticaria

BACKGROUND

The pathogenesis chronic urticaria (CU) hasn't been fully understood. In recent years, it has been shown that thiol-disulphide homoeostasis, as an antioxidant system, plays important roles in both healthy individuals and various diseases. In different ischaemia-reperfusion states, high oxidative stress causes ischaemia-modified albumin (IMA) generation.

AIM

To investigate thiol/disulphide balance and IMA level in children with CU and their association with disease severity.

METHODS

Thirty children with CU and 20 healthy children as controls, aged 1-18 years, were included in this cross-sectional study. In all subjects, total thiol, native thiol, disulphide levels and IMA levels were measured in plasma by spectrophotometry. Disulphide/native thiol, disulphide/total thiol and native thiol/total thiol ratios were calculated. The disease severity was rated by Urticaria Activity Score (UAS).

RESULTS

In the children with CU, the levels of native thiol (375.56 ± 56.22 μmol/L) and total thiol (415.69 ± 54.75 μmol/L) were significantly lower than the control group (475.20 ± 71.87 and 511.20 ± 73.73 μmol/L, respectively) (p = 0.000, p = 0.000). The ratio of native/total thiol * 100 was lower in patients than the control group (p = 0.002). IMA was significantly higher in the patient group than control group (p = 0.000). No significant correlation was found between UAS and thiol/disulphide homoeostasis (p > 0.05). The disulphide levels, disulphide/native thiol and disulphide/total thiol levels were found to be higher in patients with positive family history for autoimmune disorders than those without (p < 0.05).

CONCLUSION

In children with CU, impaired thiol/disulphide homoeostasis and increased IMA suggest that oxidative stress may play role in the disease pathogenesis.

How guideline can shape clinical practice globally: the diagnosis and rationale for action against cow's milk allergy experience

PURPOSE OF REVIEW

Allergic diseases are increasing worldwide and are considered an important public health problem causing severe and even life-threatening reactions. The creation of guidelines aims to help clinicians improving the quality of diagnosis and management of such diseases. Clinical practice guidelines alone are not sufficient and there is a need for implementation strategies for their introduction into daily practice. We report here the main international allergy guidelines with a more focused look on the Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines and their effect on clinical practice.

RECENT FINDINGS

DRACMA guidelines have clearly modified the approach to cow's milk allergy (CMA) from its diagnosis to treatment tailoring the choices for each patient. Although they strongly recommend oral food challenge for diagnosing CMA, they also indicate that it may not be necessary in many cases with the introduction of the pretest probability of CMA. Studies on the implementation of DRACMA guidelines show how they influenced the formula market, making appropriate treatments more affordable.

SUMMARY

DRACMA reconciled international differences in the diagnosis and management of CMA. They introduced the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology in the field of food allergy and highlighted the importance for meta-analyses to be able to adapt recommendations to the local context.

Predictive factors for progression to chronicity or recurrence after the first attack of acute urticaria in preschool-age children

INTRODUCTION AND OBJECTIVES

Preschool-aged group is frequently affected by urticaria, and infections are the most frequently documented factors that cause acute urticaria in children. This prospective study was designed to investigate the underlying factors of acute urticaria in under five-year-old children and to describe predictive factors for progression to chronicity or recurrence after the first attack.

PATIENTS AND METHODS

Children younger than five years of age with acute urticaria were recruited between July 2015 and July 2016. Patients (n=83) were grouped into those below and above two years of age. In order to assess the risk factors for progression to chronicity or recurrence, logistic regression analysis was performed.

RESULTS

Upper respiratory tract infection was the most common detectable reason for acute urticaria (49.4%). Herpes Simplex Virus type 1 was significantly isolated in the cases with the manifestation of an acute single-episode urticaria (p=0.042). Angioedema and food allergy were predominantly observed under two years old (p=0.001, p=0.006 respectively). A positive relationship was determined between the duration of urticaria and chronicity (r=0.301, p=0.006). The absence of atopic dermatitis (OR: 6.95, 95% CI: 1.35-35.67, p=0.020), negative Herpes virus serology (OR: 4.25, 95% CI: 0.83-21.56, p=0.040), and unknown etiology (OR: 3.30, 95% CI: 1.12-9.71, p=0.030) were the independent risk factors for recurrent urticaria.

CONCLUSIONS

Preschool-aged children with acute urticaria should be evaluated for infections at the time of admission. Patients with unknown etiology, negative Herpes virus serology, absence of atopic dermatitis, and long lasting urticaria should be followed up for chronicity and recurrence.

A retrospective analysis omalizumab treatment patterns in patients with chronic spontaneous urticaria: a real-world study in Belgium

Background

Chronic spontaneous urticaria (CSU) is characterized by the repeated occurrence of persistent hives and/or angioedema for ≥6 weeks, without specific external stimuli. H₁‐antihistamines have long been the standard of care of CSU, but many patients remain uncontrolled even at 4× the approved dose. Add‐on therapy with omalizumab has proven effective in clinical trials, but little is known about omalizumab treatment in Belgium.

Objective

To collect real‐world clinical data on omalizumab treatment in adults with CSU in Belgium.

Methods

This was an observational, retrospective chart review of adults with CSU, who initiated omalizumab treatment between August 2014 and December 2016 (maximum 28 months follow‐up).

Results

In total, 235 patients were included (median time from symptom onset to diagnosis, 5.4 months; median time from diagnosis to commencing omalizumab, 6.7 months). Treatments used before/after commencing omalizumab did not always adhere to guidelines; many patients (26.4%/11.1%) received first‐generation H₁‐antihistamines, while 20.4% used omalizumab monotherapy after initiating treatment. The mean interval between omalizumab administrations was 4.8 (SD 1.7) weeks; 67.8% of patients had ≥1 interval prolongation and/or shortening. Mean baseline 7‐day Urticaria Activity Score (UAS7) was 32.0 (SD 6.05); this improved to 12.6 (SD 11.2) after 1 month of omalizumab. About 67.2% of patients reached UAS7 ≤ 6 (well controlled) during the study. A total of 87 patients stopped omalizumab and never restarted before the end of the observation period; the most prevalent reason was remission of symptoms (49.4% of patients), followed by lack of effect (12.6%), lost to follow‐up (6.9%) and adverse events (3.4%). Headache was the most common adverse event (n = 8/82). No anaphylaxis was reported.

Conclusions

This study revealed that patients initiated on omalizumab in Belgium had severe CSU at baseline, and showed substantial improvements after 1 month of treatment. Greater adherence to the prescription of guideline‐recommended medications is needed for the treatment of CSU.

Bloodletting Therapy for Patients with Chronic Urticaria: A Systematic Review and Meta-Analysis

Background

Many trials have reported that bloodletting therapy is effective when treating chronic urticaria. There are currently no systematic reviews of bloodletting therapy for chronic urticaria.

Objective

The aim of this review is to assess the effectiveness and safety of bloodletting therapy for chronic urticaria.

Methods

A systematic review and meta-analysis of randomized controlled trials were performed. Disease activity control was assessed as the primary outcome. Response rate, recurrence rate, and adverse events were assessed as secondary outcomes.

Results

Seven studies with 512 participants were included. One trial showed a significant difference between bloodletting therapy plus medicine and medicine alone in disease activity control (MD 0.67; 95% CI 0.03 to 1.31; p=0.04). Six trials (372 participants) showed a significant difference between bloodletting therapy and pharmacological medication in response rate (RR 1.10; 95% CI 0.97-1.26; P =0.15). Two studies (170 participants) showed a significant difference between bloodletting therapy plus pharmacological medication and pharmacological medication in response rate (RR 1.34; 95% CI 1.10-1.63; p=0.003). Two studies (126 participants) reported a statistically significant difference between bloodletting therapy and pharmacological medication in recurrence rate. No serious adverse events related to bloodletting therapy were reported.

Conclusions

Bloodletting therapy might be an effective and safe treatment for chronic urticaria, but the evidence is scarce. More high quality trials are needed in the future.

Awareness of Family Physicians Towards Antihistamines

BACKGROUND

Antihistamines are one of the commonly prescribed groups of drugs for allergic disorders and pruritus. They are broadly grouped into two generations, the second-generation ones being more effective and with less side effects. The family physicians frequently use antihistamines as patients contact them initially for their problem. It will be interesting to know the mode of selection of antihistamines by them.

MATERIALS AND METHODS

The study was carried out on a sample of 100 family physicians. Primary data were collected from them after taking informed consent. A pre-validated questionnaire regarding knowledge, awareness, and prescribing schedule of antihistamines was filled up. The data were then analyzed with suitable statistical tests.

RESULTS

Almost 73% of physicians prescribed second-generation antihistamines, while 27% prescribed the first-generation ones. Only 15% of them were aware about the ARIA and GA2LEN guidelines and their recommendations for prescribing second-generation antihistamines over the older first-generation antihistamines, while 85% had not heard about them previously. A minimum 7% of practitioners revealed that they updosed the same drug four times in the treatment of urticaria, while 93% did not do it.

CONCLUSION

Even though a sizeable percentage of family physicians prescribed second-generation antihistamines, most of them were not aware of their dosing guidelines.

Characterization of chronic urticaria and associated conditions in a large population of adolescents

BACKGROUND

Although chronic spontaneous urticaria (CSU) affects all age groups, data regarding CSU in adolescents is scarce.

OBJECTIVE

To characterize the epidemiology, demographics, and comorbidities associated with CSU in a large, cross-sectional nationwide population of adolescents.

METHODS

Medical records of 16-year-old candidate conscripts to the Israeli Defense Forces were reviewed. Data were collected on the prevalence and severity of CSU, as well as the demographics, medical comorbidities, medication use, and blood test results of affected individuals.

RESULTS

Medical records of 1,108,833 consecutive 16-year-old adolescents were reviewed. A total of 6617 (0.6%) adolescents received CSU diagnoses. CSU was increased in female conscripts (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.07-1.19, P < .001) and adolescents with higher socioeconomic scores (OR 1.92, 95% CI 1.56-2.32, P < .001). Individuals with CSU were significantly more likely to have allergic diseases, including food allergy (OR 7.31, 95% CI 6.13-8.72), allergic rhinitis (OR 2.9, 95% CI 2.71-3.11), atopic dermatitis (OR 2.35, 95% CI 2.03-2.72), and asthma (OR 1.46, CI 1.35-1.57).

CONCLUSION

Our work provides an account of CSU in a large cohort of adolescents. We found a strong link between CSU and atopic diseases. Further investigation is needed to decipher the mechanism underlying this observed association.

Natural course of new-onset urticaria: Results of a 10-year follow-up, nationwide, population-based study

BACKGROUND

Previous epidemiologic studies of the natural course of urticaria mainly focused on chronic spontaneous urticaria and were conducted at hospitals. The natural course of new-onset urticaria in the general population is unknown.

METHODS

Patients with new-onset urticaria were identified from the National Health Insurance Service-National Sample Cohort data. Patients who had at least one visit for urticaria in 2002 and 2003 were excluded and the study cohort consisted of 1,027,620 subjects with no history of urticaria. We analyzed cumulative incidences of urticaria, chronic urticaria, and chronic urticaria remission using the life table estimation method from 2004 to 2013. Their association with related factors was analyzed using the Cox proportional hazards analysis.

RESULTS

From 2004 to 2013, a total of 49,129 patients with new-onset urticaria were identified. The 10-year cumulative incidence rate of urticaria for the general population was 4.9% and that of chronic urticaria among patients with new-onset urticaria was 7.8%. Remission rates of chronic urticaria were 52.6% at 1 year and 88.9% at 5 years. Age, sex, residential area, and autoimmune thyroid disease were significantly associated with urticaria or chronic urticaria, but not with chronic urticaria remission, after adjusting for covariates. Female individuals were more likely to have new-onset urticaria but less likely to develop chronic urticaria compared with male individuals.

CONCLUSIONS

During the 10-year follow-up period, only a small proportion of patients with new-onset urticaria developed chronic urticaria. Remission was achieved in the majority of patients with chronic urticaria regardless of demographic characteristics or accompanying thyroid disease.

Mas-Related G Protein-Coupled Receptor-X2 (MRGPRX2) in Drug Hypersensitivity Reactions

The human ortholog MRGPRX2 and the mice ortholog, Mrgprb2 are activated by basic secretagogues and neurokinins. A number of commonly used small-molecule drugs (e.g., neuromuscular blocking agents, fluoroquinolones, vancomycin) have been recently shown to activate these receptors under in vitro experimental conditions, what results in mast cell degranulation. The above drugs are also known to cause IgE-mediated anaphylactic reactions in allergic patients. The new findings on mechanisms of drug-induced mast cell degranulation may modify the current management of drug hypersensitivity reactions. Clinical interpretation of mild drug-provoked hypersensitivity reactions, interpretation of skin test with a drug of interest or further recommendations for patients suspected of drug allergy are likely to be reconsidered. In the paper we discussed future directions in research on identification and differentiation of MRGPRX2-mediated and IgE-dependent mast cell degranulation in patients presenting clinical features of drug-induced hypersensitivity reactions.

Improvement in the quality of life of patients with chronic spontaneous urticaria treated with omalizumab in real life

OBJECTIVE

Evaluation of the impact on the quality of life (QOL) relating to health in patients with chronic urticaria (CSU) treated with omalizumab.

METHOD

Longitudinal descriptive observational study of quality of life based on18 patients with chronic urticaria ≥12 years treated with omalizumab. Changes in QOL examined at 1 month (T1), at 6 months (T6) and 12 months (T12), by: Visual Analogical Scale (UAS), specific urticaria QOL questionnaire (CU-Q2oL), general health questionnaire (SF-36) and activity of urticaria questionnaire (Score UAS7).

RESULTS

The most disabling symptoms for patients were: pruritus (61.1%); decrease in health and physical activity (55.5%), wheals, swelling and nervousness (50%); depression and shame of marks (38.89%); side effects to drugs (33.33%); sleepiness and tiredness (27.78%); work (22.22%); "choosing clothes and pain" 16.67% and social relations (11.11%). Statistically significant differences were observed in T1, T6 and T12. In T1, UAS -4.72 (p=.001); CU-Q2oL -16.38 (p<.001); SF-36 15.44 (p=.006); UAS7 wheals -7.27 (p=.001), UAS7 pruritus -8.72 (p=.003). In T6, UAS -4.26 (p=.001); CU-Q2oL -18.94 (p<.001); SF-36 15.41 (p<.001); UAS7 wheals -7.41 (p=.001), UAS7 pruritus -7.11 (p=.001). In T12 UAS -9.61 (p=.004); CU-Q2oL -21.38 (p=.01); SF-36 17.53 (p=.04); UAS7 wheals -8.23 (p=.004), UAS7 pruritus -10.69 (p=.004).

CONCLUSIONS

There was a very good response in T1, which was maintained in T6 and T12. Patients with chronic urticaria treated with omalizumab presented good results with a reduction of CUE activity and improvement of their QOL.