Antihistamine-resistant urticaria factitia successfully treated with anti-immunoglobulin E therapy

Chronic Inducible Urticaria

Chronic inducible urticaria (CIndU) is characterized by the appearance of hives (urticaria) and/or angioedema in response to specific triggers or stimuli. For accurate diagnosis, anamnesis-driven specific, and if available, standardized trigger testings, as well as patient reported outcomes, should be applied. The currently recommended treatment algorithm is the same as for chronic spontaneous urticaria but is largely off-label for CIndU. New, and possibly more disease-specific, treatment options are needed for CIndU patients, who are often severely impacted by their disease. Several clinical trials are currently ongoing.

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.

Taiwanese dermatological association consensus for the definition, classification, diagnosis, and management of urticaria: A 2021 update

Urticaria is a prevalent disease with substantial physical, psychological, and economic impacts. With the advent of understandings of the disease and the emerging evidence of treatments, the international guidelines for treating urticaria have been updated in recent years. In order to update the 2014 edition of the Taiwanese Dermatological Association (TDA) consensus of urticaria, a total of 17 dermatologists with extensive experience in urticaria management were invited to and attended the TDA consensus meetings. All the specific aspects of the content were approved by at least 75% of the experts in attendance. Comparing to the former edition, several substantial modifications were made. For diagnosis, D-dimer was added as the recommended routine test in patients with chronic spontaneous urticaria. For pharmacological management, treatment suggestions were simplified. The approved-dosed, the up-dosed second-generation antihistamines, omalizumab, and cyclosporine were listed as the first-line to the fourth-line treatment, respectively. In addition, the management for patients of special considerations, such as the elderly, children, and pregnant women, were all discussed and mentioned in the consensus. We hope the updated TDA consensus can serve as a reference for all physicians and can help the physicians providing up-to-dated managements for these patients.

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.

Emerging treatments for chronic urticaria

INTRODUCTION

Across the globe, chronic urticaria (CU), i.e. chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CINDU), is common, long-persisting and difficult to manage. Still, at least one-fifth is not sufficiently controlled by guideline-recommended treatment with H1-antihistamines and add-on therapy with the anti-IgE monoclonal antibody omalizumab.

AREAS COVERED

Using PubMed, ClinicalTrials.gov, Congress websites, and websites of the manufacturers, this review explored the pipeline, namely anti-IgE-, anti-cytokine-, anti-receptor biologics, and small molecules, in clinical development for CU.

EXPERT OPINION

The CU pipeline is promising. While three omalizumab biosimilars are investigated, the assumed early approval of ligelizumab will expand the effective and safe anti-IgE approach observed with omalizumab. For other anti-IgEs like UB-221, the development is behind. Data are too limited so far to clearly define the role of anti-cytokine and anti-cytokine receptor biologics such as dupilumab, tezepelumab, mepolizumab, benralizumab, and CDX-0159, of which only dupilumab is actually investigated in phase 3. Among three selective oral BTK inhibitors, remibrutinib, rilzabrutinib, and fenebrutinib, the development of remibrutinib is most advanced (phase 3). As the pipeline addresses different targets, study results will give deeper insights into the pathomechanisms of CU. Hopefully, in the next future additional approved and also more targeted approaches will be available.

Clinical impact of omalizumab in refractory chronic urticaria: One centre experience

Chronic spontaneous urticaria is a debilitating disorder, which has a major impact on the quality of life of affected individuals, and is a substantial global burden. Refractory, difficult to treat cases pose a difficult challenge to patients and clinicians alike. Advances in the field of immunotherapy have led to novel and effective therapeutic strategies. Omalizumab, an immunomodulatory anti-IgE monoclonal antibody, inaugurated a new era in the treatment of refractory chronic urticaria. Several multicenter clinical trials have proven omalizumab to be a safe and effective option for the treatment of refractory symptoms of chronic spontaneous urticaria, while some small studies have shown its efficacy in chronic inductible urticaria as well. In this study, we bring forth updates in chronic urticaria approach, with a focus on our experience with anti-IgE therapy in different forms of chronic urticaria treated at the Allergy Department of the Professor Doctor Octavian Fodor Regional Institute of Gastroenterology and Hepatology (Cluj-Napoca, Romania).

How to Approach Chronic Inducible Urticaria

Chronic inducible urticaria (CIndU) is a group of chronic urticarias characterized by the appearance of recurrent wheals, recurrent angioedema or both, as a response to specific triggers. CIndU includes both physical (symptomatic dermographism, cold and heat urticaria, delayed pressure urticaria, solar urticaria, and vibratory urticaria) and nonphysical urticarias (cholinergic urticaria, contact and aquagenic urticaria). Here, we review the different forms of CIndU with an emphasis on symptomatic dermographism, cold urticaria, cholinergic urticaria, and delayed pressure urticaria. We discuss the clinical features, the diagnostic workup including provocation and threshold testing, and available treatment options.

Management problems in severe chronic inducible urticaria: Two case reports

Chronic inducible urticaria (CIndU) is a subgroup of chronic urticaria which can cause severe quality of life impairment by their refractory forms. The recommended treatment approach in CindU is the same as that for chronic spontaneous urticaria (CSU). However, CIndU seem to be more resistant to standard doses of H1 antihistamines (AHs) and higher doses of AHs are required for symptom control. Omalizumab, a recombinant anti-IgE antibody, effectively treats CSU. Nevertheless, there is not enough evidence in patients with CIndU, especially in AHs resistant cases. This study analyzed 2 severe cases of CIndU (cold urticaria and symptomatic dermographism) with completely different response to omalizumab. We describe 2 patients with 2 subtypes of CIndU: one with severe cold urticaria (including anaphylaxis) and the other with severe extensive symptomatic dermographysm. In both cases, we performed complete positive and differential diagnostic work-up. Management strategies included first line and second line symptomatic therapy, but with no success in either case. Avoidance of eliciting triggers was difficult to achieve (occupational reasons). We decided to start omalizumab treatment, 300 mg every 4 weeks for 6 months. The cold urticaria patient gained complete symptom relief 10 days after the first dose of omalizumab; the quality of life improved substantially with no side effects of the treatment. The urticaria factitia patient showed no benefit of the add-on 5 months treatment with omalizumab. He refused the 6th dose of omalizumab due to the lack of response, and also cyclosporine, but he showed some benefits of oral corticosteroids. Although many clinical studies support the use of omalizumab in the treatment of patients with CIndU, we certainly need more data for prediction of a good clinical response.

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

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

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

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

Review of Physical Urticarias and Testing Methods

PURPOSE OF REVIEW

This review aims to update the information available on the prevalence, clinical picture, diagnostic methods, and treatment of urticarias induced by external physical stimuli.

RECENT FINDINGS

Physical urticarias are present in up to 5% of the general population, and in 10 to 50% of patients with chronic urticaria. Recent investigations have provided evidence that the presence of physical urticaria alone or when comorbid with chronic spontaneous urticaria is associated with a worse prognosis and duration. Most frequent subtypes of physical urticaria are dermographism and delayed pressure urticaria. The diagnosis is established through specific provocation tests and the management encompasses avoidance measures, pharmacologic therapy with nonsedating antihistamines, and alternative medications in refractory cases.

Omalizumab treatment in patients with chronic inducible urticaria: A systematic review of published evidence

BACKGROUND

Omalizumab, a recombinant anti-IgE antibody, effectively treats chronic spontaneous urticaria. Evidence is lacking in patients with chronic inducible urticarias (CIndUs), which are frequently H₁-antihistamine resistant.

OBJECTIVE

From the current published literature, we aimed to determine the strength of evidence for omalizumab efficacy and safety in the treatment of CIndUs.

METHODS

We performed a PubMed search to identify evidence on omalizumab use in the following 9 CIndU subtypes: symptomatic dermographism, cold urticaria, delayed-pressure urticaria, solar urticaria, heat urticaria, vibratory angioedema, cholinergic urticaria, contact urticaria, and aquagenic urticaria.

RESULTS

Forty-three trials, case studies, case reports, and analyses were identified. Our review indicates that omalizumab has substantial benefits in patients with various CIndUs. The evidence is strongest for symptomatic dermographism, cold urticaria, and solar urticaria. Little/no evidence was available on vibratory angioedema and aquagenic and contact urticaria. Our review supports rapid onset of action demonstrated through early symptom control in most cases, sometimes within 24 hours. Many patients gained complete/partial symptom relief and substantially improved quality of life. Adverse events were generally low, with omalizumab being well tolerated by most patients, including children.

CONCLUSIONS

A strong body of evidence supports the use of omalizumab in the treatment of patients with therapy-refractory CIndU. More data from randomized controlled studies are warranted.

Management of chronic inducible urticaria according to the guidelines: A prospective controlled study

BACKGROUND

The recommended treatment approach in chronic inducible urticarias (CIndU) is the same as that for chronic spontaneous urticaria (CSU). But there is a lack of controlled trials assessing efficacy of available treatment options.

OBJECTIVE

We aimed to evaluate the efficacy of treatment algorithm recommended by the guidelines and comparison of treatment responses in CIndU vs CSU.

METHODS

This prospective parallel group controlled study included 70 CIndU and 66 CSU patients. The same treatment algorithm recommended by the European Academy of Allergology and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum/World Allergy Organization (EAACI/GA²LEN/EDF/WAO) was implemented to both CSU and CIndU patients. Treatment responses of the groups were evaluated with urticaria control test (UCT) and dermatology life quality questionnaire (DLQI) scores at the 0, 4, 8, 12 and 24th weeks for CIndU and 0, 4, 12 and 24 weeks for CSU.

RESULTS

Fourteen patients (20,9%) with CIndU and 25 (37,9%) with CSU responded to standard doses of H1-AHs which was significantly higher in the CSU group (p=0,031, p<0,05). Patients with CIndU and CSU showed statistically similar responses to 2nd line treatments (combining or updosing AHs) (p=0,979; p>0,05). Twenty-seven (40,3%) of CIndU patients and 21 (31,8%) of CSU patients were diagnosed as AH-resistant urticaria. Omalizumab was administered to 15 CSU patients and 17 CIndU patients. Response rates to omalizumab were similar in both groups. Total response rates increased from 37,9% (n:25) to 68,2% (n:45) with the 2nd line treatments in CSU group while it increased from 20,9% (n:14) to 59,7% (n:40) in CIndU group. When omalizumab was introduced to AH-refractory cases as a 3rd line treatment, total response rates evaluated at the 12th week were 76,1% (n:51) in patients with CIndU and 83,3% (n:55) in CSU. Continuing omalizumab treatment for 24 weeks increased response rates in patients who were unresponsive at week 12.

CONCLUSION

CIndU seem to be more resistant to standard doses of AHs and higher doses of AHs are required for the control of symptoms. The same guidelines for CSU may be implemented to patients with CIndU.

IgE-Related Chronic Diseases and Anti-IgE-Based Treatments

IgE is an immunoglobulin that plays a central role in acute allergic reactions and chronic inflammatory allergic diseases. The development of a drug able to neutralize this antibody represents a breakthrough in the treatment of inflammatory pathologies with a probable allergic basis. This review focuses on IgE-related chronic diseases, such as allergic asthma and chronic urticaria (CU), and on the role of the anti-IgE monoclonal antibody, omalizumab, in their treatment. We also assess the off-label use of omalizumab for other pathologies associated with IgE and report the latest findings concerning this drug and other new related drugs. To date, omalizumab has only been approved for severe allergic asthma and unresponsive chronic urticaria treatments. In allergic asthma, omalizumab has demonstrated its efficacy in reducing the dose of inhaled corticosteroids required by patients, decreasing the number of asthma exacerbations, and limiting the effect on airway remodeling. In CU, omalizumab treatment rapidly improves symptoms and in some cases achieves complete disease remission. In systemic mastocytosis, omalizumab also improves symptoms and its prophylactic use to prevent anaphylactic reactions has also been discussed. In other pathologies such as atopic dermatitis, food allergy, allergic rhinitis, nasal polyposis, and keratoconjunctivitis, omalizumab significantly improves clinical manifestations. Omalizumab acts in two ways: by sequestering free IgE and by accelerating the dissociation of the IgE-Fcε receptor I complex.

Omalizumab in the Treatment of Chronic Inducible Urticaria

Omalizumab is a recombinant humanized monoclonal antibody that inhibits immunoglobulin E. It has been approved for the treatment of severe asthma and chronic spontaneous urticaria refractory to other treatments. Its use in the management of chronic inducible urticaria (a type triggered by certain stimuli) is still considered off-label, although this use has been discussed in some consensus papers. This review brings together case reports and case series describing the use of omalizumab to treat chronic inducible urticaria. We analyze the most important aspects of the cases and the outcomes reported. The results seem to position omalizumab as a potentially effective, safe treatment alternative in some cases of chronic inducible urticaria.

The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision

These recommendations for the definition, diagnosis and management of chronic inducible urticaria (CIndU) extend, revise and update our previous consensus report on physical urticarias and cholinergic urticaria (Allergy, 2009). The aim of these recommendations is to improve the diagnosis and management of patients with CIndU. Our recommendations acknowledge the latest changes in our understanding of CIndU, and the available therapeutic options, as well as the development of novel diagnostic tools.

Chronic spontaneous urticaria: latest developments in aetiology, diagnosis and therapy

Chronic urticaria is a debilitating disease characterized by itching and hives with or without angioedema lasting for more than 6 weeks. The disease carries a significant emotional and economic burden for the patient and often results in an odyssey between doctors of different specialities. Patients suffering from chronic urticaria are considered more difficult to satisfy, treat and to have a bigger emotional burden than the average patient in dermatology, paediatric and general practice settings. A joint initiative under the Dermatology section of the European Academy of Allergy and Clinical immunology (EAACI), the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) has resulted in recently published guidelines for the diagnosis, classification and treatment of chronic urticarial: these guidelines are clinically useful and have a high success rate when followed in daily clinical practice. The treatment of choice for chronic urticaria is still nonsedating antihistamines although other treatments are available, with omalizumab (humanized IgG anti IgE antibodies) as the newest therapy. The pathogenesis of urticaria is poorly understood but autoimmunity is considered as one of the major underlying causes for this disease, although other theories exist.

The use of biologicals in cutaneous allergies - present and future

PURPOSE OF REVIEW

Up-to-date biologicals in cutaneous allergies play - unfortunately - only a minor role. However, this situation might change. Recently, omalizumab was licensed for chronic urticaria; this article reviews recent advances in the use of biologicals in cutaneous allergies.

RECENT FINDINGS

Interestingly, the mechanism of omalizumab appears to be different in urticaria and allergic asthma for which the drug has been licensed previously. In urticaria dosage is not dependent on serum IgE-levels and response is seen very often after only 12 h. Other indications in cutaneous allergy in which biologicals have been investigated, at least in case reports or small studies, are TNF-α-antagonists and rituximab in chronic urticaria, omalizumab, rituximab and TNF-α-antagonists in atopic dermatitis as well as mepolizumab in this disease. However, all these studies appear to show a benefit for individual patients but not a clear breakthrough for the whole group of patients involved. This, however, might also be one of the future approaches that sub-groups of patients who have different responses to biologicals may be identified, as apparently different cytokine patterns are predominantly involved in the individual patient.

SUMMARY

In conclusion, although currently only one biological is approved in chronic urticaria, there is hope that a rapid better understanding of individual disease factors will support the development of other novel drugs in this field.

Methods report on the development of the 2013 revision and update of the EAACI/GA2 LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria

This methods report describes the process of guideline development in detail. It is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS) and is published in Allergy 2014; 69:868-887.

The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update

This guideline is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The life-time prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria do not only cause a decrease in quality of life, but also affect performance at work and school and, as such, are members of the group of severe allergic diseases. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Effectiveness of omalizumab in a patient with a life-threatening episode of bronchospasm and larynx angioedema after exposure to house dust

Omalizumab is a monoclonal antibody against IgE, nowadays approved for the treatment of persistent severe (EU) or moderate-to severe (USA) IgE-mediated asthma but there is also some evidence (case reports and four published clinical trials) on the effectiveness of this medication in urticaria and angioedema. The case of a 42-year-old woman suffering from severe allergic asthma and severe chronic urticaria with concomitant angioedema is presented in the article. She had a life-threatening episode of bronchospasm and larynx edema after exposure to house dust recorded in her medical history. The patient did not respond to standard therapy. The improvement in asthma control and remission of chronic urticaria and angioedema was achieved after introducing the therapy with omalizumab.

Omalizumab in the treatment of chronic urticaria

Omalizumab is a monoclonal anti-immunoglobulin E antibody currently only approved for use in severe, refractory asthma. In recent years, many authors have reported satisfactory results with omalizumab in patients with difficult-to-treat chronic urticaria. As a result, clinical trials were undertaken to broaden the indication of omalizumab to include chronic urticaria, and the drug was recently cited as a third-line treatment after selective antihistamines at high doses in a consensus document on the treatment of chronic urticaria. In this article our aim is to provide a comprehensive update on the use of omalizumab in the treatment of chronic urticaria. The structure of this biologic agent and its possible mechanisms of actions in this setting will be presented. Treatment strategies and the different dosage regimens used in the series of cases published to date will also be reviewed. Finally, we will discuss the adverse effects that may arise with treatment and the recommended strategies for minimizing the most feared effect, anaphylaxis. Based on the experience of many researchers, omalizumab is emerging as a novel treatment for certain types of spontaneous refractory chronic urticaria and has shown promising results in this setting. The drug has a good safety profile and the main limitation is its high cost.

Biologic agents in the treatment of urticaria

Numerous controlled studies as well as case reports have demonstrated that Omalizumab can be employed successfully in approximately 75 % of patients with chronic spontaneous urticaria, leading to a dramatic decrement in symptoms with very few side effects. No other drug currently available is comparable, and the success rate in patients resistant to antihistamines is no different. In the U.S., Phase I and Phase II trials are complete and we await the results of a Phase III multicenter study, with a view to eventual submission to the Food and Drug Administration in the U.S. and to comparable agencies abroad seeking approval for this indication. Omalizumab is currently marketed for the treatment of severe allergic asthma. Case reports suggest efficacy in difficult cases of physical urticaria, but no controlled trails have been done. Other agents require further evaluation for possible efficacy in the treatment of chronic spontaneous urticaria, including antibody to CD20, a B-lymphocyte cell surface marker, anti-TNFα, and anti-Interleukin 1. Thus far, targeting TNFα has been disappointing for this indication, while targeting Interleukin I has dramatically ameliorated autoinflammatory disorders with urticaria or urticaria-vasculitic-like lesions such as cold-induced autoinflammatory syndrome, Muckle-Wells syndrome, and Schnitzler syndrome.

Diagnosis and treatment of urticaria and angioedema: a worldwide perspective

: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.

Omalizumab for chronic urticaria: a case series and overview of the literature

Omalizumab is a recombinant humanized monoclonal antibody that blocks the high-affinity Fc receptor of IgE. Omalizumab has been approved for the treatment of moderate to severe asthma; however, there is currently more and more data showing promising results in the management also of chronic urticaria. We present a case series of 19 patients with chronic urticaria treated in a university department with omalizumab and give an overview of the existing literature comprising an additional 59 cases as well as a total of 139 patients enrolled in two randomized controlled trials comparing omalizumab with placebo. The collective evidence points to omalizumab as a safe and effective treatment option for patients with chronic urticaria who do not sufficiently respond to standard therapy as recommended by existing guidelines.

Six cases of antihistamine-resistant dermographic urticaria treated with oral ciclosporin

BACKGROUND

Dermographic urticaria (DU) is characterized by strong itch and wheals induced by mechanical scratching. H(1)-receptor antagonists may reduce symptoms of DU to some extent, but other treatments being used for chronic spontaneous urticaria, such as H(2)-receptor antagonists and corticosteroids, are not usually effective for DU.

CASE SUMMARY

We here report six cases of antihistamine-resistant DU treated with oral ciclosporin. Four cases suffering from severe itches that spontaneously occurred before the appearance of wheals in response to scratching were substantially improved by use of ciclosporin for 21, 16, 32, and 8 months, and one of them reached complete remission. Two cases did not obtain a benefit from the treatment, because of insufficient effects and/or side effects.

DISCUSSION

Oral ciclosporin may be of value as a potential treatment of anti-histamine-resistant DU.

[Therapeutic alternatives for antihistamine-refractory urticaria]

Patients with chronic spontaneous urticaria, the most frequent non-acute form of urticaria, generally exhibit a clinical picture of persistent disease, a high degree of disease activity, considerable impairment of quality of life, and poor response to treatment. More than half of the patients continue to develop symptoms despite standard therapy with non-sedating antihistamines. In these cases, the antihistamine dose should be increased (up to four times the daily dose). If this approach also does not result in symptom control, the high-dose antihistamine should be combined with a leukotriene antagonist and if necessary an H2 blocker. If the patient does not respond to this combination therapy, cyclosporin A, dapsone, or omalizumab should be administered.