Urticaria

Common autoimmune diseases and urticaria: the causal relationship from a bidirectional two-sample mendelian randomization study

Objective

The immune response assumes a pivotal role in the underlying mechanisms of urticaria pathogenesis. The present study delves into an investigation of the genetic causal connections between urticaria and prevalent autoimmune afflictions, notably rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), ulcerative colitis (UC), and Crohn's disease (CD).

Methods

A bidirectional two-sample Mendelian randomization (MR) analysis was conducted to investigate the causal relationships involving four autoimmune diseases and urticaria. The genome-wide association study (GWAS) summary data of four autoimmune disease were sourced from the IEU OpenGWAS database. The GWAS summary data for urticaria were derived from the Finnish consortium dataset. The principal analytical approach employed in this study was the random-effects inverse variance weighted (IVW) method. Subsequently, a series of sensitivity analyses were performed, encompassing assessments of heterogeneity, horizontal pleiotropy, outliers, "Leave-one-out" analyses, and tests for adherence to the assumption of normal distribution.

Results

The random-effects IVW analysis indicate a positive genetic causal association between RA and urticaria (P < 0.001, OR 95% CI = 1.091 [1.051-1.133]). Conversely, SLE, UC, and CD do not exhibit a significant genetic causal relationship with urticaria. The reverse MR analysis reveals a positive genetic causal linkage between urticaria and SLE (P = 0.026, OR 95% CI = 1.289 [1.031-1.612]). However, the analysis demonstrates no substantial genetic causal relationship between urticaria and RA, UC, or CD. Importantly, the genetic causal assessment absence of heterogeneity, horizontal pleiotropy, and outliers. Furthermore, it remains unaffected by any individual single nucleotide polymorphism (SNP), demonstrating adherence to a normal distribution.

Conclusion

This investigation establishing RA as a predisposing factor for urticaria. Moreover, urticaria as a plausible risk determinant for SLE. Heightened vigilance is recommended among RA patients to monitor the manifestation of urticaria within clinical settings. Similarly, individuals afflicted by urticaria should duly acknowledge the prospective susceptibility to SLE.

Investigation of intestinal microbiome in chronic spontaneous urticaria patients

BACKGROUND

Chronic urticaria is a disorder characterized by itchy erythematous plaques with edema lasting 6 weeks or more. The prevalence is 1%, and two thirds of these cases are "chronic spontaneous urticaria (CSU)." Drugs, food, infections, and systemic diseases may be etiologic factors for CSU, although it may be idiopathic.

OBJECTIVES

The aim of this study was to compare the diversity and distribution of the intestinal microbiome in CSU patients with that of healthy individuals. The hypothesis was to determine the probable association of intestinal microbiome with CSU.

METHODS

This study was conducted in Sakarya University Training and Research Hospital, Department of Dermatology. In this study, 20 CSU patients and 10 healthy volunteers were included. Stool samples were collected from all participants. 16S RNA sequencing and bioinformatic analysis were performed after isolation of DNA isolation from all samples.

RESULTS

Diversity in microorganisms, stool pH averages, Bristol scores, and the ratio of Firmicutes/Bacteroidetes were the significant changes between the two groups.

LIMITATIONS

Due to high cost involved in microbiota studies, only a limited number of patients and volunteers participated.

CONCLUSION

The alteration in the intestinal microbiota (dysbiosis) may be an essential factor for CSU development and may explain idiopathic cases.

Diagnosis and treatment of urticaria in primary care

Urticaria, also known as hives among people, is a very common disease characterized by erythematous, edematous, itchy, and transient plaques that involve skin and mucous membranes. It is classified as acute spontaneous urticaria, chronic spontaneous urticaria, chronic inducible urticaria, and episodic chronic urticaria. Many factors such as infections, medicines, food, psychogenic factors, and respiratory allergens are accused of etiology, but sometimes, it is idiopathic. Clinical presentation involves red, swelling, and itchy plaques. The lesions usually resolve spontaneously within 2-3 h without a trace. The patients are sometimes confronted with an angioedema that can also involve the respiratory tract. In this case mucous membranes, such as eyelids, lips, swell with some pain and burning sensation. If respiratory tracts are involved, it may be life threatening and should be treated urgently. The diagnosis is usually straightforward, urticarial vasculitis, drug eruptions, viral eruptions, and urticaria pigmentosa must also be considered. H1 antihistamines and, sometimes, short-term systemic corticosteroids are preferred for the treatment; H2 antagonists may be added during resistant cases, although other treatment options, such as omalizumab, cyclosporine, and leukotriene receptor antagonists, may be considered during missed events.

Usefulness of the autologous serum test for the diagnosis of chronic idiopathic urticaria

BACKGROUND

The majority of chronic urticaria cases are chronic idiopathic urticaria (CIU) with no specific identifiable etiology. The role of autoantibodies in such cases remains controversial.

OBJECTIVE

This study determined the positivity rate of autologous serum tests in CIU patients.

METHODS

This study was performed on 30 patients with CIU and 30 individuals without any systemic or dermatologic disease. After the volar parts of right and left forearms were cleansed, 0.05 ml serum physiologic and 0.05 ml autologous serum were injected intradermally on the right forearm 5 cm apart from each other, resulting in the formation of small papules; meanwhile, 0.05 ml histamine alone was injected to the left forearm. The test results were evaluated after 30 minutes as positive in positive cases.

RESULTS

The autologous serum test produced significant and non-significant results in patients with CIU and controls, respectively. The positivity rates of the autologous serum test in the CIU and control groups were 53.3% and 26.6%, respectively. There was no relationship between autologous serum test positivity and sex in either group. In male patients with CIU, positive results ranged widely with age, while in female patients, positive results were mainly observed at younger ages with a narrow age range.

CONCLUSION

The autologous serum test is a useful test in the diagnosis and treatment of CIU as well as the selection of immunotherapy, especially in patients refractory to classic therapy.

Evaluation of autologous serum skin test and skin prick test reactivity to house dust mite in patients with chronic spontaneous urticaria

Background

Chronic spontaneous urticaria (CSU) is a common skin disorder with etiology that is not well understood.

Methods

In this study, we evaluated the prevalence of autologous serum skin test (ASST) and skin prick testing (SPT) to house dust mite (HDM) in 862 CSU cases in China. Clinical features, courses and treatment responses were also recorded.

Results

The prevalence of positive ASST was 46.3%, and patients aged 30–39 years had the highest positive rate (52.1%). Positive SPT to HDM was seen in 153 patients (17.7%) with the highest positive rate (34.2%) in patients aged 20 or less. Patients with positive ASST had higher urticaria activity scores (UAS) (4.18±0.65 vs. 3.67±0.53) but lower positive rates of HDM (24.6% vs. 37.6%), as compared with those with negative ASST (odds ratio (OR) 1.84, 95% CI 1.38–2.47). Patients could be categorized into four groups based on the results of ASST and SPT to HDM and patients with positive ASST and positive SPT to HDM had the highest disease activity scores, experienced higher frequencies of angioedema, diseases duration, and required higher dosage of loratadine every month, compared with other subgroups (P<0.0001).

Conclusions

Patients with CSU showed varied responses of positive ASST and varied sensitivity to HDM, Patients with positive ASST and/or positive SPT had more disease activity compared with patients with negative ASST and/or negative SPT. Further classification can be made based on the result of SPT and ASST.

The role of focal infections in the pathogenesis of psoriasis and chronic urticaria

INTRODUCTION

The Focal Infection Theory, originally presented at the beginning of the 20(th) century, postulates that systemic diseases can be caused by microorganisms that arise from the focus of infection. Foci of infections have been described as sinuses, adenoids, tonsils, teeth, genitourinary tract, gall bladder and kidneys. A focus of infection is defined as the area that can occur in any part of the body, contains a pathogen (microorganism) and is usually asymptomatic. There are discordant opinions about the role of focal infections in the pathogenesis of psoriasis and urticaria.

AIM

To establish whether there is a higher incidence of focal infections in patients with chronic urticaria and psoriasis.

MATERIAL AND METHODS

We retrospectively reviewed 129 patients with a history of psoriasis and chronic urticaria: 58 women and 71 men treated in the Department of Dermatology of the Jagiellonian University Medical College in Krakow.

RESULTS

In the analyzed group, 11 patients had a dental consultation, 58 - laryngological consultation and 29 women had a gynecological consultation. The most common examples of focal infection were tonsillitis, upper respiratory tract infections, sinusitis, dental caries and genitourinary tract infections. Aggravating factors were similar to previously described.

CONCLUSIONS

A high incidence of focal infections in patients with psoriasis and urticaria suggests that infections may play a significant role in the pathogenesis of these skin disorders. Treatment of infection foci may play the key role in the remission of skin changes.

Psychosocial factors and chronic spontaneous urticaria: a systematic review

BACKGROUND

Chronic spontaneous urticaria (CSU) is one of the most costly allergic conditions challenging physicians as well as patients and their families. Despite evident lacunae in the understanding of the pathogenesis, at least some findings suggest that psychosocial factors likely contribute to the development and exacerbation of CSU. We aim to assess the contribution of psychological factors to CSU.

METHODS

Systematic search of PubMed and OVID/Medline databases was conducted from 1 January 1935 to 1 January 2012. Studies selected include original research in English, Spanish and French exploring the association between CSU and psychosocial factors. Two investigators independently reviewed all titles and abstracts to identify potentially relevant articles and resolved discrepancies by repeated review and discussion and arbitration of a third reviewer. Quality of systematic reviews and meta-analyses was assessed using a measure based on the Newcastle-Ottawa Scale and psychological conditions of CSU patients.

RESULTS

We identified 114 eligible studies spanning 77 years and featuring 17 reviews, 67 studies related to neither CSU nor psychosocial factors, and eight studies that provided either no prevalence estimates or insufficient sample size. Pooling effect sizes using random effects, analyses revealed that, despite large heterogeneity (I(2) of 97.60%), psychosocial factors had a prevalence of 46.09% (95% confidence interval, 44.01%, 48.08%).

CONCLUSION

Future research needs to better establish the contribution of psychosocial factors to the pathogenesis and exacerbation of CSU, and explore the possible benefit of behavioural interventions to the development of new management strategies.

Bilastine: in allergic rhinitis and urticaria

Bilastine is an orally administered, second-generation antihistamine used in the symptomatic treatment of seasonal or perennial allergic rhinoconjunctivitis and urticaria. In two well designed phase III trials, 14 days' treatment with bilastine was associated with a significantly lower area under the effect curve (AUEC) for the reflective total symptom score (TSS) than placebo in patients with symptomatic seasonal allergic rhinitis. Additionally, reflective nasal symptom scores were significantly lower in bilastine than placebo recipients in patients with a history of seasonal allergic rhinitis who were challenged with grass pollen allergen in a single-centre, phase II study. Neither bilastine nor cetirizine was effective in the treatment of perennial allergic rhinitis with regard to the mean AUEC for reflective TSS in another well designed phase III trial. However, results may have been altered by differences in some baseline characteristics and placebo responses between study countries. In another well designed phase III trial, compared with placebo, bilastine was associated with a significantly greater change from baseline to day 28 in the mean reflective daily urticaria symptom score in patients with chronic urticaria. There were no significant differences in primary endpoint results between bilastine and any of the active comparators used in these trials (i.e. cetirizine, levocetirizine and desloratadine). Bilastine was generally well tolerated, with a tolerability profile that was generally similar to that of the other second-generation antihistamines included in phase III clinical trials.

Delayed pressure urticaria - dapsone heading for first-line therapy?

BACKGROUND

Pressure urticaria as a subform of physical urticaria is rare and treatment is often difficult. Established therapeutic regimes include antihistamines (generally exceeding approved dosages in order to achieve a therapeutic benefit) or antihistamines combined with montelukast. Complete relief of symptoms is difficult.

PATIENTS AND METHODS

We used dapsone as an early therapeutic alternative in the event of treatment failure and established a standardized therapeutic regime at our clinic. We surveyed 31 patients retrospectively who had received dapsone between 2003-2009.

RESULTS

In 74 % of patients in whom symptoms persisted despite established therapies, the results of treatment with dapsone were good or very good. Longer-term pressure urticaria and the co-existence of a chronic spontaneous urticaria were associated with a smaller benefit (p<0.05). No significant effects were found related to age, gender, duration of therapy, side-effects, or Met-Hb elevation (a tendency toward a decreased benefit was associated with middle-age, male sex, shorter duration of therapy, observed side-effects, and Met-Hb elevation).

CONCLUSIONS

Therapy is well tolerated and results in a good therapeutic benefit which lasts after termination of therapy. With adequate monitoring, the use of dapsone in patients with pressure urticaria has such a good risk-benefit ratio that we support early treatment initiation.

Urticaria and infections

Urticaria is a group of diseases that share a distinct skin reaction pattern. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear. In spontaneous acute urticaria there is no doubt for a causal relationship to infections and all chronic urticaria must have started as acute. Whereas in physical or distinct urticaria subtypes the evidence for infections is sparse, remission of annoying spontaneous chronic urticaria has been reported after successful treatment of persistent infections. Current summarizing available studies that evaluated the course of the chronic urticaria after proven Helicobacter eradication demonstrate a statistically significant benefit compared to untreated patients or Helicobacter-negative controls without urticaria (p < 0.001). Since infections can be easily treated some diagnostic procedures should be included in the routine work-up, especially the search for Helicobacter pylori. This review will update the reader regarding the role of infections in different urticaria subtypes.

Mastocytosis: a disease of the hematopoietic stem cell

INTRODUCTION

Mastocytosis is an unusual clonal disease of the hematopoietic stem cell.

METHODS

This article is based on a selective literature search and on the authors' clinical and pathological experience.

RESULTS

The clinical manifestations of mastocytosis range from cutaneous mastocytosis, a common, prognostically favorable presentation, to mast cell leukemia, a rare, life-threatening disease. The mediator-induced symptoms usually respond well to H1 antihistamines. Therapeutic standards for cytoreduction in the progressive, systemic forms of mastocytosis are still lacking.

DISCUSSION

Because some of the manifestations of mastocytosis are nonspecific and can be mimicked by other diseases, there is a risk of two types of diagnostic error: Mastocytosis may remain undiagnosed when it is actually present, or it may be diagnosed even though morphological and molecular findings rule out mastocytosis. Well-defined criteria should be used to differentiate mastocytosis from other diseases with a similar clinical presentation.