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Le M, Zhu CK, Perlman L, Gabrielli S, Netchiporouk E, Nguyen A, Zhang X, Ensina LF, Ben-Shoshan M. Prevalence of atopic conditions in children with chronic urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00546-4. [PMID: 38802056 DOI: 10.1016/j.jaip.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 04/30/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Michelle Le
- Division of Dermatology, McGill University Health Center, Montreal, QC, Canada.
| | - Catherine K Zhu
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Lauren Perlman
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Sofianne Gabrielli
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Elena Netchiporouk
- Division of Dermatology, McGill University Health Center, Montreal, QC, Canada
| | - Alex Nguyen
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Xun Zhang
- Center for Outcome Research and Evaluation, McGill University Health Center Research Institute, Montreal, QC, Canada
| | - Luis F Ensina
- Department of Pediatrics, Federal University of Sao Paolo, Sao Paulo, Brazil
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy and Clinical Immunology, McGill University Health Center, Montreal, QC, Canada
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2
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Wagner N, Berking C. [Recognition and management of relevant comorbidities in chronic spontaneous urticaria]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:289-294. [PMID: 38411698 DOI: 10.1007/s00105-024-05311-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Abstract
Various mechanisms contributing to the activity of chronic spontaneous urticaria (CU) have been postulated. Associated comorbidities are increasingly leading to the discovery of further signaling pathways which may support the activity of chronic urticaria or contribute to low-grade systemic inflammation. Moreover psychoimmunological factors may also be involved. The aim of this work is to improve the clinical care of patients with CU by increasing knowledge regarding optional influencing factors due to comorbidities and to possibly influence disease activity. Chronic urticaria due to autoimmune mechanisms may dispose to other autoimmune diseases, especially autoimmune thyroiditis, which can trigger chronic disease. Association of CU with metabolic syndrome has received little attention to date. Obesity may contribute to low-grade systemic inflammation by cytokine-secreting adipose tissue and hence to mediator-release of mast cells. Furthermore, neuroimmunological pathways, especially increased release of substance P, an activating ligand of Mas-related G protein-coupled receptor X2 (MRGPX2) on mast cells, should be addressed when optimizing therapy.
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Affiliation(s)
- Nicola Wagner
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054, Erlangen, Deutschland.
| | - Carola Berking
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054, Erlangen, Deutschland
- Hautklinik, Uniklinikum Erlangen, 91054, Erlangen, Germany
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Kovalkova E, Fomina D, Borzova E, Maltseva N, Chernov A, Serdoteckova S, Weller K, Maurer M. Comorbid Inducible Urticaria Is Linked to Non-Autoimmune Chronic Spontaneous Urticaria: CURE Insights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:482-490.e1. [PMID: 38008357 DOI: 10.1016/j.jaip.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/24/2023] [Accepted: 11/16/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Patients with chronic spontaneous urticaria (CSU) can have comorbid inducible urticaria (CIndU). How comorbid CIndU affects patients and their CSU is largely unclear. OBJECTIVE To compare patients with CSU with and without comorbid CIndUs for differences in demographic features, clinical characteristics, and laboratory markers. METHODS We analyzed 708 patients with CSU of our Urticaria Center of Reference and Excellence enrolled in CURE, the chronic urticaria registry. CURE data collected until October 2022 were used to compare patients with and without comorbid CIndU for their demographic characteristics, disease onset, activity, impact, and control, as well as concomitant allergic and autoimmune diseases and laboratory parameters associated with autoimmune CSU. RESULTS Of 708 patients with CSU, 247 (35%) had comorbid CIndU. Compared with patients with standalone CSU, patients with CSU with comorbid CIndU were significantly younger, had earlier disease onset, longer disease duration, higher impact on quality of life, and a higher rate of concomitant allergic diseases. Moreover, patients with CSU with comorbid CIndU less often had features linked to autoimmune CSU such as angioedema, concomitant autoimmune diseases, eosinopenia, low levels of total IgE, and low total IgE combined with elevated anti-thyroid peroxidase IgG. CONCLUSIONS Autoimmune CSU may be less common in patients with comorbid CIndU than without, and comorbid CIndU may point to autoallergic CSU.
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Affiliation(s)
- Elena Kovalkova
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Moscow City Research and Practical Center of Allergology and Immunology, Moscow Healthcare Department, City Clinical Hospital 52, Moscow, Russia.
| | - Daria Fomina
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Moscow City Research and Practical Center of Allergology and Immunology, Moscow Healthcare Department, City Clinical Hospital 52, Moscow, Russia; Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Department of Pulmonology, Astana Medical University, Astana, Kazakhstan
| | - Elena Borzova
- Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Dermatology Division, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Natalya Maltseva
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Moscow City Research and Practical Center of Allergology and Immunology, Moscow Healthcare Department, City Clinical Hospital 52, Moscow, Russia
| | - Anton Chernov
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Moscow City Research and Practical Center of Allergology and Immunology, Moscow Healthcare Department, City Clinical Hospital 52, Moscow, Russia
| | - Sofia Serdoteckova
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Moscow City Research and Practical Center of Allergology and Immunology, Moscow Healthcare Department, City Clinical Hospital 52, Moscow, Russia
| | - Karsten Weller
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcus Maurer
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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4
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Maurer M, Albuquerque M, Boursiquot JN, Dery E, Giménez-Arnau A, Godse K, Guitiérrez G, Kanani A, Lacuesta G, McCarthy J, Nigen S, Winders T. A Patient Charter for Chronic Urticaria. Adv Ther 2024; 41:14-33. [PMID: 37991694 PMCID: PMC10796664 DOI: 10.1007/s12325-023-02724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
Chronic urticaria (CU) is the recurring development of wheals (aka "hives" or "welts"), angioedema, or both for more than 6 weeks. Wheals and angioedema occur with no definite triggers in chronic spontaneous urticaria, and in response to known and definite physical triggers in chronic inducible urticaria. Approximately 1.4% of individuals globally will have CU during their lifetime. The itching and physical discomfort associated with CU have a profound impact on daily activities, sexual function, work or school performance, and sleep, causing significant impairment in a patient's physical and mental quality of life. CU also places a financial burden on patients and healthcare systems. Patients should feel empowered to self-advocate to receive the best care. The voice of the patient in navigating the journey of CU diagnosis and management may improve patient-provider communication, thereby improving diagnosis and outcomes. A collaboration of patients, providers, advocacy organizations, and pharmaceutical representatives have created a patient charter to define the realistic and achievable principles of care that patients with CU should expect to receive. Principle (1): I deserve an accurate and timely diagnosis of my CU; Principle (2): I deserve access to specialty care for my CU; Principle (3): I deserve access to innovative treatments that reduce the burden of CU on my daily life; Principle (4): I deserve to be free of unnecessary treatment-related side-effects during the management of my CU; and Principle (5): I expect a holistic treatment approach to address all the components of my life impacted by CU. The stated principles may serve as a guide for healthcare providers who care for patients with CU and translate into better patient-physician communication. In addition, we urge policymakers and authors of CU treatment guidelines to consider these principles in their decision-making to ensure the goals of the patient are achievable.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | | | | | - Elaine Dery
- Canadian Chronic Urticaria Society, Quebec City, Canada
| | - Ana Giménez-Arnau
- Hospital del Mar Research Institute, Universitat Pompeu Fabra, Barcelona, Spain
| | | | | | - Amin Kanani
- University of British Columbia, Vancouver, Canada
| | | | | | - Simon Nigen
- Montreal General Hospital, McGill University, Montreal, Canada
| | - Tonya Winders
- Global Allergy & Airways Patient Platform, Vienna, Austria.
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Xu SY, Lv HQ, Zeng CL, Peng YJ. Prevalence and bidirectional association between rhinitis and urticaria: A systematic review and meta-analysis. Allergy Asthma Proc 2023; 44:402-412. [PMID: 37919842 DOI: 10.2500/aap.2023.44.230063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Background: Rhinitis, allergic rhinitis in particular, and urticaria are both common diseases globally. However, there is controversy with regard to the correlation between rhinitis and urticaria. Objective: To examine the accurate association between rhinitis and urticaria. Methods: Three medical literature data bases were searched from data base inception until January 11, 2022. The prevalence and association between rhinitis and urticaria were estimated by meta-analysis. Quality assessment was performed by using the Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% confidence intervals (CI) and pooled prevalence were calculated by using random-effects models. Results: Urticaria prevalence in patients with rhinitis was 17.6% (95% CI, 13.2%-21.9%). The pooled prevalence of rhinitis was 31.3% (95% CI, 24.2%-38.4%) in patients with urticaria, and rhinitis prevalence in patients with acute urticaria and chronic urticaria was 31.6% (95% CI, 7.4%-55.8%) and 28.7% (95% CI, 20.4%-36.9%), respectively. Rhinitis occurrence was significantly associated with urticaria (OR 2.67 [95% CI, 2.625-2.715]). Urticaria and rhinitis were diagnosed based on different criteria, possibly resulting in a potential error of misclassification. Conclusion: Rhinitis and urticaria were significantly correlated. Physicians should be cognizant with regard to this relationship and address nasal or skin symptoms in patients.
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Konstantinou GN, Konstantinou GN. Psychiatric comorbidities in children and adolescents with chronic urticaria. World J Pediatr 2023; 19:315-322. [PMID: 36376557 DOI: 10.1007/s12519-022-00641-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic urticaria (CU) has been shown to impact patients' quality of life negatively and may coexist with psychiatric disorders. We systematically reviewed the published evidence of comorbid psychiatric disorders in children and adolescents with CU. METHODS A systematic review of studies published until February 2022 in PubMed, Google Scholar, and Scopus was performed. An a priori set of inclusion criteria was predefined for the studies to be included: (1) clear distinction between urticaria and other allergies; (2) precise distinction between acute and CU; (3) participants younger than 18 years old, exclusively; (4) use of appropriate standardized questionnaires, psychometric tools, and standard diagnostic nomenclature for the mental health and behavioral disorders diagnosis; and (5) manuscripts written or published in the English language. RESULTS Our search identified 582 potentially relevant papers. Only eight of them satisfied the inclusion criteria. Quantitative meta-analysis was not deemed appropriate, given the lack of relevant randomized control trials, the small number of relevant shortlisted, the small sample size of the patients included in each study, and the remarkable heterogeneity of the studies' protocols. CONCLUSIONS The included studies suggest an increased incidence of psychopathology among children and adolescents with CU as opposed to healthy age-matched individuals, but the data are scarce. Further research is required to clarify whether psychopathology is just a comorbid entity, the cause, or the consequence of CU. Meanwhile an interdisciplinary collaboration between allergists/dermatologists and psychiatrists is expected to substantially minimize CU burden and improve patients' quality of life.
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Affiliation(s)
- George N Konstantinou
- Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Thessaloníki, Greece.
| | - Gerasimos N Konstantinou
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Center for Addiction and Mental Health (CAMH), Toronto, ON, Canada
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Khaliliya R, Confino-Cohen R, Lachover-Roth I, Meir-Shafrir K, Cohen-Engler A, Rosman Y. Chronic Urticaria in Elderly-New Insights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1290-1294. [PMID: 36649801 DOI: 10.1016/j.jaip.2022.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/11/2022] [Accepted: 12/26/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Many medical conditions have a unique profile in older adults. Chronic urticaria (CU) is a common disease, but data regarding elderly patients are limited. OBJECTIVE To describe the demographics, clinical characteristics, comorbidities, and outcome of elder patients with CU. METHODS This retrospective, single-center study included patients older than 65 years, diagnosed with CU in our clinic. Data for the entire cohort were retrieved from electronic medical records. RESULTS Of 1859 patients older than 65 years, 181 patients diagnosed with CU were included: 166 had chronic spontaneous urticaria (CSU) and 15 chronic inducible urticaria. Most patients with CSU were female (119, 72%). The mean age at diagnosis was 72 ± 5.9 years. Comorbidities included autoimmunity in 38 (22.9%), malignancy in 23 (13.8%), and atopy in 19 (11.5%). The time to referral to a specialist was 22.8 ± 53 months from the onset of symptoms. Specialist intervention improved patient outcomes. This was evident by reduced systemic steroid use (odds ratio [OR] = 0.145, [95% confidence interval (CI): 0.08-0.26], P < .001), all-cause hospitalization (OR = 0.09, [95% CI: 0.01-0.75], P = .01), emergency department visits (OR = 0.08, [95% CI: 0.08-0.35], P < .001), and primary physician visits (P < .001, Cramer's V = 0.528). CONCLUSIONS Older people with CU have unique characteristics, including high prevalence of autoimmunity and malignancy and lower prevalence of atopy. Raising awareness of CU in elderly and prompt referral to an allergy specialist may improve outcomes.
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Affiliation(s)
- Rasha Khaliliya
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Confino-Cohen
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idit Lachover-Roth
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Meir-Shafrir
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel
| | - Anat Cohen-Engler
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Rosman
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Sandoval-Ruballos M, Domínguez O, Ortiz de Landazuri I, Gereda D, Espinoza Cisneros M, Quesada Sequeira F, Ramos Rodríguez SM, Machinena A, Piquer M, Folqué MDM, Lozano J, Jiménez-Feijoo R, Pascal M, Alvaro-Lozano M. Pediatric chronic urticaria: Clinical and laboratory characteristics and factors linked to remission. Pediatr Allergy Immunol 2023; 34:e13929. [PMID: 36974641 DOI: 10.1111/pai.13929] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/06/2023] [Accepted: 02/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Chronic urticaria (CU) is defined as the occurrence of wheals/angioedema for ≥6 consecutive weeks. Until now, guidelines and publications addressing CU have focused mainly on adults. As a result, evidence and guidance in the pediatric population are scarce. METHODS This study aims to describe clinical and laboratory findings in pediatric CU and to determine factors associated with remission. RESULTS 185 patients, 54% female, median age at onset of 8.8 years. Angioedema was present in almost half. The most common type of CU was chronic spontaneous urticaria (CSU) in 74%. At least one atopic comorbidity was found in almost a third (35%). In addition, 8% had an autoimmune disorder (exclusively in CSU) and 9% had a psychiatric condition. Basopenia was found in 67% and was more frequently associated with CSU. The basophil activation test (BAT) was positive in 40%. With regard to remission, being of male sex, angioedema absence, the absence of physical triggers, and eosinophil counts >0.51 × 109 /L were associated with shorter CU duration. CONCLUSION Atopy is a common condition in pediatric CU. CSU is the most common type. Autoimmune comorbidities and basopenia were significantly more common in CSU. In addition, ours is one of the few studies, assessing BAT utility in the pediatric population, being positive in a relevant percentage (40%). BAT positivity was more frequent in CSU. Our results suggest that the absence of angioedema and physical triggers, male sex, and eosinophil counts >0.51 × 109 /L appear to be associated with a better prognosis in terms of remission.
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Affiliation(s)
- Mónica Sandoval-Ruballos
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Olga Domínguez
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Daniella Gereda
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | | | - Adrianna Machinena
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Mónica Piquer
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - María Del Mar Folqué
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jaime Lozano
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Rosa Jiménez-Feijoo
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Mariona Pascal
- Immunology Department, CDB, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
| | - Montserrat Alvaro-Lozano
- Pediatric Allergology and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
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Papapostolou N, Xepapadaki P, Katoulis A, Makris M. Comorbidities of Chronic Urticaria: A glimpse into a complex relationship. FRONTIERS IN ALLERGY 2022; 3:1008145. [PMID: 36465885 PMCID: PMC9712803 DOI: 10.3389/falgy.2022.1008145] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/17/2022] [Indexed: 08/05/2023] Open
Abstract
Chronic Urticaria (CU) is a chronic inflammatory, predominantly mast cell-driven disease, characterized by the development of wheals and/or angioedema for more than 6 weeks. It affects approximately 1%-5% of the total population worldwide and imposes a substantial burden on health-related quality of life, significantly affecting patients' daily life. The economic impact on the health system is also not negligible, with an estimated cost per patient per year of approximately 2.000 $ in the United States. Although the underlying pathophysiology is not fully explored, autoimmune mechanisms have been proposed, including type I ("autoallergy" by means of autoantibodies to self-antigens) and type IIb (autoimmunity). Atopic, autoimmune, and psychiatric disorders are prevalent comorbidities in both children and adults with Chronic Spontaneous Urticaria (CSU). Although malignancies, cardiovascular diseases and other comorbidities have also been reported as associated diseases in patients with CSU, data remain scarce. It is still unknown whether the aforementioned comorbidities share common pathophysiological mechanisms with specific endotypes of CSU. The current review aims to overview current data on comorbidities of CU, and furthermore to comment on the potential linked pathways underlying these diseases.
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Affiliation(s)
- Niki Papapostolou
- Allergy Unit, 2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexander Katoulis
- Allergy Unit, 2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Michael Makris
- Allergy Unit, 2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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