Urticarial Vasculitis – Response to Gold Therapy

Urticarial vasculitis in northern Spain: clinical study of 21 cases

Urticarial vasculitis (UV) is a subset of cutaneous vasculitis (CV), characterized clinically by urticarial skin lesions of more than 24 hours' duration and histologically by leukocytoclastic vasculitis. We assessed the frequency, clinical features, treatment, and outcome of a series of patients with UV. We conducted a retrospective study of patients with UV included in a large series of unselected patients with CV from a university hospital. Of 766 patients with CV, UV was diagnosed in 21 (2.7%; 9 male and 12 female patients; median age, 35 yr; range, 1-78 yr; interquartile range, 5-54 yr). Eight of the 21 cases were aged younger than 20 years old. Potential precipitating factors were upper respiratory tract infections and drugs (penicillin) (n = 4; in all cases in patients aged <20 yr), human immunodeficiency virus (HIV) infection (n = 1), and malignancy (n = 1). Besides urticarial lesions, other features such as palpable purpura (n = 7), arthralgia and/or arthritis (n = 13), abdominal pain (n = 2), nephropathy (n = 2), and peripheral neuropathy (n = 1) were observed. Hypocomplementemia (low C4) with low C1q was disclosed in 2 patients. Other abnormal laboratory findings were leukocytosis (n = 7), increased erythrocyte sedimentation rate (n = 6), anemia (n = 4), and antinuclear antibody positivity (n = 2). Treatment included corticosteroids (n = 12), antihistaminic drugs (n = 6), chloroquine (n = 4), nonsteroidal antiinflammatory drugs (n = 3), colchicine (n = 2), and azathioprine (n = 1). After a median follow-up of 10 months (interquartile range, 2-38 mo) recurrences were observed in 4 patients. Apart from 1 patient who died because of an underlying malignancy, the outcome was good with full recovery in the remaining patients. In conclusion, our results indicate that UV is rare but not exceptional. In children UV is often preceded by an upper respiratory tract infection. Urticarial lesions and joint manifestations are the most frequent clinical manifestation. Low complement serum levels are observed in a minority of cases. The prognosis is generally good, but depends on the underlying disease.

Therapeutic alternatives for chronic urticaria: an evidence-based review, Part 2

OBJECTIVE

To evaluate the use of alternative therapies for chronic urticaria refractory to first-line treatments in an evidence-based manner.

DATA SOURCES

MEDLINE searches were performed cross-referencing urticaria with the names of multiple therapies. Articles were then reviewed for additional citations. Articles published after 1950 were considered.

STUDY SELECTION

All articles, including case reports, were reviewed for soundness and relevance.

RESULTS

Experience has been reported for a wide variety of alternative therapies in the treatment of chronic idiopathic and physical urticarias. Evidence for most agents is limited to anecdotal reports. The therapies reviewed are also categorized based on criteria of safety, efficacy, convenience, and cost. The less preferred alternative agents in the second part of this review are divided between third-line therapies and others that are unable to be firmly recommended or that seem promising but lack substantial evidence.

CONCLUSIONS

Third-line alternative agents should be considered in patients with chronic urticaria who are severely affected and unresponsive to antihistamines and second-line therapies. Although monitoring for toxicity is important in management with third-line agents, safety remains favorable for most agents compared with corticosteroids.

Urticaria and angioedema: an overview

Persistent or frequent episodes of urticaria are difficult to evaluate and treat. The best test to identify most patients with a specific underlying cause (eg, physical trigger, allergen, systemic disease) likely is the taking of a careful and detailed history and performance of a physical examination by a specialist who is knowledgeable in urticarial disease. Further study of the pathogenesis and treatment of urticaria is crucial. Given the limited efficacy of presently approved antihistamine treatments and the significant side effects of steroids and cyclosporine, there is a pressing need to evaluate other anecdotally supported urticaria treatments in randomized, controlled trials.

Urticarial vasculitis and hypocomplementemic urticarial vasculitis syndrome

Urticarial vasculitis is a clinicopathologic entity in which episodes of urticaria are accompanied by histopathologic features of cutaneous vasculitis. The histopathologic definition of vasculitis varies from report to report. In this article, vasculitis is defined as histopathologic features of blood vessel damage: There should be evidence of leukocytoclasis and vessel wall destruction, which may or may not be accompanied by fibrinoid deposits. Red blood cell extravasation and perivascular inflammatory cell infiltrate also may be present. The extent to which each of these elements must be present has been debated.

Urticaria. Recognition, causes and treatment

The urticarias are a complex group of disorders characterised by transient whealing or swelling of the skin. Understanding the many possible causes is the first step in assessing urticaria. Allergic and drug-induced urticaria respond to removal of the cause. The physical urticarias, particularly delayed pressure urticaria and also urticarial vasculitis, require separate consideration. For the majority of patients with chronic idiopathic urticaria, nonsedating antihistamines are the mainstay of treatment. There are several to choose from, including cetirizine, astemizole, loratadine, terfenadine and acrivastine, each with its own pharmacokinetics and antiallergic properties. When these fail, histamine H2-antagonists may help either alone or in combination with H1-antagonists. Older sedative antihistamines are still useful. Ketotifen, oxatomide and azelastine have mast cell stabilising effects that are considered an advantage in treating these disorders. Second-line therapies include a wide range of drugs such as doxepin, dapsone, attenuated androgens, calcium antagonists, antimalarials, gold and methotrexate. The most effective and regularly used second-line agents are corticosteroids. These are best limited to short term crisis management, except in severe recalcitrant cases, and in patients with pressure urticaria or urticarial vasculitis. Recent work on circulating histamine releasing autoantibodies suggests that there is scope for more aggressive immunosuppression in selected patients. However, effective treatment with immunosuppression often requires plasma exchange and more toxic agents such as cyclosporin. Such treatments are only likely to be entertained in exceptional cases.