Chronic idiopathic urticaria and anxiety symptoms

Shedding light on dermographism: a narrative review

Dermographism is a common subtype of chronic urticaria. It generally manifests as a linear wheal after scratching or friction, with or without angioedema. The pathophysiology is not clear, but currently, we believe that the stimulation of the skin by mechanical stress leads to the activation of mast cells, which provoke the release of histamine and pro-inflammatory mediators, ultimately forming wheal along the stressed area. The gold standard for diagnosis is a medical history and provocation test or dermatographic test. As one of the subtypes of chronic urticaria, the Urticaria Control Test (UCT), Chronic Urticaria Quality of Life questionnaire (CU-Q2oL), and Dermatology Life Quality Index (DLQI) are also effective tools for evaluating disease control in dermographism patients. In addition to avoiding triggers, nonsedating H1 antihistamines are the first-line medications recommended by EAACI and other guidelines; for those who do not respond to standard doses, the recommended dosage can be increased up to 4 times. When necessary, the off-label use of omalizumab can be considered, and some drugs with potential therapeutic effects are still being explored. However, there is still a lack of biomarkers for predicting disease severity, efficacy, and prognosis. Here, we review what we know about dermographism and some points that need exploration in the future.

Quality of life measurement in urticaria: Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient-Oriented Outcomes and Urticaria and Angioedema

The European Academy of Dermatology and Venereology (EADV) Task Forces on quality of life (QoL) and patient-oriented outcomes and on urticaria and angioedema recommendations for the assessment of Health-related (HR) QoL in all patients with urticaria in research and practice are as follows: to use the DLQI for adults and the CDLQI for children as dermatology-specific and the CU-Q2oL as a disease-specific HRQoL instruments in urticaria; to use generic instruments to provide comparison of data on urticaria with non-dermatologic diseases, or to compare with healthy volunteers or the general population; to select validated HRQoL instruments with appropriate age limits; to present exact numeric data for HRQoL results; correct title of any HRQoL instrument should be used, along with its correct abbreviation and the reference to its original publication, where possible. The EADV TFs discourage the use of non-validated HRQoL instruments and modified HRQoL instruments that have not undergone standard validation.

The Effectiveness and Safety of Cupping Therapy on CV8 Shenque for Urticaria; a Protocol for Systematic Review and Meta-Analysis

Purpose

Urticaria is a common mast-cell-driven disease that poses a great burden on patients and society. Suggested therapeutic methods include avoidance of triggers and the use of medications, such as H1-antihistamines; however, limitations remain regarding efficacy, dealing with comorbidities, and adverse events. Cupping therapy (CT) at CV8 Shenque has been used in traditional Chinese medicine for the treatment of various dermatological diseases, including urticaria. The efficacy of the treatment has been revealed by previous clinical trials and case reports. This study was performed to provide a protocol for a systematic review and meta-analysis to analyze the effectiveness and safety of CT at CV8 Shenque for urticaria patients.

Patients and Methods

Searches of electronic databases using manual searches and contact with the corresponding authors will be performed using predefined criteria for all randomized controlled trials on CT at CV8 Shenque for urticaria patients. Every part of the process will be conducted by two independent researchers, with conflicts being solved by a third author. The primary outcomes will be symptom scores, quality of life, and effective rate. Secondary outcomes will be adverse events and diagnostic test results. RevMan 5.4 software will be used to perform the meta-analysis. The Cochrane Collaboration "Risk of bias" tool will be used for risk of bias judgments.

Results

Our study will evaluate the effectiveness and safety of CT at CV8 Shenque as a treatment option for urticaria.

Conclusion

This systematic review is the first to investigate the effect of CT at CV8 Shenque for urticaria patients. Our study will provide objective evidence of an alternative approach to urticaria for clinicians and patients.

Study Registration

PROSPERO (Registration number: CRD42023434913).

Neuro-Immuno-Psychological Aspects of Chronic Urticaria

Urticaria is a condition characterized by the development of itchy wheals (hives), angioedema, or both. The pathophysiology of chronic spontaneous urticaria (CSU) is still poorly understood. It is suggested that there is no dominant and independent mechanism of CSU; however, there are different immunological and non-immunological abnormalities that act simultaneously or/and follow each other resulting in clinical symptoms. The latest hypothesis points out that mast cells (MCs) to be activated via autoantibodies in autoallergic or autoimmune mechanism mediators released from degranulated MCs are responsible for the vasoactive and neurospecific effect in CSU. According to many clinical observations, it is suggested that psychological stress can be both a triggering factor in the onset of CSU and a modulating one in the course of the disease and therapy effectiveness. Of importance, the mechanistic background of the psychological stress response in the skin has not yet been fully elucidated. However, of note, a variety of inflammatory mediators, neuropeptides, and neurotransmitters facilitate this phenomenon. This review presents recent findings on the neuro-immuno-psychological aspects of CSU, highlighting an emerging role of neuro-immune interactions. It also points out the usefulness of psychological tools employment for the baseline diagnosis of perceived stress level and the presence of its symptoms. Furthermore, it proposes the implementation of non-invasive interventions to reduce psychological stress and anxiety. A bio-psycho-social approach including psychological support and patient education seems to be as important as traditional pharmacotherapy for CSU. It facilitates the effective control of active disease and a prolonged remission time in this disease.

Comorbidities of Chronic Urticaria: A glimpse into a complex relationship

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.

Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review

Purpose

Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU.

Patients and methods

Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results

Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H₁-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU.

Conclusion

Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H₁- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.

The burden of symptomatic patients with chronic spontaneous urticaria: a real-world study in Korea

BACKGROUND/AIMS

Chronic spontaneous urticaria (CSU) poses a considerable burden both on the quality of life (QoL) of individual patients and on healthcare systems. Real‑world data evaluating the disease burden of CSU are limited in this country. This study evaluated the disease burden and healthcare resource utilization (HRU) among symptomatic CSU patients.

METHODS

This multicenter, noninterventional, retrospective, and cross-sectional study assessed CSU patients symptomatic for more than 6 months despite step-wise H1-antihistamine medications. Primary outcomes included Urticaria Activity Score over 7 days (UAS7) and Chronic Urticaria QoL scale (CU-QoL). Secondary outcomes included EuroQol 5-Dimension 5-Level (EQ-5D-5L), Dermatology Life Quality Index (DLQI), association of disease activity with QoL, medications used for the past 6 months, and HRU.

RESULTS

Five hundred patients with CSU were enrolled. Mean disease duration was 3.7 years. Based on UAS7, 22.2% of patients were in well-controlled status and 31.2%, 28.4%, and 18.2% of them had mild, moderate, and severe disease, respectively. Mean CU-QoL and DLQI scores were 57.5 ± 29.7 and 10.2 ± 7.6, respectively, while the EQ-5D-5L utility score was 0.8 ± 0.2. H1-antihistamines were prescribed to 95% of patients, while omalizumab was prescribed to 33% of patients. Most patients (98%) had outpatient visits in the past 6 months. Negative correlations were noted between UAS7 and CU-QoL, EQ-5D-5L, EQ-5D-5L visual analog scale scores, but a positive correlation was noted with DLQI score (p < 0.001 for all). The number of outpatient department visits increased with disease activity (p = 0.001).

CONCLUSION

CSU affects QoL, leading to increased HRU, particularly in patients with severe disease.

Epidemiology of urticaria in China: a population-based study

Background:

Urticaria is a common skin disease characterized by episodes of wheals, and it has a negative effect on patients’ quality of life. Large-scale population-based epidemiological studies of urticaria are scarce in China. The aim of this survey was to determine the prevalence, clinical forms, and risk factors of urticaria in the Chinese population.

Methods:

This survey was conducted in 35 cities from 31 provinces, autonomous regions, and municipalities of China. Two to three communities in each city were selected in this investigation. Participants completed questionnaires and received dermatological examinations. We analyzed the prevalence, clinical forms, and risk factors of urticaria.

Results:

In total, 44,875 questionnaires were distributed and 41,041 valid questionnaires were collected (17,563 male and 23,478 female participants). The lifetime prevalence of urticaria was 7.30%, with 8.26% in female and 6.34% in male individuals (P < 0.05). The point prevalence of urticaria was 0.75%, with 0.79% in female and 0.71% in male individuals (P < 0.05). Concomitant angioedema was found in 6.16% of patients. Adults had a higher prevalence of urticaria than adolescents and children. Living in urban areas, exposure to pollutants, an anxious or depressed psychological status, a personal and family history of allergy, thyroid diseases, and Helicobacter pylori infection were associated with a higher prevalence of urticaria. Smoking was correlated with a reduced risk of urticaria.

Conclusion:

This study demonstrated that the lifetime prevalence of urticaria was 7.30% and the point prevalence was 0.75% in the Chinese population; women had a higher prevalence of urticaria than men. Various factors were correlated with urticaria.

Efficacy of acupuncture treatment for chronic spontaneous urticaria: study protocol for a randomised controlled trial

INTRODUCTION

Chronic spontaneous urticaria (CSU) is a troublesome dermatological problem that can have a significant impact on quality of life. Previous studies have indicated that acupuncture may be beneficial for patients with CSU. However, well-designed studies determine the effects of acupuncture on CSU are rare. The aim of this study is to investigate the efficacy and safety of acupuncture treatment for patients with CSU.

METHODS AND ANALYSIS

This study is designed as a multicentre, parallel, three-arm, randomised, sham-controlled trial. A total of 330 patients diagnosed as CSU will be randomly allocated into three groups: the verum acupuncture group, the sham acupuncture group and the waiting-list control group in a 1:1:1 ratio. Patients in the verum and sham acupuncture groups will receive 16 treatment sessions over 4 weeks, while patients in the waiting-list control group will not receive any acupuncture treatment. The primary outcome is the changes of weekly urticaria activity scores at the end of treatment. Secondary outcomes include itching severity measurement, Dermatology Life Quality Index, Hamilton Depression Scale, Hamilton Anxiety Scale, Pittsburgh Sleep Quality Index and serum total IgE level. Adverse events will be recorded during the study observation period. All patients who are randomised in this study will be included in the intention-to-treat analysis.

ETHICS AND DISSEMINATION

Ethical approval of this study has been granted by the Sichuan Regional Ethics Review of Committee on Traditional Chinese Medicine (TCM) (ID: 2019 kl-006), the Medical Ethic Committee of the First Hospital of Wuhan (ID: (2019) number 7)) and the Medical Ethics Committee of the First Hospital of Hunan University of TCM (ID: HN-LLKY-2019-017-01/03) in three clinical centres in China, respectively. The results will be disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR1900022994.

The challenges of chronic urticaria part 1: Epidemiology, immunopathogenesis, comorbidities, quality of life, and management

This is Part 1 of an updated follow-up review of a World Allergy Organization (WAO) position paper published in 2012 on the diagnosis and treatment of urticaria and angioedema. Since 2012, there have been advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics, such as omalizumab, in patients with severe refractory disease. For these reasons, the 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, including 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 manage patients with this common ailment.

Patients with Chronic Urticaria Remain Largely Undertreated: Results from the DERMLINE Online Survey

Introduction

Chronic urticaria (CU) is an unpredictable disease, with high disease burden and a significant negative impact on quality of life, especially in patients of working age. Many patients are undertreated, and there is poor awareness of strategies to manage patients with CU in the real-world setting. The current study aimed to gain a better understanding of CU from the patients’ perspective, including the body areas most affected by wheals and angioedema, the disease burden and current use of the healthcare system.

Methods

A nationwide online survey was performed in Germany involving individuals who reported a diagnosis of CU and experienced symptoms within 3 months prior to inclusion.

Results

This self-report survey included 1037 participants (89.2% female), with a mean ± standard deviation (SD) age of 33.4 ± 11.0 years and a mean ± SD disease duration of 10.0 ± 9.4 years. On average, participants suffered from urticaria symptoms for 3.0 ± 4.3 years before diagnosis. In 73% of participants, symptoms worsened due to external factors, with the majority specifying stress in their personal life or work-related stress as eliciting factors. Within the previous 3 months, 87.4 and 44.1% of participants experienced wheals and angioedema, respectively, at multiple body areas, and most (79.6%) participants had uncontrolled symptoms as measured with the Urticaria Control Test. Despite the high burden of disease, 60.3% of participants stated that they were not currently receiving treatment. The most commonly used therapies to treat CU were oral (72.8%) and non-prescription (43.3%) and prescription (47.3%) topical drugs, with 18.0% of the participants receiving injectable/infused drugs.

Conclusion

The majority of the participants responding to the survey reported that CU is not sufficiently controlled, thereby severely influencing a highly productive time in their life. The body areas most affected by wheals and angioedema are specified, based on data provided by a large group of affected participants. A greater awareness of disease burden and available treatment options is needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00537-5.

The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

BACKGROUND

In chronic spontaneous urticaria (CSU), the guidelines recommend very limited diagnostic procedures during the routine workup, although additional investigations might be indicated in some patients with CSU. For physicians treating patients with CSU, it is often difficult to decide which diagnostic tests are useful.

OBJECTIVE

To provide recommendations on what diagnostic tests should be performed on which patients with CSU.

METHODS

We performed an extensive literature search on the respective topics and identified relevant questions that should prompt diagnostic procedures based on the published evidence and expert consensus among all authors.

RESULTS

We provide questions, diagnostic testing, where appropriate, and recommendation that should be included when assessing the history of a patient with CSU, to explore and rule out differential diagnoses, to assess patients for underlying causes and modifying conditions, to explore patients for comorbid diseases and consequences of having CSU, and to assess patients for CSU components that can help to predict their disease course and response to treatment.

CONCLUSIONS

Here, we provide physicians treating patients with CSU with information about which clues should lead to which tests and why.

Anxiety, depression, and stress in Korean patients with chronic urticaria

BACKGROUND/AIMS

Emotional distress is thought to cause or maintain chronic urticaria (CU). We aimed to investigate the presence of anxiety, depression, and stress in Korean adult CU patients and to explore their potential impact on treatment.

METHODS

We enrolled 79 CU patients and a disease control group comprising 39 persistent asthma patients. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate depression and anxiety. Stress and quality of life (QoL) were assessed by Stress Response Inventory and CU-QoL questionnaires. The sociodemographic and clinical data such as urticaria activity score (UAS-15, UAS-6) were obtained.

RESULTS

The prevalence of depression and anxiety based on the HADS were 48.1% and 38.0%. Although the prevalence of anxiety didn't differ between the CU and asthma patients, depression was significantly more prevalent in the CU patients (48.1% vs. 28.2%). Stress tended to be lower in CU patients. Anxiety, depression, and stress exhibited negative correlations with QoL. Anxiety showed significant correlation with UAS-6 and pruritus-visual analog scale (VAS; r = 0.256, r = 0.272, p < 0.05, respectively); depression correlated with sleep difficulty-VAS (r = 0.261, p < 0.05). Stress was associated with UAS-15, UAS-6, pruritus-VAS, and sleep difficulty-VAS (r = 0.251, r = 0.317, r = 0.302, r = 0.258, p < 0.05, respectively).

CONCLUSION

The current study first presented that Korean CU patients frequently have anxiety and depression, which affect their QoL and demonstrated that anxiety, depression, and stress had different effects on sleep difficulty, pruritus, and urticaria severity in Korean CU patients.

Improving of psychological status and inflammatory biomarkers during omalizumab for chronic spontaneous urticaria

Background:

Depression and anxiety are the most common psychiatric comorbidities in chronic spontaneous urticaria (CSU). Omalizumab is a monoclonal antibody approved for CSU treatment. We evaluated the prevalence of anxiety and depression in CSU patients before and after treatment with omalizumab.

Materials & methods:

A total of 30 patients were enrolled in the study: 15 patients affected by CSU and treated with omalizumab and the other 15 healthy subjects did not receive any systemic therapy. All patients were evaluated using Hospital Anxiety and Depression Scale, CRP and erythrocyte sedimentation rate, at baseline and after 6 months.

Results:

The omalizumab group after 6 months of therapy had a decrease of all the scores and biomarkers.

Conclusion:

Omalizumab allowed an improvement of urticaria and mental comorbidities.

Depression and anxiety are the most common psychiatric comorbidities in chronic spontaneous urticaria (CSU). We evaluated the prevalence of anxiety and depression in CSU cases and serum levels of inflammatory biomarkers in CSU patients affected also by psychiatric disorders before and after treatment with omalizumab. Omalizumab induced an improvement of urticaria and concurrent mental comorbidities.

Clinical characteristics and management of chronic spontaneous urticaria in patients refractory to H1-Antihistamines in Asia, Middle-East and Africa: Results from the AWARE-AMAC study

Background

Chronic urticaria (CU) is a condition characterized by recurrent itchy hives and/or angioedema for ≥6 weeks. Most of the data about CU come from western countries with very little information available about CU in Asia, Africa, and the Middle East.

Methods

AWARE-AMAC is a 24-month prospective, observational, real-world, non-interventional study in patients aged ≥18 years from Asia, the Middle East, and Africa (AMAC) with CU refractory to H1-antihistamines (H1-AH). The main objective was to describe the real-world experience with CU, including clinical characteristics, presence of angioedema, treatment patterns (shifts between treatment classes and changes within a treatment class), investigator-assessed disease control, and the impact on quality of life. Subgroups of interest were type of CU at Baseline and treatment class (based on 2013 urticaria guidelines). There were no mandatory visits and diagnostic/monitoring procedures additional to routine practice, except the patient diary (7-day Urticaria Activity Score) and patient reported outcome assessments.

Results

The focus of the current manuscript is on patients with chronic spontaneous urticaria (CSU), who formed 98% of the sample. Patients were predominantly female (69.6% female, mean age ± SD 39.8 ± 13.29 years). Time since current diagnosis (Mean ± SD) was 28.6 ± 49.06 months. Amongst patients with CSU, 31.0% had comorbid chronic inducible urticaria (CINDU) and 46.4% had a history of angioedema. 91.9% received H1-AH therapy (±other treatments). The most frequently prescribed treatment classes at Baseline were any/combination of medications, not classified under the other 7 treatment classes, named “Others” (30.5%) followed by, omalizumab (OMA; 23.6%) and second-generation H1-AH monotherapy (sgAH; 15.1%). At Month 12, the most prescribed treatment classes (>15%) for patients were OMA (23.5%) and "Other" (21.3%); 19.7% received "No drug". At Month 24, OMA (22.5%), and "Other" (17.9%) were most frequently prescribed; 28.6% received "No drug". Overall, 79.5% of patients had some type of change in treatment. Over the study period, improvement in self-reported QoL increased, which was mirrored by better disease control.

Conclusion

In AMAC countries, the non-recommended "Other" treatment class played a major role in the initial management of CU patients. High usage of H1-AH (±other treatments) and OMA was observed. Treatment changes were observed in a majority of patients. Treatment escalation from sgAH was mostly via OMA. Improvement of disease control and QoL was achieved during the study period.

Trial registration

Observational study (NA).

A Meta-Analysis of Observational Studies on the Association of Chronic Urticaria With Symptoms of Depression and Anxiety

Background: Chronic urticaria (CU) is a frequently occurring skin condition associated with many psychological factors, but the effect size of associations varied in literature.

Objectives: To perform a systematic review and meta-analysis on the associations of CU with the symptoms of depression and anxiety.

Methods: According to a pre-specified protocol, we systematically searched articles published in PubMed, Web of Science, CNKI, and CQVIP databases between January 2000 and January 2019. Pooled estimates in terms of odds ratios (ORs) or standardized mean differences (SMDs) were calculated according to outcome measures. Subgroup analysis by disease subtypes and tool of measurement, and sensitivity analysis were performed. Risk of bias and quality of studies were evaluated.

Results: Twelve studies were selected for the systematic review. The ORs were 3.99 [95% confidence interval (CI): 3.24–4.91, P < 0.001] for anxiety and 2.94 (95% CI: 2.42–3.58, P < 0.001) for depression. The SMDs of severity were 0.98 for anxiety (95% CI: 0.76–1.200, P < 0.001) and 0.84 for depression (95% CI: 0.59–1.10, P < 0.001). Subgroup analysis by disease subtypes and tool of measurement showed variations in effect size, where chronic spontaneous urticaria showed greater effects on anxiety (OR = 6.62, 95% CI: 3.67–11.95, P < 0.001) and depression (OR = 6.13, 95% CI: 2.31–16.31, P < 0.001). Sensitivity analysis demonstrated consistent results.

Conclusion: CU is associated with higher risks of anxiety and depression.

Risk of comorbidities in patients diagnosed with chronic urticaria: A nationwide registry-study

Background

The autoimmune profile of Chronic Urticaria (CU) patients is an increasing topic of interest. Associated diseases suggest shared pathogenic pathways, and they may provide important knowledge on specific targets for future treatment models. In this study we examined the prevalence and risk of comorbidities in CU.

Methods

The Danish National Patient Registry was used to identify all CU patients from 1994 to 2015. Five of 5 specialized dermatological units in Denmark were covered. Analyses were conducted as a nested case control study and a matched cohort study. CSU patients were matched 1:10 on age and sex to an otherwise random group of people from the background population.

Results

A total of 12,185 CU patients were identified, with an overweight of female cases (69% versus 32%). There was an overrepresentation of mast cell mediated diseases including mastocytosis and anaphylaxis, as well as atopic diseases including type 1 allergies and atopic dermatitis. The prevalence of rheumatoid arthritis, systemic lupus erythematosus, thyroiditis and vitiligo was also increased, as was the prevalence of depression. CU patients who did not have any of the co-morbidities at the time of their CU diagnosis had an increased risk of developing both mast cell mediated diseases, atopic diseases, and autoimmune diseases excluding thyroiditis and diabetes.

Conclusion

The autoimmune profile of the comorbidities of CU was demonstrated with an evident risk of developing rheumatoid arthritis. CU patients were also at increased risk of either having or achieving depression. Mast cell related diseases seemed to be overrepresented, although registry data within this disease category are questionable and similar to symptoms of CU to the untrained eye. Thus, CU patients constitute a multimorbid group of patients, which must be recognized among treating physicians.

Patients with chronic urticaria have a higher risk of psychiatric disorders: a population-based study

BACKGROUND

The prevalence of psychiatric comorbidities in patients with chronic urticaria (CU) in a national population is largely unknown.

OBJECTIVES

To investigate the prevalence of psychiatric disorders and psychiatric medication use in patients with CU in Taiwan.

METHODS

Data were sourced from Taiwan's National Health Insurance Research Database for 2011. Patients who had a primary/secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 708·1, 708·8 or 708·9 during 2011 with at least two outpatient visits and an antihistamine prescription were identified as CU cases. Patients with CU were classified into three disease severity groups according to their medication types. Psychiatric disorders were identified by patients having three outpatient visits with a primary or secondary diagnosis of a given psychiatric disease. Psychiatric medication use was defined by having at least four outpatient visits with prescriptions for anxiolytics, antidepressants or sleeping pills in 2010 or 2011.

RESULTS

Of the 167 132 patients with CU, 82·5% had mild CU, 17·0% had moderate CU and 0·4% had severe CU. Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication prescription than control groups. The relative risk (RR) of psychiatric disorders was 1·43 for patients with mild, 1·50 for patients with moderate and 2·32 for patients with severe CU vs. the controls (P < 0·001). For psychiatric medication prescription, the RRs were 1·95, 2·70 and 2·09, respectively, vs. controls (P < 0·001).

CONCLUSIONS

Patients with CU had a higher prevalence and risk of psychiatric disorders and psychiatric medication prescription than control groups. What's already known about this topic? Previous studies have shown a high prevalence of psychiatric comorbidities in patients with chronic urticaria (CU), with rates ranging from 35% to 60%. Anxiety, depression and somatoform disorders have been reported as the most prevalent mental disorders in patients with CU. What does this study add? Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication use than control groups in the general population. The relative risk (RR) of psychiatric disorders was 1·43 for those with mild CU, 1·50 for those with moderate CU and 2·32 for those with severe CU vs. controls. The RR for psychiatric medication use was 1·95 for those with mild CU, 2·70 for those with moderate CU and 2·09 for those with severe CU vs. controls. Mental health evaluations and management are important elements in CU management.

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.

Antihistamine-resistant chronic spontaneous urticaria: 1-year data from the AWARE study

BACKGROUND

Previous reports indicate that patients with chronic spontaneous urticaria (CSU) are undertreated and that physicians show poor adherence to guideline recommendations. Awareness of CSU has improved in recent years, but it remains unclear if this has improved the management of these patients in clinical practice.

OBJECTIVE

To describe disease burden, quality of life (QoL), and treatment patterns of patients with H₁ -antihistamine-refractory CSU in Germany.

METHOD

A World-wide Antihistamine-Refractory chronic urticaria (CU) patient Evaluation (AWARE) is a global prospective, non-interventional study of CU in the real-world setting, supported by the manufacturer of omalizumab. Patients (18-75 years) were included who had H₁ -antihistamine-refractory CSU for ≥2 months. Disease characteristics, pharmacological treatments, and QoL (dermatology life quality index [DLQI], CU-QoL questionnaire, and angioedema QoL questionnaire) are reported for patients enrolled in Germany.

RESULTS

After 1 year in AWARE, CSU remained uncontrolled (urticaria control test [UCT] score <12) in 432 of 1032 (42.2%) patients. QoL impairment remained high after 1 year, with 28.2% of patients reporting that CSU had a moderate/very large/extremely large effect on the DLQI. Most patients did not receive guideline-recommended treatments at the end of the 1-year observation period. Changes in treatments were most evident at the first patient visit, with an increase in patients receiving omalizumab vs prior therapy from 8.5% to 21.4%, and a decrease in those receiving no treatment from 29.9% to 12.8%. These changes were associated with reduced hives, angioedema, UCT scores, and QoL scores at Month 3, but only modest improvements thereafter. Of 528 patients with uncontrolled CSU and who were eligible for treatment escalation, only 3% received up-dosing of H₁ -antihistamines and only 5% were initiated on omalizumab during 1 year of treatment.

CONCLUSIONS & CLINICAL RELEVANCE

This study highlights a significant discrepancy between recommendations for managing CSU in international guidelines, and in real-world clinical practice in Germany.

Omalizumab treatment in a 12 year-old girl with chronic spontaneous urticaria

Background: Omalizumab is a recombinant humanized IgG monoclonal antibody, which binds the Fc region of free IgE prevent its binding to its high-affinity receptor (FcεR1) on mast cells and basophils. Omalizumab was approved as add-on therapy for moderate-to-severe persistent allergic asthma and for patients with chronic spontaneous urticaria resistant to antihistamine treatment. Patient and results: This article reports effective and safe treatment of a 12 years old girl with add-on omalizumab. On an initial dose of omalizumab of 300 mg once every 4 weeks, the patient experienced resolution of symptoms to a degree that exceeded the effect of previous treatments. Conclusion: Convincing evidence in support of the efficacy and safety of Omalizumab in the treatment of CSU in adolescent has accumulated over the past few years.

Omalizumab rapidly improves angioedema-related quality of life in adult patients with chronic spontaneous urticaria: X-ACT study data

Background

The X‐ACT study aimed to examine the effect of omalizumab treatment on quality of life (QoL) in chronic spontaneous urticaria (CSU) patients with angioedema refractory to high doses of H₁‐antihistamines.

Methods

In X‐ACT, a phase III, double‐blind, placebo‐controlled study, CSU patients (18‐75 years) with ≥4 angioedema episodes during the 6 months before inclusion were randomized (1:1) to receive omalizumab 300 mg or placebo every 4 weeks for 28 weeks. Angioedema‐related QoL, skin‐related QoL impairment, and psychological well‐being were assessed.

Results

Ninety‐one patients were randomized and 68 (omalizumab, n = 35; placebo, n = 33) completed the 28‐week treatment period. At baseline, the mean (SD) total Angioedema QoL (AE‐QoL; 56.2 [18.7] and 59.9 [19.2]) and Dermatology Life Quality Index (DLQI; 14.6 [5.7] and 16.6 [7.3]) score were high in the omalizumab and placebo group, respectively. At Week 4 (after the first treatment), the least squares mean difference in the AE‐QoL and DLQI score between groups was −17.6 (P < .001) and −7.2 (P < .001), respectively. Significant QoL improvements in the omalizumab vs placebo groups continued until Week 28, but returned to placebo levels at the follow‐up visit. The mean (SD) baseline 5‐item World Health Organization Well‐being Index was 10.0 (5.5, omalizumab) and 7.7 (5.3, placebo), which increased above the depression threshold (<13) from Week 4 and throughout with omalizumab but not placebo treatment. Compared to placebo, omalizumab was also associated with decreased fear of suffocation due to angioedema.

Conclusions

Our findings support omalizumab treatment in patients with severe H1‐antihistamine‐refractory CSU with angioedema.

Does Problem Focused Coping Buffer the Effects of Trait Anxiety on Depressive Symptoms of Chronic Urticaria Patients?

The present study examined the moderating role of problem-focused coping in trait anxiety-depressive symptoms' relationship in patients with chronic urticaria (CU). Eighty-eight CU patients, who applied to an outpatient clinic of Clinical Immunology and Allergic Diseases, filled out a questionnaire set including State-Trait Anxiety Inventory, Ways of Coping Inventory, and Beck Depression Inventory. The results suggested that CU patients high on trait anxiety reported more depressive symptoms, and the ones using more problem-focused coping (PFC) strategies reported less depressive symptoms. Also, PFC strategies moderated trait anxiety-depressive symptoms relation. Accordingly, PFC strategies did not lead to any significant difference in CU patients who were low on trait anxiety in terms of the level of depressive symptoms. However, CU patients with high trait anxiety experienced significantly less depressive symptoms if they used more PFC strategies. The findings were discussed in the light of the relevant literature.

Epidemiology and comorbidities of patients with chronic urticaria in Taiwan‏: A nationwide population-based study

BACKGROUND

Comprehensive data regarding the epidemiology of chronic urticaria (CU) in general populations are scant.

OBJECTIVES

To investigate the prevalence, incidence, and comorbidities of CU in general population.

METHODS

The data were sourced from the National Health Insurance Research Database (NHIRD) for 2009-2012. Patients who had a primary/secondary ICD-9-CM diagnosis code of 708.1, 708.8, or 708.9 during the year with at least two outpatient visits and an antihistamine prescription, were identified as the cases of CU for each year. The incidence, persistence and comorbidities of CU were examined.

RESULTS

The prevalence of CU ranged from 0.69% to 0.79% for each year from 2009 to 2012, and the incidence was around 0.50% per year from 2010 to 2012. Comparing to the Standard Population, the standardized prevalence ratios (SPRs) for the rheumatic diseases, thyroid disorders, inflammatory diseases, and psychiatric disorders among CU patients were 2.74, 1.81, 1.57 and 1.87, respectively.

CONCLUSION

The prevalence of CU in Taiwan is about 0.69-0.79%. CU is associated with a significantly increased risk of psychiatric disorders, inflammatory diseases, thyroid disorders, and rheumatic diseases. Except for thyroid disorders, the prevalence of these comorbidities tends to increase the longer CU persists.

Sense of coherence as a protective factor in chronic urticaria

INTRODUCTION

Chronic urticaria (CU) seems to be perceived as a psychodermatological disorder. Different psychological factors play an important role in CU triggering and course. One of them is a sense of coherence (SOC), which is believed to be a protective factor against anxiety and depression.

AIM

To investigate quality of life (QoL) in CU patients and to compare selected psychological parameters (anxiety, depression and sense of coherence) between CU individuals and the control group.

MATERIAL AND METHODS

The study comprised 46 female patients with chronic urticaria and 33 healthy females as a control group. The following methods were employed: Urticaria Activity Score (UAS), Hospital Anxiety and Depression Scale (HADS), Sense of Coherence Questionnaire (SOC-29) and Dermatology Life Quality Index (DLQI).

RESULTS

The CU patients presented a significantly higher anxiety level in comparison to the control group (z = 4.488; p < 0.001). There were no statistically significant differences regarding depression intensity and SOC. In both groups anxiety and depression negatively correlated with global SOC and all its components. Disease severity positively correlated with QoL (ρ = 0.46, p < 0.01) and negatively with global SOC (ρ = -0.33, p < 0.05).

CONCLUSIONS

Bearing in mind higher prevalence of anxiety and depressive symptoms in our CU group, it would be useful to perform screening of these aspects in all CU patients and subsequently develop respective psychological interventions, based on enhancement of personal resources.

Alexithymia in food-allergic versus healthy children and young adults

Alexithymia is a multifaceted personality construct associated with several medical illnesses. However, no studies have focused on food allergy. We investigated alexithymia among food-allergic youths, compared to a matched healthy sample. A total of 220 participants aged 9–25 years were assessed using the Toronto Alexithymia Scale and the Alexithymia Questionnaire for Children. Food-allergic patients reported higher levels of alexithymia compared to a matched healthy sample. Furthermore, an association between alexithymia and a clinical history of anaphylaxis was found among patients. Some possible hypotheses have been discussed considering physiological, psychological, developmental, and cognitive/behavioral factors.

Sense of alexithymia in patients with anxiety disorders comorbid with recurrent urticaria

AIM

Alexithymia is associated with limited cognitive processing of emotions by an individual suffering from recurrent urticaria and alexithymia and makes them focus on somatic manifestations of emotional arousal and on poorly controlled compulsive reactions to negative stimulation. Alexithymia is considered to be a personality trait, which, along with other factors, predisposes individuals toward developing somatic diseases. The aim of the study was to assess the measurement of alexithymic features in patients with recurrent urticaria and to assess the types of concurrent anxiety disorders and overall anxiety level.

METHODS

In order to diagnose clinical anxiety symptoms in patients, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the Hamilton Anxiety Rating Scale were applied. Alexithymic features were measured by means of a shortened version of the Toronto Alexithymia Scale, characterized by high discrimination power, internal coherence, and reliability.

RESULTS

According to the Toronto Alexithymia Scale results, the greatest contributing factor was "inability to differentiate between feelings and bodily sensations". This was observed in both males and females. Most frequently, the patients were found to suffer from generalized anxiety disorder and social phobia.

CONCLUSION

Alexithymia may result from the difficulty associated with expressing emotions caused by anxiety disorders. Undergoing treatment for anxiety disorders may contribute to reduced exacerbation of urticaria.

ASSURE-CSU: a real-world study of burden of disease in patients with symptomatic chronic spontaneous urticaria

Background

Chronic spontaneous urticaria (CSU) formerly known as chronic idiopathic urticaria (CIU) is a severe and distressing skin condition that remains uncontrolled in approximately one half of patients, despite the use of licensed, recommended doses of modern, second-generation H₁-antihistamines. So far, the humanistic, societal and economic burden of CSU/CIU has not been well quantified. Therefore it is important to broaden our understanding of how CSU/CIU impacts patients, society, and healthcare systems, by determining the disease burden of CSU/CIU and the associated unmet need; as well as to further guide the use of new treatments in an efficient and cost-effective manner.

Methods

ASSURE-CSU is an observational, multicenter study being conducted in the UK, Germany, Canada, France, Italy, Spain, and The Netherlands. The study comprises a retrospective medical chart review in conjunction with patient surveys (including validated tools for assessment of disease impact) and an 8-day patient diary. The primary objectives of the study are to describe patient demographics, medical history, treatments, and healthcare resource utilization based on medical-record data and to assess the impact of disease, healthcare resource utilization, work days missed, and productivity loss based on patient-reported data. Approximately 700 patients (aged ≥18 years) will be enrolled who have CSU/CIU despite currently receiving treatment, and have had persistent symptoms for at least 12 months. Data will be collected retrospectively for the 12 months (±1 month) prior to enrolment wherever possible, and prospectively for the week following enrolment.

Discussion

ASSURE-CSU will be the first study to examine the economic and humanistic burden of disease in patients diagnosed with CSU/CIU who are symptomatic despite treatment. By combining retrospective evaluation of medical records with prospective patient surveys and 8-day diaries, across seven different countries, the ASSURE-CSU study will contribute to a better understanding and acknowledgement of the burden of disease in patients with symptomatic chronic spontaneous urticaria.

A cohort study of the relationship between anger and chronic spontaneous urticaria

INTRODUCTION

Anger plays a major role in psychodermatological diseases. Researchers have reported that anger and other psychological factors play a role in the etiology of chronic urticaria. This study aimed to examine symptoms of anger, anger-related behavioral patterns, thoughts associated with anger, situations that cause anger and experiences of interpersonal anger in patients with chronic spontaneous urticaria (CSU). The authors hypothesized that patients with CSU react to more situations with anger and experience more anger symptoms as compared to alopecia areata (AA) patients and healthy controls.

METHODS

The cohort study population consisted of literate adult patients aged <65 years that were diagnosed with CSU at the outpatient dermatology clinics of Başkent and Gazi University, Ankara, Turkey, between September 2011 and October 2012. The first control group included individuals without any physical or mental disorders and the second one included literate adult patients diagnosed with AA. The patients and controls were matched according to age, gender, and level of education. A sociodemographic data form, and the Hospital Anxiety and Depression Scale and Multi-Dimensional Anger Inventory were administered to the participants. Data were analyzed using SPSS v.17.0 for Windows. The primary outcome was to determine whether there was a relationship between anger and CSU.

RESULTS

The CSU group consisted of 30 participants; AA group consisted of 30 participants; and the healthy group consisted of 39 participants. Anxiety and depression scores in the CSU group were significantly higher than those in the healthy control group. Symptoms of anger, situations that cause anger, and thoughts associated with anger were significantly more common in the CSU group compared to AA group and healthy group.

CONCLUSION

More of the CSU patients were observed to respond with excessive anger to most situations, to have high levels of anxiety anger and passive aggressive interpersonal relationships.

Real-life experiences with omalizumab for the treatment of chronic urticaria

BACKGROUND

Evidence has shown that omalizumab, a subcutaneous anti-IgE monoclonal antibody, is highly effective for the treatment of chronic urticaria.

OBJECTIVE

To evaluate omalizumab 150 mg/month in severe, difficult-to-treat, chronic urticaria in a real-life setting.

METHODS

This prospective open-label study evaluated of 150 mg of omalizumab in severe urticaria defined by a 7-day urticaria activity score (UAS-7) higher than 30, a history of oral glucocorticoid use, and by suboptimal response to previous treatments. Two subgroups of patients at different centers (Toronto and Quebec City, Canada) were included. The primary efficacy evaluation was a change in UAS-7 from baseline. A quantitative medication score assessed the use of other anti-urticarial medications.

RESULTS

Sixty-eight patients were included: 61 with chronic spontaneous urticaria, 6 with cold urticaria, and 1 with urticarial vasculitis. Patients were followed for up to 25 months. In Toronto, mean UAS-7 decreased from 32.2 at baseline to 5.7 after the last omalizumab treatment. Seventy-nine percent achieved complete remission during omalizumab therapy (UAS-7 0) and 6 (18%) showed improvement but never achieved complete remission. The most common maintenance dosing intervals were 1 to 3 months. In Quebec City, from baseline to 18 months, mean UAS-7 decreased from 24.4 to 2.2 and the quantitative medication score decreased from 13.3 to 3.0. All 6 patients with cold urticaria became symptom free, with a significant decrease of their cold stimulation tolerance test.

CONCLUSION

Omalizumab 150 mg was effective in difficult to treat patients with severe, chronic urticaria refractory to recommended treatments who usually required prednisone. Omalizumab induced a long-lasting positive response and was well tolerated without side effects.

Integrated modelling of alexithymia: psychological predictors and method of response functions

The objective of this study was to construct the integrated model of alexithymia (ALEX) based on the method of response function approach that allows to predict the impact of the subjects' psychological variables on the actual level of alexithymia. Extraversion, neuroticism, autonomy, locus of control and hostility were selected as the appropriate predictors of the alexithymia level. Evaluation of ALEX model's parameters and its validation was provided on a wide set of experimental data (N = 224). ALEX model predicts the level of alexithymia satisfactorily and allows obtaining the partial response functions of its psychological predictors.

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.

The evaluation of primary idiopathic focal hyperhidrosis patients in terms of alexithymia

The aim of this study was to evaluate the primary focal hyperhidrosis patients in terms of alexithymia. Participants ( n = 50) diagnosed with primary focal hyperhidrosis by a dermatologist were referred to a psychiatrist and evaluated via Structured Clinical Interview for DSM-IV Axis I Disorders and Toronto Alexithymia Scale-20. The rate of alexithymia was 45.6 percent and 18.2 percent, respectively, for primary focal hyperhidrosis and control participants ( n = 44). Multivariate analysis of variance results showed that the primary focal hyperhidrosis group scored significantly higher than the control group in Difficulty Identifying Feelings and Difficulty Describing Feelings subscales, and total score. Psychotherapeutic interventions can increase the chances of dermatological treatment success and can have a positive impact on the quality of life in chronic cases.