Chronic urticaria: a role for newer immunomodulatory drugs?

Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology

Background

Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous.

Objectives

To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US).

Methods

A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults.

Results

Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence).

Conclusions

Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Urticarial Dermatitis: Clinical Characteristics of Itch and Therapeutic Response to Cyclosporine

Background

Urticarial dermatitis, which is characterised by persistent wheals with eczematous papules and plaques, is frequently misdiagnosed and difficult to treat. Patients commonly experience intolerable pruritus which may greatly affect their quality of life.

Objective

The objective of this study is to characterize the clinical patterns of pruritus in patients with urticarial dermatitis and to determine the effectiveness of cyclosporine treatment.

Methods

This prospective study included 50 histopathologically confirmed patients with urticarial dermatitis. A face-to-face structured questionnaire was given to all patients, and they were treated with low-dose cyclosporine (1~3 mg/kg/d) for at least 2 weeks.

Results

The majority of patients (80.0%) had moderate to severe pruritus. Most patients experienced exacerbation of the itch in the evening (74.0%), with the extremities (upper, 86.0%; lower, 94.0%) being the most commonly involved sites. Due to severe pruritus, patients complained about reduced social contact, quality of life and difficulties in falling asleep et al. Cyclosporine significantly reduced the mean itch score and extent of erythema, and improved interference with daily activities and sleep.

Conclusion

Our study highlights the detailed description and characteristics of pruritus in patients with urticarial dermatitis. And we recommend alternative and effective therapeutic option of low-dose cyclosporine.

Treatment of refractory chronic urticaria: current and future therapeutic options

Chronic urticaria is a distressing disease that affects up to 1 % of the general population at a time point in life and may severely worsen the quality of life. First-line treatment has been based on antihistamines, and presently relies on the use of non-sedating, second-generation antihistamines; following the recommendations of the recent international guidelines, in patients who do not respond to antihistamines at licensed doses, the daily dosage of these drugs can be increased up to fourfold. Nonetheless, a significant proportion of patients with chronic urticaria remain poorly controlled; in these cases, alternative therapeutic approaches have to be considered. This article critically reviews all of the third- and fourth-line treatment options suggested for patients whose disease is refractory to antihistamines, including systemic corticosteroids, leukotriene receptor antagonists, several different anti-inflammatory drugs (dapsone, sulfasalazine, hydroxychloroquine), various immunosuppressive drugs (calcineurin inhibitors, methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil), intravenous immunoglobulin, and newer treatment options, such as omalizumab and other biologic drugs. In addition, the article examines possible future treatment options based on recent findings about pathogenic mechanisms, and considers the treatment of antihistamine-unresponsive urticaria in special conditions such as children and pregnancy/lactation. The evidence supporting the use of several of the discussed drugs is presently limited and thus insufficient to recommend their routine use; as a consequence, such compounds should be considered only in specific cases and in adequate settings.

[Chronic spontaneous urticaria: An autoimmune disease?]

The identification of the causes of chronic spontaneous urticaria (CSU) is difficult. The recognition of functional autoantibodies against FcεRI and/or against IgE in some patients with CSU led to the concept of autoimmune etiology of the disease. Clinical and laboratory features in a subpopulation of CSU patients also point to an autoimmune etiology of the disease. This review will present and discuss the relevance of functional autoantibodies in CSU pathogenesis and their implications for treatment and prognosis.

Diagnosis and treatment of urticaria and angioedema: a worldwide perspective

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

Management of difficult urticaria

Chronic urticaria, a major health problem causing patient's distress, induces often physicians' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.

Urticaria : a review

Urticaria is often classified as acute, chronic, or physical based on duration of symptoms and the presence or absence of inducing stimuli. Urticarial vasculitis, contact urticaria, and special syndromes are also included under the broad heading of urticaria. Recent advances in our understanding of the pathogenesis of chronic urticaria include the finding of autoantibodies to mast cell receptors in nearly half of patients with chronic idiopathic urticaria. These patients may have more severe disease and require more aggressive therapies. Extensive laboratory evaluation for patients with chronic urticaria is typically unrevealing and there are no compelling data that associate urticaria with chronic infections or malignancy. Pharmacologic therapy consists primarily of the appropriate use of first- and second-generation histamine H(1) receptor antihistamines. Additional therapy may include leukotriene receptor antagonists, corticosteroids, and immunomodulatory agents for severe, unremitting disease. Despite our greater understanding of the pathogenesis of urticaria, the condition remains a frustrating entity for many patients, particularly those with chronic urticaria.

Dapsona como alternativa no tratamento de urticária crônica não responsiva a anti-histamínicos

FUNDAMENTOS: A urticária crônica é dermatose que interfere negativamente na qualidade de vida de seus portadores. O tratamento clássico com anti-histamínicos muitas vezes é ineficaz. OBJETIVO: Avaliar a eficácia e a segurança do uso da dapsona no tratamento da urticária crônica não responsiva a anti-histamínicos. METÓDOS: Realizou-se estudo retrospectivo mediante a revisão de prontuários de pacientes atendidos em ambulatório especializado em urticária entre novembro de 1996 e março de 2007. RESULTADOS: Foram avaliados 20 pacientes com urticária crônica de difícil controle, que receberam tratamento com dapsona na dose de 100mg/dia. Associados à dapsona, foram mantidos anti-histamínicos em altas doses, que, isoladamente, não controlavam os sintomas. Quatorze pacientes (70%) responderam com melhora do quadro, observada tanto na diminuição ou desaparecimento das lesões quanto na redução do prurido; três (15%) não obtiveram nenhum sucesso com a medicação; e três (15%) tiveram o tratamento suspenso em decorrência de efeitos colaterais. CONCLUSÃO: Neste estudo, conclui-se que a dapsona é opção segura e eficaz para pacientes com urticária crônica grave não responsiva a anti-histamínicos.

Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1

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 second-line therapies reviewed are also categorized based on criteria of safety, efficacy, convenience, and cost, in relation to the first-line antihistamines.

CONCLUSIONS

Alternative agents should be considered in patients with chronic urticaria who are both severely affected and unresponsive to antihistamines. Although monitoring for toxicity is important in management with many alternative agents, safety is favorable compared with corticosteroids.

Pathophysiology of chronic urticaria

OBJECTIVE

To review the literature on the pathogenesis of chronic urticaria (excluding physical urticaria).

DATA SOURCES

PubMed was searched using the keywords urticaria and either chronic or autoimmune or pathogenesis for articles published from January 1972 to June 2007. All searches were limited to the English language. References from review articles on chronic urticaria were also considered for inclusion in this review.

STUDY SELECTION

The authors selected relevant and current sources for inclusion in this review.

RESULTS

No concise pathogenic mechanism has been identified for all cases of chronic urticaria, although evidence for a serologic mediator that may be autoimmune in nature has been identified in many cases. The activation of basophils and/or mast cells is a central feature in any theory proposed to explain this troubling disease.

CONCLUSION

Further research is needed to better define the mechanism or mechanism(s) responsible for the development of chronic urticaria. Such research will lead to more effective and possibly even curative treatments.

Cysteinyl-leukotrienes and their receptors in asthma and other inflammatory diseases: critical update and emerging trends

Cysteinyl-leukotrienes (cysteinyl-LTs), that is, LTC4, LTD4, and LTE4, trigger contractile and inflammatory responses through the specific interaction with G protein-coupled receptors (GPCRs) belonging to the purine receptor cluster of the rhodopsin family, and identified as CysLT receptors (CysLTRs). Cysteinyl-LTs have a clear role in pathophysiological conditions such as asthma and allergic rhinitis (AR), and have been implicated in other inflammatory conditions including cardiovascular diseases, cancer, atopic dermatitis, and urticaria. Molecular cloning of human CysLT1R and CysLT2R subtypes has confirmed most of the previous pharmacological characterization and identified distinct expression patterns only partially overlapping. Interestingly, recent data provide evidence for the immunomodulation of CysLTR expression, the existence of additional receptor subtypes, and of an intracellular pool of CysLTRs that may have roles different from those of plasma membrane receptors. Furthermore, genetic variants have been identified for the CysLTRs that may interact to confer risk for atopy. Finally, a crosstalk between the cysteinyl-LT and the purine systems is being delineated. This review will summarize and attempt to integrate recent data derived from studies on the molecular pharmacology and pharmacogenetics of CysLTRs, and will consider the therapeutic opportunities arising from the new roles suggested for cysteinyl-LTs and their receptors.

Dermographism and delayed pressure urticaria

There are few papers in the literature that describe pressure urticaria in the maxillofacial region. We present 2 cases and discuss the significance and principles of management. One case describes the diagnosis of pressure urticaria and the second describes the dental management of a patient with severe pressure urticaria.

Treatment of severe chronic idiopathic urticaria with oral mycophenolate mofetil in patients not responding to antihistamines and/or corticosteroids

BACKGROUND

Urticarial patients are usually treated with oral antihistamines and 50% respond well to this treatment; however, the other 50% do not respond to antihistamines and need a more aggressive approach, such as short or prolonged courses of oral corticosteroids or cyclosporine. Potential adverse effects, however, limit this regimen.

OBJECTIVE

To determine the efficacy of mycophenolate mofetil, an immunomodulatory drug, in the treatment of patients with severe chronic urticaria.

METHODS

In an open-label, uncontrolled trial, nine patients with documented chronic urticaria who had been treated previously with antihistamines and/or corticosteroids with poor response were enrolled in the trial. After 2 weeks of baseline assessment, patients received 1000 mg twice daily of mycophenolate mofetil for 12 weeks. Improvement was monitored using the urticarial activity score, which is the sum of the wheal number score and itch severity score. Patients also recorded their daily need for other medications to control allergic symptoms.

RESULTS

There was a significant decrease in the urticarial activity score relative to the baseline assessment at the end of the study period (P < 0.001). All patients were able to stop prednisone on completion of the study. There was also a decrease in antihistamine dose, but this did not reach statistical significance. Treatment with mycophenolate mofetil was not associated with significant adverse effects.

CONCLUSIONS

Mycophenolate mofetil may be a valuable and safe treatment for patients with chronic urticaria who do not respond to antihistamines and/or corticosteroids, and who require aggressive treatment to control their disease symptoms. Further controlled clinical studies are needed to determine its value.

Prospects for vaccines for allergic and other immunologic skin disorders

The human skin hosts a variety of immune response-associated components that together form the skin immune system. Any abnormality in the functioning of the skin immune system leads to a variety of dermatologic complications, including dermatitis, psoriasis, and eczema. Exposure to antigens/allergens can lead to allergic skin disorders such as atopic dermatitis, urticaria, and allergic contact dermatitis. Recent investigations have provided new insights into the immunologic processes leading to the development of skin diseases. T cells play a central role in the activation and regulation of immune responses by recognizing antigen and inducing cytokine production. Despite advances in the understanding of the immunologic events leading to the development of skin diseases, no effective prevention measure exists. Current therapeutic treatments are based on either alleviating the symptoms or suppressing the immune system with immunosuppressive drugs. Allergen-specific immunotherapy is expected to induce specific T cells that abolish allergen-induced proliferation of T helper cells, as well as their cytokine production. Recent approaches using recombinant protein, polycytosine guanine oligonucleotides, and plasmid DNA for vaccination suggest the possibility of protection against these skin disorders. The involvement of T cells in psoriasis indicates that the development of a T-cell receptor peptide vaccine may be beneficial. Dendritic cell-based vaccines using tolerogenic dendritic cells that can induce T-cell tolerance have been shown to be useful in dealing with autoimmune disorders and allergic conditions. In the light of these developments, this article presents the current status and prospects of developing vaccines for allergic and other immunologic skin disorders.

Urticaria: selected highlights and recent advances

Urticaria has been called a vexing problem and remains so today. The most important part of the diagnostic evaluation remains a comprehensive and detailed history and physical examination, supplemented with limited laboratory testing. Although acute urticaria has been relatively well understood for some time, significant and important recent advances in under-standing the pathogenesis of chronic urticaria are beginning to provide insight in this challenging field, notably the identification of many of these patients with an autoimmune etiology. Antihistamines of various types continue to represent the keystone of symptomatic treatment, with adjunctive support from medications of other classes, such as antileukotrienes, adrenergics, and immunosuppressive and anti-inflammatory agents (including steroids and cyclosporine). Although some progress has been made at improving symptomatic control of urticaria, further research and discovery are necessary before there can yet be an effective impact on the underlying course and natural history of this condition.

Urticária

A urticária apresenta-se com diversas formas clínicas e causas distintas. Constitui uma das dermatoses mais freqüentes: 15% a 20% da população têm pelo menos um episódio agudo da doença em sua vida, resultando em percentual que varia de um a 2% dos atendimentos nas especialidades de Dermatologia e Alergologia. A urticária é classificada do ponto de vista de duração da evolução temporal em aguda (inferior a seis semanas) ou crônica (superior a seis semanas). O tratamento da urticária pode compreender medidas não farmacológicas e intervenções medicamentosas, as quais são agrupadas em tratamentos de primeira (anti-histamínicos), segunda (corticosteróides e antileucotrienos) e terceira linha (medicamentos imunomoduladores). As medidas terapêuticas de segunda e terceira linha apresentam maiores efeitos adversos, devendo ser reservadas aos doentes que não apresentaram controle da doença com os de primeira linha, ou àqueles a respeito dos quais não é possível estabelecer uma etiologia, tal como nas urticárias auto-imunes.

The effectiveness of montelukast for the treatment of anti-histamine-resistant chronic urticaria

Many patients with chronic idiopathic urticaria are not sufficiently controlled with histamine H(1)-receptor antagonists. Leukotriene receptor antagonists have been reported to be effective for certain cases of urticaria, although their proper application remains to be established. To study the effectiveness of montelukast, a leukotriene receptor antagonist, for the treatment of chronic urticaria that was not controlled by histamine H(1)-receptor antagonists. Twenty-five patients with chronic idiopathic urticaria were treated with 10 mg of montelukast for one week or more, without changing any precedent treatment that they were using before the study including histamine H(1)-receptor antagonists. The effectiveness of montelukast for each patient was evaluated and compared with clinical features and/or backgrounds of the patients. Twelve patients, including six who had been treated with corticosteroids, were evaluated as "markedly improved" or "improved" following treatment with montelukast. There was no statistically significant relation of the effectiveness to the complications with non-steroidal anti-inflammatory drugs (NSAIDs) intolerance, mechanical urticaria, or reactions to autologous serum skin test. However, the patients for whom montelukast was effective were younger (33.2+/-16.3 years, mean +/- SD)(P<0.05, Mann-Whitney test) and their duration of illness shorter (15.9+/-18.3 months) (P<0.005, Mann-Whitney test) than those of patients for whom montelukast was ineffective (45.9+/-15.0 years, 89.6+/-71.7 months). Montelukast may be worth trying for patients with chronic idiopathic urticaria, when the condition is not sufficiently controlled with histamine H(1)-receptor antagonists.

Urticaria and angioedema. Controlling acute episodes, coping with chronic cases

Urticaria can be frustrating for patients and physicians alike. Its triggers may be medications, food allergies, insect stings, or physical stimuli and are often difficult to determine, especially when the urticaria has become chronic. In this article, Dr Varadarajulu gives an overview of both acute and chronic urticaria and the angioedema that accompanies it in about 40% of patients. She also outlines an approach to help evaluate and manage these common conditions.

Second-Generation Antihistamines

Antihistamines are useful medications for the treatment of a variety of allergic disorders. Second-generation antihistamines avidly and selectively bind to peripheral histamine H1 receptors and, consequently, provide gratifying relief of histamine-mediated symptoms in a majority of atopic patients. This tight receptor specificity additionally leads to few effects on other neuronal or hormonal systems, with the result that adverse effects associated with these medications, with the exception of noticeable sedation in about 10% of cetirizine-treated patients, resemble those of placebo overall. Similarly, serious adverse drug reactions and interactions are uncommon with these medicines. Therapeutic interchange to one of the available second-generation antihistamines is a reasonable approach to limiting an institutional formulary, and adoption of such a policy has proven capable of creating substantial cost savings. Differences in overall efficacy and safety between available second-generation antihistamines, when administered in equivalent dosages, are not large. However, among the antihistamines presently available, fexofenadine may offer the best overall balance of effectiveness and safety, and this agent is an appropriate selection for initial or switch therapy for most patients with mild or moderate allergic symptoms. Cetirizine is the most potent antihistamine available and has been subjected to more clinical study than any other. This agent is appropriate for patients proven unresponsive to other antihistamines and for those with the most severe symptoms who might benefit from antihistamine treatment of the highest potency that can be dose-titrated up to maximal intensity.

Desloratadine: an update of its efficacy in the management of allergic disorders

Desloratadine (Clarinex, Neoclarityn, Aerius, Azomyr, Opulis, Allex), the principal metabolite of loratadine, is itself an orally active, nonsedating, peripheral histamine H(1)-receptor antagonist. It is indicated in the US and Europe for the treatment of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR) and chronic idiopathic urticaria (CIU). It has a rapid onset of effect, efficacy throughout a 24-hour dosage interval, and sustained efficacy in these allergic conditions, as demonstrated in placebo-controlled trials of up to 6 weeks' duration in adult and adolescent patients. At present, there are no published direct comparisons of desloratadine and other H(1)-antihistamines; however, the principal, potential clinical advantages of desloratadine over late-generation H(1)-antihistamines are the drug's decongestant activity, which has been corroborated in several studies of patients with allergic rhinitis, and its anti-inflammatory effects. Indeed, the decongestant activity of desloratadine did not differ from that of pseudoephedrine in a trial in patients with SAR, and in patients with SAR and coexisting asthma, desloratadine reduced asthma symptoms and beta(2)-agonist use, and improved forced expiratory flow in 1 second. However, these issues warrant further study. Desloratadine is generally well tolerated. The overall incidence of adverse events in adults, adolescents and children was not significantly different to that with placebo, and similar proportions of desloratadine or placebo recipients reported events such as pharyngitis, dry mouth, myalgia, somnolence, dysmenorrhoea or fatigue. Desloratadine does not cause sedation or prolong the corrected QT (QTc) interval, can be administered without regard to concurrent intake of food and grapefruit juice, and appears to have negligible potential for drug interactions mediated by several metabolic systems.

CONCLUSION

Although comparative studies with second-generation and other recently developed H(1)-antihistamines are needed to define the drug's clinical profile more clearly, desloratadine can be expected to claim a prominent place in the management of allergic disorders in general, and in the amelioration of specific symptoms of allergy (e.g. nasal congestion) in patients with such disorders.