Rapid desensitization with autologous sweat in cholinergic urticaria

Potential Therapeutic Approaches for Chronic Urticaria: Beyond H1-Antihistamines and Biologics

Chronic urticaria is a disease that can significantly impact a patient's quality of life and ability to function. There are effective treatment options, such as nonsedating antihistamines or biologics, but some patients do not respond to these therapies, or the therapies are not available or affordable to all patients. This review aims to summarize potential treatment strategies for patients (1) who do not respond to antihistamines and (2) cannot readily access or do not respond to biologics. The review emphasizes the importance of sound clinical practice, including correct diagnosis of chronic urticaria phenotypes, treatment of associated comorbidities, and consideration of add-on pharmacological and nonpharmacological approaches. Although some treatments may lack high-quality evidence, they may still be justifiable in certain cases, provided that there is shared decision-making, regular reassessment, and early recognition of adverse events.

Cholinergic Urticaria: Subtype Classification and Clinical Approach

Cholinergic urticaria (CholU) is a subtype of chronic inducible urticaria with a chief complaint of itching and/or stinging, painful papular wheals that develop simultaneously with sweating. This review specifically focuses on several subtypes of CholU and specifically investigates the relationship between CholU and anhidrosis. We review recent publications and update the evidence around CholU, including the epidemiology, clinical features, diagnostic approaches, physiopathology, subtype classification, and therapeutic approaches. Multiple mechanisms contribute in a complex manner to the development of CholU, including histamine, sweat allergy, cholinergic-related substances, poral occlusion, and hypohidrosis/anhidrosis. A new schematic of the currently known pathological conditions has been created. Specific methods for diagnosing CholU, a provocation test, and evaluation methods for disease severity/activity and disease burden of CholU are summarized. The characteristics of the diseases that should be differentiated from CholU and examination methods are also summarized. The primary finding of this review is that CholU should be categorized based on the etiology and clinical characteristics of each subtype to properly manage and treat the disease. This categorization leads to improvement of therapeutic resistance status of this disease. In particular, a sweating abnormality should be given more attention when examining patients with CholU. Because CholU is not a homogeneous disease, its subtype classification is important for selection of the most suitable therapeutic method. Further elucidation of the pathophysiology of each subtype is expected.

Impaired sweating in patients with cholinergic urticaria is linked to low expression of acetylcholine receptor CHRM3 and acetylcholine esterase in sweat glands

Background

Cholinergic urticaria (CholU), a frequent form of chronic inducible urticaria, is characterized by itchy wheals and angioedema in response to sweating. As of now, the rate and pathophysiological relevance of impaired sweating in patients with CholU are ill-defined.

Aim

To assess in CholU patients the rate and extent of impaired sweating and its links to clinical and pathophysiological features of CholU.

Patients and methods

We assessed sweating in patients with CholU (n = 13) subjected to pulse-controlled ergometry (PCE) provocation testing. Pre- and post-PCE biopsies of lesional (L) and non-lesional (NL) skin were analyzed for the expression of acetylcholine receptor M3 (CHRM3) and acetylcholine esterase (ACh-E) by quantitative histomorphometry and compared to those of healthy control subjects (HCs). CholU patients were assessed for disease duration and severity as well as other clinical features.

Results

Of the 13 patients with CholU, 10 showed reduced sweating in response to PCE provocation, and 3 had severely reduced sweating. Reduced sweating was linked to long disease duration and high disease severity. CholU patients with impaired sweating responses showed reduced sweat gland epithelial expression of CHRM3 and ACh-E.

Conclusion

Reduced sweating is common in CholU patients, especially in those with long-standing and severe disease, and it can be severe. Reduced expression of CHRM3 and ACh-E may be the cause or consequence of CholU in patients with impaired sweating, and this should be explored by further studies.

Evidence for histamine release in chronic inducible urticaria – A systematic review

Background

Chronic inducible urticaria (CIndU) constitutes a group of nine different CIndUs in which pruritic wheals and/or angioedema occur after exposure to specific and definite triggers. Histamine released from activated and degranulating skin mast cells is held to play a key role in the pathogenesis of CIndU, but evidence to support this has, as of yet, not been reviewed systematically or in detail. We aim to characterize the role and relevance of histamine in CIndU.

Methods

We systematically searched 3 electronic databases (PubMed, Scopus, and Embase) for studies that reported increased serum or skin histamine concentration (direct evidence) or in vitro or ex vivo histamine release (indirect evidence) following trigger exposure.

Results

An initial total of 3,882 articles was narrowed down to 107 relevant studies of which 52 were in cold urticaria, 19 in cholinergic urticaria, 14 in heat urticaria, 10 in contact urticaria, 7 each in solar urticaria and vibratory angioedema, 4 each in symptomatic dermographism and aquagenic urticaria, and 3 in delayed pressure urticaria. The results of our review support that histamine has a key pathogenic role in the pathogenesis of all CIndUs, but it is not the sole mediator as evidenced by the often poor relationship between the level of histamine and severity of symptoms and the variable clinical efficacy of H1-antihistamines.

Conclusions

Histamine released from skin mast cells is a key driver of the development of signs and symptoms and a promising therapeutic target in CIndU.

Cholinergic Urticaria, an Effective and Safe "Off Label" Use of Dupilumab: A Case Report with Literature Review

Cholinergic Urticaria (CholU) is a form of generalized urticaria induced by an increase in core body temperature that activates the sweat reflex. Clinically it is characterized by localized and highly itchy wheals with surrounding erythema and can occur in response to exercise, hot baths and/or emotional stress. Dupilumab is a fully human monoclonal antibody specifically designed to simultaneously inhibit the activity of interleukin-4 (IL-4) and interleukin-13 (IL-13), which play a key role in the inflammation cascade of type 2. We report the case of a 26-year-old man suffering from CholU for 3 years, unresponsive to standard treatment in which off-label therapy was undertaken with Dupilumab, 600 mg subcutaneous as a loading dose and then 300 mg every 15 days. The daily Visual Analogue Scale (VAS) score was used to assess the efficacy of the therapy. Already after the first two administrations, the patient no longer had CholU episodes and resumed regular sporting activity, with a marked improvement in the quality of life. A possible mechanism of Dupilumab in reducing the manifestations of CholU is the blocking of the IL-4 pathway and the expression of the high-affinity IgE receptor (FcεR1) on B cells, mast cells (MCs) and basophils. By decreasing the production of FcεR1, the adhesion of IgE to the surface of MCs decreases with consequent reduction of MCs activation and histamine release. Further experience and large-scale studies may be needed to establish whether Dupilumab can be a therapeutic alternative in CholU, especially in patients who do not respond to standard treatment.

Chronic Urticaria: Advances in Understanding of the Disease and Clinical Management

Chronic urticaria (CU) is a common skin condition characterized by the recurrence of wheals, with or without angioedema, which lasts for at least 6 weeks. Owing to its pruritus and incurability, this disease adversely affects the patients' physical and mental health and diminishes the quality of life. CU is generally classified into two subtypes based on the relevance of eliciting factors: chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU), the latter of which is further divided into several subtypes. To improve the understanding and clinical management of this highly heterogeneous disorder, the EAACI/GA²LEN/EDF/WAO guideline was developed and published in 2018 based on evidence and expert consensus. The diagnostic and treatment algorithms proposed by the guideline have largely facilitated dermatologists in clinical practice. However, several questions remained unsolved and have been widely investigated in the recent years. First, a better understanding of the association between chronic urticaria and its potential underlying causes or eliciting factors such as autoimmunity, infections, coagulation aberrance, and vitamin D deficiency is warranted. This would lead to updates in the diagnostic and treatment procedures of different subtypes of chronic urticaria. Secondly, treatment for recalcitrant cases, especially those resistant to or intolerant of second-generation antihistamines and (or) omalizumab, calls for novel therapeutic measures or strategies. In the present review, we summarized recent advances in the understanding and management of both CSU and CIndU, with special emphasis on their underlying causes or eliciting factors, pathogenic mechanisms, potential targets for intervention, and advances in treatment strategies.

Remission of a case of multiple Hymenoptera stings-associated chronic urticaria during venom immunotherapy

Hymenoptera stings mostly cause acute urticaria but we describe a case of CU after wasp stings which remitted during venom immunotherapy. IgE-mechanisms have not been fully clarified in CU, except for isolated circumstances. In our case immunotherapy has played a positive role reducing immune cells reactivity and improving urticaria symptoms.

Sensitization against skin resident fungi is associated with atopy in cholinergic urticaria patients

Background

Cholinergic urticaria (CholU) is a common type of chronic inducible urticaria, characterized by small itchy wheals that appear upon physical exercise or passive warming. Malassezia globosa, a skin resident fungus, has been identified as an antigen that induces mast cell/basophil degranulation and wheal formation through specific IgE, in Japanese patients with atopic dermatitis and CholU. In this study we aimed in assessing the rate of IgE sensitizations against skin resident fungi in European CholU patients.

Methods

We assessed serum IgE levels to Malassezia furfur, Candida albicans and Trichophyton mentagrophytes using routine lab testing and Malassezia globosa using a newly established ELISA. We correlated the results to wheal formation and other clinical features.

Results

Four patients (of 30 tested) had elevated levels of IgE against Malassezia furfur and Candida albicans and two had elevated levels of IgE against Trichophyton mentagrophytes. Four sera (of 25 tested) had elevated levels of IgE to the Malassezia globosa antigen supMGL_1304. Sensitization to one skin fungus was highly correlated with sensitization to the other tested fungi. We saw highly significant correlations of sensitization to supMGL_1304 with wheal size in the autologous sweat skin test (r_s = 0.7, P = 0.002, n = 19), the Erlangen atopy score (r_s = 0.5, P = 0.03, n = 19), total IgE serum levels (r_s = 0.5, P = 0.04, n = 19) and a positive screen for IgE against common airborne/inhalant allergens s (sx1; r_s = 0.54, P = 0.02, n = 19).

Conclusions

Sensitization to skin resident fungi including Malassezia globosa is uncommon in European CholU patients, but is associated with atopy and pronounced wheal formation upon dermal contact with their own sweat.

Trial registration German Clinical Trials Registry DRKS-ID: DRKS00004277

Urticaria: recommendations from the Italian Society of Allergology, Asthma and Clinical Immunology and the Italian Society of Allergological, Occupational and Environmental Dermatology

BACKGROUND

Urticaria is a disorder affecting skin and mucosal tissues characterized by the occurrence of wheals, angioedema or both, the latter defining the urticaria-angioedema syndrome. It is estimated that 12-22% of the general population has suffered at least one subtype of urticaria during life, but only a small percentage (estimated at 7.6-16%) has acute urticaria, because it is usually self-limited and resolves spontaneously without requiring medical attention. This makes likely that its incidence is underestimated. The epidemiological data currently available on chronic urticaria in many cases are deeply discordant and not univocal, but a recent Italian study, based on the consultation of a national registry, reports a prevalence of chronic spontaneous urticaria of 0.02% to 0.4% and an incidence of 0.1-1.5 cases/1000 inhabitants/year.

METHODS

We reviewed the recent international guidelines about urticaria and we described a methodologic approach based on classification, pathophysiology, impact on quality of life, diagnosis and prognosis, differential diagnosis and management of all the types of urticaria.

CONCLUSIONS

The aim of the present document from the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC) and the Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA) is to provide updated information to all physicians involved in diagnosis and management of urticaria and angioedema.

Clinical utility of the basophil activation test in the diagnosis of sweat allergy

BACKGROUND

Many patients with atopic dermatitis and cholinergic urticaria display an immediate-type allergy to autologous sweat. Although the histamine release test (HRT) using semi-purified sweat antigen (QR) was available for the detection of immediate sweat allergy, the existence of HRT low responders could not be disregarded. Furthermore, it has not been established whether the results of the HRT are consistent with the autologous sweat skin test (ASwST). We aimed to compare the HRT and basophil activation test (BAT) for the diagnosis of immediate sweat allergy.

METHODS

The HRT and BAT were performed on 47 subjects (35 ASwST positive, 12 negative) whose symptoms had worsened on sweating. For the BAT, blood was incubated with QR or crude sweat and CD203c upregulation was assessed. A commercial HRT was performed and histamine release induced by QR was quantified.

RESULTS

When excluding non-responders for anti-IgE antibody, the BAT using QR and the HRT had a sensitivity of 100% and 44% and specificity of 75% and 100%, respectively. The BAT and HRT had a positive predictive value of 91.3% and 100% and negative predictive value of 100% and 30%, respectively. The BAT detected 0% non-responders, whereas the HRT identified 22.5%. When using crude sweat for the BAT, the false-positives observed when using QR were not detected.

CONCLUSIONS

The BAT using QR displayed a higher sensitivity and negative predictive value and a lower number of non-responders compared with the HRT. Furthermore, the BAT using crude sweat can also be an alternative tool for the ASwST.

How to Approach Chronic Inducible Urticaria

Chronic inducible urticaria (CIndU) is a group of chronic urticarias characterized by the appearance of recurrent wheals, recurrent angioedema or both, as a response to specific triggers. CIndU includes both physical (symptomatic dermographism, cold and heat urticaria, delayed pressure urticaria, solar urticaria, and vibratory urticaria) and nonphysical urticarias (cholinergic urticaria, contact and aquagenic urticaria). Here, we review the different forms of CIndU with an emphasis on symptomatic dermographism, cold urticaria, cholinergic urticaria, and delayed pressure urticaria. We discuss the clinical features, the diagnostic workup including provocation and threshold testing, and available treatment options.

Sweat allergy

Sweat allergy is defined as a type I hypersensitivity against the contents of sweat, and is specifically observed in patients with atopic dermatitis (AD) and cholinergic urticaria (CholU). The allergic reaction is clinically revealed by positive reactions in the intradermal skin test and the basophil histamine release assay by sweat. A major histamine-releasing antigen in sweat, MGL_1304, has been identified. MGL_1304 is produced at a size of 29 kDa by Malassezia (M.) globosa and secreted into sweat after being processed and converted into the mature form of 17 kDa. It induces significant histamine release from basophils of patients with AD and/or CholU with MGL_1304-specific IgE, which is detected in their sera. Patients with AD also show cross-reactivity to MGL_1304-homologs in Malassezia restricta and Malassezia sympodialis, but MGL_1304 does not share cross antigenicity with human intrinsic proteins. Malassezia or its components may penetrate the damaged epidermis of AD lesions and interact with the skin immune system, resulting in the sensitization and reaction to the fungal antigen. As well as the improvement of impaired barrier functions by topical interventions, approaches such as anti-microbial treatment, the induction of tolerance and antibody/substance neutralizing the sweat antigen may be beneficial for the patients with intractable AD or CholU due to sweat allergy. The identification of antigens other than MGL_1304 in sweat should be the scope for future studies, which may lead to better understanding of sweat allergy and therapeutic innovations.

Cholinergic urticaria: epidemiology, physiopathology, new categorization, and management

PURPOSE

The aim of this study was to review the evidence on the epidemiology, physiopathology, categorization, and management of cholinergic urticaria. We specifically focused on several subtypes of cholinergic urticaria and investigated the relationship between cholinergic urticaria and idiopathic anhidrosis.

METHODS

Using an integrative approach, we reviewed publications addressing the epidemiology, clinical features, diagnostic approach, physiopathology, subtype classification, and therapeutic approach to cholinergic urticaria.

RESULTS

Multiple mechanisms were found to contribute to the development of cholinergic urticaria. This disorder should be classified based on the pathogenesis and clinical characteristics of each subtype. Such a classification system would lead to better management of this resistant condition. In particular, sweating function should be given more attention when examining patients with cholinergic urticaria.

CONCLUSIONS

Because cholinergic urticaria is not a homogeneous disease, its subtype classification is essential for selection of the most suitable therapeutic method.

The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision

These recommendations for the definition, diagnosis and management of chronic inducible urticaria (CIndU) extend, revise and update our previous consensus report on physical urticarias and cholinergic urticaria (Allergy, 2009). The aim of these recommendations is to improve the diagnosis and management of patients with CIndU. Our recommendations acknowledge the latest changes in our understanding of CIndU, and the available therapeutic options, as well as the development of novel diagnostic tools.

Cholinergic urticaria: More than a simple inducible urticaria

BACKGROUND

Cholinergic urticaria (ChU) is characterized by small wheals induced by an elevated core temperature. Its pathomechanism and various aspects of its clinical manifestations are still poorly understood. This study aimed to evaluate the spectrum of symptoms and signs of ChU in Korean patients.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with ChU.

RESULTS

Among 203 patients (188 male and 15 female), 29 (14%) complained only of an itching or burning sensation without visible skin eruption. The prevalence of ChU was highest in patients in their twenties (56%), while most patients first developed their symptoms during their teens (65%). Patients with a visible skin eruption showed better responses to antihistamines than those without skin lesions.

CONCLUSIONS

Physicians should consider the varying manifestations of ChU, including cholinergic pruritus and erythema as minor variants, to provide better management of ChU.

The association of cholinergic and cold-induced urticaria: diagnosis and management

Physical urticaria is often challenging to diagnose and manage. We present a case of both cholinergic and cold-induced urticaria and discuss the diagnosis and management strategies of these two important conditions.

Clinical characteristics of cholinergic urticaria in Korea

BACKGROUND

Cholinergic urticaria is a type of physical urticaria characterized by heat-associated wheals. Several reports are available about cholinergic urticaria; however, the clinical manifestations and pathogenesis are incompletely understood.

OBJECTIVE

The purpose of this study was to investigate the clinical characteristics of cholinergic urticaria in Korea.

METHODS

We performed a retrospective study of 92 patients with cholinergic urticaria who were contacted by phone and whose diagnoses were confirmed by the exercise provocation test among those who had visited The Catholic University of Korea, Catholic Medical Center from January 2001 to November 2010.

RESULTS

All 92 patients were male, and their average age was 27.8 years (range, 17~51 years). Most of the patients had onset of the disease in their 20s and 30s. Non-follicular wheals were located on the trunk and upper extremities of many patients, and the symptoms were aggravated by exercise. Eight patients showed general urticaria symptoms and 15 had accompanying atopic disease. Forty-three patients complained of seasonal aggravation. Most patients were treated with first and second-generation antihistamines.

CONCLUSION

Dermatologists should consider these characteristics in patients with cholinergic urticaria. Further investigation and follow-up studies are necessary to better understand the epidemiological and clinical findings of cholinergic urticaria.

Elevated serum IgE against MGL_1304 in patients with atopic dermatitis and cholinergic urticaria

BACKGROUND

MGL_1304 secreted by Malassezia globosa is contained in human sweat and induces histamine release from basophils in patients with atopic dermatitis (AD) at a high positive rate. The aims of this study were to establish the enzyme-linked immunosorbent assay (ELISA) measuring specific immunoglobulins against MGL_1304 and to investigate the levels of these immunoglobulins in sera of patients with various allergic diseases.

METHODS

Purified MGL_1304 from human sweat (QRX) and recombinant MGL_1304 (rMGL_1304) were prepared for ELISA. To quantify the amount of MGL_1304-specific immunoglobulins, the standard serum was created by pooling sera of 20 patients with AD whose basophils released histamine in response to QRX. A monoclonal antibody which exhibited the highest neutralizing ability against QRX was established as Smith-2, and used as a capture antibody for the assay of QRX-specific IgE. A total of 156 subjects [normal controls (n = 23), AD (n = 63), cholinergic urticaria (CU) (n = 24), bronchial asthma (n = 32), and allergic rhinitis (n = 14)] were enrolled in this study.

RESULTS

ELISA methods to quantify the specific IgE, IgG and IgG4 against MGL_1304 in sera were successfully established. Levels of QRX-specific IgE in sera of patients with AD and CU were significantly higher than those of normal controls. Moreover, the levels of QRX-specific IgE and rMGL_1304-specific IgE in patients with AD were significantly correlated with their disease severities.

CONCLUSIONS

These ELISA methods to quantify the specific immunoglobulins against MGL_1304 are easy and useful means to assess allergy to MGL_1304. MGL_1304 contained in sweat is an important antigen for patients with AD and CU.

Evaluation of different combined regimens in the treatment of cholinergic urticaria

BACKGROUND

: Cholinergic urticaria is uncommon and accounts for 10% of all young adults. To date, there is no effective therapy for cholinergic urticaria.

OBJECTIVE

: To determine the therapeutic efficacy of different drug combinations in the treatment of cholinergic urticaria.

PATIENTS AND METHODS

: The participants included in the study are in the age range of 16 to 29 years, with cholinergic urticaria of any duration as diagnosed by physicians. Patients were recruited from Asthma and Allergy Centers in Baghdad and Tikrit. The selected patients were divided randomly into 3 groups according to the treatment protocol. All patients completed screening before treatment.

RESULTS

: The study indicated that cholinergic urticaria was completely controlled in 30.4% of patients (group A) receiving 4 mg of chlorpheniramine maleate, half hour before the exercise, plus chlordiazopoxide (5 mg) and clindium bromide (2.5 mg) tablets, 3 times daily. However, cure rate was higher (83.1%) in patients (group B) receiving 4 mg of chlorpheniramine maleate (histadine), 3 times daily, plus 25 mg of maprotiline HCl (ludiomil), once daily at night. Furthermore, the complete cure rate was 85.4% in patients (group C) receiving 4 mg of chlorpheniramine maleate (histadine)3 times daily, plus 200 mg of cimetidine (tagadine), 3 times daily. The frequency of relapse was higher in group A (89%) as compared with group B (68.4%) and group C (23.5%) (P < 0.0001).

CONCLUSIONS

: Combination of H1 and H2 antagonists was more effective based on complete control of cholinergic urticaria with lower relapsing rate. However, a future placebo-controlled clinical trial taking in consideration higher H1 antagonists than we used is warranted.