Consensus statement on the management of urticaria

Comparative study on the efficacy and safety of bepotastine besilate versus levocetirizine in chronic spontaneous urticaria: A randomised, open-label, parallel study

Background Urticaria is a common skin disease which often causes impairment in the quality of life. The ideal drug for chronic urticaria would have antihistaminic and anti-inflammatory actions. Bepotastine besilate is a recently approved novel anti-allergic agent with multiple mechanisms of action; levocetirizine is a potent and selective second-generation H1 receptor antagonist used in the treatment of urticaria. Aim To compare the efficacy and safety of bepotastine besilate versus levocetirizine in patients with chronic spontaneous urticaria. Methods The study design is a randomised, open-label, parallel-group, prospective interventional study. The study subjects were randomly assigned to either of the two groups a and b, each group had 50 patients with chronic urticaria. Statistical analyses were performed using (SPSS, version 18) for all the variables. Chi-square test was used for comparison between categorical variables. An unpaired student's t-test was done for quantitative variables. Results There was a significant decrease in mean urticaria activity score (P < 0.001), chronic urticaria quality of life (P < 0.001) and clinical global improvement (P < 0.001) in both the treatment groups but this improvement was higher in the bepotastine than in the levocetirizine group. There was no significant difference in the mean of absolute eosinophil count, C-reactive protein, aspartate transaminase, alanine transaminase from baseline to 4th week between the two study groups. Visual analogue scale showed statistically significant improvement from baseline to 4th week (P < 0.001) of follow-up but this increase was higher in levocetirizine group (0.64-4.24) than in bepotastine group (0.56-2.56) Limitations Blinding was not done. To assess the efficacy and safety of bepotastine, a larger study can be planned. Conclusion This study found that bepotastine is superior to levocetirizine and showed a statistically significant reduction in mean urticaria activity score 7, improved quality of life and clinical global improvement in patients with urticaria.

Diagnosis and Management of Urticaria in Indian Settings: Skin Allergy Research Society's Guideline-2022

Urticaria is a common skin disorder. Chronic urticaria, i.e., the presence of symptoms for more than six weeks, is associated with a significant adverse impact on sleep, performance, quality of life, and financial status of the patients. Although several treatment options are available, the condition can be challenging to treat for many clinicians. Several updates have been published on the subject of urticaria and its management since the publication of an updated consensus statement in 2018 by Indian experts. The objective of this consensus statement is to summarize the updates and provide concise information, including classification, diagnosis, and management of urticaria. Understanding and elimination of the underlying eliciting trigger are essential in all possible cases. The goal of pharmacological treatment is to provide symptomatic relief. Second-generation nonsedating H1 antihistamine continue to be recommended as the first-line treatment, the dose of which can be increased up to four times in patients not responding satisfactorily, in the second step. The role of omalizumab, cyclosporine, H2 antihistamines, and other options is also discussed.

Institute of Child Health, Kolkata, 1956–2022

Institute of Child Health, Kolkata is an iconic pediatric institution of India, which had its inception as one of the first pediatric hospital of the country. Pediatrics, as a separate branch of medicine, different from the principles and practices of adult medicine, was conceptualized and materialized in India by the founder of this institution, who is referred to as one of the Father of Indian Pediatrics, Dr. Kshirode Chandra Chaudhuri. This article portrays the journey of ICH, the popular acronym of the famed Institute, through the last seven decades from 1956 till the present, trying to capture the initial years of its establishment in the late 1950s, followed by its gradual evolution to an institution of central importance in pediatric healthcare, medical education, research and development, and service to the society, particularly in Eastern India.

Clinico-epidemiological features of chronic urticaria in children: A retrospective analysis of 296 children from a tertiary care institute in Northern India

Background

Urticaria is a common dermatosis affecting approximately 25% of the population. Childhood chronic urticaria is frequently encountered, however, epidemiologic data on pediatric urticaria are limited.

Aim

The objective of this study was to study the clinico-epidemiological profile of children with chronic urticaria.

Methods

A retrospective study including children less than 14 years with chronic urticaria was conducted from January 2010 to December 2015. Detailed history, clinical examination, investigation results, treatment taken, and follow-up details were recorded on a prefixed proforma. As per the practice of the urticaria clinic, the children were investigated only in case of inadequate therapeutic response or had features of atopy/autoimmune disorders.

Results

Two hundred and ninety-six children (166 boys, 130 girls; mean age, 11.3 years) with chronic urticaria were included in the study. Urticaria was spontaneous in onset in 57.1% (169) children; precipitating factors were reported in 42.9% children, most common being physical factors, food allergy, drug intake and infections. Investigations were done in 48 (16.2%) patients; Antinuclear antibody was negative in all patients, raised serum IgE in 20/48 (41.6%), positive autologous serum skin test in 32/48 (66.6%) and raised anti-TPO titre in 10/48 (20.8%) children. A diagnosis of chronic spontaneous urticaria was made in 245 (82.77%) children, chronic dermographic urticaria in 35 (11.82%), cholinergic urticaria and drug-induced urticaria in 5 (1.69%) each, aquagenic urticaria in 4 (1.35%) and cold-induced urticaria in 2 (0.68%) children. Two hundred and fifteen (72.6%) children responded to nonsedating antihistamines alone, 61 (20.6%) required addition of a sedating antihistamine, 7 (0.02%) required addition of montelukast, 3 (0.01%) ranitidine and 10 (20.8%) required a short course of oral corticosteroids to control acute flare. None of the patients required any long-term immunomodulatory or immunosuppressive agent. The mean duration of treatment required was 3 to 12 months.

Limitations

The main limitation is the study being retrospective in nature with associated drawbacks of data loss. In addition, we did not use objective scoring system such as urticaria severity score and not all children were extensively investigated.

Conclusions

Chronic spontaneous urticaria is the most common type of chronic urticaria in children. Majority of these children can be managed conservatively with long-term antihistamines.

Comparative Efficacy and Safety of Ebastine 20 mg, Ebastine 10 mg and Levocetirizine 5 mg in Acute Urticaria

INTRODUCTION

Acute and chronic urticaria can result in severely impaired quality of life from pruritus and associated sleep lessness, as well as anxiety and depression. Various treatment modalities are available out of which second generation non sedating H1 antihistamines e.g., fexofenadine, loratidine, desloratadine, cetirizine, levocetirizine, ebastine etc., are used as the first line treatment.

AIM

To compare the safety and efficacy of ebastine 20 mg, ebastine 10 mg and levocetirizine 5 mg in the patients of urticaria.

MATERIALS AND METHODS

A longitudinal study was conducted in dermatology Outpatient Department (OPD) of Adesh Institute of Medical Sciences and Research, Bathinda, India. A total of 150 patients between the age group 10-70 years, both men and women having urticaria were enrolled and divided into three groups of 50 each. Group A was given ebastine 20 mg OD, Group B was given ebastine 10 mg OD and Group C was given levocetirizine 5 mg OD. The patients were asked to scale their severity of disease over a period of follow up based on Urticarial Activity Score 7 (UAS7).

RESULTS

The mean age of patients was 32.82 years. The mean UAS 7 score at the end of 4th week was 1.08 with ebastine 20 mg, 1.98 with levocetirizine 5 mg and 3.98 with ebastine 10 mg. In group A, 40 out of 50 patients (i.e., 80%), in Group B 25 out of 50 (i.e., 50%) get UAS7=0 and in Group C, 35 (i.e., 70%) patients who got relieved of symptoms at the end of treatment. When the scores were redefined and categorized under relieved and not relieved, and comparison done between all three groups, then there was a significant difference in the number of patients getting relieved, with p<0.001 (highly significant). Levocetirizine 5 mg had shown more side effects like dryness of mouth and sedation as compare to ebastine irrespective of dosage. The comparison made between the number of patients developing side effects among the groups was highly significant (p<0.001) for all the side effects.

CONCLUSION

Ebastine 20 mg is found to have superior efficacy for treatment of Urticaria as compared to ebastine 10 mg but with levocetirizine 5 mg the results were almost similar. Tolerability of ebastine 20 mg is similar to ebastine 10 mg but with levocetirizine 5 mg there were more side effects and less tolerability.

Computer-assisted Medical Decision-making System for Diagnosis of Urticaria

Background: Urticaria is a common allergic disease that affects all age groups. Allergic disorders are diagnosed at allergy testing centers using skin tests. Though skin tests are the gold standard tests for allergy diagnosis, specialists are required to interpret the observations and test results. Hence, a computer-assisted medical decision-making (CMD) system can be used as an aid for decision support, by junior clinicians, in order to diagnose the presence of urticaria. Methods: The data from intradermal skin test results of 778 patients, who exhibited allergic symptoms, are considered for this study. Based on food habits and the history of a patient, 40 relevant allergens are tested. Allergen extracts are used for skin test. Ten independent runs of 10-fold cross-validation are used to train the system. The performance of the CMD system is evaluated using a set of test samples. The test samples were also presented to the junior clinicians at the allergy testing center to diagnose the presence or absence of urticaria. Results: From a set of 91 features, a subset of 41 relevant features is chosen based on the relevance score of the feature selection algorithm. The Bayes classification approach achieves a classification accuracy of 96.92% over the test samples. The junior clinicians were able to classify the test samples with an average accuracy of 75.68%. Conclusion: A probabilistic classification approach is used for identifying the presence or absence of urticaria based on intradermal skin test results. In the absence of an allergy specialist, the CDM system assists junior clinicians in clinical decision making.

Updosing of Nonsedating Anti-histamines in Recalcitrant Chronic Urticaria

Chronic urticaria (CU) is a persistent, debiliating condition that causes severe impairment on the quality of life (QoL) of patient by interrupting work productivity. Current guidelines recommend second-generation (nonsedating) anti-histamines for the treatment for all forms of urticaria. In patients who do not respond adequately to conventional doses of anti-histamines, it is recommended to increase the dose to up to four times to obtain control. But there are only few controlled studies that have assessed the efficacy and safety of nonsedating anti-histamines. Though sedating histamines are frequently used as an add-on therapy in severe cases, they have a negative impact on QoL by compromising sleep and performance. The use of other suggested therapeutic options (omalizumab, cyclosporine A, montelukast and dapsone) is also limited by paucity of data on their efficacy and adverse effect profile. Second-generation anti-histamines which are relatively safer require more proven data to support their judicious use to improve disease in patients with CU.

Position statement for the use of omalizumab in the management of chronic spontaneous urticaria in Indian patients

Chronic spontaneous urticaria (CSU) affects 1% of the world population and also their quality of life, and 50% of these patients are refractory to H1-antihistamines. Omalizumab is a humanized monoclonal anti-IgE antibody that binds with free IgE antibodies and reduces the circulating levels of free IgE. This reduction in free IgE prevents mast-cell degranulation. The EAACI/GA2LEN/EDF/WAO guidelines recommend omalizumab as the third-line of therapy as an add-on to antihistamines. The recommended dose of omalizumab is 300 mg, 4 weekly in the management of CSU refractory to standard of care with H1-antihistamines in adults and adolescents ≥12 years of age. In some patients, a dose of 150 mg may be acceptable. Omalizumab has a good safety profile. However, due to the biologic nature of the drug, all patients administered omalizumab must be observed for 2 h after administration for anaphylactoid reactions. There have been no studies on the effect of impaired renal or hepatic function on the pharmacokinetics of omalizumab. While no particular dose adjustment is recommended, omalizumab should be administered with caution in these patients.

Food hypersensitivity in patients over 14 years of age suffering from atopic dermatitis

BACKGROUND

Patients suffering from atopic dermatitis often describe food hypersensitivity. Rising prevalence of food hypersensitivity and severe allergic reactions to foods have been reported, but the data are scarce.

AIMS AND OBJECTIVES

Evaluation of food hypersensitivity reactions in patients suffering from atopic dermatitis.

MATERIALS AND METHODS

The dermatological examination was performed in patients of age 14 years and above and the detailed history was taken concerning the food hypersensitivity.

RESULTS

A total of 228 patients were examined-72 men, 156 women, average age 26.2 (SD 9.5) years. The food hypersensitivity reactions were recorded in 196 patients from 228 (86%), no reactions were recorded in 32 patients (24%). Foods with the most often recorded reactions are: Nuts (in 35% of patients), tomatoes (in 20%), and kiwi (in 17, 5%), apples and spices (in 16%), tangerines and oranges (in 15%), capsicum (in 13%), fishes (in 12%), celery (in 9%), and chocolate (in 7%).

CONCLUSION

Food hypersensitivity reactions are recorded in 86% of patients suffering from atopic dermatitis. Nuts, tomatoes, and pollen-associated foods play a role in the majority of patients suffering from atopic dermatitis.

Night-time sedating H1 -antihistamine increases daytime somnolence but not treatment efficacy in chronic spontaneous urticaria: a randomized controlled trial

Background

Many physicians believe that the most effective way to treat chronic urticaria is to take a nonsedating second-generation H₁-antihistamine in the morning and a sedating first-generation H₁-antihistamine, usually hydroxyzine, at night to enhance sleep. But is this belief well founded?

Objectives

To test this belief by comparing the effectiveness and prevalence of unwanted sedative effects when treating patients with chronic spontaneous urticaria (CSU) with levocetirizine 15 mg daily plus hydroxyzine 50 mg at night (levocetirizine plus hydroxyzine) vs. levocetirizine 20 mg daily (levocetirizine monotherapy).

Methods

In this randomized, double-blind, cross-over study, 24 patients with difficult-to-treat CSU took levocetirizine plus hydroxyzine or levocetirizine monotherapy for periods of 5 days each. At the end of each treatment period, assessments were made of quality of life (Chronic Urticaria Quality of Life Questionnaire, CU-Q₂oL), severity of urticaria symptoms (Urticaria Activity Score, UAS), sleep disturbance during the night and daytime somnolence.

Results

Both treatments significantly decreased UAS, night-time sleep disturbances and CU-Q₂oL scores (P < 0·001) without significant differences between the two. Compared with baseline, daytime somnolence was significantly reduced by levocetirizine monotherapy (P = 0·006) but not by levocetirizine plus hydroxyzine (P = 0·218). Direct comparison of the two treatment modalities in terms of daytime somnolence favoured levocetirizine monotherapy (P = 0·026).

Conclusions

The widespread belief that sleep is aided by the addition of a sedating first-generation H₁-antihistamine, usually hydroxyzine, at night is not supported. These results are in line with the urticaria guidelines, which state that first-line treatment for urticaria should be new-generation, nonsedating H₁-antihistamines only.

Up-dosing of non-sedating antihistamines in chronic urticaria: Need for well-designed clinical trials in India

Urticaria is a heterogeneous group of diseases. Chronic urticaria significantly impacts quality-of-life of patients. Second generation, non-sedating antihistamines are recommended as first line treatment for chronic spontaneous urticaria. In patients with inadequate control of symptoms, increase in dosage of non-sedating antihistamines up to four fold has been recommended. This recommendation is based on low cost, good safety and good evidence of efficacy of non-sedating, second generation antihistamines. This article reviewed Indian data on up-dosing of antihistamines in chronic urticaria. There is a need for well-designed clinical trials with -up-dosing of individual antihistamines in Indian patients.

Clinical effectiveness and safety of cetirizine versus rupatadine in chronic spontaneous urticaria: a randomized, double-blind, 6-week trial

BACKGROUND

Urticaria is a distressing condition associated with diverse clinical presentations. Chronic spontaneous urticaria (CsU) is characterized by wheals and angioedema. Its treatment requires an algorithmic approach to identify the optimum medication.

OBJECTIVES

Cetirizine is commonly used in the treatment of urticaria. Rupatadine is a selective non-sedating H1 -antihistamine approved for the treatment of CsU. This trial was conducted to ascertain whether the properties of rupatadine offer advantages over cetirizine.

METHODS

Seventy patients with CsU were enrolled. Parameters assessed included: (i) mean number of wheals (MNW); (ii) pruritus; (iii) mean total symptom score (MTSS); (iv) size of wheal; (v) interference of wheals with sleep; and (vi) sedation. Patients with CsU were divided randomly into two groups. Routine investigations were performed at baseline and at the end of the study.

RESULTS

Evaluations of MTSS, MNW, and pruritus revealed statistically significant differences at week 3 compared with baseline in the cetirizine group. However, greater reductions in these parameters were obtained with rupatadine. In patients receiving rupatadine, reductions in the MNW, size of wheals, and intensity of erythema were also significant at six weeks (P < 0.001) and were significantly greater than those in the cetirizine group (P < 0.05).

CONCLUSIONS

Improvements in MTSS, MNW, size of wheals, intensity of erythema, and differential eosinophil count imply that rupatadine is a particularly attractive therapeutic modality compared with cetirizine for the treatment of CsU.

Chronic urticaria: Indian context-challenges and treatment options

Urticaria is a common condition that occurs in both children and adults. Most cases have no specific allergic trigger and the aetiology of urticaria remains idiopathic and occasionally spontaneous in nature. Inappropriate advice such as avoidance of foods (milk, egg, prawn, and brinjal) is common place in certain sections of India mostly by nonspecialists that should not be routinely recommended. It is important to look for physical urticarias such as pressure urticaria in chronic cases, which may be present either alone or in combination with other causes. Autoimmune causes for chronic urticaria have been found to play an important role in a significant proportion of patients. Long-acting nonsedating antihistamines at higher than the standard doses is safe and effective. Quality of life is affected adversely in patients with chronic symptomatic urticaria and some may require multidisciplinary management.