Etiology of chronic urticaria: the Ecuadorian experience

Background

The purpose of this study was to identify chronic urticaria (CU) etiologies and treatment modalities in Ecuador. We propose that the sample distribution fits the expected one, and that there is an association between the etiology and its treatment.

Methods

We performed a retrospective study involving 112 patients diagnosed with CU using a Checklist for a complete chronic urticaria medical history. Demographic and clinical variables were collected. The etiology of CU was classified using the EAACI/GA2LEN/EDF/WAO guideline. Descriptive analyses were performed for demographical and clinical variables. Chi square tests were applied to analyze the fit of distribution and the independence of variables. P values less than 0.05 were considered significant.

Results

Among all the patients, 76.8% were diagnosed with chronic spontaneous urticaria (CSU), of which 22.3% had a known etiology or possible exacerbating condition. Food allergy was identified as the most common accompanying condition in patients with CSU (10.7%) (p < 0.01).. On the other hand, 23.2% inducible urticarias (CIndU) were indentified; dermographism was the most common (10.7%) (p < 0.01).

Regarding treatment regimens, sg-H1-antihistamines alone represented the highest proportion (44.6%). The combination of any H1-antihistamine plus other drug was a close second (42.0%) (p < 0.01). Almost 48% of CSUs of unknown etiology were treated with any antihistamine plus another drug. In patients with known etiology, sg-antihistamines alone (44.0%) was the most common management. In addition, 53.8% of CIndUs were treated with sg-antihistamines alone. Though, these associations were not statistically significant.

Conclusion

CSU is the most frequent subtype of CU. Modern non-sedating antihistamines in licensed doses are the drug of choice. Nevertheless, a great proportion of patients require the addition of another type of medication.

Loratadine versus cetirizine: assessment of somnolence and motivation during the workday

OBJECTIVE

This parallel-group, double-blind study compared the somnolence and motivation profiles of 2 second-generation antihistamines, loratadine and cetirizine, in patients with allergic rhinitis.

BACKGROUND

Second-generation antihistamines were developed to provide symptomatic relief from allergic disorders without the unwanted side effects of first-generation antihistamines, including somnolence. Recent research has indicated that not all second-generation antihistamines are comparable with respect to somnolence and other cognitive processes.

METHODS

Patients aged > or = 12 years and actively exhibiting symptoms of allergic rhinitis were randomized to 2 treatment groups to receive 10 mg loratadine or 10 mg cetirizine daily at 8:00 AM for 1 week. After patients took the medication, their somnolence and degree of motivation to perform activities were recorded in an electronic diary using a visual analog scale 4 times during the workday (8:00 AM, 10:00 AM, noon, and 3:00 PM).

RESULTS

Sixty patients (31 men, 29 women) were randomized to treatment. Somnolence scores were similar for both groups at baseline and at the time of dosing (8:00 AM). However, there was a statistically significant difference in somnolence scores between the loratadine and cetirizine groups at 10:00 AM (P = 0.008), noon (P = 0.001), and 3:00 PM (P < 0.001), with the cetirizine group showing a greater degree of somnolence. The scores on motivation to perform activities were similar for both groups at the baseline and 8:00-AM measurements. In parallel with the somnolence scores, there were statistically significant differences in motivation scores between the loratadine and cetirizine groups at 10:00 AM (P = 0.014), noon (P = 0.001), and 3:00 PM (P < 0.001), indicating that patients taking loratadine were relatively more motivated during the workday.

CONCLUSION

The results of this study demonstrate that in patients aged > or = 12 years who had allergic rhinitis, cetirizine use promoted somnolence and decreased motivation to perform activities during the workday compared with loratadine.

Doxepin incorporated into a dermatologic cream: an assessment of both doxepin antipruritic action and doxepin action as an inhibitor of papules, in allergen and histamine-caused pruritus

"Doxederm", a 5% doxepin hydrochloride ("doxepin") cream, has been used for assessments on patients' response to histamine and allergens by means of a prick test. Parameters selected papule diameters, and pruritus intensity. Doxederm was applied: (a) immediately before tests, (b) 10 minutes after tests, and (c) 72 hours before tests. All test reactions have been compared to similar tests that had been performed with a placebo cream. Tests yielded the following findings: (1) a remarkable remission of pruritus when doxederm was applied according to above mentioned (a), (b), and (c) schedules; (2) no inhibition of papule size --should either antigens or histamine be administered, could be observed when doxederm was applied immediately before tests or 10 minutes after tests had been performed (p > 0.10 vs placebo); (3) an evident remission of papules when doxederm had been applied 72 hours before tests were performed. No difference, however, could be detected with patientś forearms placebo cream had been applied whereon (difference among previously observed papules, and papules observed 72 after doxederm application: p > 0.005. Difference between doxederm and placebo: p > 0.10). Pursuant to the above mentioned observations, it can be suggested that doxederm evidences a highly siwft response on pruritus. Doxederm local effect, however, does not alter histaminic responses. Responses, however, are likely to be altered after a doxederm percutaneous absorption.

[Effects of levamisole in the treatment of a group of patients with atopic asthma and depression cellular immunity]

We investigated the possibility of decreased cellular immunity (C.I.) in a substantial group of atopic asthmatic patients with respiratory tract infections during autumn and winter. Two-hundred and ten atopic asthmatic patients were selected, and the following tests for cellular immunity were performed. Skin tests with 11 bacterial and fungal antigens. Normal average value of the skin reactions is 2.5 mm. E rosettes with sheep erythrocytes. Normal value for patients of this age is 60 +/- 8%. Immunoglobulins A, G and M and complement fractions C3 and C4 were determined by radial immunodiffusion. IgE was determined using PRIST (Phadebas, Pharmacia). IgE was elevated in all except two of the patients. IgG, IgA and IgM, C3 and C4 were normal. Twenty five of the 85 patients had some depression in cellular immunity (decreased E rosettes and/or decreased skin reactions). Patients with depressed cellular immunity were given 2.5 mg Levamisol three times a week for three months. Their progress was evaluated clinically and immunologically and a positive correlation was found between clinical improvement and increased C.I. in 18 of the 25 patients. We consider Levamisol to be useful in approximately 8.5% of all asthmatic patients.

Research on a new type of antiinsulin antibody in a diabetic female patient: the cytotoxic antibody. antiinsulin cytotoxic antibody

A study was carried out on a diabetic patient showing allergy to insulin, with urticaria and Quincke's edema, apparently owing to sensitization with IgE antibodies. By means of a hyposensitizing treatment her allergy improved due to the building up of IgG protecting antibodies, but at the same time she showed resistance to insulin, probably owing to IgG antibodies as well. This suggest that caution should be exerted before applying hyposensitization with insulin on diabetic patients allergic to the hormone. We were able to describe on the same patient a type II sensitization caused by a cytotoxic antibody against insulin. It was shown that this antibody agglutinates leukocytes which had been previously incubated with insulin and damage occurred when complement was present. Those effects could be especifically inhibited when the antigen (insulin) was added to the medium. The antibody belongs to the IgG group and it acts both in vivo and in vitro. In the case under study, the cytotoxic antibody disappeared as soon as treatment with insulin was discontinued for a year, and reappeared when renewed. It does not seem to occur very frequently, for it was not found in 20 consecutive diabetic patients under insulin treatment.

[Immunological studies on patients with mycosis fungoides]

Recently, much has been published on the immunological status of patients affected with various lymphomas. In the particular case of Mycosis fungoide, there was no general agreement on the immunological status of the corresponding patients. In fact, López Borrasca et al, found severe depression of cellular immunity in such patients. On the contrary, Blaylock and Clendenning found very little change in cellular immunity, but a very high serum-IgA. We want to offer our experience on this problem with the immunological survey of four patients with the Alibert-Bazin-form of Mycosis fungoide. The following tests were performed on each patient: a) Intracutaneous test with candidina, PPD and other bacterial antigens. b) Sensitization to a concentrate solution of dinitrochlorobencene (DNCB). c) Lymphocyte Transformation Test (LTT), with phytohemagglutinin as mitogen. d) Quantitative determination of IgG, IgM, IgA and beta1C, with the radial immunodiffusion technique (Mancini et al.). e) Agar immunoelectrophoresis. The following results were obtained: 1) The cellular immunity was markedly depressed in the four patients when any of a, b or c-test was performed. 2) All the patients showed very high levels of serum IgA, 150% higher than control. The reason for this is unknown. On the contrary, IgG in serum was less elevated and IgM and beta1C serum levels were normal. 3) No monoclonal bands were found in any case (immunoelectrophoresis). 4) No definite conclusions could be reached due to the limited number of cases, but the uniformity of results should encourage to carry this work further.