Management of urticaria: a consensus report

This consensus report is the result of a panel discussion during the International Clinically Oriented ESDR Symposium Urticaria 2000. Urticaria has a profound impact on the quality of life and effective treatment is required. The most important are nonsedating H1 antihistamines. They have been proven to be effective in double-blind controlled studies, but concentrations higher than those recommended may be necessary. Due to different urticaria subtypes and the individual variation in the course of the disease and response to treatment, however, alternative therapies may be required. Immunosuppressive drugs like cyclosporine A and corticosteroids should not be used long term due to undesirable side-effects.

Medical surveillance of allergy in laboratory animal handlers

Allergic disease is a serious occupational health concern for individuals who have contact with laboratory animals. The principal respiratory symptoms include allergic rhinitis, conjunctivitis, and asthma. Urticaria (" hives") is the most common skin manifestation. The overall prevalence of allergic disease among laboratory animal handlers is about 23%, and respiratory allergy is much more common than skin allergy. Various studies have found annual incidence rates ranging from 2% to 12%. Prevention of animal allergy depends on control of allergenic material in the work environment. Personal protective equipment such as air filtering respirators should be used in addition to the other exposure control technologies where conditions require. Pre-placement evaluation and periodic medical surveillance of workers are important pieces of the overall occupational health program. The emphasis of these medical evaluations should be on counseling and early disease detection. The article gives recommendations for the content of the medical evaluations.

Prevention of acute urticaria in young children with atopic dermatitis

BACKGROUND

There are no published prospective, randomized, double-blind, placebo-controlled studies of urticaria prevention in children.

OBJECTIVE

Our objective was to study the effect of long-term treatment with the H(1)-receptor antagonist cetirizine in the prevention of urticaria in young children with atopic dermatitis.

METHODS

In the prospective, double-blind, parallel-group Early Treatment of the Atopic Child study, 817 children with atopic dermatitis who were 12 to 24 months of age at study entry were randomized to receive either cetirizine, 0.25 mg/kg, or matching placebo twice daily for 18 months and to be followed up for an additional 6 months, during which time the study medication code remained unbroken. During both these double-blind phases of the study, for a total of 24 months, caregivers prospectively recorded all symptoms and events, including hives, in a diary on a weekly basis when the child was well and on a daily basis when a symptom or event was observed. The diaries were reviewed and validated with the investigators at each regularly scheduled study visit.

RESULTS

Acute urticaria occurred in 16.2% of the placebo-treated children and in 5.8% of the children treated with cetirizine (P <.001). The protective effect of cetirizine disappeared when treatment was stopped. In the study population as a whole, urticaria episodes were most commonly associated with intercurrent infection or with food ingestion or direct skin contact.

CONCLUSION

Acute urticaria is common in toddlers with atopic dermatitis and can be prevented with cetirizine in this high-risk population.

The role of psychological stress in skin disease

BACKGROUND

Numerous case reports and studies have suggested that psychological stress may have a role in the onset or exacerbation of a variety of skin diseases.

OBJECTIVE

We review the literature pertaining to the role of psychological stress in the exacerbation of psoriasis, urticaria, eczematous dermatitis, herpesvirus infections, and other skin diseases; discuss potential mechanisms of stress-induced skin disease; and review studies and case reports of psychotherapeutic interventions that have been found helpful in the therapy of skin diseases.

CONCLUSIONS

There is evidence linking psychological stress to exacerbation of certain skin diseases. Both the clinical and the basic science evidence, however, can be hard to interpret in light of the difficulty of defining and quantifying psychological stress as well as the questions regarding the etiologic significance of neuroimmunologic findings in skin diseases.

Wearing test with 2 different types of latex gloves with and without the use of a skin protection cream

72 subjects reporting symptoms indicating Type I hypersensitivity reactions to natural rubber latex (NRL) gloves were included in this study. 44 of them had a positive prick test to NRL. They underwent wearing tests using 2 types of NRL gloves with high (n=63) and low (n=70) allergen contents. Unigloves Malaysia with a high allergen content caused positive skin reactions in 47% of SPT-positive and no IgE-negative subjects. After application of Hand Sense skin protection cream, the frequency of positive skin responses in wearing tests decreased to 30% in prick-test-positive subjects. The Biogel Diagnostic gloves with low allergen caused hypersensitivity with and without Hand Sense in 2 cases (5%) of the prick-test-positive. 60% of all test participants had a positive prick test to NRL. No prick-test-negative subjects showed any urticaria during the glove-wearing test. Our study demonstrates that high allergen contents in latex gloves frequently elicit skin responses in NRL-sensitized subjects. Since other skin protection creams have shown to increase allergic symptoms, it is encouraging to report that Hand Sense skin cream may hamper the uptake of allergens from gloves, thus decreasing allergic reactions.

Pharmacokinetic and pharmacodynamic modeling of mizolastine in healthy volunteers with an indirect response model

OBJECTIVE

The aim of this work was to model the pharmacokinetic and pharmacodynamic relationship of mizolastine, a new H1-receptor antagonist obtained from histamine-induced wheal and flare inhibition test.

METHODS

Fifteen healthy volunteers participated in this double-blind crossover study and randomly received single doses of 5, 10, 15, and 20 mg of mizolastine and placebo at 1 week intervals. Simultaneous histamine tests and blood samples were performed before and at 9 different times up to 24 hours after each dosing. Pharmacokinetic and pharmacodynamic modeling were performed subject by subject for the 4 doses altogether by nonlinear regression. First, plasma concentrations were fit according to a two-compartment open model with zero order absorption and first order elimination. Then an indirect response model with inhibition of the formation rate was developed to describe the pharmacodynamic relationships between flare or wheal raw areas and plasma concentrations with the use of the pharmacokinetic parameters that were previously estimated.

RESULTS

Mizolastine dose dependently inhibited the histamine-induced wheal and flare formation with a submaximum effect attained after 10 mg. The mean values of the pharmacodynamic parameters of apparent zero-order rate constant for the flare or wheal spontaneous appearance (k(in)), the first-order rate constant for the flare or wheal disappearance, the mizolastine concentration that produced 50% suppression of the maximum attainable inhibition of k(in), and the maximum attainable inhibition of the effect production were 14.1 cm2/h (coefficient of variation [CV], 32%), 0.68 h(-1) (CV, 24%), 21.1 ng/mL (CV, 77%), and 0.92 (CV, 8%), respectively, for the flare and 1.9 cm2/h (CV, 64%), 0.63 h-1 (CV, 39%), 43.9 ng/mL (CV, 68%), and 0.87 (CV, 12%), respectively, for the wheal inhibition.

CONCLUSION

Pharmacokinetic and pharmacodynamic relationships of mizolastine were reliably described with the use of an indirect pharmacodynamic model; this led to an accurate prediction of the pharmacodynamic activity of mizolastine.

Leukotriene receptor antagonists may prevent NSAID-induced exacerbations in patients with chronic urticaria

BACKGROUND

About 30% of patients with chronic urticaria experience flares of hives and/or angioedema after ingesting either aspirin or nonsteroidal anti-inflammatory drugs. In such patients, cross-reactivity to all NSAIDs seems to occur suggesting a mechanism dependent on cyclooxygenase inhibition.

OBJECTIVE

To evaluate the preventive effect of leukotriene receptor antagonists on urticaria exacerbations induced by NSAIDs in a patient with chronic urticaria.

METHODS

A 59-year-old woman with a 2-year history of recurrent urticaria exacerbated by different NSAIDs including aspirin 500 mg (2 episodes), piroxicam 20 mg, and nimesulide 100 mg (1 episode each) was studied. Acetaminophen 375 mg and floctafenine 50 mg induced a marked flare of urticaria/angioedema in a single-blind, placebo-controlled challenge.

RESULTS

The patient was totally urticaria free during a 3-week course of montelukast 10 mg once a day. After montelukast withdrawal, a gradual relapse of urticaria/angioedema occurred along with a further acute urticaria/angioedema episode after a single piroxicam, 20-mg tablet. Zafirlukast 20 mg twice daily was started. After some days the patient was urticaria-free again, and after 3 weeks she tolerated a 6-day course of injective piroxicam (20 mg once a day) without any problem. To date the patient is still urticaria-free.

CONCLUSION

Leukotriene receptor antagonists may prevent the severe urticaria/angioedema exacerbations which follow the use of NSAIDs in some patients with chronic urticaria.

Adverse skin reactions to low molecular weight heparins: frequency, management and prevention

Adverse skin reactions to low molecular weight heparins (LMWH) are rare even though their true incidence is probably underestimated because of under-reporting. These reactions may occur as an urticarial rash, presumably due to local histamine release or have the features of a classic type I immediate hypersensitivity reaction. They can also present as skin necrosis often due to vasculitis (type III Arthus reaction) or heparin-induced thrombocytopenia. Erythematous, well circumscribed lesions without necrosis are usually secondary to a delayed type IV hypersensitivity reaction. Although most LMWH-induced skin lesions are benign, treatment should be discontinued. In type I reactions or in the presence of skin necrosis with or without heparin-induced thrombocytopenia, the LMWH should be replaced by an alternative medication such as danaparoid sodium or hirudin. Platelet counts should be monitored to diagnose heparin-induced thrombocytopenia. In a type IV delayed hypersensitivity reaction, in the absence of severe, extensive, life-threatening mucocutaneous manifestations, a first-line pragmatic approach consists, in our view, of replacing the particular LMWH with another one. If the skin symptoms do not improve, cutaneous tests may help detect the presence of a cross-reactivity between the available preparations of LMWHs and danaparoid sodium. In the presence of a negative subcutaneous provocation test, the compound can be used with little risk. If all types of LMWH and danaparoid sodium are positive in skin testing, mechanical prevention or oral anticoagulants should be used, and intravenous injections of any kind of heparin should be avoided because of the potential risk of anaphylactic shock. Alternatively, hirudin might be administered but experience with this compound is still very limited. Prevention is only possible in type IV hypersensitivity skin reactions, by avoiding long term LMWH therapy, particularly in middle-aged, obese women and during pregnancy. In these patients, oral anticoagulation should be preferred, whenever possible. In conclusion, though rare, skin reactions to LMWH may have important consequences which can be reduced by rapid diagnosis and appropriate management.

A novel wheat gliadin as a cause of exercise-induced anaphylaxis

BACKGROUND

Food-dependent, exercise-induced anaphylaxis is a severe form of allergy; the reaction is caused by ingestion of a specific food before exercise. This disorder often escapes diagnosis because neither the ingested food nor the exercise alone induces the symptoms.

OBJECTIVE

The aim of the study was to characterize the allergens involved in wheat-dependent, exercise-induced anaphylaxis and to describe the clinical outcome in a series of 18 adult patients.

METHODS

All 18 patients had experienced recurrent episodes of generalized urticaria during exercise, 17 patients in association with collapse and 15 patients with an anaphylactic reaction. The symptoms appeared only when the patients had eaten food containing wheat before exercise. Wheat allergens were detected by immunoblotting, purified by gel filtration and reversed-phase chromatography, and subjected to N-terminal sequencing. The IgE-binding ability of the purified proteins was studied by ELISA, and their in vivo reactivity was studied by skin prick testing.

RESULTS

IgE antibodies from pooled patient sera were bound to 65-kd and 40-kd wheat proteins in immunoblotting. The 65-kd allergen was a previously undescribed wheat protein, showing 61% sequence identity to gamma-gliadin, whereas the 40-kd allergen had 100% identity to alpha-gliadin. In ELISA, all 18 patients showed elevated IgE levels to the novel gamma-like gliadin, and 13 of the patients showed elevated IgE levels to the alpha-gliadin. None of the 54 control subjects with wheat allergy, urticaria, or coeliac disease had IgE antibodies to the gamma-like gliadin. The in vivo reactivity of the gamma-like gliadin was verified by positive skin prick test responses in all of the 15 patients who were tested. During the follow-up on a gluten-free or wheat-free diet, 3 patients experienced reactions after having unknowingly eaten wheat before exercise, but all the other patients who were adhering to the diet remained symptom-free.

CONCLUSION

This study shows that wheat is a frequent cause of food-dependent, exercise-induced anaphylaxis and suggests that the major allergen is a previously undescribed gamma-like gliadin. For screening of this life-threatening allergy, we recommend skin prick testing with crude gliadin and we recommend a gluten-free diet for treatment.

Repeated hand urticaria due to contact with fishfood

BACKGROUND

The etiology of urticaria is often difficult to determine. However, in case of repeated circumstance-connected urticaria, the reason may be easily clarifyable.

CASE

A 51-year-old healthy woman repeatedly experienced occupational hand urticaria when handling fish food. An unexpected reason for the urticaria was found in that the fishfood contained histamine as a "contaminant".

CONCLUSIONS

In fishfood batches, biological degradation can produce histamine and possibly other toxic substances that can lead to occupational health problems.

[Airborne dermatoses]

Airborne dermatoses are due to various gas and particles in suspension in air. They have irritative, toxic or allergic origins. They may be associated with ocular and respiratory complaints. Such diseases are likely underestimated in both their prevalence and practical considerations dealing with their prevention.

Solar urticaria. A report of 25 cases and difficulties in phototesting

BACKGROUND

Solar urticaria is a rare photosensitive disease, and its differential diagnosis with respect to polymorphous light eruption is sometimes difficult. We report our experience with 25 cases of solar urticaria and discuss the pitfalls in phototesting such patients.

OBSERVATION

The most important locations in this patient series are the V of the neck and the arms, which are similar to those of polymorphous light eruption. In all of the patients, however, the lesions appeared within 30 minutes of sun exposure or phototesting and disappeared within 24 hours. Notably, 12 (48%) of the patients had a history of atopy. Phototesting helps confirm the diagnosis, but, in some patients, this was difficult.

CONCLUSIONS

A negative phototest result from a single light source does not necessarily exclude a diagnosis of solar urticaria. In patients in whom phototesting elicits negative reactions, other light sources should be used, and, if the phototest result is still negative, a provocative test with natural sunlight should be done. Histamine1-receptor antihistamines are a useful first-line therapy, although more severely affected persons may require prophylactic courses of phototherapy or photochemotherapy. The main problem is maintenance treatment.

The effects of topical doxepin on responses to histamine, substance P and prostaglandin E2 in human skin

The tricyclic antidepressant, doxepin, is known to have H1 and H2 antihistaminic effects. Recently, 5% doxepin cream has been marketed in the U.S.A. for treatment of eczematous dermatoses. We investigated the effects of topical doxepin treatment on histamine-, substance P- and prostaglandin E2- (PGE2) induced responses in the skin of normal and atopic subjects. We compared the effects of topical doxepin with those of the oral antihistamine terfenadine. The weal volume and flare area responses to histamine were significantly reduced by treatment with topical doxepin or oral terfenadine in both normal and atopic subjects (P < 0.05). The mean +/- SEM percentage reduction in flare area for 10 micrograms/site of histamine in non-atopics and atopics was 48 +/- 8% and 60 +/- 17% with terfenadine, and 54 +/- 12% and 81 +/- 4% with topical doxepin, respectively. The mean percentage reduction in weal volume for the same dose of histamine in non-atopics and atopics was 70 +/- 9% and 63 +/- 16% with terfenadine, and 96 +/- 2% and 89 +/- 6% with topical doxepin, respectively. The flare but not the weal response to substance P was inhibited by both treatments in all subjects (P < 0.05). The mean +/- SEM percentage reduction in flare area for 200 pmol/site of substance P in non-atopics and atopics was 53 +/- 10% and 73 +/- 4% with terfenadine, and 74 +/- 7% and 75 +/- 4% with topical doxepin, respectively. The cutaneous responses to PGE2 were not affected by either drug. The inhibitory effects of doxepin were as great as those of terfenadine, and doxepin had a significantly greater effect than terfenadine in inhibiting the weal response to histamine and flare response to substance P in normal volunteers (P < 0.05). There was no significant difference between atopics and non-atopics in the percentage reduction of cutaneous responses by oral terfenadine or topical doxepin. Marked sedation occurred in three of the first 10 subjects treated with topical doxepin, necessitating a reduction in dosage for the remaining six subjects. In summary, topical doxepin was as effective as, and sometimes more effective than, a standard dose of oral terfenadine in the inhibition of histamine-induced and axon-reflex-mediated cutaneous responses. The marked sedative effect may limit its clinical use in some patients.

Prolonged benefit following ultraviolet A phototherapy for solar urticaria

Two patients with severe idiopathic solar urticaria, previously resistant to a variety of therapies including plasma exchange, benefited from springtime courses of ultraviolet A (UVA) monotherapy. Sites which are normally exposed to sunlight were treated, in a cabinet fitted with Philips R-UVA lamps (emitting UVA and visible wavelengths, with peak at 350 nm), twice daily for 2-3 weeks. One patient has been treated in this way for 3, and the other for 2, consecutive years. Repeat monochromator phototesting 3 months after their latest courses of UVA showed a persistent reduction in severity of abnormal photosensitivity. Both patients describe a sustained improvement in their condition lasting over 6 months after treatment.

Asthma and allergy in pregnancy

Rhinitis is extremely common during pregnancy, and asthma is one of the most common potentially serious medical problems to complicate pregnancy. Cutaneous allergy (urticaria/angioedema and eczema) also may occur during pregnancy. All of these entities may worsen with pregnancy in some patients and appear to improve in others. Uncontrolled asthma may directly threaten the fetus, and morbidity from the other illnesses may indirectly affect pregnancy through an effect on eating, sleeping, or emotional well-being. Appropriate diagnosis, avoiding triggering factors when possible; appropriate use of pharmacotherapy; and, when indicated, allergen immunotherapy usually allow these chronic conditions to be controlled during pregnancy so as to optimize both the health of the mother and that of her baby.

Azelastine: its clinical application for radiation dermatitis

A retrospective analysis was performed to investigate the radioprotective effects of azelastine against radiation dermatitis for patients with head and neck cancers. The effects of azelastine were studied in 19 patients with laryngeal cancers treated by irradiation. As controls, 29 patients with laryngeal cancers treated by irradiation without the administration of azelastine were studied. All patients were irradiated using 3 MV linac X-rays. Azelastine was administered orally twice a day. Moist desquamation was observed in four of 29 control patients whereas no such moist desquamation developed after the administration of azelastine. Two cases of moist desquamation that developed before the administration of azelastine regressed during irradiation in patients placed on azelastine. Radiotherapy was completed without interruption in all patients treated with azelastine. No severe side effects were observed. Azelastine, administered orally, was a safe drug and has the potential of improving skin tolerance in irradiation therapy.

Tachyphylaxis to histamine-induced wheal suppression by topical 0.05% clobetasol propionate in normal versus croton oil-induced dermatitic skin

BACKGROUND

Patients often tell about reduced effectiveness of topical steroids on repeated use. Tachyphylaxis to these agents has been demonstrated in humans for vasoconstriction and histamine-induced wheal suppression in normal skin, but not in diseased skin. Relevance of these data to diseased skin is not clear. Further, the clinical impression does not appear to match tachyphylaxis shown in normal skin with regard to the time course.

OBJECTIVES

To examine whether tachyphylaxis to histamine-induced wheal suppression by a topical steroid occurs in dermatitic skin and to determine its time course vis-à-vis normal skin.

METHODS

Pharmacodynamic response to 0.05% clobetasol propionate applied daily under occlusion was measured by histamine-induced wheal suppression assay in 10 individuals. This test was performed on a steroid-treated normal site, on a steroid-treated site where dermatitis was induced by occlusive application of 40% croton oil, and on a vehicle-treated site in each individual at different intervals up to 14 days.

RESULTS

Suppression of wheal volume started from second day in steroid-treated sites. There was significant difference in the wheal volume in steroid treated normal vs. dermatitic sites from day 2 to day 10. Maximum wheal suppression occurred earlier in dermatitic skin (day 4 vs. day 6). After this, the volume of wheal started increasing and became equal to control (complete tolerance) on 12th day in dermatitic skin and on 14th day in normal skin.

CONCLUSIONS

Time courses of tachyphylaxis to the action of 0.05% clobetasol propionate were significantly different in normal skin and dermatitic skin. Complete tolerance occurred earlier in dermatitic skin compared to normal skin.

[Delayed-type pressure urticaria]

Delayed pressure urticaria (DPU) is a rare disease of unclear pathophysiology and difficult to treat. Its typical manifestations are reddish, not itching swellings on parts of the body previously exposed to pressure and mostly only appearing 3 to 6 hours later. About 50% of the patients have general symptoms like fever, nausea and arthralgies. We report the case of a 36-year-old man who has suffered from DPU for 7 years. The incidence, symptoms and therapy of DPU are summarized and discussed in a short review of the existing literature.

Narrow-band UVB (TL-01) phototherapy: an effective preventative treatment for the photodermatoses

Twenty patients with photodermatoses [actinic prurigo (n = 6), hydroa vacciniforme (n = 4), idiopathic solar urticaria (n = 1), amiodarone-induced photosensitivity (n = 1) and a range of cutaneous porphyrias (n = 8)] were treated with a 'hardening' course of narrow-band ultraviolet B (TL-01) phototherapy in springtime. The response to phototherapy was monitored subjectively, by interviewing patients after the summer, and objectively by monochromator phototesting, before and after phototherapy. Fifteen patients reported that treatment was worthwhile. Monochromator phototesting after phototherapy revealed a fourfold increase in the minimal erythema dose in those with abnormal photosensitivity to ultraviolet A wavebands. Adverse effects included erythema (seven patients), pruritus (five) and provocation of the eruption (four). We now routinely consider narrow-band UVB phototherapy for problem photodermatoses.

The effects of topical corticosteroids on delayed pressure urticaria

Six patients with delayed pressure urticaria (DPU) applied clobetasol propionate (0.05%) ointment or its base to predetermined test sites on the right and left thigh as part of a randomized, double-blind study. A pressure challenge was administered to each test site at the initial visit and repeated after 3 days and 6 weeks of treatment and at between 4 and 8 weeks after treatment. The areas of pressure-induced weals were measured 6 h after each challenge. At the 6-week visit, a 4-mm punch biopsy was taken from pressure-challenged skin on each test site. Sections were stained for mast cells and immunohistochemical labelling was used to demonstrate neutrophils (neutrophil elastase), eosinophils (eosinophil cationic protein), monocytes/macrophages (EBM 11), cells expressing the beta-2 integrins (CD11/18) and the vascular adhesion molecules, E selectin and intercellular adhesion molecule-1 (ICAM-1). In the steroid-treated sites, there was a significant decrease (P < 0.05, Wilcoxon's matched-pairs test) in the size of the pressure weals compared with baseline at 3 days, 6 weeks and at follow-up. Demonstrable mast cells were significantly decreased (P = 0.059) in the pressure-challenged areas in the steroid-treated sites compared with the base-treated sites. The histological response to pressure was minimal in both sites perhaps demonstrating an active pharmacological effect of the ointment base. In conclusion, the application of potent topical steroids significantly reduced the clinical response to pressure in patients with DPU, possibly through a reduction in mast cells.

A case of urticarial vasculitis associated with macroglobulinemia (Schnitzler's syndrome)

We report a case of urticarial vasculitis associated with macroglobulinemia in a 50-year-old woman. She suffered from intermittent fever with wheals persisting for more than 24 hours. Skin histology revealed perivascular neutrophilic infiltrates with nuclear dusts. Laboratory study demonstrated leucocytosis and a high serum IgM level (2350 mg/dl) with an M component. No overt lymphoid proliferative disease was found. As far as we know, this is the first report of such a case in Japan. Predonizolone and nonsteroidal anti-inflammatory drugs have proved transiently effective for controlling the urticaria, but not for the IgM gammopathy.