The association of chronic spontaneous urticaria (CSU) with anxiety and depression: a nationwide cohort study

Exploring the association between urticaria subtypes, anxiety, and depression and potential role of gut microbiota

AIMS

In observational studies, the causal relationship between urticaria and the risk of psychiatric disorders (anxiety and depression) remains inconclusive. Furthermore, there is growing evidence that gut microbiota (GM) contributes to the pathogenesis of urticaria. This study aimed to assess the causal relationships between the genetically predicted urticaria subtypes and psychiatric disorders and further examined the role of GM in influencing the risk of these urticaria subtypes.

METHODS

We conducted a meta-analysis of observational studies identified from four databases to evaluate the associations between urticaria, anxiety, and depression over the past decade. In addition, we estimated the genetic correlation and causality between genetically predicted urticaria subtypes and psychiatric disorders using linkage disequilibrium score regression and Mendelian Randomization (MR) analyses. Finally, univariable two-sample MR and multivariable MR analyses were employed to evaluate the combined and independent effects of GM from two datasets on urticaria subtypes associated with psychiatric disorders.

RESULTS

Thirteen observational studies comprising 7321 participants were included in the meta-analysis. There was a positive association between urticaria and anxiety risk (n = 13, OR: 3.96; 95%CI: 2.90-5.41) as well as depression risk (n = 12, OR: 3.03; 95%CI: 2.30-4.01). The MR results indicated that idiopathic urticaria increased the risk of anxiety (OR = 1.14; 95%CI = 1.01-1.28; P = 3.31 × 10-2), while allergic urticaria increased the risk of major depressive disorder (OR = 1.07; 95%CI = 1.02-1.13; P = 6.65 × 10-3). Our analysis identified nineteen gut bacterial taxa that were causally associated with idiopathic and allergic urticaria. Notably, Intestinibacter and Victivallales were strongly associated with an increased risk of allergic urticaria, even after accounting for the effect of smoking or alcohol consumption in the multivariable MR analysis. FamilyXIIIAD3011group and Bacteroides vulgatus were found to exert protective roles in idiopathic urticaria.

CONCLUSIONS

The study provides evidence for the association between urticaria subtypes and psychiatric disorders, complementing existing observational studies. In addition, our study implies the involvement of gut microbiota in idiopathic and allergic urticaria. However, the specific mechanisms of bacterial action remain to be clarified.

Inequalities in Access to Specialist Allergy Services in the United Kingdom: A Report From the BSACI Registry for Immunotherapy (BRIT)

BACKGROUND

There is an unmet need for specialist allergy treatment in the United Kingdom. Allergen immunotherapy and treatment with omalizumab for chronic spontaneous urticaria (CSU) are key markers for these services. The British Society for Allergy and Clinical Immunology (BSACI) Registry for Immunotherapy (BRIT) is a national project to record the real-world effectiveness, safety and access to treatment for aero-allergen, venom and peanut immunotherapy as well as omalizumab for CSU.

METHODS

We described participant demographics, the index of multiple deprivation (IMD) and access to treatment from the registry launch. Data for 1835 participants were available for analysis from 63 centres enrolled between 1st October 2018 and 24th August 2023.

RESULTS

96.5% (1771/1835) were living in England, with only 3.5% (64) being from the devolved nations. 14.4% (251/1748) were in the most affluent IMD decile compared to 4.5% (78/1748) in the most deprived IMD decile. White participants were 1.74 times more likely to be referred directly from primary care compared to people of Asian, black, mixed or other minority ethnic groups. Instead, these groups were referred more frequently from secondary or tertiary hospital services. The median distance travelled from home to the treatment centre was 15.2 miles, with evidence of clustering around specialist centres.

CONCLUSIONS

We have described disparities and unwarranted variation in the provision of treatment around the UK. The data suggest that there is limited access to immunotherapy in the devolved nations. Access is also reduced by socioeconomic deprivation. White participants were more likely to receive a direct referral from primary care than those from other ethnic groups whose referral pathways were more complex. Registry data are limited by participant enrolment and may have selection bias. Nevertheless, BRIT has highlighted inequity in access to specialist allergy services in the UK.

Beyond the itch: the complex interplay of immune, neurological, and psychological factors in chronic urticaria

Chronic urticaria (CU) arises from a multifaceted interplay of immunological, neurological, and psychological components. Immune dysregulation, mediated through both immunoglobulin E (IgE)-dependent and IgE-independent pathways, plays a pivotal role in CU pathogenesis, involving key effector cells such as mast cells (MCs), basophils, and eosinophils. This dysregulation culminates in the release of histamine, prostaglandins, and other mediators, which precipitate pruritus. The chronicity of the disease leads to sustained pruritic symptoms, contributing to both central and peripheral sensitization. The excitation of the itch circuit is augmented, leading to the release of neurotransmitters and neuropeptides, which subsequently interact with immune cells. Psychological factors such as depression, anxiety, and stress exacerbate CU symptoms and diminish quality of life. These factors disrupt the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS). Furthermore, the act of scratching activates the reward circuit, resulting in the manifestation of the itch-scratching cycle. Current treatments, such as antihistamines, omalizumab, and cyclosporine, demonstrate variable efficacy and are often associated with adverse effects. A holistic approach addressing both psychological and physiological aspects is advocated. This review highlights the critical importance of understanding neuroimmune interactions and the influence of psychosomatic factors in CU. It aims to enhance diagnostic and therapeutic strategies by integrating psychological, neurological, and immunological perspectives.

MRI-based neuroimaging alterations in immune-related skin diseases: a comprehensive review

The skin, as the largest organ in the human body, serves as the primary physical barrier and plays a crucial role in the immune defense process. Immune-related skin diseases encompass a spectrum of complex dermatological conditions characterized by aberrant immune responses, including the production of autoantibodies and dysregulation of inflammatory mediators. Growing evidence suggest a heightened prevalence of comorbid neuropsychiatric disorders among patients with immune-related skin diseases, indicative of potential shared pathogenesis. In recent years, the brain connectome, delineating the intricate network of neural connections, has gained prominence in elucidating various neurological and psychiatric conditions. Researchers have begun to investigate whether alterations in brain connectivity occur in patients with immune-related skin diseases, thereby exploring the connectome perspective in understanding the pathogenesis of these diseases. This review aims to synthesize and analyze recent neuroimaging studies about immune-related skin diseases, including systemic lupus erythematosus, psoriasis, chronic spontaneous urticaria, and atopic dermatitis. We mainly discussed the connectome studies related to these diseases and summarized the underlying mechanisms associated with their clinical manifestations, progression, and treatment. Then from our perspectives, we believe that interdisciplinary collaborations encompassing fields such as neurology, psychiatry, dermatology, and neuroimaging will be instrumental in advancing our understanding of immune-related skin diseases. Furthermore, multi-omics approaches will enable a comprehensive exploration of the molecular mechanisms underlying these neural changes, facilitating the identification of novel diagnostic biomarkers and therapeutic targets.

Chronic Spontaneous Urticaria: A Review

Importance

Chronic spontaneous urticaria affects approximately 1% of the general population worldwide, including approximately 3 million people in the US, impairs patients' quality of life, and is associated with multiple comorbidities.

Observations

Chronic spontaneous urticaria affects patients of any age but is most common in females aged 30 to 50 years. Diagnosis is based on clinical presentation, ie, spontaneously recurring wheals, angioedema, or both. Chronic spontaneous urticaria persists for more than 1 year in most patients (1 or repeated episodes) and may present with comorbidities including chronic inducible urticaria (>10%), autoimmune thyroiditis (approximately 20%), metabolic syndrome (6%-20%), and anxiety (10%-31%) and depression (7%-29%). Known autoimmune endotypes (subtypes of urticaria defined by distinct pathogenesis) of chronic spontaneous urticaria are mediated by mast cell-activating IgE and/or IgG autoantibodies (>50%). Approximately 40% of patients with chronic spontaneous urticaria have a Dermatology Life Quality Index of more than 10, corresponding to a very large or extremely large negative effect on quality of life. Second-generation H1 antihistamines are first-line treatment; partial or complete response, defined as a reduction in urticaria symptoms of greater than 50%, is observed in approximately 40% of patients. The 2022 international urticaria guideline recommends the monoclonal anti-IgE antibody omalizumab as second-line treatment for antihistamine-refractory chronic spontaneous urticaria. However, at least 30% of patients have an insufficient response to omalizumab, especially those with IgG-mediated autoimmune urticaria. Cyclosporine, used off-label, can improve symptoms in approximately 54% to 73% of patients, especially those with autoimmune chronic spontaneous urticaria and nonresponse to omalizumab, but has adverse effects such as kidney dysfunction and hypertension.

Conclusions and Relevance

Chronic spontaneous urticaria is an inflammatory skin disease associated with medical and psychiatric comorbidities and impaired quality of life. Second-generation H1 antihistamines are first-line treatment, omalizumab is second-line treatment, and cyclosporine is third-line treatment for chronic spontaneous urticaria.

Allergic Diseases and Mental Health

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

Non-Skin Related Symptoms Are Common in Chronic Spontaneous Urticaria and Linked to Active and Uncontrolled Disease: Results From the Chronic Urticaria Registry

BACKGROUND

Chronic spontaneous urticaria (CSU) can present with non-skin related symptoms (NSRS), including recurrent unexplained fever, joint, bone, or muscle pain (JBMP), and malaise, which also occur in other conditions that manifest with wheals (eg, urticarial vasculitis or autoinflammatory disorders) or without wheals (eg, infection).

OBJECTIVE

We sought to determine the rate of patients with CSU affected by fever, JBMP, and malaise, their trigger factors, links with clinical and laboratory characteristics, and their impact on everyday life and treatment responses.

METHODS

We analyzed baseline data from the Chronic Urticaria Registry of 2,521 patients with CSU who were aged 16 years or older.

RESULTS

One third of CSU patients (31.2%; 786 of 2,521) had one or more NSRS, including recurrent fever (5.3%), JBMP (19.1%), and/or malaise (18.6%). In a multivariable analysis, having one or more of these NSRS correlated with food and infection as trigger factors of urticaria (adjusted odds ratio [aOR] = 1.7 and 1.5), wheals of 24 hours or greater duration (aOR = 2.5), sleep disturbance (aOR = 2.4), anxiety (aOR = 2.8), comorbid atopic dermatitis (aOR = 2.1), gastrointestinal disease (aOR = 1.8), elevated leukocytes (aOR = 1.7) and erythrocyte sedimentation rate (aOR = 1.5). In a bivariate analysis, these NSRS were additionally associated with higher disease activity (weekly Urticaria Activity Score, median: 21 vs 14; P = .009), longer disease duration (years, median: 2 vs 1; P = .001), the presence of angioedema (74.6% vs 58.7%; P < .001), worse quality of life (Chronic Urticaria Quality of Life Questionnaire, median: 42 vs 29; P < .001) and more frequent poor control of CSU (78% vs 69%; P < .001).

CONCLUSIONS

The presence of NSRS in a subpopulation of patients with CSU points to the need for better control of the disease, exclusion of comorbid conditions, and/or exclusion of urticarial vasculitis and urticarial autoinflammatory diseases.

Comorbid Inducible Urticaria Is Linked to Non-Autoimmune Chronic Spontaneous Urticaria: CURE Insights

BACKGROUND

Patients with chronic spontaneous urticaria (CSU) can have comorbid inducible urticaria (CIndU). How comorbid CIndU affects patients and their CSU is largely unclear.

OBJECTIVE

To compare patients with CSU with and without comorbid CIndUs for differences in demographic features, clinical characteristics, and laboratory markers.

METHODS

We analyzed 708 patients with CSU of our Urticaria Center of Reference and Excellence enrolled in CURE, the chronic urticaria registry. CURE data collected until October 2022 were used to compare patients with and without comorbid CIndU for their demographic characteristics, disease onset, activity, impact, and control, as well as concomitant allergic and autoimmune diseases and laboratory parameters associated with autoimmune CSU.

RESULTS

Of 708 patients with CSU, 247 (35%) had comorbid CIndU. Compared with patients with standalone CSU, patients with CSU with comorbid CIndU were significantly younger, had earlier disease onset, longer disease duration, higher impact on quality of life, and a higher rate of concomitant allergic diseases. Moreover, patients with CSU with comorbid CIndU less often had features linked to autoimmune CSU such as angioedema, concomitant autoimmune diseases, eosinopenia, low levels of total IgE, and low total IgE combined with elevated anti-thyroid peroxidase IgG.

CONCLUSIONS

Autoimmune CSU may be less common in patients with comorbid CIndU than without, and comorbid CIndU may point to autoallergic CSU.

Role of stress in skin diseases: A neuroendocrine-immune interaction view

Psychological stress is a crucial factor in the development of many skin diseases, and the stigma caused by skin disorders may further increase the psychological burden, forming a vicious cycle of psychological stress leading to skin diseases. Therefore, understanding the relationship between stress and skin diseases is necessary. The skin, as the vital interface with the external environment, possesses its own complex immune system, and the neuroendocrine system plays a central role in the stress response of the body. Stress-induced alterations in the immune system can also disrupt the delicate balance of immune cells and inflammatory mediators in the skin, leading to immune dysregulation and increased susceptibility to various skin diseases. Stress can also affect the skin barrier function, impair wound healing, and promote the release of pro-inflammatory cytokines, thereby exacerbating existing skin diseases such as psoriasis, atopic dermatitis, acne, and urticaria. In the present review, we explored the intricate relationship between stress and skin diseases from a neuroendocrine-immune interaction perspective. We explored the occurrence and development of skin diseases in the context of stress, the stress models for skin diseases, the impact of stress on skin function and diseases, and relevant epidemiological studies and clinical trials. Understanding the relationship between stress and skin diseases from a neuroendocrine-immune interaction perspective provides a comprehensive framework for targeted interventions and new insights into the diagnosis and treatment of skin diseases.

Psychosocial factors and chronic spontaneous urticaria: a systematic review

BACKGROUND

Psychosocial factors have been informally associated with Chronic Spontaneous Urticaria (CSU); however, the relationship between psychosocial factors and CSU remains relatively unexplored in the scientific literature.

OBJECTIVE

This review aims to provide an evaluation of peer reviewed studies exploring psychosocial factors and CSU.

METHODS

A systematic search was performed over four databases identifying studies exploring psychosocial factors in relation to CSU published between the years 1995 and 2022.

RESULTS

Eighteen studies were included for narrative analysis, and 33 psychosocial factors were identified. These were split into two subgroups: psychosocial factors that were associated with CSU symptoms aggravation/onset (n = 20), and psychosocial factors expected to be impacted by CSU symptoms (n = 13).

CONCLUSION

This review has highlighted a need for more research and interventions to support individuals with psychosocial factors involved in CSU.

Acupuncture Decreases Risk of Hypertension in Patients with Chronic Spontaneous Urticaria in Taiwan: A Nationwide Study

Patients with chronic spontaneous urticaria (CSU) have a higher risk of developing hypertension. This study aimed to determine whether acupuncture could decrease the risk of hypertension in patients with CSU. We enrolled patients newly diagnosed with CSU between 1 January 2008, and 31 December 2018, from the Taiwanese National Health Insurance Research Database. The claims data were assessed from the index date to 31 December 2019. A Cox regression model was used to compare the hazard ratios (HRs) of the two cohorts. The cumulative incidence of hypertension was estimated using the Kaplan-Meier method. After propensity score matching with a 1:1 ratio, 43,547 patients with CSU who received acupuncture were matched with 43,547 patients with CSU who did not receive acupuncture in this study. After considering potential confounding factors, patients who received acupuncture had a significantly lower risk of hypertension than those in the control group (adjusted hazard ratio = 0.56, 95% confidence interval = 0.54-0.58). Patients who received medications combined with acupuncture tended to have the lowest risk of hypertension. This study revealed that acupuncture decreases the risk of hypertension in patients with CSU in Taiwan. The detailed mechanisms can be further clarified through prospective studies.

Neuro-Immuno-Psychological Aspects of Chronic Urticaria

Urticaria is a condition characterized by the development of itchy wheals (hives), angioedema, or both. The pathophysiology of chronic spontaneous urticaria (CSU) is still poorly understood. It is suggested that there is no dominant and independent mechanism of CSU; however, there are different immunological and non-immunological abnormalities that act simultaneously or/and follow each other resulting in clinical symptoms. The latest hypothesis points out that mast cells (MCs) to be activated via autoantibodies in autoallergic or autoimmune mechanism mediators released from degranulated MCs are responsible for the vasoactive and neurospecific effect in CSU. According to many clinical observations, it is suggested that psychological stress can be both a triggering factor in the onset of CSU and a modulating one in the course of the disease and therapy effectiveness. Of importance, the mechanistic background of the psychological stress response in the skin has not yet been fully elucidated. However, of note, a variety of inflammatory mediators, neuropeptides, and neurotransmitters facilitate this phenomenon. This review presents recent findings on the neuro-immuno-psychological aspects of CSU, highlighting an emerging role of neuro-immune interactions. It also points out the usefulness of psychological tools employment for the baseline diagnosis of perceived stress level and the presence of its symptoms. Furthermore, it proposes the implementation of non-invasive interventions to reduce psychological stress and anxiety. A bio-psycho-social approach including psychological support and patient education seems to be as important as traditional pharmacotherapy for CSU. It facilitates the effective control of active disease and a prolonged remission time in this disease.

The efficacy and safety of high-dose nonsedating antihistamines in chronic spontaneous urticaria: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Standard doses of second-generation H₁-antihistamines (sgAHs) as first-line treatment are not always effective in treating chronic spontaneous urticaria (CSU), and hence an increase in the dose of sgAHs is recommended. However, literature evaluating the efficacy and safety of this treatment remains inconclusive, highlighting the need for a systematic review and meta-analysis. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of high-dose sgAHs compared with standard-dose sgAHs in treating CSU.

METHODS

A systematic literature search of double-blind, randomized controlled trials (RCT) utilizing multiple doses of sgAHs was performed by searching the electronic databases Medline, Embase, PsycInfo, Cochrane databases, and Web of Science. Bibliographies were also manually searched. The Cochrane Risk of Bias Tool for assessing risk of bias was used to assess the quality of randomized controlled trials (RCTs). Two reviewers screened studies, extracted data, and evaluated the risk of bias independently. The response rate, the number of adverse events, somnolence, and withdrawal due to adverse events were extracted from each article. The data were combined and analyzed to quantify the safety and efficacy of the treatment. RevMan (V5.3) software was used for data synthesis.

RESULTS

A total of 13 studies were identified, seven of which met the eligibility criteria for the meta-analysis. Our pooled meta-analyses showed that high-dose sgAHs was associated with a significantly higher response rate than standard-dose (RR 1.13, 95% CI 1.02 to 1.26; P = 0.02). Conversely, high doses of sgAHs were associated with significantly higher somnolence rates than standard dose (RD 0.05, 95% CI 0.01 to 0.09; P = 0.02). There was no significant difference in adverse events or withdrawal due to adverse events between standard- and high-dose treatments.

CONCLUSIONS

Our analyses showed that a high dose of sgAHs (up to two times the standard dose) might be more effective than a standard dose in CSU treatment. High-dose and standard-dose sgAHs showed similar adverse events, except for somnolence, where incidence was found to be dose-dependent in some studies. However, given the limited number of studies, our meta-analysis results should be interpreted with caution.

Pediatric chronic urticaria: Clinical and laboratory characteristics and factors linked to remission

BACKGROUND

Chronic urticaria (CU) is defined as the occurrence of wheals/angioedema for ≥6 consecutive weeks. Until now, guidelines and publications addressing CU have focused mainly on adults. As a result, evidence and guidance in the pediatric population are scarce.

METHODS

This study aims to describe clinical and laboratory findings in pediatric CU and to determine factors associated with remission.

RESULTS

185 patients, 54% female, median age at onset of 8.8 years. Angioedema was present in almost half. The most common type of CU was chronic spontaneous urticaria (CSU) in 74%. At least one atopic comorbidity was found in almost a third (35%). In addition, 8% had an autoimmune disorder (exclusively in CSU) and 9% had a psychiatric condition. Basopenia was found in 67% and was more frequently associated with CSU. The basophil activation test (BAT) was positive in 40%. With regard to remission, being of male sex, angioedema absence, the absence of physical triggers, and eosinophil counts >0.51 × 109 /L were associated with shorter CU duration.

CONCLUSION

Atopy is a common condition in pediatric CU. CSU is the most common type. Autoimmune comorbidities and basopenia were significantly more common in CSU. In addition, ours is one of the few studies, assessing BAT utility in the pediatric population, being positive in a relevant percentage (40%). BAT positivity was more frequent in CSU. Our results suggest that the absence of angioedema and physical triggers, male sex, and eosinophil counts >0.51 × 109 /L appear to be associated with a better prognosis in terms of remission.

Chronic Spontaneous Urticaria in Patients With Interstitial Cystitis/Bladder Pain Syndrome: Insights From Big Data Analyses

OBJECTIVE

To examine the association between chronic spontaneous urticaria (CSU) and interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

A population-based retrospective cross-sectional study was performed using the Clalit Health Services medical database. The prevalence of CSU was compared between patients diagnosed with IC/BPS and age- and gender-matched controls. Univariate analysis was performed using Chi-square and Student t test and a multivariable analysis was performed using a logistic regression model.

RESULTS

The study included 681 patients with IC/BPS and 3376 demographically matched controls. The mean age of IC/BPS patients was 60 years old. The prevalence of CSU among patients with IC/BPS was higher as compared to the control group (20% vs 13.7%; P <.001). The adjusted OR for CSU in patients with IC/BPS was 1.58 (95% CI 1.28-1.97). Female gender and Jewish ethnicity were associated with the coexistence of these disorders (OR 1.7 95% CI 1.36-2.13, and 1.6 95% CI 1.28-2, respectively).

CONCLUSION

A significant association was found between IC/BPS and CSU. This finding may support the presence of allergic/immune components in the pathogenesis of IC/BPS.

Comorbidities of Chronic Urticaria: A glimpse into a complex relationship

Chronic Urticaria (CU) is a chronic inflammatory, predominantly mast cell-driven disease, characterized by the development of wheals and/or angioedema for more than 6 weeks. It affects approximately 1%-5% of the total population worldwide and imposes a substantial burden on health-related quality of life, significantly affecting patients' daily life. The economic impact on the health system is also not negligible, with an estimated cost per patient per year of approximately 2.000 $ in the United States. Although the underlying pathophysiology is not fully explored, autoimmune mechanisms have been proposed, including type I ("autoallergy" by means of autoantibodies to self-antigens) and type IIb (autoimmunity). Atopic, autoimmune, and psychiatric disorders are prevalent comorbidities in both children and adults with Chronic Spontaneous Urticaria (CSU). Although malignancies, cardiovascular diseases and other comorbidities have also been reported as associated diseases in patients with CSU, data remain scarce. It is still unknown whether the aforementioned comorbidities share common pathophysiological mechanisms with specific endotypes of CSU. The current review aims to overview current data on comorbidities of CU, and furthermore to comment on the potential linked pathways underlying these diseases.

Multicentric and Observational Study of Omalizumab for Chronic Spontaneous Urticaria in Real-Life in Colombia

Background

Although chronic urticaria (CU) is a common, cause of medical consulting both in general practitioners and allergist specialists worldwide, there is little information about its behavior and management in Latin America. Currently, national and international guidelines recommend using Omalizumab for cases refractory to management with antihistamines. Despite advances in the knowledge of Omalizumab for the management of CU, although there are few studies in underdeveloped countries, there are many studies evaluating the impact of Omalizumab treatment. There is not clinical information related with CSU-Omalizumab in patient settled in the Caribbean area. This research aims to evaluate the management of CU with Omalizumab in a real-life scenario in Colombia.

Methodology

We conducted an observational, descriptive, and retrospective study with patient recruitment between 2014 and 2017 of individuals diagnosed with Chronic Urticaria (CU) treating allergology specialists in five Colombian cities. We included patients with CU who failed to achieve disease control after treatment for 4 weeks with fourfold doses of second-generation H1-antihistamines, as recommended by the EAACI/GA²LEN/EDF/WAO guidelines and who received treatment with Omalizumab.

Results

We included 123 patients, 73.1% (n = 90) were women. The mean age was 47.1 years (Standard Deviation, SD: 16.2). The median of the total months of disease evolution was 30 (IQR = 13–58). 81.3 % (n = 100) of patients were diagnosed with chronic spontaneous urticarial (CSU). 4.8% (n = 6) had inducible CU (CIndU), and 13.8% (n = 17) reported mixed urticaria (spontaneous CU with at least one inducible component). Regarding emotional factors, 34.9% (n = 43) of subjects indicated anxiety symptoms, 34.1% (n = 42) had exacerbations associated with stress, and 14.6% (n = 18) manifested episodes of sadness. The percentage of patients with CSU controlled according to medical criteria at 3 months with Omalizumab were 80% (n = 80/100) and at 6 months 87% (n = 87/100). The frequency of adverse events was 29.2% (n = 36), with headache being the most frequent adverse event.

Conclusions

This real-life study with Omalizumab at CU describes percentages of effectiveness and safety similar to those observed in pivotal and real-life studies conducted in other regions around the world.

Alopecia Areata as a Proximal Risk Factor for the Development of Comorbid Depression: A Population-based Study

Alopecia areata and depression tend to co-occur; however, their temporal association has not been comprehensively investigated. The aim of this study was to examine the temporal association between alopecia areata and depression. The study included only cases with a comorbid presentation of alopecia areata and depression (n = 1,936), extracted from the databases of the Clalit Health Services, Israel. Survival analyses were used to assess the cumulative probability of receiving alopecia areata as comorbid diagnosis in the years following depression, and vice versa, compared with the opposite trajectory. The results indicate that patients with alopecia areata had greater odds of subsequent depression within 2 years from alopecia areata diagnosis, and showed a steeper increase in cumulative probability of depression as time progressed (log-rank =336.38, p < 0.001), compared with the opposite trajectory. All patients with alopecia areata had comorbid depression within 10 years of alopecia areata, compared with 70% of depression patients receiving diagnoses of comorbid alopecia areata within the same time-frame.

Omalizumab Reduces Unplanned Healthcare Interactions in Irish Patients With Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is a common, debilitating skin disorder associated with impaired quality of life and psychological comorbidity. Symptoms can be difficult to control and many individuals will not respond to first line treatment. Due to the chronic and unpredictable nature of the disorder, patients frequently have repeated healthcare attendances. Despite this, little is known about healthcare resource utilization internationally. Furthermore, there is no Irish data to inform fundholding decision makers. Omalizumab is an anti IgE monoclonal antibody used in refractory urticaria. It is a comparatively high cost medicine and access to this treatment can be challenging. Recent assessments of omalizumab compared with usual care suggest that omalizumab is a cost-effective treatment for refractory urticaria. We carried out a retrospective review of 47 patients commenced on omalizumab. We evaluated unplanned primary and secondary care attendances and urticaria symptomatology before and after treatment. As expected, patients with refractory disease that were commenced on omalizumab had objective improvements in urticaria symptoms. Importantly, we show that this is reflected in a dramatic reduction in unplanned healthcare interactions at primary care and emergency departments. These data suggest that omalizumab may benefit these patients by reducing disease activity and thereby reducing the need for unplanned healthcare interactions.

Abnormalities in Gut Microbiota and Metabolism in Patients With Chronic Spontaneous Urticaria

Background

Increasing evidence suggests that the gut microbiome plays a role in the pathogenesis of allergy and autoimmunity. The association between abnormalities in the gut microbiota and chronic spontaneous urticaria (CSU) remains largely undefined.

Methods

Fecal samples were obtained from 39 patients with CSU and 40 healthy controls (HCs). 16S ribosomal RNA (rRNA) gene sequencing (39 patients with CSU and 40 HCs) and untargeted metabolomics (12 patients with CSU and 12 HCs) were performed to analyze the compositional and metabolic alterations of the gut microbiome in CSU patients and HCs.

Results

The 16S rRNA gene sequencing results showed a significant difference in the β-diversity of the gut microbiota, presented as the Jaccard distance, between CSU patients and HCs. No significant differences were found in the α-diversity of the gut microbiota between patients and HCs. At the phylum level, the major bacteria in the gut microbiome of patients with CSU were Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria. At the genus level, Lactobacillus, Turicibacter, and Lachnobacterium were significantly increased and Phascolarctobacterium was decreased in patients with CSU. PICRUSt and correlation analysis indicated that Lactobacillus, Turicibacter, and Phascolarctobacterium were positively related to G protein-coupled receptors. Metabolomic analysis showed that α-mangostin and glycyrrhizic acid were upregulated and that 3-indolepropionic acid, xanthine, and isobutyric acid were downregulated in patients with CSU. Correlation analysis between the intestinal microbiota and metabolites suggested that there was a positive correlation between Lachnobacterium and α-mangostin.

Conclusions

This study suggests that disturbances in the gut microbiome composition and metabolites and their crosstalk or interaction may participate in the pathogenesis of CSU.

Effect of the Mediterranean diet in patients with chronic spontaneous urticaria

OBJECTIVE

Patients with chronic spontaneous urticaria often want to be informed about dietary modifications. There have been many studies evaluating dietary approaches in chronic spontaneous urticaria. In this study, we aimed to investigate the relationship between adherence to the Mediterranean diet and chronic spontaneous urticaria.

METHODS

In this cross-sectional case-control observational study, 100 patients (70 males and 30 females, mean age: 38.6±13.0 years) with chronic spontaneous urticaria and age- and sex-matched 100 healthy controls 70 males and 30 females, mean age: 38.7±13.8 years) were enrolled. A validated 14-item questionnaire evaluating the Mediterranean diet score was used for the assessment of adherence to the Mediterranean diet. The severity and the control of chronic spontaneous urticaria were assessed by Urticaria Activity Score over 7 days and Urticaria Control Test, respectively.

RESULTS

The mean Mediterranean diet score in the patient group was 5.40±1.88, whereas in healthy controls it was 6.30±1.39 (p<0.001). The Urticaria Activity Score over 7 days score of the patients was negatively correlated with the Mediterranean diet score, whereas the Urticaria Control Test score was positively correlated.

CONCLUSION

We reported that adherence to the Mediterranean diet may be an independent factor that decreases the risk of chronic spontaneous urticaria. It may also reduce the severity of chronic spontaneous urticaria symptoms.

The challenges of chronic urticaria part 1: Epidemiology, immunopathogenesis, comorbidities, quality of life, and management

This is Part 1 of an updated follow-up review of a World Allergy Organization (WAO) position paper published in 2012 on the diagnosis and treatment of urticaria and angioedema. Since 2012, there have been advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics, such as omalizumab, in patients with severe refractory disease. For these reasons, the WAO decided to initiate an update targeted to general practitioners around the world, incorporating the most recent information on epidemiology, immunopathogenesis, comorbidities, quality of life, clinical case presentations, and the management of chronic spontaneous and chronic inducible urticaria, including urticaria in special situations such as childhood and pregnancy. A special task force of WAO experts was invited to write the different sections of the manuscript, and the final document was approved by the WAO Board of Directors. This paper is not intended to be a substitute for current national and international guidelines on the management of urticaria and angioedema but to provide an updated, simplified guidance for physicians around the world who manage patients with this common ailment.