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

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.

The Role of Coagulation/Fibrinolysis Biomarkers in Pathophysiology, Disease Severity, and Treatment Response in Patients with Urticaria: A Scoping Review

The pathology of urticaria is complex. Recently, researchers have widely focused on the role that the coagulation/fibrinolysis system plays in the pathology of urticaria. The potential of coagulation/fibrinolysis biomarkers as disease severity or treatment response biomarkers remains uncertain, lacking comprehensive analysis in previous studies. Hence, we performed a scoping review to thoroughly analyze coagulation/fibrinolysis biomarkers that may predict disease progression and treatment response of urticaria. Data from 71 studies showed that chronic spontaneous urticaria (CSU) was the most-studied subtype (39 articles), with D-dimers being the most researched marker (56 articles). Twenty-one biomarkers were investigated, and ten biomarkers were significantly correlated with disease severity. Specifically, D-dimers (26 articles) and prothrombin fragment 1 + 2 (F1+2) (12 articles) plasma levels increased with exacerbation and decreased with remission. Biomarkers such as D-dimer also correlated significantly with inflammatory cytokines and complement, suggesting interactions among coagulation, immunity, and inflammation in the pathology of urticaria. While these biomarkers may predict treatment response, more evidence is needed. Additionally, anticoagulants such as warfarin, heparin sodium and tranexamic acid have been proved effective for urticaria. This review emphasizes that some coagulation/fibrinolysis biomarkers (such as D-dimer and F1+2) may be not only indicators of disease status but also potential predictors of treatment response. It aims to assist researchers and practitioners in gaining a better understanding of the close relationships among coagulation/fibrinolysis biomarkers, the condition of urticaria (especially chronic urticaria, CU), and its prognosis. It also provides new directions for future research on exploring treatment methods via the coagulation/fibrinolysis pathways.

Factors associated with the efficacy of omalizumab treatment in chronic spontaneous urticaria

BACKGROUND

Omalizumab is a preferred treatment in antihistamine-refractory chronic spontaneous urticaria (CSU) patients. However, factors that may impact treatment response remain to be explored.

OBJECTIVE

This study aimed to examine the factors affecting treatment response in CSU patients receiving omalizumab.

METHODS

This was a retrospective study that included 123 patients who received omalizumab treatment for CSU between January 2015 and April 2024. After administering omalizumab, we evaluated therapeutic efficacy with the urticaria control test (UCT). According to UCT, patients were classified as complete responders, partial responders, and nonresponders.

RESULTS

The median age of the patients was 42 (31-50) years, and there were 77 (62.9%) female patients. Sixty-four (52%) patients exhibited complete response, and 43 (35%) patients exhibited partial response to omalizumab treatment, whereas 16 (13%) patients were nonresponders. Autoimmune disease (AID) was present in 31 (25.2%) patients. The most common AID was thyroid autoimmunity, seen in 24 (77.4%) patients. AID was significantly higher in omalizumab treatment nonresponders than in partial and complete responders. The presence of an autoimmune thyroid disease was an independent risk factor for failure to respond to omalizumab treatment. Baseline IgE levels were significantly higher in omalizumab treatment responders with a complete response compared to those with a partial response and nonresponders.

CONCLUSION

Response to omalizumab treatment was influenced by the presence of an AID and baseline serum total IgE level. A concurrent autoimmune thyroid disease was found to be an independent risk factor affecting failed treatment response. Factors that can predict response to omalizumab treatment can help guide patients to more effective treatment.

Distinct IgE sensitization profiles in chronic urticaria: a comparative study with classic allergic diseases

Introduction

Chronic urticaria (CU) is not traditionally classified as an allergic disease, but emerging evidence suggests a link to atopy. The quintessential marker of atopy is IgE sensitization, there is scarce information on the IgE sensitization characteristics of CU.

Methods

To investigate IgE sensitization characteristics in CU, and compare them with classic allergic diseases. We retrospectively analyzed the results of specific IgE (sIgE) and total IgE (tIgE) in CU patients, explored the distribution patterns of these atopic markers in CU, and compared these data with those of atopic dermatitis (AD), allergic rhinitis (AR), asthma (AS), and healthy controls (HC).

Results

1149 patients (396 CU, 411 AD, 101 AR, 139 AS and 102 HC) were included in the study. 33.1% of CU patients showed positive sIgE and 49.0 % had elevated tIgE levels, significantly higher than those in HC. Comparative analysis with classic allergic diseases showed CU patients had a lower sIgE positivity rate but no significant difference in tIgE levels. Gender and age influenced sensitization profiles, with male CU patients showing a higher sIgE positivity rate. The distribution of sIgE levels, allergen categories, and tIgE elevated levels range in CU differed from classic allergic disease. The concordance rate between sIgE and tIgE results in CU was lower than in classic allergic disease.

Conclusion

Our study reveals that a significant proportion of CU patients display IgE sensitization, suggesting a clear atopic background compared to the general population. However, the IgE sensitization profile in CU differs from that of classical allergic diseases such as AD, AR, and AS, characterized by relatively lower intensity of IgE sensitization. The underlying reasons for this phenomenon and its clinical implications in CU warrant further research.

A systematic review and meta-analysis of efficacy and safety of compound glycyrrhizin combined with second-generation non-sedated antihistamine for the treatment of chronic urticaria

BACKGROUND

Chronic urticaria (CU) is a prevalent dermatologic disease that negatively affects life, current therapies remain suboptimal. Hence, there is an urgent need to identify effective and safe treatment.

OBJECTIVE

Assess the efficacy and safety of compound glycyrrhizin (CG) combined with second-generation nonsedated antihistamine for the treatment of CU.

METHODS

Nine databases were queried to screen RCTs related. Two reviewers independently assessed the risk of bias using Cochrane Collaboration. Primary objective was the total efficiency rate, while secondary was rate of recurrence, adverse events, and cure. Statistical analyses using Review Manager 5.4 and Stata17.

RESULTS

Twenty-four RCTs were identified. Significant differences were noted in rate of total efficiency (n = 2649, RR = 1.36, 95%CI:1.30-1.43, p < 0.00001), cure (n = 2649, RR = 1.54, 95%CI:1.42-1.66, p < 0.00001) and recurrence (n = 446, RR = 0.34, 95%CI:0.20-0.58, p < 0.00001) between the combination of CG with second-generation non-sedated antihistamine and antihistamine monotherapy. Contrastingly, adverse events rate (n = 2317, RR = 0.76, 95% CI:0.59-0.97, p = 0.03) was comparable between the two groups. Our results indicated that CG combined with second-generation non-sedated antihistamine could significantly mitigate the symptoms in CU compared with antihistamine monotherapy. No serious adverse events were reported.

CONCLUSIONS

CG combined with second-generation nonsedated antihistamine is effective for CU. Nevertheless, higher-quality studies are warranted to validate our results.

Therapies for Chronic Spontaneous Urticaria: Present and Future Developments

Chronic spontaneous urticaria (CSU) is a complex dermatological condition characterized by recurrent wheals and/or angioedema lasting for more than six weeks, significantly impairing patients' quality of life. According to European guidelines, the first step in treatment involves second-generation H1-antihistamines (sgAHs), which block peripheral H1 receptors to alleviate symptoms. In cases with inadequate responses, the dose of antihistamines can be increased by up to fourfold. If symptoms persist despite this adjustment, the next step involves the use of omalizumab, a monoclonal anti-IgE antibody, which has shown efficacy in the majority of cases. However, a subset of patients remains refractory, necessitating alternative treatments such as immunosuppressive agents like cyclosporine or azathioprine. To address these unmet needs, several new therapeutic targets are being explored. Among them, significant attention is being given to drugs that block Bruton's tyrosine kinase (BTK), such as remibrutinib, which reduces mast cell activation. Therapies like dupilumab, which target the interleukin-4 (IL-4) and IL-13 pathways, are also under investigation. Additionally, molecules targeting the Mas-related G protein-coupled receptor X2 (MRGPRX2), and those inhibiting the tyrosine kinase receptor Kit, such as barzolvolimab, show promise in clinical studies. These emerging treatments offer new options for patients with difficult-to-treat CSU and have the potential to modify the natural course of the disease by targeting key immune pathways, helping to achieve longer-term remission. Further research is essential to better elucidate the pathophysiology of CSU and optimize treatment protocols to achieve long-term benefits in managing this condition. Altogether, the future of CSU treatments that target pathogenetic mechanisms seems promising.

Global Burden of Vaccine-Associated Chronic Urticaria, 2010-2023: From the Global Pharmacovigilance Database

PURPOSE

The etiology and pathophysiology of vaccine-associated chronic urticaria (CU) remain unclear, particularly during the coronavirus disease 2019 (COVID-19) pandemic. Thus, this study aimed to comprehensively investigate the global burden and long-term trends of vaccine-associated CU, with a focus on the associated vaccines and the distribution of cases across different age groups and sexes.

METHODS

Using data from the World Health Organization international pharmacovigilance database (VigiBase), which encompasses reports from 156 countries and territories between 1968 and 2023, we systematically analyzed the global burden and long-term trends in vaccine-associated CU reports (total individual case safety reports = 131,255,418). We estimated the global and regional reports, information component (IC) with IC0.25 using disproportionality analyses, and reporting odds ratio (ROR) with 95% confidence interval (CI) to investigate the potential associations between 27 vaccines and CU.

RESULTS

Among the 3,474 reports of all-cause CU, 1,898 vaccine-associated CU reports were identified between 2010 and 2023. A dramatic surge in vaccine-associated CU reports has been observed since 2020, primarily driven by the COVID-19 mRNA vaccines. The COVID-19 mRNA vaccines were associated with the most CU reports (ROR, 26.52 [95% CI, 24.33-28.90]; IC, 3.18 [IC0.25, 3.10]), followed by papillomavirus (ROR, 4.23 [95% CI, 2.55-7.03]; IC, 1.93 [IC0.25, 1.06]), influenza (ROR, 3.09 [95% CI, 2.16-4.43]; IC, 1.57 [IC0.25, 0.96]), Ad5-vectored COVID-19 (ROR, 2.82 [95% CI, 2.40-3.31]; IC, 1.42 [IC0.25, 1.16]), and zoster vaccines (ROR, 2.28 [95% CI, 1.32-3.93]; IC, 1.12 [IC0.25, 0.18]). These increased risks were particularly pronounced for males and older adults. No fatal outcomes have been reported in vaccine-associated CU.

CONCLUSIONS

This study underscores the importance of clinicians considering the potential risk factors associated with vaccine-associated CU, especially in the context of COVID-19-related vaccines. Ongoing pharmacovigilance efforts facilitated by robust reporting systems are required to further validate our findings.

Minimal clinically important difference for acupuncture for patients with chronic spontaneous urticaria: secondary analysis from a multicentre randomised controlled trial in China

OBJECTIVES

To evaluate the minimal clinically important difference (MCID) value for acupuncture treatment in chronic spontaneous urticaria (CSU), providing guidance for its application in CSU management.

DESIGN

Secondary analysis of data from a multicentre randomised controlled trial.

SETTING

Three tertiary hospitals across three cities in China.

PARTICIPANTS

103 CSU patients (78.7% female) with an average age of 39.97 years.

INTERVENTIONS

Participants received acupuncture treatment for 4 weeks in the original study.

OUTCOME MEASURES

MCID and minimal detectable change (MDC) for the Urticaria Activity Score over 7 days (UAS7) in acupuncture treatment of CSU. Convergent validity assessed by intraclass correlation coefficient (ICC). Responsiveness evaluated through Spearman correlation between UAS7 improvements and anchor tools (physician's and patient's assessments). MDC calculated using SE of measurement of changes in UAS7 scores. MCID estimated using distribution-based and anchor-based methods.

RESULTS

The ICC for UAS7 was 0.86. Improvements in UAS7 scores were significantly correlated with patient (r=0.44, p<0.01) and physician (r=0.85, p<0.01) assessments of CSU activity shifts. The MDC for UAS7 was 5.08. The MCID for acupuncture treatment in CSU was 8.3.

CONCLUSIONS

This study provides the first MCID value for acupuncture treatment in CSU. These findings contribute to the understanding of acupuncture's effects in treating CSU and may inform future research and clinical practice in the management of this condition.

TRIAL REGISTRATION NUMBER

ChiCTR1900022994.

Evaluation of Bilastine's Efficacy and Safety in Treating Chronic Idiopathic Urticaria in Iraqi Patients

Background

Many drugs have been found to be effective in treating chronic urticaria, and many others are under investigation. Second-generation antihistamines are the first-line treatment for this condition, as they block peripheral histamine receptors with minimal drowsiness and anticholinergic effects. Therefore, the aim of the current study was to investigate the short-term efficacy and safety of bilastine in Iraqi patients with chronic idiopathic urticaria.

Methods

This prospective study was conducted at Dermatology Unit/ AL-Diwaniyah Teaching Hospital/ Iraq during the period from January to June 2023. A total of 100 patients, 50 males and 50 females, were enrolled in this study. All these patients were switched over to Bilastine 20 mg/day for one month. The patients were evaluated using the UAS7 scoring system before and one month after bilastine therapy. Statistical analysis was performed using the Statistical Package for Social Sciences, and a paired t-test was used to compare between means. The level of statistical significance was considered at a P value < 0.05.

Results

The mean UAS7 score before Bilastine treatment was 18.91 ±7.18, which was significantly reduced (P < 0.001) to 2.38 ±0.72 after one month of treatment with bilastine. Also, before Bilastine treatments, 19 patients (19%) had mild symptoms, 24 patients (24%) had moderate symptoms, and 57 patients (57%) had severe symptoms. However, after treatment, 51 patients (51%) became symptom-free and 49 patients (49%) had well-controlled urticaria.

Conclusion

Switching over to bilastine 20mg/day resulted in significant improvement in patients with chronic idiopathic urticaria who had no/ or poor response to conventional antihistamines.

A Retrospective Cohort Study on the Comorbidity in 19,264 Chinese Patients of Different Ages with Urticaria

To examine the prevalence of comorbidities in Chinese urticaria patients and assess medication use patterns across different ages (6-11 years, 12-17 years, above 18 years), a retrospective cohort study was performed in 192,647 urticaria patients within the Health Database. After 1:1 propensity score matching, 166,921 people were divided into the urticaria group and the control group, and the follow-up data were collected within 2 years. During the 12-month and 24-month follow-up period, significant comorbidities identified included allergic rhinitis and asthma, with distinct patterns observed across age groups. Chronic urticaria patients often have complications, such as allergic rhinitis, upper respiratory infection, oropharyngeal infection, and dental caries. The study underscores the need for age-specific treatment strategies in urticaria management.

Comparative efficacy and safety of the treatment by Omalizumab for chronic idiopathic urticaria in the general population: A systematic review and network meta-analysis

BACKGROUND

Omalizumab is the only licensed drug that serves as a third-line treatment for chronic idiopathic urticaria (CIU). The optimum doses of omalizumab remain controversial. Therefore, this study aims to estimate the efficacy and safety of different doses of omalizumab in the treatment of CIU patients.

MATERIALS AND METHODS

Four databases were searched from the database's creation to April 8, 2023. Several keywords such as omalizumab and urticarias were used to retrieve related studies. The meta-analytical outcomes were analyzed in R 4.2.1 software and Stata 15.1 software. Cochrane risk-of-bias tool Ver. 2 was used to evaluate the risk of bias in randomized controlled trials (RCTs).

RESULTS

In total, 2331 patients were included. Five indexes were employed to assess, including weekly Itch Severity Score (ISS7), weekly Hive Severity Score (HSS7), weekly Urticaria Activity Score (UAS7), Dermatology Life Quality Index (DLQI), and adverse events (AE). A 300 mg dose of omalizumab was the optimum dose to treat CIU, followed by the 150 mg dose. Furthermore, 600 mg of omalizumab only showed a significant difference from the placebo in HSS7. No significant statistical difference was observed in AE. Meta-regression analysis revealed that time, as a covariate, was statistically significant in the comparison of omalizumab 150 mg with placebo.

CONCLUSION

300 mg of omalizumab was the optimum dosage to treat CIU patients, with a 150 mg dose also exhibiting good efficacy. Further studies are required to explore the efficacy and safety of different doses of omalizumab in the treatment of CIU patients.

Atopy in chronic urticaria: an important yet overlooked issue

Chronic urticaria (CU) is one of the most common dermatological diseases and has a significant impact on the quality of life of patients. However, the pathogenesis of this disease remains unclear. Autoimmunity in chronic spontaneous urticaria (CSU) has received considerable attention and has been studied previously. Atopy is an important characteristic of CU; however, it has not been fully recognized. Atopy predisposes individuals to immune responses to allergens, leading to type 2 inflammation and immunoglobulin E (IgE) overproduction. Compared with healthy individuals, patients with CU have a higher proportion of atopy, and an atopic background is correlated with the clinical characteristics of CU. The total IgE levels in patients with CU is significantly higher than those in healthy individuals. Although its level is not higher than that in classic allergic diseases, it is closely related to CU. Exogenous allergens, auto-allergens, and specific IgEs, which are closely related to atopy, have been reported, and their roles in CU pathogenesis are also being studied. Local and systemic atopic inflammation is present in patients with CU. This review summarizes the current knowledge regarding atopy and CU, speculating that there are CU subtypes, such as atopic CSU or atopic chronic inducible urticaria (CIndU) and that atopy may be involved in the pathogenesis of CU. These findings provide a new perspective for a comprehensive understanding of the clinical features of CU and further research regarding its pathogenesis.

Evaluation of Pediatric Chronic Urticaria with Emphasis on Clinical and Laboratory Characteristics and Treatment Response to Omalizumab: A Real-Life Experience from a Tertiary Allergy Center

Pediatric data on the clinical and etiologic features, treatment response, and use of omalizumab for chronic urticaria (CU) are quite limited. The aim of this study was to evaluate the clinical and demographic characteristics, laboratory findings, and response to treatment of CU in children. Children with a diagnosis of CU between 2019 and 2023 were included in the study. Information on demographic characteristics, clinical features, laboratory tests, provocation tests for inducible urticaria, urticaria activity scores (UAS7), and treatment responses were obtained from patients' medical records. A total of 150 children (50.7% male) with CU were enrolled in the study. A total of 14 (9.3%) patients had autoimmune diseases of which 11 (7.3%) had autoimmune thyroiditis. Overall, 97 (64.7%) patients had chronic spontaneous urticaria (CSU) and 53 (35.3%) had chronic inducible urticaria. A total of 16 patients who remained symptomatic despite high-dose antihistamines were treated with omalizumab, with a good response in 13 (81.3%) and a partial response in 3 (18.7%) patients. CSU accounts for the majority of pediatric CU, with the etiology being in part related to an autoimmune background. This study provides an overview of CU in children and demonstrates the safety and efficacy of treatment with omalizumab.

Allergic manifestations in women with silicone breast implants

INTRODUCTION

Silicone breast implants (SBI) result in immune dysregulation and are associated with autoimmune diseases. Recently, we reported dysregulated levels of IgG autoantibodies directed against G protein-coupled receptors (GPCRs) of the autonomic nervous system which were linked to the autoimmune dysautonomia in silicone breast implant illness (SBII).

AIMS

We aimed to explore the possible association between allergy with dysregulated IgE autoantibodies directed against GPCRs of the autonomic nervous system in women with SBI.

METHODS

Circulating levels of IgE autoantibodies against GPCRs of the autonomic nervous system (adrenergic, muscarinic, endothelin and angiotensin receptors) have been evaluated in women with SBIs who complained of allergic symptoms, and compared to subjects with SBI without allergic manifestations and to age-matched healthy women without SBI.

RESULTS

We report a significant dysregulation in three circulating autoantibodies: IgE-beta1 adrenergic receptor (B1AR), IgE-alpha 1 adrenergic receptor (A1AR) and IgE-muscarinic acetylcholine receptor type 1 (M1R) autoantibodies in women with SBI who complained of allergic symptoms.

CONCLUSIONS

Allergic reactions associated with SBI are not uncommon. Imbalance of circulating levels of IgE autoantibodies against GPCRs of the autonomic nervous system might play a role not only in allergic reactions, but also in other enigmatic aspects of SBII such as autoimmune dysautonomia.

Efficacy and safety of Tripterygium glycosides as an add-on treatment in adults with chronic urticaria: a systematic review and meta-analysis

CONTEXT

Tripterygium glycosides (TG), a traditional Chinese medicine, has been used to treat chronic urticaria (CU) in China, and the evidence of TG for CU needs to be updated thoroughly.

OBJECTIVE

To systematically evaluate the efficacy and safety of TG combined with H1-antihistamine (H1-AH) in adults with CU.

METHODS

Eligible randomized controlled trials were searched in eight databases until May 31, 2022, including CNKI, WanFang, VIP, SinoMed, PubMed, Cochrane Library, Embase, and Web of Science. The search terms included urticaria, Tripterygium, Lei Gong Teng, and Leigongteng. Rev Man 5.3 and Stata 12.0 were used for statistical analysis.

RESULTS

A total of 27 studies with 2788 patients were included. The pooled results showed that TG plus H1-AH was superior to H1-AH alone in cure rate (RR = 1.37, 95% CI = 1.15 to 1.63, p = 0.0003), total efficacy rate (RR = 1.40, 95% CI = 1.30 to 1.50, p < 0.00001), pruritus (MD = -0.32, 95% CI = -0.54 to -0.11, p = 0.003), wheal number (MD = -0.31, 95% CI = -0.55 to -0.07, p = 0.01), wheal size (MD = -0.32, 95% CI = -0.46 to -0.19, p < 0.00001), and the serum level of immunoglobulin E (SMD = -1.39, 95% CI = -2.42 to -0.36, p = 0.008). Moreover, adverse events between two groups were mild, and their incidences were not significantly different.

CONCLUSIONS

The combination of TG and H1-AH is a promising and safe treatment for adults with refractory CU. Further high-quality studies are needed to confirm the evidence.

Efficacy of Acupuncture for Chronic Spontaneous Urticaria : A Randomized Controlled Trial

BACKGROUND

The effectiveness of acupuncture for patients with chronic spontaneous urticaria (CSU), reported in a few small-scale studies, is not convincing.

OBJECTIVE

To investigate whether acupuncture leads to better effects on CSU than sham acupuncture or waitlist control.

DESIGN

A multicenter, randomized, sham-controlled trial. (Chinese Clinical Trial Registry: ChiCTR1900022994).

SETTING

Three teaching hospitals in China from 27 May 2019 to 30 July 2022.

PARTICIPANTS

330 participants diagnosed with CSU.

INTERVENTION

Participants were randomly assigned in a 1:1:1 ratio to receive acupuncture, sham acupuncture, or waitlist control over an 8-week study period (4 weeks for treatment and another 4 weeks for follow-up).

MEASUREMENTS

The primary outcome was the mean change from baseline in the Weekly Urticaria Activity Score (UAS7) at week 4. Secondary outcomes included itch severity scores, self-rated improvement, and Dermatology Life Quality Index scores.

RESULTS

The mean change in UAS7 (range, 0 to 42) for acupuncture from baseline (mean score, 23.5 [95% CI, 21.8 to 25.2]) to week 4 (mean score, 15.3 [CI, 13.6 to 16.9]) was -8.2 (CI, -9.9 to -6.6). The mean changes in UAS7 for sham acupuncture and waitlist control from baseline (mean scores, 21.9 [CI, 20.2 to 23.6] and 22.1 [CI, 20.4 to 23.8], respectively) to week 4 (mean scores, 17.8 [CI, 16.1 to 19.5] and 20.0 [CI, 18.3 to 21.6], respectively) were -4.1 (CI, -5.8 to -2.4) and -2.2 (CI, -3.8 to -0.5), respectively. The mean differences between acupuncture and sham acupuncture and waitlist control were -4.1 (CI, -6.5 to -1.8) and -6.1 (CI, -8.4 to -3.7), respectively, which did not meet the threshold for minimal clinically important difference. Fifteen participants (13.6%) in the acupuncture group and none in the other groups reported adverse events. Adverse events were mild or transient.

LIMITATION

Lack of complete blinding, self-reported outcomes, limited generalizability because antihistamine use was disallowed, and short follow-up period.

CONCLUSION

Compared with sham acupuncture and waitlist control, acupuncture produced a greater improvement in UAS7, although the difference from control was not clinically significant. Increased adverse events were mild or transient.

PRIMARY FUNDING SOURCE

The National Key R&D Program of China and the Science and Technology Department of Sichuan Province.

Efficacy and safety of Runzao Zhiyang capsule for chronic urticaria: a systematic review and meta-analysis of randomized controlled trials

Background: Chronic urticaria (CU) is a commonly seen skin disorder featured by recurring wheals, with or without angioedema, lasting for at least 6 weeks. Runzao Zhiyang capsule (RZC) has been widely applied to treat patients with CU. This study is aimed at systematically evaluating the efficacy and safety of RZC in treating CU. Materials and Methods: Randomized controlled trials (RCTs) of RZC on treating CU from Chinese and English databases were searched. Data were collected by two independent researchers. The Cochrane Collaboration tool was adopted for evaluating the risk of bias. The meta-analysis was performed with Review Manager 5.3 software. Sensitivity analysis and publication bias assessment were conducted by Stata 14.0 software. Results: Totally 27 studies were included in the analysis, involving 2,703 patients. The pooled results showed that compared with second-generation H1-antihistamines (sgAHs) therapy alone, RZC combined with sgAHs is more effective in improving the total effective rate (RR = 1.32, 95% CI: 1.25 to 1.39, p < 0.00001), the quality of life measured by Dermatology Life Quality Index (DLQI) (MD = -2.63, 95% CI: -3.68 to -1.58, p < 0.00001) and the serum IFN-γ level (SMD = 3.10, 95% CI: 1.58 to 4.62, p < 0.0001), and reducing the recurrence rate (RR = 0.39, 95% CI: 0.27 to 0.55, p < 0.00001), the serum total IgE level (SMD = -2.44, 95% CI: -3.51 to -1.38, p < 0.00001), the serum IL-4 level (SMD = -2.96, 95% CI: -4.10 to -1.83, p < 0.00001), and the incidence of adverse events including dizziness, fatigue, dry mouth, and constipation (RR = 0.53, 95% CI: 0.33 to 0.85, p = 0.009; RR = 0.46, 95% CI: 0.26 to 0.84, p = 0.01; RR = 0.57, 95% CI: 0.34 to 0.95, p = 0.03; RR = 0.24, 95% CI: 0.07 to 0.85, p = 0.03). Conclusion: The current evidence indicates that RZC may be an efficient therapeutic regimen in patients with CU. Nevertheless, owing to the suboptimal quality of the included studies, more large-scale, well-designed RCTs are required to verify the obtained findings. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/; Identifier: CRD42022313177.

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

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

Association Between Serum Total IgE Levels and Clinical Response to Omalizumab for Chronic Spontaneous Urticaria: A Systematic Review and Meta-Analysis

BACKGROUND

Omalizumab is the only biological agent approved for patients with chronic spontaneous urticaria (CSU), but no biomarker is well established for predicting clinical response to omalizumab.

OBJECTIVE

We aimed to determine the association between baseline total serum IgE levels and the effects of omalizumab in patients with CSU.

METHODS

PubMed, Web of Science, Scopus, and Cochrane Library were systematically searched for relevant studies from inception to August 23, 2022. The research protocol was registered on PROSPERO (CRD42022355592). No language restrictions were applied. A random-effects model was used for meta-analysis.

RESULTS

Ten interventional studies, including 1 randomized controlled trial, were included in the final meta-analysis, and a total of 866 patients with CSU were included. A pooled analysis showed significantly higher serum total IgE levels in complete responders (CRs) than in nonresponders (NRs) (mean difference [MD]: 56.509 IU/mL; 95% confidence interval [CI]: 24.230-88.789) and in partial responders (PRs) than in NRs (MD: 62.688 IU/mL; 95% CI: 32.949-92.427), but no significant difference was detected between CRs and PRs. The mean total IgE levels for CRs, PRs, and NRs were 163.154, 179.926, and 51.535 IU/mL, respectively. Further, the serum total IgE levels in early CRs were significantly higher compared with late CRs (MD: 55.194 IU/mL; 95% CI: 13.402-96.986). The sensitivity analyses with the leave-one-out method validated the robustness of all findings.

CONCLUSIONS

This systematic review and meta-analysis provide convincing evidence that pretreatment total serum IgE levels in patients with CSU are associated with clinical responses to omalizumab.

Characteristics of immune response profile in patients with immediate allergic and autoimmune urticarial reactions induced by SARS-CoV-2 vaccines

Severe allergic reactions following SARS-COV-2 vaccination are generally rare, but the reactions are increasingly reported. Some patients may develop prolonged urticarial reactions following SARS-COV-2 vaccination. Herein, we investigated the risk factors and immune mechanisms for patients with SARS-COV-2 vaccines-induced immediate allergy and chronic urticaria (CU). We prospectively recruited and analyzed 129 patients with SARS-COV-2 vaccine-induced immediate allergic and urticarial reactions as well as 115 SARS-COV-2 vaccines-tolerant individuals from multiple medical centers during 2021-2022. The clinical manifestations included acute urticaria, anaphylaxis, and delayed to chronic urticaria developed after SARS-COV-2 vaccinations. The serum levels of histamine, IL-2, IL-4, IL-6, IL-8, IL-17 A, TARC, and PARC were significantly elevated in allergic patients comparing to tolerant subjects (P-values = 4.5 × 10^-5-0.039). Ex vivo basophil revealed that basophils from allergic patients could be significantly activated by SARS-COV-2 vaccine excipients (polyethylene glycol 2000 and polysorbate 80) or spike protein (P-values from 3.5 × 10^-4 to 0.043). Further BAT study stimulated by patients' autoserum showed positive in 81.3% of patients with CU induced by SARS-COV-2 vaccination (P = 4.2 × 10^-13), and the reactions could be attenuated by anti-IgE antibody. Autoantibodies screening also identified the significantly increased of IgE-anti-IL-24, IgG-anti-FcεRI, IgG-anti-thyroid peroxidase (TPO), and IgG-anti-thyroid-related proteins in SARS-COV-2 vaccines-induced CU patients comparing to SARS-COV-2 vaccines-tolerant controls (P-values = 4.6 × 10^-10-0.048). Some patients with SARS-COV-2 vaccines-induced recalcitrant CU patients could be successfully treated with anti-IgE therapy. In conclusion, our results revealed that multiple vaccine components, inflammatory cytokines, and autoreactive IgG/IgE antibodies contribute to SARS-COV-2 vaccine-induced immediate allergic and autoimmune urticarial reactions.

Baseline Characteristics of Patients Enrolled in Clinical Trials of Biologics for Severe Asthma as Potential Predictors of Outcomes

(1) Background: Over the past 20 years, monoclonal antibodies have been developed for the treatment of severe asthma, with numerous randomised controlled trials (RCTs) conducted to define their safety and efficacy. The growing availability of biologics, which until now have only been available for T2-high asthma, has been further enriched by the arrival of tezepelumab. (2) Methods: This review aims to evaluate the baseline characteristics of patients enrolled in RCTs of biologics for severe asthma to understand how they could potentially predict outcomes and how they can help differentiate between available options. (3) Results: The studies reviewed demonstrated that all biologic agents are effective in improving asthma control, especially with regard to reducing exacerbation rates and OCS use. As we have seen, in this regard, there are few data on omalizumab and none yet on tezepelumab. In analysing exacerbations and average doses of OCSs, pivotal studies on benralizumab have enrolled more seriously ill patients. Secondary outcomes, such as improvement in lung function and quality of life, showed better results-especially for dupilumab and tezepelumab. (4) Conclusion: Biologics are all effective, albeit with important differences. What fundamentally guides the choice is the patient's clinical history, the endotype represented by biomarkers (especially blood eosinophils), and comorbidities (especially nasal polyposis).

Consecutive injections of low-dose interleukin-2 improve symptoms and disease control in patients with chronic spontaneous urticaria

PURPOSE

To describe the effectiveness and tolerability of low-dose interleukin (IL)-2 in treating patients with chronic spontaneous urticaria (CSU) refractory to H₁-antihistamines.

METHODS

This retrospective study included CSU patients who received treatment with at least one cycle of IL-2, injected intramuscularly at a dose of 1.0 million international units daily for 7 consecutive days, after failing treatment with H₁-antihistamines. Patients were followed up for ≥12 weeks.

RESULTS

Of the 15 patients, 7 (46.7%) and 11 (73.3%) achieved complete response at Week 2 and Week 12, respectively. The mean change of urticaria control test (UCT) and weekly urticaria activity score (UAS7) from baseline was 6.6 (95% CI, 4.2 to 8.9) and - 16.9 (95% CI, -24.0 to -9.8), respectively, at Week 12. Local injection-site reactions were the most common adverse events. No serious adverse events were reported.

CONCLUSION

Low-dose IL-2 treatment improves symptoms and disease control for CSU patients refractory to H₁-antihistamines.

Efficacy of Fangfeng Tongsheng Granule Combined with Levocetirizine in the Treatment of Chronic Urticaria and Its Effect on Serum Complement, IL-4, IgE, and IFN-γ Levels in Patients

Objectives

To investigate the efficacy of Fangfeng Tongsheng granule combined with levocetirizine in the treatment of chronic urticaria and its effect on serum complement, interleukin (IL)-4, immunoglobulin E (IgE), and interferon-γ (IFN-γ) levels in patients.

Methods

A total of 98 patients with chronic urticaria who were admitted to our hospital from July 2021 to March 2022 were selected and divided into random odd-even numbers. The odd numbers were included in the observation group, with a total of 49 cases, and they were treated with Fangfeng Tongsheng granule combined with levocetirizine; the even numbers were included in the control group, with a total of 49 cases and were treated with levocetirizine alone. The two groups of patients were treated continuously for 4 weeks, and the clinical efficacy of the two groups was observed. Before treatment, 2 weeks and 4 weeks after treatment, evaluate the clinical symptom scores of patients such as itching, flushing, wheal, edema, observe the improvement of clinical symptoms of patients, and the changes in Dermatology Life Quality Index (DLQI). Serum complement C3, C4, T lymphocyte subsets CD₃⁺, CD₄⁺, CD₈⁺ levels and CD₄⁺/CD₈⁺ ratio, IL-4, IgE, and IFN-γ levels and the occurrence of adverse reactions in the two groups were calculated and observed. All patients were followed up for 2 months after treatment to observe the recurrence of patients.

Results

The scores of clinical symptoms such as wheal, itching, flushing, edema, and attack frequency in the observation group at each time point after treatment were lower than those in the control group (F times were 725.365, 851.521, 936.411, 3943.136, and 2226.147, all P < 0.05 (F between-group were 40.642, 102.124, 188.523, 259.291, and 23.92, P < 0.05); the total effective rate of the observation group was 93.88% (46/49), which was significantly higher than that of the control group, 73.47% (36/49) (χ² = 7.470, P=0.006). The DLQI scores of the observation group at each time point after treatment were lower than those of the control group (F time was 282.214, P < 0.05; F between-group was 6.546, P < 0.05). There was no significant difference in serum C4 levels between the two groups at each time point (F time was 1.225, P > 0.05; F between-group was 0.408, P > 0.05); serum complement C3, CD₃⁺, and CD₄⁺/the ratio of CD₈⁺ and IFN-γ were higher than those in the control group (F time was 407.352, 107.823, 32.941, and 2354.147, P < 0.05; F between-group was 40.941, 24.710, 54.982, and 264.921, P < 0.05); the observation group at each time after treatment the levels of IgE and IL-4 were lower than those of the control group (F time were 373.124 and 395.612, P < 0.05; F between-group were 21.802 and 62.591, P < 0.05). The incidence of adverse reactions in the observation group was 12.24% (6/49) compared with 10.20% (5/49) in the control group, which had no significant difference (χ² = 0.102, P=0.749). Both groups were followed up for 2 months after treatment. The recurrence rate in the observation group was 12.24% (6/49), which was lower than that in the control group, which was 32.65% (16/49) (χ² = 5.861, P=0.015).

Conclusion

The application of Fangfeng Tongsheng granules combined with levocetirizine in patients with chronic urticaria can effectively improve the clinical symptoms of patients, improve clinical efficacy, reduce the impact of the disease on life, improve the immune status of patients, and reduce the risk of recurrence.

Efficacy and safety of total glucosides of paeony as an add-on treatment in adolesents and adults with chronic urticaria: A systematic review and meta-analysis

Background: Total glycosides of paeony (TGP), an active compound extracted from the dried roots of Paenoia lactiflora Pall., has been widely used to treat chronic urticaria (CU) in China. This study aims to systematically evaluate the efficacy and safety of TGP as an add-on treatment for the treatment of CU in adolescents and adults.

Methods: Eight literature databases and two clinical trial registries were searched from their inception to 31 May 2022. Randomized controlled trials on TGP as an add-on treatment for CU in adolescents and adults were included. The Cochrane Collaboration’s risk of bias tool was used for the methodological quality assessment, and RevMan 5.3 software and Stata 12.0 software were used for data analyses.

Results: A total of 30 studies with 2,973 participants were included in this meta-analysis. The methodological qualities of all included studies were suboptimal. The pooled results showed that TGP combined with H1-antihistamine was superior to H1-antihistamine alone in the cure rate (risk ratio (RR) = 1.54, 95% confidence interval (CI) = 1.39 to 1.71, p &lt; 0.00001), total efficacy rate (RR = 1.33, 95%CI = 1.26 to 1.40, p &lt; 0.00001), urticaria activity score 7 (mean difference (MD) = -4.03, 95%CI = -6.62 to -1.44, p = 0.002), recurrence rate (RR = 0.31, 95%CI = 0.20 to 0.46, p &lt; 0.00001), and the level of IgE in serum (standardized mean difference (SMD) = -1.96, 95%CI = -3.02 to -0.90, p = 0.0003). In terms of safety, the incidence of diarrhea (RR = 6.19, 95%CI = 3.39 to 11.29, p &lt; 0.00001) was significantly increased in the TGP plus H1-antihistamine groups, and no abnormal results of laboratory tests and electrocardiogram were reported in two groups. The qualities of evidences were evaluated as moderate to low.

Conclusions: TGP as an add-on treatment could provide a good effect for CU in adolescents and adults with mild and tolerable adverse events. However, in view of poor methodological quality, high-quality and long-term clinical trials are needed in the future to confirm and update the evidence.

Mast Cells and Vitamin D Status: A Clinical and Biological Link in the Onset of Allergy and Bone Diseases

The immune system is made up by an extremely composite group of cells, whose regulated and harmonious activity is fundamental to maintain health. The mast cells are an essential effector of inflammatory response which is characterized by a massive release of mediators accumulated in cytoplasmic secretory granules. However, beyond the effects on immune response, mast cells can modify bone metabolism and are capable of intervening in the genesis of pathologies such as osteoporosis and osteopenia. Vitamin D is recognized to induce changes in bone metabolism, but it is also able to influence immune response, suppressing mast cell activation and IgE synthesis from B cells and increasing the number of dendritic cells and IL-10-generating regulatory T cells. Vitamin D deficit has been reported to worsen sensitization and allergic manifestations in several different experimental models. However, in clinical situations, contradictory findings have been described concerning the correlation between allergy and vitamin D deficit. The aim of this review was to analyze the close relationships between mast cells and vitamin D, which contribute, through the activation of different molecular or cellular activation pathways, to the determination of bone pathologies and the onset of allergic diseases.

Epidemiology of urticaria in China: a population-based study

Background:

Urticaria is a common skin disease characterized by episodes of wheals, and it has a negative effect on patients’ quality of life. Large-scale population-based epidemiological studies of urticaria are scarce in China. The aim of this survey was to determine the prevalence, clinical forms, and risk factors of urticaria in the Chinese population.

Methods:

This survey was conducted in 35 cities from 31 provinces, autonomous regions, and municipalities of China. Two to three communities in each city were selected in this investigation. Participants completed questionnaires and received dermatological examinations. We analyzed the prevalence, clinical forms, and risk factors of urticaria.

Results:

In total, 44,875 questionnaires were distributed and 41,041 valid questionnaires were collected (17,563 male and 23,478 female participants). The lifetime prevalence of urticaria was 7.30%, with 8.26% in female and 6.34% in male individuals (P < 0.05). The point prevalence of urticaria was 0.75%, with 0.79% in female and 0.71% in male individuals (P < 0.05). Concomitant angioedema was found in 6.16% of patients. Adults had a higher prevalence of urticaria than adolescents and children. Living in urban areas, exposure to pollutants, an anxious or depressed psychological status, a personal and family history of allergy, thyroid diseases, and Helicobacter pylori infection were associated with a higher prevalence of urticaria. Smoking was correlated with a reduced risk of urticaria.

Conclusion:

This study demonstrated that the lifetime prevalence of urticaria was 7.30% and the point prevalence was 0.75% in the Chinese population; women had a higher prevalence of urticaria than men. Various factors were correlated with urticaria.

The Role of Crosstalk of Immune Cells in Pathogenesis of Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined as recurrent episodes of spontaneous wheal development and/or angioedema for more than six weeks and at least twice a week. The core link in the pathogenesis of CSU is the activation of mast cells, T cells, eosinophils, and other immune cells infiltrating around the small venules of the lesion. Increased vascular permeability, vasodilatation, and recruitment of inflammatory cells directly depend on mast cell mediators’ release. Complex regulatory systems tightly influence the critical roles of mast cells in the local microenvironment. The bias toward Th2 inflammation and autoantibodies derived from B cells, histamine expressed by basophils, and initiation of the extrinsic coagulation pathway by eosinophils or monocytes exerts powerful modulatory influences on mast cells. Cell-to-cell interactions between mast cells and eosinophils/T cells also are regulators of their function and may involve CSU’s pathomechanism. This review summarizes up-to-date knowledge regarding the crosstalk between mast cells and other immune cells, providing the impetus to develop new research concepts and treatment strategies for CSU.

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.

Integrated Bioinformatics and Validation Reveal IL1B and Its Related Molecules as Potential Biomarkers in Chronic Spontaneous Urticaria

Background

The etiopathogenesis of chronic spontaneous urticaria (CSU) has not been fully understood, and there has been extensive interest in the interaction between inflammatory dermatosis and pyroptosis. This study intends to investigate the molecular mechanism of pyroptosis-related genes in CSU via bioinformatic ways, aiming at identifying the potential key biomarker.

Methods

GSE72540, the RNA expression profile dataset of CSU, was utilized as the training set, and GSE57178 as the validation set. Differently expressed pyroptosis-related genes (DEPRGs), GO, KEGG, and DO analyses were performed. The hub genes were explored by the protein–protein interaction analysis. Moreover, CIBERSORT was employed for estimating immune cell types and proportions. Then, we constructed a DEmRNA–miRNA–DElncRNA ceRNA network and a drug–gene interaction network. Finally, ELISA was used for gene expression analysis.

Results

We recognized 17 DEPRGs, whose enrichment analyses showed that they were mostly enriched in inflammatory response and immunomodulation. Moreover, 5 hub genes (IL1B, TNF, and IRF1 are upregulated, HMGB1 and P2RX7 are downregulated) were identified via the PPI network and verified by a validation set. Then immune infiltration analysis displayed that compared with normal tissue, CSU owned a significantly higher proportion of mast cells activated, but a lower proportion of T cells CD4 naive and so on. Furthermore, IL1B was statistically and positively associated with mast cells activated in CSU, and SNHG3, the upstream factor of IL1B in the ceRNA we constructed, also related with mast cells in CSU. Further analysis exhibited that the protein subcellular localization of IL1B was extracellular, according with its intercellular regulation role; IL1B was significantly correlated with key immune checkpoints; and the NOD-like receptor signaling pathway was the mainly involved pathway of IL1B based on the couple databases. What is more, the result of ELISA of CSU patients was the same as the above analyses about IL1B. In addition, the drug–gene interaction network contained 15 potential therapeutic drugs targeting IL1B, and molecular docking might make this relationship viable.

Conclusion

IL1B and its related molecules might play a key role in the development of CSU and could be potential biomarkers in CSU.