Pathophysiology, Diagnosis, and Management of Chronic Spontaneous Urticaria: A Literature Review

Quality of life, sleep, and psychological well-being in chronic spontaneous urticaria patients receiving omalizumab: a case-control study

Chronic spontaneous urticaria (CSU) impacts both physical and mental well-being, causing distress and sleep disturbances. While omalizumab reduces disease activity, its effects on mental health and quality of life remain unclear. This study assesses the psychosocial burden and sleep disturbances in CSU patients receiving omalizumab compared to healthy controls and explores their relationship with disease parameters. This case--control study included 210 CSU patients receiving omalizumab for at least three months and 210 age- and sex-matched healthy controls. Disease severity was assessed using the Urticaria Activity Score over 7 Days (UAS7) and Urticaria Control Test (UCT), while quality of life was evaluated with the Chronic Urticaria Quality of Life Questionnaire (CU-Q₂oL). Psychological distress and sleep disturbances were measured using validated scales, including the Perceived Stress Scale (PSS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS). CSU patients had significantly higher scores for perceived stress, depression, anxiety, and daytime sleepiness compared to controls (p < 0.001). Patients with a good response to omalizumab also showed significantly higher psychological distress and poorer sleep quality than controls (p < 0.001). Omalizumab response was good in 29.5%, moderate in 38.6%, and limited in 31.9% of patients. Despite treatment, 32.9% reported no change in quality of life, while 35.7% had mild and 31.4% had moderate improvement. A history of atopic disease was present in 55.7% of patients, who had significantly higher daytime sleepiness scores than those without (p = 0.045). In CSU patients, while omalizumab improves symptoms and quality of life, psychological distress persists in substantial subsets, highlighting the need to address mental health and lifestyle factors.

Immunomodulatory Significance of Mast Cell Exosomes (MC-EXOs) in Immune Response Coordination

Mast cells (MCs) communicate with other cells by direct cell-to-cell interaction, secreting mediators, and releasing exosomes (EXOs). MC-exosomes (MC-EXOs) contain proteins, lipids, mRNAs, and noncoding RNAs (ncRNAs), exhibit typical EXO markers such as heat shock proteins, tetraspanins, tumor susceptibility gene 101 protein (TSG101), and ALG-2-interacting protein X (ALIX), and are released constitutively or following MC degranulation. MC-EXOs also have signature MC markers like FcεRI and KIT (CD117), which allows for their identification and comparison with other EXO populations. Following their release, MC-EXOs may interact with the recipient cell(s) directly or be internalized and then release their protein and nucleic acid content. This may contribute to the regulation of immune responses and other biological processes and reprogramming of recipient cells. MC-EXO proteins may integrate and become a functional part of the recipient cell membrane. The mRNA transferred by MC-EXOs is functional and the transfer of exosomal RNA to other MCs results in the expression of donor MC proteins in the recipient MCs. Moreover, MCs may function as the recipients of EXOs that are released by other non-immune and immune cells, altering the secretome of MCs. In this review, we focus on how MC-EXOs modulate the biology of other cells and vice versa; and we highlight the role of MC-EXOs in the pathogenesis of allergic and non-allergic diseases.

The prevelance of food allergy in patients with chronic idiopathic urticaria: a systematic review and meta-analysis

Chronic idiopathic urticaria (CIU) is difficult for patients and healthcare professionals to manage owing to its chronic and unpredictable nature. While the exact cause of CIU is unknown, it is suggested that food allergies may contribute to the development of symptoms. To determine the prevalence of food allergy in patients diagnosed with CIU. This systematic review is reported in accordance with PRISMA guidelines. We included all relevant articles published from inception to April 2023 in Scopus, Midline, and Web of Science. The initial search yielded 282 articles, of which only seven were included after applying the inclusion and exclusion criteria. The systematic review included a total of 1551 patients with urticaria. Approximately 25% of patients with food allergies had CIU. The prevalence of a family history of atopy was 37.9% (range, 24.3-53.8%, P = 0.133). There was a significant risk of angioedema in patients with urticaria (P = 0.039). The risk of CIU among patients with food allergies was estimated to be one in every four patients with urticaria, with a similar risk among the adult and pediatric populations. Patients with food allergies and a history of atopy were at higher risk of CIU. Angioedema is a common concomitant manifestation associated with common urticaria. This knowledge is important to identify patients at higher risk of urticaria and implement the necessary management to minimize potential complications and maintain a controlled disease.

PTGS2: A potential immune regulator and therapeutic target for chronic spontaneous urticaria

AIMS

Chronic spontaneous urticaria (CSU) is a common and debilitating skin disease that is difficult to control with existing treatments, and the pathogenesis of CSU has not been fully revealed. The aim of this study was to explore the underlying mechanisms of CSU and identify potential treatments.

MATERIALS AND METHODS

Microarray datasets of CSU were obtained from Gene Expression Omnibus database. Differentially expressed genes between skin lesions of CSU and normal controls (LNS-DEGs) were identified, and the enrichment analyses of LNS-DEGs were performed. Hub genes of LNS-DEGs were selected by protein-protein interaction analysis. The co-expression and transcriptional regulatory networks of hub genes were conducted using GeneMANIA and TRRUST database, respectively. CIBERSORT was utilized for immune cell infiltration analysis. Experimental validation was performed by β-hexosaminidase release examination and passive cutaneous anaphylaxis (PCA) mouse model.

KEY FINDINGS

A total of 247 LNS-DEGs were identified, which were enriched in cell migration, cell chemotaxis, and inflammatory pathways such as TNF and interleukin (IL) -17 signaling pathway. Among LNS-DEGs, seven upregulated (PTGS2, CCL2, IL1B, CXCL1, IL6, VCAM1, ICAM1) and one downregulated hub gene (PECAM1) were selected. Immune infiltration analysis identified eight different immune cells, such as activated/resting mast cells and neutrophils. Furthermore, PTGS2, encoding cyclooxygenase 2 (COX2), was selected for further validation. COX2 inhibitor, celecoxib, significantly inhibited mast cell degranulation, and reduced vascular permeability and inflammatory cytokine expression in PCA mouse model.

SIGNIFICANCE

PTGS2 may be a potential regulator of immunity and inflammation in CSU. Targeting PTGS2 is a new perspective for CSU treatment.

Omalizumab for Patients with Chronic Spontaneous Urticaria: A Narrative Review of Current Status

Chronic spontaneous urticaria (CSU) is a debilitating inflammatory disorder of the skin, characterized by a fluctuating natural history, a complex mechanism of action, and a significant burden on patients, including effect on quality of life, development of psychosocial disorders, and a range of comorbidities. Recent international guidelines recommend a therapeutic approach of first-line treatment with second generation H1-antihistamines and second-line treatment with the biologic omalizumab. Here, the salient aspects of CSU and current status of data for omalizumab for patients with CSU are reviewed, with a focus on mechanism of action, efficacy and real-world effectiveness (including patient outcomes, response, relapse, and remission), and safety (including consideration of the risk of anaphylaxis). The review also considers recent data on COVID-19, CSU, and omalizumab and presents our perspective on future needs. Overall, the data suggest that omalizumab is an effective and well-tolerated treatment for patients with CSU that provides benefits for a wide range of patients.

IgG food hypersensitivity: A potential hidden precipitant for chronic spontaneous urticaria A case report

BACKGROUND

While the link between foods and chronic spontaneous urticaria (CSU) is controversial, many immunological mechanisms have been proposed to establish a causal relationship.

OBJECTIVE

To explore the potential benefit of avoiding immunoglobulin G (IgG)-mediated food hypersensitivity as a triggering factor in a case with CSU.

HISTORY

The patient is a 50-year-old woman who complained of CSU for 1 and half year, which responded partially and temporarily to antihistamine medications. Of interest, it started 6 months after she followed an oat-rich diet. Her Urticaria Activity Score 7 was 23 out of 40.

RESULTS

Specific immunoglobulin E responses to common food and inhalant allergens were negative. A food-specific IgG antibody test was conducted, and it was mainly elevated for chicken eggs, rye, sweet pepper, gluten, garlic, wheat, and pineapple. Avoiding these foods had a curative effect on the CSU over a 2-month period.

CONCLUSION

To the best of our knowledge, this is the first case report of symptoms of CSU that resolved after identifying and avoiding food items with IgG antibodies. Furthermore, well-controlled studies are advocated to verify the potential role of IgG food hypersensitivity in the pathogenesis of CSU.