Increased circulating pro-inflammatory cytokines and imbalanced regulatory T-cell cytokines production in chronic idiopathic urticaria

Omalizumab in Chronic Spontaneous Urticaria: A Real-World Study on Effectiveness, Safety and Predictors of Treatment Outcome

Background

Although omalizumab has shown success in treating chronic spontaneous urticaria (CSU) patients unresponsive to antihistamines, the exact mechanism of action and predictive markers of response remain unclear.

Purpose

The aim of this study was to examine the correlation between baseline levels of biomarkers and clinical parameters with omalizumab response and response rate in patients with CSU.

Methods

This retrospective study included 82 adult CSU patients who received omalizumab 300mg every 4 weeks for 16 weeks between January 2022 and December 2023. Treatment response was assessed using UAS7 and DLQI scores at baseline and weeks 4, 8, 12, and 16. Responders were defined as patients achieving UAS7 < 7, with early and late responders categorized based on response within or after 4 weeks, respectively. Baseline clinical features and laboratory biomarkers were compared between responders and non-responders.

Results

The overall response rate was 71.95% (59/82), with 23 early responders and 36 late responders. Responders had significantly lower baseline UAS7 (median: 28 vs 35, P < 0.01), DLQI (median: 8 vs 15, P < 0.001), and IL-17 levels (median: 0.53 vs 1.26 pg/mL, P < 0.001) compared to non-responders. Baseline UAS7 > 31, DLQI > 9.5, and IL-17 > 0.775 pg/mL predicted non-response with sensitivities of 78.26%, 100%, and 78.26%, and specificities of 67.8%, 59.32%, and 72.88%, respectively. ASST positivity and comorbid allergic diseases were associated with early response (P < 0.05). Adverse events were reported in 6.09% of patients, including mild injection site reactions and transient urticaria exacerbation, not requiring treatment discontinuation.

Conclusion

This study suggests that omalizumab is an effective and safe treatment option for antihistamine-refractory CSU. Baseline UAS7, DLQI, ASST status, serum total IgE levels, and IL-17 may serve as potential predictors of omalizumab response. Notably, ASST positivity and comorbid allergic diseases were associated with an early response to treatment. These findings highlight the importance of considering individual patient characteristics when predicting the likelihood and timing of response to omalizumab in CSU.

Chronic Spontaneous Urticaria: Etiology and Pathogenesis

Urticaria, also known as hives, is a common condition thought to affect up to 20% of individuals worldwide in their lifetime. This skin condition is characterized by the appearance of pruritic, erythematous papules or plaques with superficial swelling of the dermis. The major complaint is the symptom of pruritus. Angioedema, which involves a deeper swelling of dermal or mucosal tissues, may accompany urticaria. Urticaria can be classified by both time course of symptoms and the underlying etiology.

The Alarmin Triad-IL-25, IL-33, and TSLP-Serum Levels and Their Clinical Implications in Chronic Spontaneous Urticaria

This study delves into the critical role of alarmins in chronic spontaneous urticaria (CSU), focusing on their impact on disease severity and the quality of life (QoL) of patients. We investigated the alterations in alarmin levels in CSU patients and their correlations with the Urticaria Activity Score (UAS7) and the Dermatology Life Quality Index (DLQI). We analyzed serum levels of interleukin-25 (IL-25), interleukin-33 (IL-33), and thymic stromal lymphopoietin (TSLP) in 50 CSU patients, comparing these to 38 healthy controls. The study examined the relationship between alarmin levels and clinical outcomes, including disease severity and QoL. Elevated levels of IL-33 and TSLP in CSU patients (p < 0.0001) highlight their potential role in CSU pathogenesis. Although IL-25 showed higher levels in CSU patients, this did not reach statistical significance (p = 0.0823). Crucially, IL-33's correlation with both UAS7 and DLQI scores underscores its potential as a biomarker for CSU diagnosis and severity assessment. Of the alarmins analyzed, IL-33 emerges as particularly significant for further exploration as a diagnostic and prognostic biomarker in CSU. Its substantial correlation with disease severity and impact on QoL makes it a compelling candidate for future research, potentially serving as a target for therapeutic interventions. Given these findings, IL-33 deserves additional investigation to confirm its role and effectiveness as a biomarker and therapeutic target in CSU.

Chronic Urticaria Biomarkers IL-6, ESR and CRP in Correlation with Disease Severity and Patient Quality of Life-A Pilot Study

(1) Background: To assess the relationship between serum interleukin-6 (IL-6), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values and disease severity in patients with chronic spontaneous urticaria (CSU) and to examine which of these serum biomarkers better indicates disease severity. (2) Methods: Our pilot study included 20 patients with CSU who filled out questionnaires concerning disease severity and quality of life (the Urticaria Activity Score summed over 7 days [UAS7], the once-daily Urticaria Activity Score [UAS], the Urticaria Control Test [UCT], and the Dermatology Life Quality Index [DLQI]). Blood samples were taken to measure IL-6, ESR and CRP. (3) Results: ESR significantly correlated with the UAS7 (linear and moderate correlation; r = 0.496; p = 0.026), while CRP did not correlate with disease severity. IL-6 correlated with the once-daily UAS (r = 0.472; p = 0.036) and DLQI (r = 0.504; p = 0.023) (linear and moderate correlation) but not the UAS7 or UCT. (4) Conclusions: IL-6 was a better indicator of the once-daily UAS and DLQI, while ESR was a better indicator of the UAS7 (there was no correlation between IL-6, CRP and ESR parameters). Although our results are promising, this study should be conducted with a larger number of CSU patients.

Chronic urticaria and the pathogenic role of mast cells

The signs and symptoms of chronic urticaria (CU) are caused by the activation and degranulation of skin mast cells (MCs). Recent studies have added to our understanding of how and why skin MCs are involved and different in CU. Also, novel and relevant mechanisms of MC activation in CU have been identified and characterized. Finally, the use of MC-targeted and MC mediator-specific treatments has helped to better define the role of the skin environment, the contribution of specific MC mediators, and the relevance of MC crosstalk with other cells in the pathogenesis of CU. Here, we review these recent findings and their impact on our understanding of CU, with a focus on chronic spontaneous urticaria (CSU). Also, we highlight open questions, issues of controversy, and unmet needs, and we suggest what studies should be performed moving forward.

Inhibition of interleukin-1 with rilonacept is not effective in cold urticaria-Results of a randomized, placebo-controlled study

BACKGROUND

Cold urticaria (ColdU) is characterized by pruritic wheals following exposure of the skin to cold. Many patients show insufficient response to antihistamines, the first line treatment. Based on the high efficacy of interleukin-1(IL-1)-inhibition in cold-induced urticarial autoinflammatory diseases, we assessed the effects of rilonacept, an IL-1 inhibitor, in ColdU patients unresponsive to standard treatment.

METHODS

In this randomized, double-blind, placebo-controlled two-center study, we included 20 patients with ColdU. In the first part, patients received 320 mg rilonacept or placebo (1:1) followed by weekly doses of 160 mg rilonacept or placebo for 6 weeks. In the second part, all patients received weekly 160 mg or 320 mg rilonacept for 6 weeks, open-label. The primary endpoint was change in critical temperature threshold (CTT). Secondary endpoints included changes in quality of life impairment (Dermatology Life Quality Index, DLQI), differences of inflammatory mediators upon cold provocation and safety assessment over the study period.

RESULTS

Baseline mean CTTs were 20.2°C (placebo) and 17.3°C (rilonacept). Mean CTTs did not change significantly during the 6-week double-blind treatment (placebo - 0.45°C; rilonacept +0.89°C). IL-6, IL-18 and HSP-70 blood levels showed interindividual variability without significant changes during hand cold water bath provocation in placebo- or rilonacept-treated patients. In contrast, DLQI significantly improved in the rilonacept (mean DLQI reduction of 3.8; p = 0.002) but not in the placebo group (mean DLQI reduction of 0). Comparing baseline with the rilonacept open-label treatment, there were no changes in CTTs or DLQI scores.

CONCLUSION

IL-1 inhibition with rilonacept did not improve ColdU, but demonstrated a good safety profile.

CLINICAL TRIAL REGISTRATION

EudraCT number: 2012-005726-30.

CLINICALTRIALS

gov identifier: NCT02171416.

In silico Identification of Immune Cell-Types and Pathways Involved in Chronic Spontaneous Urticaria

Background

The immunopathogenesis of chronic spontaneous urticaria (CSU) is poorly understood, but recent research suggests that patients can be divided into autoallergic and autoimmune subtypes. Given that not all patients can be controlled with current treatment regimens, including anti-IgE monoclonal antibodies, a better understanding of the immune pathways involved in CSU may enable the repurposing of monoclonal antibodies used for other dermatologic diseases (e.g., Th2 and Th17 inhibitors). Therefore, we investigated the implicated immune cells and pathways by reanalyzing publicly available transcriptomic data.

Methods

Microarray data of CSU and healthy control (HC) skin and blood were obtained from the Gene Expression Omnibus (GSE72542, GSE57178). Differentially expressed genes were defined as a false discovery rate <0.05 and a |log₂ fold change| ≥1. Pathway analyses were conducted using ToppGene and KEGG. Cell-type enrichment was determined by CIBERSORT and xCell and was correlated with clinical characteristics.

Results

Th2 (IL-4/13 signaling) and Th17-related (IL-17/23 signaling) pathways were upregulated in lesional compared to non-lesional and HC samples. In non-lesional versus lesional samples, CIBERSORT analysis revealed increased regulatory T-cells (Treg) and resting mast cells. xCell analysis established that Th1 and Th2 scores were not significantly different between lesional and HC samples. However, Th2 scores in both lesional and non-lesional samples correlated positively with disease severity. Few differentially expressed genes and pathways were identified between CSU and HC blood samples.

Conclusion

Our results support the involvement of Th2 and Th17-related genes and pathways in CSU. Th2 scores associate with disease severity, which indicates the clinical relevance of these findings. Increased resting mast cell and Treg scores in non-lesional samples may suggest local suppression of wheal formation. Moreover, disease activity seemed to be restricted to the skin as there were limited findings from blood. Larger studies using next-generation sequencing will be helpful to confirm these results.

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.

The Role of Interleukin 10 and 18 in Chronic Spontaneous Urticaria Pathogenesis in the Context of Angioedema Coexistence

Chronic spontaneous urticaria (CSU) is defined using clinical symptoms as spontaneous occurrence of itchy wheals and/or angioedema for at least 6 weeks. Angioedema is underdiagnosed in CSU patients, and its presence has significant negative impact on health-related quality of life, daily activities, health care resource utilization, and work. Various cytokines have been found to be involved in pathogenesis of CSU. To study levels of interleukin (IL)-10 and IL-18 in CSU patients and to look for the differences in CSU subgroups divided with regard to angioedema reoccurrence, we included consecutive CSU patients into the study. To assess disease activity, urticaria activity score was used. In addition, we calculated disease duration time. In all groups, Il-10 and Il-18 serum concentrations were measured. The study involved 52 patients with CSU and 47 healthy volunteers. The IL-10 level was statistically significantly higher in patients with CSU compared to the control group. There were no significant differences in level of IL-18 between those groups. Comparison of patients with CSU and angioedema with those without angioedema showed no significant differences in level of IL-10 and IL-18. We see the need for further studies of serum levels of IL-10 and IL-18 to better understand the pathogenesis of the disease and to find markers useful in predicting the symptom type in the course of CSU.

The Pathogenesis of Chronic Spontaneous Urticaria: The Role of Infiltrating Cells

Chronic spontaneous urticaria is characterized by a perivascular non-necrotizing cellular infiltrate around small venules of the skin. It consists primarily of CD4(+) lymphocytes, a prominence of the T helper (Th)2 subtype but also Th1 cells, with Th17 cell-derived cytokines elevated in plasma. There are also neutrophils, eosinophils, basophils, and monocytes. Chemokines derived from mast cells and activated endothelial cells drive the process. Although the role of the cellular infiltrate has not previously been addressed, each constituent can contribute to the overall pathogenesis. It is of interest that CSU responds to corticosteroid, yet, short-term steroids do not affect autoimmunity or degranulation of mast cells, and act on margination of cells along the endothelium and chemotaxis to enter the surrounding dermis. In this review, we address each cell's contribution to the overall inflammatory response, as it is currently understood, with a view toward development of therapeutic options that impede the function of critical cells and/or their secretory products.

Case Report: Refractory Chronic Spontaneous Urticaria Treated With Omalizumab in an Adolescent With Crohn's Disease

Chronic spontaneous urticaria (CSU) is a mast cell-driven disease that is often associated with autoimmune or autoinflammatory conditions. Omalizumab is recommended in the treatment of refractory CSU in patients over 12 years of age who do not respond to four standard doses of antihistamines. Omalizumab blocks the mast cells’ degranulation, thus interrupting the resulting inflammatory cascade driven by T-helper 2 (Th2) cytokines. The efficacy of omalizumab in controlling CSU and possible associated diseases has been studied in few patients so far. In particular, some case reports describe adults with CSU and concomitant inflammatory bowel diseases (IBD), such as Crohn’s disease (CD) or ulcerative colitis (UC). Although the treatment of CD with anti-tumor necrosis factors-α (TNF-α) seems to be effective in controlling CSU, no cases of the utility of omalizumab in patients with both conditions have been described so far. At the moment, there is no evidence that the pathogenetic mechanisms underlying CD are linked to the same pathways that are inhibited by omalizumab for the treatment of CSU. We present the first pediatric case of refractory CSU and CD in which omalizumab led to CSU remission, even if the follow-up period was limited. In conclusion, our experience shows how CSU could be associated with CD and successfully treated with the monoclonal anti-IgE antibody in a patient on immunosuppressive therapy. However, more data is needed from a larger population.

Correlation of urticaria activity score in chronic spontaneous urticaria with serum C-reactive protein level and neutrophil/lymphocyte ratio

Chronic spontaneous urticaria (CSU) lacks a specific trigger. The urticaria activity score (UAS) is used to evaluate disease status. Some studies have reported elevated serum levels of high-sensitivity C-reactive protein (hsCRP) in CSU patients, which is correlated with disease severity. The neutrophil/lymphocyte (N/L) ratio is a significant indicator of systemic inflammation. We investigated the potential correlation between serum levels of hsCRP and N/L ratio, as well as urticaria activity, in CSU patients. We included 52 CSU patients treated at the Dermatology Polyclinic of Beysehir State Hospital between August and October 2020, and 50 controls. The 7-day UAS were graded mild, moderate, or intense. We measured N/L ratios, erythrocyte sedimentation rates (ESRs), and the levels of hsCRP, T4, and thyroid-stimulating hormone (TSH) in each group. The anti-thyroglobulin (anti-TG) and anti-microsomal antibody (anti-TPO) levels of CSU patients were also assayed. There were no significant differences in hsCRP, T4, or TSH levels between the groups; however, both the ESR and N/L ratio were significantly higher in CSU patients hsCRP (P = .96), T4 (P = .07), TSH (P = .67), ESR (P < .001), N/L(P < .001). No correlation was evident between the UAS day 7 (UAS7) score and the hsCRP level or the N/L ratio (P = .528 and P = .387). Of all the CSU patients, 19.2% tested positive for anti-TPO and 9.6% were positive for anti-TG; these data were not correlated with the UAS7 (P = 1 and P = .637). Inflammation plays a role in CSU. Although we did not find a correlation between the UAS and either the hsCRP level or the N/L ratio, the ESR and N/L ratio were higher in CSU patients than in controls.

The Emerging Role of IL-17 in the Immune-Pathogenesis of Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is considered to be an autoimmune disorder (type I and type II) in 50% of all cases. However, autoreactive T cells and their proximity with activated mast cells in the skin of CSU patients are believed to be the primary event in mast cell degranulation. The finding of anti-FcɛRIα on mast cells or IgE autoantibodies against thyroid antigens should be considered to be a consequence of the auto-reactive T cells’ recognition of the above-mentioned antigens. Our recent finding of increased Th17 and IL-17 expression in both CD4+ T cells and mast cells in the skin of severe CSU patients is supportive for the major role that T cells perform in the pathogenesis of CSU. Supporting this are numerous previous reports in which increased serum IL-17 was found to be in association with CSU disease severity. The beneficial effect of anti-IL-17A (secukinumab) in CSU patients in whom high dose anti-histamines, recurrent course of steroids and omalizumab fail to achieve a reasonable response should be investigated as a new therapeutic strategy in future studies with a large cohort of patients.

Interleukin 17 receptor A haplotype analysis in chronic spontaneous urticaria: A preliminary study

BACKGROUND

Chronic spontaneous urticaria (CSU) is a distressing skin disease. Family clustering and heterogeneity in the onset and progression indicate that susceptibility to CSU is a complex trait. In this study, we performed haplotype analysis for one of the key player gene, IL17RA, for CSU to test the association with disease susceptibility and severity.

METHODOLOGY

The study included 70 CSU patients and 30 healthy controls. The severity of the disease was evaluated by autologous serum skin test (ASST) and urticaria activity score (UAS). ASST test was done and quality of life was assessed using a questionnaire. Allelic discrimination analysis for rs4819554 and rs879577 was performed using real-time polymerase chain reaction technology.

RESULTS

Carriers of rs4819554*G were more prone to develop CSU than its counterpart (P = .039), while rs4819554*A allele displayed more severe phenotype in the form of more prolonged disease duration (P = .040), concurrent angioedema (P < .001), higher level of treatment (P < .001), and higher score of quality of life (P < .001). Additionally, homozygote patients with rs879577*CC were associated with angioedema (P < .001). Haplotype analysis revealed that cohorts with both rs4819554*A and rs879577*T conferred protection against developing CSU (OR = 0.07, 95% CI = 0.01-0.32, P = .001).

CONCLUSION

Our results showed that IL17RA gene polymorphisms might contribute to the increased susceptibility to CSU.

Does adiponectin play a role in the pathogenesis of chronic spontaneous urticaria?

Introduction

Chronic spontaneous urticaria constitutes an interdisciplinary problem and its pathogenesis is still a subject of debate. Overweight and hyperlipidemia are supposed to be related to chronic spontaneous urticaria. Fatty tissue can be the source of adipokines.

Aim of the study

To assess the potential role of adiponectin in chronic spontaneous urticaria pathogenesis.

Material and methods

The study included 52 chronic spontaneous urticaria patients and 43 healthy controls. The patients were divided into two subgroups: patients with wheals only, and patients with urticaria and an accompanying angioedema. The adiponectin concentration was measured in all studied subjects.

Results

No statistically significant difference in adiponectin level was determined between the studied groups and subgroups.

Conclusions

We are among the first to present the results of study to determine a possible role of adipokines in chronic spontaneous urticaria pathogenesis. We did not observe any difference in adiponectin level. In our opinion, it is necessary to conduct further analyses in this field.

Dietary habits in Japanese patients with chronic spontaneous urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) is defined as the spontaneously appearing weals and/or angioedema for more than 6 weeks. Dietary habits can modulate the pathogenesis of CSU. However, dietary intakes of nutrients or food in CSU patients, compared with healthy controls, have not been examined in quality and quantity.

METHODS

We evaluated dietary habits in adult Japanese patients with chronic spontaneous urticaria using a validated, brief-type self-administered diet history questionnaire and compared the results to those of age- and sex-matched healthy controls. The severity of CSU was evaluated using the Urticaria Control Test.

RESULTS

Japanese CSU patients showed higher body mass indices, higher intakes of eggs, vegetables other than green/yellow vegetables/mushrooms/algae, cholesterol, folic acid, dietary fibres, vitamin D, vitamin K, Cu, Fe, Pi, Ca, Mg, Na and salt, and lower intake of alcohol, compared to controls. The logistic regression analysis showed that CSU was associated with high body mass index and high intake of eggs. The intake of beverages was higher in uncontrolled CSU patients (Urticaria Control Test ≦11 points) than in controlled patients. The logistic regression analysis showed that uncontrolled CSU was associated with high intake of beverages. The intake of coffee, caffeine-rich and non-alcohol beverage, in uncontrolled CSU patients was higher than that in controlled patients.

CONCLUSIONS

Chronic spontaneous urticaria was associated with high body mass index and high intake of eggs. Uncontrolled CSU was associated with high intake of beverages. Further studies should elucidate the relationships of these results with the development or exacerbation of CSU.

Chronic urticaria and osteoporosis: a longitudinal, community-based cohort study of 11 944 patients

BACKGROUND

Chronic urticaria (CU) carries many risk factors for osteoporosis, but data on the relationships between CU and osteoporosis are lacking.

OBJECTIVES

To evaluate the association between CU and osteoporosis in a large community-based study.

METHODS

A nationwide observational longitudinal cohort study was conducted. CU was defined as four pairs of urticaria diagnoses; each pair was recorded within a period of 6 weeks and was registered by physicians in a primary-care setting. Patients with CU and their age- and sex- matched controls were followed for the incidence of osteoporosis and other laboratory data between 2002 and 2017. Data regarding systemic steroid exposure and other relevant risk factors for osteoporosis were obtained. Analyses of risk for osteoporosis were performed in Cox regression models adjusted for age, sex, exposure to systemic corticosteroids, obesity, smoking and hyper- and hypothyroid disease.

RESULTS

The study included 11 944 patients with CU and 59 829 controls. During the study's observation period, 1035 (8·7%) patients with CU were diagnosed with osteoporosis, compared with 4046 (6·8%) controls. The adjusted multivariate analysis demonstrated that CU was significantly associated with a higher risk for osteoporosis (hazard ratio 1·23, 95% confidence interval 1·10-1·37, P < 0·001).

CONCLUSIONS

CU may impose a risk for osteoporosis. Appropriate targeted screening should be considered.

Evaluation of carotid intima media thickness and hematologic inflammatory markers in patients with chronic spontaneous urticaria

Introduction

Low grade inflammation is associated with chronic spontaneous urticaria (CSU) and atherosclerosis. There are little data on the relationship between urticarial inflammation and atherosclerosis. The neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) and mean platelet volume (MPV) have recently been studied in many diseases as a biomarker of inflammation.

Aim

To evaluate hematologic inflammatory parameters and subclinical atherosclerosis in CSU patients.

Material and methods

C-reactive protein (CRP), NLR, PLR, MPV and carotid intima media thickness (CIMT) in CSU patients were compared with healthy controls. Thirty CSU patients and 30 healthy controls participated in the study.

Results

Thirty CSU patients and 30 healthy controls participated in the study. 53.3% of the patient group were females, 46.7% were males and the mean age was 37.7 ±7.7. 53.3% of the healthy control group were females, 46.7% were males and the mean age was 37.1 ±7.2. Body mass index was 24.63 ±2.7 kg/m² in the patient group and 24.83 ±2.5 kg/m² in the control group. Left and right CIMT and CRP values were higher in CSU patients and high-density lipoproteins (HDL) values were lower in the CSU patients. There was a positive correlation between the right and left CIMT and urticaria activity severity 4 (UAS4), disease severity, and triglycerides in the patient group, also a negative correlation was found between the right and left CIMT and the HDL values. C-reactive protein was also correlated with UAS4 and disease severity.

Conclusions

This is the first study to evaluate subclinical atherosclerosis in CSU patients. Chronic spontaneous urticaria may be associated with an increased atherosclerotic risk. Serum CRP concentration can also be used as an objective parameter to evaluate disease severity.

Interplay between acute phase response and coagulation/fibrinolysis in chronic spontaneous urticaria

Background

Chronic spontaneous urticaria (CSU) is associated with activation of systemic inflammatory response and coagulation/fibrinolysis.

Aim

To study whether there is a relationship between the acute phase response and coagulation/fibrinolysis in chronic spontaneous urticaria (CSU) patients.

Methods

Serum concentrations of C-reactive protein (CRP) and interleukin 6 (IL-6), key markers of acute phase response and of D-dimer, a marker of fibrin turnover were investigated in 58 CSU patients assessed with the urticaria activity score (UAS) and the controls.

Results

Serum concentrations of IL-6, CRP, and D-dimer were significantly higher in CSU patients as compared with the controls. We found statistically significant correlations between D-dimers concentrations and the inflammatory markers: CRP and IL-6 as well as UAS.

Conclusions

Markers of inflammation (IL-6 and CRP) and of fibrinolysis (D-dimer) are related to each other in CSU, suggesting a possible cross-talk between inflammation and coagulation/fibrinolysis. It might be implicated in pathogenesis of the disease and may be associated with higher risks of cardiovascular diseases in CSU patients.

Chronic Spontaneous Urticaria: The Devil's Itch

Chronic urticaria is defined as the presence of urticaria for a period exceeding 6 weeks, assuming symptoms for most days of the week. It is divided into chronic inducible urticarias and chronic spontaneous urticaria, previously termed chronic idiopathic urticaria. The latter designation emphasizes that patients can experience urticaria independent of any exogenous stimulus even if one can define circumstances that may worsen symptoms. A search for such an external "cause" is fruitless because the underlying abnormality is "intrinsic," whether it is autoimmune, or some unknown process. Approximately 40% of patients with chronic spontaneous urticaria report accompanying episodes of angioedema, whereas 10% have angioedema as their primary manifestation. In most cases, it is a self-limiting disorder, persisting for 2 to 5 years in most cases, although 20% of patients suffer for more than 5 years. The treatment that has evolved is largely empiric, based on double-blind, placebo-controlled studies whenever possible, but is not yet targeted to any particular pathogenic mechanism. In this article, we review the current status regarding pathogenesis, discuss the diagnostic workup, and update the approach to treatment including consideration of published guidelines, our own experience, and guideline updates that are being prepared.

Increased plasma IL-17, IL-31, and IL-33 levels in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is considered in a subset of patients to be an autoimmune disorder. Interleukin(IL)-17, IL-31, and IL-33 are involved in some immune response. The aim of this study was to quantify plasma IL-17, IL-31, and IL-33 levels in CSU patients and to examine their relationships with disease severity. Plasma IL-17, IL-31, and IL-33 concentration were measured in 51 CSU patients and 20 healthy subjects (HCs). Plasma IL-17 (P < 0.001), IL-31 (P < 0.001), and IL-33 (P < 0.001) concentrations were significantly higher in CSU patients when compared with those of HCs. Concerning UAS7, severe group of CSU patients had significantly higher IL-17 levels than the moderate and mild groups (P = 0.028 and 0.007, respectively), and significantly higher IL-33 concentrations than the mild group (P = 0.026). Regarding only pruritus, severe group of patients had significantly higher IL-31 levels than the mild group (P = 0.003). The IL-33 levels in the total IgE positive group were significantly higher than that of negative group (P = 0.010). Our results showed higher plasma levels of IL-17, IL-31, and IL-33 among CSU patients which may highlight a functional role of these cytokines in the pathogenesis of CSU.

Association of TG2 from mast cells and chronic spontaneous urticaria pathogenesis

BACKGROUND

Mast cells and their mediators play important roles in chronic spontaneous urticaria (CSU) pathogenesis. Transglutaminase 2 (TG2) is expressed in activated mast cells and contributes to airway inflammation in allergic asthma.

OBJECTIVE

To investigate the role of TG2 in CSU.

METHODS

Patients with CSU (n = 72) and healthy controls (n = 51) were evaluated. Skin biopsy specimens were obtained from 5 patients with CSU and 2 healthy controls. Cord blood-derived human mast cells and peripheral blood-derived human mast cells were activated with IgE. TG2 activity and inflammatory mediators, such as histamine, leukotriene C4, and cytokines, were measured in serum or supernatant from cultured mast cells by enzyme-linked immunosorbent assay. Colocalization of mast cells and TG2 was determined in skin tissues by immunofluorescence.

RESULTS

TG2 activity was significantly higher in serum samples from patients with CSU than in serum samples from healthy controls (P < .001). Colocalization of mast cell surface marker c-kit and TG2 was significantly increased in the lesional skin of patients with CSU compared with that in healthy controls. The levels of histamine, leukotriene C4, tumor necrosis factor α, transforming growth factor β, and interleukins 4, 5, and 6 were significantly higher in patients with CSU than in healthy controls (P < .001). Serum TG2 levels had positive correlations with each inflammatory mediator (P < .001). TG2 activity was increased in cord blood-derived human mast cells (CBMCs) and peripheral blood-derived human mast cells activated with IgE compared with those without activation (P < .05).

CONCLUSION

Our findings suggest that TG2 expressed in and released from mast cells plays an important role in CSU pathogenesis.

Single nucleotide polymorphisms of IL-2, but not IL-12 and IFN-γ, are associated with increased susceptibility to chronic spontaneous urticaria

BACKGROUND

A clear picture of interaction of Th1/Th2 cytokines in pathogenesis of chronic spontaneous urticaria (CSU), remains elusive. Impaired IFN-γ production and decreased levels of IL-2 have been reported. The aim of this study was to evaluate the association of Th1 cytokines; IL-2, IL-12 and IFN-γ polymorphisms with CSU.

METHODS

90 patients with CSU and 140 age-sex matched subjects were included in this study. DNA samples were evaluated through PCR-SSP assay in order to detect single nucleotide polymorphisms of IL-12 (A/C -1188) or (rs3212227), IFN-γ (A/T UTR5644) or (rs2069717) and IL-2 (G/T -330 and G/T +166) or (rs2069762 and rs2069763).

RESULTS

G allele at -330 at promoter region of IL-2 gene was overrepresented in CSU. Heterozygotes (GT) at this locus and heterozygotes at +166 of IL-2 gene (GT) were more prevalent in CSU group. Additionally, the haplotype GT for loci -330 and +166 of IL-2 gene was powerfully associated with CSU (OR (95%CI)=57.29 (8.43-112.7)).

CONCLUSIONS

SNP at position -330 and +166 of IL-2 gene are differently expressed in CSU. The haplotype GT of IL-2 at -330 and +166 might confer vulnerability to a number of immunological disorders in Iranian region.

The relationship between circulating concentrations of interleukin 17 and C reactive protein in chronic spontaneous urticaria

Background

Up-regulation of interleukin 17 (IL-17) family cytokines and acute phase response have been observed in patients with chronic spontaneous urticaria (CSU). It has been demonstrated that IL-17 stimulates C-reactive protein (CRP) expression.

Aim

To determine relationship between circulating concentrations of IL-17 and CRP in CSU.

Methods

Concentrations of IL-17 in plasma and CRP in serum were measured in patients with CSU of varying severity and in the healthy subjects.

Results

IL-17 and CRP concentrations were significantly higher in CSU patients as compared to the healthy subjects. In addition, there were significant differences in IL-17 and CRP concentrations between CSU patients with mild, moderate-severe symptoms and the healthy subjects. CRP did not correlate significantly with IL-17.

Conclusions

Increased circulating IL-17 concentration may represent an independent index of systemic inflammatory response in CSU, which is not related to increased CRP concentration.

Analysis of the association of chronic spontaneous urticaria with interlekin-4, -10, transforming growth factor-β1, interferon-γ, interleukin-17A and -23 by autologous serum skin test

Aim

To contribute to the understanding of the pathogenesis of chronic spontaneous urticaria (CSU) by identifying its relationship with autoimmunity and cytokines using the autologous serum skin test (ASST) and peripheral blood mononuclear cell culture (PBMC) method.

Material and methods

Interleukins (IL)-4, IL-10, transforming growth factor (TGF-β1), interferon (IFN)-γ, IL-17A, and IL-23 levels in cell supernatants obtained by the PBMC method were measured using ELISA. Disease activity was assessed by determining the urticaria activity score (UAS).

Results

A total of 40 patients diagnosed with CSU participated in this study. Twenty patients had positive ASST results, and 20 had negative results. The control group included 20 healthy volunteers. We found that the IL-23 (p = 0.01), IL-10 (p = 0.04) and IL-4 (p = 0.04) levels of the patient groups were significantly lower compared with those of the control group. The IL-23 (p = 0.009), IL-10 (p = 0.009), IL-4 (p = 0.001), and IL-17 (p = 0.05) levels of the ASST(–) patient group were significantly lower compared with those of the control group. In addition, the IL-4 (p = 0.03) and IFN-γ (p = 0.05) levels of the ASST(+) patient group were significantly lower compared with those of the control group, and the ASST(+) patients had a significantly higher UAS than the ASST(–) patients (p = 0.021).

Conclusions

These results, when considered together with current reports in the literature, indicate that immune dysregulation occurs in the pathogenesis of CSU, causing cytokine imbalance.

Plasma Levels of Matrix Metalloproteinase-9 in Children With Chronic Spontaneous Urticaria

Purpose

Chronic spontaneous urticaria (CSU) is a disease that is primarily seen in adults and is comparatively rare in children. Consequently, only a few studies have focused on the pathogenesis of the disease in children. This study investigated the possible role of metalloproteinase-9 (MMP-9) in the pathogenesis of CSU in children.

Methods

The study group was composed of 54 children with CSU; 34 healthy children comprised the control group. The demographic and clinical features of the study group were extensively evaluated, and laboratory assessments were also performed. An enzyme-linked immunosorbent assay was used to evaluate levels of plasma MMP-9. Disease activity was quantified using the urticaria activity score (UAS).

Results

The median value of plasma MMP-9 was 108.9 ng/mL (interquartile range, 93.3-124.1) in the CSU group and 87.8 ng/mL (69.4-103.0) in the control group. The difference between the 2 groups was statistically significant (P<0.001). Also, MMP-9 levels showed a significant positive correlation with UAS (rho=0.57, P<0.001). Twenty-six percent of patients had positive autologous serum skin test (ASST) results. Neither UAS nor plasma MMP-9 levels were significantly different between ASST-positive and -negative patients (P>0.05).

Conclusions

Plasma MMP-9 levels were elevated in children with CSU and were positively correlated with disease activity. MMP-9 may be both a good biomarker of disease activity and a potential therapeutic target in CSU.

Hyperlipidemia Is Associated with Chronic Urticaria: A Population-Based Study

The etiology of chronic urticaria (CU) is diverse, with chronic infections and inflammation being reported as considerable contributing factors. Although the prevalence of metabolic syndrome was found to be significantly elevated in patients with CU, no one has specifically estimated the effects on CU following hyperlipidemia. This study aimed to examine the association between hyperlipidemia and CU using a population-based dataset in Taiwan. This study included 9798 adults with CU as cases and 9798 sex- and age-matched controls. These patients were examined for whether they had received a prior diagnosis of hyperlipidemia. We used conditional logistic regression analyses to calculate the odds ratio (OR) and its corresponding 95% confidence interval (CI) for having been previously diagnosed with hyperlipidemia between cases and controls. In total, 7066 (36.1%) patients had received a prior diagnosis of hyperlipidemia, including 4287 (43.8%) among CU cases and 2779 (28.4%) among controls. The conditional logistic regression revealed that the OR of prior hyperlipidemia for cases was 1.97 (95% CI: 1.85~2.09) compared to the controls. Furthermore, compared to patients without CU, patients with CU independently experienced a 1.65-fold (95% CI = 1.55~1.76; p<0.001) increased risk of having a prior hyperlipidemia diagnosis, after adjustments were made. We concluded that CU was associated with having received a prior diagnosis of hyperlipidemia.

Diamine oxidase levels in different chronic urticaria phenotypes

BACKGROUND

Diamine oxidase (DAO) is a polyamine-degrading enzyme also implicated in histamine metabolism. Chronic urticaria (CU) has a wide spectrum of clinical presentations and causes. Anisakis sensitisation associated chronic urticaria (CU+) has been characterised as a phenotype with different clinical and immunological characteristics and possibly associated with previous acute parasitism. We aimed to analyse serum DAO levels in different CU phenotypes. We further analysed the possible association of DAO with fish eating habits.

METHODS

We studied 35 CU+ patients and 39 non-sensitised CU patients (CU-) as well as 19 controls. We analysed fish-eating frequency as well as fish intake associated exacerbation of CU (FIAE) or gastro-intestinal complaints (GI). DAO levels were further analysed with respect to lymphoproliferative responses, cytokine and specific IgE production.

RESULTS

DAO levels were not different between CU and controls, but were significantly higher in CU+ than in CU-. CU+ patients with FIAE had lower DAO levels, but no differences were detected in patients with GI. DAO levels correlated positively with oily and canned fish consumption in CU-. In CU+, DAO levels correlated positively with specific Anisakis IgE, percentages of proliferation in Anisakis stimulated peripheral blood lymphocytes, serum IL-2 and IL-6, but correlated negatively with mitogen stimulated TGF-β in supernatants.

CONCLUSIONS

DAO levels in CU depend on fish-eating habits and in CU+ on the amount of specific IgE production. In the CU+ phenotype, lower levels of DAO predispose to urticaria exacerbation after fish intake, probably due to a relative insufficient enteric availability of this enzyme.

Vitamin D as a Marker for Disease Severity in Chronic Urticaria and Its Possible Role in Pathogenesis

BACKGROUND

Chronic urticaria is defined as repeated episodes of wheals lasting for 6 weeks or longer. Nowadays, the role of vitamin D in various chronic diseases is a matter of great interest, but limited data is available on the vitamin D status in patients with chronic urticaria.

OBJECTIVE

The goal of this study was to investigate the relationship between vitamin D status and clinical characteristics of chronic urticaria.

METHODS

The clinical records of 72 patients with chronic urticaria, 26 with acute urticaria and 26 with atopic dermatitis, along with 72 healthy controls, were retrospectively reviewed.

RESULTS

The serum 25-(OH)D3 level was found to be significantly reduced in patients with chronic urticaria compared to those in the other groups. In particular, the proportion of patients with critically low vitamin D levels (<10 ng/ml) was significantly higher in the chronic urticaria group than in the other groups. The serum vitamin D levels showed significant negative associations with urticaria activity score and disease duration. In addition, serum vitamin D levels were significantly lower in subjects with a positive autologous serum skin test than in subjects with a negative result.

CONCLUSION

In conclusion, the serum vitamin D level was more likely to be critically low in patients with chronic urticaria, and an inverse relationship with disease severity and disease duration was observed. These findings may open up the possibility of the clinical use of vitamin D as a contributing factor in the pathogenesis of chronic urticaria and a predictive marker for disease activity in chronic urticaria.

Interleukin-6 and tumor necrosis factor-alpha gene polymorphisms in chronic idiopathic urticaria

BACKGROUND

This study was performed to evaluate association of gene polymorphisms among proinflammatory cytokines and susceptibility to chronic idiopathic urticaria (CIU).

METHODS

Ninety patients with prolonged urticaria more than 6 weeks were included as case group. Single nucleotide polymorphisms (SNPs) of IL-6 (G/C -174, G/A nt565) and TNF-α (G/A -308, G/A -238) were evaluated, using polymerase chain reaction (PCR); and the results were compared to the control group.

RESULTS

G allele was significantly higher in the patients at locus of -238 of promoter of TNF-α gene (p<0.001). Frequency of following genotypes were significantly lower in patients with CIU, compared to controls: AG at -308 and GA at -238 of TNF-α gene (p<0.05 and p<0.001, respectively), CG at -174 and GG at +565 of IL-6 gene (p<0.05). Additionally, following genotypes were more common among patients with CIU: GG at -308 and -238 of TNF-α gene (p<0.05 and p<0.001, respectively), GG at -174 and GA at +565 of IL-6 gene (p<0.05).

CONCLUSIONS

Pro-inflammatory cytokine gene polymorphisms can affect susceptibility to CIU. TNF-α promoter polymorphisms as well as IL-6 gene polymorphisms are associated with CIU.

Circulating level of CD4+ CD25+ FOXP3+ T cells in patients with chronic urticaria

BACKGROUND

CD4+ CD25+ T-regulatory (Treg) cells play critical roles in maintaining peripheral tolerance and preventing autoimmunity. As characteristics of Treg cells have not been precisely investigated in chronic urticaria (CU) yet, this study was performed.

OBJECTIVE

To determine the frequencies of circulating CD4+ CD25+ FOXP3+ T cells and serum levels of interleukin (IL)-10, transforming growth factor (TGF)-β, and IL-17 in patients with chronic autoimmune urticaria and chronic idiopathic urticaria compared to healthy controls.

METHODS

Peripheral blood mononuclear cells (PBMCs) were obtained from patients with CU and healthy controls. The frequency of CD4+ CD25+ T cells in PBMCs and expression levels of FOXP3 were detected by flow cytometry. The serum levels of IL-10, TGF-β, and IL-17 were measured by enzyme-linked immunosorbent assay.

RESULTS

A significant decrease in the percentage of circulating CD4+ CD25+ FOXP3+ T cells was detected in patients with CU, compared to control subjects. However, no significant difference was detected on the serum levels of IL-10, TGF-β, and IL-17 between patients with CU and control subjects.

CONCLUSIONS

This study demonstrated that the frequency of Treg cells in PBMCs was decreased in patients with CU. Further studies are needed to clarify the exact role of Treg cells in the pathogenesis of CU and factors regulating their function.

Pathogenesis of chronic urticaria: an overview

The pathogenesis of chronic urticaria is not well delineated and the treatment is palliative as it is not tied to the pathomechanism. The centrality of mast cells and their inappropriate activation and degranulation as the key pathophysiological event are well established. The triggering stimuli and the complexity of effector mechanisms remain speculative. Autoimmune origin of chronic urticaria, albeit controversial, is well documented. Numerical and behavioral alterations in basophils accompanied by changes in signaling molecule expression and function as well as aberrant activation of extrinsic pathway of coagulation are other alternative hypotheses. It is also probable that mast cells are involved in the pathogenesis through mechanisms that extend beyond high affinity IgE receptor stimulation. An increasing recognition of chronic urticaria as an immune mediated inflammatory disorder related to altered cytokine-chemokine network consequent to immune dysregulation resulting from disturbed innate immunity is emerging as yet another pathogenic explanation. It is likely that these different pathomechanisms are interlinked rather than independent cascades, acting either synergistically or sequentially to produce clinical expression of chronic urticaria. Insights into the complexities of pathogenesis may provide an impetus to develop safer, efficacious, and targeted immunomodulators and biological treatment for severe, refractory chronic urticaria.

Positive associations between infections of Toxoplasma gondii and seropositivity with Anisakis simplex in human patients suffering from chronic urticaria

Toxoplasma gondii is a food-borne and orofecal microorganism which produces chronic infection, and attempts have been made to prove its negative association with atopy in the context of the hygiene hypothesis. Anisakis simplex is a fish parasite associated with chronic urticaria (CU) in endemic regions. We analysed the relationship between both infectious agents in CU. We included 42 patients with chronic urticaria (18 patients with CU associated with A. simplex sensitization and 24 not sensitized CU patients). Patients were assessed for atopy by a skin prick test (SPT) against common aeroallergens and for respiratory symptoms. Anisakis simplex sensitization was assessed by SPT and specific IgE by CAP fluoro-enzyme immunoassay (CAP-FEIA). Anti-T. gondii IgG levels were measured by enzyme-linked immunosorbent assay (ELISA). CU patients were analysed with respect to T. gondii seropositivity, A. simplex sensitization, atopy and immigrant status. The seroprevalence of T. gondii was 40.5% in CU patients and 42.1% in the control group. Immigrants were more frequently infected by T. gondii (41.2% versus 12%; P =0.036). Anti-T. gondii IgG antibodies were associated with past A. simplex parasitism (odds ratio 6.73; P =0.03) and independently with atopic sensitization (odds ratio 5.85; P =0.04). In CU patients, T. gondii has no protective effect on atopic sensitization or A. simplex sensitization.

Chronic spontaneous urticaria: etiology and pathogenesis

Urticaria affects individuals of all ages and is commonplace. Nearly 1 in 5 individuals will experience an episode of urticaria in their lifetime, while the chronic form of disease has an estimated annual prevalence of approximately 1% of the population. Given the similarity of chronic urticaria symptoms to those seen in patients suffering an allergic reaction, the condition often leads to a search for an external cause. In most cases, no external trigger factor is identified. At present several theories of pathogenesis exist, none of which is firmly established.

Interleukin 1-β, interleukin-1 receptor antagonist, and interleukin 18 in children with acute spontaneous urticaria

Very little is known about the role of interleukin-1β (IL-1β) and interleukin-18 (IL-18) in urticaria. Material and Methods. Serum levels of IL-1β, IL-1 receptor antagonist (IL-1RA), and IL-18 were measured in 56 children with urticaria and in 41 healthy subjects. Results. Serum IL-1β did not differ between children with acute urticaria and controls. Children with single episode of urticaria had higher levels of IL-1RA and IL-18 than healthy subjects. In children with single episode of urticaria, level of IL-1RA correlated with C-reactive protein (CRP), D-dimer, and IL-1β levels. In subjects with recurrence of urticaria IL-1RA was positively correlated with WBC and D-dimer levels. No correlation of cytokine levels and urticaria severity scores (UAS) in all children with urticaria was observed. In children with single episode of urticaria UAS correlated with CRP level. In the group with single episode of urticaria and in children with symptoms of upper respiratory infection, IL-1RA and IL-18 levels were higher than in controls. The former was higher than in noninfected children with urticaria. In conclusion, this preliminary study documents that serum IL-1RA and IL-18 levels are increased in some children with acute urticaria. However further studies are necessary to define a pathogenic role of IL-1β, IL-1RA, and IL-18 in urticaria.

Chronic urticaria: Indian context-challenges and treatment options

Urticaria is a common condition that occurs in both children and adults. Most cases have no specific allergic trigger and the aetiology of urticaria remains idiopathic and occasionally spontaneous in nature. Inappropriate advice such as avoidance of foods (milk, egg, prawn, and brinjal) is common place in certain sections of India mostly by nonspecialists that should not be routinely recommended. It is important to look for physical urticarias such as pressure urticaria in chronic cases, which may be present either alone or in combination with other causes. Autoimmune causes for chronic urticaria have been found to play an important role in a significant proportion of patients. Long-acting nonsedating antihistamines at higher than the standard doses is safe and effective. Quality of life is affected adversely in patients with chronic symptomatic urticaria and some may require multidisciplinary management.

Endostatin and Thrombospondin-1 levels are increased in the sera of patients with chronic spontaneous urticaria

Chronic urticaria (CU) is a common disease characterized by recurrent itchy wheals and/or angioedema for more than 6 weeks. Increased levels of the pro-angiogenic mediator vascular endothelial growth factor (VEGF) have been described in skin disorders, such as chronic urticaria (CU), psoriasis and atopic dermatitis. Up to now, no data on the role of VEGF endogenous inhibitors Endostatin (ES) and Thrombospondin-1 (TSP-1) in CU are available. The aim of our study is to investigate the potential involvement of ES and TSP-1 in patients with chronic spontaneous urticaria (CSU). The levels of ES and TSP-1 were measured in the sera of 106 adult patients with CSU and 98 healthy subjects by enzyme immunoassays. The serum levels of the anti-angiogenic mediators ES and TSP-1 resulted significantly higher in CSU than in control subjects. Analysis of these mediators in CSU sub-groups, defined by the results of the autologous serum skin test (ASST), identified a significant increase of ES and TSP-1 in both ASST-positive and ASST-negative sub-groups as compared to the controls. Levels of ES and TSP-1 do not parallel the disease severity in CSU. Our study suggests that the extracellular matrix (ECM) fragments ES and TSP-1 with anti-angiogenic activity play a potential role in the pathogenesis of CSU but do not parallel disease activity.

Different fish-eating habits and cytokine production in chronic urticaria with and without sensitization against the fish-parasite Anisakis simplex

BACKGROUND

Anisakis simplex sensitization has been associated with acute, but also with chronic urticaria. The objective of this study is to characterize chronic urticaria with (CU+) and without sensitization (CU-) against the ubiquitous fish parasite A. simplex in a transversal and longitudinal evaluation.

METHODS

16 CU+ and 22 CU- patients were included and assessed for Urticaria activity score (UAS), fish-eating habits by standardized questionnaire and cytokine production (assessed by flow cytometric bead-based array) of peripheral blood mononuclear cells after stimulation with A. simplex extract or Concanavalin A (Con A). Patients were randomly put on a fish-free diet for three months and UAS, as well as cytokine production were again assessed. A difference of ≥1 in UAS was defined as improvement.

RESULTS

There was no difference in UAS in both groups. Anisakis induced IL-2, IL-4 and IFN-γ production was higher in CU+. Con A induced IL-6 and IL-10 production was higher in CU+. CU+ was associated with higher total fish intake, whereas CU- was associated with oily fish intake. The correlation of UAS was positive with oily fish, but negative with total fish intake. There was a better UAS-based prognosis in CU+ without diet. Improvement was associated with higher Con A induced IL-10/IFN-γ as well as IL-10/IL-6 ratios. Further, previous higher oily fish intake was associated with improvement.

CONCLUSIONS

Our data confirm the different clinical and immunological phenotype of CU+. Our results show a complex relationship between fish-eating habits, cytokine production and prognosis, which could have important consequences in dietary advice in patients with CU. When encountering A. simplex sensitization, patients should not be automatically put on a diet without fish in order to reduce contact with A. simplex products.

Determination of dermatology life quality index, and serum C-reactive protein and plasma interleukin-6 levels in patients with chronic urticaria

INTRODUCTION

C-reactive protein (CRP) and interleukin-6 (IL-6), which is one of its most important simulators, were determined in great amounts in the sera of patients with chronic urticaria (CU).

AIM

To determine the levels of IL-6 in patients with urticaria, and evaluate its relationship with urticaria activity scores and Dermatology Life Quality Index (DLQI).

MATERIAL AND METHODS

Fifty-three patients with CU were included in the study successively by determining their urticaria activity scores (0-3) and DLQI (0-5). The CRP and IL-6 were measured by immune assay methods. Thirty-two healthy subjects were included as a control group.

RESULTS

Serum levels of IL-6 and CRP were significantly higher in patients with CU compared to healthy controls (p < 0.001, p = 0.026 respectively). There was a statistically significant correlation among urticaria activity scores and IL-6 and CRP concentration (p = 0.004, p = 0.042). This correlation was more significant in patients who had moderate and severe disease activity scores than in those who had mild disease activity score (p < 0.001, p < 0.001, respectively). There was a statistically significant association between DLQI and IL-6 (p = 0.025). This correlation was very significant in patients who had severe and very severe disease activity scores (p < 0.001, p < 0.001, respectively). DLQI scores and serum levels of IL-6 were significantly different in the very severe group compared to healthy controls (p = 0.024).

CONCLUSIONS

The levels of CRP and IL-6 are increased in patients with CU. A relationship of DLQI and urticaria activity scores with CRP and IL-6 was found. These findings support the relationship between the inflammatory process in CU and the clinical findings.

Development of autoimmune hair loss disease alopecia areata is associated with cardiac dysfunction in C3H/HeJ mice

Alopecia areata (AA) is a chronic autoimmune hair loss disease that affects several million men, women and children worldwide. Previous studies have suggested a link between autoimmunity, stress hormones, and increased cardiovascular disease risk. In the current study, histology, immunohistology, quantitative PCR (qPCR) and ELISAs were used to assess heart health in the C3H/HeJ mouse model for AA and heart tissue response to adrenocorticotropic hormone (ACTH) exposure. Mice with AA exhibited both atrial and ventricular hypertrophy, and increased collagen deposition compared to normal-haired littermates. QPCR revealed significant increases in Il18 (4.6-fold), IL18 receptor-1 (Il18r1; 2.8-fold) and IL18 binding protein (Il18bp; 5.2-fold) in AA hearts. Time course studies revealed a trend towards decreased Il18 in acute AA compared to controls while Il18r1, Il18bp and Casp1 showed similar trends to those of chronic AA affected mice. Immunohistochemistry showed localization of IL18 in chronic AA mouse atria. ELISA indicated cardiac troponin-I (cTnI) was elevated in the serum and significantly increased in AA heart tissue. Cultures of heart atria revealed differential gene expression between AA and control mice in response to ACTH. ACTH treatment induced significant increase in cTnI release into the culture medium in a dose-dependent manner for both AA and control mice. In conclusion, murine AA is associated with structural, biochemical, and gene expression changes consistent with cardiac hypertrophy in response to ACTH exposure.

Serum concentration of IL-17, IL-23 and TNF-α among patients with chronic spontaneous urticaria: association with disease activity and autologous serum skin test

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common skin disorder, which is considered in a subset of patients to be an autoimmune disorder. T helper 17 (Th17) cells are crucially involved in the pathogenesis of some autoimmune diseases.

OBJECTIVES

Our aim was to test the association of Th17 with CSU. We examined interleukin (IL)-17, IL-23 and tumor necrosis factor-alpha (TNF-α) serum levels in CSU patients and studied their association with urticaria activity and autologous serum skin test (ASST).

SUBJECTS AND METHODS

Serum concentration of IL-17, IL-23 and TNF-α were measured in 75 patients with CSU and 30 healthy control subjects. Disease activity was assessed by using urticaria activity score (UAS) as recommended by EAACI/GA(2)LEN/EDF/WAO Guidelines.

RESULTS

Serum concentration of IL-17, IL-23 and TNF-α were significantly higher in CSU patients as compared with the healthy control subjects (mean: 35.51 ± 31.14 vs. 4.60 ± 1.38 pg/mL; P < 0.001, 38.95 ± 27.82 vs. 9.87 ± 4.62 pg/mL; P > 0.001 and 17.93 ± 6.05 vs. 6.87 ± 3.73 pg/mL; P = 0.004, respectively). There were significant positive correlation between serum IL-17, IL-23, TNF-α and disease activity assessed by cumulative UAS for 7 days before blood sampling. The Serum concentration of IL-17, IL-23 and TNF-α were also significantly higher in ASST positive patients than in ASST negative patients.

CONCLUSION

Our results showed high serum levels of IL-17, IL-23 and TNF-α among CSU patients which may highlight a functional role of these cytokines in the pathogenesis of this important and common skin disease. It also may provide the rationale for new treatment strategies in chronic urticaria.