The natural history of chronic urticaria in childhood: A prospective study

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.

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.

The many faces of pediatric urticaria

Urticaria is a common disease that can affect individuals of all age groups, with approximately one-quarter of the population experiencing it at least once in their lifetime. Lesions characterized by erythema and itchy hives can appear anywhere on the body. These can vary in size ranging from millimeters to centimeters, and typically clear within 24 h. About 40% of patients with urticaria have accompanying angioedema, which involves localized deep tissue swelling. Urticaria usually occurs spontaneously and is classified into acute and chronic forms, with the latter referring to a condition that lasts for more than 6 weeks. The prevalence of chronic urticaria in the general population ranges from 0.5% to 5%, and it can either be inducible or spontaneous. The most common form of pediatric urticaria is acute and is usually self-limiting. However, a broad differential diagnosis should be considered in children with urticaria, particularly if they also have accompanying systemic complaints. Differential diagnoses of pediatric urticaria include chronic spontaneous urticaria, chronic inducible urticaria, serum sickness-like reaction, urticarial vasculitis, and mast cell disorders. Conditions that can mimic urticaria, including but not limited to cryopyrinopathies, hyper IgD syndrome, Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis (PFAPA), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPs), and Schnitzler syndrome should also be considered. The many faces of pediatric urticaria can be both easy and confusing. A pragmatic approach relies on clinical foresight and understanding the various forms of urticaria and their potential mimickers. This approach can pave the way for an accurate and optimized diagnostic approach in children with urticaria.

Psychiatric comorbidities in children and adolescents with chronic urticaria

BACKGROUND

Chronic urticaria (CU) has been shown to impact patients' quality of life negatively and may coexist with psychiatric disorders. We systematically reviewed the published evidence of comorbid psychiatric disorders in children and adolescents with CU.

METHODS

A systematic review of studies published until February 2022 in PubMed, Google Scholar, and Scopus was performed. An a priori set of inclusion criteria was predefined for the studies to be included: (1) clear distinction between urticaria and other allergies; (2) precise distinction between acute and CU; (3) participants younger than 18 years old, exclusively; (4) use of appropriate standardized questionnaires, psychometric tools, and standard diagnostic nomenclature for the mental health and behavioral disorders diagnosis; and (5) manuscripts written or published in the English language.

RESULTS

Our search identified 582 potentially relevant papers. Only eight of them satisfied the inclusion criteria. Quantitative meta-analysis was not deemed appropriate, given the lack of relevant randomized control trials, the small number of relevant shortlisted, the small sample size of the patients included in each study, and the remarkable heterogeneity of the studies' protocols.

CONCLUSIONS

The included studies suggest an increased incidence of psychopathology among children and adolescents with CU as opposed to healthy age-matched individuals, but the data are scarce. Further research is required to clarify whether psychopathology is just a comorbid entity, the cause, or the consequence of CU. Meanwhile an interdisciplinary collaboration between allergists/dermatologists and psychiatrists is expected to substantially minimize CU burden and improve patients' quality of life.

Clinical features of patients with chronic spontaneous urticaria associated with autoimmune thyroiditis

The aim of the study was to focus on children with both chronic spontaneous urticaria (CSU) and autoimmune thyroiditis (AT) as this topic is rarely studied in children although some publications show a higher proportion of antithyroid antibodies in children with CSU. We highlight two cases of children with both CSU and AT and compare their data with reports from the literature. Since only case reports or case series were available, we performed a descriptive analysis of 15 patients. There were 7 (46.7%) cases of hypothyroidism and the rest were euthyroid. Hypothyroidism appears before, during, and after the diagnostic of CSU. One patient with hypothyroidism and one with euthyroidism receiving l-thyroxine experienced remission of urticaria. Three patients over 12 years of age (20%) received omalizumab. Three patients (20%) had another autoimmune disease and seven (58.3%) had a family history of thyroid disease or autoimmune disease. CONCLUSION: Children with CSU need repeated testing for antithyroid antibodies. Children with both CSU and AT require close medical supervision focused on the development of other autoimmune diseases. l-thyroxine may improve urticaria in patients with hypothyroidism, but there is not enough evidence for patients with euthyroidism. Omalizumab may be of benefit in this population but well-controlled studies in children with AT and CSU are needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prospective analysis of clinical evolution in chronic urticaria: Persistence, remission, recurrence, and pruritus alone

Background

Population and study's methodology heterogenicity became clinical evolution of chronic spontaneous urticaria (CSU) highly variable.

Objective

In a prospective cohort, we evaluated the different pathways of clinical evolution of CSU and identified possible risk factors.

Methods

A total of 685 CSU patients (>12 years) were prospectively followed over 5 years. Diagnosis and follow-up of urticaria were based on medical evaluation and photographic records. Remission was defined as at least 6 months without symptoms (hives, angioedema, or pruritus) and medication. The follow-up included at least 2 visits per year, with photographic registration and clinical evaluation. Predefined clinical and paraclinical variables were included in the regression analyses.

Results

We identified four clinical evolution pathways; The cumulative prevalence of remission at 5 years was 59.1%, recurrence was 17.1%, persistence was 11.6%, and chronic pruritus without hives or angioedema was 12.2%. The probability of persistence increased with hypothyroidism diagnosis (HR 0.425, 95% CI 0.290-0.621) and each point in the UAS7 (HR 0.931 95% CI 0.918-0.945).

Conclusion

Chronic urticaria has different evolutions. Disease activity and hypothyroidism predict persistence and remission. Recurrence and chronic pruritus phenotypes require further study to evaluate their causality and prognosis.

Pediatric chronic spontaneous urticaria: a brief clinician's guide

INTRODUCTION

Chronic urticaria (CU) appears with daily or intermittent/recurrent wheals with/without angioedema for more than six weeks. When no specific eliciting factors are found, chronic urticaria is defined as spontaneous (CSU). Up to 50% of patients with CSU do not respond to therapy, leading to a prolonged disease course and the need for expensive therapies, impacting the quality of life (QoL) and healthcare resources.

AREAS COVERED

Diagnosis of CSU is made when other potential causes of chronic urticaria are excluded. CSU therapy aims to achieve complete control of symptoms and normalization of QoL. Current treatment options for urticaria aim to target mast cell mediators such as histamine, or activators, such as autoantibodies. Guidelines recommend starting with second generation antihistamines (sgAHs) and adding omalizumab therapy if symptoms are not controlled. This review aims to provide a practical guide for CSU in the pediatric population.

EXPERT OPINION

Treatment options for pediatric CSU are primarily based on adult data that have been extrapolated for children. Current guidelines should be reevaluated based on pediatric data, new biological treatments, and the COVID-19 pandemic. Future research is needed to investigate strategies to personalize current treatments and identify potential predictive biomarkers.

Natural History and Influencing Factors of Chronic Urticaria in Children

Purpose

Chronic urticaria (CU) can reduce the quality of life of children and their parents, but there are only a few studies on the course of CU in children. This study aimed to investigate the natural course of CU in children and identify the factors that influence its prognosis.

Methods

We evaluated 77 children diagnosed with CU, who were monitored for at least 48 months. Subjects were classified as either chronic spontaneous urticaria (CSU) or other CU, and the clinical features were compared. Remission was defined as having no symptoms without treatment for more than 1 year. The remission rate was analyzed, and the factors influencing the prognosis were investigated.

Results

The average age of the study population was 5.96 ± 4.06 years, and 64 (83.1%) patients had CSU. The remission rates at 6 months, 1 year, 2 years, 3 years, and 4 years after symptom onset were 22.1%, 40.3%, 52.0%, 63.7%, and 70.2%, respectively, for children with CU. For children with CSU, these values were 23.4%, 43.7%, 56.2%, 68.7%, and 75.0%, respectively. The total serum immunoglobulin E (IgE) levels were positively correlated with disease duration (r = 0.262, P = 0.021); no other factors were associated with the duration of the disease.

Conclusions

A high proportion of children with CU were classified as CSU. No indicators, except for total IgE were found to predict the timing of spontaneous remission. The CU remission rate identified in this study is expected to be used as one of the reference data for the progress of CU in patients.

An evaluation of the factors affecting the clinical and laboratory findings, prognosis, and treatment response in children with chronic urticaria

Chronic urticaria (CU) is a rare disease in childhood, and studies in children are limited. In this study, the aim was to investigate the clinical and laboratory findings and demographic characteristics of children with CU and to determine the factors affecting prognosis. The study included 141 patients aged 0-18 years who were diagnosed with CU in the pediatric allergy outpatient clinic between January 1, 2013, and December 31, 2018. Risk factors related to prognosis were investigated by comparing the duration of CU and treatment response with clinical and etiological features. IBM SPSS version 24 was used for statistical analyses. In the study group, the female/male ratio was 69/55, and the median age at first visit was 9.5 years (min:1, max:17). Among patients, 63 (44.5%) had an accompanying atopic disease, and 23 (16.3%) had chronic disease. Of the patients, 124 (88%) had chronic spontaneous urticaria, and 17 patients (12%) had chronic inducible urticaria (CIU). Of those with CIU, 72.2% had symptomatic dermographism, 16.7% had cholinergic urticaria, and 11.1% had cold urticaria. After the evaluations, the most common pathological findings in our patients were intestinal parasitosis (n = 14), anemia (n = 10), and urinary tract infection (n = 8). The median total duration of urticaria was 47 weeks (min:8, max:284). The duration of urticaria was longer in patients with atopy (p < 0.05), and the group that went into remission with standard-dose antihistamine was the group with highest eosinophil count (p = 0.022). In most children with CU, the underlying cause/disease cannot be determined. In our study, treatable triggers were found in some of the patients. Therefore, it is appropriate for each patient to be evaluated with selected laboratory tests after detailed history and physical examination.

Immunological Targets of Biologic Drugs in Allergic Skin Diseases in Children

Atopic dermatitis and urticaria are two invalidating skin disorders that are very common in children. Recent advances in the understanding of their specific intracellular molecular pathways have permitted the development of precise biological molecules, targeting inflammatory mediators and arresting the pathogenetic pathways of skin diseases. Many biologics with promising results have been studied, although few are currently approved in children. In this review, we aim to provide the latest evidence about the use, indications, efficacy and safety of biologic therapies to treat atopic dermatitis and chronic urticaria in children and adolescents.

Chronic urticaria in children - New insights from a large cohort

BACKGROUND

Chronic spontaneous urticaria is well-described in adults, but less so in children. The aim of this study is to describe the demographics, clinical characteristics, comorbidities, and outcomes of children with chronic, spontaneous urticaria.

METHODS

This retrospective study followed children up to 18 years old, diagnosed with chronic spontaneous urticaria, between the years 2002-2018, and treated in a tertiary referral allergy and clinical immunology center. Data including demographics, clinical characteristics, comorbidities, treatments, and outcomes were extracted from electronic medical records.

RESULTS

Records of 380 children coded to have chronic urticaria were reviewed, of which 250 (65.8%) fulfilled the diagnostic criteria for chronic spontaneous urticaria. There were 136 females (54.4%). Mean age at diagnosis was 11.4 years, and 122 (48%) were adolescents. The average duration of chronic spontaneous urticaria was 12.25 ± 15.2 months. The urticaria in 208 children )83.2%) resolved within 24 months. Eighty-seven patients (34.8%) had at least one atopic disease. Atopic comorbidities included atopic dermatitis in 17.2%, allergic rhinitis in 16%, asthma in 13.2%, and food allergy in 3.2%. Eighteen patients (7.2%) had a concomitant autoimmune disease. Nine (3.6%) had thyroid disease.

CONCLUSIONS AND CLINICAL RELEVANCE

Chronic spontaneous urticaria in children is a self-limited disease with favorable prognosis. Atopic diseases are more prevalent in children with chronic spontaneous urticaria than in the general pediatric population, increasing the possibility of a special subgroup of TH2-related chronic urticaria in children.

Chronic urticaria in children under 15 years of age: Clinical experience beyond the clinical trials

BACKGROUND/OBJECTIVES

The aim of the study was to describe the clinical characteristics, management, and outcome of a series of children with chronic urticaria (CU).

METHODS

We retrospectively studied children aged <15 years diagnosed with CU in a tertiary teaching hospital in Palma de Mallorca, Spain, between January 2014 and March 2019. CU was defined as persistence of symptoms of wheals, with or without angioedema, for >6 weeks.

RESULTS

Twenty-nine patients (17 girls, mean age 8 years) were included. Family history of atopy was found in 31% of the cases. In 41.3% of patients, episodes of CU were associated with angioedema. Physical triggers were found in 34.5% of the cases. Most episodes of CU were successfully managed with the recommended (60.7%) or double the recommended dose (17.2%) of H1-antihistamines. Quadruple the recommended dose of H1 antihistamines was used in six patients, five of whom were finally treated with off-label omalizumab. Treatment with anti-leukotrienes was needed in one patient. Associated thyroiditis was diagnosed in one patient, which was controlled with levothyroxine.

CONCLUSIONS

Pediatric CU showed features similar to CU in adulthood, including a greater predominance in females and frequent association with personal or family history of atopy. Adult guidelines for the treatment of CU are currently extrapolated to the pediatric population. Specific tools for the assessment of disease activity and impairment of quality of life in pediatric CU are needed for use in prospective studies aimed to define treatment strategies for children with CU.

Chronic inducible urticaria subtypes in children: Clinical features and prognosis

BACKGROUND

Chronic inducible urticaria (CIndU) is a subtype of chronic urticaria induced by a physical stimulus.

OBJECTIVE

To evaluate the clinical features, prognostic factors, and natural course of childhood CIndU subtypes.

METHODS

Patients (1-18 years old, n = 117) diagnosed with CIndU between March 2011 and March 2019 were analyzed. Patients (n = 101) were re-evaluated for the status of their CIndU at least 6 months after the initial evaluation.

RESULTS

The study population comprised of 117 children with a median (inter-quartile range) age of 10.3 (6-14.8) years at admission and a male predominance (53%). Symptomatic dermographism was the most common type of CIndU, affecting 65% of the group, followed by cold urticaria and cholinergic urticaria, which affected 17% and 15.4%, respectively. Baseline serum tryptase levels in cholinergic urticaria and cold urticaria were higher than those in symptomatic dermographism [7.0 (3.3-10.7) μg/L, 4.2 (2.8-9.3) μg/L, and 2.7 μg/L (1.8-5.9), respectively; P = .020]. Recovery was observed in 9.6%, 25.3%, and 34.7% of the CIndU children after 12, 36, and 60 months, respectively. Of the patients with symptomatic dermographism, 40% had remission in 5 years, whereas this rate was only one-fifth in patients with cold urticaria. The worst prognosis was observed in patients with cholinergic urticaria.

CONCLUSION

This study concluded that nearly one-third of children with CIndU recovered within 5 years and symptomatic dermographism has the best prognosis. Cholinergic urticaria is the CIndU type with the worst prognosis, male dominance, and highest baseline serum tryptase levels.

Presence of positive skin prick tests to inhalant allergens and markers of T2 inflammation in subjects with chronic spontaneous urticaria (CSU): a systematic literature review

BACKGROUND

Current guidelines do not recommend performing aeroallergen skin prick testing (SPT) in chronic spontaneous urticaria (CSU).

OBJECTIVE

The objective of this review was to investigate the presence of aeroallergen sensitization and markers of T2 inflammation in subjects with CSU.

METHODS

Systematic literature reviews to identify all studies that evaluated the presence of T2 markers of allergic inflammation in CSU subjects were performed.

RESULTS

In 16 studies that assessed the prevalence of positive SPT to multiple aeroallergens in CSU, 38.5% of CSU subjects had positive SPT. In three controlled studies, 34.2% of CSU subjects had positive SPT to multiple aeroallergens, compared to 13.6% of controls (p = 0.047). In 18 studies that assessed the prevalence of house dust mite (HDM) positive SPT in CSU, 27.5% of CSU subjects had positive SPT. In three controlled studies, 27.5% of CSU subjects had positive SPT to HDM, compared to 2.1% of controls (p = 0.047). Overall, CSU subjects were 3.1 times more likely to be aeroallergen-sensitized (95% CI 1.7-5.8, p = 0.0002) and 6.1 times more likely to be HDM-sensitized (95% CI 3.7-9.9, p < 0.00001) than controls. Mean total serum IgE (tIgE) levels were 238 kU/L and median tIgE levels were 164 kU/L, which was greater than the upper 90th percentile of normal (< 137 kU/L). Compared to healthy controls, CSU subjects were 6.5 times more likely to have IgG autoantibody against FcεR1α (p = 0.001), 2.4 times more likely to have IgG anti-IgE antibody (p = 0.03) and 5 times more likely to have anti-thyroid peroxidase (anti-TPO) antibody (p = 0.02). When corticosteroids were withheld for ≥ 28 days, mean blood eosinophil percentage was elevated at 5.9% (normal < 4%), but other studies reporting absolute count found the mean was in the normal range, 239 × 10 6 / L (normal < 400 × 10 6 / L).

CONCLUSION

Increased aeroallergen sensitization, tIgE, autoantibodies and blood eosinophil percentage in the CSU subjects indicates the possible importance of T2 inflammation in the pathogenesis of CSU. Further studies may be warranted to determine if specific allergen avoidance, desensitization or improvement in the mucosal allergic inflammation present in asthma and/or rhinitis has any benefit in the management of CSU.

Cupping therapy for patients with chronic urticaria: A systematic review and meta-analysis

BACKGROUND

Chronic urticaria (CU) is a common skin disease, which has a negative effect on quality of life. Current treatments do not fully control the symptoms of urticaria for many CU patients, thus effective and safe treatments for CU are still needed.

OBJECTIVE

This review aims to evaluate the effectiveness and safety of cupping therapy in patients with CU.

SEARCH STRATEGY

The search strategy looked for the presence of related keywords, such as "chronic urticaria" and "cupping therapy," in the title and abstract of research articles indexed in major databases. Randomized controlled trials (RCTs) were selected after querying nine electronic databases from their inception to May 2019 with the above search terms.

INCLUSION CRITERIA

RCTs were included if they recruited patients with CU who were intervened with dry or wet cupping. Publications could be written in Chinese or English.

DATA EXTRACTION AND ANALYSIS

Data were extracted, and the studies were assessed for the quality of their methodological design and risk of bias. Meta-analyses of the RCT data were conducted to assess the total effective rate of the treatment as the primary outcome. Skin disease quality of life index score, recurrence rate, and adverse events were assessed as secondary outcomes. Subgroup analyses were conducted based on different interventions.

RESULTS

Thirteen comparisons from 12 RCTs involving 842 participants were included. There were no significant differences between wet cupping and medications in total effective rate (n = 372; risk ratio [RR] = 1.10, 95% confidence interval [CI] 0.97 to 1.25; P = 0.14) or recurrence rate (n = 240; RR = 0.56, 95% CI 0.23 to 1.36; P = 0.20). Cupping therapy, in combination with antihistamine treatment was more efficacious than antihistamines alone, with a greater total effective rate (n = 342; RR = 1.18, 95% CI 1.01 to 1.39; P = 0.03) and lower recurrence rate (n = 342; RR = 0.52, 95% CI 0.32 to 0.84; P = 0.007). Cupping therapy combined with acupuncture was more effective than acupuncture alone (n = 156; RR = 1.25, 95% CI 1.07 to 1.46; P = 0.006). No serious adverse events were reported.

CONCLUSION

Wet cupping may be as effective as treatment with antihistamines. When cupping therapy is used as an adjuvant therapy to antihistamines or acupuncture, it may enhance the efficacy. Results drawn from these studies should be interpreted with caution and applied with care to clinical practice, because of the poor quality among the studies that were reviewed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019137451.

Urticaria, Angioedema, and Anaphylaxis

Urticaria and, to a lesser extent, angioedema are common occurrences in the pediatric population. There are multiple causes of acute and chronic urticaria and angioedema. Most causes are benign, although they can be worrisome for patients and their parents. An allergist should evaluate acute urticaria and/or angioedema if there are concerns of an external cause, such as foods or medications. Chronic urticaria and angioedema can severely affect quality of life and should be managed aggressively with antihistamines and immunomodulators if poorly controlled. Chronic symptoms are unlikely to be due to an external cause. Anaphylaxis is a more serious allergic condition characterized by a systemic reaction involving at least 2 organ systems. Anaphylaxis should be initially managed with intramuscular epinephrine. Patients who experience anaphylaxis should be evaluated by an allergist for possible causes; if found, avoidance of the inciting antigen is the best management. All patients should also be given an epinephrine autoinjector and an action plan. Foods are a common cause of anaphylaxis in the pediatric population. New evidence suggests that the introduction of highly allergic foods is safe in infancy and should not be delayed. In addition, the early introduction of foods such as peanuts may help prevent the development of food allergies.

Can allergy patch tests with food additives help to diagnose the cause in childhood chronic spontaneous urticaria?

INTRODUCTION

Chronic spontaneous urticaria (CSU) is characterized by the onset of symptoms which are not induced by specific triggers, but are rather spontaneous. A considerable number of patients report that foods or food additives might be responsible for their chronic urticaria.

AIM

To determine the prevalence of sensitization to food additives in children with CSU using atopy patch tests (ATP).

MATERIAL AND METHODS

Atopy patch tests for 23 different food additives were applied to 120 children with CSU and 61 healthy controls.

RESULTS

Seventeen (14.1%) children with CSU were sensitized with food additives. None of the control group had positive APT. Azorubine and Cochineal red were the food additives detected with the highest sensitization rates (5.8% (n = 7) and 6.7% (n = 8), respectively).

CONCLUSIONS

There can be an association between food additives and CSU. APT tests may be a helpful tool in the assessment and management of CSU so that easier to follow diets and effective treatments can be offered to families.

Neutrophil-lymphocyte ratio: a possible marker of remission in children with chronic spontaneous urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) is a disease that seriously disturbs the quality of life of the patient. Currently there is no prognostic marker of the disease. Our aim in this study was to determine possible prognostic markers of CSU in children.

METHOD

All patients younger than 18 years of age who were followed by the Pediatric Immunology and Allergy Clinic of Diyarbakir Children's Hospital with a diagnosis of CSU between June 2017 and February 2019 were included in the study. Clinical and laboratory findings were compared between the symptomatic patient group and the patient group that remained in remission for at least three months without use of medication.

RESULTS

Of the 52 cases included in the study, 32 (61.5%) were male. Mean age at time of diagnosis was 9.4 ± 4.4 years. Twenty-four cases (46.2%) went into remission. Young age at the time of diagnosis and being in the initial months of the disease were found to be associated with good prognosis (p < 0.05). Among laboratory results, elevation in absolute neutrophil count and neutrophil/lymphocyte ratio (NLR) were found to be associated with poor prognosis (p < 0.05). NLR was positively correlated with disease duration (p < 0.05).

CONCLUSION

For childhood CSU, younger age and initial months of the disease are good prognostic indicators, while only neutrophil/lymphocyte count can be used as a remission marker.

Pharmacologic Management of Chronic Urticaria in Pediatric Patients: The Gap Between Guidelines and Practice

Chronic urticaria is an uncommon disorder in children but can present considerable morbidity, as well as frustration for the healthcare provider and parent. The prevalence is 0.1-0.3% but can vary considerably by country. Chronic spontaneous urticaria (no identifiable cause) is responsible for 70-80% of chronic urticaria, about half of this due to a subtype called chronic autoimmune urticaria identified by the presence of autoantibodies to IgE or the IgE receptor. Chronic urticaria that is triggered by external physical stimuli is called chronic inducible urticaria and is present in another 15-20%. Allergies, infection, and other underlying diseases such as thyroid disease, celiac disease, or Helicobacter pylori infection cause a minor proportion of cases. Chronic urticaria has considerable impact on quality of life and healthcare costs. An adverse impact on quality of life is more prevalent in older children and adolescents and can be comparable to other diseases of childhood such as diabetes and epilepsy. Healthcare costs can be 50% higher than the national estimates for healthy patients and include more hospitalizations, longer duration of hospitalizations, and more emergency department (ED) and outpatient visits. Allergic and autoimmune diseases can be comorbidities that add to healthcare utilization. Resolution can take years. Guidelines are available for diagnosis and treatment. A good history is the key to identifying the cause. Minimal laboratory tests are required and should be guided by the history. Patients with easily controlled urticaria may not need any laboratory tests. Suggested treatment emphasizes the use of non-sedating antihistamines, utilized in a step-wise fashion beginning with normal doses and advancing the dose based on the response up to four times the recommended dose for age. Other treatments are left to the urticaria specialist and are not discussed in this paper. These guidelines are not well utilized based on real-world studies; sedating antihistamines and oral steroids are overutilized. Medications should be taken daily, not as needed. Additional medications, if required, should be added to prior medications in a step-wise fashion. The gap between the guidelines for diagnosis and treatment and what is happening in the real world needs to be closed to reduce the cost and morbidity associated with this disorder.

Emerging Biomarkers and Therapeutic Pipelines for Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined as the appearance of evanescent wheals, angioedema, or both, for at least 6 weeks. CSU is associated with intense pruritus and poor quality of life, with higher odds of reporting depression, anxiety, and sleep difficulty. As of yet, the assessment of the activity and course of the disease along with the response to several treatments in CSU are based purely on the patient's medical history and the use of the patient-reported outcomes. Recently, several reports have suggested that certain parameters could be considered as potential disease-related biomarkers. Moreover, with the advent of such biomarkers, newer biologic agents are coming forth to revolutionize the management of potential refractory diseases such as CSU. The purpose of this article is to review the most promising biomarkers related to important aspects of CSU, such as the disease activity, the therapeutic response, and the natural history of the disease, and discuss the mechanisms of action and therapeutic effectiveness of the latest agents available or currently under investigation for the management of antihistamine-refractory CSU. The knowledge of these features could have an important impact on the management and follow-up of patients with CSU.

Investigation of Autoimmune Disease in Children with Chronic Spontaneous Urticaria

INTRODUCTION

Chronic spontaneous urticaria (CSU) in childhood affects the quality of life of the patient and may be associated with other autoimmune diseases. The aim of this study was to investigate the association of autoimmune diseases with CSU in children.

METHODS

In a 3-year period, from 2015 to 2018, forty-nine children were diagnosed with CSU and monitored in the Outpatient Pediatric Allergy Clinic of the University Hospital of Ioannina in Northwestern Greece. The comorbidity with other autoimmune diseases was investigated in this population by autoantibody evaluation.

RESULTS

Of the 49 children with CSU, 1 had autoantibodies for celiac disease (CD), which was confirmed by duodenal biopsy via gastroscopy. Four children had high serum levels of anti-thyroid peroxidase antibodies but normal thyroid function. No other specific autoantibodies were detected.

CONCLUSION

The prevalence of autoimmune diseases among our children with CSU was low. Nevertheless, we think it is important to test children with CSU for other autoimmune diseases. CD can be diagnosed in children with CSU even in the absence of other indicative signs.

Cupping for patients with chronic urticaria: A systematic review protocol

BACKGROUND

The program aims to evaluate the effectiveness and safety of cupping in patients with chronic urticaria (CU).

METHODS

We will search the databases including PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China Science Journal Database, China National Knowledge Infrastructure, Wan-fang Database, and China Biomedical Literature Database from their inception to May 2019. In addition, we will manually search the list of medical journals as a supplement. The clinical randomized controlled trials or quasi-randomized controlled trials related to cupping for the treatment of CU will be included in the study. Data were synthesized by using a fixed-effect model or random effect model depend on the heterogeneity test. The primary outcome is the total effective rate. Secondary outcomes include skin disease quality of life index scores, adverse events, and recurrence rates. RevMan V.5.3 statistical software will be used for meta-analysis. If it is not appropriate for a meta-analysis, then a descriptive analysis will be conducted. Data synthesis will use the risk ratio and the standardized or weighted average difference of continuous data to represent the results.

RESULTS

This study will provide a comprehensive review of the available evidence to assess the effectiveness and safety of cupping for patients with CU.

CONCLUSION

This systematic review (SR) will provide evidence to judge whether cupping is an effective intervention for patients with CU.

ETHICS AND DISSEMINATION

The protocol of the SR does not require ethical approval because it does not involve humans. We will publish this article in peer-reviewed journals and presented at relevant conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019137451.

Paediatric severe chronic spontaneous urticaria: successful management through conventional drug therapy

Chronic spontaneous urticaria (CSU) can occur in children and the clinical management is quite challenging. Here, we described a paediatric clinical case of CSU successfully managed by conventional therapy, including systemic steroids, cetirizine, anti-leukotriene drug and dietary restriction (for histamine-releasing foods). This patient showed neither atopy nor any allergic sensitisation; moreover, the autologous serum skin test resulted negative. This category of patients with no comorbidity and no evidence of atopy might benefit from the conventional drug management; however, a protracted course of steroid treatment with very slow and gradual tapering may be needed. This approach was successful and safe in our clinical case, but a careful follow-up, due to the potential side effects of steroids, should be recommended.

Management of chronic urticaria in children: a clinical guideline

The aim of this guidance is to provide recommendations to clinicians and other interested parties on chronic urticaria in children. The Italian Society for Pediatrics (SIP), the Italian Society for Allergy and Immunology (SIAIP), the Italian Society for Pediatric dermatology (SIDerP) convened a multidisciplinary panel that prepared clinical guidelines for diagnosis and management of chronic urticaria in childhood. Key questions on epidemiology, natural history, diagnosis, and management were developed. The literature was systematically searched and evaluated, recommendations were rated and algorithms for diagnosis and treatment were developed. The recommendations focus on identification of diseases and comorbidities, strategies to recognize triggering factors, improvement of treatment by individualized care.

Headache deteriorates the quality of life in children with chronic spontaneous urticaria

BACKGROUND

Quality of life, which is impaired in patients with chronic spontaneous urticaria (CSU), is influenced by comorbid mental disorders. Headaches could be another comorbid mental disorder that affects quality of life in children with CSU.

OBJECTIVES

To investigate the effect of headaches on urticaria symptoms, disease activity and quality of life in children with CSU.

METHODS

A total of 83 patients with CSU were enrolled in the study and were separated into two groups as those with or without headache. Demographic and clinical characteristics were studied with the Urticaria Activity Score (UAS7), Urticaria Control test (UCT) and Chronic Urticaria Quality of Life Questionnaire (CU-Q2QoL). The headache questionnaire designed according to the Department of International Classification of Headache Disorders, second edition (ICHD-II) was used and VAS (Visual Analogue Scale) and NRS (Numerical Rating Scale) were used to assess the pain measurement. In patients diagnosed with migraine, the paediatric Migraine Disability Assessment Scale (PedMIDAS) was applied.

RESULTS

CU-QoL total scores were significantly higher in patients with CSU with headache than in those without headache (p=0.015). In the five domains of CU-QoL, impact of daily life activities domain and sleep problems domain had higher scores in CSU with headache (p=0.008, 0.028, respectively). There was no significant relationship between UCT, UAS and CU-QoL and headache severity (p<0.05). No differences were found between the groups in respect of duration of urticaria, UAS7 and UCT.

CONCLUSION

Headache may be an important factor that affects and impairs quality of life in children with chronic urticaria.

Characterization of chronic urticaria and associated conditions in a large population of adolescents

BACKGROUND

Although chronic spontaneous urticaria (CSU) affects all age groups, data regarding CSU in adolescents is scarce.

OBJECTIVE

To characterize the epidemiology, demographics, and comorbidities associated with CSU in a large, cross-sectional nationwide population of adolescents.

METHODS

Medical records of 16-year-old candidate conscripts to the Israeli Defense Forces were reviewed. Data were collected on the prevalence and severity of CSU, as well as the demographics, medical comorbidities, medication use, and blood test results of affected individuals.

RESULTS

Medical records of 1,108,833 consecutive 16-year-old adolescents were reviewed. A total of 6617 (0.6%) adolescents received CSU diagnoses. CSU was increased in female conscripts (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.07-1.19, P < .001) and adolescents with higher socioeconomic scores (OR 1.92, 95% CI 1.56-2.32, P < .001). Individuals with CSU were significantly more likely to have allergic diseases, including food allergy (OR 7.31, 95% CI 6.13-8.72), allergic rhinitis (OR 2.9, 95% CI 2.71-3.11), atopic dermatitis (OR 2.35, 95% CI 2.03-2.72), and asthma (OR 1.46, CI 1.35-1.57).

CONCLUSION

Our work provides an account of CSU in a large cohort of adolescents. We found a strong link between CSU and atopic diseases. Further investigation is needed to decipher the mechanism underlying this observed association.

Urticaria in children and adolescents: An updated review of the pathogenesis and management

The present survey represents the latest data on diagnosis and management of childhood urticaria. It has been observed that urticaria occurs less often in children than adults, with symptoms rarely lasting for over 6 weeks. Triggers or aggravating factors can be found only in 21%-55% of cases. Finding autoantibodies in children does not impact a disease prognosis, unlike in adult patients, where the presence of autoantibodies is associated with a more prolonged run of the disease, a more severe prognosis and more intensive treatment methods. The incidence of food allergy equals to 8%-10% of cases. The incidence of Helicobacter Pylori infection in children is lower than that in adults and comes to 10%-18%. Medical experts recommend using the same treatment schemes for adults and children. This survey describes different urticaria management patterns suggested by experts from Europe, America, and Russia in their recent guidelines. It has been noted that unlike the guidelines from 2014, the 2018 clinical practice guidelines for the diagnosis and management of urticarial once again suggest a four-step treatment scheme with assigning omalizumab for Step 3 and cyclosporine A for Step 4 in the event of low therapeutic efficacy of the previous step or its impossibility. Leukotriene antagonists (LTRAs) are currently removed from basic management to alternative programs.

Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H₁ antihistamines alone or in combination with other classes of medications, including H₂ antihistamines, leukotriene receptor antagonists, or first-generation H₁ antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H₁ antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).

Natural course of new-onset urticaria: Results of a 10-year follow-up, nationwide, population-based study

BACKGROUND

Previous epidemiologic studies of the natural course of urticaria mainly focused on chronic spontaneous urticaria and were conducted at hospitals. The natural course of new-onset urticaria in the general population is unknown.

METHODS

Patients with new-onset urticaria were identified from the National Health Insurance Service-National Sample Cohort data. Patients who had at least one visit for urticaria in 2002 and 2003 were excluded and the study cohort consisted of 1,027,620 subjects with no history of urticaria. We analyzed cumulative incidences of urticaria, chronic urticaria, and chronic urticaria remission using the life table estimation method from 2004 to 2013. Their association with related factors was analyzed using the Cox proportional hazards analysis.

RESULTS

From 2004 to 2013, a total of 49,129 patients with new-onset urticaria were identified. The 10-year cumulative incidence rate of urticaria for the general population was 4.9% and that of chronic urticaria among patients with new-onset urticaria was 7.8%. Remission rates of chronic urticaria were 52.6% at 1 year and 88.9% at 5 years. Age, sex, residential area, and autoimmune thyroid disease were significantly associated with urticaria or chronic urticaria, but not with chronic urticaria remission, after adjusting for covariates. Female individuals were more likely to have new-onset urticaria but less likely to develop chronic urticaria compared with male individuals.

CONCLUSIONS

During the 10-year follow-up period, only a small proportion of patients with new-onset urticaria developed chronic urticaria. Remission was achieved in the majority of patients with chronic urticaria regardless of demographic characteristics or accompanying thyroid disease.

Comorbidity of chronic spontaneous urticaria and autoimmune thyroid diseases: A systematic review

Patients with chronic spontaneous urticaria (CSU) are widely held to often have other autoimmune disorders, including autoimmune thyroid disease. Here, we systematically evaluated the literature on the prevalence of thyroid autoimmunity in CSU and vice versa. There is a strong link between CSU and elevated levels of IgG antithyroid autoantibodies (AAbs), with most of a large number of studies reporting rates of ≥10%. Levels of IgG against thyroid peroxidase (TPO) are more often elevated in CSU than those of other IgG antithyroid AAbs (strong evidence). Levels of IgG antithyroid AAbs are more often elevated in adult patients with CSU than in children (strong evidence). Patients with CSU exhibit significantly higher levels of IgG antithyroid AAbs (strong evidence) and IgE-anti-TPO (weak evidence) than controls. Elevated IgG antithyroid AAbs in CSU are linked to the use of glucocorticoids (weak evidence) but not to disease duration or severity/activity, gender, age, or ASST response (inconsistent evidence). Thyroid dysfunction rates are increased in patients with CSU (strong evidence). Hypothyroidism and Hashimoto's thyroiditis are more common than hyperthyroidism and Graves' disease (strong evidence). Thyroid dysfunction is more common in adult patients with CSU than in children (strong evidence) and in female than in male patients with CSU (weak evidence). Urticaria including CSU is more prevalent in patients with thyroid autoimmunity than in controls (weak evidence). CSU can improve in response to treatment with levothyroxine or other thyroid drugs (strong evidence). Pathogenic mechanisms in CSU patients with thyroid autoimmunity may include IgE against autoantigens, immune complexes, and complement.

Recurrence of Chronic Urticaria: Incidence and Associated Factors

BACKGROUND

Chronic urticaria (CU) is urticaria that has been present continuously or intermittently for at least 6 weeks. Although the prevalence and characteristics of CU are well established, little is known about recurrent CU (RCU).

OBJECTIVES

We sought to establish a definition, determine the frequency, and evaluate risk factors for RCU.

METHODS

A retrospective chart review of adult patients with CU evaluated at the University of Texas Southwestern allergy and immunology clinic was performed. RCU was defined as CU recurring at least 6 months after cessation of controller therapy and resolution of prior CU symptoms. Charts were reviewed for symptom resolution and recurrence, subtypes of CU (idiopathic, physical, and urticarial vasculitis), and medication usage (first-line agents, alternative agents, and steroid dependence).

RESULTS

Forty-five of 341 patients (13%) had RCU. The recurrence group had a higher frequency of alternative agent use at 57.8% (n = 26) compared with the nonrecurrence group at 34.8% (n = 103), which was statistically significant (P < .01). The rate of steroid dependence was similar in both groups (13.3% in the recurrence group vs 14.5%) and not statistically significant. Individuals exposed to anti-inflammatory agents, immunosuppressants, and omalizumab had a significantly higher relative risk of recurrence compared with those who only used first-line agents (relative risk [RR] 2.32, P < .01; RR 2.69, P < .01; and RR 2.18, P = .05, respectively).

CONCLUSIONS

RCU occurs in approximately 13% of patients with CU in our clinic population. Alternative agent use and antihistamine refractoriness appear to place patients at increased risk for recurrence compared with first-line agent use alone.

The Expanding Field of Biologics in the Management of Chronic Urticaria

Chronic urticaria (CU) is the occurrence of urticaria with or without angioedema for at least 6 weeks. Management has traditionally involved antihistamines as first-line therapy with various alternative therapies for refractory cases. Largely based on the success of biologics for various diseases, this class of drugs has come to the forefront of medical research. The first and only Food and Drug Administration-approved biologic for the management of CU is omalizumab (humanized anti-IgE mAb). In the past decade, a substantial amount of research has been centered on the mechanism of action, efficacy, dosing, and safety of omalizumab. This review will focus on the data surrounding the management of CU with omalizumab, off-label use of other biologics for CU, and biologics currently under investigation for use in CU. We will also discuss management considerations and areas of interest for future research.

Factors linked to disease severity and time to remission in patients with chronic spontaneous urticaria

Biomarkers useful for the evaluation and management of patients with chronic spontaneous urticaria (CSU) are not currently available. A review of various clinical and laboratory markers that have been studied to assess their value for determining the severity or predicting the evolution of disease in adult patients with CSU was carried out. A search of the medical literature on PubMed and MEDLINE including the terms urticaria, chronic urticaria, chronic idiopathic urticaria, CSU, severity, prognosis and treatment was performed. Based on our review of the literature, among the clinical markers studied, higher age at onset, being female, long disease duration and aspirin/NSAID hypersensitivity may be linked to both severe CSU and a long time to spontaneous remission. In addition, a positive autologous serum skin test (ASST) may be associated with severe CSU, and comorbidity of inducible urticaria and concomitant recurrent angio-oedema may be linked to longer CSU duration. Potential biomarkers of CSU severity and/or duration include basophil numbers and susceptibility to activation, inflammatory markers, markers of activation of the extrinsic coagulation pathway, immunoglobulin E and vitamin D. Although the described markers are promising, further studies on representative and well-characterized patient populations are needed to determine the value of these clinical and biological markers for predicting the severity and course of disease in patients with CSU.

Positive CD63 Basophil Activation Tests Are Common in Children with Chronic Spontaneous Urticaria and Linked to High Disease Activity

BACKGROUND

The basophil activation test (BAT) using CD63 expression is a sensitive and specific tool for the diagnostic workup of autoimmune chronic spontaneous urticaria (CSU). The definition of a positive BAT is directly dependent on the reference range and the cutoff values established in control populations. As of now, the pediatric reference range and cutoff values of the CD63 BAT remain to be established.

METHODS

In this study, we analyzed CD63 expression in 80 children (1-17 years old) without chronic urticaria (i.e., controls) and compared the values to those of a pediatric cohort of 105 CSU patients and 23 physical urticaria (PU) patients.

RESULTS

Based on the log-normal distribution of CD63 values in control subjects, the reference range and the cutoff for positive CD63 BAT values was established to be 1.2-1.8% (95% CI) and 1.8%, respectively. Children with CSU showed significantly elevated and significantly increased BAT values compared to healthy controls (Wilcoxon rank test p value <0.001). In contrast, no difference was found between BAT results in controls and PU patients. In pediatric CSU patients, a higher disease activity was associated with higher BAT values.

CONCLUSIONS

Our study provides, for the first time, reference and cutoff values for the CD63 BAT in children. Our findings show that positive CD63 BAT are common in children with CSU and linked to a high disease activity.