Psychiatric morbidity and quality of life in patients with chronic idiopathic urticaria

Topical corticosteroids for hives and itch (urticaria): Systematic review and Bayesian meta-analysis of randomized trials

BACKGROUND

Topical corticosteroids are widely used as a treatment for itch and wheals (urticaria), but their benefits and harms are unclear.

OBJECTIVE

To systematically synthesize the benefits and harms of topical corticosteroids for the treatment of urticaria.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL from database inception to March 23, 2024, for randomized trials comparing topical corticosteroids with placebo for patients with urticaria (either chronic spontaneous or inducible urticaria or acute urticaria elicited from skin/intradermal allergy testing). Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects meta-analyses addressed urticaria severity, itch severity (numeric rating scale; range 0-10; higher is worse), and adverse events. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed certainty of evidence ratings. PROSPERO registration: CRD42023455182.

RESULTS

A total of 19 randomized controlled trials enrolled 379 participants with a median of mean age of 30.1 (range 21.1-44.0) years. Compared with placebo, topical corticosteroids may reduce wheal size (ratio of means 0.47, 95% CI 0.38-0.59; low certainty) and itch severity (mean difference -1.30, 95% CI -5.07 to 2.46; very low certainty). Topical corticosteroids result in little to no difference in overall adverse events (94 fewer patients per 1000, 95% credible intervals 172 fewer to 12 more; high certainty).

CONCLUSION

Compared with placebo, topical corticosteroids may result in a reduction of wheal size and little to no difference in overall adverse events. Topical corticosteroids may reduce itch severity, but the evidence is very uncertain. Future large, randomized trials addressing the use of topical corticosteroids would further support optimal urticaria management.

Chronic Spontaneous Urticaria: Quality of Life and Economic Impacts

This study focuses on quality of life (QoL) assessment in chronic urticaria, delving into tools, disease-specific measures, and its profound impact. With expanding therapeutic options, understanding QoL becomes crucial. QoL measures often involve comparisons of patient-reported outcomes in addition to quantitative measures of disease control. Emerging tools include the Urticaria Activity and Impact Measure, which may provide a balanced evaluation. In addition to discussions of the various QoL measures, the psychological impact of chronic urticaria are highlighted, covering emotional burden, stress, and psychiatric comorbidities. Finally, the economic impacts reveal escalating health care costs and cost-effectiveness considerations of therapies like omalizumab.

Global Prevalence of Anxiety, Depression, and Stress Among Patients with Skin Diseases: A Systematic Review and Meta-analysis

The changes in human lifestyle over the past few decades have impacted the prevalence of skin diseases within different societies. Skin diseases may result in various physical and mental disorders. The most common mental disorders observed among the patients are stress, anxiety, and depression. This study aims to investigate the global prevalence of anxiety, depression, and stress in patients with skin diseases. In this Systematic Review and Meta-Analysis study, the PubMed, Scopus, Science Direct, Embase, Web of science, and Google Scholar repositories were searched without a lower time limit. Heterogeneity among the identified studies was examined using the I2 index, and accordingly random effects model was adopted for analysis. Data analysis was conducted within the Comprehensive Meta-Analysis software (v. 2). In total, 113 studies were included for the final analysis. The overall pooled prevalence of stress, depression, and anxiety in skin disease patients was found to be 39.4%, 27.2% and 28.8%, respectively. Among patients with psoriasis, acne, vitiligo or atopic dermatitis diseases, the highest number of patients suffering from stress was related to patients with acne (75.7%). The highest prevalence of depression, and anxiety was reported in patients with vitiligo (38.3%) and acne (36.5%), respectively. Considering the high prevalence of mental disorders among patients with skin diseases and recognising the impacts of mental health challenges on patients' well-being, the findings of this study provide valuable insights for identifying specific populations that require targeted interventions for the diagnosis, treatment, and prevention of mental illnesses. Accordingly, healthcare policymakers should incorporate psychological treatment and support measures as integral components of comprehensive care strategies for patients with skin diseases.

Quality of life measurement in urticaria: Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient-Oriented Outcomes and Urticaria and Angioedema

The European Academy of Dermatology and Venereology (EADV) Task Forces on quality of life (QoL) and patient-oriented outcomes and on urticaria and angioedema recommendations for the assessment of Health-related (HR) QoL in all patients with urticaria in research and practice are as follows: to use the DLQI for adults and the CDLQI for children as dermatology-specific and the CU-Q2oL as a disease-specific HRQoL instruments in urticaria; to use generic instruments to provide comparison of data on urticaria with non-dermatologic diseases, or to compare with healthy volunteers or the general population; to select validated HRQoL instruments with appropriate age limits; to present exact numeric data for HRQoL results; correct title of any HRQoL instrument should be used, along with its correct abbreviation and the reference to its original publication, where possible. The EADV TFs discourage the use of non-validated HRQoL instruments and modified HRQoL instruments that have not undergone standard validation.

A Patient Charter for Chronic Urticaria

Chronic urticaria (CU) is the recurring development of wheals (aka "hives" or "welts"), angioedema, or both for more than 6 weeks. Wheals and angioedema occur with no definite triggers in chronic spontaneous urticaria, and in response to known and definite physical triggers in chronic inducible urticaria. Approximately 1.4% of individuals globally will have CU during their lifetime. The itching and physical discomfort associated with CU have a profound impact on daily activities, sexual function, work or school performance, and sleep, causing significant impairment in a patient's physical and mental quality of life. CU also places a financial burden on patients and healthcare systems. Patients should feel empowered to self-advocate to receive the best care. The voice of the patient in navigating the journey of CU diagnosis and management may improve patient-provider communication, thereby improving diagnosis and outcomes. A collaboration of patients, providers, advocacy organizations, and pharmaceutical representatives have created a patient charter to define the realistic and achievable principles of care that patients with CU should expect to receive. Principle (1): I deserve an accurate and timely diagnosis of my CU; Principle (2): I deserve access to specialty care for my CU; Principle (3): I deserve access to innovative treatments that reduce the burden of CU on my daily life; Principle (4): I deserve to be free of unnecessary treatment-related side-effects during the management of my CU; and Principle (5): I expect a holistic treatment approach to address all the components of my life impacted by CU. The stated principles may serve as a guide for healthcare providers who care for patients with CU and translate into better patient-physician communication. In addition, we urge policymakers and authors of CU treatment guidelines to consider these principles in their decision-making to ensure the goals of the patient are achievable.

Psychosocial factors and chronic spontaneous urticaria: a systematic review

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current and Emerging Therapies for Chronic Spontaneous Urticaria: A Narrative Review

Chronic spontaneous urticaria (CSU) is a condition in which wheals, angioedema, and pruritus occur spontaneously and recurrently for at least 6 weeks. The etiology of this disease is partially dependent on production of autoantibodies that activate and recruit inflammatory cells. Although the wheals can resolve within 24 h, symptoms have a significant detrimental impact on the quality of life of these patients. Standard therapy for CSU includes second-generation antihistamines and omalizumab. However, many patients tend to be refractory to these therapies. Available treatments such as cyclosporine, dapsone, dupilumab, and tumor necrosis factor alpha (TNFa) inhibitors have been used with success in some cases. Furthermore, various biologics and other novel drugs have emerged as potential treatments for this condition, and many more are currently under investigation in randomized clinical trials.

Common but neglected problem in chronic spontaneous urticaria: Sleep disturbance

Background: Association of chronic spontaneous urticaria (CSU) with sleep disturbance has not been evaluated in studies that involve a large number of patients. Objective: In this study, we aimed to evaluate the sleep attitude and circadian rhythm in patients with CSU. Methods: As the patient group, recently diagnosed 100 patients with CSU, 100 patients with allergic rhinitis (AR) as the patient control group, and 100 healthy controls (HCs) were included. The Pittsburgh Sleep Quality Index (PSQI) questionnaire, sleep hygiene index (SHI), Epworth Sleepiness Scale (ESS) questionnaire, and the morningness-eveningness questionnaire (MEQ) were filled to assess sleep quality and circadian rhythm. CSU disease activity was evaluated by urticaria activity score-7 (UAS-7). Patients with concomitant diseases, e.g., psychiatric illnesses, that possibly affect sleep status or those who use related medications and at moderate or high risk of obstructive sleep apnea according to the STOP-Bang questionnaire were excluded from the study. Results: PSQI, SHI, and ESS scores were higher, and the MEQ score was lower in patients with CSU and patients with AR than those in the HCs (p < 0.001, for each score). However, the scores were not different among the patients with CSU and the patients with AR. UAS-7 was only correlated with PSQI scores (r = 0.402, p < 0.001). In addition, blood eosinophil counts and the serum C Reactive Protein (CRP) level were correlated with sleep quality (p = 0.02). Conclusion: The poor sleep quality, impaired sleep hygiene, increased daytime sleepiness, and intermediate type of circadian rhythm were observed in the patients with CSU and the patients with AR. Physicians should be aware of sleep problems in patients with CSU that might affect their quality of life and the success of their treatment.

Neuro-Immuno-Psychological Aspects of Chronic Urticaria

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

Association of Chronic Urticaria with Psychological Distress: A Multicentre Cross-sectional Study

Chronic urticaria is a debilitating disease that affects health-related quality of life, but few studies have evaluated its impact on psychological wellbeing. The aim of this study was to evaluate the quality of life of patients with chronic urticaria and determine its impact on their emotional and psychological wellbeing. A cross-sectional multicentre study of a cluster of 264 Lebanese patients visiting dermatology/immunology clinics was conducted between July 2018 and June 2020. The impact of chronic urticaria on quality of life was assessed using the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and Dermatology Life Quality Index (DLQI), as well as its consequences on mood changes using the Patient Health Questionnaire-9 (PHQ-9) and Beirut Distress Score 22 (BDS-22) scores. A multivariable analysis of covariates was performed to determine the effect of the triggering factors of urticaria on both CU-Q2oL and PHQ-9. A moderate negative correlation was found between Urticaria Control Test and quality of life scores as well as PHQ-9 and BDS-22 (p < 0.001). Patients with the lowest Urticaria Control Test score had the highest impairment in quality of life and depression scores. In conclusion, chronic urticaria compromises patients' quality of life and emotional wellbeing. This distress is more pronounced when the disease is more severe.

Psychological well-being, quality of life and patient satisfaction among adults with chronic spontaneous urticaria in a multi-ethnic Asian population

Patients with chronic spontaneous urticaria (CSU) have an increased risk of psychological distress. This cross-sectional study aimed to determine factors associated with psychological burden, quality of life (QoL) and patient satisfaction among adults living with CSU. Participants completed the self-administered Urticaria Activity Score-7 (UAS-7), Depression Anxiety Stress Scale (DASS 21), Dermatology Life Quality Index (DLQI), and Short Assessment Patient Satisfaction (SAPS) questionnaires. Multivariate logistic regression was used to determine the independent predictors of depression, anxiety, stress, QoL and patient satisfaction. From a total of 115 subjects with a median age of 42.6 years, range (19-89 years). 60.9% subjects reported moderate-to-severe CSU, 26.1% reported symptoms of depression, 54.8% had anxiety, 40.0% had stress, and 36.5% reported severely impaired QoL. The median UAS-7 score was 20 (IQR 11-27) while the median score of DLQI was 8 (IQR 4-13). The median score of SAPS was 20 (IQR 17-21). Low-income and severe disease were the significant predictors for depression while severe disease was predictive of impaired QoL and depression. Subjects who were diagnosed at older ages and those who required medical leave due to flares of CSU were less likely to be satisfied with their care. (192 words).

Chinese version of the chronic urticaria quality of life questionnaire: cultural adaptation, factor analysis, assessment of reliability and validity

Chronic urticaria is a common skin disorder that contributes profound impact on patients' quality of life (QoL). However, the cause of the disease is not clear, and the treatment still faces challenges. To better evaluate the effectiveness of treatment, an effective questionnaire survey on quality of life is needed. For the first time in Italy, a new questionnaire for chronic spontaneous urticaria, the chronic urticaria quality of life questionnaire (CU-Q2oL), has been developed. The purpose of this study was to develop and verify the Chinese version of the chronic urticaria quality of life questionnaire (CU-Q2oL). Three hundred and twenty-eight chronic urticaria patients were prospectively recruited and evaluated by the translated Chinese version of CU-Q2oL along with the Dermatology Life Quality Index (DLQI). Factor analysis, internal consistency, convergent validity, sensitivity to change and known-group validity were determined. Multiple linear regressions were used to determine the predicting factors of CU-Q2oL results. Factor analysis revealed a six-dimensional structure, and five of the six scales showed good internal consistency. Convergent validity and know-group validity showed good correlations. It was found to distinguish well between patients with different levels of urticaria activity and those to be sensitive to change in the Chinese CU-Q2oL. Disease severity was highly significantly predictive of the CU-Q2oL score on all scales. The CU-Q2oL Chinese version is a valid, reliable and sensitive instrument. It can be widely adopted to evaluate treatment outcomes and be applied in clinical research in Chinese patients.

Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review

Purpose

Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU.

Patients and methods

Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results

Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H₁-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU.

Conclusion

Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H₁- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.

How to Measure Disease Activity, Impact, and Control in Patients with Recurrent Wheals, Angioedema, or Both

Chronic spontaneous urticaria and chronic inducible urticaria are characterized by wheals, angioedema, or both, whereas other conditions such as hereditary angioedema present only with angioedema. The unpredictability of outbreaks, disfigurement, pruritus, and associated sleep and work disturbance can cause a significant impact on quality of life (QoL). Significant breakthroughs in the understanding of these conditions in recent years have led to the development of novel therapies. Assessment of patients with these conditions not only focuses on the clinical activity of the condition, but also on the impact on QoL and disease control with treatment. Patient-reported outcome measures, especially if sufficiently validated, give due prominence to the patient's perspective regarding disease impact and treatment outcomes. This article will review the tools readily available to assess activity, impact, and control in patients with recurrent wheals, angioedema, or both.

Psychological burden of COVID-19 on mild and moderate chronic spontaneous urticaria

Background: The impact of coronavirus disease 2019 (COVID-19) related mental health status on chronic spontaneous urticaria (CSU) has not been addressed before. Objective: The aim of this study was to evaluate the depression, anxiety and stress levels, and the fear of COVID-19 in patients with mild-to-moderate CSU and to determine their impact on urticaria activity during the pandemic. Methods: A total of 509 patients with mild-to-moderate CSU were prospectively evaluated with validated scales, the Depression Anxiety Stress Scale 21 (DASS-21) and the Fear of COVID-19 Scale (FCV-19S) during the lockdown period (LP) and the return to normal period (RTNP). CSU activity was determined with the urticaria activity score summed over 7 days (UAS7) and medication scores (MS). UAS7 and MS before the pandemic were retrospectively collected from medical records. Results: The median UAS7 and MS were both significantly higher in the LP than in the median of related scores during the prepandemic period (p < 0.0001) and the RTNP (p < 0.0001). The mean FCV-19S and DASS-21 scores were both significantly higher in the LP than in the RTNP (p < 0.0001). The FCV-19S and the DASS-21 anxiety and stress subscales were significantly higher in women. The UAS7s were positively correlated with the FCV-19S and depression, anxiety, and stress subscale scores. Conclusion: Fear of COVID-19, anxiety, depression, and stress during the COVID-19 pandemic, especially when strict isolation measures are taken, have a significant impact on mental health and urticaria activity in patients with mild-to-moderate CSU, even though they are not infected. Psychological support for patients with CSU seems to be important to control disease activity during the pandemic.

Angioedema Coexisting Chronic Spontaneous Urticaria Negatively Influences Patients' Sense of Coherence, What Results in Susceptibility to Anxiety Symptoms Occurrence

Background: Angioedema coexisting chronic spontaneous urticaria (CSU) is proved to result in patient anxiety occurrence, but the mechanisms and susceptibility patterns are unknown. Sense of coherence (SOC) is one of methods of coping with stress and is defined as a person’s general orientation toward life. We decided to assess SOC disturbances in CSU patients in the context of possible angioedema association. Methods: The study comprised 71 CSU subjects. To analyze disease activity, the Urticaria Activity Score seven-day assessment questionnaire (UAS7) was used. For anxiety assessment, the STAI questionnaire was used. The SOC-29 questionnaire, consisting of questions related to comprehensibility (SOC-C), manageability (SOC-M), and meaningfulness (SOC-Mf), was used to analyze SOC parameters (SOC-T). Results: In patients with coexisting angioedema, we observed statistically significantly lower values of SOC-Mf and SOC-T in comparison to the wheals only group. In the angioedema group, we noticed significant negative correlations between SOC-M and SOC-Mf, as well as SOC-T values and anxiety. In the wheals only group, we proved statistically significant correlations between SOC-Mf and SOC-T and anxiety assessed as a state. Conclusions: It is necessary to identify CSU patients manifesting angioedema as they are more likely to have impaired SOC. Lower SOC in this specific group of patients can be related to anxiety symptoms occurrence and should probably be an indication for psychological support.

The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

BACKGROUND

In chronic spontaneous urticaria (CSU), the guidelines recommend very limited diagnostic procedures during the routine workup, although additional investigations might be indicated in some patients with CSU. For physicians treating patients with CSU, it is often difficult to decide which diagnostic tests are useful.

OBJECTIVE

To provide recommendations on what diagnostic tests should be performed on which patients with CSU.

METHODS

We performed an extensive literature search on the respective topics and identified relevant questions that should prompt diagnostic procedures based on the published evidence and expert consensus among all authors.

RESULTS

We provide questions, diagnostic testing, where appropriate, and recommendation that should be included when assessing the history of a patient with CSU, to explore and rule out differential diagnoses, to assess patients for underlying causes and modifying conditions, to explore patients for comorbid diseases and consequences of having CSU, and to assess patients for CSU components that can help to predict their disease course and response to treatment.

CONCLUSIONS

Here, we provide physicians treating patients with CSU with information about which clues should lead to which tests and why.

A Systematic Review and Meta-Analysis of Health Utility Estimates in Chronic Spontaneous Urticaria

Background: Chronic spontaneous urticaria (CSU) is a common recurrent skin disease that adversely affect patient's quality of life condition to treat. Economic evaluations of health care often include patient preferences for health outcomes using utilities.

Objectives: The study aimed to determine pooled estimates of utility-based quality of life in patients with CSU.

Methods: We conducted a systematic review, meta-analysis, and meta-regression of peer-reviewed articles and conference papers that published from database inception to 31 April 2019 that reported utility estimates in patients with CSU. Scores reported with the EQ-5D, SF-6D, SF-12, and SF-36 instruments were converted to utilities using published mapping algorithms. Meta-analysis was used to calculate the pooled and meta-regression was used to examine the effects of possible factors.

Results: The pooled utility estimate for CSU was 0.68 [95% confidence interval (CI): 0.67–0.70]. The pooled utility estimate that converted from SF-36 or SF-12 was 0.66 (95% CI: 0.58–0.74), 0.72 (95% CI: 0.70–0.74) for EQ-5D, and 0.65 (95% CI: 0.63–0.67) for SF-6D, respectively. According to the meta-regression, higher proportion of female patients was significantly associated lower utility estimates (p = 0.013).

Conclusions: The study provides evidence-based utility estimates to inform health-related burden analysis of CSU and reference for the follow-up cost-effectiveness evaluation of chronic spontaneous urticaria intervention. These results highlight differences in common utility-based instruments and need to be cognizant of the specific instruments used when comparing the results of outcome studies.

In Chronic Spontaneous Urticaria, Comorbid Depression Linked to Higher Disease Activity, and Substance P Levels

Background: Patients with chronic spontaneous urticaria often exhibit psychiatric comorbidities including depression that contribute to the impairment of their quality of life. How CSU and depression are linked isn't well-understood. Substance P has been shown to be increased in patients with CSU and is held to contribute to the pathogenesis of depression. Methods: We measured disease activity in 30 CSU patients without depression and 30 CSU patients with depression by using the urticaria activity score. The severity of depression was assessed with the Beck Depression Inventory. We measured SP levels in these patients as well as in 30 healthy control subjects. In patients with comorbid depression, we correlated SP levels with CSU disease activity and the severity of depression. Results: In CSU patients, disease activity and the severity of depression were positively linked. UAS7 values were higher in CSU patients with comorbid depression as compared to those without (p < 0.05). SP levels were higher in CSU patients with depression than in those without (p < 0.001), but was similar in all CSU patients compared to healthy controls. SP levels weren't correlated with UAS7 values in CSU patients with depression, whereas they were weakly but significantly correlated with BDI scores (p < 0.05). Conclusion: Our results suggest that, in CSU patients with comorbid depression, CSU disease activity affects the severity of depression. CSU patients with high disease activity should be explored for comorbid depression.

Anxiety, depression, and stress in Korean patients with chronic urticaria

BACKGROUND/AIMS

Emotional distress is thought to cause or maintain chronic urticaria (CU). We aimed to investigate the presence of anxiety, depression, and stress in Korean adult CU patients and to explore their potential impact on treatment.

METHODS

We enrolled 79 CU patients and a disease control group comprising 39 persistent asthma patients. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate depression and anxiety. Stress and quality of life (QoL) were assessed by Stress Response Inventory and CU-QoL questionnaires. The sociodemographic and clinical data such as urticaria activity score (UAS-15, UAS-6) were obtained.

RESULTS

The prevalence of depression and anxiety based on the HADS were 48.1% and 38.0%. Although the prevalence of anxiety didn't differ between the CU and asthma patients, depression was significantly more prevalent in the CU patients (48.1% vs. 28.2%). Stress tended to be lower in CU patients. Anxiety, depression, and stress exhibited negative correlations with QoL. Anxiety showed significant correlation with UAS-6 and pruritus-visual analog scale (VAS; r = 0.256, r = 0.272, p < 0.05, respectively); depression correlated with sleep difficulty-VAS (r = 0.261, p < 0.05). Stress was associated with UAS-15, UAS-6, pruritus-VAS, and sleep difficulty-VAS (r = 0.251, r = 0.317, r = 0.302, r = 0.258, p < 0.05, respectively).

CONCLUSION

The current study first presented that Korean CU patients frequently have anxiety and depression, which affect their QoL and demonstrated that anxiety, depression, and stress had different effects on sleep difficulty, pruritus, and urticaria severity in Korean CU patients.

Efficacy of Bloodletting Therapy in Patients with Chronic Idiopathic Urticaria: A Randomized Control Trial

Objective

To assess the efficacy of bloodletting therapy (acupoint pricking and cupping) in patients with chronic idiopathic urticaria (CIU) in a randomized, control, parallel-group trial.

Methods

A total of 174 patients with CIU enrolled from March 2018 to October 2019 were randomized into three groups: group A treated with bloodletting therapy and ebastine, group B treated with placebo treatment (acupoint pseudopricking and cupping) and ebastine, and group C treated with ebastine only. The intention-to-treat analysis was conducted, and the primary outcome was the effective rate of UAS7 score being reduced to 7 or below after treatment phase.

Results

The effective rates at the end of treatment phase were different among the three groups (P < 0.05), which were 73.7% in group A, 45.6% in group B, and 42.9% in group C. Multiple analysis indicated differences between groups A and B (P < 0.0125) and groups A and C (P < 0.0125) and no difference between groups B and C (P > 0.0125). No severe bloodletting therapy-related adverse events were observed.

Conclusions

In this study on patients with CIU, one month of bloodletting therapy combined with ebastine is clinically beneficial compared with placebo treatment combined with ebastine and treatment with ebastine only. Thus, bloodletting therapy can be an effective complementary treatment in CIU. This trial is registered with ChiCTR1800015294.

Urticaria: recommendations from the Italian Society of Allergology, Asthma and Clinical Immunology and the Italian Society of Allergological, Occupational and Environmental Dermatology

BACKGROUND

Urticaria is a disorder affecting skin and mucosal tissues characterized by the occurrence of wheals, angioedema or both, the latter defining the urticaria-angioedema syndrome. It is estimated that 12-22% of the general population has suffered at least one subtype of urticaria during life, but only a small percentage (estimated at 7.6-16%) has acute urticaria, because it is usually self-limited and resolves spontaneously without requiring medical attention. This makes likely that its incidence is underestimated. The epidemiological data currently available on chronic urticaria in many cases are deeply discordant and not univocal, but a recent Italian study, based on the consultation of a national registry, reports a prevalence of chronic spontaneous urticaria of 0.02% to 0.4% and an incidence of 0.1-1.5 cases/1000 inhabitants/year.

METHODS

We reviewed the recent international guidelines about urticaria and we described a methodologic approach based on classification, pathophysiology, impact on quality of life, diagnosis and prognosis, differential diagnosis and management of all the types of urticaria.

CONCLUSIONS

The aim of the present document from the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC) and the Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA) is to provide updated information to all physicians involved in diagnosis and management of urticaria and angioedema.

Prevalence of chronic urticaria in children and adults across the globe: Systematic review with meta-analysis

BACKGROUND AND OBJECTIVES

Urticaria is a frequent skin condition, but reliable prevalence estimates from population studies particularly of the chronic form are scarce. The objective of this study was to systematically evaluate and summarize the prevalence of chronic urticaria by evaluating population-based studies worldwide.

METHODS

We performed a systematic search in PUBMED and EMBASE for population-based studies of cross-sectional or cohort design and studies based on health insurance/system databases. Risk of bias was assessed using a specific tool for prevalence studies. For meta-analysis, we used a random effects model.

RESULTS

Eighteen studies were included in the systematic evaluation and 11 in the meta-analysis including data from over 86 000 000 participants. Risk of bias was mainly moderate, whereas the statistical heterogeneity (I² ) between the studies was high. Asian studies combined showed a higher point prevalence of chronic urticaria (1.4%, 95%-CI 0.5-2.9) than those from Europe (0.5%, 0.2-1.0) and Northern American (0.1%, 0.1-0.1). Women were slightly more affected than men, whereas in children < 15 years we did not find a sex-specific difference in the prevalence. The four studies that examined time trends indicated an increasing prevalence of chronic urticaria over time.

CONCLUSIONS

On a global level, the prevalence of chronic urticaria showed considerable regional differences. There is a need to obtain more sex-specific population-based and standardized international data particularly for children and adolescents, different chronic urticaria subtypes and potential risk and protective factors.

Approach to the Patient with Hives

Urticaria is a common presenting problem to the primary care provider. Acute urticaria lasting less than 6 weeks may be associated with a drug or food allergens. Chronic urticaria lasting more than 6 weeks is often associated without a known underlying cause. Inducible stimuli causing hives should be excluded using specific provocation testing. Treatment follows a standardized algorithmic approach as outlined by the Joint Task Force Practice Parameter and/or International Urticaria guidelines. Patients not responsive to steps 1 or 2 should be referred to an urticaria specialist for further evaluation and treatment. The prognosis and outcome of urticaria is generally very favorable for most patients.

Patients with chronic urticaria have a higher risk of psychiatric disorders: a population-based study

BACKGROUND

The prevalence of psychiatric comorbidities in patients with chronic urticaria (CU) in a national population is largely unknown.

OBJECTIVES

To investigate the prevalence of psychiatric disorders and psychiatric medication use in patients with CU in Taiwan.

METHODS

Data were sourced from Taiwan's National Health Insurance Research Database for 2011. Patients who had a primary/secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 708·1, 708·8 or 708·9 during 2011 with at least two outpatient visits and an antihistamine prescription were identified as CU cases. Patients with CU were classified into three disease severity groups according to their medication types. Psychiatric disorders were identified by patients having three outpatient visits with a primary or secondary diagnosis of a given psychiatric disease. Psychiatric medication use was defined by having at least four outpatient visits with prescriptions for anxiolytics, antidepressants or sleeping pills in 2010 or 2011.

RESULTS

Of the 167 132 patients with CU, 82·5% had mild CU, 17·0% had moderate CU and 0·4% had severe CU. Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication prescription than control groups. The relative risk (RR) of psychiatric disorders was 1·43 for patients with mild, 1·50 for patients with moderate and 2·32 for patients with severe CU vs. the controls (P < 0·001). For psychiatric medication prescription, the RRs were 1·95, 2·70 and 2·09, respectively, vs. controls (P < 0·001).

CONCLUSIONS

Patients with CU had a higher prevalence and risk of psychiatric disorders and psychiatric medication prescription than control groups. What's already known about this topic? Previous studies have shown a high prevalence of psychiatric comorbidities in patients with chronic urticaria (CU), with rates ranging from 35% to 60%. Anxiety, depression and somatoform disorders have been reported as the most prevalent mental disorders in patients with CU. What does this study add? Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication use than control groups in the general population. The relative risk (RR) of psychiatric disorders was 1·43 for those with mild CU, 1·50 for those with moderate CU and 2·32 for those with severe CU vs. controls. The RR for psychiatric medication use was 1·95 for those with mild CU, 2·70 for those with moderate CU and 2·09 for those with severe CU vs. controls. Mental health evaluations and management are important elements in CU management.

Psychiatric comorbidity in chronic urticaria patients: a systematic review and meta-analysis

Background

Dermatological illness can affect the quality of life and may coexist with psychiatric disorders.

Objective

The aim of this review was to systematically evaluate the published evidence of any psychiatric disorders that may coexist with chronic urticaria (CU) and any effect psychiatric interventions may have on CU.

Methods

Following the Cochrane guidance, we conducted a systematic literature search using web-based search engines provided by PubMed (for Medline database), Google Scholar and Scopus for studies that have investigated the existence of psychiatric comorbidity in patients with CU. To be included, a study had to possess features, such as: (1) distinction between chronic urticaria and allergic conditions, (2) direct collection of diagnostic psychiatric data by using clinical interview and standardized questionnaires, (3) International Classification of Disorders criteria or the Diagnostic and Statistical Manual of Mental Disorders criteria for the diagnosis of mental disorders, and (4) manuscripts written or published in the English language. Unpublished research and research in progress were not included. All the eligible studies were scrutinized for any reported psychiatric interventions that had any effect on CU. The systematic review has been registered on PROSPERO (registration number CRD42019122811) and was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

Results

Twenty-five studies were identified. Almost one out of three CU patients have at least one underlying psychiatric disorder. None of the studies clarified whether the psychiatric disorders pre-existed the CU onset, and no association was found between CU severity and duration, and psychological functioning. Only one case report and two case series mentioned that treatment of psychiatric disorders with either anti-depressants, anti-anxiety drugs or psychological interventions might result in improvement of urticaria.

Conclusions

Patients with CU frequently experience psychiatric disorders. This highlights the need for a multidisciplinary therapeutic approach involving prompt recognition and management of any potential psychiatric disorder in addition to urticaria treatment. Further studies are needed to assess whether psychiatric disorders coexist with CU independently or follow urticaria onset and whether any psychological or psychiatric intervention may help in CU control.

An Uncontrolled Open Trial of a Brief Behavioural Activation Treatment for Depression in Patients with Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) has been associated with depression and can have an impact on quality of life. Therefore, researchers have suggested the potential utility of psychological interventions for targeting depression among CSU patients. Psychological interventions that may hold the most promise are those that are brief and easily transportable, such as brief behavioural activation treatment for depression. We report results of a preliminary investigation of an uncontrolled open trial of a one-session behavioural activation treatment for depression designed for patients with CSU (BATD-CSU) at a university-based allergy and immunology clinic. Participants were 11 females with chronic, poorly controlled urticaria and symptoms of depression. Following the completion of pretreatment questionnaires, participants were administered BATD-CSU primarily by non-mental health professionals trained and supervised in its delivery. One month post-BATD-CSU, participants completed follow-up questionnaires. Participants exhibited significant reductions in depression severity, avoidance/rumination, and work/school impairment. BATD-CSU was also associated with improvements in urticaria control one month post-treatment. Moreover, five of nine patients reported reliable and clinically significant improvement on at least one outcome. Results demonstrate that BATD-CSU may have benefits for CSU patients even when consisting of one session and delivered by professionals with limited background in psychological interventions, thus speaking to its feasibility and transportability.

Omalizumab in elderly patients with chronic spontaneous urticaria: An Italian real-life experience

BACKGROUND

Omalizumab therapy is effective and safe in patients with chronic spontaneous urticaria (CSU) resistant to nonsedating histamine₁ (H₁) antihistamines (nsAHs).

OBJECTIVE

To evaluate the efficacy and safety of omalizumab in elderly (aged ≥65 years) patients with nonsedating H₁-antihistamine-refractory CSU in a real-life setting.

METHODS

Patients with nonsedating H₁-antihistamine-refractory CSU (n = 322) treated with omalizumab administered every 4 weeks in doses of 300 mg for 24 weeks were divided into 2 groups according to age at omalizumab treatment onset: 15 to 64 years and 65 years or older. Treatment response was assessed using a 7-day urticaria activity score (UAS7). Adverse effects of omalizumab therapy were recorded.

RESULTS

Among patients, 32 (9.9%) were 65 years or older. At baseline, CSU characteristics were generally similar among the groups, although the presence of angioedema was statistically significantly lower in patients younger than 65 years. Any differences in weekly itch severity score, hive score, and UAS7 between the 2 age groups were not significant at weeks 4, 12, and 24, with the exception of the hive score at 24 weeks and the UAS7 at week 24. No significant between-group differences were seen in the proportion of patients with a UAS7 of 6 or lower and with a UAS7 score of 0 at weeks 4, 12, 24, and 40. The proportion of patients with at least one adverse event reported as suspected to be caused by study drug was 10% in the younger group vs 6.3% in the older group (P = .53).

CONCLUSION

Our study found that omalizumab is a well-tolerated and effective therapy for elderly patients with nonsedating H₁-antihistamine-refractory CSU.

Stress, itch and quality of life in chronic urticaria females

Introduction

Chronic urticaria (CU) belongs to a group of psychodermatological disorders, thus stress can play a significant role in this dermatosis onset and/or exacerbation. On the other hand, the disease itself accompanied by itch, may be a source of distress and could worsen patients' quality of life (QoL).

Aim

The first goal of our study was to compare stress intensity between CU subjects and the control group. The second aim was to investigate the relationships between disease-related parameters (CU severity, itch) and psychological variables (stress and QoL) in CU patients.

Material and methods

Forty-six female patients with CU participated in our study. Thirty-three healthy females constituted a control group. The following methods were applied: Urticaria Activity Score (UAS), Itch Severity Evaluation Questionnaire, Visual analogue scale (VAS), Social Readjustment Rating Scale (SRRS) and the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL).

Results

Chronic urticaria patients demonstrated a significantly higher stress level in comparison to the control group (z = 2.699; p < 0.001). Regarding the total pruritus score, all CU-Q2oL dimensions were affected, except for subscale swelling/mental status. The strongest link was revealed between global itch and QoL subscale embarrassment (r = 0.51, p < 0.001). There were also statistically significant correlations between stress (VAS scale and SRRS) and QoL (all at least p < 0.05).Conclusions: Taking into account the significant pruritus contribution to QoL impairment, it would be worth employing itch-coping trainings in the CU group. As a consequence, feeling of self-control and self-efficacy could be enhanced, thus resulting in the well-being improvement.

Burden of Illness and Quality-of-Life Measures in Angioedema Conditions

Burden of illness studies and evaluation of health-related quality of life using validated questionnaires have become an important task in the comprehensive management of angioedema conditions, mainly angioedema associated with chronic spontaneous urticaria and hereditary angioedema caused by C1-inhibitor deficiency. A review of the principal tools and studies is presented. Both diseases present a higher proportion of psychiatric disorders, impair work and studies productivity, and produce high direct and indirect costs. These assessments also have been useful to evaluate the positive impact of new drugs and interventions. More studies are desirable, especially in other types of angioedema disorders, such as hereditary angioedema with normal C1 inhibitor.

Disease-specific impairment of the quality of life in adult patients with chronic spontaneous urticaria

BACKGROUND/AIMS

Chronic urticaria (CU) is a common skin disorder characterized by wheals and pruritus lasting more than 6 weeks. Due to its long duration and changeable symptoms, the quality of life (QOL) of patients with CU can be impaired substantially. We evaluated the CU-QOL, a previously validated CU-specific QOL measure, and investigated factors influencing QOL in chronic spontaneous urticaria (CSU) patients.

METHODS

A hospital-based cross-sectional study was performed on 390 adult patients diagnosed with CSU from March 2009 to December 2012 at the Allergy and Clinical Immunology Clinic at Ajou University Hospital. The CU-QOL questionnaire, urticaria activity score (UAS), combined angioedema, and serum total immunoglobulin E (IgE) levels were investigated.

RESULTS

The average CU-QOL score obtained from the questionnaire was 70.6 (of 100 points). The CU-QOL scores correlated significantly with the UAS, particularly with the 15-point UAS (UAS-15; coefficient -0.532, p < 0.01) rather than the 6-point UAS (-0.502, p < 0.01). The patients presenting with angioedema and urticaria had poorer scores in the urticaria symptom domain than those with urticaria alone (37.4 vs. 46.9, p = 0.004). Log-transformed serum total IgE levels correlated significantly with CU-QOL (-0.131, p < 0.05). Multivariate regression models indicated that severe CU (UAS-15 score ≥ 13), log (total IgE), and the presence of angioedema were significant predictors of impaired CU-QOL (< 85 points).

CONCLUSIONS

CU has a substantial negative impact on QOL. The assessment of UAS-15, total IgE, and the presence of angioedema can be useful to predict QOL of the patients with CSU.

Burden of chronic urticaria relative to psoriasis in five European countries

Background

Quantification of burden of chronic spontaneous urticaria (CSU) vs. psoriasis (PsO) is limited.

Objective

To evaluate the burden associated with CSU vs. PsO of all severities (overall PsO), mild and moderate/severe PsO.

Methods

This retrospective cross‐sectional analysis compared data from adult patients with chronic urticaria (CU), used as a proxy for CSU, and PsO from the National Health and Wellness Survey in France, Germany, Italy, Spain and the United Kingdom. Outcomes included mental and physical component summary scores (MCS and PCS) calculated from the Short Form (SF)‐36v2 or SF‐12v2, SF‐6D health utility scores, self‐reported psychological complaints (anxiety, depression and sleep difficulties), work productivity and activity impairment, and self‐reported healthcare resource utilization. Bivariate and multivariate analyses for each outcome and comparative groups were conducted.

Results

This analysis included 769 CU and 7857 PsO (26.9% moderate/severe) patients. Following adjustment for covariates, CU patients showed a greater health‐related quality of life (HRQoL) impairment vs. overall PsO (MCS: −2.4, PCS: −1.6, SF‐6D: −0.03; all P < 0.001). CU patients showed a higher risk of anxiety, depression and sleep difficulties [odds ratio (OR): 1.63, 1.34 and 1.56, respectively; all P < 0.01] and greater healthcare resource use vs. overall PsO. The overall activity impairment was significantly greater in CU patients than in overall PsO patients (P = 0.001), while the impact on work was not significantly different. The results vs. moderate/severe PsO group showed no significant differences on all outcomes.

Conclusion

Burden of illness in CU is higher than PsO of all severities but similar to that observed in moderate/severe PsO. Both diseases have a similar negative impact on work productivity.

Chronic Urticaria Patient Perspective (CUPP): The First Validated Tool for Assessing Quality of Life in Clinical Practice

BACKGROUND

There is a need for validated tools to assess health-related quality of life (HRQoL) in routine clinical practice.

OBJECTIVE

The aim of this study was to validate the Chronic Urticaria Patient Perspective (CUPP) for assessment of patients with chronic urticaria (CU) in clinical practice.

METHODS

A provisional CUPP was developed from candidate items identified by following an iterative process in a retrospective analysis of 249 Chronic Urticaria Quality of Life Questionnaire questionnaires. The psychometric properties of the CUPP were then tested on a sample of patients enrolled in 13 Italian centers.

RESULTS

The study population in the validation phase comprised 152 patients. The 10-item version of the CUPP showed satisfactory internal consistency (Cronbach's alpha values of 0.76 at visit 1 and 0.90 at visit 2), good criteria, and discriminative and convergent validity. Reliability was assessed in 34 patients with no changes in health (Global Rating Scale = 0 at visit 2) and was satisfactory (CCC [concordance correlation coefficient] = 0.9). Changes in CUPP scores were significantly associated with changes in Urticaria Activity Score (UAS)-Hive count (r = 0.36, P < .001), UAS-Itch severity (r = 0.48, P < .001), and UAS-Total score (r = 0.342, P < .001), all of which indicated good responsiveness. The minimal important difference was 1.5.

CONCLUSIONS

CUPP is a simple 10-question tool with good psychometric properties that provides a valid, reliable, and standardized measurement of HRQoL in patients with CU.

Epidemiology and comorbidities of patients with chronic urticaria in Taiwan‏: A nationwide population-based study

BACKGROUND

Comprehensive data regarding the epidemiology of chronic urticaria (CU) in general populations are scant.

OBJECTIVES

To investigate the prevalence, incidence, and comorbidities of CU in general population.

METHODS

The data were sourced from the National Health Insurance Research Database (NHIRD) for 2009-2012. Patients who had a primary/secondary ICD-9-CM diagnosis code of 708.1, 708.8, or 708.9 during the year with at least two outpatient visits and an antihistamine prescription, were identified as the cases of CU for each year. The incidence, persistence and comorbidities of CU were examined.

RESULTS

The prevalence of CU ranged from 0.69% to 0.79% for each year from 2009 to 2012, and the incidence was around 0.50% per year from 2010 to 2012. Comparing to the Standard Population, the standardized prevalence ratios (SPRs) for the rheumatic diseases, thyroid disorders, inflammatory diseases, and psychiatric disorders among CU patients were 2.74, 1.81, 1.57 and 1.87, respectively.

CONCLUSION

The prevalence of CU in Taiwan is about 0.69-0.79%. CU is associated with a significantly increased risk of psychiatric disorders, inflammatory diseases, thyroid disorders, and rheumatic diseases. Except for thyroid disorders, the prevalence of these comorbidities tends to increase the longer CU persists.

Psychoneuroimmunoendocrinology: clinical implications

Psychoneuroimmunoendocrinology, which was first described in 1936, is the study of the interactions between the psyche, neural and endocrine functions and immune responses. The aim of psychoneuroimmunoendocrinology is to apply medical knowledge to the treatment of different allergic, immune, autoimmune, rheumatic, neoplastic, endocrine, cardiovascular and dental pathologies, among other disorders. Epigenetic factors and major stresses from different types of stimuli acting through distinct pathways and neurotransmitters are highly involved in altering the psychoneuroimmunoendocrine axis, resulting in the emergence of disease. The main purpose of this report is to expand the understanding of psychoneuroimmunoendocrinology and to demonstrate the importance of the above-mentioned interactions in the etiology of multiple pathologies. In this review, a search of the medical literature using PubMed (free access search engine for the Medline database of the National Library of Medicine of the United States) over the years 1936 to 2016 was conducted, and descriptive and experimental studies and reviews of the scientific literature were included.

Sense of coherence as a protective factor in chronic urticaria

INTRODUCTION

Chronic urticaria (CU) seems to be perceived as a psychodermatological disorder. Different psychological factors play an important role in CU triggering and course. One of them is a sense of coherence (SOC), which is believed to be a protective factor against anxiety and depression.

AIM

To investigate quality of life (QoL) in CU patients and to compare selected psychological parameters (anxiety, depression and sense of coherence) between CU individuals and the control group.

MATERIAL AND METHODS

The study comprised 46 female patients with chronic urticaria and 33 healthy females as a control group. The following methods were employed: Urticaria Activity Score (UAS), Hospital Anxiety and Depression Scale (HADS), Sense of Coherence Questionnaire (SOC-29) and Dermatology Life Quality Index (DLQI).

RESULTS

The CU patients presented a significantly higher anxiety level in comparison to the control group (z = 4.488; p < 0.001). There were no statistically significant differences regarding depression intensity and SOC. In both groups anxiety and depression negatively correlated with global SOC and all its components. Disease severity positively correlated with QoL (ρ = 0.46, p < 0.01) and negatively with global SOC (ρ = -0.33, p < 0.05).

CONCLUSIONS

Bearing in mind higher prevalence of anxiety and depressive symptoms in our CU group, it would be useful to perform screening of these aspects in all CU patients and subsequently develop respective psychological interventions, based on enhancement of personal resources.

Autologous serum and plasma skin test to predict 2-year outcome in chronic spontaneous urticaria

Background

Autologous serum skin test (ASST) and autologous plasma skin test (APST) are simple methods to diagnose autoimmune chronic urticaria. However, the association data of ASST or APST with disease severity and long-term outcome are still unclear.

Objective

The results of ASST and APST might be used to predict urticaria symptom severity and long-term outcomes among chronic spontaneous urticaria (CSU) patients.

Methods

We evaluated the prevalence of reactive ASST and APST in 128 CSU patients. The patients were characterized by 4 groups: negative, ASST positive, APST positive, and both ASST and APST positive. We observed remission rate among the CSU patients during 2 years.

Results

Forty-four of 128 CSU patients (34%) had negative autologous skin test. The CSU patients with positive ASST, positive APST, and both positive ASST and APST were 47 (37%), 6 (5%), and 31 (24%), respectively. No significant difference was found between the groups according to urticaria severity score (USS) and dermatology life quality index (DLQI). Mean wheal diameter of ASST showed positive correlation with DLQI. Also, mean wheal diameter of APST showed positive correlation with USS and DLQI. Both the positive ASST and APST groups had a high proportion of 4-fold dose of H1-antihistamine than the positive ASST (p = 0.03) and negative groups (p = 0.0009). The rate of remission over 2 years in the negative, positive ASST, positive APST, and both positive ASST and APST groups were 81.1%, 62.3%, 60%, and 46.1%, respectively. The urticaria remission rate in patients in the negative group was significantly higher compared with both positive ASST and APST groups (odds ratio, 5.0; 95% confidence interval, 1.61–15.44; p = 0.006).

Conclusion

ASST and APST results could predict remission rates among patients with CSU. Our results suggested investigating ASST and APST among CSU patients before starting treatment.

FLG single nucleotide polymorphisms in chronic idiopathic urticaria

BACKGROUND

Filaggrin (FLG), which is formed from profilaggrin protein during epidermal terminal differentiation, is a prerequisite to squame biogenesis and thus for perfect formation of the skin barrier. Yet, the relationship between genetic polymorphisms of FLG and chronic idiopathic urticaria (CIU) has not been investigated.

METHODS

The study population consisted of 93 CIU patients and 93 healthy control subjects without a history of allergic, autoimmune or any other systemic disease. Five single nucleotide polymorphisms (SNPs) of FLG were investigated: rs2485518, rs3126065, rs2786680, rs3814300, and rs3814299.

RESULTS

For all the investigated polymorphisms, 100% of both CIU patients and control subjects exhibited one given allele and consequently one given genotype as following: A/A genotype for two SNPs, rs3126065 and rs2786680, C/C genotype for two SNPs, rs2485518 and rs3814300, and G/G genotype for one SNP rs3814299 of FLG, and hence no association was found between either allele frequencies or genotype distributions of FLG SNPs and CIU in an Iranian population.

CONCLUSIONS

The present study examined the possible relationship between SNPs of FLG and CIU for the first time, and demonstrated that none of five investigated SNPs (rs2485518, rs3126065, rs2786680, rs3814300, and rs3814299) are correlated with CIU in an Iranian population. Further investigations are required to address whether ethnicity/race impacts on relationship between SNPs of FLG and CIU.

Clinically relevant outcome measures for assessing disease activity, disease control and quality of life impairment in patients with chronic spontaneous urticaria and recurrent angioedema

PURPOSE OF REVIEW

The aim of this review is to highlight the most important, clinically relevant patient-reported outcome (PRO) measures for chronic spontaneous urticaria and recurrent angioedema.

RECENT FINDINGS

The use of PROs becomes increasingly important in modern patient-centred medicine. In the past years, several new, validated and reliable tools for the assessment of disease activity, disease control and health-related quality of life impairment of chronic spontaneous urticaria and recurrent angioedema patients have become available. These are required to optimize and standardize clinical trials. In addition, they are of increasing relevance in routine management. The major advantage of their application is that they do not only improve and standardize medical record keeping and care but also release valuable time for the actual physician-patient consultation. A prerequisite for this to work out is, however, that the PROs are well embedded into patient management.

SUMMARY

The currently available PRO measures can help to better determine the patient's disease status, to aid, document and back treatment decisions as well as to improve the assessment of treatment effects. Linguistically validated versions of the PROs are available for many but not all languages yet. Here, further research is needed to close these gaps.

Association among stress, hypocortisolism, systemic inflammation, and disease severity in chronic urticaria

BACKGROUND

Chronic urticaria (CU) is an immune-mediated disease characterized by wheals for at least 6 weeks. The role of stress and the correlation of stress, hypocortisolism, and inflammatory markers are not well understood.

OBJECTIVES

To estimate C-reactive protein (CRP), interleukin (IL)-18, and cortisol levels in patients with CU and to explore their association with disease severity and stress.

METHODS

Forty-five patients with CU and 45 age- and sex-matched healthy controls were recruited for this cross-sectional study. Disease severity was assessed by the urticaria activity score (UAS) and stress by Presumptive Stressful Life Events (PSLE) and Daily Hassles and Uplifts Scale-Revised (DHUS-R) scoring. IL-18 and high-sensitivity CRP (hs-CRP) were estimated using enzyme-linked immunosorbent assay kits and cortisol levels by chemiluminescence.

RESULTS

We observed significant systemic inflammation (increased hs-CRP and IL-18 levels) and stress scores, whereas there was a lowering of basal cortisol levels in patients with CU compared with controls. This finding was more pronounced with increasing disease severity and autoimmune disease, except for stress scores, which did not vary between patients with positive and negative autologous plasma skin test results. We further observed that patients with CU with hypocortisolism had higher levels of hs-CRP and IL-18 and higher PSLE and DHUS-R scores compared with those without hypocortisolism. The hs-CRP level, IL-18 level, PSLE score, DHUS-R score, and duration of the symptoms are significantly positively correlated with UAS, whereas the cortisol level is significantly negatively correlated with UAS. Cortisol has a significant negative correlation with PSLE score, DHUS-R score, and the duration of the disease.

CONCLUSION

CU is associated with systemic inflammation and stress, along with a significant lower basal cortisol, especially with severe disease and autoimmune urticaria. Thus, chronic stress may precipitate the vicious cycle in the pathogenesis of CU.