The burden of chronic spontaneous urticaria is substantial: Real-world evidence from ASSURE-CSU

Mortality in adult patients with chronic spontaneous urticaria: A real-world cohort study

BACKGROUND

Chronic spontaneous urticaria (CSU), a common and debilitating disease, is widely held not to be life limiting, but the mortality of CSU has not been investigated.

OBJECTIVE

We sought to assess all-cause mortality in patients with CSU, risk for comorbidities that are leading causes of death, and impact of guideline-recommended urticaria treatments on mortality rates.

METHODS

This was a retrospective population-based cohort study of electronic health records of 272,190 adult patients with CSU and 12,728,913 controls without urticaria from the US collaborative network TriNetX.

RESULTS

The study included 264,680 propensity score-matched patients with CSU (mean [SD] age = 47.5 [19.8] years; 71.5% female) and a corresponding number of controls without urticaria. Patients with CSU had higher 3-month (hazard ratio [HR] 2.10, 95% CI 1.97-2.22), 1-year (HR 1.77, 95% CI 1.71-1.83), and 5-year (HR 1.69, 95% CI 1.65-1.73) all-cause mortality (all P < .0001). Compared with controls, patients with CSU exhibited higher risk and rates of the leading causes of death in the United States, including suicidal ideations/suicide attempts (HR 3.14, 95% CI 3.00-3.28) and malignant neoplasms (HR 2.09, 95% CI 2.02-2.16). The risk of mortality appeared to be more pronounced in White and younger patients with CSU. All-cause mortality rates at 5 years were significantly lower in patients treated with second-generation H1 antihistamines versus untreated patients (1.0% vs 2.3%; HR 1.84, P < .0001) and omalizumab-treated patients versus antihistamine-treated patients (0.7% vs 2.6%; HR 3.99, P = .0003).

CONCLUSIONS

CSU is associated with increased mortality likely due to comorbidities, especially suicide, and effective CSU treatment may reduce mortality. These findings should be investigated in additional studies and in other populations.

Update on the Treatment of Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is a mast cell-mediated skin disease that presents with wheals, angioedema, or both for more than 6 weeks. Less than 10% of patients have complete control of their CSU (the main goal of CSU treatment) with second generation H1-antihistamines, the first-line treatment. About 70% of patients with antihistamine-refractory CSU do not reach complete control with omalizumab, the second-line treatment. Novel therapies are especially needed for patients with mast cell-activating immunoglobulin (Ig)G autoantibodies (autoimmune CSU) associated with nonresponse or late response to omalizumab. Furthermore, there is a lack of disease-modifying treatments that induce long-term CSU remission after drug withdrawal. Several emerging treatments can address these unmet needs including Bruton tyrosine kinase inhibitors, e.g., remibrutinib and rilzabrutinib; anti-KIT monoclonal antibodies, e.g., barzolvolimab; and anti-cytokine therapies, e.g., dupilumab. In clinical trials, 30-31%, 28-32%, and 38-51% of patients with CSU showed complete response to treatment with dupilumab (phase 3, week 24), remibrutinib (phase 3, week 24), and barzolvolimab (phase 2, week 12), respectively. The most common adverse events were injection site reactions for dupilumab (12%), respiratory tract infections (11%), headache (6%), and petechiae (4%) for remibrutinib and changes in hair color (14%), neutropenia / decreased neutrophil count (9%) and skin hypopigmentation (1%) for barzolvolimab. This review provides an update on the current state of development of treatments for CSU.

Endotypes, phenotypes, and biomarkers in chronic spontaneous urticaria: Evolving toward personalized medicine

Chronic spontaneous urticaria (CSU) is an inflammatory disorder that manifests with hives, angioedema, or both and lasts more than or equal to 6 weeks. Although certain elements of CSU pathogenesis are well defined, others remain unclear. We discuss our current understanding of the underlying CSU endotypes, distinct clinical phenotypes, and predictive biomarkers. It is increasingly recognized that CSU comprises a spectrum of different underlying pathogenic mechanisms and distinct clinical presentations. Broadly, 2 endotypes that drive CSU pathogenesis have been identified, namely type I (autoallergic) and type IIb (autoimmune). However, a subpopulation shows evidence of both types, and some patients show evidence of neither. Multiple identified biomarkers have been associated with these endotypes or with disease features, such as CSU severity and duration. There is a lack of connectivity among the identified biomarkers, genetic risk loci, phenotypes, and corresponding endotypes, and each of these is frequently considered independently of the others. These identifiable features also have been associated with response, or lack thereof, to available therapies. Future investigations should optimize the endotyping of CSU using point-of-care, noninvasive, accessible biomarkers and assess the differences in response to therapy. With multiple treatments in late-stage development, establishing clearly defined CSU endotypes will facilitate future treatment decision-making and tailored treatment approaches and will inform optimal trial design.

Urticaria in China: incidence, prevalence, and disability-adjusted life years compared with G20 countries: findings from the Global Burden of Disease study 2021

Urticaria has become a major public health challenge in China, yet comprehensive national data assessments are lacking. This study analyzes the burden of urticaria in China compared to G20 countries from 1990 to 2021. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, we examined the incidence, prevalence, and disability-adjusted life years (DALYs) of urticaria by age and sex in China. Temporal trends were assessed using Average Annual Percent Change (AAPC) estimates. We also decomposed the changes in new cases, patient numbers, and urticaria burden in G20 countries and globally from 1990 to 2021. In 2021, China reported 17.30 million (95% uncertainty interval, 15.37-19.25) new cases of urticaria, 9.87 million (8.72-10.99) existing cases of urticaria, and 0.59 million (0.39-0.82) DALYs due to urticaria, ranking second among G20 countries. These metrics peaked in females under 5 years old. Age-standardized rates in China were lower than the global average and remained stable from 1990 to 2021. The under-5 age group showed the fastest growth in prevalence and DALY rates. The number of urticaria patients increased by 8.52%, with population growth contributing 19.86%, aging - 11.31%, and age-specific prevalence - 0.03%. Despite stable age-standardized rates, the absolute burden of urticaria in China has risen, particularly among females under 5 years old, highlighting the need for targeted public health interventions. Improving public emergency awareness and response is critical for urticaria patients, who may develop severe systemic diseases and fatal allergic symptoms.

Patient and physician perspectives on disease burden in chronic spontaneous urticaria: A real-world US survey

BACKGROUND

Chronic spontaneous urticaria (CSU) is frequently associated with severe disease-related symptoms that negatively affect quality of life, but patients and physicians may differ in their opinion on CSU burden.

OBJECTIVE

To describe the clinical and humanistic burden associated with CSU and level of agreement between patient and physician perceptions of disease burden and treatment satisfaction.

METHODS

This cross-sectional, survey-based study of US physicians and their adult patients with CSU included data collected in the Adelphi CSU Disease Specific Programme from 2020 to 2021. Overall, 1082 patient record forms completed by 110 physicians (including 40 allergists/immunologists, 50 dermatologists, and 20 primary care physicians) and 474 matched patient-reported questionnaires were included. Paired physician-patient records were used to determine agreement on disease burden and treatment satisfaction.

RESULTS

Patients with CSU often experienced physician-reported itching (66%) and hives (49%) and had a history of angioedema (23%). Although current CSU severity had largely improved since diagnosis, many patients and physicians continued to report moderate/severe current disease symptoms (46% and 30%, respectively). Moderate/severe disease had greater impacts on quality of life, sleep, work impairment, and treatment satisfaction than mild disease. Most patients and physicians agreed on symptom severity (61%-74%), with disagreement largely due to physicians underreporting severity relative to patients. Patient/physician agreement on treatment satisfaction was highest with mild CSU severity (82%), mild hive severity (80%), and omalizumab or other biologic treatment (87%).

CONCLUSION

Moderate/severe CSU was associated with greater disease burden and lower treatment satisfaction than mild CSU. Physicians more frequently underreported CSU severity compared with their patients.

Mental Health Interventions in Refractory Chronic Spontaneous Urticaria: A Call to Expand Treatment Guidelines

Chronic spontaneous urticaria (CSU) is a complex inflammatory skin condition that severely impacts patients' quality of life. For some patients, conventional treatments, including second-generation antihistamines, omalizumab, and cyclosporine A, fail to achieve sustained control. Emerging evidence suggests that psychiatric comorbidities, such as generalized anxiety disorder (GAD), exacerbate CSU through neuro-immuno-cutaneous (the interaction between the nervous system, immune system, and skin) mechanisms. We present the case of a 35-year-old female with refractory CSU and GAD. Despite escalating doses of omalizumab and the addition of cyclosporine A, disease control remained unstable. The introduction of cognitive behavioral therapy (CBT) and escitalopram resulted in significant improvement, achieving complete resolution of symptoms within eight weeks. Following discontinuation of both escitalopram and omalizumab, urticaria relapsed after a stressful event and during pregnancy. The reintroduction of escitalopram and CBT reestablished full control of urticaria. The patient continues on escitalopram and CBT without needing additional pharmacological intervention for CSU. This case underscores the importance of incorporating mental health interventions in managing refractory CSU, as psychiatric comorbidities may exacerbate CSU by intensifying neuro-immune interactions, particularly during stressful periods. Integrating mental health care into treatment guidelines can offer significant benefits, improving symptom control, reducing the need for aggressive pharmacotherapy, and enhancing patients' quality of life.

Clinical burden, treatment, and disease control in patients with chronic spontaneous urticaria: Real-world evidence

BACKGROUND

Chronic spontaneous urticaria (CSU) is an unpredictable inflammatory skin condition with substantial clinical burden that affects 0.23% to 0.78% of the US population.

OBJECTIVE

To describe the incidence and prevalence of patients with a record of CSU diagnosis, treatment patterns, disease control, and clinical and economic burden in a US cohort of patients with CSU.

METHODS

Adults with a record of CSU diagnosis within the US HealthVerity claims database were eligible. Age- and gender-adjusted prevalence/incidence rates were calculated for January 2017 to December 2022. Clinical characteristics were described during the 1 year before CSU diagnosis (baseline) and the time after (follow-up). Proxy events representing uncontrolled CSU (any record of prescriptions for corticosteroids, biologics, or immunosuppressants [excluding all antihistamines and over-the-counter medication] or any CSU-related inpatient admissions or emergency department or urgent care visits) were used to identify patients with uncontrolled CSU. Health care resource utilization (HCRU) and health care costs were described.

RESULTS

Overall, 200,298 patients were followed-up for a median of 2.3 years after diagnosis. Estimated cumulative prevalence of diagnosed CSU was 0.57% (women: 0.80%; men: 0.32%). The average annual incidence rate was 0.08%. Corticosteroids were the most prescribed treatment during follow-up among the 166,195 patients prescribed at least 1 treatment (94.3%). Proxy events were observed in 59.1% of the patients. HCRU and health care costs increased from baseline in patients with uncontrolled CSU during follow-up.

CONCLUSION

Of patients with CSU who were prescribed treatment, more than 50% experienced uncontrolled CSU, which was associated with increased HCRU and health care costs.

Validity, reliability and responsiveness of digital visual analogue scales for chronic spontaneous urticaria monitoring: A CRUSE® mobile health study

BACKGROUND

CRUSE® is an app that allows patients with chronic spontaneous urticaria (CSU) to monitor their daily disease activity through the use of visual analogue scales (VASs). We aimed to determine the concurrent validity, reliability, responsiveness and minimal important difference (MID) of CRUSE® VASs.

METHODS

We evaluated the properties of three daily VASs: VAS for how much patients were affected by their CSU ('VAS urticaria'), VAS for the impact of urticaria on work/school productivity ('VAS productivity') and the VAS of EQ-5D. Concurrent validity was assessed by measuring the association between each VAS and the Urticaria Activity Score (UAS). Intra-rater reliability was determined based on the data of users providing multiple daily questionnaires within the same day. Test-retest reliability and responsiveness (ability to change), respectively, were tested in clinically stable and clinically unstable users. MIDs were determined using distribution-based methods.

RESULTS

We included 5938 patients (67,380 days). Concurrent validity was high, with VAS urticaria being more strongly associated with the UAS score than the remaining VASs. Intra-rater reliability was also high, with intraclass correlation coefficients (ICC) being above 0.950 for all VASs. Moderate-high test-retest reliability and responsiveness were observed, with reliability ICC being highest for VAS EQ-5D and responsiveness being highest for VAS urticaria. The MID for VAS urticaria was 17 (out of 100) units, compared to 15 units for VAS productivity and 11 units for VAS EQ-5D.

CONCLUSION

Daily VASs for CSU available in the CRUSE® app display high concurrent validity and intra-rater reliability and moderate-high test-retest reliability and responsiveness.

Urticaria Voices: Real-World Experience of Patients Living with Chronic Spontaneous Urticaria

INTRODUCTION

The impact of chronic spontaneous urticaria (CSU) on patients' health-related quality of life (HRQoL) is well documented. However, considerable gaps remain in understanding the experience, perception and needs of patients with CSU. In this study, we investigate the perspective of patients with CSU about the disease journey, treatment and management of the condition as well as the physical and psychosocial impact of the disease.

METHODS

A multinational, cross-sectional online survey was completed by patients with chronic urticaria (CU) and physicians treating CU. This analysis focuses on data from the patients with CSU. The patient survey included customized questions and a validated patient-reported outcomes measure, the Urticaria Control Test (UCT).

RESULTS

A total of 582 patients with CSU (62% women; mean [standard deviation, SD] age: 42.2 [11.9] years) completed the online survey. Patients reported a mean (SD) diagnostic delay of 2 (5.4) years and saw 6.1 (8.9) physicians. The majority (79%) of patients were on antihistamines, of which 84% were inadequately controlled (UCT score of < 12) and reported a significantly higher negative impact of CSU on the HRQoL domains than adequately controlled patients, with the highest impact on mental and emotional well-being and social life and intimate relationships. More than half (55%) of the patients experienced angioedema with a mean (SD) of 7.7 (14.0) episodes per year. In addition, sleeping problems (62%), pain (55%) and fatigue (49%) were frequently reported physical symptoms during an exacerbation.

CONCLUSION

Patients with CSU experience substantial burden due to delayed diagnosis, insufficient symptom control (despite treatment) as well as mental and emotional well-being and social impact, particularly when uncontrolled. Early diagnosis and patient-centered approaches to symptom management and disease control should be prioritized to minimize the negative impact of CSU on patients' life.

Can urticaria severity be used as a biomarker for transition from acute to chronic urticaria?

BACKGROUND

Acute urticaria usually resolves spontaneously; however, in some cases, it may progress to CSU. We aimed to investigate the underlying factors of AU in children and the clinical and laboratory factors affecting the progression of AU to CSU.

METHODS

A prospective analysis was performed in 155 patients under 18 years of age who were diagnosed with AU and treated in our hospital. Factors affecting the transition from acute urticaria to chronic urticaria were analyzed using logistic regression.

RESULTS

Progression of AU to CSU was observed in 9% of patients. The urticaria activity scores of the first week (UAS7) in patients who progressed to CSU were significantly higher than those of patients who did not develop CSU (UAS7: Median 14.5, Min-Max 6-32, p < .001). Additionally, elevated eosinophil levels (Median 3.6%, Min-Max 0-11, p = .006) and the need for more intensive treatments, including parenteral steroids, antihistamines, and additional therapies (42.9% of CU patients, p = .038), were identified as significant risk factors for progression to CSU. In univariate regression analysis, the UAS7 score was found to be statistically significant (OR: 1.131, 95% CI: 1.056-1.212, p < .001). In multivariate analysis, we found that high UAS7 scores (OR: 1.169, 95% CI: 1.072-1.275, p < .001) and the need for combined treatment with additional therapies (OR: 8.240, 95% CI: 1.007-67.441, p = .049) were independent risk factors for progression from AU urticaria to CU.

CONCLUSION

We found that the severity of urticaria during the first week and the need for additional therapies are important indicators in predicting the risk of chronicity. These findings may help to develop strategies to effectively manage AU in the early stages.

From wheal to wellness: efficacy and safety of ligelizumab in chronic spontaneous urticaria: a systematic review and meta-analysis

Chronic spontaneous urticaria (CSU) is characterized by persistent hives and itching that lasts longer than six weeks. Ligelizumab, a humanized monoclonal antibody specifically targeting IgE, has emerged as a promising option for managing CSU. This study evaluates the effectiveness and safety of ligelizumab for this debilitating condition. A comprehensive literature search was conducted at PubMed, Cochrane Library, Google Scholar, and ClinicalTrials.gov to identify relevant studies published until December 2024. The review included randomized controlled trials that compared ligelizumab with a placebo. Our meta-analysis of 2581 patients found that ligelizumab significantly improves outcomes in chronic spontaneous urticaria. A dose-dependent response was observed, with 24 mg being non-superior to placebo. Doses of 72 mg significantly reduced Itch Severity Score (MD: - 3.54; 95% CI - 4.36 to - 2.73; P < 0.00001), Urticaria Activity Score (UAS7) (MD: - 9.79; 95% CI - 10.65 to - 8.93; P < 0.00001),  provided complete UAS7 response (UAS7 = 0) (OR: 7.30; 95% CI 2.99 to 17.83; P < 0.0001), and Angioedema free weeks (MD: 2.22; 95% CI 1.63 to 2.82; P < 0.00001), with further improvements noted at the 120 mg dose. Statistically significant results were also observed for the Dermatological Life Quality Index and Hives Severity Score. No significant adverse effects were reported with ligelizumab 72 mg, but very mild adverse effects were discovered with the 120 mg dose. Ligelizumab, at doses of 72 mg and 120 mg, effectively manages CSU by reducing symptoms and improving overall quality of life compared to placebo, although 120 mg Ligelizumab is associated with mild Adverse Events.

Tezepelumab for the treatment of chronic spontaneous urticaria: Results of the phase 2b INCEPTION study

BACKGROUND

Tezepelumab, an mAb inhibiting thymic stromal lymphopoietin, is an upstream-targeted therapy with potential to inhibit multiple pathways in chronic spontaneous urticaria (CSU).

OBJECTIVE

We sought to evaluate tezepelumab efficacy and safety in patients with CSU despite treatment with second-generation H1 antihistamines.

METHODS

This phase 2b study randomized 183 patients (125 anti-IgE therapy-naive; 58 anti-IgE therapy-experienced) to placebo every 2 weeks, tezepelumab 210 mg every 4 weeks, tezepelumab 420 mg every 2 weeks, or omalizumab 300 mg every 4 weeks (anti-IgE-naive only) for 16-week treatment. The primary end point was change from baseline in weekly Urticaria Activity Score (UAS7) at week 16. Safety and exploratory end points were evaluated through week 32.

RESULTS

The 16-week primary end point was not met. In the overall population, tezepelumab 210 mg and 420 mg did not significantly improve UAS7 versus placebo (least squares mean [SE]: -13.5 [1.6] and -14.7 [1.5], respectively, vs -13.6 [1.6], P = .99, nominal and P = .60, nominal, respectively). Greater improvement in UAS7 versus placebo was observed in the anti-IgE-naive tezepelumab-treated populations (nominal significance); a trend toward significance was observed with omalizumab. In the anti-IgE-naive population, there was delayed, sustained, 32-week off-treatment improvement in UAS7 versus placebo with tezepelumab 210 mg (nominally significant) and 420 mg (trend), but not with omalizumab. This effect was larger in patients with lower baseline IgE levels and longer CSU duration and accompanied sustained IL-5 and IL-13 reductions. Tezepelumab and placebo safety findings were balanced.

CONCLUSION

Although the 16-week primary end point was not met, tezepelumab showed post-treatment reductions in CSU activity through week 32, suggesting a delayed, sustained, thymic stromal lymphopoietin blockade treatment effect.

Prevalence and Burden of Chronic Spontaneous Urticaria in Japan: A Cross-Sectional Study

Background: Real-world data on the prevalence and burden of patients with chronic spontaneous urticaria (CSU) are limited in Japan. This study aimed to estimate CSU prevalence and assess its humanistic and economic burden. Methods: This analysis utilized data from Japanese adult respondents self-reporting physician-diagnosed CSU collected through the 2019 National Health and Wellness Survey. The weighted 12-month prevalence was estimated using 2018 international census projections. Outcomes included the SF-12v2 (physical and mental component summary [PCS and MCS] scores), health utility index (SF-6D and EQ-5D), Dermatology Life Quality Index (DLQI), Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Work Productivity and Activity Impairment scores at data collection, and healthcare resource utilization over the past 6 months. Results: Among 30,006 respondents, 334 reported having CSU, of whom 62.3% were female. The mean (SD) age at data collection and CSU diagnosis was 50.8 (15.3) and 39.2 (14.9) years, respectively. The weighted prevalence of CSU was 1.1%. The mean (SD) PCS and MCS scores were 50.3 (7.0) and 45.1 (10.0), respectively. The mean (SD) health utility measures (SF-6D and EQ-5D) were 0.71 (0.13) and 0.79 (0.18), respectively. The mean (SD) DLQI score was 3.8 (6.0). More than 40% of patients reported mild/moderate/severe anxiety and depression. The mean % (SD) scores for absenteeism, presenteeism, overall work impairment, and activity impairment were 7.6 (17.6), 27.2 (27.2), 30.3 (29.6), and 28.5 (27.8), respectively. Approximately 90.0% of patients visited healthcare providers, including emergency room visits (6.9%) and hospitalizations (9.9%). Conclusions: This study provides insights into the diagnosed prevalence and burden of CSU in Japan, highlighting its impact on patients' lives.

Substantial psychosocial impairments in patients with chronic urticaria are associated with delayed referral to urticaria centers, non-academic treatments, and dietary changes

BACKGROUND

Chronic idiopathic urticaria (CIU) is common in allergological practice. Although therapeutic options have improved in the past decade, patients still suffer from a significant burden of disease and are often treated insufficiently.

OBJECTIVE

We aimed at analyzing the psychiatric comorbidities, social impairments, and treatment gap in a real-world setting.

MATERIALS AND METHODS

Adult patients with CIU were investigated for demographical data, medical history, and psychosocial burden. Validated questionnaires were used to assess urticaria activity, control of disease, quality-of-life impairment, and psychiatric comorbidities.

RESULTS

82 patients (78% female; 47.5 ± 14.8 years) were included. 65.9% had insufficient disease control, 11% reported on prior self-medication with drugs, 19.5% were seeking help from non-academic medicine, and 54.9% tried a change of diet. The use of non-academic treatment was significantly associated with higher disease activity. Self-initiated dietary changes were significantly associated with less control of disease. Delayed referrals to a urticaria-specialized center were significantly linked to self-reported psychiatric diseases, self-medication with drugs and self-initiated dietary changes.

CONCLUSION

Our data show an unsatisfactory control of CIU in many patients and substantial psychosocial impairments which are also associated with a delayed referral to urticaria centers, self-initiated non-academic treatments, and dietary changes.

Omalizumab Treated Urticaria Patients Display T Cell and Thrombocyte-Associated Gene Regulation

BACKGROUND

Chronic spontaneous urticaria (CSU) is a debilitating inflammatory skin disease with a prevalence of approximately 1% of the population. It is characterized by recurrent itchy wheals and/or angioedema for more than 6 weeks without known triggers leading to a high quality of life impairment. The pathogenesis of CSU remains not fully understood.

OBJECTIVE

This study aimed to explore the pathomechanism of CSU beyond mast cells and IgE-dependent histamine release and to identify possible biomarkers for the disease and its treatment.

METHODS

We investigated a patient cohort in the first month of omalizumab treatment regarding the IgE levels and changes in gene and miRNA expression in peripheral blood. The cohort was divided into responders and nonresponders (depending on the score of the urticaria control test) and compared to a group of healthy controls.

RESULTS

Our messenger RNA and microRNA microarray analyses revealed the greatest changes in expression levels on Day 2 after the first omalizumab dose.

CONCLUSION

We identified several genes and miRNAs of interest, most of which have not been described to be linked to CSU so far, underlining, for example, to T cell involvement or even suggesting platelet involvement.

Prognosis of chronic spontaneous urticaria with an inadequate response to omalizumab

BACKGROUND

Chronic spontaneous urticaria (CSU) exhibits notable responsiveness to omalizumab (OMA). The prognosis and subsequent therapeutic strategies warrant comprehensive exploration in cases exhibiting inadequate responses to OMA.

METHODS

We conducted a multicenter retrospective analysis to investigate the 12-month prognosis of patients inadequately responding to three injections of OMA. The endpoints encompassed identifying predictive factors for a favorable prognosis and assessing interventions related to an ameliorated prognostic outlook.

RESULTS

The study involved 48 patients who met the inclusion criteria. After three OMA administrations, therapeutic interventions included the continuation of OMA in 34 patients, systemic corticosteroids in seven patients, and immunosuppressants in 12 patients. After 12 months, 28 of the 48 patients exhibited a good prognosis, whereas the remaining 20 displayed a less favorable prognosis. Good prognostic determinants encompassed the duration of CSU within 51 weeks, the presence of angioedema, IgE levels ≤100 IU/mL pre-OMA, blood eosinophil counts ≥100/mm3 post-OMA, and urticaria control test (UCT) scores ≥5 pre-OMA and ≥6 post-OMA. Following the third OMA injection, the implementation of immunosuppressants presented an association with a good prognosis, while the employment of systemic corticosteroids correlated with an unfavorable prognosis.

CONCLUSIONS

More than half of patients inadequately responding to OMA achieved a good prognosis 12 months later. Several clinical variables appear to be predictive of prognosis, and certain therapeutic agents can be associated with prognostic outcomes.

Factors associated with quality of life of chronic spontaneous urticaria patients in a Vietnamese population

OBJECTIVE

Chronic spontaneous urticaria (CSU) is a challenging condition that significantly impacts the affected patients. This study aimed to evaluate the quality of life (QoL) among patients with CSU in Vietnam and identify factors associated with QoL.

METHODS

A cross-sectional study was conducted at the Vietnam National Dermatology and Venereology Hospital from June 2023 to March 2024. A total of 358 CSU patients aged 16 years or older were recruited. Data were collected using a structured questionnaire covering demographic, clinical, and laboratory characteristics. The Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and the Weekly Urticaria Activity Score (UAS7) were utilized to assess QoL and disease severity. Multivariate Tobit regression models were performed.

RESULTS

The CU-Q2oL total score had a mean of 48.67 (SD = 16.90) and a median of 46 (IQR = 35-59). The scores for individual CU-QoL subscales were as follows: pruritus (5.42±2.02), swelling (2.86±1.54), life activities (13.89±6.00), sleep problems (11.12±4.96), limits (6.52±2.66), and looks (8.85±4.09). Higher UAS7 scores were associated with lower QoL, and angioedema in the eyes and lips were associated with increased swelling domain and poorer overall QoL. Longer disease duration was associated with higher pruritus scores, while a history of allergy was related to poorer total QoL, sleep, and looks. Severe itching further degraded sleep quality. Positive Autologous Serum Skin Test (ASST) was correlated with lower overall QoL, particularly in swelling and limits domains. Positive Basophil Histamine Release Assay (BHRA) status was linked to poorer sleep quality domain.

CONCLUSION

CSU significantly impairs the QoL of patients, affecting physical, emotional, and social dimensions. Regular QoL assessments should be integrated into clinical practice to ensure comprehensive and patient-centered treatment strategies.

CT-P39 Compared With Reference Omalizumab in Chronic Spontaneous Urticaria: Results From a Double-Blind, Randomized, Active-Controlled, Phase 3 Study

BACKGROUND

This study compared the therapeutic equivalence of CT-P39 (an omalizumab biosimilar) and EU-approved reference omalizumab (ref-OMA) in patients with chronic spontaneous urticaria.

METHODS

This double-blind, randomized, active-controlled Phase 3 study (NCT04426890) included two 12-week treatment periods (TPs). In TP1, patients received CT-P39 300 mg, ref-OMA 300 mg, CT-P39 150 mg, or ref-OMA 150 mg. In TP2, patients treated with ref-OMA 300 mg were rerandomized to CT-P39 300 mg or ref-OMA 300 mg; patients initially randomized to CT-P39 300 mg continued this regimen; and patients initially randomized to CT-P39 or ref-OMA 150 mg received 300 mg dosing with the same drug. The primary endpoint for the assessment of therapeutic equivalence of CT-P39 300 mg and ref-OMA 300 mg was change from baseline in weekly itch severity score (ISS7) at week 12.

RESULTS

In TP1, 619 patients were randomized (CT-P39 300 mg, n = 204; ref-OMA 300 mg, n = 205; CT-P39 150 mg, n = 107; ref-OMA 150 mg, n = 103). Equivalence was demonstrated between CT-P39 300 mg and ref-OMA 300 mg for mean change from baseline in ISS7 at week 12; confidence intervals (CIs) were within predefined equivalence margins: global analysis: treatment difference 0.77, 95% CI -0.37 to 1.90; US analysis: treatment difference 0.70, 90% CI -0.22 to 1.63. The proportion of patients experiencing ≥ 1 treatment-related adverse event was comparable across groups. Secondary efficacy, quality of life, pharmacokinetic, safety, and immunogenicity outcomes were comparable between groups at a given dose level, with no evident impact of switching.

CONCLUSIONS

Equivalent efficacy was observed between CT-P39 and ref-OMA, with comparable safety also evident.

Cost-of-illness analysis of chronic urticaria clinical management in five countries of Latin America

INTRODUCTION

Chronic spontaneous urticaria (CSU) is a disease with a high impact on the quality of life of patients. There are some evaluations of the economic cost of the disease in developed countries, but there is little information about the economic cost of the disease in developing countries. Our aim was to assess the economic diagnostic and therapeutic expenses of CSU in five Latin American (LA) countries.

METHODS

A noninterventional multicenter cross-sectional study was conducted in five LA countries: Brazil, Colombia, Ecuador, Mexico, and Peru. To determine the frequency of medical interventions as well as clinical and sociodemographic characteristics of CSU patients, questionnaires were administered to patients, primary care physicians, allergists, and dermatologists. In each country, diagnostics and therapeutic expenses were calculated by reviewing medical records, health insurance, and interviews. The main outcome was the yearly economic burden from the healthcare insurance perspective in each country.

RESULTS

According to the projected costs, Brazil had the highest urticaria cost per patient/year (7009.4 USD), followed by Mexico (3695.1 USD), Ecuador (3132.8 USD), Peru (2693.9 USD), and Colombia (2392.8 USD); the cost and the frequency of use of omalizumab and antihistamines explain the total cost differences between countries. Interventions such as medical visits and exams had similar costs between countries and represented less than 10% of total urticaria cost analysis in the five countries.

CONCLUSION

The cost of the CSU in LA varies widely based on the health insurance coverage, the cost of the therapies, and the frequency of therapies used. Strengthening national health systems, as well as following the recommendations of international guidelines, seems to reduce the cost of CSU and improve the quality of patients.

[Spectrum of morphological changes in chronic spontaneous urticaria and urticarial vasculitis]

The prevalence of chronic spontaneous urticaria (CSU) in the population is 0.5%-1%. According to modern guidelines for the management of patients with urticaria, the diagnosis of CSU does not require histological examination. However, in controversial clinical setting requiring differential diagnosis with urticarial vasculitis (UV), pathologists discover a wide range of pathomorphological changes in skin preparations in the absence of generally accepted differential diagnostic criteria. In this connection, it is of interest to study the spectrum of morphological changes in chronic spontaneous urticaria and urticarial vasculitis.

OBJECTIVE

To analyze morphological changes in CSU and UV to improve differential diagnosis in clinical practice.

MATERIAL AND METHODS

The material of 15 patients with urticarial rashes was analyzed. Comparative analysis of the number of neutrophils and mast cells in skin samples from patients with chronic spontaneous urticaria and urticarial vasculitis was performed.

RESULTS

The material of 15 patients with urticarial rashes was analyzed. The group of patients with CSU (n=5) was characterized by the absence of signs of leukocytoclastic vasculitis; endothelial cells and mild of moderate swelling were visualized in all samples, the perivascular infiltrate was located in the upper layer of the dermis and was sparse. And when stained with toluidine blue, a large number of mast cells were noted. In the group of patients with UV (n=10), signs of leukocytoclastic vasculitis of varying severity, dense and deep perivascular neutrophilic infiltrates with a small number of mast cells were visualized.

CONCLUSION

Considering the wide range of morphological changes in the skin in CSU and UV, for the differential diagnosis of diseases, a comprehensive histological examination of preparations in combination with an assessment of the number of mast cells in the dermis and an assessment of the composition of the cellular infiltrate for the number of neutrophils can be recommended.

Chronic Spontaneous Urticaria: A Review

Importance

Chronic spontaneous urticaria affects approximately 1% of the general population worldwide, including approximately 3 million people in the US, impairs patients' quality of life, and is associated with multiple comorbidities.

Observations

Chronic spontaneous urticaria affects patients of any age but is most common in females aged 30 to 50 years. Diagnosis is based on clinical presentation, ie, spontaneously recurring wheals, angioedema, or both. Chronic spontaneous urticaria persists for more than 1 year in most patients (1 or repeated episodes) and may present with comorbidities including chronic inducible urticaria (>10%), autoimmune thyroiditis (approximately 20%), metabolic syndrome (6%-20%), and anxiety (10%-31%) and depression (7%-29%). Known autoimmune endotypes (subtypes of urticaria defined by distinct pathogenesis) of chronic spontaneous urticaria are mediated by mast cell-activating IgE and/or IgG autoantibodies (>50%). Approximately 40% of patients with chronic spontaneous urticaria have a Dermatology Life Quality Index of more than 10, corresponding to a very large or extremely large negative effect on quality of life. Second-generation H1 antihistamines are first-line treatment; partial or complete response, defined as a reduction in urticaria symptoms of greater than 50%, is observed in approximately 40% of patients. The 2022 international urticaria guideline recommends the monoclonal anti-IgE antibody omalizumab as second-line treatment for antihistamine-refractory chronic spontaneous urticaria. However, at least 30% of patients have an insufficient response to omalizumab, especially those with IgG-mediated autoimmune urticaria. Cyclosporine, used off-label, can improve symptoms in approximately 54% to 73% of patients, especially those with autoimmune chronic spontaneous urticaria and nonresponse to omalizumab, but has adverse effects such as kidney dysfunction and hypertension.

Conclusions and Relevance

Chronic spontaneous urticaria is an inflammatory skin disease associated with medical and psychiatric comorbidities and impaired quality of life. Second-generation H1 antihistamines are first-line treatment, omalizumab is second-line treatment, and cyclosporine is third-line treatment for chronic spontaneous urticaria.

The socio-economic burden of H1-antihistamine-refractory chronic spontaneous urticaria in Germany

BACKGROUND AND STUDY AIM

Data from the AWARE study (A Worldwide Antihistamine-Refractory chronic urticaria patient Evaluation) illustrate a substantial disease burden in German patients with H1-antihistamine (-H1-AH)-refractory chronic spontaneous urticaria (CSU). Detrimental effects on patients' quality of life, poor disease control and impairment in the ability to work and perform other daily activities are reported. Based on these findings, this study aims to quantify the epidemiological and socio-economic burden of H1-AH-refractory CSU in Germany.

METHODS

To determine the epidemiological burden of H1-AH-refractory CSU, the age- and gender-specific prevalence of CSU and the proportion of H1-AH-refractory patients in Germany anonymized data from the InGef research database have been used. In a second step, the socio-economic burden in terms of lost numbers of hours in paid and unpaid work was calculated by extrapolating the age- and gender-specific work productivity and activity impairment (WPAI) observed in AWARE to the H1-AH-refractory CSU population in Germany. Finally, productivity losses in paid and unpaid work were monetized using the human capital and the friction cost approach respectively. Moreover, socio-economic burden was calculated depending on symptom control of the patients (measured by urticaria control test [UCT]).

RESULTS

In Germany, over 203,000 patients (20 years or older) had H1-AH-refractory CSU in 2018. The avoided lost paid and unpaid work hours attributable to H1-AH-refractory CSU summed up to over 100 million. Overall, the socio-economic burden of H1-AH-refractory CSU in monetary terms was evaluated at € 2.2 billion and the majority of this was due to unpaid work loss. Patients with poor disease control, as indicated by UCT score < 12, were more likely to suffer from high impairment than patients with controlled disease, resulting in a higher socio-economic burden.

CONCLUSIONS

The results of our analyses picture the substantial socio-economic burden of H1-AH-refractory CSU and therefore the tremendous impact it has on daily lives of individuals and society overall.

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.

Prioritising patient-centred care in the management of chronic urticaria in Asia-Pacific countries

Background

Chronic urticaria (CU), in both inducible and spontaneous forms, is associated with a substantial burden in the Asia-Pacific region (APAC). Patient-centred care recognises patients desire to be involved in decisions regarding their health. Although patient-centred approaches have previously not been studied in the context of CU management, they have demonstrated benefits in the management of other chronic conditions.

Methods

Information and opinions regarding the barriers and solutions to the implementation of patient-centred approaches to the management of CU were gathered from a group of 13 expert dermatologists and allergist/immunologists from APAC through surveys and a face-to-face meeting.

Results

Barriers identified there included a lack of awareness of CU amongst patients, delays in consulting healthcare providers, financial constraints, and low adherence. Particular issues raised included a lack of suitable online information for patients (83% of experts), and patients accessing oral corticosteroids without a prescription. Compliance issues were also identified as key reasons for inadequate responses to treatments (67% of experts). Solutions proposed by the authors were improving patients' knowledge about their condition (92% strongly agree, 8% agree), physicians' consideration of patient characteristics when choosing treatments (92% strongly agree, 8% agree), implementing shared decision-making (85% strongly agree, 15% agree), and using patient-reported outcome measures (70% strongly agree, 23% agree).

Conclusion

Expert opinion within APAC supports the use of patient-centred approaches to improve the management of CU. We provide several recommendations focusing on patient education and involvement in disease management as well as disease monitoring methods that can be implemented by physicians in APAC.

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

OBJECTIVES

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

DESIGN

Secondary analysis of data from a multicentre randomised controlled trial.

SETTING

Three tertiary hospitals across three cities in China.

PARTICIPANTS

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

INTERVENTIONS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

ChiCTR1900022994.

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

Background

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

Methods

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

Results

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

Conclusion

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

Efficacy evaluation of acupuncture combined with pricking blood therapy in the treatment of chronic spontaneous urticaria: a randomized controlled trial

OBJECTIVE

To assess the efficacy of combining acupuncture with pricking blood therapy to treat chronic spontaneous urticaria (CSU) and compare its outcomes with those of second-generation H1-antihistamines.

METHODS

Seventy CSU patients were enrolled and randomly assigned to receive treatment with either oral loratadine tablets or a combination of acupuncture and pricking blood therapy (n=35 each). Evaluations were conducted at baseline, at the conclusion of the 4-week treatment period, and at the 4th and 8th weeks post-treatment time points. We used six scales to gauge the severity of the skin lesions, itchiness, quality of life, and emotional and sleep states of the CSU patients.

RESULTS

Upon completion of the treatment, both groups demonstrated a significant reduction in the scores of six scales from the baseline (P < 0.05). Notably, the scores of the itch visual analog scale (VAS), Hamilton Anxiety Scale, and Hamilton Depression Scale in the acupuncture and pricking blood therapy group were lower than those in the loratadine group (all P < 0.05). At the 8-week follow-up, the scores for all six scales were reduced from baseline in both groups (all P < 0.05), though the acupuncture and pricking blood therapy group showed significantly lower scores on the 7-day urticaria activity scale, with the Dermatology Life Quality Index, and the itchiness VAS compared with the loratadine group (all P < 0.05).

CONCLUSIONS

Acupuncture combined with pricking blood therapy significantly ameliorated skin lesions, itchiness, and the associated psychological distress in CSU patients. This integrative approach not only matched the short-term efficacy of oral loratadine but surpassed its long-term benefits.

Omalizumab for the Treatment of Chronic Spontaneous Urticaria in Adults and Adolescents: An Eight-Year Real-Life Experience

Background: Omalizumab, an anti-IgE monoclonal antibody, is an effective treatment for patients with chronic spontaneous urticaria (CSU) resistant to antihistamines, but about 10% are unresponsive. Our aim was to assess the effectiveness, safety, and drug survival (DS) of omalizumab by considering clinical and laboratory characteristics. Methods: We conducted a retrospective study on 296 patients with severe CSU treated with omalizumab. Disease activity, comorbidities, and serum levels of total IgE and anti-thyroid autoantibodies were evaluated over a period of up to 8 years. DS was analyzed using unadjusted Kaplan-Meier survival curves. When applicable, the risk of discontinuation was assessed using Cox regression analysis. Results: Out of 296 patients, 118 (40.4%) were early responders, 72 (25.0%) were late responders, 76 (26.0%) were partial responders, and 25 (8.6%) were non-responders. Early responders were more likely to be patients without associated inducible urticaria (p = 0.021, χ2 = 9.692), without autoimmune thyroiditis (p = 0.007, χ2 = 12.037), and those with higher IgE levels (p = 0.039, χ2 = 8.385). Overall, DS was 53.5% at 8 years, primarily due to clinical remission. DS due to inefficacy and clinical remission were 83.9% and 62.1%, respectively, at 8 years. No patients discontinued omalizumab due to adverse events. Patients with normal IgE levels (p = 0.012, HR = 4.639, CI: 1.393-15.445) and those with autoimmune thyroiditis (p = 0.028, HR = 3.316, CI: 1.128-8.718) had a higher risk of discontinuing omalizumab due to inefficacy. Conclusions: This study confirms the long-term effectiveness and safety of omalizumab in the treatment of CSU over a period of up to 8 years. Most patients discontinued omalizumab due to clinical remission, while only 5.1% discontinued it due to ineffectiveness.

Stapokibart (CM310) targets IL-4Rα for the treatment of type 2 inflammation

Stapokibart (CM310) is a humanized IL-4Rα monoclonal antibody currently undergoing phase 3 trials for type 2 inflammatory diseases. In contrast to dupilumab, which bound exclusively to human IL-4Rα, stapokibart demonstrated cross-species reactivity to IL-4Rα from human, cynomolgus monkey, and rat. Stapokibart exhibited comparable blocking activity to dupilumab. Epitope mapping revealed that stapokibart bound to distinct sites on IL-4Rα compared to dupilumab. In vitro assays showed that stapokibart was comparable or numerically superior in blocking IL-4Rα-mediated signaling compared to dupilumab. In vivo studies further demonstrated that stapokibart effectively inhibited the progression of type 2 inflammation. Pharmacokinetic studies revealed a circulating half-life of approximately 298-351 h in cynomolgus monkeys and 55-142 h in rats for stapokibart. Toxicity studies indicated a favorable safety profile in cynomolgus monkeys and rats. The preclinical evaluation of stapokibart supports its clinical development.

Disease modification in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a debilitating, inflammatory skin condition characterized by infiltrating immune cells. Available treatments are limited to improving the signs and symptoms. There is an unmet need to develop therapies that target disease-driving pathways upstream of mast cell activation to inhibit or delay the progression of CSU and associated comorbidities. Here, we aim to define disease modification due to a treatment intervention and criteria that disease-modifying treatments (DMTs) must meet in CSU. We have defined disease modification in CSU as a favorable treatment-induced change in the underlying pathophysiology and, therefore, the disease course, which is clinically beneficial and enduring. A DMT must fulfil the following criteria: (1) prevents or delays the progression of CSU, (2) induces long-term, therapy-free clinical remission, which is the sustained absence of CSU signs and symptoms without the need for treatment, and (3) affects the underlying mechanism of CSU, as demonstrated by an effect on disease-driving signals and/or a biomarker. DMTs in CSU should slow disease progression, achieve long-lasting disease remission, target disease-driving mechanisms, reduce mast cell-activating IgE autoantibodies, target cytokine profile polarization, and normalize the gut microbiome and barrier. Treating CSU at the immune system level could provide valuable alternatives to pharmacotherapy in CSU management. Specific DMTs in CSU are yet to be developed, but some show potential benefits, such as inhibitors of Bruton's Tyrosine Kinase, IL-4 and IL-13. Future therapies could prevent CSU signs and symptoms, achieve long-term clinical benefits after discontinuing treatment, and prevent associated concomitant disorders.

Lin-CD117+CD34+FcεRI+ progenitor cells are increased in chronic spontaneous urticaria and predict clinical responsiveness to anti-IgE therapy

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common, debilitating skin disorder characterized by recurring episodes of raised, itchy and sometimes painful wheals lasting longer than 6 weeks. CSU is mediated by mast cells which are absent from peripheral blood. However, lineage-CD34hiCD117int/hiFcεRI+ cells in blood have previously been shown to represent a mast cell precursor.

METHODS

We enumerated FcεRI-, FcεRI+ and FcεRIhi lineage-CD34+CD117+ cells using flow cytometry in blood of patients with CSU (n = 55), including 12 patients receiving omalizumab and 43 not receiving omalizumab (n = 43). Twenty-two control samples were studied. Disease control and patient response to omalizumab was evaluated using the urticaria control test. We performed single-cell RNA sequencing (scRNA-Seq) on lineage-CD34hiCD117hi blood cells from a subset of patients with CSU (n = 8) and healthy controls (n = 4).

RESULTS

CSU patients had more lineage-CD34+CD117+FcεRI+ blood cells than controls. Lineage-CD34+CD117+FcεRI+ cells were significantly higher in patients with CSU who had an objective clinical response to omalizumab when compared to patients who had poor disease control 90 days after initiation of omalizumab. scRNA-Seq revealed that lineage-CD34+CD117+FcεRI+ cells contained both lymphoid and myeloid progenitor lineages, with omalizumab responsive patients having proportionally more myeloid progenitors. The myeloid progenitor lineage contained small numbers of true mast cell precursors along with more immature FcεRI- and FcεRI+ myeloid progenitors.

CONCLUSION

Increased blood CD34+CD117+FcεRI+ cells may reflect enhanced bone marrow egress in the setting of CSU. High expression of these cells strongly predicts better clinical responses to the anti-IgE therapy, omalizumab.

Dupilumab Reduces Urticaria Activity, Itch, and Hives in Patients with Chronic Spontaneous Urticaria Regardless of Baseline Serum Immunoglobulin E Levels

INTRODUCTION

In chronic spontaneous urticaria (CSU), interleukin (IL)-4 and IL-13 may promote mast cell activation directly via IL-4 receptor expression, or indirectly via upregulated immunoglobulin E (IgE) production. Dupilumab significantly improved CSU signs and symptoms in the phase 3, randomized, placebo-controlled LIBERTY-CSU CUPID Study A. This analysis explores the impact of dupilumab on CSU signs and symptoms and serum IgE levels in patients from LIBERTY-CSU CUPID Study A with serum total IgE above and below 100 IU/mL at baseline.

METHODS

Patients with H1-antihistamine-refractory CSU received dupilumab (n = 70) or placebo (n = 68) for 24 weeks. Efficacy endpoints were change from baseline to weeks 12 and 24 in serum total IgE levels, Itch Severity Score over 7 days (ISS7), Urticaria Activity Score over 7 days (UAS7), and Hives Severity Score over 7 days (HSS7) in dupilumab- or placebo-treated patients with serum total IgE above and below 100 IU/mL at baseline.

RESULTS

Dupilumab treatment significantly reduced median (interquartile range) IgE levels at week 12 [dupilumab: -31.9% (-41.9; -22.6); placebo: -6.3% (-21.3; 14.9)] and week 24 [dupilumab: -48.2% (-56.8; - 39.5); placebo: - 6.3% (-34.5; 14.8)]. Similar IgE reductions relative to baseline were observed in dupilumab-treated patients regardless of baseline IgE level. Dupilumab treatment improved ISS7, UAS7, and HSS7 over 12 and 24 weeks, regardless of baseline serum IgE level (interaction p ≥ 0.59 for all treatment by subgroup comparisons), with weak correlations (r < 0.2) observed between IgE level changes and ISS7, UAS7, and HSS7 outcomes.

CONCLUSIONS

Dupilumab significantly improved CSU signs and symptoms and reduced serum IgE, regardless of baseline IgE levels. In the current analysis, baseline total IgE had no predictive value as a dupilumab treatment response biomarker in CSU. Downregulation of IgE, a key mediator of mast cell activation and histamine release, may at least partially explain the effectiveness of dupilumab in reducing CSU signs and symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04180488.

The Effect of Placebo on Pruritus in Patients with Chronic Urticaria: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

BACKGROUND

The anti-pruritic effect of placebo in patients with chronic urticaria has gained increasing attention in clinical research. However, the extent of placebo effect and its influencing factors in the treatment of chronic urticaria are not well understood.

OBJECTIVE

The objective of this systematic review and meta-analysis was to investigate the effect of placebo on pruritus in patients with chronic urticaria and to explore relevant influencing factors.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, and PsycINFO were searched from inception to 10 July, 2024. Primary outcome included pruritus scores. The secondary outcomes focused on global symptoms and quality of life. Subgroup analyses and meta-regression analyses were conducted based on drug types, sample size, participants' age, and other variables. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and a trial sequential analysis were employed to establish the reliability of evidence.

RESULTS

A total of 65 eligible publications (including 67 randomized controlled trials) involving 10,704 patients with chronic urticaria were included. The pruritus scores decreased following placebo treatment (moderate evidence). In addition, favorable results were observed in global symptoms (moderate evidence) and quality of life (low evidence) after placebo treatment. Subgroup analyses indicated that the type of active medication in intervention groups was an influencing factor of placebo effect of pruritus. Meta-regression analyses demonstrated that the anti-pruritic effect of placebo was inversely correlated with sample size and positively correlated with participants' age. A trial sequential analysis provided further support for the anti-pruritic effect of placebo.

CONCLUSIONS

A substantial improvement of pruritus after placebo treatment was observed in patients with chronic urticaria. The anti-pruritic effect of placebo varied with sample size, participants' age, and type of active medication used. Future research should further investigate the effect size of placebo and clarify the potential mechanism.

PROSPERO REGISTRATION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42023482608.

Identification of pyruvic and maleic acid as potential markers for disease activity and prognosis in chronic urticaria

BACKGROUND

Population-based studies have highlighted the link between chronic urticaria (CU) and metabolic syndrome, and metabolic alterations have been revealed in CU. However, to our knowledge, a comprehensive metabolomics study on a large cohort of patients with CU has not been reported.

OBJECTIVE

We sought to explore the underlying metabolic subtypes and novel metabolite biomarkers for CU diagnosis and therapy.

METHODS

Plasma samples from 80 patients with CU and 82 healthy controls were collected for metabolomics quantification and bioinformatics analysis. Another independent cohort consisting of 144 patients with CU was studied to validate the findings. Bone marrow-derived mast cells and mice with IgE-induced passive cutaneous anaphylaxis were used for in vitro and in vivo experiments, respectively.

RESULTS

We observed clear metabolome differences between CU patients and healthy controls. Meanwhile, differential metabolites N6-acetyl-l-lysine, l-aspartate, maleic acid, and pyruvic acid were used to construct random forest classifiers and achieved area under receiver operating characteristic curve values greater than 0.85, suggesting their potential as diagnostic biomarkers of CU. More importantly, by exploring the underlying metabolic subtypes of CU, we found that the low abundance of pyruvic acid and maleic acid was significantly related to the activity of CU, poor efficacy of second-generation H1 antihistamines, and short relapse-free time. The results were validated in the independent cohort. Moreover, supplementation with pyruvate or maleate could significantly attenuate IgE-mediated mast cell activation in vitro and in vivo.

CONCLUSIONS

Plasma pyruvic acid and maleic acid may be effective biomarkers for predicting disease activity, therapeutic efficacy, and prognosis for patients with CU.

Benralizumab does not elicit therapeutic effect in patients with chronic spontaneous urticaria: results from the phase IIb multinational randomized double-blind placebo-controlled ARROYO trial

BACKGROUND

Chronic spontaneous urticaria (CSU) is a relatively common skin disease associated with hives and angio-oedema. Eosinophils play a role in CSU pathogenesis. Benralizumab, an anti-interleukin-5 receptor-α monoclonal antibody, has been shown to induce nearly complete depletion of eosinophils.

OBJECTIVES

To determine the clinical efficacy and safety of benralizumab in patients with CSU who were symptomatic despite H1 antihistamine treatment.

METHODS

The 24-week, randomized, double-blind, placebo-controlled, phase IIb portion of the ARROYO trial enrolled adult patients with CSU who were currently on H1 antihistamine treatment. Patients were randomized to one of five treatment groups according to benralizumab dose and regimen for a 24-week treatment period. The primary endpoint was change from baseline in Itch Severity Score (ISS)7 at week 12. The key secondary endpoint was change from baseline in Urticaria Activity Score (UAS)7 at week 12. Additional secondary endpoints included other metrics to assess CSU at week 24, blood eosinophil levels, and pharmacokinetics and immunogenicity assessments. Exploratory subgroup analyses were conducted to explore responses according to demographics, clinical features and biomarkers. Safety was assessed in all treatment groups.

RESULTS

Of 155 patients, 59 were randomized to benralizumab 30 mg, 56 to benralizumab 60 mg and 40 to placebo. Baseline and disease characteristics were consistent with what was expected for patients with CSU. There were no significant differences in change from baseline in ISS7 score at week 12 between benralizumab and placebo [benralizumab 30 mg vs. placebo, least-squares mean difference -1.01, 95% confidence interval (CI) -3.28 to 1.26; benralizumab 60 mg vs. placebo, least-squares mean difference -1.79, 95% CI -4.09 to 0.50] nor in change from baseline in UAS7 score at week 12 between benralizumab and placebo (benralizumab 30 mg vs. placebo, P = 0.407; benralizumab 60 mg vs. placebo, P = 0.082). Depletion of blood eosinophil levels was observed at week 24 in patients treated with benralizumab. All other secondary endpoints and exploratory/subgroup analyses indicated no significant differences between benralizumab and placebo. Safety results were consistent with the known profile of benralizumab.

CONCLUSIONS

Although benralizumab resulted in near-complete depletion of blood eosinophils, there was no clinical benefit over placebo.

Non-Skin Related Symptoms Are Common in Chronic Spontaneous Urticaria and Linked to Active and Uncontrolled Disease: Results From the Chronic Urticaria Registry

BACKGROUND

Chronic spontaneous urticaria (CSU) can present with non-skin related symptoms (NSRS), including recurrent unexplained fever, joint, bone, or muscle pain (JBMP), and malaise, which also occur in other conditions that manifest with wheals (eg, urticarial vasculitis or autoinflammatory disorders) or without wheals (eg, infection).

OBJECTIVE

We sought to determine the rate of patients with CSU affected by fever, JBMP, and malaise, their trigger factors, links with clinical and laboratory characteristics, and their impact on everyday life and treatment responses.

METHODS

We analyzed baseline data from the Chronic Urticaria Registry of 2,521 patients with CSU who were aged 16 years or older.

RESULTS

One third of CSU patients (31.2%; 786 of 2,521) had one or more NSRS, including recurrent fever (5.3%), JBMP (19.1%), and/or malaise (18.6%). In a multivariable analysis, having one or more of these NSRS correlated with food and infection as trigger factors of urticaria (adjusted odds ratio [aOR] = 1.7 and 1.5), wheals of 24 hours or greater duration (aOR = 2.5), sleep disturbance (aOR = 2.4), anxiety (aOR = 2.8), comorbid atopic dermatitis (aOR = 2.1), gastrointestinal disease (aOR = 1.8), elevated leukocytes (aOR = 1.7) and erythrocyte sedimentation rate (aOR = 1.5). In a bivariate analysis, these NSRS were additionally associated with higher disease activity (weekly Urticaria Activity Score, median: 21 vs 14; P = .009), longer disease duration (years, median: 2 vs 1; P = .001), the presence of angioedema (74.6% vs 58.7%; P < .001), worse quality of life (Chronic Urticaria Quality of Life Questionnaire, median: 42 vs 29; P < .001) and more frequent poor control of CSU (78% vs 69%; P < .001).

CONCLUSIONS

The presence of NSRS in a subpopulation of patients with CSU points to the need for better control of the disease, exclusion of comorbid conditions, and/or exclusion of urticarial vasculitis and urticarial autoinflammatory diseases.

Real-world outcomes in patients with chronic spontaneous urticaria receiving omalizumab: insights from a clinical practice survey

OBJECTIVE

Chronic spontaneous urticaria (CSU) is a debilitating inflammatory skin condition, often impacting quality of life. International guidelines recommend omalizumab, an anti-immunoglobulin E antibody, for second-line treatment. Our objective was to understand patient characteristics associated with prescription of omalizumab, and assess real-world outcomes in patients with CSU treated with omalizumab.

METHODS

We analyzed data from the Adelphi Real World CSU Disease Specific Programme, a cross-sectional survey with retrospective data collection (December 2020-October 2021) from physicians and patients with CSU in the United States.

RESULTS

Data from allergists (n = 45), dermatologists (n = 51), and primary care physicians (PCPs; n = 20) were included. At the time of data collection, one-third of patients were receiving omalizumab (n = 220) and 67% were eligible for but not receiving omalizumab (n = 455). Using logistic regression, the odds of receiving omalizumab were higher in patients whose entire bodies were affected by hives [odds ratio (OR) = 2.551; 95% confidence interval (CI) 1.502-4.333; p < 0.001] or with deteriorating/unstable prognoses at treatment initiation [OR = 2.219; 95% CI 1.031-4.777; p = 0.042], and lower in patients managed by PCPs [OR = 0.276; 95% CI 0.130-0.584; p < 0.001]. Estimates from an inverse probability weighted regression adjustment model indicated that patients receiving omalizumab had higher treatment satisfaction, improvements in itching, hives, angioedema, insomnia, and anxiety, and lower impact on work productivity, compared with patients not receiving omalizumab.

CONCLUSION

Around two-thirds of patients with CSU considered eligible for omalizumab were not receiving the guideline-recommended therapy. Patients receiving omalizumab had better real-world outcomes compared with patients not receiving omalizumab. Ensuring patients receive the most appropriate treatment could benefit patients with CSU.

The effectiveness of omalizumab therapy in patients with chronic spontaneous urticaria: the experience of a single-centre study in Poland

Introduction

Omalizumab, which is a recombinant, humanised anti-immunoglobulin-E antibody, is the only approved drug for antihistamine refractory chronic spontaneous urticaria (CSU). It has been reported that it is an effective and safe drug, but the data about long-term effectiveness are still lacking.

Aim

To perform a retrospective analysis of the patients with CSU treated with omalizumab at the dermatology department to assess effectiveness of omalizumab therapy in the single centre in Poland.

Material and methods

A two-and-a-half-year retrospective analysis of patients with CSU undergoing the therapy with omalizumab was conducted. Patients' data were analysed for many factors such as age, gender, severity indexes (UAS7, DLQI), duration and effects of the treatment used.

Results

Sixty-one patients with CSU have been treated with omalizumab in the drug program. The number of female patients - 42 (68.9%) significantly dominated over the number of male patients - 19 (31.1%). The mean UAS7 during the first course of treatment declined from 33.2 to 2.8, during the second from 30.9 to 1.7 and during the third 32.7 to 2.5. In case of DLQI the mean scores decrease from 18 to 2.1 in the first cycle, from 16.9 to 1.9 in the second and from 18.6 to 1.1 in the third.

Conclusions

Our study confirmed that omalizumab is an effective medicine in a long-term treatment which improves a physical as well as psychological condition of the patients with antihistamine-resistant CSU. To our knowledge, it is the first study in Poland that presents omalizumab effectiveness during three courses of treatment.

A Practical Approach to Diagnosing and Managing Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is an unpredictable inflammatory skin condition characterized by the spontaneous onset of itchy wheals, angioedema, or both, which occurs for longer than 6 weeks overall. Despite the relatively straightforward diagnostic algorithm for CSU, relying primarily on a detailed medical history and only limited laboratory tests, patients often wait years to be diagnosed, with many cycling through different healthcare practitioners before a diagnosis is made. Even then, current treatment options for CSU are limited, with approximately half of patients resistant to standard-of-care second-generation antihistamines at standard or higher doses. As such, there is an unmet need for improved, streamlined management for patients with CSU. Here, we review the evidence-based diagnostic algorithm for CSU, consider the required steps of the diagnostic workup, and provide practical, real-world advice on the management of CSU to improve the timely diagnosis and care of patients with this debilitating disease.

Global, regional, and national levels and trends in burden of urticaria: A systematic analysis for the Global Burden of Disease study 2019

Background

Urticaria places a significant burden on individuals and society due to its widespread nature. The aim of this study was to evaluate the burden of urticaria in different regions and nations by analysing data from the Global Burden of Disease study 2019 (GBD 2019), with the goal of providing information to health care policymakers.

Methods

By utilising data from the GBD 2019 database, this study analysed metrics such as incidence, prevalence, disability-adjusted life years (DALYs), age-standardised rate (ASR), and estimated annual percentage changes (EAPC) globally and across 204 countries and regions. The data was further stratified by age, sex, and sociodemographic index (SDI).

Results

In 2019, global incidence cases, prevalence cases, and overall disease burden as measured by DALYs all increased. The distribution of the burden exhibited marked geographical heterogeneity. At the regional level, the burden is highest in Central and Eastern Europe and Central Asia, with the strongest growth in South Asia, compared with a decline in the high-income Asia Pacific. At the country level, Nepal reports the highest burden of urticaria, while Portugal has the lowest. Gender and age analyses showed that the burden of urticaria is higher in females than in males, with urticaria cases declining with age, especially in children, and picking up among the elderly. The study also finds a correlation between the burden of urticaria and the SDI, with the central part of the SDI showing a consistent increasing trend.

Conclusion

This study found that the global burden of urticaria has risen from 1990 to 2019. Factors like geographic location, gender, and SDI influenced the urticaria burden. Overall, these results offer a resource to guide public health strategies seeking to reduce the burden of urticaria.

Disease Control and Treatment Satisfaction in Patients with Chronic Spontaneous Urticaria in Japan

Background: Chronic spontaneous urticaria (CSU), characterized by the recurrence of pruritic hives and/or angioedema for >6 weeks with no identifiable trigger, has a negative impact on health-related quality of life (HRQoL). Methods: The objective of this web-based cross-sectional study was to evaluate disease control, disease burden, and treatment satisfaction in Japanese adults with CSU using the Urticaria Control Test (UCT), HRQoL outcomes, and the Treatment Satisfaction Questionnaire for Medication-9 items (TSQM-9). Results: In total, 529 adults were included in the analysis (59.9% female), with a mean ± standard deviation (SD) in CSU duration of 13.2 ± 13.0 years. Based on UCT scores, two-thirds of patients had poor (score of 0-7; 23.6%) or insufficient (score of 8-11; 43.3%) symptom control, and one-third had good control (score of 12-16; 33.1%). Overall treatment satisfaction was not high, with mean ± SD TSQM-9 scores of 55.5 ± 17.6% for effectiveness, 68.2 ± 18.8% for convenience, and 59.2 ± 18.4% for global satisfaction. No apparent differences in TSQM-9 scores were observed between patients receiving different medications. HRQoL outcomes were worse among patients with poor/insufficient symptom control. Conclusions: Japanese adults with CSU have a high disease burden, and better treatment options are needed to increase treatment satisfaction.

Bilastine for the treatment of allergic rhinoconjunctivitis and urticaria: results from an international Delphi study

Background

Second-generation oral H1-antihistamines, including bilastine, represent the emerging treatments of allergic rhinitis (including rhinoconjunctivitis) and chronic urticaria in both adults and children. This study analyses available evidence supporting the use of bilastine amongst second-generation antihistamines for the symptomatic treatment of allergic rhinitis and urticaria in adults and children.

Methods

Consensus amongst experts from 17 countries on the ideal treatment of rhinitis and urticaria, and the specific role of bilastine was measured by means of a modified Delphi process. A total of 12 statements were voted on by the experts using a five-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree). The definition of consensus was set at a minimum of 80% concordance for 4+5 scores (agree or strongly agree).

Results

All proposed statements reached consensus, with a concordance of ≥98% for five statements and ≥96% for seven.

Conclusions

The wide consensus obtained for the proposed statements suggests a prominent role for bilastine in the management of allergic rhinitis and urticaria.

Disparities in chronic spontaneous urticaria: Eligibility for drug reimbursement associated with clinical outcomes

Background

Chronic spontaneous urticaria (CSU) is an immunologic condition with an estimated prevalence of 0.1%. For CSU that is poorly controlled despite the use of antihistamines, omalizumab is the only treatment approved and recommended by international guidelines.

Objective

Our aim was to outline the impact of treatment accessibility on CSU outcomes in the real world.

Methods

Serial data on adult patients with CSU receiving care for at least 6 months at a dedicated, immunologist-led urticaria clinic at Grantham Hospital in Hong Kong between 2018 and 2023 were analyzed. Patients' clinicodemographic data, drug eligibility status (eligible for reimbursement or not), treatment step, and disease activity (weekly Urticaria Activity Score [UAS7]) were collected and compared according to drug eligibility status.

Results

This study included 238 patients, 80 (33.6%) of whom were eligible for reimbursement and 158 of whom were not. No significant clinicodemographic differences, including disease activity, were found at baseline. At latest follow-up, significantly more patients in the eligible group were receiving omalizumab (28.7% vs 5.7% [P < .001]), which is equivalent to a multivariate odds ratio of 9.35 (95% CI = 3.689-23.703 [P < .001]). The discrepancy persisted even in patients with moderate-to-severe CSU whose UAS7 was 16 or higher (40.6% [13 of 32] vs 10.2% [6 of 59]; P < .001). In addition, there was significantly less dose reduction (<300 mg every 4 weeks) in the eligible omalizumab users (4.3% vs 44.4% [P = .015]). Clinically, significantly greater improvements in UAS7 were reported by the eligible group (median change -8.0 vs -5.0 [P = .021]).

Conclusion

Patterns of management varied largely among patients with different drug eligibility statuses and led to disparities in health outcomes. More efforts to secure equitable access to guideline-based CSU care are warranted.

Immunopathogenesis of urticaria: a clinical perspective on histamine and cytokine involvement

BACKGROUND

Urticaria is a clinical condition characterized by the appearance of wheals (hives), angioedema, or both. Over the last several decades, a better understanding of the mechanisms at play in the immunopathogenesis of urticaria has underscored the existence of numerous urticaria subtypes. Separating the different kinds of urticaria explicitly helps find the best detection method for the management of this skin disorder. Subtypes of urticaria also include both spontaneous and physical types. The conventional ones include spontaneous urticaria, constituting both acute and chronic urticaria. Therefore, a broad and effective therapy is essential for the diagnosis and treatment of urticaria.

METHODS

To understand the immunopathogenesis of urticaria, various databases, including PubMed, Scopus, and Web of Science, were used to retrieve original articles and reviews related to urticaria. While information on several clinical trials were obtained from clinicaltrials.gov database.

RESULTS

This article highlights the immunopathogenesis involved in the intricate interaction between cellular infiltration, immune reactions, coagulation cascades, and autoantibodies that underlie urticaria's pathophysiology.

CONCLUSION

The recent progress in understanding urticaria can help to understand the intricate characteristics in the immunopathogenesis of urticaria and could play a beneficial role in the management of urticaria.

Different doses and courses of omalizumab for patients with chronic spontaneous urticaria: A systematic review with meta-analysis and trial sequential analysis

Background

The stability, efficacy, and safety of omalizumab at different doses and regimens for chronic spontaneous urticaria (CSU) are yet to be studied.

Objective

A systematic review (SR) with meta-analysis (MA) and trial sequential analysis (TSA) was performed to assess the efficacy and safety of omalizumab in CSU.

Methods

Randomised controlled trials (RCTs) of administering omalizumab versus placebo for CSU were searched. Random-effects MAs were performed using planned subgroup analyses. TSA was performed to control for the risk of random errors and assess the stability of our MA results. Publication bias was visually assessed using a contour-enhanced funnel plot and the trim-and-fill method. The quality of RCTs was assessed using the Cochrane Risk of Bias Tool 2.

Results

Twelve studies met the inclusion criteria. Omalizumab had remarkable effects on the patient percentage of the weekly urticaria activity score is zero (UAS = 0) [RR 4.64, 95% CI (3.38, 6.37)], percentage of no angioedema-burdened days [MD 3.15, 95% CI (0.10, 6.19], patient percentage of UAS ≤6 [RR 3.05, 95% CI (2.46, 3.78)], and patient percentage of the weekly itch severity score minimally important difference (ISS7 MID) [RR 1.50, 95% CI (1.36, 1.66)]. Omalizumab was well tolerated across studies [RR 0.98, 95% CI (0.90, 1.08)]. TSA confirmed the above results, except for "the percentage of no angioedema-burdened day".

Conclusion

Among the different doses and courses assessed, omalizumab (300 mg, 12 weeks) can be recommended as an effective treatment for patients with CSU. However, whether omalizumab improves angioedema requires further investigation. The clinical management of angioedema accompanying CSU requires further attention.

Does chronic urticaria affect quality of sleep and quality of life?

Background

Urticaria affects a wide range of daily activities and social relationships. It has a severe impact on quality of life (QOL) and causes psychological problems.

Objective

was to assess the impact of chronic urticaria (CU) on quality of sleep, the levels of depression, anxiety, QOL and their interaction with each other and their relation to disease related factors.

Patients and methods

The study included 25 patients with CU and 25 healthy controls. Urticaria Activity Score (UAS) was used for objective evaluation of the intensity of urticaria. Patients completed a 10-cm visual analogue score (VAS) indicating the overall severity of their itching over the previous 2 weeks. The Dermatology Life Quality Index (DLQI) was used to evaluate patients' QOL. Patients were also assessed for anxiety and depression with the Hospital Anxiety and Depression Scale (HADS). Pittsburgh Sleep Quality Index (PSQI) was used for evaluation of sleep quality and sleep disturbances.

Results

In our CU patients the mean of UAS7 score was 39.72 ± 2.76 and the mean of VAS score was 28 ± 1.34. The mean of DLQI score was 24.8 ± 4.37 indicating severe impact of QOL. CU patients had higher total HADS score when compared to controls; 72% of the patients had depression and 92% had anxiety. By using PSQI, CU patients had significantly longer sleep latency onset, shorter total sleep duration, lower sleep efficiency and higher PSQI scores compared to controls.

Conclusion

CU highly affects the QOL of patients and is associated with higher levels of anxiety, depression and poor sleep quality.

Impact of Chronic Spontaneous or Inducible Urticaria on Occupational Activity

The impact of chronic urticaria on work has been scarcely reported, whereas its peak incidence is between the ages of 20 and 40. The aim of this study was to assess the occupational impact of chronic urticaria and its treatment, by combining objective and patient-reported data. A monocentric observational study was performed using questionnaires over a 1-year period from 2021 to 2022 in chronic urticaria patients who were in a period of professional activity and agreed to participate. Of the 88 patients included, 55.7% assessed the occupational impact of their chronic urticaria as significant, and even more severe when chronic urticaria was poorly controlled. Some 86% of patients had symptoms at work, in a third of cases aggravated by work. However, occupational physical factors were not associated with an aggravation of inducible chronic urticaria. A total of 20% reported treatment-related adverse effects affecting their work. Despite low absenteeism, presenteeism and reduced productivity were important (> 20%). Six patients (6.8%) had difficulties keeping their work. For 72.7% of the patients, the occupational physician was not informed. The occupational impact of chronic urticaria should be discussed during consultations, particularly when it is insufficiently controlled. The occupational physician should be informed in order to support patients' professional project.