Chronic urticaria - What does the new guideline tell us?

[Anti-IgE-directed treatment of urticaria in a dermatological practice]

We conducted a retrospective data analysis of 26 patients with chronic spontaneous urticaria (CSU), 12 of whom had been treated with anti-IgE therapy (omalizumab). The subcohort of patients treated with omalizumab displayed more severe and prolonged courses of disease. In addition, they had often undergone various inpatient therapies, frequently presenting with concomitant angioedema. Collecting the Urticaria Activity Scores from the seven daily values for wheals and itching (UAS7) proved an important and suitable instrument for the determination and assessment of the course of therapy in the dermatological office. Elaborate laboratory screenings, however, seem far less indicative of the severity, prognosis and course of the disease. Omalizumab proved to be a viable and well-tolerated treatment option. One third of the patients were completely free of all symptoms, another third showed very good improvement, whereas the last third showed no improvement at all, even when omalizumab and/or concomitant therapies were escalated.

Factors Associated With Refractoriness to an Up to Fourfold Dosage of Antihistamines in Isolated Chronic Spontaneous Urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common skin disease and has a significant impact on patients' quality of life. The aim of treatment is complete symptom control.

AIM

To identify potential factors associated with antihistamine-refractory isolated CSU and to determine the factors that predict response to second-generation H₁ antihistamines at dosages from one- to fourfold.

METHODS

We conducted a retrospective cohort study, which included adult patients diagnosed with isolated CSU and had complete symptom control. Clinical and laboratory findings were compared between the patients who were responsive to second-generation H₁ antihistamines (< fourfold) and those who were refractory to a fourfold dose. Clinical and laboratory data were compared by dosage in the antihistamine-responsive group.

RESULTS

There were 182 isolated CSU patients who met the study criteria, of whom 150 (82.4%) were responsive to treatment with up to a fourfold dose of second-generation H₁ antihistamines, while 32 (17.6%) were refractory. In univariate analysis, age at onset, body mass index, baseline Urticaria Activity Score-7 (UAS7), white blood cell count, total neutrophil count, neutrophil-lymphocyte ratio, platelet count, and new generation antihistamines were significantly higher in the antihistamine-refractory group. According to multivariate analysis, baseline UAS7 was the only independent factor associated with antihistamine-refractory isolated CSU (odds ratio 1.14, 95% CI 1.01-1.28, P = .03). In the antihistamine-responsive group, white blood cell count tended to predict response to antihistamine treatment (P < .001, 0.04, 0.34 between onefold and twofold, twofold and threefold, and threefold and fourfold, respectively).

CONCLUSION

Baseline UAS7 was an independent factor associated with antihistamine-refractory isolated CSU.

Treatment satisfaction in chronic urticaria during guideline-based therapy

BACKGROUND AND OBJECTIVES

Patients with chronic urticaria are often unsatisfied with their treatment. We aimed to assess patient satisfaction, chronic urticaria control, treatment goals, self-treatment competence, knowledge, and factors influencing treatment satisfaction.

PATIENTS AND METHODS

Eighty-seven adult patients with chronic urticaria who were previously insufficiently treated with oral antihistamines received guideline-based care for six months and completed questionnaires.

RESULTS

This study included patients with chronic spontaneous (80 %) and/or inducible urticaria (CIndU, 32 %). Significant median improvements were observed with the urticaria control test (UCT, from 7 to 11), the urticaria activity score for patients with chronic spontaneous urticaria (from 19 to 10), and treatment satisfaction (from 5.2 to 8.4). Six significant, independent factors of treatment satisfaction after six months of treatment were identified (negative: male sex, CIndU, sleep disturbances; positive: UCT, baseline treatment satisfaction, perceived competence of the study physician). Adequate urticaria control (UCT ≥ 12) was achieved in 19 % of patients with CIndU and 61 % of patients without CIndU.

CONCLUSIONS

In patients with chronic urticaria who were previously insufficiently treated with antihistamines, six months of guideline-based therapy significantly improved disease control and treatment satisfaction. Adequate control requires several consultations for many patients and is considerably more difficult to achieve for CIndU.

Cold Agglutinins and Cryoglobulins Associate With Clinical and Laboratory Parameters of Cold Urticaria

Mast cell-activating signals in cold urticaria are not yet well defined and are likely to be heterogeneous. Cold agglutinins and cryoglobulins have been described as factors possibly associated with cold urticaria, but their relevance has not been explained. We performed a single-center prospective cohort study of 35 cold urticaria patients. Cold agglutinin and cryoglobulin test results, demographics, detailed history data, cold stimulation test results, complete blood count values, C-reactive protein, total immunoglobulin E levels, and basal serum tryptase levels were analyzed. Forty six percent (n = 16) of 35 tested patients had a positive cold agglutinin test and 27% (n = 9) of 33 tested patients had a positive cryoglobulin test. Cold agglutinin positive patients, when compared to cold agglutinin negative ones, were mainly female (P = 0.030). No gender-association was found for cryoglobulins. A positive cold agglutinin test, but not a positive cryoglobulin test, was associated with a higher rate of reactions triggered by cold ambient air (P = 0.009) or immersion in cold water (P = 0.041), and aggravated by increased summer humidity (P = 0.007). Additionally, patients with a positive cold agglutinin test had a higher frequency of angioedema triggered by ingestion of cold foods or drinks (P = 0.043), and lower disease control based on Urticaria Control Test (P = 0.023). Cold agglutinin levels correlated with erythrocyte counts (r = −0.372, P = 0.028) and monocyte counts (r = −0.425, P = 0.011). Cryoglobulin concentrations correlated with basal serum tryptase levels (r = 0.733, P = 0.025) and cold urticaria duration (r = 0.683, P = 0.042). Results of our study suggest that cold agglutinins and cryoglobulins, in a subpopulation of cold urticaria patients, are linked to the course and possibly the pathogenesis of their disease.

[Treatment of simultaneously occurring urticaria and atopic dermatitis with dupilumab]

Our 21-year-old woman presented with symptoms of chronic spontaneous urticaria with angioedema and of cholinergic urticaria as well as of atopic dermatitis. Treatment with the IgE antibody omalizumab resulted in an improvement of urticaria; however, relapses of the atopic dermatitis occurred. The use of the monoclonal IL-4/13 receptor antibody dupilumab resulted in complete healing of the atopic dermatitis, complete remission of the chronic spontaneous urticaria with angioedema, and the satisfactory control of cholinergic flare ups over a follow-up period of 26 weeks.

Chronic Urticaria: An Overview of Treatment and Recent Patents

Background:

Up to 1% of the general population in the USA and Europe suffer from chronic urticaria (CU) at some point in their lifetime. CU has an adverse effect on the quality of life.

Objective:

This study aims to provide an update on the epidemiology, pathogenesis, clinical manifesta-tions, diagnosis, aggravating factors, complications, treatment and prognosis of CU.

Methods:

The search strategy included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term “chronic urticaria” at the following links: www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com.

Results:

CU is a clinical diagnosis, based on the episodic appearance of characteristic urticarial lesions that wax and wane rapidly, with or without angioedema, on most days of the week, for a period of six weeks or longer. Triggers such as medications, physical stimuli, and stress can be identified in 10 to 20% of cases. C-reactive protein/erythrocyte sedimentation rate, and complete blood cell count with differential are the screening tests that may be used to rule out an underlying disorder. The mainstay of therapy is reassurance, patient education, avoidance of known triggers, and pharmacotherapy. Second-generation H1 antihistamines are the drugs of choice for initial therapy because of their safety and efficacy profile. If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable, the dose of second-generation H1 antihistamines can be increased up to fourfold the manufacturer’s recom-mended dose (all be it off license). If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable after the fourfold increase in the dosage of second-generation H1 antihis-tamines, omalizumab should be added. If satisfactory improvement does not occur after 6 months or earli-er if the symptoms are intolerable after omalizumab has been added, treatment with cyclosporine and sec-ond-generation H1 antihistamines is recommended. Short-term use of systemic corticosteroids may be considered for acute exacerbation of CU and in refractory cases. Recent patents for the management of chronic urticaria are also discussed. Complications of CU may include skin excoriations, adverse effect on quality of life, anxiety, depression, and considerable humanistic and economic impacts. On average, the duration of CU is around two to five years. Disease severity has an association with disease duration.

Conclusion:

CU is idiopathic in the majority of cases. On average, the duration of CU is around two to five years. Treatment is primarily symptomatic with second generation antihistamines being the first line. Omalizumab has been a remarkable advancement in the management of CU and improves the quality of life beyond symptom control.

The safety and tolerability profile of bilastine for chronic urticaria in children

Background

Urticaria is a condition defined by the development of wheals, angioedema or both. It is classified based on its duration as acute (≤ 6 weeks) or chronic (> 6 weeks). Chronic urticaria is less frequent than acute one in children, but it represents a debilitating condition, always needing treatment. Symptoms affect child's daily activities and disturb sleeping patterns, causing emotional distress and negatively influencing learning and cognition. Therefore, the management of chronic urticaria must point to a complete control of symptoms, taking into account tolerability and the patient quality of life.

Review of literature

The recently revised version of EAACI/GA²LEN/EDF/WAO guideline on the management of urticaria, in addition to recommending the use of second-generation H₁ antihistamines as the treatment of choice, gives particular attention to their use in the paediatric population. Bilastine has been studied in children; at the dose of 10 mg/once daily, it is licenced for the symptomatic relief of urticaria in children ≥ 6 to 11 years, in the European Union, in appropriate formulation, as oral solution or orodispersible tablet.

Conclusions

In line with the recent guideline recommendation for the use of second generation H₁ antihistamines in children we have reviewed the safety and tolerability profile of bilastine in children with chronic urticaria.

Thyroid Autoimmunity and Autoimmunity in Chronic Spontaneous Urticaria Linked to Disease Severity, Therapeutic Response, and Time to Remission in Patients with Chronic Spontaneous Urticaria

Background

Chronic spontaneous urticaria (CSU) is autoimmune in nature and associated with thyroid autoimmunity (TA), but evidence on autoimmunity in relation to CSU progression and prognosis is limited. We evaluated whether TA and autoimmunity in CSU are correlated with disease severity, therapeutic response, and time to remission and establish an association between CSU characteristics linked to thyroid autoantibody.

Methods

Medical records of patients diagnosed with urticaria attending outpatient dermatology clinic at a university-based hospital from 2013 to 2017 were retrospectively reviewed. Data on the clinical characteristics, laboratory investigations particularly thyroid antibody titers, autologous serum skin test (ASST) and autologous plasma skin test (APST) results and their link to disease severity, treatments, and time to remission of CSU patients were analyzed.

Results

Of 1,096 patients with urticaria, 60.2% had CSU. Three-hundred patients fulfilled the inclusion criteria for CSU with complete thyroid antibody testing. Positive TA was significantly associated with female gender and age > 35 years (p = 0.008). Antithyroid peroxidase (anti-TPO)-positive patients suffered from CSU longer than 12 and 18 months compared to anti-TPO-negative patients (100.0% vs. 82.6%, p = 0.042, and 100.0% vs. 75.9% p = 0.020, respectively). The presence of urticarial attacks > 4 days/week was significantly seen in ASST and APST-positive patients compared to those without (84.6% vs. 61.3%, p = 0.011, and 85.3% vs. 61.8%, p = 0.006, respectively). Positive APST patients were more difficult to treat than those with negative results (61.2% vs. 37.8%, p = 0.017).

Conclusions

Antithyroid peroxidase is a predictor of time to remission, while autologous skin testing is linked to disease severity (ASST and APST) and therapeutic response (APST) in CSU patients.