Delayed pressure urticaria, objective evaluation of a variable disease using a dermographometer and assessment of treatment using colchicine

Potential Therapeutic Approaches for Chronic Urticaria: Beyond H1-Antihistamines and Biologics

Chronic urticaria is a disease that can significantly impact a patient's quality of life and ability to function. There are effective treatment options, such as nonsedating antihistamines or biologics, but some patients do not respond to these therapies, or the therapies are not available or affordable to all patients. This review aims to summarize potential treatment strategies for patients (1) who do not respond to antihistamines and (2) cannot readily access or do not respond to biologics. The review emphasizes the importance of sound clinical practice, including correct diagnosis of chronic urticaria phenotypes, treatment of associated comorbidities, and consideration of add-on pharmacological and nonpharmacological approaches. Although some treatments may lack high-quality evidence, they may still be justifiable in certain cases, provided that there is shared decision-making, regular reassessment, and early recognition of adverse events.

S3 Guideline Urticaria. Part 2: Treatment of urticaria - German-language adaptation of the international S3 guideline

This publication is the second part of the German-language S3 guideline on urticaria. It covers the management of urticaria and should be used together with Part 1 of the guideline on classification and diagnosis. This publication was prepared according to the criteria of the AWMF on the basis of the international English-language S3 guideline with special consideration of health system conditions in German-speaking countries. Chronic urticaria has a high impact on the quality of life and daily activities of patients. Therefore, if causal factors cannot be eliminated, effective symptomatic treatment is necessary. The recommended first-line treatment is to administer new generation, non-sedating H1 antihistamines. If the standard dose is not sufficiently effective, the dose should be increased up to fourfold. For patients who do not respond to this treatment, the second-line treatment in addition to antihistamines in the treatment algorithm is omalizumab and, if this treatment fails, ciclosporin. Other low-evidence therapeutic agents should only be used if all treatments in the treatment algorithm agreed upon by the guideline group fail. Both the benefit-risk profile and cost should be considered. Corticosteroids are not recommended for long-term treatment due to their inevitable severe side effects.

The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria

This update and revision of the international guideline for urticaria was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA²LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), the European Dermatology Forum (EDF; EuroGuiDerm), and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology with the participation of 64 delegates of 50 national and international societies and from 31 countries. The consensus conference was held on 3 December 2020. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease that presents with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous or inducible urticaria is disabling, impairs quality of life, and affects performance at work and school. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Colchicine in Managing Skin Conditions: A Systematic Review

(1) Background: Colchicine is a natural alkaloid with anti-inflammatory properties used to treat various disorders, including some skin diseases. This paper aims to incorporate all the available studies proposing colchicine as a treatment alternative in the management of cutaneous conditions. (2) Methods: In this systematic review, the available articles present in various databases (PubMed, Scopus-Embase, and Web of Science), proposing colchicine as a treatment for cutaneous pathological conditions, have been selected. Exclusion criteria included a non-English language and non-human studies. (3) Results: Ninety-six studies were included. Most of them were case reports and case series studies describing colchicine as single therapy, or in combination with other drugs. Hidradenitis suppurativa, pyoderma gangrenosum, erythema nodosum, erythema induratum, storage diseases, perforating dermatosis, bullous diseases, psoriasis, vasculitis, acne, urticaria, stomatitis, actinic keratosis, and pustular dermatosis were the main diseases discussed in literature. Although the therapeutic outcomes were variable, most of the studies reported, on average, good clinical results (4) Conclusions: Colchicine could be, as a single therapy or in combination with other drugs, a possible treatment to manage several skin diseases.

Successful treatment of delayed pressure urticaria with 300 mg of omalizumab every 14 days

Delayed pressure urticaria is a rare form of chronic inducible urticaria characterized by erythematous-painful plaques that develop in areas of the skin exposed to prolonged pressure. Its treatment is very difficult, and its response to antihistamines is variable. Cases of delayed pressure urticaria, which have been completely controlled with the use of omalizumab in recent years, have been reported.

Delayed Pressure Urticaria: A Systematic Review of Treatment Options

BACKGROUND

Delayed pressure urticaria (DPU) is characterized by recurrent erythematous and often painful swelling after the skin is exposed to sustained pressure. Treatment is challenging. Antihistamines, the first-line and only approved treatment, are often not effective.

OBJECTIVE

To systematically review the treatment options for DPU.

METHOD

A literature search of electronic databases for all relevant articles published till April 29, 2019, was conducted using the search terms "delayed pressure urticaria" and "pressure urticaria." This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

RESULTS

Twenty-one studies (8 randomized controlled trials [RCTs], 10 retrospective cohort studies, and 3 open-label prospective studies) were included. Second-generation H₁ antihistamines (sgAHs) were effective in 3 RCTs. The combination of an sgAH and montelukast (2 RCTs) or an sgAH and theophylline (1 non-RCT) was more effective than the sgAH alone. The disease improved with omalizumab (4 non-RCTs), sulphones (3 non-RCTs), oral prednisolone (1 RCT and 2 non-RCTs), intravenous immunoglobulin (1 non-RCT), and gluten-free diet (1 non-RCT). There are no studies on updosing of antihistamines over standard dosage in DPU.

CONCLUSIONS

Overall, the quality of studies on DPU is low. Because of the lack of other evidence, antihistamines remain the first-line therapy. Updosing of sgAHs could be considered in patients with uncontrolled symptoms on the basis of the extrapolation of evidence from chronic spontaneous urticaria, even though there is no evidence of its efficacy over standard dosage. Addition of montelukast may be considered. Omalizumab or sulphones may be used in treatment-resistant patients. High-quality DPU studies should be conducted.

How to Approach Chronic Inducible Urticaria

Chronic inducible urticaria (CIndU) is a group of chronic urticarias characterized by the appearance of recurrent wheals, recurrent angioedema or both, as a response to specific triggers. CIndU includes both physical (symptomatic dermographism, cold and heat urticaria, delayed pressure urticaria, solar urticaria, and vibratory urticaria) and nonphysical urticarias (cholinergic urticaria, contact and aquagenic urticaria). Here, we review the different forms of CIndU with an emphasis on symptomatic dermographism, cold urticaria, cholinergic urticaria, and delayed pressure urticaria. We discuss the clinical features, the diagnostic workup including provocation and threshold testing, and available treatment options.

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

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

The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Colchicine in dermatology: A review

Colchicine is an anti-inflammatory agent that has been used for decades for the treatment of various diseases including gout, familial Mediterranean fever and pericarditis and in recent years for dermatological indications including chronic urticaria, cutaneous vasculitis and psoriasis. Despite its efficacy in various cutaneous diseases, the use of colchicine may be limited by concerns over its side-effects and the potential for toxicity. This article reviews the current literature on the pharmacology of colchicine and its clinical applications in dermatology.

Chronic inducible urticaria: A systematic review of treatment options

BACKGROUND

Chronic inducible urticaria (CindU) is a condition characterized by the appearance of recurrent wheals, angioedema, or both as a response to specific and reproducible triggers.

OBJECTIVE

We sought to systematically assess evidence on the efficacy and safety of treatment options for CindU. Results were used to inform the 2017 update of "The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria."

METHODS

Randomized controlled trials and controlled intervention studies were searched systematically in various databases. Included studies were evaluated with the Cochrane Risk of Bias tool. Where possible, results from single studies were meta-analyzed, applying the Mantel-Haenszel approach by using a random-effects model (Der Simonian-Laird).

RESULTS

We identified 30 studies that included patients with cold urticaria, symptomatic dermographism, delayed-pressure urticaria, or cholinergic urticaria. No studies on other forms of CindU were eligible. Risk of bias was often rated as unclear or high. Overall, second-generation antihistamines were more effective than placebo, and available data indicate that updosing might be effective. Omalizumab proved effective in patients with symptomatic dermographism, who did not respond to antihistamines. Detailed results are given for each type of CindU.

CONCLUSIONS

The available evidence is limited by small samples, heterogeneous efficacy outcomes, and poor reporting quality in many of the included studies. The findings are congruent with the suggested stepwise approach to treating CindUs. However, the data do not allow for drawing specific conclusions for specific subtypes of CindU.

Therapy of antihistamine-resistant chronic spontaneous urticaria

INTRODUCTION

Chronic urticaria affects up to 1-3% of the general population and contributes to significant direct and indirect medical costs as well as decreased quality of life, which has a significant economic impact on our health care system. Areas covered: Given the prevalence of this condition on a large sector of the population, finding lasting relief for refractory cases is essential and is the focus of this review. Expert commentary: The choice of appropriate therapy in chronic refractory urticaria is not a 'one-size fits all' approach. Treatment should take multiple factors into consideration including the chronicity of hives, presence of physical urticaria, type of cellular infiltrate on skin histopathology, patient age, concomitant comorbid conditions, as well as patient preference and cost.

The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision

These recommendations for the definition, diagnosis and management of chronic inducible urticaria (CIndU) extend, revise and update our previous consensus report on physical urticarias and cholinergic urticaria (Allergy, 2009). The aim of these recommendations is to improve the diagnosis and management of patients with CIndU. Our recommendations acknowledge the latest changes in our understanding of CIndU, and the available therapeutic options, as well as the development of novel diagnostic tools.

Chronic spontaneous urticaria: latest developments in aetiology, diagnosis and therapy

Chronic urticaria is a debilitating disease characterized by itching and hives with or without angioedema lasting for more than 6 weeks. The disease carries a significant emotional and economic burden for the patient and often results in an odyssey between doctors of different specialities. Patients suffering from chronic urticaria are considered more difficult to satisfy, treat and to have a bigger emotional burden than the average patient in dermatology, paediatric and general practice settings. A joint initiative under the Dermatology section of the European Academy of Allergy and Clinical immunology (EAACI), the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) has resulted in recently published guidelines for the diagnosis, classification and treatment of chronic urticarial: these guidelines are clinically useful and have a high success rate when followed in daily clinical practice. The treatment of choice for chronic urticaria is still nonsedating antihistamines although other treatments are available, with omalizumab (humanized IgG anti IgE antibodies) as the newest therapy. The pathogenesis of urticaria is poorly understood but autoimmunity is considered as one of the major underlying causes for this disease, although other theories exist.

Colchicine--Update on mechanisms of action and therapeutic uses

OBJECTIVES

To review the literature and provide an update on the mechanisms of action and therapeutic uses of oral colchicine in arthritis and inflammatory conditions.

METHODS

We performed PubMed database searches through June 2014 for relevant studies in the English literature published since the last update of colchicine in 2008. Searches encompassed colchicine mechanisms of action and clinical applications in medical conditions. A total of 381 articles were reviewed.

RESULTS

The primary mechanism of action of colchicine is tubulin disruption. This leads to subsequent down regulation of multiple inflammatory pathways and modulation of innate immunity. Newly described mechanisms include various inhibitory effects on macrophages including the inhibition of the NACHT-LRRPYD-containing protein 3 (NALP3) inflammasome, inhibition of pore formation activated by purinergic receptors P2X7 and P2X2, and stimulation of dendritic cell maturation and antigen presentation. Colchicine also has anti-fibrotic activities and various effects on endothelial function. The therapeutic use of colchicine has extended beyond gouty arthritis and familial Mediterranean fever, to osteoarthritis, pericarditis, and atherosclerosis.

CONCLUSION

Further understanding of the mechanisms of action underlying the therapeutic efficacy of colchicine will lead to its potential use in a variety of conditions.

Investigation of patient-specific characteristics associated with treatment outcomes for chronic urticaria

BACKGROUND

Identifying clinical characteristics of patients with chronic urticaria (CU) responsive to medication may help guide clinicians select treatment.

OBJECTIVE

The objective of this study was to investigate patient characteristics and medication use associated with urticaria control.

METHODS

A retrospective longitudinal chart review of adult patients with CU was conducted at a multisite allergy practice. Inclusion criteria required at least 4 CU office visits to allow for pre- and posttreatment assessment. Control corresponding to medication(s) used was assessed each visit. Univariate analysis followed by multiple logistic regression was performed.

RESULTS

A total of 221 patients with CU were included; 140 (63%) achieved complete control. The average time to control was 1.4 ± 2.7 years, which required 1-3 classes of medications. Dermatographia odds ratio (OR) = 1.85 (95% CI 1.3-2.7) or other physical urticarias, OR = 1.51 (1-2.4) and neutrophilic infiltrates on skin biopsy were markers of poor control. Thyroid autoantibodies were associated with better control using an H1-antihistamine. Whereas 22% were controlled on a second-generation H1-receptor antagonist plus a leukotriene receptor antagonist (LTRA), an additional 33% were controlled when cyclosporine was added. Use of a first or second H1-antagonist or LTRA was associated with a 3.5-16.9 times higher odds of complete CU control in those with dermatographia. The odds of achieving control for other forms of physical urticaria was greatest when colchicine was added (aOR = 32.6 [12.7-83.2]).

CONCLUSIONS

Patient-specific CU characteristics associated with medication-disease control may be useful for selecting treatment regimens. A subset of CU patients remains poorly controlled that indicates an unmet need for novel therapeutic agents.

The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update

This guideline is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The life-time prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria do not only cause a decrease in quality of life, but also affect performance at work and school and, as such, are members of the group of severe allergic diseases. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Alternative agents in refractory chronic urticaria: evidence and considerations on their selection and use

Patients with chronic urticaria (CU) who are refractory to antihistamines are frequently encountered by allergy specialists. Several alternative agents have been used to treat these patients; however, the evidence to support these agents is generally limited. This review focuses on some of the more commonly used alternative agents in refractory CU, including anti-inflammatory agents (montelukast, hydroxychloroquine, dapsone, sulfasalazine, methotrexate, colchicine), immunosuppressants (cyclosporine, tacrolimus, mycophenolate), and immunomodulatory agents (omalizumab, immune globulin). The evidence to support their use, dosing, potential toxicity, monitoring, and selection of these alternative agents is reviewed. Although numerous knowledge gaps exist for alternative agents in refractory CU, a rational, patient-based approach can be used with a goal of improving control and quality of life and minimizing adverse medication effects.

The definition and diagnostic testing of physical and cholinergic urticarias--EAACI/GA2LEN/EDF/UNEV consensus panel recommendations

The recommendations for the definition and diagnosis presented in this position paper are the result of a panel consensus meeting held in December 2008 in Berlin. This consensus meeting was a joint initiative of EAACI (European Academy of Allergology and Clinical Immunology) Dermatology Section, the EU-funded network of excellence, GA(2)LEN (Global Allergy and Asthma European Network), the EDF (European Dermatology Forum) and UNEV (urticaria network e.V.). The aim of these recommendations is to improve the diagnosis and management of patients with physical urticaria or cholinergic urticaria and to promote research and a better understanding of these diseases. Our recommendations used the paper produced by a 1996 expert meeting (1) and they acknowledge the latest changes in our understanding of physical urticarias and cholinergic urticaria as well as the recent development of novel diagnostic tools. In addition, this consensus paper highlights areas of need for further research.

EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria

This guideline, together with its sister guideline on the classification of urticaria (Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: definition, classification and diagnosis of urticaria. Allergy 2009;64: 1417-1426), is the result of a consensus reached during a panel discussion at the Third International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO). As members of the panel, the authors had prepared their suggestions regarding management of urticaria before the meeting. The draft of the guideline took into account all available evidence in the literature (including Medline and Embase searches and hand searches of abstracts at international allergy congresses in 2004-2008) and was based on the existing consensus reports of the first and the second symposia in 2000 and 2004. These suggestions were then discussed in detail among the panel members and with the over 200 international specialists of the meeting to achieve a consensus using a simple voting system where appropriate. Urticaria has a profound impact on the quality of life and effective treatment is, therefore, required. The recommended first line treatment is new generation, nonsedating H(1)-antihistamines. If standard dosing is not effective, increasing the dosage up to four-fold is recommended. For patients who do not respond to a four-fold increase in dosage of nonsedating H(1)-antihistamines, it is recommended that second-line therapies should be added to the antihistamine treatment. In the choice of second-line treatment, both their costs and risk/benefit profiles are most important to consider. Corticosteroids are not recommended for long-term treatment due to their unavoidable severe adverse effects. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1

OBJECTIVE

To evaluate the use of alternative therapies for chronic urticaria refractory to first-line treatments in an evidence-based manner.

DATA SOURCES

MEDLINE searches were performed cross-referencing urticaria with the names of multiple therapies. Articles were then reviewed for additional citations. Articles published after 1950 were considered.

STUDY SELECTION

All articles, including case reports, were reviewed for soundness and relevance.

RESULTS

Experience has been reported for a wide variety of alternative therapies in the treatment of chronic idiopathic and physical urticarias. Evidence for most agents is limited to anecdotal reports. The second-line therapies reviewed are also categorized based on criteria of safety, efficacy, convenience, and cost, in relation to the first-line antihistamines.

CONCLUSIONS

Alternative agents should be considered in patients with chronic urticaria who are both severely affected and unresponsive to antihistamines. Although monitoring for toxicity is important in management with many alternative agents, safety is favorable compared with corticosteroids.

Desloratadine in combination with montelukast suppresses the dermographometer challenge test papule, and is effective in the treatment of delayed pressure urticaria: a randomized, double-blind, placebo-controlled study

BACKGROUND

Delayed pressure urticaria (DPU) comes under the heading of physical urticaria. Characteristically itchy, tender or painful weals occur at sites of local pressure including the waistband, soles of the feet and palms of the hands. Lesion onset is typically 3-12 h after the application of pressure, and lesions may persist for more than 24 h. The treatment of DPU is often unsatisfactory.

OBJECTIVES

To determine the efficacy of desloratadine and montelukast in the treatment of DPU.

METHODS

The study was conducted in 36 subjects affected by DPU. A challenge test with a dermographometer was administered to confirm the diagnosis. After diagnosis, patients were randomized to receive the following treatment once daily for 2 weeks: (i) oral desloratadine 5 mg plus oral placebo; (ii) oral desloratadine 5 mg plus montelukast 10 mg; and (iii) oral placebo alone.

RESULTS

At rechallenge, patients from the treatment groups (desloratadine plus montelukast group and desloratadine alone group) demonstrated a significant reduction in mean diameter of papules after 70 s of pressure compared with the placebo group (P < 0.05). Moreover, patients treated with desloratadine plus montelukast showed a significant reduction in mean diameter of papules at 70 s of pressure compared with those treated with desloratadine alone (P < 0.05). In addition, the combination was effective in improving clinical parameters (erythema, oedema and pruritus, and number of separate urticarial episodes).

CONCLUSIONS

This study has demonstrated that both desloratadine alone and desloratadine plus montelukast administered once daily yield improvements with respect to the baseline assessment, regarding the suppression of the dermographometer challenge test papule and clinical improvement of urticaria. However, the combination of desloratadine and montelukast was shown to be more efficacious and may therefore be proposed in patients with DPU, in order to avoid corticosteroid therapy.

EAACI/GA2LEN/EDF guideline: management of urticaria

This guideline is the result of a consensus reached during a panel discussion at the second International Consensus Meeting on Urticara, Urticaria 2004, a joint initiative of the EAACI Dermatology Section and GA2LEN. Urticaria has a profound impact on the quality of life, and effective treatment is therefore required. The recommended first line treatment are nonsedating H1 antihistamines. They have proven to be effective in double-blind controlled studies, but dosages increased up to fourfold over the recommended doses may be necessary. However, for different urticaria subtypes and in view of individual variation in the course of the disease and response to treatment, additional or alternative therapies may be required. Immunosuppressive drugs like cyclosporin A and corticosteroids are not recommended for long-term treatment due to unavoidable severe adverse effects. This guideline was, in addition, accepted by the European Dermatology Forum (EDF) and formally approved by the European Union of Medical Specialists (UEMS).

Bullous delayed pressure urticaria: pathogenic role for eosinophilic granulocytes?

Bullous delayed pressure urticaria (DPU) is a rare variant of DPU. Treatment of DPU is difficult and the underlying pathogenic mechanism of DPU remains elusive. We report a 72-year-old man with DPU and associated chronic urticaria as well as delayed urticarial dermographism. Pressure challenge gave rise to a deep weal covered by multiple vesicles and bullae after 24 h. Histological examination of a skin biopsy specimen obtained 24 h after pressure challenge demonstrated intraepidermal bullae filled with eosinophils accompanied by a dense, predominantly eosinophilic infiltrate in the dermis. Whereas the numbers and morphology of mast cells were unaltered, the extracellular deposition of eosinophil cationic protein revealed evidence for eosinophil activation. Concomitantly, both CD4+ and CD8+ T lymphocytes were present in the infiltrate and expressed interleukin 5. As bullous DPU may represent the maximal variant of DPU, the investigation of the cellular infiltrate and the chemokines/cytokines released may reveal potential pathogenic mechanisms. A possible effector role of eosinophilic granulocytes, T-cell subsets and mast cells is discussed.

[Urticaria. Classification and diagnosis]

Urticaria belongs to the most frequent dermatologic diseases. Although the pathogenesis of urticaria is not fully understood, systematic studies in recent years have identified the most important triggering factors of the different forms of urticaria. Based on these results, it is recommended to restrict diagnostic procedures in acute urticaria to history and physical examination, while in chronic urticaria, one should exclude drugs, infections, pseudoallergic reactions, and autoimmune processes as causes. For the diagnosis of physical urticaria, standardized provocation test are recommended.

Delayed pressure urticaria

Delayed pressure urticaria is a mechanical urticaria in which pressure causes whealing. Delayed cutaneous erythema and edema occur in association with marked subcutaneous swelling after the application of a sustained pressure stimulus to the skin. The earliest reports and theories of the pathogenesis of delayed pressure urticaria are summarized. Detailed attention is given to making the diagnosis by taking a history and provoking the lesions. The clinical features and natural history are considered. The effects of the disorder on quality of life are delineated, and management strategies are suggested.

Effect of high-dose intravenous immunoglobulin in delayed pressure urticaria

BACKGROUND

Delayed pressure urticaria (DPU) is difficult to treat. High-dose intravenous immunoglobulin (IVIG) has been found to be effective in treating patients with autoimmune chronic urticaria.

OBJECTIVES

To report the effect of IVIG on eight patients with severe unremitting DPU.

METHODS

IVIG was administered at a dose of 2 g kg-1 over 2-3 days on an in-patient basis. The response to treatment was assessed subjectively and recorded as remission, improved or unchanged. An autologous serum skin test (ASST) was performed in seven patients.

RESULTS

Three of eight patients achieved remission; two after one infusion and one after three infusions. Two patients improved. Three patients remained unchanged; of these, two declined further treatment after two infusions, and one failed to improve after six infusions at monthly intervals. Four of seven patients had positive ASST; three responded to IVIG. Two developed delayed positive ASST; both responded to IVIG. Of three patients with negative ASST, two responded.

CONCLUSIONS

IVIG induced remission or improved symptoms in five of eight patients with DPU with severe unremitting disease who had failed to respond to other therapies or were controlled only with systemic corticosteroids. Those who responded did so with three or fewer infusions. ASST is not a reliable predictor of response to IVIG.

Evaluating chronic urticaria patients for allergies, infections, or autoimmune disorders

Urticaria is a common disorder affecting one-fifth of the world's population. The pathophysiology is characterized by an increased propensity for mast cell degranulation with the release of potent mediators into the dermal and subdermal tissues with resulting vasoactive, chemotactic, and inflammatory effects. The final clinical manifestation of the typical urticarial lesion is the effect of several diverse effects and causes. The general classification is acute, chronic, and physical urticaria. In general, allergenic triggers can be identified in between 60-80% of acute urticarias. Physical urticarias are characterized by the onset after the specific inciting stimulus, which can reproduce the characteristic lesion which is usually of shorter duration (with the exception of delayed pressure urticaria). Chronic idiopathic urticaria is associated with thyroid autoimmunity and, more recently, anti-mast cell receptor antibodies. An extensive work-up is usually not indicated or helpful in identifying a cause. Food or other allergens are rare causes of this type of presentation. The evaluation and work-up is dependent on clues identified by history. The treatment is removal of specific and non-specific triggers and the use of symptomatic medications generally attenuating the mediator effects.

Delayed pressure urticaria

Delayed pressure urticaria is a physical urticaria where erythematous, often painful swellings occur at sites of sustained pressure on the skin, after a delay of several hours. If sought, it is present in up to 40% of patients with ordinary chronic "idiopathic urticaria" to a varying degree. Compared with other urticarias, the pressure-induced lesions impair the quality of life of patients most severely. The pathogenesis is not well characterized, but whealing is dependent on mast cell activation, with the histology of lesions also showing a deep dermal inflammatory infiltrate of neutrophils and eosinophils, without vasculitis. Treatment of delayed pressure is generally unsatisfactory, and is often resistant to antihistamine and a range of anti-inflammatory medication. Oral steroids, although the most effective therapy, are unsuitable for long-term use. Delayed pressure urticaria may persist for many years, and improved or novel methods of management are under investigation.

Management of urticaria: a consensus report

This consensus report is the result of a panel discussion during the International Clinically Oriented ESDR Symposium Urticaria 2000. Urticaria has a profound impact on the quality of life and effective treatment is required. The most important are nonsedating H1 antihistamines. They have been proven to be effective in double-blind controlled studies, but concentrations higher than those recommended may be necessary. Due to different urticaria subtypes and the individual variation in the course of the disease and response to treatment, however, alternative therapies may be required. Immunosuppressive drugs like cyclosporine A and corticosteroids should not be used long term due to undesirable side-effects.

Management of urticaria

Urticaria is a very common and disabling disorder. Recent advances in understanding of pathomechanisms has led to important advances in diagnosis and treatment. However, the cause in many patients remains obscure and the treatment poorly effective.

Assessment of urticaria and angio-oedema

There are many types of urticaria and the principal form of assessment is by clinical history and examination. Urticarial weal formation involves acute, reversible vasodilatation and increased vascular permeability. If the process is deeper the more diffuse swelling is termed angio-oedema. The major types of urticaria include allergic, physical and idiopathic forms. In allergic urticaria, IgE-mediated degranulation of mast cells results in weals of short duration which typically respond well to antihistamines. Physical urticarias are induced by physical insults including pressure, scratch, cold, etc. The distribution and duration of individual weals may suggest the causal factor. Chronic idiopathic urticaria can be very variable, with individual weals lasting between 90 min and 24 hours. Longer-lasting weals are less responsive to anti-histamines and clearly involve other mediators. When long-lasting weals fade leaving a bruised appearance urticarial vasculitis is present which may only respond to systemic corticosteroids. In a proportion of individuals with chronic idiopathic urticaria, auto-antibodies are present with specificity for the high affinity receptor for IgE or sometimes, for IgE itself. In general laboratory tests for allergic factors or other assessments of general health are completely unhelpful.

Cutaneous inflammatory cell infiltrate in chronic idiopathic urticaria: comparison of patients with and without anti-FcepsilonRI or anti-IgE autoantibodies

BACKGROUND

Previous studies defining the histopathologic features of patients with chronic idiopathic urticaria (CIU) were performed on wheals of uncertain duration and before the identification of functional autoantibodies against FcepsilonRI and/or IgE, now known to be present in approximately 30% of patients with CIU.

OBJECTIVE

We sought to determine the timing of the inflammatory infiltrate in the wheals of patients with CIU and to detect differences between patients with and without autoantibodies.

METHODS

Immunohistochemistry was used to identify neutrophils (neutrophil elastase), T lymphocytes (CD3), and activated eosinophils (EG2) in biopsy specimens from uninvolved skin and wheals present for less than 4 hours and greater than 12 hours in 22 patients with CIU, as well as in biopsy specimens from the skin of 12 healthy control subjects. Patients were identified as having functional autoantibodies on the basis of their serum-evoked histamine release in vitro from the basophils of 2 healthy donors.

RESULTS

EG2(+), neutrophil elastase+, and, to a lesser extent, CD3(+) cells were found in greater numbers in wheals undergoing biopsy at less than 4 and greater than 12 hours than in uninvolved skin (P <.05). Patients without autoantibodies (n = 12) had significantly more EG2(+) cells in wheals of greater than 12 hours' duration than patients with autoantibodies (n = 10; P =.02). There was no other difference between patients with and without autoantibodies in the cutaneous cellular infiltrate.

CONCLUSION

Neutrophil and eosinophil accumulation occurs early in the evolution of a wheal in patients with CIU, but eosinophil activation may occur later or be more persistent in patients without autoantibodies.

Chronic idiopathic urticaria: comparison of the clinical features of patients with and without anti-FcepsilonRI or anti-IgE autoantibodies

BACKGROUND

Previous studies defining the clinical features of patients with chronic idiopathic urticaria (CIU) were performed before the identification of functional autoantibodies against FcepsilonRI and/or IgE, now known to be present in approximately 30% of patients with CIU.

OBJECTIVE

Our purpose was to determine whether there are differences between patients with and those without autoantibodies in the clinical features or severity of CIU.

METHODS

The clinical features of 107 patients with CIU were evaluated prospectively. Patients were identified as having functional autoantibodies on the basis of the serum-evoked histamine release in vitro from the basophils of 2 healthy donors.

RESULTS

Patients with autoantibodies (31%) had more wheals (P = .005), a wider distribution of wheals (P = .009), higher itch scores for the most severe episodes of itching (P = .002), more systemic symptoms (P = .03), and lower serum IgE levels (P < .0005) than patients without autoantibodies.

CONCLUSION

The presence of autoantibodies indicates a subset of patients with more severe CIU.

Mast cells and T lymphocytes in chronic urticaria

Mast cells are considered to be the primary effector cells in urticaria but it is possible that lymphocytes contribute to the formation of weals by secreting histamine releasing factors. The aim of this study was to examine the population of mast cells and to quantify the T cell subsets and their activation status in delayed pressure urticaria (DPU), chronic idiopathic urticaria and normal controls. Three biopsies were obtained from each of four patients with chronic idiopathic urticaria but not DPU. Three biopsies were taken from each of 13 patients with DPU, from a combination of unchallenged skin and at 0, 2, 6, 24, 48, and 120 h after weighted steel rods (diameter 1.5 cm) had been applied to the thighs. Three biopsies were similarly obtained from each of four normal controls before an identical pressure challenge and at 6, 24 and 48 h afterwards. The chloracetate esterase stain was used to demonstrate mast cells and an alkaline phosphatase anti-alkaline phosphatase immunohistochemical technique to assess the phenotypic and activation characteristics of the T cell infiltrate. The mast cell count did not differ significantly between unchallenged skin from DPU patients and normal controls. Following a pressure challenge to the DPU patients, the number of stainable mast cells decreased significantly to a level comparable with that in spontaneous weals of chronic idiopathic urticaria. Investigation of T cell subsets showed a preponderance of CD4+ cells over CD8+ cells.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of topical corticosteroids on delayed pressure urticaria

Six patients with delayed pressure urticaria (DPU) applied clobetasol propionate (0.05%) ointment or its base to predetermined test sites on the right and left thigh as part of a randomized, double-blind study. A pressure challenge was administered to each test site at the initial visit and repeated after 3 days and 6 weeks of treatment and at between 4 and 8 weeks after treatment. The areas of pressure-induced weals were measured 6 h after each challenge. At the 6-week visit, a 4-mm punch biopsy was taken from pressure-challenged skin on each test site. Sections were stained for mast cells and immunohistochemical labelling was used to demonstrate neutrophils (neutrophil elastase), eosinophils (eosinophil cationic protein), monocytes/macrophages (EBM 11), cells expressing the beta-2 integrins (CD11/18) and the vascular adhesion molecules, E selectin and intercellular adhesion molecule-1 (ICAM-1). In the steroid-treated sites, there was a significant decrease (P < 0.05, Wilcoxon's matched-pairs test) in the size of the pressure weals compared with baseline at 3 days, 6 weeks and at follow-up. Demonstrable mast cells were significantly decreased (P = 0.059) in the pressure-challenged areas in the steroid-treated sites compared with the base-treated sites. The histological response to pressure was minimal in both sites perhaps demonstrating an active pharmacological effect of the ointment base. In conclusion, the application of potent topical steroids significantly reduced the clinical response to pressure in patients with DPU, possibly through a reduction in mast cells.

Adhesion molecule expression and the inflammatory cell infiltrate in delayed pressure urticaria

We have investigated the kinetics of the leucocyte infiltrate in delayed pressure urticaria (DPU) in relation to the in vivo expression of the cytokine-regulated cell surface adhesion molecules, E-selectin (endothelial adhesion molecule-1, ELAM-1), intercellular adhesion molecule-1 (ICAM-1), and vascular adhesion molecule-1 (VCAM-1). Immunohistochemical analysis was performed on biopsies taken from unchallenged skin, and at 0, 2, 6, 24, 48 and 120 h after weighted rods had been applied to 13 patients with DPU. There was moderate to marked upregulation of E-selectin at 6 and 24 h after application of pressure. At 24 h, more patients showed expression of VCAM-1 on perivascular cells than before pressure. Moderate expression of ICAM-1 was present in some biopsies from both unchallenged and pressure-challenged skin, but there was no clear trend. In DPU, there was a significant increase in the neutrophil count at 2 h after a pressure challenge, with further increases at 6 and 24 h. The median cell counts per high-power field of eosinophils and monocyte/macrophages increased significantly at 24 h after pressure. Biopsies from four normal controls subjected to an identical pressure challenge showed no detectable changes in adhesion molecule expression or in the cell infiltrate. The findings in four patients with chronic idiopathic urticaria not associated with DPU were qualitatively similar to (but intermediate in severity between) the findings in DPU weals at 6 and 24 h. These results suggest that vascular endothelial activation is an early response to pressure challenge in DPU, and is also present in chronic idiopathic urticaria.(ABSTRACT TRUNCATED AT 250 WORDS)