EAACI/GA2LEN/EDF guideline: management of urticaria

Chronic spontaneous urticaria guidelines: What is new?

Urticaria is a heterogeneous inflammatory disorder that can be acute or chronic and is defined by the appearance of wheals, angioedema, or both. Very recently, the newest update and revision of the international European Academy of Allergy and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum/Asia Pacific Association of Allergy Asthma Clinical Immunology guideline for the definition, classification, diagnosis, and management of urticaria was published. It aims to help primary care physicians and specialists in the management of their patients with urticaria. The guideline applied the Grading of Recommendations Assessment Development and Evaluations approach to developing consensus recommendations. These recommendations were then discussed in a Delphi conference that included more than 250 specialists in the field, and they are endorsed by more than 50 international societies. Here, we highlight changes from previous versions of the international urticaria guideline and their impact on clinical practice.

A Comparative, Three-Arm, Randomized Clinical Trial to Evaluate the Effectiveness and Tolerability of Bilastine vs Fexofenadine vs Levocetirizine at the Standard Dose and Bilastine vs Fexofenadine at Higher Than the Standard Dose (Up-Dosing) vs Levocetirizine and Hydroxyzine (in Combination) in Patients with Chronic Spontaneous Urticaria

Introduction

Though second-generation antihistamines (SGAH) are first-line drugs in chronic spontaneous urticaria (CSU), 50% of patients do not respond to them. In such patients, guidelines recommend either up-dosing of SGAH or combination of different antihistamines. However, the studies comparing these treatment regimens are limited.

Methods

In this comparative, three-arm study, CSU patients were randomized to receive standard dose of either bilastine, fexofenadine, or levocetirizine for 2 weeks. After 2 weeks of treatment, non-responders received double dose of either bilastine or fexofenadine, while hydroxyzine 25 mg once daily was added in the levocetirizine group. Patients were primarily evaluated for improvement in CSU, quality of life, and somnolence.

Results

A total of 110 patients with CSU were recruited. At the end of 4 weeks, 33/39, 26/35, and 22/36 patients in the bilastine, fexofenadine, and levocetirizine groups showed improvement in urticaria symptoms. At week 2, there was no statistical difference in urticaria activity score (UAS7) improvement between any of the groups; however, at week 4, there was a statistical difference between the bilastine and levocetirizine groups (p<0.05). Somnolence was significantly lower in the bilastine group (p<0.05). Bilastine was statistically significant (p<0.05) in the improvement of quality of life as compared to both groups. No major adverse events were reported during study period; however, bilastine was associated with significantly lower levels of AEs compared to levocetirizine (p<0.05).

Conclusion

Two-fold up-dosing of bilastine improves CSU symptoms without compromising safety as compared to two-fold up-dosing of fexofenadine and combination of first- and second-generation antihistamines.

Chronic urticaria in children - New insights from a large cohort

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS AND CLINICAL RELEVANCE

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

Chronic urticaria treatment patterns and changes in quality of life: AWARE study 2-year results

Background

A Worldwide Antihistamine-Refractory Chronic Urticaria (CU) patient Evaluation (AWARE) is a non-interventional, multicenter study including patients from Europe, Central and Latin America, Asia-Pacific, and the Middle East. AWARE describes real-world evidence for CU, including clinical characteristics, treatment patterns and the impact on quality of life.

Methods

Over the 2-year study, therapy changes, angioedema occurrence, and patient-reported outcomes (PROs) were recorded over 9 visits, including dermatology life quality index (DLQI) and 7-day urticaria activity score (UAS7). Data were stratified into subgroups: chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU), or CSU + CIndU.

Results

Out of 4838 patients analyzed, 9.9% were receiving no treatment for their CU symptoms at baseline, and 20.4% were receiving first-line non-sedating H₁-antihistamine at approved doses. The predominant baseline therapy was up-dosed non-sedating H₁-antihistamines (25.5%). By Visit 2, omalizumab was the overall most commonly used therapy (29.6%), increasing to 30.1% by the end of the study. Baseline DLQI scores for patients with CSU, CIndU and CSU + CIndU were 8.3, 7.6 and 9.1, respectively; scores decreased over the study for CSU and CSU + CIndU patients, but fluctuated for CIndU patients. Baseline angioedema occurrence was higher in CSU and CSU + CIndU patients, reported in 45.4% and 45.5% of patients, respectively, compared to 17.0% in CIndU patients. By the final visit, angioedema had decreased to 11.9% and 11.2% for CSU and CSU + CIndU, respectively, and 9.6% for CIndU.

Conclusion

CU patients are undertreated at baseline; after entering the AWARE study, more patients received appropriate treatment. However, over two thirds are not escalated to third-line treatments.

How guideline can shape clinical practice globally: the diagnosis and rationale for action against cow's milk allergy experience

PURPOSE OF REVIEW

Allergic diseases are increasing worldwide and are considered an important public health problem causing severe and even life-threatening reactions. The creation of guidelines aims to help clinicians improving the quality of diagnosis and management of such diseases. Clinical practice guidelines alone are not sufficient and there is a need for implementation strategies for their introduction into daily practice. We report here the main international allergy guidelines with a more focused look on the Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines and their effect on clinical practice.

RECENT FINDINGS

DRACMA guidelines have clearly modified the approach to cow's milk allergy (CMA) from its diagnosis to treatment tailoring the choices for each patient. Although they strongly recommend oral food challenge for diagnosing CMA, they also indicate that it may not be necessary in many cases with the introduction of the pretest probability of CMA. Studies on the implementation of DRACMA guidelines show how they influenced the formula market, making appropriate treatments more affordable.

SUMMARY

DRACMA reconciled international differences in the diagnosis and management of CMA. They introduced the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology in the field of food allergy and highlighted the importance for meta-analyses to be able to adapt recommendations to the local context.

A retrospective analysis omalizumab treatment patterns in patients with chronic spontaneous urticaria: a real-world study in Belgium

Background

Chronic spontaneous urticaria (CSU) is characterized by the repeated occurrence of persistent hives and/or angioedema for ≥6 weeks, without specific external stimuli. H₁‐antihistamines have long been the standard of care of CSU, but many patients remain uncontrolled even at 4× the approved dose. Add‐on therapy with omalizumab has proven effective in clinical trials, but little is known about omalizumab treatment in Belgium.

Objective

To collect real‐world clinical data on omalizumab treatment in adults with CSU in Belgium.

Methods

This was an observational, retrospective chart review of adults with CSU, who initiated omalizumab treatment between August 2014 and December 2016 (maximum 28 months follow‐up).

Results

In total, 235 patients were included (median time from symptom onset to diagnosis, 5.4 months; median time from diagnosis to commencing omalizumab, 6.7 months). Treatments used before/after commencing omalizumab did not always adhere to guidelines; many patients (26.4%/11.1%) received first‐generation H₁‐antihistamines, while 20.4% used omalizumab monotherapy after initiating treatment. The mean interval between omalizumab administrations was 4.8 (SD 1.7) weeks; 67.8% of patients had ≥1 interval prolongation and/or shortening. Mean baseline 7‐day Urticaria Activity Score (UAS7) was 32.0 (SD 6.05); this improved to 12.6 (SD 11.2) after 1 month of omalizumab. About 67.2% of patients reached UAS7 ≤ 6 (well controlled) during the study. A total of 87 patients stopped omalizumab and never restarted before the end of the observation period; the most prevalent reason was remission of symptoms (49.4% of patients), followed by lack of effect (12.6%), lost to follow‐up (6.9%) and adverse events (3.4%). Headache was the most common adverse event (n = 8/82). No anaphylaxis was reported.

Conclusions

This study revealed that patients initiated on omalizumab in Belgium had severe CSU at baseline, and showed substantial improvements after 1 month of treatment. Greater adherence to the prescription of guideline‐recommended medications is needed for the treatment of CSU.

The Efficacy of a Two-Fold Increase of H1-Antihistamine in the Treatment of Chronic Urticaria - the Vietnamese Experience

BACKGROUND

Chronic urticaria, a mast cell-driven condition, is common, debilitating and hard to treat. H1-antihistamines are the first line treatment of chronic urticaria, but often patients do not get satisfactory relief with the recommended dose. European guidelines recommend increased antihistamine doses up to four-fold.

AIM

We conducted this study to evaluate the efficacy of increased H1-antihistamine doses up to two-fold in Vietnamese chronic urticaria patients.

METHODS

One hundred and two patients with chronic urticaria were recruited for treatment with levocetirizine (n = 52) or fexofenadine (n = 50). Treatment started at the conventional daily dose of 5 mg levocetirizine or 180 mg fexofenadine for 2 weeks and then increased to 10 mg levocetirizine or 360 mg fexofenadine for 2 weeks if patients did not have an improvement in symptoms. At week 0, week 2 and week 4 wheal, pruritus, size of the wheal, total symptom scores, and associated side-effects were assessed.

RESULTS

With the conventional dose, the total symptom scores after week 2 decreased significantly in both groups compared to baseline figures, i.e. 7.4 vs 2.3 for levocetirizine group and 8.0 vs 2.6 for fexofenadine group (p < 0.05). However, there were still 26 patients in each group who did not have improvements. Of these 26 patients, after having a two-fold increase of the conventional dose, 11.5% and 38.5% became symptom-free at week 4 in levocetirizine group and fexofenadine group, respectively. At week 4 in both groups, the total symptom scores had significantly decreased when compared with those at week 2 (2.8 ± 1.5 versus 4.7 ± 1.6 in levocetirizine group; 2.1 ± 1.9 versus 5.1 ± 1.4 in fexofenadine group). In both groups, there was no difference in the rate of negative side effects between the conventional dose and the double dose.

CONCLUSION

This study showed that increasing the dosages of levocetirizine and fexofenadine by two-fold improved chronic urticaria symptoms without increasing the rate of negative side effects.

Antihistamine-resistant chronic spontaneous urticaria: 1-year data from the AWARE study

BACKGROUND

Previous reports indicate that patients with chronic spontaneous urticaria (CSU) are undertreated and that physicians show poor adherence to guideline recommendations. Awareness of CSU has improved in recent years, but it remains unclear if this has improved the management of these patients in clinical practice.

OBJECTIVE

To describe disease burden, quality of life (QoL), and treatment patterns of patients with H₁ -antihistamine-refractory CSU in Germany.

METHOD

A World-wide Antihistamine-Refractory chronic urticaria (CU) patient Evaluation (AWARE) is a global prospective, non-interventional study of CU in the real-world setting, supported by the manufacturer of omalizumab. Patients (18-75 years) were included who had H₁ -antihistamine-refractory CSU for ≥2 months. Disease characteristics, pharmacological treatments, and QoL (dermatology life quality index [DLQI], CU-QoL questionnaire, and angioedema QoL questionnaire) are reported for patients enrolled in Germany.

RESULTS

After 1 year in AWARE, CSU remained uncontrolled (urticaria control test [UCT] score <12) in 432 of 1032 (42.2%) patients. QoL impairment remained high after 1 year, with 28.2% of patients reporting that CSU had a moderate/very large/extremely large effect on the DLQI. Most patients did not receive guideline-recommended treatments at the end of the 1-year observation period. Changes in treatments were most evident at the first patient visit, with an increase in patients receiving omalizumab vs prior therapy from 8.5% to 21.4%, and a decrease in those receiving no treatment from 29.9% to 12.8%. These changes were associated with reduced hives, angioedema, UCT scores, and QoL scores at Month 3, but only modest improvements thereafter. Of 528 patients with uncontrolled CSU and who were eligible for treatment escalation, only 3% received up-dosing of H₁ -antihistamines and only 5% were initiated on omalizumab during 1 year of treatment.

CONCLUSIONS & CLINICAL RELEVANCE

This study highlights a significant discrepancy between recommendations for managing CSU in international guidelines, and in real-world clinical practice in Germany.

A Comparison of the United States and International Perspective on Chronic Urticaria Guidelines

Urticaria is a heterogeneous skin disorder that may be acute or chronic and is defined by the appearance of wheals, angioedema, or both. The European perspective is expressed in a recent international guideline and the American perspective has been based on the US Joint Task Force chronic urticaria practice parameter published in 2014. Both the international guideline (initiated by the European societies European Academy of Allergology and Clinical Immunology [EAACI]/Global Allergy and Asthma European Network [GA²LEN]/European Dermatology Forum [EDF] in collaboration with the World Allergy Organization [WAO]) and the US (American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology) guideline have been developed to help direct primary care physicians and specialists in the management of their patients with urticaria. The EAACI/GA²LEN/EDF/WAO guideline applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to developing consensus recommendations and these were then discussed in a Delphi conference including more than 250 specialists in the field and have been endorsed by more than 40 international societies. In contrast, the US Joint Task Force CU practice parameter made recommendations based on scientific evidence whenever possible; however, when there was insufficient evidence, recommendations were based on expert consensus opinion. Although both agree on most points regarding the definition, general evaluation, and treatment, there are some differences that exist between the 2 guidelines. Most of these differences pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these 2 groups, highlighting the key similarities and differences.

The clinical pharmacology of non-sedating antihistamines

We previously reported on brain H₁ receptor occupancy measurements of antihistamines in human brain using [¹¹C]doxepin and positron emission tomography (PET). We proposed the use of brain H₁ receptor occupancy to classify antihistamines objectively into three categories of sedating, less-sedating, and non-sedating antihistamines according to their sedative effects. Non-sedating antihistamines are recommended for the treatment of allergies such as pollinosis and atopic dermatitis because of their low penetration into the central nervous system. Physicians and pharmacists are responsible for fully educating patients about the risks of sedating antihistamines from pharmacological points of view. If a sedating antihistamine must be prescribed, its sedative effects should be thoroughly considered before choosing the drug. Non-sedating antihistamines should be preferentially used whenever possible as most antihistamines are equally efficacious, while adverse effects of sedating antihistamines can be serious. This review summarizes the pharmacological properties of clinically useful non-sedating antihistamines from the perspective of histamine function in the CNS.

Chronic urticaria in adults: state-of-the-art in the new millennium

Chronic urticaria has been explored in several investigative aspects in the new millennium, either as to its pathogenesis, its stand as an autoimmune or auto-reactive disease, the correlation with HLA-linked genetic factors, especially with class II or its interrelation with the coagulation and fibrinolysis systems. New second-generation antihistamines, which act as good symptomatic drugs, emerged and were commercialized over the last decade. Old and new drugs that may interfere with the pathophysiology of the disease, such as cyclosporine and omalizumab have been developed and used as treatments. The purpose of this article is to describe the current state of knowledge on aspects of chronic urticaria such as, pathophysiology, diagnosis and the current therapeutic approach proposed in the literature.

Methods report on the development of the 2013 revision and update of the EAACI/GA2 LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria

This methods report describes the process of guideline development in detail. It 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. 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) and is published in Allergy 2014; 69:868-887.

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).

Treatment of refractory chronic urticaria: current and future therapeutic options

Chronic urticaria is a distressing disease that affects up to 1 % of the general population at a time point in life and may severely worsen the quality of life. First-line treatment has been based on antihistamines, and presently relies on the use of non-sedating, second-generation antihistamines; following the recommendations of the recent international guidelines, in patients who do not respond to antihistamines at licensed doses, the daily dosage of these drugs can be increased up to fourfold. Nonetheless, a significant proportion of patients with chronic urticaria remain poorly controlled; in these cases, alternative therapeutic approaches have to be considered. This article critically reviews all of the third- and fourth-line treatment options suggested for patients whose disease is refractory to antihistamines, including systemic corticosteroids, leukotriene receptor antagonists, several different anti-inflammatory drugs (dapsone, sulfasalazine, hydroxychloroquine), various immunosuppressive drugs (calcineurin inhibitors, methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil), intravenous immunoglobulin, and newer treatment options, such as omalizumab and other biologic drugs. In addition, the article examines possible future treatment options based on recent findings about pathogenic mechanisms, and considers the treatment of antihistamine-unresponsive urticaria in special conditions such as children and pregnancy/lactation. The evidence supporting the use of several of the discussed drugs is presently limited and thus insufficient to recommend their routine use; as a consequence, such compounds should be considered only in specific cases and in adequate settings.

The evaluation of prevalence of fibromyalgia in patients with chronic urticaria

Background

The pathophysiology of chronic idiopathic urticaria (CIU) is not fully understood; however, it has been hypothesized that a subset of people with CIU may have an autoimmune disease and that peripheral cutaneous nerve fibers may be involved in CIU. Similarly, it has been postulated that fibromyalgia syndrome (FMS) is an autoimmune disorder and may be associated with alterations of peripheral cutaneous nerve fibers. Accordingly, the present study aimed to determine whether the frequency of FMS is higher in patients with CIU.

Material/Methods

A total of 72 patients with CIU and 67 sex- and age-matched healthy controls were included. Urticaria activity score (UAS), fibromyalgia impact questionnaire (FIQ), tender point number, and visual analogue scale (VAS) were assessed.

Results

The frequency of FMS was similar between the groups (9.7% vs. 4.5%, p=0.32). However, symptom duration of FMS was significantly longer, and tender point number and FIQ were significantly higher in patients with CIU than in controls. In addition, patients with CIU had significantly higher VAS scores. UAS was significantly correlated with presence of FMS, symptom duration of FMS, tender point number, and FIQ and VAS scores. Logistic regression analysis revealed that UAS was an independent predictor of presence of FMS (β=0.34, p=0.003).

Conclusions

Frequency of FMS was slightly, but not significantly, higher in patients with CIU than in controls. However, symptom duration of FMS, tender point number, and FIQ and VAS scores were significantly higher in patients with CIU, and UAS reflecting severity of the disease was significantly and independently associated with presence of FMS.

Bilastine: a new nonsedating oral H1 antihistamine for treatment of allergic rhinoconjunctivitis and urticaria

Bilastine is a new, well-tolerated, nonsedating H1 receptor antihistamine. In the fasting state bilastine is quickly absorbed, but the absorption is slowed when it is taken with food or fruit juice. Therefore, it is recommended that bilastine is taken at least one hour before and no sooner than two hours after a meal. Clinical studies sponsored by the manufacturer have shown that bilastine 20 mg once daily is as efficacious as other nonsedating antihistamines in allergic rhinoconjunctivitis and chronic urticaria in individuals from 12 and 18 years of age, respectively. Bilastine is efficacious in all nasal symptoms including obstruction and in eye symptoms. The observations indicate that non-sedating antihistamines, as opposed to what has been thought previously, may be helpful in patients with allergic rhinitis in whom nasal obstruction is a major concern. Current international guidelines need to be revised in the light of the recent evidence. Research into aspects of pharmacokinetics and efficacy and adverse effect profiles of bilastine in children under 12 years of age is needed as are dose-response assessments and studies planned rigorously with the aim of assessing quality of life effects.

Effects of the polysaccharide nucleic acid fraction of bacillus Calmette-Guérin on the production of interleukin-2 and interleukin-10 in the peripheral blood lymphocytes of patients with chronic idiopathic urticaria

Urticaria is one of the most frequent dermatoses and its prevalence in the general population is estimated to be ~20%, whereas a substantial percentage of the cases may be classified as chronic idiopathic urticaria (CIU). The inflammatory response presenting with spontaneous wheals exhibits pro-inflammatory characteristics, involving a prominent role for lymphocytes with a mixed Th1/Th2 response in which interleukin (IL)-2 and IL-10 are prominently secreted by Th1 and Th2 cells, respectively. In CIU patients, it was demonstrated that IL-10 production was elevated and IL-2 reduced compared to controls. Therefore, inhibition of IL-10 and promotion of IL-2 production by the lymphocytes, indicating Th2 inhibition and Th1 promotion, may facilitate the treatment of CIU. Whether the polysaccharide nucleic acid fraction of bacillus Calmette-Guérin (BCG-PSN), which possesses multiple immunomodulatory properties, has that potential, remains to be elucidated. In this study, BCG-PSN was used on lymphocytes isolated from CIU patients, with healthy donors used as controls. Immunocytochemistry and ELISA were used to detect IL-2 and IL-10 production. It was demonstrated that the IL-2 production by the lymphocytes in the CIU group was significantly lower compared to that in the healthy control group and it increased sequentially with the increase of the concentration of BCG-PSN used. By contrast, the IL-10 production by the lymphocytes in the CIU group was significantly higher compared to that in the healthy control group and decreased sequentially with the increase of the concentration of BCG-PSN used. Thus, it may be concluded that the BCG-PSN has the potential to promote IL-2 and inhibit IL-10 production in the lymphocytes of CIU patients, facilitating the treatment of CIU.

Comparative study of systemic psoralen and ultraviolet A and narrowband ultraviolet B in treatment of chronic urticaria

BACKGROUND

Previous success rates of psoralen and ultraviolet A (PUVA) and narrowband UVB (NB-UVB) in the treatment of chronic urticaria are reported in few studies with no previous reports on the comparable efficacy of both modalities in the disease.

AIM

We aimed to compare the efficacy of PUVA versus NB-UVB in the treatment of chronic urticaria.

METHODS

Twenty-four patients with chronic urticaria were included and divided into two groups: 12 patients subjected to PUVA and 12 subjected to NB-UVB. They were compared according to the urticaria Total Severity Score (TSS) before and after treatment, cumulative dose, and side effects.

RESULTS

There was a statistically significant decrease in urticaria TSS in both the NB-UVB- and PUVA-treated groups after than before treatment (P < 0.05), with no significant difference between both groups regarding the percentage of improved patients and the mean decrease of urticaria TSS (P > 0.05). Gastrointestinal upset was reported at a significantly higher percentage in the PUVA-treated group than in the NB-UVB-treated group.

CONCLUSION

Both NB-UVB and PUVA show comparable efficacy in the treatment of chronic urticaria with minimal reversible side effects.

Japanese guidelines for diagnosis and treatment of urticaria in comparison with other countries

Several guidelines for urticaria and angioedema have been published in Europe and United States since 1997. General principles for diagnosis and treatments of them are similar. However, each guideline has its own characteristics and shows differences in areas such as the coverage of urticaria subtypes, nomenclatures, and hierarchy of the medications. In Japan, the Japanese Dermatological Association (JDA) published its first guideline for urticaria and angioedema in 2005. It established a new classification of urticaria and angioedema together with the definition of each subtype. It emphasized the importance of discriminating idiopathic urticaria, consisting of acute urticaria and chronic urticaria from inducible urticaria, such as allergic urticaria, physical urticaria and cholinergic urticaria. It contains several unique algorithms for diagnosis and treatment of urticaria from a view point of clinical practices, and was further enforced by a style of EBM in 2011. Nevertheless, these guidelines have not been recognized outside of Japan, because of a language barrier. In this article, the outline of the newest guidelines by JDA are introduced and compared with the guidelines in other countries published in English.

Narrowband ultraviolet B (311 nm, TL01) phototherapy in chronic ordinary urticaria

BACKGROUND

Chronic ordinary urticaria (COU) can severely reduce quality of life and be difficult to control. Ultraviolet (UV) A and UVB phototherapy has been reported to decrease the release of histamine from either mast cells and/or basophils. Previous small studies have suggested that UVB phototherapy is a good alternative treatment for COU.

OBJECTIVES

The purpose of this study was to assess the efficacy of narrow-band UVB (NB-UVB) phototherapy for COU.

MATERIALS AND METHODS

Twenty-two patients (three male, 19 female) received NB-UVB phototherapy. These patients had not responded to at least two H1 antihistamines, and most had been treated with a variety of antihistamine combinations. Clinical responses were assessed according to an outcome scoring scale. During both visits, patients were administered the following: the visual analogue scale (VAS) on present pruritus and/or whealing; chronic urticaria impact on patients' quality of life according to the interference with daily activities, quality of sleep, and flare-up rates.

RESULTS

The median number of treatments was 31.4 (9-44), and the mean top dose was 9.46 J/cm(2) (1.1-16.4 J/cm(2)). NB-UVB treatment led to clearance in 10 patients (45%), marked improvement in five (22%), and moderate improvement in seven (31%) patients according to an outcome scoring scale. Mild side effects were observed in two patients. Six patients who cleared or observed marked improvement remained clear at follow-up for a period of six months to one year, and other patients had a few recurrent lesions that did not need retreatment. For VAS scores and total chronic urticaria impact on patients' quality of life scores, the differences between baseline and after treatment scores were significantly lower (P < 0.001, P < 0.001, respectively).

CONCLUSION

Narrow-band UVB (NB-UVB) therapy is an effective, well-tolerated treatment option in second-line therapy for COU. This therapy can lead to subjective relief of pruritus and whealing and objective reduction of whealing. Further larger studies with longer follow-up periods are necessary to determine the proper clinical response and long-term complications of this therapy in COU.

Effects of omalizumab treatment in patients with refractory chronic urticaria

Purpose

Chronic urticaria (CU) is a common and debilitating disease, and the need for effective treatment has increased. Omalizumab may be an alternative regimen in patients with CU who do not respond to conventional treatments. The aim of this study is to investigate the efficacy and to observe the clinical results of omlizumab in patients with refractory CU.

Methods

We conducted a retrospective analysis of 26 patients with refractory CU who were treated with omalizumab. Omalizumab was administered every 2 or 4 weeks, depending on body weight and the total serum IgE level, for 24 weeks.

Results

Fourteen patients (53.8%) achieved remission after the treatment; they had a significantly higher prevalence of personal (P=0.033) and family history of allergic diseases (P=0.002) than those who did not achieve remission. During omalizumab treatment, the urticaria activity score declined significantly (12.11±1.97 to 2.7±4.23; P=0.001) and the CU-quality of life score improved significantly (34.65±13.58 to 60.88±11.11; P=0.004). There were significant decreases in the use of systemic steroids (42.3%-11.5%; P=0.027) and immunomodulators (65.4%-19.2%; P=0.002). The dose of antihistamines required to control CU also decreased significantly (215.66±70.06 to 60.85±70.53 mg/week of loratadine equivalents; P<0.001). No serious adverse event was noted.

Conclusions

These findings suggest that omalizumab can be an effective and safe treatment in patients with refractory CU.

Establishing the place in therapy of bilastine in the treatment of allergic rhinitis according to ARIA: evidence review

BACKGROUND

The ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines development group examined the properties of oral H(1)-antihistamines and made proposals about an 'optimal' drug. Several criteria should be met by oral H(1)-antihistamines in terms of their pharmacological, and clinical efficacy and safety profiles.

OBJECTIVE

Bilastine, a new H(1)-antihistamine, has been approved in 28 European countries for the symptomatic treatment of allergic rhinoconjunctivitis and urticaria in adults and children older than 12 years. To determine its potential place in therapy in the treatment of allergic rhinitis, this manuscript examines whether bilastine meets the criteria defined in the European Academy of Allergy and Clinical Immunology (EAACI)/ARIA proposals for oral H(1)-antihistamines.

METHODS

The optimal properties of oral H(1)-antihistamines and current ARIA recommendations for their use in allergic rhinitis are presented, as well as relevant pharmacological and clinical data for bilastine obtained from the published literature that specifically address the defined criteria.

RESULTS

Bilastine is a potent inhibitor of the histamine H(1) receptor. Data from preclinical studies have confirmed its selectivity for the histamine H(1) receptor over other receptors, and demonstrated antihistaminic properties in vitro and in vivo. Bilastine does not interfere with the cytochrome P450 system and is devoid of cardiac side effects. Studies in healthy volunteers and patients have shown that bilastine does not affect driving ability, cardiac conduction or alertness. In large pivotal randomized, placebo-controlled trials (RCTs), bilastine had a favourable safety profile. Bilastine 20 mg once daily improved all nasal and ocular symptoms of allergic rhinitis with greater efficacy than placebo and comparable to that of cetirizine and desloratadine. Moreover, bilastine was shown to improve quality of life, an important outcome of RCTs in allergic diseases. There were no significant changes in laboratory tests, electrocardiograms or vital signs. A potential limitation of this assessment of bilastine is that it is a literature-based review and the findings are dependent upon the quality of the published evidence.

CONCLUSIONS

Bilastine meets current EAACI/ARIA criteria for medications used in the treatment of allergic rhinitis.

Management of chronic spontaneous urticaria in real life--in accordance with the guidelines? A cross-sectional physician-based survey study

BACKGROUND

Recently, the updated EAACI/GA(2) LEN/EDF/WAO guidelines for urticaria have been published.

OBJECTIVE

To examine how chronic spontaneous urticaria (csU) patients in Germany are diagnosed and treated, and to compare the outcome to the guideline recommendations.

METHODS

During this cross-sectional survey study, most dermatologists, paediatricians and 5149 general practitioners in private practice in Germany were asked to participate. All physicians who agreed were requested to complete a standardized questionnaire about their diagnostic and therapeutic management of csU.

RESULTS

A total of 776 questionnaires were available for analysis. Most physicians (82%) were attempting to identify underlying causes in their csU patients, but with only limited success. More than 70% reported to check for total serum IgE and to do skin prick testing (not suggested in first line by guideline). In contrast, only 10% applied the autologous serum skin test. The most common first-line treatments were non-sedating antihistamines in standard or higher doses (as recommended). However, many physicians reported still using first generation sedating antihistamines (23%) (not recommended) or systemic steroids (18%). Experience with alternative options was low. Less than one-third of the participants reported to be familiar with the guidelines. Those who did, were found to be more likely to check for underlying causes, to be more experienced with antihistamine updosing and to be more reluctant to use sedating antihistamines or systemic steroids.

CONCLUSION

The diagnostic and therapeutic management of csU by private practice physicians does not sufficiently comply with the guidelines. Awareness of the guidelines can lead to improved care.

Chronic urticaria

Chronic urticaria (CU) is a disturbing allergic condition of the skin. Although frequently benign, it may sometimes be a red flag sign of a serious internal disease. A multitude of etiologies have been implicated in the causation of CU, including physical, infective, vasculitic, psychological and idiopathic. An autoimmune basis of most of the 'idiopathic' forms is now hypothesized. Histamine released from mast cells is the major effector in pathogenesis and it is clinically characterized by wheals that have a tendency to recur. Laboratory investigations aimed at a specific etiology are not always conclusive, though may be suggestive of an underlying condition. A clinical search for associated systemic disease is strongly advocated under appropriate circumstances. The mainstay of treatment remains H1 antihistaminics. These may be combined with complementary pharmacopeia in the form of H2 blockers, doxepin, nifedipine and leukotriene inhibitors. More radical therapy in the form of immunoglobulins, plasmapheresis and cyclophosphamide may be required for recalcitrant cases. Autologous transfusion and alternative remedies like acupuncture have prospects for future. A stepwise management results in favorable outcomes. An update on CU based on our experience with patients at a tertiary care centre is presented.

Pruritus: management algorithms and experimental therapies

Pruritus (itch) is a major symptom in many dermatologic as well as systemic diseases and has a dramatic impact on the quality of life in these patients. The symptom of itch has to be treated on the basis of its pathophysiology and its underlying disease. In daily practice, a "quick" diagnosis of the underlying disease is often difficult, although a rapid relief of the itch is desired. We often treat patients on the basis of the symptomatology. A rational therapeutic ladder for a symptomatic therapy is useful until the final diagnosis has been confirmed. There are probably many subtypes of pruritus, just as there are many diseases that cause itch. The pathophysiology in many subtypes of pruritus is still poorly understood, hindering a rapid and targeted treatment strategy. An extensive diagnostic workup is often required to determine the final cause(s) of the itch. Thus, in daily life, physicians often start with a more or less rational therapeutic strategy to combat the debilitating itch. We present possible therapeutic ladders that form the basis for effective therapeutic itch strategies in various diseases. On the basis of our current knowledge about the different pathophysiologies of itch, on clinical trials or case reports, and our own clinical experience, we aim to present therapeutic ladders for the rapid as well as long-term management of itch. Finally, we summarize current exciting developments of experimental strategies in itch research and in clinical development for itch therapy.

Identification of core competencies for primary care of allergy patients using a modified Delphi technique

BACKGROUND

The majority of allergy patients who seek medical advice are seen in primary care. In-service training of professionals in general practice is needed in order to increase knowledge among primary care clinicians about allergy. Therefore it is important to establish a consensus about what primary care professionals should be able to do, and what the public can expect. We sought to identify core competencies for good practice amongst primary care providers with respect to diagnosis and therapy of allergic diseases and to outline learning objectives for a postgraduate training programme in this field.

METHODS

The study involved three rounds, involving a total of 43 expert panelists. In the first round, a panel was asked to indicate competencies (knowledge, diagnostics, therapy and communication) necessary for primary care providers. The second and third rounds were answered by primary care physicians (26) and nurses (10). A Likert scale 1-4 was applied in the second round and two choices ("agree"/"disagree") in the third round, with a criterion of 75% being adopted.

RESULTS

The second round included 80 competencies and the third 50. The third round selected a consensus of 46 competencies defining nine learning outcomes for in-service medical training.

CONCLUSIONS

The competencies in the field of allergy recommended in this study may serve as a reference of what can be expected from primary care providers.

Aquatic sports dermatoses: part 1. In the water: freshwater dermatoses

The first of this three-part series on water-related dermatoses involving the athlete will include sports occurring with the majority of time spent in the water. These sports include swimming, diving, scuba, snorkeling and water polo. Numerous authors have described dermatologic conditions commonly seen in swimmers. This series provides an updated and comprehensive review of these water dermatoses. In order to organize the vast number of skin conditions related to water exposure, we divided the skin conditions into groupings of infectious and organism-related dermatoses, irritant and allergic dermatoses and miscellaneous dermatoses. The vast majority of skin conditions involving the water athlete result from chemicals and microbes inhabiting each environment. When considering the effects of swimming on one's skin, it is also useful to differentiate between exposure to freshwater (lakes, ponds and swimming pools) and exposure to saltwater. This review will serve as a guide for dermatologists, sports medicine physicians and other medical practitioners in recognition and treatment of these conditions.

Prevalence of allergic diseases in a sample of Taif citizens assessed by an original Arabic questionnaire (phase I) A pioneer study in Saudi Arabia

BACKGROUND

In recent decades, the prevalence of allergic diseases has markedly increased worldwide; however, there are still many cases which remain undiagnosed. Epidemiological studies have the potential to elucidate the prevalence and risk factors for these diseases.

OBJECTIVES

This study aimed at evaluating the capability of a new original non-translated questionnaire in Arabic language to determine the prevalence and severity of these diseases in a sample from Taif citizens. Thus, it could provide a framework as an initial step towards accomplishing the first national questionnaire-based survey study determining the actual prevalence of various allergic diseases in Saudi Arabia.

METHODS

A detailed seven-section questionnaire including 143 closed questions covering almost all of the usual and unusual symptoms of various allergic diseases, in Arabic language, was handed out to 1050 subjects, from whom 877 (83.52%) questionnaires were completed; however, 23 questionnaires were discarded as they were not accurately filled in. Thus, 854 (81.33%) were enrolled in this study.

RESULTS

Urticaria, allergic rhinitis with or without other co-morbidities, and atopic dermatitis were the most prevalent allergic morbidities, however, other allergic diseases could be diagnosed by the aid of the questionnaire. Likelihood ratio-evidenced agreement between diagnosis reached by the questionnaire and that reached by doctor occurred in 50 sample cases (p<0.0001).

CONCLUSIONS

The questionnaire proved its capability in aiding the diagnosis of various allergic morbidities. It evidenced a high prevalence of allergic diseases in Taif city. This is an important health issue which requires strategic application of primary health care facilities to achieve adequate control.

Impact of sedative and non-sedative antihistamines on the impaired productivity and quality of life in patients with pruritic skin diseases

BACKGROUND

The impairment that pruritic skin diseases have on patient productivity at work, in the classroom, and in daily activities is substantial and needs to be characterized. The objective of this study was to determine how pruritic skin diseases impact patient productivity and quality of life (QOL), in order to improve the measurement of these endpoints to allow the influence of treatment options including sedative and non-sedative antihistamines to be analyzed.

METHODS

The impact of pruritic skin diseases and the effect of antihistamine therapy on work, classroom, and daily productivity were evaluated using the Work Productivity Assessment Index-Allergy Specific Questionnaire. The intensity of itch and patient QOL were assessed using a visual analogue scale and Skindex-16, respectively.

RESULTS

Pruritic skin diseases resulted in significant impairment of work, classroom, and daily productivity. The severity of overall work impairment in atopic dermatitis (AD), urticaria, and prurigo was higher than for other diseases analyzed. However, classroom activity was more adversely affected in patients with urticaria relative to other diseases. All pruritic diseases in this study negatively impacted daily activity to a similar degree. Impaired productivity was significantly improved in patients taking non-sedative antihistamines for 1 month, and the improvements correlated with the alleviation of itch and improved QOL.

CONCLUSIONS

These results indicate that pruritic skin diseases reduce patient productivity at work, in the classroom, and during daily activities, and that non-sedative antihistamines may offer an advantage over sedative antihistamines for alleviating certain negative consequences of these skin diseases.

Significant factors associated with severity and outcome of an initial episode of acute urticaria in children

The aim of this study was to determine the predictive factors of severity and duration of an initial episode of acute urticaria in children. This was a retrospective study of 1120 children of <18 yr who presented to the emergency department (ED) with an initial episode of acute urticaria during the period January 1, 2001, to December 31, 2007. These patients were followed in the ED or outpatient department (OPD) until their symptoms subsided. Variables comprising mild, moderate, and severe urticaria were compared to determine the predictors of severity. The relationships between duration of urticaria and clinical features, including physician-diagnosed causes and treatment modalities, were also analyzed. Significant predictive factors of severity of an initial episode of acute urticaria in children included age, physician-diagnosed causes of urticaria, clinical presentation, coexistent pyrexia or angioedema, and personal allergic history (all p < 0.001). The duration of urticaria was dependent on the physician-diagnosed causes and treatment. Inhalants and unknown causes were predictive of longer duration, while contact materials were associated with shorter duration of urticaria (p < 0.001). Combination treatment comprising an oral plus injectable form of antihistamine or corticosteroid significantly shortened the duration of urticaria compared to single treatment (p < 0.001), especially in children receiving short-term aggressive treatment in the pediatric observation unit (POU) of the ED.

Histamine, histamine receptors and antihistamines: new concepts

Drugs with antihistamine action are the most commonly prescribed medication in daily dermatologic practice, both to adults and children. This article addresses new concepts of the role of histamine receptors (H1 receptors) and discusses the anti-inflammatory effects of these drugs. Second generation antihistamines differs from first generation because of their high specificity and affinity for peripheral H1-receptors. Second generation antihistamines are also less likely to produce sedation because they have less effect on the central nervous system. Although the efficacy of the various H1-antihistamines in the treatment of allergic patients is similar, even when comparing first- and second-generation drugs, these drugs are still very different in terms of their chemical structure, pharmacology and toxic properties. Consequently, knowledge of their pharmacokinetic and pharmacodynamic characteristics is essential for a better medical care, especially that offered to pregnant women, children, the elderly, and patients with comorbidities.

Guidelines in dermatology--quo vadis?: Facts and controversies

Since their introduction in 1980s, medical guidelines have become a milestone in the modern medical practice and science. Being a key feature of modern evidence-based medicine, guidelines offer the opportunity for unification and standardization of diagnostic procedures, their use guarantees the equal access of patients to medical service, and they represent a scaffold for inexperienced physicians. The implementation of guidelines also can serve as a basis in malpractice issues and can contribute to the formation of national and international health care policies. In past decades, the process of development, update, and practical application of clinical guidelines has been seriously improved; however, certain limitations still exist, namely cost-effectiveness issues, editorial independence, applicability, accessibility, and external validity. This contribution discusses the advantages and the drawbacks in the use and the development of medical guidelines, emphasizing future perspectives and challenges in the development of clinical guidelines.