Chronic urticaria in children under 15 years of age: Clinical experience beyond the clinical trials

Managing Chronic Urticaria in Children: An Update

PURPOSE OF REVIEW

To provide an update and new insights into the management of pediatric patients with chronic urticaria.

RECENT FINDINGS

Chronic urticaria in children may be more prevalent than previously thought, with a high resolution rate within two years. Patient-reported outcome measures (PROMs) are effective tools for assessing disease severity and control in pediatric populations. Children with chronic urticaria generally respond better to H1-antihistamines compared to adults. For patients refractory to antihistamines, omalizumab has shown excellent efficacy. Additionally, dupilumab has emerged as a potential treatment option, as it has been approved for chronic spontaneous urticaria in some countries. Managing chronic urticaria in children remains a diagnostic and therapeutic challenge. However, advancements in understanding disease mechanisms, the validation of tools to assess disease activity and control, the development of reliable biomarkers, and the availability of novel therapies offer significant promise. These developments will enable more effective treatment and improved outcomes for pediatric patients.

Chronic urticaria treatment challenges in children

OBJECTIVE

This paper aims to review the efficacy and safety of current chronic urticaria (CU) treatment in children and the existing patient-reported outcome measures (PROMs) used in this age group.

DATA SOURCE

Since there are few studies of CU in children, the authors performed a non-systematic review of published articles in English, Spanish, and Portuguese in the PubMed database in the last decade. Keywords used were (antihistamines OR omalizumab OR cyclosporine OR treatment) AND (chronic urticaria) AND (children OR adolescents).

DATA SYNTHESIS

According to the current guideline's algorithm, the treatment of CU involves using high doses of antihistamines when there is no response with the licensed dosage. The effectiveness of this increase in children has been demonstrated with control rates ranging from 35% to 92%, with few studies addressing safety profiles. Omalizumab is approved for children over 12 years of age as a second step in the algorithm. Although more studies with children are needed to assess its effectiveness and safety, some data show complete control of symptoms in more than 80% of pediatric cases with no adverse effects, including in children under 12 years. When monitored closely, cyclosporine showed a good response rate in pediatric CU with few adverse events. Also, PROMs validated for this age can be helpful in clinical decisions, such as Urticaria Activity Score summed over 7 days, Urticaria Control Test, and Chronic Urticaria Quality of Life Questionnaire.

CONCLUSIONS

Collaborative studies are necessary to generate stronger evidence to support the guideline recommendations for children. The existing data indicate that these drugs are safe and effective for treatment when dose adjustments are made.

A systematic review and meta-analysis of efficacy and safety of compound glycyrrhizin combined with second-generation non-sedated antihistamine for the treatment of chronic urticaria

BACKGROUND

Chronic urticaria (CU) is a prevalent dermatologic disease that negatively affects life, current therapies remain suboptimal. Hence, there is an urgent need to identify effective and safe treatment.

OBJECTIVE

Assess the efficacy and safety of compound glycyrrhizin (CG) combined with second-generation nonsedated antihistamine for the treatment of CU.

METHODS

Nine databases were queried to screen RCTs related. Two reviewers independently assessed the risk of bias using Cochrane Collaboration. Primary objective was the total efficiency rate, while secondary was rate of recurrence, adverse events, and cure. Statistical analyses using Review Manager 5.4 and Stata17.

RESULTS

Twenty-four RCTs were identified. Significant differences were noted in rate of total efficiency (n = 2649, RR = 1.36, 95%CI:1.30-1.43, p < 0.00001), cure (n = 2649, RR = 1.54, 95%CI:1.42-1.66, p < 0.00001) and recurrence (n = 446, RR = 0.34, 95%CI:0.20-0.58, p < 0.00001) between the combination of CG with second-generation non-sedated antihistamine and antihistamine monotherapy. Contrastingly, adverse events rate (n = 2317, RR = 0.76, 95% CI:0.59-0.97, p = 0.03) was comparable between the two groups. Our results indicated that CG combined with second-generation non-sedated antihistamine could significantly mitigate the symptoms in CU compared with antihistamine monotherapy. No serious adverse events were reported.

CONCLUSIONS

CG combined with second-generation nonsedated antihistamine is effective for CU. Nevertheless, higher-quality studies are warranted to validate our results.

Biological drugs for the treatment of children with chronic spontaneous urticaria

INTRODUCTION

There is a significant prevalence of chronic spontaneous urticaria (CSU) in children across the globe. Some children with CSU do not achieve disease control with first-line antihistamine treatment and may need anti-IgE therapy with omalizumab. Recently, several novel treatment options, including dupilumab and BTK inhibitors, showed promising results in the treatment of antihistamine-refractory CSU in adults. However, information regarding their use in pediatric CSU is scarce, and most data is extrapolated from adult studies.

AREAS COVERED

The review highlights the evidence on the use of mAbs and small-molecule inhibitors in pediatric CSU and aims to bridge the knowledge gaps and highlight unmet needs.

EXPERT OPINION

Omalizumab is approved for allergic asthma patients aged ≥6 years, and some experience with omalizumab in children with CSU at this age has been published. However, approximately 5-10% of pediatric CSU patients may show insufficient response to omalizumab, necessitating other therapies. The available information on the off-label use of biologics other than omalizumab in children is limited to case reports. No data is available for other new therapies.

Chronic Urticaria in Children: A Single-Center Retrospective Study From Turkey

The studies on childhood chronic urticaria (CU) are limited. We aimed to investigate the epidemiological and etiological factors of children with CU. Demographic characteristics, laboratory findings, and etiological factors of patients diagnosed with CU younger than the age of 18 were retrospectively evaluated. Of the 124 participants, 68 (54.8%) were aged 12 and older. Angioedema accompanied 18.5% of the patients. Chronic spontaneous urticaria (CSU) was found in 75%, while 24.2% had chronic inducible urticaria. Symptomatic dermographism (16.1%) was the most common among chronic inducible urticaria, followed by cholinergic urticaria (4.8%). No etiological factor could be detected in 56.5% of the children. Infections (29.8%) were the most common etiological factor, followed by drugs (8%). Dental problems (16.9%) were the primary infections associated with CU. Chronic urticaria prevalence in children increased with age, with CSU being the most common type. Infections played a significant role in childhood CU.

Evaluation of Pediatric Chronic Urticaria with Emphasis on Clinical and Laboratory Characteristics and Treatment Response to Omalizumab: A Real-Life Experience from a Tertiary Allergy Center

Pediatric data on the clinical and etiologic features, treatment response, and use of omalizumab for chronic urticaria (CU) are quite limited. The aim of this study was to evaluate the clinical and demographic characteristics, laboratory findings, and response to treatment of CU in children. Children with a diagnosis of CU between 2019 and 2023 were included in the study. Information on demographic characteristics, clinical features, laboratory tests, provocation tests for inducible urticaria, urticaria activity scores (UAS7), and treatment responses were obtained from patients' medical records. A total of 150 children (50.7% male) with CU were enrolled in the study. A total of 14 (9.3%) patients had autoimmune diseases of which 11 (7.3%) had autoimmune thyroiditis. Overall, 97 (64.7%) patients had chronic spontaneous urticaria (CSU) and 53 (35.3%) had chronic inducible urticaria. A total of 16 patients who remained symptomatic despite high-dose antihistamines were treated with omalizumab, with a good response in 13 (81.3%) and a partial response in 3 (18.7%) patients. CSU accounts for the majority of pediatric CU, with the etiology being in part related to an autoimmune background. This study provides an overview of CU in children and demonstrates the safety and efficacy of treatment with omalizumab.

Current and future management of chronic spontaneous urticaria and chronic inducible urticaria

Background: Chronic urticaria (CU), characterized by ≥6 weeks of intense pruritus, remains a debilitating condition for patients. New and safe treatments are needed to manage CU recalcitrant to standard therapy. Objective: A review of the current literature of standard and novel therapeutics in the management of CU was conducted. Methods: A literature search via a medical literature data base and clinical trial data base was conducted to identify treatment options for CU and current clinical trials. Results: Second-generation antihistamines, omalizumab, and cyclosporine remain the most proven therapeutic options for CU. Dupilumab, mepolizumab, benralizumab, tezepelumab, and CDX-0159 are all undergoing clinical trials for CU. Although ligelizumab demonstrated initial promising results, a phase III study was discontinued due to a nonsuperior clinical impact compared with omalizumab. Conclusion: Novel therapies are needed for the treatment of recalcitrant CU. With a deeper understanding of the pathophysiology of CU, promising therapeutics are in clinical trials for CU.

Comorbidities of Chronic Urticaria: A glimpse into a complex relationship

Chronic Urticaria (CU) is a chronic inflammatory, predominantly mast cell-driven disease, characterized by the development of wheals and/or angioedema for more than 6 weeks. It affects approximately 1%-5% of the total population worldwide and imposes a substantial burden on health-related quality of life, significantly affecting patients' daily life. The economic impact on the health system is also not negligible, with an estimated cost per patient per year of approximately 2.000 $ in the United States. Although the underlying pathophysiology is not fully explored, autoimmune mechanisms have been proposed, including type I ("autoallergy" by means of autoantibodies to self-antigens) and type IIb (autoimmunity). Atopic, autoimmune, and psychiatric disorders are prevalent comorbidities in both children and adults with Chronic Spontaneous Urticaria (CSU). Although malignancies, cardiovascular diseases and other comorbidities have also been reported as associated diseases in patients with CSU, data remain scarce. It is still unknown whether the aforementioned comorbidities share common pathophysiological mechanisms with specific endotypes of CSU. The current review aims to overview current data on comorbidities of CU, and furthermore to comment on the potential linked pathways underlying these diseases.

Urticaria in a Pediatric Population: A Portuguese Single-Center Cohort Report

Background

Urticaria typically involves the skin and mucosa and is characterized by the development of wheals, angioedema, or both. According to the temporal evolution of the lesions, urticaria is classified as acute (AU) or chronic (CU), depending on whether the episodes last for fewer or more than six weeks, respectively. This study aimed to characterize a group of children and adolescents with urticaria and describe its subtypes, associated comorbidities, treatment, and evolution.

Methodology

This retrospective, observational study included patients aged <18 years who were diagnosed with urticaria in a tertiary teaching hospital in Portugal, and followed up in a Pediatric Allergy Unit, between January 2019 and December 2021.

Results

A total of 43 patients, aged nine months to 16 years were included. Of these, 22 (51%) were males. AU was identified in 12 (28%) cases, chronic spontaneous urticaria in 21 (63%), and physical urticaria (to cold) in four (9%). Autoantibodies were detected in four patients with spontaneous urticaria. In 6% of patients with CU, the episodes were associated with angioedema. Most CU episodes were successfully managed with the recommended or double the recommended dose (48%) of H1 antihistamines. Three patients requiring fourfold higher than the recommended dose of H1 antihistamines remained unresponsive and were started on omalizumab. Associated autoimmune thyroiditis was diagnosed in four patients.

Conclusions

In this cohort of patients, urticaria was equally distributed between the genders and the first-line therapy was second-generation antihistamines, consistent with current guidelines. Universal screening for autoimmune diseases in patients with chronic spontaneous urticaria revealed four cases of thyroiditis, which supports the relevance of this approach when managing CU.

An Overview of Off-Label Use of Humanized Monoclonal Antibodies in Paediatrics

In recent years, off-label and unlicensed drug use has extensively developed in the paediatric population. For a long time, clinical trials in the paediatric population were considered complicated to perform because of ethical problems, causing frequent off-label use. Off-label drug use remains an important public health issue, especially for children with rare conditions or with diseases not responsive to conventional treatments. The present paper is a narrative review of the literature of off-label drug use in children. The aim of our study is to summarize the main works dealing with the off-label use of biological drugs in paediatrics. Further studies analyzing their efficacy, safety, and cost-benefit ratios are needed to extend the use of biological therapies to the paediatric population.