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Yang X, Chen L, Wang S, Wu Y, Zhou X, Meng Z. The correlation between Th17/Treg immune dysregulation and the disease severity in chronic spontaneous urticaria patients. Immun Inflamm Dis 2023; 11:e920. [PMID: 37506162 PMCID: PMC10373571 DOI: 10.1002/iid3.920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE Chronic spontaneous urticaria (CSU) has a profound impact on the sleep quality, productivity and overall quality of life of affected individuals. This study aimed to investigate the correlation between serum Th17/Treg immune dysregulation and the severity of CSU in patients. METHODS Clinical baseline data of 120 CSU patients and matched healthy controls were recorded. The pruritus level, disease severity, and quality of life of CSU patients were assessed using the visual analogue scale, weekly Urticaria Activity Score and chronic urticaria quality of life questionnaire, respectively. The Th17/Treg cell ratio was detected by flow cytometry. ELISA was used to measure the levels of serum Th17 cytokines (IL-17, IL-21) and Treg cytokines (TGF-β1, IL-35). Pearson's correlation analysis was conducted to examine the associations between these indicators. RESULTS No significant differences were identified in terms of sex, age, and BMI between the two groups. However, CSU patients exhibited a significant increase in the Th17 cell ratio, as well as the elevated serum levels of TGF-β1, IL-17 and, IL-21. Conversely, the proportion of Treg cells and the levels of IL-35 were remarkably decreased in CSU patients. Peripheral blood Th17 cells were negatively correlated with Treg cells. The severity of pruritus, life quality, and disease severity in CSU patients were positively correlated to Th17 cell ratio, and inversely correlated with Treg cell proportion. CONCLUSIONS A positive correlation was found between the percentage of peripheral blood Th17 cell in CSU patients and the pruritus level, life quality, and disease severity. In constrast, there was a negative correlation between the proportion of peripheral blood Treg cells and these clinical parameters.
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Affiliation(s)
- Xiaojing Yang
- Department of Dermatology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Leigang Chen
- Department of Dermatology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Shining Wang
- Department of Dermatology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Yuanhui Wu
- Department of Dermatology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Xiangzhao Zhou
- Department of Dermatology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Zhaoying Meng
- Department of Dermatology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
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Karim J, Gabrielli S, Mule P, Torabi B, Byrne A, De Schryver S, Gadoury-Lévesque V, Alizadehfar R, McCusker C, Zhang X, Ben-Shoshan M. Bridging knowledge gaps in paediatric chronic urticaria through a video-based educational tool. Clin Exp Dermatol 2023; 48:108-111. [PMID: 36730510 DOI: 10.1093/ced/llac054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/27/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is a lack of patient educational resources about chronic urticaria (CU). AIMS To develop and test the effectiveness of an education tool to help paediatric patients and their families better understand CU and its management. METHODS From July 2020 to May 2022, paediatric patients with a history of CU who presented to the allergy outpatient clinics at our institution were recruited. Consenting families and patients were asked to complete five questions related to the definition, causes and management of CU at the time of presentation to the clinic. Participants were shown a 5-min animated video addressing the main knowledge gaps about CU. At the end of the video, participants were redirected to the same five questions to respond again. The scores were recorded as a proportion of correct answers (range 0·0-1·0). RESULTS In total, 53 patients [30 girls (56·6%), 23 boys (43·4%); mean age 9·7 ± 5·1 years, range 1·4-18·5 years] were recruited. The mean baseline pre-video education questionnaire score was 0·67 ± 0·2 (range 0·2-1·0), while the mean post-video score was 0·94 ± 0·1 (range 0·4-1·0), a mean score difference of 0·27, which was statistically significant (P < 0·001). At the 1-year follow-up, 14 (26·4%) patients answered the questionnaire again to assess retention of knowledge; the mean score was 0·83 ± 0·2 (range 0·2-1·0). CONCLUSIONS Our educational video was successful in educating patients and their families to better understand urticaria. Future studies should aim to optimize patient education through nontraditional tools such as videos, and compare knowledge gain using different methods of education.
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Affiliation(s)
- Jumanah Karim
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Sofianne Gabrielli
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Pasquale Mule
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Bahar Torabi
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Adam Byrne
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Sarah De Schryver
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Vanessa Gadoury-Lévesque
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Reza Alizadehfar
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Christine McCusker
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Xun Zhang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada, UK
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Prosty C, Gabrielli S, Le M, Ensina LF, Zhang X, Netchiporouk E, Ben-Shoshan M. Prevalence, Management, and Anaphylaxis Risk of Cold Urticaria: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:586-596.e4. [PMID: 34673287 DOI: 10.1016/j.jaip.2021.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/08/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cold urticaria is a subtype of chronic inducible urticaria (CIndU) associated with significant morbidity and a risk for anaphylaxis. Few studies have assessed the prevalence, management, and prevalence of associated anaphylaxis of cold urticaria. OBJECTIVES To evaluate the prevalence of cold urticaria among CIndU and chronic urticaria (CU) cases, to assess the management of cold urticaria, and to determine the prevalence of associated anaphylaxis. METHODS We searched PubMed and EMBASE for studies pertaining to cold urticaria and/or CIndU published in the past 10 years. We conducted meta-analyses to evaluate the prevalence of cold urticaria among CIndU and CU cases, the management of cold urticaria with H1-antihistamines and omalizumab, and the prevalence of associated anaphylaxis. RESULTS Twenty-two studies were included in the systematic review and 14 in the meta-analysis. The pooled prevalence of cold urticaria among patients with CU and CIndU was 7.62% (95% confidence interval [CI], 3.45% to 15.99%; I2 = 98%) and 26.10% (95% CI, 14.17% to 43.05%; I2 = 97%), respectively. Cold urticaria was managed by H1-antihistamines in 95.67% (95% CI, 92.47% to 97.54%; I2 = 38%) of patients and omalizumab in 5.95% (95% CI , 2.55% to 13.27%; I2 = 83%) of patients. The pooled prevalence of anaphylaxis among patients with cold urticaria was 21.49% (95% CI, 15.79% to 28.54%; I2 = 69%). CONCLUSIONS Cold urticaria constitutes an appreciable proportion of CIndU and CU cases and is predominantly managed with H1-antihistamines; few patients receive omalizumab. Anaphylaxis is common, and an epinephrine autoinjector prescription may be considered.
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Affiliation(s)
- Connor Prosty
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
| | - Sofianne Gabrielli
- Division of Allergy, Immunology, and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Michelle Le
- Division of Dermatology, McGill University, Montreal, Quebec, Canada
| | - Luis F Ensina
- Department of Pediatrics, Federal University of São Paolo, São Paolo, Brazil
| | - Xun Zhang
- Centre for Outcome Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Moshe Ben-Shoshan
- Division of Allergy, Immunology, and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada
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4
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Çildağ S, Yenisey Ç, Ünübol M, Şentürk T. Comparison of immunoglobulin E anti-thyroid peroxidase antibodies in patients with Hashimoto thyroiditis and chronic spontaneous urticaria. Med Pharm Rep 2021; 94:53-57. [PMID: 33629049 PMCID: PMC7880074 DOI: 10.15386/mpr-1598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/27/2020] [Accepted: 09/30/2020] [Indexed: 12/04/2022] Open
Abstract
Background and aim Chronic spontaneous urticaria (CSU) is a disease of unknown etiology and autoimmunity has been thought to be an etiological factor. Immunoglobulin E (IgE)-anti-thyroid peroxidase antibodies (anti-TPO) may play a role in the pathogenesis of certain cases of urticaria. The aim of this study is to investigate IgE-anti-TPO in patients with chronic spontaneous urticaria and in patients with Hashimoto’s thyroiditis. Methods A total of 175 subjects were included in this study. 59 patients had chronic spontaneous urticaria without history of Hashimoto’s thyroiditis, while 58 patients had Hashimoto’s thyroiditis without history of urticaria. The control group consisted of 58 participants without history of Hashimoto’s thyroiditis and urticaria. Serum IgE-anti-TPO levels were analyzed by site-directed IgE capture Enzyme-Linked Immunosorbent Assay technique. We used this technique by modifying it. Results IgE-anti-TPO antibodies were detected in all three groups and in all subjects. There was no significant difference between the three groups in terms of IgE-anti-TPO levels. Although total IgE and IgE-anti-TPO levels were higher in the IgG-anti-TPO positive chronic spontaneous urticaria, there was no significant difference. Conclusions IgE-anti-TPO antibodies do not play a pathogenic role in the majority of patients with chronic spontaneous urticaria.
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Affiliation(s)
- Songül Çildağ
- Department of Immunology and Allergy, Adnan Menderes University, Turkey
| | - Çiğdem Yenisey
- Department of Biochemistry, Adnan Menderes University, Turkey
| | - Mustafa Ünübol
- Department of Endocrinology and Metabolism, Adnan Menderes University, Turkey
| | - Taşkın Şentürk
- Department of Immunology and Allergy, Adnan Menderes University, Turkey
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5
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Alen Coutinho I, Regateiro FS, Fernandes RA, Pita JS, Gomes R, Coelho C, Todo Bom A. Refractory chronic urticaria in adults: clinical characterization and predictors of severity. Allergy Asthma Clin Immunol 2020; 16:97. [PMID: 33292453 PMCID: PMC7661155 DOI: 10.1186/s13223-020-00496-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/28/2020] [Indexed: 12/04/2022] Open
Abstract
Background Chronic urticaria (CU) is defined as recurrent urticaria lasting for more than 6 weeks. Objectives We aimed to characterize the phenotypes of patients with CU refractory to standard dose anti-H1 antihistamine treatment and search for clinical predictors of poor disease control. Methods Retrospective collection of data regarding clinical characteristics, comorbidities, treatment, and disease control of all adult refractory CU patients presenting to the Allergy and Immunology Department during 1 year. Results Sixty-one adult patients were included, 74% females, average age 44.5 years (18 to 84 years old). Most patients (78.7%) had initiated CU less than 1 year before enrolment. Chronic spontaneous urticaria (CSU) accounted for 55.7% of the patients, CSU associated with chronic inducible urticaria (CIndU) as a comorbidity for 44.3%, and angioedema was present in 55.7%. Medically-confirmed psychiatric disorders were present in 78.7%. Complementary diagnostic tests were performed in cases with more severe presentation (UAS7 ≥ 28 and/or UCT < 12) or with longer evolution (> 1 year), corresponding to 42 tested patient. Evidence for autoimmunity (positive anti-thyroid peroxidase antibodies, anti-nuclear antibodies or autologous serum test) was found in 45.2% (n = 19/42), and high C-reactive protein was present in 14.3% (n = 6/42), half of these also had positive antinuclear antibodies. Forty-six patients (75.4%) had at least one significant exacerbation, requiring medical appointment, emergency room, hospitalization or job absenteeism. The number of exacerbations correlated with the presence of angioedema (p = 0.022), with a recent diagnosis (< 1 year), and with higher UAS7 severity (p = 0.006). Although ClndU was associated with poor symptom control (p = 0.022), it was also associated with less exacerbations requiring medical observation or hospitalization (p = 0.015). All patients were using antihistamines and 21.3% (n = 13) of them were also under treatment with omalizumab, ciclosporine or montelukast for disease control. Conclusions Autoimmunity can affect about half of the patients with severe or long-term CU. UAS7 and angioedema are associated with disease exacerbations. UAS7 and UCT presented unequal accuracy, with UAS7 better associating with the occurrence of exacerbations and treatment doses. Patients with refractory CU frequently present psychiatric disorders. Accurate diagnostic tests, namely autoimmune parameters and inflammatory markers, should be recommended in some individual cases.
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Affiliation(s)
- Iolanda Alen Coutinho
- Allergy and Clinical Immunology Departement, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal.
| | - Frederico Soares Regateiro
- Allergy and Clinical Immunology Departement, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal.,Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,ICBR - Coimbra Institute for Clinical and Biomedical Research, CIBB, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Rosa Anita Fernandes
- Allergy and Clinical Immunology Departement, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | - Joana Sofia Pita
- Allergy and Clinical Immunology Departement, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Gomes
- Allergy and Clinical Immunology Departement, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | | | - Ana Todo Bom
- Allergy and Clinical Immunology Departement, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal.,ICBR - Coimbra Institute for Clinical and Biomedical Research, CIBB, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Institute of Pathophysiology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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6
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Saleh AA, Al-Obaidi AM, Behiry EG, Hamed AM. Serum Levels of Eosinophil-derived Neurotoxin in Patients with Chronic Urticaria. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2020; 13:21-23. [PMID: 33133337 PMCID: PMC7577334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND: Despite the many theories that have been published over the years, the exact pathology of chronic urticaria (CU) is still largely unknown. Eosinophils have been implicated in many cutaneous disorders-serving as major effector cells, inducing tissue damage and dysfunction by releasing granule proteins, including eosinophil cationic protein (ECP), inflammatory lipid mediators, mitochondrial DNA, and eosinophil-derived neurotoxin (EDN), which is relatively neutral with some cytotoxic properties. OBJECTIVE: We sought to evaluate serum levels of EDN in patients with CU and to correlate their levels with the severity of their disease. PARTICIPANTS: Fifty patients with CU and 30 matching healthy individuals, serving as controls, were recruited from the outpatient clinic of the Dermatology, Venereology, and Andrology Department of Benha University Hospitals. METHODS: 5ml of venous blood were drawn from all participants in a fasted state, stored in sterile tubes, and used to measure the serum level of EDN following the manufacturer's instructions. RESULTS: The serum level of EDN was statistically significantly different in both groups, and the serum level of EDN significantly correlated with the severity of CU. CONCLUSION: The significantly higher EDN level in patients with CU suggests its role in the pathogenesis of the disease, and its significant positive correlation with the severity of the disease suggests promising therapeutic solutions.
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Affiliation(s)
- Ahmed A Saleh
- Mr. Al-Obaidi, Dr. Saleh, and Dr. Hamed are with the Department of Dermatology and Andrology of the Faculty of Medicine at Benha University in Benha, Egypt
- Dr. Behiry is with the Department of Clinical and Chemical Pathology of the Faculty of Medicine at Benha University in Benha, Egypt
| | - Aiham M Al-Obaidi
- Mr. Al-Obaidi, Dr. Saleh, and Dr. Hamed are with the Department of Dermatology and Andrology of the Faculty of Medicine at Benha University in Benha, Egypt
- Dr. Behiry is with the Department of Clinical and Chemical Pathology of the Faculty of Medicine at Benha University in Benha, Egypt
| | - Eman G Behiry
- Mr. Al-Obaidi, Dr. Saleh, and Dr. Hamed are with the Department of Dermatology and Andrology of the Faculty of Medicine at Benha University in Benha, Egypt
- Dr. Behiry is with the Department of Clinical and Chemical Pathology of the Faculty of Medicine at Benha University in Benha, Egypt
| | - Ahmed Mohammed Hamed
- Mr. Al-Obaidi, Dr. Saleh, and Dr. Hamed are with the Department of Dermatology and Andrology of the Faculty of Medicine at Benha University in Benha, Egypt
- Dr. Behiry is with the Department of Clinical and Chemical Pathology of the Faculty of Medicine at Benha University in Benha, Egypt
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7
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Cao W, Xiao X, Zhang L, Liu Y, Wang L, Zou Z, Cao Y, Li C, Zheng Q, Zhou S, Li Y. Compound glycyrrhizin combined with antihistamines for chronic urticaria: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e21624. [PMID: 32872021 PMCID: PMC7437846 DOI: 10.1097/md.0000000000021624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To investigate the efficacy and safety of compound glycyrrhizin (CG) combined with antihistamines in the treatment of chronic urticaria (CU). METHODS We will use computers to search all databases including Medline, Embase, Pubmed, Web of Science and Cochrane Central Register of Controlled Trials and China's 4 databases: China National Knowledge Infrastructure Database, China Biomedical Literature Database, China Science Journal Database, and Wanfang Database. Find data from creation date to July 2020. In addition, we will manually search the list of medical journals as a supplement. The scope of the search included randomized controlled clinical studies related to CG combined with antihistamines for CU. The primary outcome is the disease activity control. Secondary outcomes include response rate, adverse events, and recurrence rates. The Cochrane RevMan V5.3 Deviation Assessment Tool will be used to assess bias assessment risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). The average difference, standard mean difference, and binary data will be used to represent continuous results. RESULTS This study will comprehensively review the existing evidence on CG combined with antihistamines for CU. CONCLUSION This systematic review will provide a basis for judging the effectiveness and safety of CG combined with antihistamines in the treatment of CU. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020156153.
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Affiliation(s)
- Wei Cao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Xianjun Xiao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
- Rehabilitation Department, The People's Hospital of Jianyang City
| | - Leixiao Zhang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Ying Liu
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Lu Wang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Zihao Zou
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Yue Cao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Chunxiao Li
- Dermatological Department, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Qianhua Zheng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Siyuan Zhou
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Ying Li
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
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8
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Gabrielli S, Le M, Netchiporouk E, Miedzybrodzki B, Baum S, Greenberger S, Staubach-Renz P, Ben-Shoshan M. Reply to "Comment on: 'Children with chronic urticaria can be effectively controlled with updosing second-generation antihistamines'". J Am Acad Dermatol 2020; 83:e365-e366. [PMID: 32622144 DOI: 10.1016/j.jaad.2020.06.997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Sofianne Gabrielli
- Division of Allergy, Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada.
| | - Michelle Le
- Division of Allergy, Immunology, and Dermatology, McGill University, Montreal, Quebec, Canada
| | | | | | - Sharon Baum
- Department of Dermatology, Sheba Medical Center, Ramat-Gan, Tel-Aviv University, Tel-Aviv, Israel
| | - Shoshana Greenberger
- Department of Dermatology, Sheba Medical Center, Ramat-Gan, Tel-Aviv University, Tel-Aviv, Israel
| | - Petra Staubach-Renz
- Department of Dermatology and Allergy, University Medical Center, Mainz, Germany
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada
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9
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Cao W, Xiao X, Zhang L, Wang L, Zheng Q, Zhou S, Liu Y, Cao Y, Chen M, Li C, Li Y. Acupoint injection of Bacillus Calmette-Guerin polysaccharide nucleic acid for patients with chronic urticaria: A protocol for systematic review. Medicine (Baltimore) 2020; 99:e19924. [PMID: 32358360 PMCID: PMC7440172 DOI: 10.1097/md.0000000000019924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To investigate the efficacy and safety of acupoint injection of Bacillus Calmette-Guerin polysaccharide nucleic acid (BCG-PSN) in the treatment of chronic urticaria (CU). METHODS The following databases will be searched from their inception: Medline, Embase, Pubmed, Web of Science, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure Database, China Biomedical Literature Database, China Science Journal Database, and Wanfang Database. All databases will be searched from the date of creation until October 2019. In addition, we will manually search the list of medical journals as a supplement. The scope of the search included randomized controlled clinical studies related to acupoint injection of BCG-PSN for CU. The primary outcome is the disease activity control. Secondary outcomes include response rate, adverse events, and recurrence rates. The Cochrane RevMan V5.3 Deviation Assessment Tool will be used to assess bias assessment risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). The average difference, standard mean difference and binary data will be used to represent continuous results. RESULTS This study will comprehensively review the existing evidence on the treatment of CU by acupoint injection of BCG-PSN. CONCLUSION This systematic review will provide a judgment basis for the effectiveness and safety of acupoint injection of BCG-PSN in the treatment of CU. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019139885.
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Affiliation(s)
- Wei Cao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Xianjun Xiao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
- Rehabilitation Department, The People's Hospital of Jianyang City
| | - Leixiao Zhang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Lu Wang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Qianhua Zheng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Siyuan Zhou
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Ying Liu
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Yue Cao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
| | - Mingling Chen
- Dermatological Department, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Chunxiao Li
- Dermatological Department, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Ying Li
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine
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10
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Fein MN, Fischer DA, O'Keefe AW, Sussman GL. CSACI position statement: Newer generation H 1-antihistamines are safer than first-generation H 1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria. Allergy Asthma Clin Immunol 2019; 15:61. [PMID: 31582993 PMCID: PMC6771107 DOI: 10.1186/s13223-019-0375-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 09/19/2019] [Indexed: 01/04/2023] Open
Abstract
Oral H1-antihistamines (AHs) are the most commonly used therapy to treat allergic rhinitis and chronic urticaria. Older, first-generation AHs (e.g. diphenhydramine, hydroxyzine) have significant and common side effects including sedation, impairment with decreased cognitive function, poor sleep quality, dry mouth, dizziness, and orthostatic hypotension. These drugs have also been found to result in death from accidents, intentional or unintentional overdoses, and sudden cardiac death. The unfavourable risk–benefit profile of first-generation AHs led to the development of newer, less-sedating second- and third-generation AHs, which first became available in Canada in the 1980s. High-quality trials have proven that newer generation AHs are superior in safety compared to older first-generation AHs. On average, they have improved potency and efficacy. Second- and third-generation AHs are the recommended first-line treatment for mild allergic rhinitis and acute and chronic urticaria. Despite this evidence, older first-generation AHs continue to be over-utilized because of their over-the-counter (OTC) status and long history of use. The Canadian Society of Allergy Clinical Immunology (CSACI) recommends that newer generation AHs should be preferred over first-generation AHs for the treatment of allergic rhino-conjunctivitis and urticaria. To promote this recommendation, education of health professionals and the public is necessary. Further, given the dangers of older first-generation AHs, we believe they should be used only as a last resort with eventual consideration given to having them only available behind the counter in pharmacies.
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Affiliation(s)
- Michael N Fein
- 1Division of Clinical Immunology and Allergy, McGill University, Montreal, QC Canada
| | - David A Fischer
- 2Division of Allergy and Clinical Immunology, Western University, London, ON Canada.,3The Canadian Society of Allergy and Clinical Immunology, Ottawa, ON Canada
| | - Andrew W O'Keefe
- 4Division of Pediatrics, Faculty of Medicine, Memorial University, St. John's, NL Canada
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Shi Y, Zheng H, Zhou S, Zheng Q, Zhang L, Xiao X, Cao W, Liu Y, Li Y. Efficacy and safety of acupuncture for patients with chronic urticaria: study protocol of a randomized, sham-controlled pilot trial. Trials 2019; 20:326. [PMID: 31164178 PMCID: PMC6549330 DOI: 10.1186/s13063-019-3433-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 05/13/2019] [Indexed: 01/06/2023] Open
Abstract
Background Chronic urticaria (CU) is a refractory skin disease with long duration and a high recurrence rate. Acupuncture has been widely used for the treatment of CU in clinical practice in China. However, until now, there has been no appropriately designed randomized controlled trial (RCT) to provide explicit evidence about the effectiveness of acupuncture for the treatment of CU worldwide. Therefore, we plan to conduct a pilot study to explore its effectiveness and safety and determine the feasibility of studying acupuncture in a future, full-scale, RCT of CU. Methods/design This randomized, sham-controlled, participant-blinded and assessor-blinded pilot trial is underway in China. A total of 60 participants with CU will be randomly assigned to two groups in a 1:1 ratio: one treated with real acupuncture and the other with sham acupuncture, for 10 sessions over 2 weeks. The experimental group will receive acupuncture on a fixed prescription of acupoints, whereas the control group will receive sham acupuncture, namely minimal acupuncture on non-acupuncture points. The primary outcome will be the urticaria activity score (UAS). The secondary outcomes will include a visual analogue scale (VAS) score for itching intensity, the Dermatology Life Quality Index (DLQI), the Hamilton Depression Scale (HAMD), the Hamilton Anxiety Scale (HAMA), the humoral immunity index, serum total IgE, and adverse events. The UAS, VAS for itching and the DLQI will be conducted at baseline and at 1, 2, 3, and 4 weeks after randomization. The HAMD, HAMA, humoral immunity index, and serum total IgE will be assessed at baseline and at 2 weeks after randomization. Adverse events will be summarized at 1 week and 2 weeks after randomization. Discussion The pilot study mainly aims to investigate trial feasibility, and confirm basic information about its effects and safety. Results of this trial will help clarify whether the acupuncture treatment is beneficial for symptom improvement in patients with CU. The finding of this study will provide preliminary evidence on the effectiveness and safety of acupuncture for CU. Trial registration Acupuncture-Moxibustion Clinical Trial Registry, AMCTR-ICR-18000190. Registered on 19 June 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3433-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yunzhou Shi
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Hui Zheng
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Siyuan Zhou
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Qianhua Zheng
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Leixiao Zhang
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Xianjun Xiao
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Wei Cao
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Ying Liu
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China
| | - Ying Li
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu, 610075, Sichuan, China.
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Shi Y, Hou T, Zheng Q, Liu Y, Yang T, Li Y. Acupoint catgut embedding for patients with chronic urticaria: A systematic review protocol. Medicine (Baltimore) 2019; 98:e16036. [PMID: 31192961 PMCID: PMC6587600 DOI: 10.1097/md.0000000000016036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The purpose of this paper is to evaluate the effectiveness and safety of acupoint catgut embedding in the treatment of chronic urticaria (CU). METHODS We will electronically search PubMed, Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, and Wan-Fang Database from their inception to March 2019. In addition, we will manually retrieve other resources including the reference lists of identified publications, conference articles, and gray literature. The clinical randomized controlled trials or quasi-randomized controlled trials related to acupoint catgut embedding for the treatment of CU will be included in the study. The language is limited to Chinese and English. Research selection, data extraction, and research quality assessment will be independently completed by 2 researchers. Data were synthesized by using a fixed effect model or random effect model depend on the heterogeneity test. The total effective rate was the primary outcomes. Skin disease quality of life index scores, adverse events, and recurrence rates will also be assessed as secondary outcomes. RevMan V.5.3 statistical software will be used for meta-analysis. If it is not appropriate for a meta-analysis, then a descriptive analysis will be conducted. Data synthesis will use the risk ratio and the standardized or weighted average difference of continuous data to represent the results. RESULTS This study will provide a high-quality synthesis to assess the effectiveness and safety of acupoint catgut embedding for patients with CU. CONCLUSION This systematic review will provide evidence to judge whether acupoint catgut embedding is an effective intervention for patients with CU. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019129459.
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Shi Y, Zhou S, Zheng Q, Huang Y, Hao P, Xu M, Zhang L, Xiao X, Zheng H, Li Y. Systematic reviews of pharmacological and nonpharmacological treatments for patients with chronic urticaria: An umbrella systematic review. Medicine (Baltimore) 2019; 98:e15711. [PMID: 31096521 PMCID: PMC6531058 DOI: 10.1097/md.0000000000015711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A wide range of pharmacological and nonpharmacological interventions for chronic urticaria (CU) have been evaluated in systematic reviews (SRs). We conducted an umbrella review of SRs of the effectiveness and safety of pharmacological and nonpharmacological interventions for CU, which allow the findings of separate reviews to be compared and contrasted and thereby provide decision makers in healthcare with the evidence they need.We included SRs evaluating pharmacological and nonpharmacological interventions for CU. Comprehensive searches were conducted in 7 bibliographic databases, relevant journals up to July 2018. Two reviewers independently assessed the studies' relevance and quality. The assessment of multiple systematic reviews tool and grading of recommendations assessment, development and evaluation method was used to assess the methodological quality of the SRs and classify the quality of the outcomes.In total, 41 SRs were included. Thirty-seven reviews performed quantitative research syntheses, and 4 reviews performed qualitative research syntheses. The majority of SRs evaluated interventions based on combination therapies, antihistamines, traditional Chinese medicines, autohemotherapy, omalizumab, acupuncture, cyclosporine, and leukotriene receptor antagonist. Positive intervention outcomes were reported in the majority (75.32%) of the reviews. However, the methodological quality and evidence quality of the reviews were generally poor.There is some evidence to support a variety of interventions for CU. However, there was much heterogeneity in evidence quality among SRs. Many of the SRs had methodological weaknesses that make them vulnerable to bias. Moreover, there remained little information on the relative effectiveness of one intervention compared with another. Therefore, further SRs that adherence to strict scientific methods are necessary, and primary studies make comparisons between the different treatment options directly.
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Affiliation(s)
- Yunzhou Shi
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Siyuan Zhou
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Qianhua Zheng
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Ying Huang
- The Dermatology Department of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, China
| | - Pingsheng Hao
- The Dermatology Department of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, China
| | - Mingmin Xu
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Leixiao Zhang
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Xianjun Xiao
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Hui Zheng
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
| | - Ying Li
- Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine
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Asero R. Efficacy of omalizumab 150 mg/month as a maintenance dose in patients with severe chronic spontaneous urticaria showing a prompt and complete response to the drug. Allergy 2018; 73:2242-2244. [PMID: 29989179 DOI: 10.1111/all.13549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Riccardo Asero
- Ambulatorio di Allergologia; Clinica San Carlo; Paderno Dugnano MI Italy
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Abstract
Urticaria (hives) is a common disorder that often presents with angioedema (swelling that occurs beneath the skin). It is generally classified as acute or chronic. Second-generation, non-sedating, non-impairing histamine type 1 (H1)-receptor antihistamines represent the mainstay of therapy for both acute and chronic urticaria. Angioedema can occur in the absence of urticaria and can be broadly divided into histamine-mediated and non-histamine-mediated angioedema. Histamine-mediated angioedema can be allergic, pseudoallergic or idiopathic. Non-histamine mediated angioedema is largely driven by bradykinin and can be hereditary, acquired or drug-induced, such as with angiotensin-converting enzyme inhibitors. Although bradykinin-mediated angioedema is often self-limited, laryngeal involvement can lead to fatal asphyxiation. The mainstay of management for angioedema is to avoid specific triggers, if possible. For hereditary angioedema, there are specifically licensed treatments that can be used for the management of acute attacks, or for prophylaxis in order to prevent attacks. In this article, the authors will review the causes, diagnosis and management of urticaria (with or without angioedema) and isolated angioedema. The diagnostic and therapeutic approaches to these two conditions are considerably different, and this review is designed to highlight these differences to the reader.
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Affiliation(s)
- Amin Kanani
- 1Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Stephen D Betschel
- 2Division of Allergy and Immunology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON Canada
| | - Richard Warrington
- 3Section of Allergy & Clinical Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB Canada
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Ben-Shoshan M, Grattan C. Reply. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1806-1808. [PMID: 30197075 DOI: 10.1016/j.jaip.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/01/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Moshe Ben-Shoshan
- Division of Allergy, Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada.
| | - Clive Grattan
- Norflok and Norwich University Hospital, Norwich, United Kingdom; St John's Institute of Dermatology, London, United Kingdom
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Ferrer M, Giménez-Arnau A, Saldana D, Janssens N, Balp MM, Khalil S, Risson V. Predicting Chronic Spontaneous Urticaria Symptom Return After Omalizumab Treatment Discontinuation: Exploratory Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1191-1197.e5. [DOI: 10.1016/j.jaip.2018.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/24/2018] [Accepted: 04/01/2018] [Indexed: 12/22/2022]
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Soliman M, Khattab FM, Ebrahim HM, Nasr M. Serum prolactin level in chronic urticaria: Is bromocriptine inducing remission in chronic urticaria? J DERMATOL TREAT 2018; 29:826-830. [PMID: 29694255 DOI: 10.1080/09546634.2018.1468062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Chronic urticaria (CU) is a disturbing disease with a negative impact on quality of life. Despite of several clinical studies on CU patients, its pathogenesis is poorly understood. Prolactin (PRL) is peptide hormone has immunomodulatory effects in some immune inflammatory skin diseases. AIM To elucidate any possible relationship between the immunomodulatory effects of PRL and CU. Besides, the study aims to investigate the crucial role of antiprolactin drugs in the management of CU patients. PATIENTS AND METHODS The serum PRL level of 40 female patients with CU was measured using the electrochemiluminescence immunoassay. The activity of CU was assessed by European Academy of Allergology and Clinical Immunology; Global Allergy and Asthma European Network; European Dermatology Forum (EAACI/GA2LEN/EDF) activity score. Patients with high PRL level had been given anti prolactin therapy to normalize their PRL levels. Then, the disease activity was reassessed in these patients. RESULTS The serum PRL level was high in 8 of 40 (20%) patients (43.18 ± 12.81). Half of patients with high PRL level had remission after treatment of hyperprolactinemia (p = .001). CONCLUSIONS Serum PRL levels could not be considered as a marker of the disease activity in CU patients.
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Affiliation(s)
- Mohamed Soliman
- a Dermatology, Venereology and Andrology Department, Faculty of Medicine , Zagazig University , Sharkia , Egypt
| | - Fathia M Khattab
- a Dermatology, Venereology and Andrology Department, Faculty of Medicine , Zagazig University , Sharkia , Egypt
| | - Howyda Mohamed Ebrahim
- a Dermatology, Venereology and Andrology Department, Faculty of Medicine , Zagazig University , Sharkia , Egypt
| | - Mohamad Nasr
- a Dermatology, Venereology and Andrology Department, Faculty of Medicine , Zagazig University , Sharkia , Egypt
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El-Sharkawy REED, Abd-Elmaged WM, Ahmed DA, Abdel-Wahed SAEF. Pattern of chronic urticaria and value of autologous serum skin test in Sohag Province, Upper Egypt. Electron Physician 2018; 10:6781-6788. [PMID: 29997762 PMCID: PMC6033132 DOI: 10.19082/6781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 03/28/2018] [Indexed: 01/16/2023] Open
Abstract
Background Chronic urticaria (CU) is a debilitating disorder with variable clinical course. It is characterized by hives occurring for at least 6 weeks, and is classified as spontaneous or inducible. Objective The aim of this study was to detect the pattern of CU, to study association between results of autologous serum skin test (ASST) and urticaria severity score (USS), and to detect serum levels of anti IgE receptors antibodies. Methods This study included all patients attending the Dermatology Outpatient Clinic, Sohag University Hospital, who were diagnosed as CU from April 2015 to March 2016. ASST and serum level of anti IgE receptor antibodies was assessed using ELISA. Data were analyzed by SPSS version 16, using descriptive statistics, Kruskal-Wallis and Mann-Whitney U test. Results A total of 108 patients with CU were included in the study. Females with mean age 33±12.4 years were more affected. A total of 58.3% complained of CSU, 6.5% physical urticaria and 35.2% mixed type of CU. According to USS, mild score represented 20.4%, moderate 46.3% and severe in 33.3%. ASST showed positive in 38% of patients. There was a statistically significant relation between ASST and USS and duration of CU. This indicates that more severe symptoms and prolonged duration of CU are observed in positive ASST (autoreactive type). In all, 91% of the anti IgE receptor antibodies positive patients had positive ASST. Conclusion In conclusion, chronic urticaria is not an uncommon disease in our locality which represented 1.13% of our patients. Urticaria severity score and duration of urticaria was higher in positive ASST patients and hence the autoreactive type.
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Affiliation(s)
| | - Wafaa Mohamed Abd-Elmaged
- Lecturer, Dermatology and Venereology Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Doaa Anwar Ahmed
- Resident at Dermatology Department, Sohag General Hospital, Sohag, Egypt
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Ben-Shoshan M, Grattan CE. Management of Pediatric Urticaria with Review of the Literature on Chronic Spontaneous Urticaria in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1152-1161. [PMID: 29550102 DOI: 10.1016/j.jaip.2018.02.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/05/2018] [Accepted: 02/16/2018] [Indexed: 12/26/2022]
Abstract
There are substantial knowledge gaps related to diagnosis and management of pediatric cases of chronic urticaria, and in particular chronic spontaneous urticaria (CSU). In this article we aimed to review the diagnosis and management of chronic urticaria in children and CSU in particular. We conducted a systematic review of articles published in English and French on pediatric CSU management in the last 10 years. We included experimental studies (eg, randomized controlled trials), other experimental designs (eg, nonrandomized methods of assignment, controlled before-after studies, and interrupted time series), and observational studies (eg, prospective or retrospective cohort studies, cross-sectional studies, case-control studies, and case reports). Our findings highlight the efficacy of second-generation antihistamines for the treatment of CSU in children and supports the use of omalizumab for more severe cases. However, our study also reveals severe knowledge gaps related to the best management strategy in children with more severe/refractory cases of CSU. Future studies are required to establish the beneficial effect of high doses of second-generation antihistamines as well as the effectiveness and safety of omalizumab and other biologics in young children.
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Affiliation(s)
- Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada.
| | - Clive E Grattan
- St John's Institute of Dermatology, Guy's Hospital, London, United Kingdom
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Syrigos N, Grapsa D, Zande M, Tziotou M, Syrigou E. Treatment response to omalizumab in patients with refractory chronic spontaneous urticaria. Int J Dermatol 2018; 57:417-422. [PMID: 29399789 DOI: 10.1111/ijd.13935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/31/2017] [Accepted: 01/09/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous clinical trials have demonstrated the efficacy and safety of the anti-IgE monoclonal antibody omalizumab in chronic spontaneous urticaria (CSU) not responding to antihistamine treatment. The primary aim of our study was to describe the response patterns of patients with refractory CSU treated with omalizumab in a real-world clinical setting. METHODS A retrospective analysis of medical records of 20 patients with refractory CSU was performed. Demographic, clinical, and laboratory features were retrieved and analyzed in correlation with treatment data. RESULTS Mean age of our patient population was 54.5 years, while the majority were females (15/20 cases, 75%). Mean disease duration prior to omalizumab administration was 21.8 months. All patients had a history of chronic urticaria, refractory to high antihistamine and corticosteroid treatment, and responded favorably to omalizumab after administration of 1-5 doses of omalizumab; complete response was observed in 17/20 patients (85%) and well-controlled disease in the remaining 3/20 patients (15%). In a subset of cases (6/20, 30%), best response to omalizumab was achieved after interval administration of a 9-day course of methylprednisolone (total dose of 188 mg). Late response to omalizumab (after three-month treatment) was significantly correlated (P = 0.026) with shorter disease duration before initiation of omalizumab. CONCLUSION In the present series, omalizumab, either alone or in combination with a short-term course of corticosteroids, was highly effective in resolution of refractory CSU. Furthermore, disease duration prior to omalizumab had a significant effect on timing of response.
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Affiliation(s)
| | - Dimitra Grapsa
- 3rd Department of Medicine, University of Athens, School of Medicine, Athens, Greece
| | - Maria Zande
- Allergy Department, "Sotiria" General Hospital, Athens, Greece
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Martins CF, Morais KL, Figueroa P, Dias NF, Valente NS, Maruta CW, Criado PR. Histopathological and clinical evaluation of chronic spontaneous urticaria patients with neutrophilic and non-neutrophilic cutaneous infiltrate. Allergol Int 2018; 67:114-118. [PMID: 28754324 DOI: 10.1016/j.alit.2017.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Chronic urticaria has an expressive prevalence in general population, especially in adults, and is defined by the presence of intermittent hives for six weeks or longer. Our study aims to characterize the histological patterns of chronic spontaneous urticaria, based on the inflammatory cell infiltrate, and correlate them to laboratory exams. METHODS It was performed a retrospective analysis of laboratory, histopathology and direct immunofluorescence data of 93 patients with chronic urticaria. For histopathological analysis, cell count was performed in four fields at high magnification (×400) for each specimen. The resulting cell count medians were submitted to statistical analysis and, then, were correlated to laboratorial findings. RESULTS We found a female predominance (76.34%) of chronic urticaria cases, and an average age of 42.5 years (SD ± 15). Two histological groups were distinctive: 1) chronic urticaria with predominance of neutrophils or eosinophils - N (%) = 39 (42.4%) - and 2) chronic urticaria with predominance of lymphocytes - N (%) = 53 (57.6%). There was not significant correlation between histological groups and laboratorial tests. Moreover, direct immunofluorescence was positive in 21 (33,87%) from 62 patients. CONCLUSIONS There is not enough scientific evidence to support neutrophilic urticaria as a solid, separate entity.
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Affiliation(s)
- Cíntia Freitas Martins
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
| | - Karina Lopes Morais
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
| | - Pamela Figueroa
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
| | - Natasha Favoretto Dias
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
| | - Neusa Sakai Valente
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
| | - Celina Wakisaba Maruta
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
| | - Paulo Ricardo Criado
- Department of Dermatology, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil.
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Netchiporouk E, Sasseville D, Moreau L, Habel Y, Rahme E, Ben-Shoshan M. Evaluating Comorbidities, Natural History, and Predictors of Early Resolution in a Cohort of Children With Chronic Urticaria. JAMA Dermatol 2017; 153:1236-1242. [PMID: 28973060 DOI: 10.1001/jamadermatol.2017.3182] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Chronic urticaria (CU) affects 0.1% to 0.3% of children. Most cases have no identifiable trigger and are classified as chronic spontaneous urticaria (CSU). At least half of patients with CSU may have an autoimmune etiology that can be determined in vitro using the basophil activation test (BAT). While 30% to 55% of CU cases resolve spontaneously within 5 years in adults, the natural history and predictors of resolution in children are not known. Objective To assess the comorbidities, natural history of CU, and its subtypes in children and identify predictors of resolution. Design, Setting, and Participants We followed a pediatric cohort with chronic urticaria that presented with hives lasting at least 6 weeks between 2013 and 2015 at a single tertiary care referral center. Exposures Data were collected on disease activity, comorbidities, physical triggers, BAT results, complete blood cell count, C-reactive protein levels, thyroid-stimulating hormone levels, and thyroid peroxidase antibodies. Main Outcomes and Measures We assessed the rate of resolution (defined as absence of hives for at least 1 year with no treatment) and the association with clinical and laboratory markers. Results The cohort comprised 139 children younger than 18 years old. Thirty-one patients (20%) had inducible urticaria, most commonly cold induced. Six children had autoimmune comorbidity, such as thyroiditis and type 1 diabetes. Autoimmune disorders (24 patients [17%]) and CU (17 patients [12%]) were common in family members. Positive BAT results (CD63 levels > 1.8%) were found in 58% of patients. Patients with positive BAT results (CD63 level >1.8%) were twice as likely to resolve after 1 year compared with negative BAT results (hazard ratio [HR], 2.33; 95% CI, 1.08-5.05). In contrast, presence of basophils decreased the likelihood of resolution (HR, 0.40; 95% CI, 0.20-0.99). No correlation with age was found. Chronic urticaria resolved in 43 patients, with a rate of resolution of 10.3% per year. Levels of CD63 higher than 1.8% and absence of basophils were associated with earlier disease resolution. Conclusions and Relevance Resolution rate in children with CU is low. The presence of certain biomarkers (positive BAT result and basophil count) may help to predict the likelihood of resolution.
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Affiliation(s)
- Elena Netchiporouk
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Denis Sasseville
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Linda Moreau
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Youssef Habel
- Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elham Rahme
- Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
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Advances in Chronic Urticaria. CURRENT DERMATOLOGY REPORTS 2017. [DOI: 10.1007/s13671-017-0198-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lima H, Gooderham M, Dutz J, Lynde C, Chapdelaine H, Ellis A, Gilbert M, Ho V, Papp K, Poulin Y, Sussman G. Management of chronic spontaneous urticaria (CSU): a treat to target approach using a patient reported outcome. Allergy Asthma Clin Immunol 2017; 13:38. [PMID: 28852410 PMCID: PMC5569543 DOI: 10.1186/s13223-017-0210-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/04/2017] [Indexed: 11/22/2022] Open
Abstract
Background Treat-to-target therapy approaches are established for chronic diseases such as diabetes, hypertension, and more recently rheumatoid arthritis, resulting in improved patient outcomes. These approaches do not use patient reported outcomes (PRO) as targets of therapy. Chronic spontaneous urticaria (CSU), also called chronic idiopathic urticaria (CIU), is defined as recurrent urticaria of known and unknown cause, lasting more than 6 weeks. Treatment of CSU can be challenging. However, with the advent of proven therapies and validated instruments for measuring disease activity, the concept of treat-to-target (T2T) can be successfully applied to CSU. Herein, we propose a potential PRO therapeutic target and suggest a T2T approach for the management of patients with CSU. Methods Principles and recommendations for a treat-to-target approach in CSU (T2T/CSU) were developed by a Canadian task force, consisting of dermatologists, immunologists, and allergists. The task force formulated recommendations for therapeutic targets in CSU on the basis of a systematic literature review and expert opinion. Results The key features of these T2T/CSU recommendations are the use of a PRO as the principal target, with symptom control as measured by Urticaria Activity Score 7 (UAS7 ≤ 6), targeting symptom remission (UAS7 = 0). Conclusion Treatment targets such as UAS7 ≤ 6 and UAS7 = 0 provide a benchmark for success in the care of patients with CSU, and will permit the evaluation of a PRO-based T2T approach in the care of these patients and the effect of this approach on improved patient care as seen in other chronic diseases.
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Affiliation(s)
- Hermenio Lima
- Division of Dermatology, Department of Medicine, McMaster University, HSC-3U8, 1280 Main St. West, Hamilton, ON L8S 4K1 Canada
| | - Melinda Gooderham
- SKiN Centre for Dermatology and Probity Medical Research, Peterborough, ON Canada
| | - Jan Dutz
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC Canada
| | | | - Hugo Chapdelaine
- Division of Allergy & Immunology, Department of Medicine, Université de Montréal, Montreal, QC Canada
| | - Anne Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON Canada
| | - Martin Gilbert
- Hôpital du Saint-Sacrement du CHU de Québec, Quebec City, QC Canada
| | - Vincent Ho
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC Canada
| | - Kim Papp
- Clinical Research and Probity Medical Research, Waterloo, ON Canada
| | - Yves Poulin
- Department of dermatology, Hôpital Hôtel-Dieu du CHU de Québec, and Centre de Recherche Dermatologique du Québec métropolitain, Quebec City, QC Canada
| | - Gordon Sussman
- Division of Allergy and Clinical Immunology, St. Michael's Hospital, Toronto, ON Canada
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Le M, Miedzybrodzki B, Olynych T, Chapdelaine H, Ben-Shoshan M. Natural history and treatment of cutaneous and systemic mastocytosis. Postgrad Med 2017; 129:896-901. [PMID: 28770635 DOI: 10.1080/00325481.2017.1364124] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Mastocytosis, a heterogeneous group of disorders, is characterized by an abnormal increase in the number of mast cells that is limited to the skin (cutaneous mastocytosis), involving extracutaneous tissues (systemic mastocytosis), or presenting as solid tumours (mastocytoma and mast cell sarcoma). Recent studies estimate that 1 in 10,000 people are diagnosed with mastocytosis. Although prompt diagnosis and appropriate management are crucial, little is known about the natural history and currently there are no established management guidelines. We have conducted a systematic review to assess the natural history and management of different mastocytosis subtypes. METHODS A systematic review and meta-analysis were conducted using the PubMed and Ovid database of studies published in English and French over the last fifteen years, from January 2001 to December 2016. Keywords 'Cutaneous mastocytosis', 'Systemic mastocytosis', 'pathophysiology', 'clinical course', 'prognosis', 'drug therapy', and 'therapy' were searched. Rate of complete resolution was subjected to pooled analysis for different mastocytosis subtypes. Meta-analysis was conducted using Stata version 12.0. RESULTS We reviewed 634 papers, of which 5 were included in the analysis of resolution, and 138 were included in the assessment of management. Pooled estimate for rate of complete resolution varied depending on the mastocytosis subtype. In cutaneous mastocytosis, the complete resolution rate for mastocytoma was 10% per year (95% CI: 4.8%, 15.1%) while the rate for urticaria pigmentosa was 1.9% per year (95% CI: -0.5%, 4.3%). Diffuse cutaneous mastocytosis and systemic mastocytosis subtypes did not show evidence of complete resolution in the studies reviewed. Treatment of cutaneous and systemic mastocytosis is purely symptomatic with topical corticosteroids, antihistamines, omalizumab and imatinib being common choices. CONCLUSION Rate of resolution of mastocytosis is only shown in urticaria pigmentosa and mastocytoma. Better management guidelines are required to improve the health of these patients.
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Affiliation(s)
- Michelle Le
- a Division of Allergy, Immunology and Dermatology, Department of Pediatrics , McGill University Health Centre, Montreal Children's Hospital , Montreal , Canada
| | - Barbara Miedzybrodzki
- a Division of Allergy, Immunology and Dermatology, Department of Pediatrics , McGill University Health Centre, Montreal Children's Hospital , Montreal , Canada
| | - Tim Olynych
- b Department of Medicine , The Ottawa Hospital , Ottawa , Canada
| | - Hugo Chapdelaine
- c Division of Allergy and Immunology, Department of Medicine , Centre Universitaire de Montréal, Cliniques de Montréal , Montreal , Canada
| | - Moshe Ben-Shoshan
- a Division of Allergy, Immunology and Dermatology, Department of Pediatrics , McGill University Health Centre, Montreal Children's Hospital , Montreal , Canada
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Giménez-Arnau AM. Omalizumab for treating chronic spontaneous urticaria: an expert review on efficacy and safety. Expert Opin Biol Ther 2017; 17:375-385. [DOI: 10.1080/14712598.2017.1285903] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ana M Giménez-Arnau
- Dermatology Department, Hospital del Mar IMIM, Universitat Autònoma and Universitat Pompeu Fabra, Barcelona, Spain
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Netchiporouk E, Moreau L, Rahme E, Maurer M, Lejtenyi D, Ben-Shoshan M. Positive CD63 Basophil Activation Tests Are Common in Children with Chronic Spontaneous Urticaria and Linked to High Disease Activity. Int Arch Allergy Immunol 2016; 171:81-88. [PMID: 27846634 DOI: 10.1159/000451084] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/27/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The basophil activation test (BAT) using CD63 expression is a sensitive and specific tool for the diagnostic workup of autoimmune chronic spontaneous urticaria (CSU). The definition of a positive BAT is directly dependent on the reference range and the cutoff values established in control populations. As of now, the pediatric reference range and cutoff values of the CD63 BAT remain to be established. METHODS In this study, we analyzed CD63 expression in 80 children (1-17 years old) without chronic urticaria (i.e., controls) and compared the values to those of a pediatric cohort of 105 CSU patients and 23 physical urticaria (PU) patients. RESULTS Based on the log-normal distribution of CD63 values in control subjects, the reference range and the cutoff for positive CD63 BAT values was established to be 1.2-1.8% (95% CI) and 1.8%, respectively. Children with CSU showed significantly elevated and significantly increased BAT values compared to healthy controls (Wilcoxon rank test p value <0.001). In contrast, no difference was found between BAT results in controls and PU patients. In pediatric CSU patients, a higher disease activity was associated with higher BAT values. CONCLUSIONS Our study provides, for the first time, reference and cutoff values for the CD63 BAT in children. Our findings show that positive CD63 BAT are common in children with CSU and linked to a high disease activity.
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Affiliation(s)
- Elena Netchiporouk
- Division of Dermatology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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29
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Abstract
There have been recent advances in the classification and management of chronic urticaria. The new term chronic spontaneous urticaria (CSU) has replaced chronic idiopathic urticaria and chronic autoimmune urticaria. In addition, chronic inducible urticaria (CINDU) has replaced physical urticaria and includes other forms of inducible urticaria, such as cholinergic and aquagenic urticaria. Furthermore, novel research has resulted in a new understanding with guidelines being revised in the past year by both the American Academy of Allergy, Asthma, and Immunology (AAAAI) and the European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA
2LEN)/European Dermatology Forum (EDF)/World Allergy Organization (WAO). There are some differences in the recommendations, which will be discussed, but the core updates are common to both groups. The basic treatment for chronic urticaria involves second-generation non-sedating non-impairing H
1 antihistamines as first-line treatment. This is followed by up to a 4-fold increase in the licensed dose of these H
1 antihistamines. The major therapeutic advance in recent years has been in third-line treatment with omalizumab, a humanized monoclonal anti-immunoglobulin E (anti-IgE) antibody that prevents binding of IgE to the high-affinity IgE receptor. Several multicenter randomized controlled trials have shown safety and efficacy of omalizumab for CSU. There are also some small studies showing efficacy of omalizumab in CINDU. While there were previously many treatment options which were lacking in strong evidence, we are moving into an era where the treatment algorithm for chronic urticaria is simplified and contains more evidence-based, effective, and less toxic treatment options.
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Affiliation(s)
- Yasmin Moolani
- Division of Clinical Immunology and Allergy, University of Toronto, Toronto, OH, Canada
| | - Charles Lynde
- Division of Dermatology, University of Toronto, Toronto, ON, Canada; Lynderm Research, Lynde Institute for Dermatology, Markham, ON, Canada
| | - Gordon Sussman
- Division of Clinical Immunology and Allergy, University of Toronto, Toronto, OH, Canada; Gordon Sussman Clinical Research Inc, GSCR, Toronto, ON, Canada
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Lee XHM, Ong LX, Cheong JYV, Sultana R, Rao R, Lim HH, Ding XM, Loh WY, Punan M, Chiang WC. A stepwise approach in the management of chronic spontaneous urticaria in children. Asia Pac Allergy 2016; 6:16-28. [PMID: 26844216 PMCID: PMC4731476 DOI: 10.5415/apallergy.2016.6.1.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/19/2016] [Indexed: 12/03/2022] Open
Abstract
Background There is limited literature in the management of chronic urticaria in children. Treatment algorithms are generally extrapolated from adult studies. Objective Utility of a weight and age-based algorithm for antihistamines in management of chronic spontaneous urticaria (CSU) in childhood. To document associated factors that predict for step of control of CSU and time taken to attain control of symptoms in children. Methods A workgroup comprising of allergists, nurses, and pharmacists convened to develop a stepwise treatment algorithm in management of children with CSU. Sequential patients presenting to the paediatric allergy service with CSU were included in this observational, prospective study. Results Ninety-eight patients were recruited from September 2012 to September 2013. Majority were male, Chinese with median age 4 years 7 months. A third of patients with CSU had a family history of acute urticaria. Ten point two percent had previously resolved CSU, 25.5% had associated angioedema, and 53.1% had a history of atopy. A total of 96.9% of patients achieved control of symptoms, of which 91.8% achieved control with cetirizine. Fifty percent of all the patients were controlled on step 2 or higher. Forty-seven point eight percent of those on step 2 or higher were between 2 to 6 years of age compared to 32.6% and 19.6% who were 6 years and older and lesser than 2 years of age respectively. Eighty percent of those with previously resolved CSU required an increase to step 2 and above to achieve chronic urticaria control. Conclusion We propose a weight- and age-based titration algorithm for different antihistamines for CSU in children using a stepwise approach to achieve control. This algorithm may improve the management and safety profile for paediatric CSU patients and allow for review in a more systematic manner for physicians dealing with CSU in children.
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Affiliation(s)
- Xin Hui Magdeline Lee
- Pharmacy Department, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Lin Xin Ong
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Jing Yi Vanessa Cheong
- Pharmacy Department, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Rehena Sultana
- Duke-NUS Graduate Medical School Singapore, Singapore 169857, Singapore
| | - Rajeshwar Rao
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Hwee Hoon Lim
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Xiao Mei Ding
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wen Yin Loh
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Monika Punan
- Pharmacy Department, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wen Chin Chiang
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
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Trevisonno J, Balram B, Netchiporouk E, Ben-Shoshan M. Physical urticaria: Review on classification, triggers and management with special focus on prevalence including a meta-analysis. Postgrad Med 2015; 127:565-70. [DOI: 10.1080/00325481.2015.1045817] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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