Chronic urticaria merits serum vitamin D evaluation and supplementation; a randomized case control study

Impact of Vitamin D on Skin Aging, and Age-Related Dermatological Conditions

Human skin is a physical and biochemical barrier that protects the internal body from the external environment. Throughout a person's life, the skin undergoes both intrinsic and extrinsic aging, leading to microscopic and macroscopic changes in its morphology. In addition, the repair processes slow with aging, making the older population more susceptible to skin diseases. Intrinsic factors associated with advanced age gradually degrade the dermal collagen matrix, resulting in fine wrinkles and reduced elasticity; this is accelerated in post-menopausal women due to estrogen deficiency. In contrast, extrinsic factors associated with advanced age, primarily caused by exposure to ultraviolet (UV) radiation, lead to coarse wrinkles, solar elastosis, hyperkeratosis, irregular pigmentation, and skin cancers. UVB radiation, while contributing to skin photo-aging, also induces the cutaneous synthesis of vitamin D. Vitamin D, in turn, protects the skin from oxidative stress, inflammation, and DNA damage, thereby delaying both chronological and photo-aging. Moreover, research has demonstrated an association between lower vitamin D levels and a higher prevalence of certain cutaneous diseases. This review explores and summarizes the critical role of vitamin D in skin aging and age-related skin diseases. The data presented highlight the importance of maintaining vitamin D adequacy throughout life.

Efficacy and Safety of Systemic Corticosteroids for Urticaria: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Short courses of adjunctive systemic corticosteroids are commonly used to treat acute urticaria and chronic urticaria flares (both with and without mast cell-mediated angioedema), but their benefits and harms are unclear.

OBJECTIVE

To evaluate the efficacy and safety of treating acute urticaria or chronic urticaria flares with versus without systemic corticosteroids.

METHODS

We searched the MEDLINE, EMBASE, CENTRAL, CNKI, VIP, Wanfang, and CBM databases from inception to July 8, 2023, for randomized controlled trials of treating urticaria with versus without systemic corticosteroids. Paired reviewers independently screened records, extracted data, and appraised risk of bias with the Cochrane 2.0 tool. We performed random-effects meta-analyses of urticaria activity, itch severity, and adverse events. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach.

RESULTS

We identified 12 randomized trials enrolling 944 patients. For patients with low or moderate probability (17.5%-64%) to improve with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by a 14% to 15% absolute difference (odds ratio [OR], 2.17, 95% confidence interval [CI]: 1.43-3.31; number needed to treat [NNT], 7; moderate certainty). Among patients with a high chance (95.8%) for urticaria to improve with antihistamines alone, add-on systemic corticosteroids likely improved urticaria activity by a 2.2% absolute difference (NNT, 45; moderate certainty). Corticosteroids may improve itch severity (OR, 2.44; 95% CI: 0.87-6.83; risk difference, 9%; NNT, 11; low certainty). Systemic corticosteroids also likely increase adverse events (OR, 2.76; 95% CI: 1.00-7.62; risk difference, 15%; number needed to harm, 9; moderate certainty).

CONCLUSIONS

Systemic corticosteroids for acute urticaria or chronic urticaria exacerbations likely improve urticaria, depending on antihistamine responsiveness, but also likely increase adverse effects in approximately 15% more.

The Correlation between Serum Vitamin D and Total IgE Levels and Chronic Spontaneous Urticaria among Chinese Population: A Retrospective Study

Objective

This study aims to investigate the relationship between serum vitamin D, total IgE levels and chronic spontaneous urticaria (CSU).

Methods

We collected data from 101 patients with chronic spontaneous urticaria (experimental group) and 115 healthy normal subjects (control group) in the same period of physical examination.

Results

The results showed that the number of deficient and absolute deficient 25-hydroxyvitamin D in the experimental group was significantly lower than in the control group (P < 0.05). Pearson correlation analysis showed that the activity score of CSU patients was negatively correlated with serum vitamin D (r = -0.2278, P = 0.0220) and positively correlated with IgE (r = 0.2078, P = 0.0380). It was observed that serum vitamin D in CSU patients was negatively correlated with their activity (r = -0.2278, P = 0.0220) and positively correlated with age (r = 0.2675, P = 0.0069). The Point-biserial correlation analysis revealed that gender was positively correlated with serum vitamin D (Pearson correlation coefficient = 0.286, P = 0.004) and UAS score (Pearson correlation coefficient = 0.273, P = 0.006). Ordinal logistic regression analysis showed that only serum vitamin D was correlated to activity scores (P = 0.008). In addition to activity scores, age (P = 0.005) and gender (P = 0.04) were correlated to serum vitamin D.

Conclusion

The activity score of CSU patients was negatively correlated with serum vitamin D and positively correlated with IgE. Serum vitamin D in CSU patients was negatively correlated with activity score and disease duration and positively correlated with age and gender.

Urticaria and Angioedema: Understanding Complex Pathomechanisms to Facilitate Patient Communication, Disease Management, and Future Treatment

Chronic spontaneous urticaria (CSU) is primarily a T2-dominant disease with a complex genetic background. Skin mast cell activation can be induced not only via the IgE-FcεRI axis but also from several other distinct mechanisms, molecules, and receptors involved in CSU onset, persistence, and exacerbation. These include autoallergy, autoimmunity, central or peripheral neuroimmune dysregulation, activation of both extrinsic and intrinsic coagulation pathways, and microbial infections. Besides mast cells, recent reports suggest the active and direct involvement of basophils and eosinophils. Several biological characteristics or biomarkers have been linked with CSU's known endotypes and may help forecast therapeutic responses. The introduction of biologic therapy for CSU has been a major advance in the last 10 years. The cornerstone of angioedema (AE) pathogenesis is increased vascular permeability and plasma leakage into the deeper dermis and subcutis, either mediated by histamine or bradykinin (BK). C1-inhibitor deficiency, hereditary or acquired, is the primary cause of BK-mediated AE due to increased plasma BK concentration. Other complex conditions have been identified, with some likely involving contact system dysregulation and other putative mechanisms related to vascular endothelial dysfunction. The approval of multiple hereditary-AE-specific therapies for both prevention and acute attacks has revolutionized treatment of this disease. Any new knowledge of the pathogenesis of CSU and AE offers the opportunity to improve patient information, physician-patient communication, prediction of therapeutic responses, selection of precise tailor-made treatment for each patient, and exploration of novel treatment options for those who do not achieve disease control with current medications.

Nutrition and urticaria

Urticaria is a distressing dermatologic condition for many. Although the wheals of urticaria are characteristically evanescent, lasting less than 24 hours, patients tend to have recurrent episodes. Hives that last less than 6 weeks are considered acute urticaria. Acute urticaria does not routinely require supplementary work-up because the history often identifies a convincing, inciting allergen. Chronic urticaria is defined as episodes that occur for longer than 6 weeks, and there is often not an easily identifiable trigger. For both acute and chronic urticaria, patients frequently report food as a precipitating cause. For acute urticaria, the foods that are associated with true allergies, such as nuts and shellfish, are the most frequent offenders. The relationship between diet and chronic urticaria is not as firmly defined. Many patients unnecessarily restrict their diets, so it becomes the role of dermatologists to help patients identify if there is a reproducible link between their symptoms and their dietary exposures. The literature suggests that diets free from pseudoallergens and histamine-releasing foods may attenuate urticaria. Supplements such as fats, vitamin D, iron, and flavonoids have also been studied and may diminish symptoms.

Effects of Serum Vitamin D Levels and Vitamin D Supplementation on Urticaria: A Systematic Review and Meta-Analysis

(1) Backgrounds: Several studies have shown that the level of 25-hydroxyvitamin D (25(OH)D) could affect urticaria. The association of Vitamin D (VitD) with urticaria has not been well established. (2) Methods: The up-to-date meta-analysis was performed to synthesize the new findings. We performed a systematic search in PubMed, EMBASE, Web of Science, and Cochrane Database. We included the observational studies with the comparisons of 25(OH)D between urticarial populations and controls and clinical studies with the clinical severity of urticaria records. (3) Results: A meta-analysis of seventeen studies of urticaria group vs. controls revealed a mean difference of −9.35 ng/mL (95% CI −12.27 to −6.44). There was also an association of urticaria with VitD deficiency. In the subgroup analysis of age and disease type, significant effects of 25(OH)D were found among adult and chronic urticarial populations. Six VitD supplementation trials showed a significant reduction in clinical urticarial score on intervention with VitD with the standard mean difference of −3.63 and −1.54 among randomized control studies and repeated measure trials, respectively. (4) Conclusions: The urticarial population, especially the adult chronic urticarial patients, may be associated with a high risk for lower serum 25(OH)D. VitD supplementations could result in a reduction of urticarial clinical symptoms.

Efficacy and safety of active vitamin D supplementation in chronic spontaneous urticaria patients

Background: Chronic spontaneous urticaria (CSU) is a common skin disorder affecting negatively patients' lives. Vitamin D deficiency has been reported to be associated to many allergic skin disorders.Objective: This study aimed to evaluate the association between the serum level of 25 hydroxy vitamin D and CSU and to assess the efficacy and safety of active vitamin D in management of CSU.Methods: The study was conducted on 77 patients with CSU and 67 healthy controls, then the 77 CSU patients were randomized to either the study group that received 0.25 µg alfacalcidol daily or the placebo group that received oral placebo for 12 weeks.Results: Serum 25(OH) D was significantly lower in CSU as compared to healthy controls and was negatively correlated to the urticarial severity. After alfacalcidol administration, the study group showed significant higher level of 25(OH) D compared to the placebo group. In addition, the mean serum level of IL6, hsCRP and TNFα significantly decreased in the study group in comparison to the placebo group and as compared to their baseline results.Conclusion: Vitamin D deficiency is more common in CSU patients as compared to healthy people and hence, alfacalcidol might have a beneficial role as add on therapy in CSU management with no reported side effects.

Emerging Biomarkers and Therapeutic Pipelines for Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined as the appearance of evanescent wheals, angioedema, or both, for at least 6 weeks. CSU is associated with intense pruritus and poor quality of life, with higher odds of reporting depression, anxiety, and sleep difficulty. As of yet, the assessment of the activity and course of the disease along with the response to several treatments in CSU are based purely on the patient's medical history and the use of the patient-reported outcomes. Recently, several reports have suggested that certain parameters could be considered as potential disease-related biomarkers. Moreover, with the advent of such biomarkers, newer biologic agents are coming forth to revolutionize the management of potential refractory diseases such as CSU. The purpose of this article is to review the most promising biomarkers related to important aspects of CSU, such as the disease activity, the therapeutic response, and the natural history of the disease, and discuss the mechanisms of action and therapeutic effectiveness of the latest agents available or currently under investigation for the management of antihistamine-refractory CSU. The knowledge of these features could have an important impact on the management and follow-up of patients with CSU.

Stress, pseudoallergens, autoimmunity, infection and inflammation in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is often associated with organ specific autoimmunity but is rarely caused by food allergy. Colourings and preservatives in pre-packaged foods, so called pseudoallergens, have also been implicated. Factors that promote inflammation or reduce anti-inflammatory mechanisms may however, predispose susceptible individuals to CSU. Chronic underlying infection and mental and emotional stress can sometimes precede the onset of CSU and once established can exacerbate the symptoms. There is early evidence of dysbiosis within the gastrointestinal tract in people with CSU and reduced levels of vitamin D are also evident. The latter may be related to the importance of vitamin D3 in increasing T regulatory function which can control a tendency to autoimmunity. It is quite possible that a state of on-going chronic inflammation with reduced anti-oxidant mechanisms may underlie the not infrequent association between CSU and metabolic syndrome. Effective treatment of CSU should involve the use of anti-histamines, intermittent steroids and anti-IgE therapy. For recalcitrant disease immune modulatory therapy has a place. However, talking therapies that reduce stress and anxiety, vitamin D3 supplementation, correction of intestinal dysbiosis and treatment of any chronic infection should also be considered.

Effects of combination of mizolastine and proteoglycan on chronic urticaria: a randomized controlled trial

The present study aimed to observe the therapeutic effect of combined mizolastine and proteoglycan in chronic urticaria. The patients were randomly divided into the treatment group (n = 56) and the control group (n = 44). The treatment group was medicated with calcium gluconate (10 mg/ time, 1 time/day), vitamin D3 (intramuscular 10 mg/time, 1 time/week), mizolastine (10 mg/time, 1 time/day), and proteoglycan (1.2 g/time, 3 times/day), while the control group was administered with the same drugs except proteoglycan for 4 weeks. After treatment with combined mizolastine and proteoglycan, therapeutic effect with symptoms decline index (SDI) more than 60% was significant different (44 vs. 24, p = 0.000973) and the relapse rate after 2 months was significantly lower (17.9% vs. 38.6%, p = 0.0202). Using ELISA, we found that the IFN-γ (37.88 ± 4.27 pg/mL vs. 21.91 ± 4.95 pg/mL, p = 0.028) levels were specifically increased in the experiment group. The combination of mizolastine plus proteoglycan is effective in treating chronic urticaria with better therapeutic effect and lower relapse rate through promoting IFN-γ production.

Relationship between vitamin D and chronic spontaneous urticaria: a systematic review

BACKGROUND

Vitamin D has been reported to be associated with many allergic diseases. There are a limited number of the studies of vitamin D supplementation in patients with chronic spontaneous urticaria (CSU). This study aims to study the relationship between vitamin D and CSU in terms of serum vitamin D levels, and the outcomes of vitamin D supplementation.

METHODS

A literature search of electronic databases for all relevant articles published between 1966 and 2018 was performed. The systematic literature review was done following Preferred Reporting Items for Systematic Reviews and Meta-analysis recommendations.

RESULTS

Seventeen eligible studies were included. Fourteen (1321 CSU cases and 6100 controls) were concerned with serum vitamin D levels in CSU patients. Twelve studies showed statistically significant lower serum vitamin D levels in CSU patients than the controls. Vitamin D deficiency was reported more commonly for CSU patients (34.3-89.7%) than controls (0.0-68.9%) in 6 studies. Seven studies concerned with vitamin D supplementation in CSU patients showed disease improvement after high-dosages of vitamin D supplementation.

CONCLUSION

CSU patients had significantly lower serum vitamin D levels than the controls in most studies. However, the results did not prove causation, and the mechanisms were not clearly explained. Despite the scarcity of available studies, this systematic review showed that a high dosage of vitamin D supplementation for 4-12 weeks might help to decrease the disease activity in some CSU patients. Well-designed randomized placebo-controlled studies are needed to determine the cut-off levels of vitamin D for supplementation and treatment outcomes.

Alternative treatments for chronic spontaneous urticaria beyond the guideline algorithm

PURPOSE OF REVIEW

The international EAACI/GALEN/EDF/WAO guideline suggests a stepwise approach for the therapeutic management of chronic spontaneous urticaria (CSU), outlined in an algorithm. The aim of this article is to summarize and review the evidence available on alternative treatment options for CSU outside of this algorithm.

RECENT FINDINGS

Although CSU is a common disease, there are a limited number of high-quality studies, and only antihistamines and omalizumab are licensed for its treatment. Most studies regarding alternative therapies for CSU show methodological limitations and a high risk of bias. For many therapies, only case reports and uncontrolled studies exist. Recent publications on alternative treatments for chronic urticaria/CSU include reports on the use of adalimumab, rituximab, vitamin D, probiotics, histaglobulin, injection of autologous whole blood or serum, and phototherapy.

SUMMARY

Numerous treatments beyond the guideline algorithm have been evaluated in patients with refractory CSU. The global level of evidence to support their efficacy in CSU is low or very low. Further research is needed to assess the efficacy and safety of alternative therapies of CSU to manage adequately those patients who do not respond to the treatments included in the algorithm.

Evaluation of 1,25-dihydroxyvitamin D3 pathway in patients with chronic urticaria

BACKGROUND

Previous studies showed the role of vitamin D (Vit D) on the progression of chronic urticaria. To the best of our knowledge, there are no other results regarding the contribution of single nucleotide polymorphisms (SNPs) in the vitamin D receptor (VDR) and vitamin D binding protein (VDBP) genes in chronic urticaria (CU).

AIM

In the present study, we investigated the Vit pathway and the association between VDR and VDBP gene polymorphisms and CU risk in Iranian population.

METHODS

All participating individuals in the present study were evaluated for serum Vit D and VDBP concentration VDR rs1544410 and rs2228570 and VDBP rs7041using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. The associations of studied analytes and three SNPs with clinical and laboratory outcomes were investigated in CU patients.

RESULTS

Patients with CU showed lower Vit D compared to controls (19.26 ± 1.26 vs. 31.72 ± 7.14 ng/ml, P-value = 0.006). There was a significant correlation between Vit D levels and urticaria activity score. Serum VDBP was significantly higher in CU patients than controls (1317.3 ± 183.71 vs. 395.77 ± 12.96 µg/ml, P-value <0.0001) and had a positive correlation to progression of CU. The A allele of this polymorphism might be a potential risk factor for progression of CU [odds ratio 4.3434, 95% confidence interval (1.7331-10.8852), Z-statistic = 3.133, P-value = 0.0017].

CONCLUSION

In summary, this study demonstrated that change in Vit D pathway in the level of gene or protein may be a risk factor for progression of CU.

Urticaria Diagnosis

Urticaria is a common skin condition that, though rarely fatal, can seriously impair a patient’s quality of life. Urticaria is caused by cutaneous mast cell activation and degranulation disease triggered by numerous stimuli. The condition is defined as chronic if it persists for >6 weeks. Self-remission is common in acute urticaria, but in chronic cases less than half of patients achieve remission within 1 year. Diagnosis is typically reached using the patient’s history along with a physical examination. Laboratory workup is based on clinical suspicion and is used to exclude underlying causes, although most cases constitute unknown or spontaneous causes. Extensive routine testing for an exogenous cause is not necessary and does not change the management. This review details the pathophysiology, aetiology, diagnosis, investigation, prognosis, differential diagnosis, and assessment of disease severity, highlighting the potential diagnosis of urticaria and enabling clinicians to make informed assessment decisions.

Potential blood biomarkers in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a mast cell-driven disease that is defined as the recurrence of weals, angioedema or both for > 6 weeks due to known or unknown causes. As of yet, disease diagnosis is purely clinical. Objective tools are needed to monitor the activity of CSU and the efficacy of treatment. Recently, several reports have suggested that blood parameters may be considered as potential disease-related biomarkers. Here, we reviewed available literature on blood biomarkers for CSU diagnosis, activity monitoring, duration, patient subgroup allocation or response to treatment. We performed a PubMed, Google Scholar and Web of Science search and identified and analysed 151 reports published prior to January 2016. We found strong evidence for significant differences between patients with CSU and healthy controls in blood levels or values of D-dimer, C-reactive protein (CRP), matrix metalloproteinase-9 (MMP-9), mean platelet volume (MPV), factor VIIa, prothrombin fragment 1 + 2 (F1 + 2), tumour necrosis factor, dehydroepiandrosterone sulphate and vitamin D. Also, there is strong evidence for a significant association between CSU activity and blood levels or values of D-dimer, F1 + 2, CRP, IL-6 and MPV. Strong evidence for reduced basophil count and high levels of IgG anti-FcεRI in the subgroup of CSU patients with positive autologous serum skin test was shown. In contrast, the evidence for all reported blood biomarkers for differentiating CSU from other diseases, or a role in prognosis, is weak, inconsistent or non-existent. Taken together, we identified 10 biomarkers that are supported by strong evidence for distinguishing patients with CSU from healthy controls, or for measuring CSU activity. There is a need for further research to identify biomarkers that predict outcome or treatment response in CSU.

Factors linked to disease severity and time to remission in patients with chronic spontaneous urticaria

Biomarkers useful for the evaluation and management of patients with chronic spontaneous urticaria (CSU) are not currently available. A review of various clinical and laboratory markers that have been studied to assess their value for determining the severity or predicting the evolution of disease in adult patients with CSU was carried out. A search of the medical literature on PubMed and MEDLINE including the terms urticaria, chronic urticaria, chronic idiopathic urticaria, CSU, severity, prognosis and treatment was performed. Based on our review of the literature, among the clinical markers studied, higher age at onset, being female, long disease duration and aspirin/NSAID hypersensitivity may be linked to both severe CSU and a long time to spontaneous remission. In addition, a positive autologous serum skin test (ASST) may be associated with severe CSU, and comorbidity of inducible urticaria and concomitant recurrent angio-oedema may be linked to longer CSU duration. Potential biomarkers of CSU severity and/or duration include basophil numbers and susceptibility to activation, inflammatory markers, markers of activation of the extrinsic coagulation pathway, immunoglobulin E and vitamin D. Although the described markers are promising, further studies on representative and well-characterized patient populations are needed to determine the value of these clinical and biological markers for predicting the severity and course of disease in patients with CSU.