Effect of Diet in Chronic Spontaneous Urticaria: A Systematic Review

Strategies for diets in chronic spontaneous urticaria (CSU) are controversial. This systematic review assessed the interest in diet for managing CSU. We searched for original reports in MEDLINE, EMBASE, CENTRAL and LILACS. Among the 278 reports screened, 20 were included, involving 1,734 patients. Reports described 3 types of systematic diet: pseudoallergen-free diet (n = 1,555 patients), low-histamine diet (n = 223) and diet without fish products (n = 47), which induced complete remission in 4.8%, 11.7% and 10.6% of patients, respectively, and partial remission in 37.0%, 43.9% and 4.3%. Eight reports described personalized exclusion diets (66 patients) adapted to symptoms/allergological test results and led to complete remission in 74.6% of patients, although the diagnosis of CSU was doubtful. No comparative randomized studies of diets were available. The only randomized studies were based on oral provocation tests with the suspected responsible diet. Population and outcomes were heterogeneous. In conclusion, there is evidence for the benefit of diets in CSU only in individual patients with clinical symptoms. However, the level of evidence is low for the benefit of systematic diets in CSU because systematic double-blind controlled trials of diet are lacking.

Diagnostic and Therapeutic Iter in Chronic Urticaria Patients

We describe a diagnostic and therapeutic protocol for the management of chronic urticaria. It is derived from an extensive review of current literature, with a cost-effective evaluation of laboratory investigations and therapeutic approaches. Our protocol may not represent a cornerstone for chronic urticaria: much has in fact to be clarified on pathogenetic mechanisms and aetiological factors. Nevertheless, its application should be able, in our opinion, to identify what is useful or not in the everyday management of chronic urticaria patients.

Diet in dermatology: Part II. Melanoma, chronic urticaria, and psoriasis

The roles of dietary factors in aggravating, preventing, or treating skin diseases are common questions encountered in dermatology practice. Part II of this two-part series reviews dietary modifications that can potentially be utilized in the management of melanoma, chronic urticaria, and psoriasis patients. Specifically, we examine the effect of alcohol consumption and supplementation with vitamins D and E, polyunsaturated fatty acids, selenium, green tea, resveratrol, and lycopene on melanoma risk. The relationships between chronic urticaria symptoms and dietary pseudoallergens, gluten, and vitamin D are analyzed. We explore weight loss, reduced alcohol consumption, and gluten avoidance as means of reducing psoriasis-associated morbidity, as well as the possible utility of supplementation with polyunsaturated fatty acids, folic acid, vitamin D, and antioxidants. With proper knowledge of the role of diet in these cutaneous disease processes, dermatologists can better answer patient inquiries and consider implementation of dietary modifications as adjuncts to other treatments and preventative measures.

Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the first 5 years of life

BACKGROUND

A mixture of neutral prebiotic oligosaccharides has been shown to reduce the incidence of atopic dermatitis (AD) and allergy associated symptoms during the first 2 years of life.

OBJECTIVE

To evaluate if this protective effect against allergy lasted beyond the intervention period until 5 y of age.

METHODS

In a prospective, double blind, placebo-controlled fashion, healthy term infants at risk of atopy were fed either a prebiotic-supplemented (0.8 g/100 ml scGOS/lcFOS) or placebo-supplemented (0.8 g/100 ml maltodextrin) hypoallergenic formula during the first 6 mo of life. Following this intervention period, follow-up continued until 5 y of life. The present study evaluated (i) the cumulative incidence of allergic manifestations during 5 y, and (ii) the prevalence of allergic and persistent allergic manifestations at 5 y. Monitored allergic manifestations were AD, recurrent wheezing, allergic rhinoconjunctivitis and urticaria.

RESULTS

Ninety-two children (50 in placebo group, 42 in intervention group) completed the 5-y follow-up. The 5-y cumulative incidences of any allergic manifestation and atopic dermatitis were significantly lower in the scGOS/lcFOS group (30.9, 19.1 %, respectively) compared to placebo group (66, 38 %, respectively) (p< 0.01 and< 0.05). Children in the scGOS/lcFOS group tended to have a lower incidence of allergic rhinoconjunctivitis, and allergic urticaria (4.8 vs 16% for both manifestations, p=0.08). There was no difference in the cumulative incidence of recurrent wheezing. With regard to the prevalences at 5 y, intervention group had significantly lower prevalence of any persistent allergic manifestation and rhinoconjunctivitis (4.8, 2.4 %, respectively) compared to placebo (26, 14 %, respectively) (p < 0.01 and =0.05). Prevalence of persistent AD tended to be lower in the intervention group (2.4 vs 12%, p= 0.09). Although intervention group had 75% reduction in the prevalence of persistent wheezing (4.8 vs 14 %), no significance was shown.

CONCLUSION

Oligosaccharide prebiotics (scGOS/lcFOS), when started early in life have a protective effect against allergic manifestations in high risk infants. The protection lasts beyond infancy until 5 y of life, for AD and allergic rhinoconjunctivitis. Long-term follow-up studies in larger populations are warranted to evaluate the potential preventive effect of this mixture on asthma.

Eosinophilic esophagitis, celiac disease, and immunoglobulin E-mediated allergy in a 2-year-old child

Celiac disease, eosinophilic esophagitis, and urticaria are 3 manifestations of food allergy with different pathogenic mechanisms. We report the case of a 2-year-old child with digestive symptoms, slow growth, and severe asthma. The results of skin prick tests were positive to several foods. Endoscopy revealed eosinophilic esophagitis and celiac disease. Treatment consisted of a gluten-free diet and a 1-month course of oral corticosteroids. Endoscopy and biopsy findings were normal at 5 years of age. A gluten-free diet is the basis of treatment of celiac disease, but the role of an elimination diet in eosinophilic esophagitis is not well established. Our patient also developed urticaria when exposed to milk and egg.We present, to our knowledge, the first report of a patient with celiac disease, eosinophilic esophagitis, and immediate-type immunoglobulin E-mediated food allergy.

Effects of a pseudoallergen-free diet on chronic spontaneous urticaria: a prospective trial

BACKGROUND

Chronic spontaneous urticaria is a skin disorder that is difficult to manage and can last for years. 'Pseudoallergens' are substances that induce hypersensitive/intolerance reactions that are similar to true allergic reactions. They include food additives, vasoactive substances such as histamine, and some natural substances in fruits, vegetables and spices. Eliminating pseudoallergens from the diet can reduce symptom severity and improve patient quality of life.

AIM

To assess the effects of a pseudoallergen-free diet on disease activity and quality of life in patient's chronic spontaneous urticaria.

METHODS

Study subjects had moderate or severe chronic spontaneous urticaria that had not responded adequately to treatment in primary care. For 3 weeks, subjects followed a pseudoallergen-free diet. They kept a clinical diary, which recorded their wheal and pruritus severity each day, to yield a clinical rating of chronic spontaneous urticaria severity (the UAS4 score). The subjects also completed the DLQI, a validated quality-of-life instrument. Use of antihistamines and glucocorticoids was minimized, recorded, and analysed. Subjects were classified into nine response categories, according to the changes in symptom severity (UAS4), quality of life (DLQI) and medication usage.

RESULTS

From the 140 subjects, there were 20 (14%) strong responders and 19 (14%) partial responders. Additionally, there were nine (6%) subjects who made a substantial reduction in their medication without experiencing worse symptoms or quality of life.

CONCLUSIONS

Altogether the pseudoallergen-free diet is beneficial for one in three patients. The pseudoallergen-free diet is a safe, healthy and cost-free measure to identify patients with chronic spontaneous urticaria that will benefit from avoiding pseudoallergens.

Italian position paper on urticaria. Italian Board on Urticaria

The Italian Board on Urticaria has prepared a document focusing on the definition and classification of urticaria, taking into account the recent progress in identifying the causes, eliciting factors, and pathomechanisms of this disease. As urticaria has a profound impact on the quality of life, effective treatment is important. Therefore, specific treatment options for the management of urticaria are evaluated on the basis of the recent literature. Non-sedating H(1) antihistamines are recommended as the first-line treatment as they have proven effective in several randomized double-blind controlled studies. Dosages higher than those recommended may be necessary in some cases. However, additional or alternative therapies may be required for different urticaria subtypes and in view of individual variations in the course of the disease and response to treatment. Immunosuppressive drugs such as corticosteroids are not recommended for long-term treatment due to unavoidable, severe adverse effects.

Role of contact sensitization in chronic urticaria

We tested the hypothesis that contact allergy plays a role in chronic urticaria, and included the Italian series of patch tests in the diagnostic workup. Of 121 patients with chronic urticaria, 50 (41%) tested positive to contact allergens. In all patients, avoidance measures led to a complete remission within 1 month. We suggest that testing for contact sensitization can be helpful in the management of chronic urticaria.

Chronic urticaria: a cutaneous manifestation of celiac disease

Celiac disease, or gluten-sensitive enteropathy, is an immune-mediated disease of the small bowel that results in malabsorption. It classically presents with gastrointestinal symptoms including chronic diarrhea, weight loss, abdominal bloating and anorexia. It is becoming more frequently identified in asymptomatic patients with a diagnosis of deficiencies related to malabsorption of iron, folic acid, vitamin B12 and vitamin D. It is increasingly identified as a cause for early or refractory osteoporosis. Occasionally, celiac disease presents with cutaneous manifestations alone. Dermatitis herpetiformis is a well-recognized cutaneous manifestation of celiac disease. Other cutaneous manifestations include alopecia, angular stomatitis and aphthous ulcerations. Described here is a case of a 24-year-old woman who presented with intermittent urticaria and gastrointestinal complaints. She was found to have celiac disease on small-bowel biopsy. Both her gastrointestinal symptoms and urticaria resolved when she was put on a gluten-free diet, suggesting that her urticaria was a cutaneous manifestation of celiac disease.

Chronic urticaria and associated coeliac disease in children: a case-control study

Celiac disease (CD) and chronic urticaria (CU) are both sustained by immune mechanisms, but there are so far few data on their clinical association. We performed a case-control study to determine the occurrence of CD in urticaria and matched control children, and to assess the clinical relevance of this association. Children and adolescents were diagnosed to have severe chronic idiopathic urticaria in the presence of hives for more than 6 wk poorly or not responsive to oral antihistamines. Other known causes of urticaria had to be excluded. A matched control group without urticaria was enrolled. In both groups, the presence of CD was searched by assaying antitransglutaminase and antiedomysial antibodies, and confirmed with endoscopic intestinal biopsy. Results. CD was diagnosed and confirmed in 4/79 (5.0%) of children with CU and in 17/2545 (0.67%) of the controls (p = 0.0003). In the four children with urticaria and CD the gluten free diet (GFD) lead to complete remission of urticaria within 5-10 wk, whereas the disappearance of serological markers occurred in longer times (5-9 months).

CONCLUSIONS

The presence of CD in children with CU was significantly more frequent than in controls. GFD resulted in urticaria remission. CD may be regarded in such subjects as a cause of CU.

Allergy and parasites reevaluated: wide-scale induction of chronic urticaria by the ubiquitous fish-nematode Anisakis simplex in an endemic region

BACKGROUND

The ubiquitous fish-nematode Anisakis simplex produces acute urticaria or angioedema in the course of gastro-allergic anisakiasis. We studied the relationship between this nematode and chronic urticaria (CU), as well as the clinical usefulness of measuring specific IgG4 in A. simplex-sensitized patients with CU.

METHODS

First, the prevalence of sensitization to A. simplex was estimated in 135 consecutive CU patients and the result was compared with known data about sensitization in a healthy population. Then, clinical response to a 2-month diet without fish was analyzed in 76 CU patients. The improvement rate in patients with and without sensitization to A. simplex was compared. Finally, the improvement rate, other clinical data and specific immunoglobulins in sensitized patients with and without detectable specific IgG4 were compared.

RESULTS

a) The A. simplex sensitization rate in CU patients was 52.6 % compared with a known prevalence of between 16 and 20 % in our region. b) Of 65 sensitized patients, 52 experienced clinical improvement after the diet compared with only three of 11 patients without sensitization to A. simplex (p = 0.001). c) Of 43 patients with detectable specific IgG4, 38 showed clinical improvement compared with only 14 of 22 patients without detectable IgG4 (p = 0.02). Eight of nine patients with previous fish-associated cutaneous symptoms had detectable specific IgG4 compared with 15 of 32 patients who reported no previous fish-associated symptoms or acute urticaria (p = 0.03).

CONCLUSIONS

Our results indicate that A. simplex is a possibly widespread etiologic agent able to induce CU. This parasite model constitutes the first report that associates an infectious agent with CU on a large scale. The detection of IgG4 antibodies reflects a previous acute parasitic infection and a temporary diet without fish improves symptoms in most patients with detectable specific IgG4.

Is Anisakis simplex responsible for chronic urticaria?

The association of chronic urticaria (CU) to parasitic infestations has been poorly studied. Recently, sensitization to the parasite larva Anisakis simplex has been described as the cause of acute urticaria and anaphylaxis. The aim of this work was to study the relationship between sensitization to A. simplex and CU. One hundred one patients with CU were studied. Data of possible contacts with A. simplex were collected and the usual CU study was performed. Furthermore, total and specific immunoglobulin E (IgE; Pharmacia CAP system IGE fluorescence enzyme immunoassay: CAP) to A. simplex, Ascaris lumbricoides, Echinococcus granulosus, and Toxocara canis were determined as well as skin-prick test with A. simplex and serology to E. granulosus. In accordance with the results of the CAP to A. simplex, the patients were divided into two groups, positive and negative, and, subsequently, subdivided into two other subgroups that were alternatively told to stop eating fish or seafood in their diet or to continue with their normal diet. Checkups were performed at 6, 12, and 18 months. Thirty-five percent of the patients had positive skin tests to A. simplex, and CAP to A. simplex was positive in 55%. The fish-eating habits, acute or chronic gastrointestinal disease, and the background of abdominal surgery were not related to the results of the CAP and/or skin test to A. simplex. A total of 21.8% of all the patients had detectable CAP to A. lumbricoides, 91% of whom had positive CAP to A. simplex. Three patients had specific IgE to T. canis and five patients had specific IgE to E. granulosus, in the absence of positive serology. All had specific IgE to A. simplex. Present infestation could not be proved in any of them. The clinical evolution and variations of CAP to A. simplex and of total IgE were not statistically different among the groups during the 6, 12, and 18 months of the study. The percentage of sensitization to A. simplex in patients with CU is elevated and determines the sensitization to other parasites because of cross-reactivity. We have not found any causal relationship between the presence of specific IgE to A. simplex and CU. The clinical importance of this finding in this disease is still undetermined.

An overview of chronic urticaria

Acknowledging urticaria as a symptom of mast cell degranulation is stressed. The biology of the mast cell, and the recognized immunologic and non-immunologic mast cell secretagogues are individually discussed along with mechanisms of activation and mediators released. The major, preformed mediator histamine in the skin produces a prototypic, short-lived urticaria, however, the clinical spectrum and pattern of "hives" indicate that other mediators contribute to the polymorphism and variable behavior of this symptom. The clinical assessment is almost exclusively restricted to the history and physical examination. Features to review and examine are presented. The cause of "acute" urticaria is identifiable (by history) in the majority of patients, and except for hives that accompany an anaphylactic reaction, these patients rarely present to the physician for care. The persistent, or "chronic" hiver whose history cannot elicit a cause, is rarely triggered by an individual trigger, despite extensive professional evaluation. Evidence to support changing the chronological, "acute" and "chronic" classification of urticaria to "identifiable" and "non-identifiable" triggered urticaria is discussed, as is the futility of extensive, costly laboratory work-ups. The natural history of urticaria reveals that management should be directed toward allowing the patient to maintain an acceptable quality of life (with or without some urticaria), until the episode resolves.

The role of allergens and pseudoallergens in urticaria

Adverse reactions to food are a frequently discussed cause of urticaria. In acute urticaria 63% of patients suspect food as the eliciting factor; however, this cannot be confirmed in prospective studies. In adults the rate of type I allergic reactions is below 1%, although in children the percentage appears to be higher. Also in chronic urticaria type I allergic reactions play only a minor role as an eliciting factor. The same holds for the physical urticarias. The role of pseudoallergic reactions has not been investigated for all types of urticaria, but apparently they are not important in physical urticarias; however, in acute urticaria pseudoallergic reactions against NSAID are responsible for approximately 9% of cases, and in a subset of patients with chronic urticaria a diet low in pseudoallergens has been proven to be beneficial in several studies, with response rates observed in more than 55% of patients. Double-blind, placebo-controlled challenge tests have shown that artificial food additives are not only to blame, with the majority of reactions being traced back to naturally occuring pseudoallergens in food.

Specific and total IgE in patients with recurrent, acute urticaria caused by Anisakis simplex

Titres of parasite-specific IgE were investigated in 19 patients thought to have recurrent, acute urticaria caused by sensitization to Anisakis simplex (Dujardin, 1845), before and after they were placed on a fish-free diet. Patients with other allergic disease and those being treated with corticosteroids or antihistaminics were excluded. Skin-prick tests were carried out with A. simplex extract, and blue- and white-fish extracts. The CAP system (Pharmacia), a commercial test kit developed for the assay of food-specific IgE, was used to monitor serum concentrations of total IgE and antigen-specific IgE against Anisakis, Ascaris, Echinococcus, Toxocara, tuna, salmon, shrimp, mussel and cod. Before going on a fish-free diet, the 19 patients had CAP scores against A. simplex of 5 (three cases), 3 (seven) or 2 (nine). After a mean of 120 days on the diet, the scores against A. simplex were unchanged in 15 of the cases, reduced in three [from 5 to 4 (one case) or from 2 to 0 (two cases)] and increased in one (from 2 to 3). Most (16) of the patients no longer had any urticaria and the others reported significant reductions in the intensity and frequency of their symptoms.

Histamine plasma levels and elimination diet in chronic idiopathic urticaria

OBJECTIVE

The aim of this study was to evaluate the effects of an oligoantigenic and histamine-free diet on patients affected with chronic idiopathic urticaria (CIU).

DESIGN

Ten patients with chronic idiopathic urticaria were prescribed an oligoantigenic and histamine-free diet for 21 days, followed by serial and controlled reintroduction of foods during a further 70 days. Modification in clinical illness as well as histamine plasma levels, post-heparin plasma diamine oxidase (DAO) and intestinal permeability were evaluated.

RESULTS

The oligoantigenic and histamine-free diet induced a significant improvement of symptoms (P<0.05). Moreover, CIU patients on free diet showed higher histamine plasma levels (P<0. 05 vs post-diet and vs controls) that fell to control levels during the oligoantigenic and histamine-free diet. Post-heparin plasma diamine oxidase values were slightly reduced and were unchanged during the diet as well as intestinal permeability, which was always normal in all patients.

CONCLUSIONS

These data suggest that histamine plays a major role in chronic idiopathic urticaria. The finding of normal intestinal permeability suggests that a morphological damage of intestinal mucosa should be excluded in these patients. However, the presence of low levels of post-heparin plasma diamine oxidase may indicate a subclinical impairment of small bowel enterocyte function that could induce a higher sensitivity to histamine-rich or histamine-producing food. European Journal of Clinical Nutrition (2000) 54, 155-158

A novel wheat gliadin as a cause of exercise-induced anaphylaxis

BACKGROUND

Food-dependent, exercise-induced anaphylaxis is a severe form of allergy; the reaction is caused by ingestion of a specific food before exercise. This disorder often escapes diagnosis because neither the ingested food nor the exercise alone induces the symptoms.

OBJECTIVE

The aim of the study was to characterize the allergens involved in wheat-dependent, exercise-induced anaphylaxis and to describe the clinical outcome in a series of 18 adult patients.

METHODS

All 18 patients had experienced recurrent episodes of generalized urticaria during exercise, 17 patients in association with collapse and 15 patients with an anaphylactic reaction. The symptoms appeared only when the patients had eaten food containing wheat before exercise. Wheat allergens were detected by immunoblotting, purified by gel filtration and reversed-phase chromatography, and subjected to N-terminal sequencing. The IgE-binding ability of the purified proteins was studied by ELISA, and their in vivo reactivity was studied by skin prick testing.

RESULTS

IgE antibodies from pooled patient sera were bound to 65-kd and 40-kd wheat proteins in immunoblotting. The 65-kd allergen was a previously undescribed wheat protein, showing 61% sequence identity to gamma-gliadin, whereas the 40-kd allergen had 100% identity to alpha-gliadin. In ELISA, all 18 patients showed elevated IgE levels to the novel gamma-like gliadin, and 13 of the patients showed elevated IgE levels to the alpha-gliadin. None of the 54 control subjects with wheat allergy, urticaria, or coeliac disease had IgE antibodies to the gamma-like gliadin. The in vivo reactivity of the gamma-like gliadin was verified by positive skin prick test responses in all of the 15 patients who were tested. During the follow-up on a gluten-free or wheat-free diet, 3 patients experienced reactions after having unknowingly eaten wheat before exercise, but all the other patients who were adhering to the diet remained symptom-free.

CONCLUSION

This study shows that wheat is a frequent cause of food-dependent, exercise-induced anaphylaxis and suggests that the major allergen is a previously undescribed gamma-like gliadin. For screening of this life-threatening allergy, we recommend skin prick testing with crude gliadin and we recommend a gluten-free diet for treatment.

Role of nonallergic hypersensitivity reactions in children with chronic urticaria

BACKGROUND

IgE-independent (pseudoallergic) reactions to food and food ingredients are common in a subgroup of adult patients with chronic urticaria, who have daily spontaneous occurrence of wheals. However, for children with chronic urticaria (duration longer than 6 weeks, no physical influence), no data on the importance of pseudoallergen-induced chronic urticaria are available. Therefore, we investigated the role of nonallergic hypersensitivity to food in all children seen with chronic continuous urticaria in our two clinics over the last 2 years (n = 16).

METHODS

All patients were given a low-pseudoallergen diet for 3 weeks followed by provocation with food rich in pseudoallergens. To identify the main eliciting agents, a subgroup of responders was exposed to food additives by double-blind, placebo-controlled food challenges.

RESULTS

Pseudoallergen-induced urticaria was diagnosed in 12 cases (75%). Reactions occurred mainly to coloring agents and preservatives, but also to monosodium glutamate and a sweetener (saccharin/cyclamate).

CONCLUSIONS

These results confirm that nonallergic hypersensitivity reactions play a role in children with chronic urticaria, although the latter disease is rare at that age. In children, food additives, especially coloring agents and preservatives, appear to play a more important role in eliciting nonallergic hypersensitivity reactions than in adult patients, where naturally occurring pseudoallergens in fruits and vegetables are mainly responsible.

Pseudoallergen-free diet in the treatment of chronic urticaria. A prospective study

In chronic urticaria, the possible pathogenetic role of pseudoallergic reactions to food has been repeatedly discussed, but stringent prospective studies regarding their clinical significance are not available. All patients with chronic urticaria and/or angioedema hospitalized at the department of dermatology during a period of 2 years were therefore included in a prospective study. Patients (n = 64) were screened for common causes of urticaria and then evaluated for possible benefits of a stringently controlled pseudoallergen-free diet. Double-blind, placebo-controlled oral provocation tests with food additives were performed on those patients benefitting from diet. In 73% of patients, symptoms ceased or were greatly reduced within 2 weeks on diet, although only 19% of them responded to individual pseudoallergens on provocation tests. Of the remaining patients, 11% responded to treatment of an associated inflammatory disease, and in 16%, no cause of the urticaria was ascertained. Follow-up at 6 months after hospitalization showed complete remission on diet in 46% and lasting improvement in all but one of the remaining patients on diet. An additive-free, stringently controlled diet thus provides a simple means of diagnosing and treating the majority of patients with chronic urticaria.

[The histamine-free diet]

Food intolerance is not IgE-mediated but caused by histamine. A diminished histamine degradation based on a deficiency of diaminoxidase is suspected to be the reason. The therapeutic efficacy of a histamine-free diet was evaluated in 100 patients with food intolerance and allergic diseases, who were required to avoid fish, cheese, hardcured sausage, pickled cabbage, wine and beer for 4 weeks. Considerable improvement was observed in 57 patients, 15 of whom had total remission. The most striking treatment results were obtained in food or wine intolerance (80% P < 0.05; treatment of choice), bronchial asthma (80%), headache (64%) and urticaria (58%). After ingestion of food rich in histamine clearcut recurrence of atopic eczema was seen in 50% of the patients affected. Histamine plays a major part in food and wine intolerance. Histamine in food causes worsening of symptoms in atopics and patients suffering from headache. The results obtained indicate a deficiency of diaminoxidase in patients with intolerance to food or wine. Histamine levels in alcoholic beverages should be displayed on the labels.

Fasting diet therapy for chronic urticaria: report of a case

We used fasting diet therapy with a 28-year-old woman with chronic urticaria who responded only to systemic administration of glucocorticosteroids. The rashes began to decrease on the third therapeutic day and completely disappeared on the 11th day. Although the eruptions relapsed three days after the termination of the therapy, they were milder than previous ones. We also discussed the possible efficacy of fasting diet therapy for chronic urticaria as reported in the literature.

Chronic urticaria exacerbated by the antioxidant food preservatives, butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT)

Two patients with chronic idiopathic urticaria in whom remissions were achieved with dye- and preservative-elimination diet had exacerbations of their urticaria when they were challenged under double-blind, placebo-controlled conditions with butylated hydroxyanisole and butylated hydroxytoluene. After elimination of butylated hydroxyanisole and butylated hydroxytoluene from their diets, there was marked abatement of the frequency, severity, and duration of their urticaria. These antioxidants appear capable of aggravating symptoms in certain patients with chronic urticaria.

The results of skin testing with food additives and the effect of an elimination diet in chronic and recurrent urticaria and recurrent angioedema

Ninety-one subjects suffering from chronic or recurrent urticaria or recurrent angioedema of 2 months to 17 yr duration were skin-prick and scratch tested with 18 various food additives. Twenty-four of the subjects (26%) had at least one histamine equivalent skin test (ST) reaction. In contrast, only 24 (10%) of 247 non-urticaria control subjects showed comparable results. An oral provocation test with food additives was carried out on 10 of the 24 ST-positive subjects with urticaria or angioedema, but only one positive reaction, caused by benzoic acid, was recorded. All 91 subjects were advised to follow an additive-free diet. The effect of the diet was investigated with a retrospective postal survey. Twenty-three ST-positive subjects returned the questionnaire, 18 had followed the diet, and 16 (89%) of these 18 had experienced marked relief of their symptoms. Correspondingly, 42 of the 47 ST-negative subjects had followed the diet, and 17 (40%) had improved. The difference was significant (P less than 0.05). Our results suggest that skin tests with food additives can be used to measure skin hyperreactivity and that they may have a predictive value in identifying patients who will respond to an additive-free diet.

[Diagnosis of chronic urticaria. Critical analysis of test results based on catamnestic studies]

305 patients suffering from chronic urticaria were tested according to a special program, which combined the common allergologic skin testing with the searching for foci of inflammation. The central part of the diagnosis, however, are oral provocation tests during potato/rice diet with non-steroidal antiphlogistic agents and so-called food additives as well as "natural" salicylates. Acetylsalicylic acid and indomethacin most frequently caused reactions of intolerance, whereas all of the patients tolerated paracetamol (500 mg) without any reactions. With food additives and "natural" salicylates, intolerance reactions were rare. In our patients, skin testing only rarely led to any relevant results; the search for foci, instead, led to numerous findings, which, however, seemed not to have much influence on the further course of the disease. Apparently, the healing rate was neither influenced by the reactions of intolerance, nor the fact whether the patient had got a proper diet or not; we suggest, therefore, that the interpretation of the test results should be reconsidered.

Dietary restrictions in the treatment of adult patients with eczema

Improvement was seen in the dermatitis of 262 of 675 patients who followed a restrictive diet for approximately 1 month. Patients included in the study were sensitive to metal salts, balsams or classical food allergens or reacted to oral challenge with food additives. Also included were patients who did not react to diagnostic tests but who experienced improvement of their dermatitis while maintaining an elimination diet. A follow-up study was carried out 1-3 years after diet treatment was instituted. Each of the 262 patients was asked to complete a questionnaire to describe the long-term course of the dermatitis. 206 responded to the questionnaire, and for 144 of them (70%; 95% confidence limits 64-76%), there was long-term improvement of the dermatitis. Long-term improvement was more common among atopic patients than among non-atopics. Symptoms of contact urticaria were more common among patients with hand eczema than those with other types of eczema.

An elimination diet for chronic urticaria of childhood

Twenty-three children with chronic urticaria were treated with an elimination diet for two weeks. Eighteen completed the period of dietary elimination; in seven of the 18 children there was a marked remission of the urticaria during the second week of the diet. The administration of challenge capsules provoked an exacerbation of urticaria in five of the 14 (36%) children given aspirin. The incidence of reactions to tartrazine, sodium benzoate and yeast (7%) was not significantly different from those to the lactose placebo (9%). In selected cases, elimination diets with controlled reintroduction of foods have a role in the management of chronic urticaria in childhood.

Adverse reactions to foods

The discovery of IgE in the mid-1960s resulted in a widespread view that allergy was the basis of most adverse reactions to food, but it is becoming increasingly clear that other, as yet poorly understood, mechanisms are responsible in the overwhelming majority of cases. This, together with the proliferation of popular literature on "food allergy" has resulted in considerable confusion in the minds of both the public and the medical profession on the subject. In the majority of patients presenting with food intolerance, recognized or otherwise, symptoms are precipitated by various small, non-immunogenic organic molecules present in the food as natural or added ingredients. These reactions are pharmacological rather than immunological in nature, although in some situations they may share a final common pathway with true allergic reactions, resulting in similar symptoms.

Pseudo-allergen-free diet in chronic urticaria

An elimination diet for additives and tyramine was prescribed to 67 patients with chronic urticaria. 55% of them reacted favorably. Success of dietary treatment was associated with atopy and normal levels of biochemical markers of inflammation.

The role of penicillin in the pathogenesis of chronic urticaria

Intracutaneous tests with penicilloyl-polylysine (PPL) and benzyl-penicillin G (PG) were performed in 245 patients suffering form chronic recurrent urticaria, including physical urticaria. Positive results were observed in fifty-nine patients (24%). Sera from fifty-seven of these fifty-nine patients were investigated for circulating anti-penicilloyl antibodies by an enzyme-linked immunosorbent assay (ELISA) and a passive haemagglutination test (HA). The results were compared to those form the ELISA and HA in a control group of thirty-five patients who had shown clinical allergic reactions to penicillin and had positive skin tests to PPL and/or PG. The in vitro tests revealed positive results in 12.3% and 37.1% respectively. In forty-three patients the course of the positive intracutaneous tests to penicillin, together with the duration of chronic urticaria, was followed over a period of time up to 3.5 years. In twenty-two out of forty-two patients with positive intracutaneous tests to penicillin, a diet free of dairy products proved to have a curative effect, compared to two out of forty control subjects with chronic urticaria and negative skin tests to penicillin. These studies indicate that penicillin has an important role in the aetiology and maintenance of chronic urticaria.

Skin testing in chronic urticaria

In 164 patients with chronic recurrent urticaria, the value of skin tests was investigated, Patch tests carried out with the standard series of the International Contact Dermatitis Research Group and with a series of penicillins revealed positive reactions in 22 (35/162) and 6.9% (11/158), respectively. IN 21.5% (33/152) positive intracutaneous tests to cilligen and/or penicillin G were observed. 35% (51!147) of the patients had one or more positive intracutaneous tests with inhalants. Scratch tests with food allergens showed positive reactions in 12.5% (12/95). There was no difference in results between patients with idiopathic urticaria or angio-oedema and those with physical urticaria. The value of these findings is discussed. Most of the patients with penicillin allergy, were recommended to be on a diet free from milk and milk products. In 50% this was successful.

Management of chronic idiopathic urticaria by the identification and exclusion of dietary factors

The role played by dietary chemical factors in the pathogenesis of chronic idiopathic urticaria (CIU) was assessed in seventy-six patients by challenge Stable remission was first established by using an empirically established 'exclusion diet'. A diet modified to exclude those chemicals giving a positive response to challlenge was demonstrated to be of therapeutic value for time periods of up to 18 months. Re-testing twelve patients at 12 months indicated that most patients positive to salicylate or benzoate challenge retained this pattern of reactivity.

Detection of urticaria with food additives intolerance by means of diet

A diet free of salicylates, benzoates and azo dyes was applied to 158 patients with chronic urticaria. On the basis of the results of this diet, 50 persons were recognized as 'sensitive' to food additives. Psychosomatic examination of the latter patients demonstrated that they do not differ significantly from the remaining ones as regards exacerbations of skin changes by psychological stress. On the other hand, the coexistence of a frustrating situation at the beginning of appearance of skin changes is markedly less frequent in persons 'sensitive' to food additives. Patients are described in whom intolerance to food additives occurred together with hypersensitivity to drugs or some kinds of food.

An Australian exclusion diet

Exclusion diets may have a practical place in determining the precipitating dietary factors in certain clinical conditions. We present an exclusion diet which is based on the exclusion of food commonly known to cause food allergies, and the exclusion of food which contains salicylates, benzoates, tartrazine, yeast, and penicillin. This provided a basis for challenge with these additives and natural chemicals. Preliminary information in urticaria suggests a use for this diet in some allergic conditions.

A dietary free from additives in the management of allergic disease

Some patients who suffer from asthma, rhinitis or urticaria undergo exacerbation of symptoms following ingestion of foods or beverages containing azo dyes, sulphur dioxide or benzoates, which are used as preservatives. These patients may be mistakenly thought to be suffering from specific food allergies. A dietary is presented which is free from these additives. Drugs and their coatings and capsules may also contain azo dyes and these should be avoided by patients on an additive-free diet. Four cases are reported illustrating recovery, one from asthma and three from chronic urticaria after commencing this diet.

An allergist looks at urticaria

Some etiologic possibilities which must be considered are foods, drugs, infection, inhalant sensitivity, psychic factors, physical agents, underlying connective tissue disease or neoplasm, insect bite or stings and genetic abnormalities. A painstaking history and a complete physical examination are, of course, mandatory. These are followed by appropriate studies for whatever etiologic factors are suggested by the history and physical examination. Certain routine or more sophisticated studies might be indicated including a complete blood count, urinalysis, stools for ova and parasites, antinuclear antibody titer, complete complement, sedimentation rate, sinus, chest and dental X rays and any other specified test depending on where the clues lead. O'Loughlin described a practical approach in the use of laboratory studies for the diagnosis of chronic urticaria. Skin tests can be helpful especially for inhalants, but food tests are usually not reliable in the diagnosis of chronic urticaria. The acute urticaria reaction to a food is clinically obvious and this type of patient does not usually seek medical attention or need extensive investigation. Treatment includes a few basic medications. Hydroxyzine (Atarax, Vistaril), which combines tranquilizer and antihistamine action, is frequently effective. Cyproheptadine HCL (Periactin) both a serotonin and histamine antagonist with anticholinergic effect, is also helpful--especially in combination with hydroxyzine. Antihistamines, ephedrine, epinephrine, aminophyllin and occasionally corticosteroids are helpful. Immunotherapy with inhalants is occasionally indicated. Eliminating possible offending foods, dyes or drugs has been previously discussed. Anti-candidal therapy and low yeast diet is effective when indicated. The final aspect of the investigation and treatment process might best be described as "patient support"--patience on the part of the physician. It should be realized that in 75% of the cases of chronic urticaria, no convincing etiology is found. It should also be realized that urticaria all too frequently "settles down" due as much to the natural course as to the careful ministrations of the physician.

A follow-up study of patients with recurrent urticaria and hypersensitivity to aspirin, benzoates and azo dyes

We have studied seventy-five patients with recurrent urticaria and angio-oedema of more than 4 months duration and with positive provocation tests to aspirin, azo dyes, and/or benzoates. Cross-reactions between the test compounds were common. The patients were recommended to be on a diet free from salicylates, benzoates, and azo dyes. They were then followed for 6-24 months. At the follow-up, 24% were free from symptoms, 57% considered themselves much better and 19% stated that they were slightly better or unchanged. All patients had followed the diet for at least 1-3 months. Most of those who became totally free of symptoms did not continue with the diet, while most of the patients who considered themselves much better found that it was necessary to continue on the recommended diet. They usually developed symptoms as soon as they ingested something containing azo dyes or benzoates. To be able to maintain such a diet, it is important that the content of additives in food and drugs be properly declared.

Challenge test battery in chronic urticaria

The use of a battery of challenge tests in the routine investigations of patients with chronic urticaria has an important place, demonstrating an exacerbating factor in over half the patients. Diets designed to reduce the ingestion of the substances concerned are associated with clearing or considerable improvements in 75% of the patients treated.

Provocation tests with antiphlogistica and food additives in recurrent urticaria

100 patients (53 women, 47 men) suffering from recurrent urticaria were tested with different food additives such as 8 dye additives, 7 preservatives and 7 antiphlogistica. In total did 62 patients react with urticaria and/or angio-oedema. 39 patients had reactions to two or more substances while 23 patients reacted to only one substance. Reactions were induced most frequently by aspirin (27/80), dextropropoxyphene (11/45) and the azo dyes tartrazin (20/96) and sunset yellow (13/86/. Asthmatic symptoms occurred in 3 and purpura in 2 patients. 13 patients out of 100 reported of immediate reactions to different foods.