Management Of Urticaria Research Articles

Taiwanese Dermatological Association consensus for the definition, classification, diagnosis, and management of urticaria.

This report describes the 2014 consensus of the Taiwanese Dermatological Association regarding the definition, classification, diagnosis, and management of urticaria. This consensus is distributed to practices throughout Taiwan to provide recommendations for diagnostic and therapeutic approaches for common subtypes of urticaria, in order to improve the quality of life of urticaria patients. The consensus, thus, serves as an important reference for dermatologists throughout Taiwan. All the consensus contents were voted on by the participating dermatologists, with approval by no less than 75% being required for inclusion. The consensus provides a comprehensive overview of urticaria, including recent advances in identifying its causes and the processes by which it develops. All the consensus meeting attendees agreed to a definition of urticaria, which states that it is characterized by the sudden appearance of wheals (also known as hives), angioedema, or both. Most of the experts (16 out of 19, or 84.2%) agreed that chronic urticaria is defined as the sudden occurrence of wheals and/or angioedema for a period of ≥ 6 weeks. In addition, the consensus attendees also approved the Urticaria Activity Score system or the Urticaria Activity Score for 7 days system as the recommended method for assessing disease activity in spontaneous urticaria. It was also determined that the treatment goal for patients with any form of urticaria should be complete cessation of suffering from all urticaria symptoms. The recommended treatment algorithms for chronic spontaneous urticaria and acute urticaria were finally proposed and approved by 100% (19/19) and 84.2% (16/19) of the consensus attendees, respectively.

Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines

Urticaria can present acutely and be self-limiting or become chronic and persist for weeks, months, or years. In either case, the condition may have a significant impact on the patient's quality of life. Two major consensus groups, the EAACI/WAO and the AAAAI/ACAAI Joint Task Force, have written guidelines on the diagnosis and management of urticaria. While both agree on most points regarding the definition, general evaluation, and treatment, there are some differences which exist. The guidelines, which are written to assist both primary practitioners and specialists in managing their patients with urticaria, have been developed based on scientific evidence, and when insufficient evidence is available, then recommendations are based on expert consensus opinion. The majority of the differences between the two guidelines pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these two groups, highlighting the key similarities and differences.

What is urticaria? Expert opinion from the 1st Global Urticaria Forum.

Chronic urticaria (CU) is defined by the recurrent occurrence of itchy hives, angioedema or both for 6 weeks or more.1 It may be further classified into chronic inducible urticaria (CINDU) or chronic spontaneous urticaria (CSU) (also called chronic idiopathic urticaria [CIU]), depending on whether a specific trigger for the development of CU signs and symptoms can be identified or not.1 The exact prevalence depends on the population studied, but reports suggest that, globally, CU can affect up to 1% of the population, with CSU accounting for approximately two-thirds of cases.2 In addition to the burden of physical symptoms of itchy hives and angioedema, many aspects of quality of life (QoL) are found to be reduced in patients with CU due to interference with daily activities, social interaction and emotional well-being,3 with the presence of angioedema further impairing QoL.4 CSU has a high overall impact on QoL when compared with many other common dermatological conditions.5 There is also a high socioeconomic impact from both the direct (medication or healthcare visits) and indirect costs (absence from or reduced efficiency while at work).2, 6 The European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA2LEN)/European Dermatology Forum (EDF)/World Allergy Organization (WAO) recently published updated recommendations for the definition, classification, diagnosis and management of CU.1 The first international Global Urticaria Forum was held in November 2014 in Prague, Czech Republic. More than 400 clinicians from across the globe attended this educational meeting which focused on both CSU and CINDU. We are pleased to report in this supplement a summary of the presentations and discussions that took place at the first international Global Urticaria Forum, including the burden of disease and unmet need associated with CU, the most up-to-date approaches to the diagnosis and management of CU, recommended patient assessment tools and their use in clinical practice, and the latest efficacy and safety data for CU treatment options. Because urticaria is a cutaneous and systemic disease, comorbidities were also discussed, as well as recommendations for the management of urticaria in special populations. Through plenary lectures, case reports, audience discussions and practical workshops, the Global Urticaria Forum presented the real urticaria, raising the profile it deserves in the context of dermatological diseases. We hope that these perspectives will be useful to your clinical practice and help to address some of the key challenges in understanding, diagnosing and effectively managing and treating CU. Editorial assistance was provided by Brian Jepson, a professional medical writer contracted to CircleScience, an Ashfield Company, part of UDG Healthcare plc. Writing support was funded by Novartis Pharma AG.

Management of chronic spontaneous urticaria in the elderly.

The guidelines for the management of urticaria in adults and children have been revised and updated recently. However, there are few data in the literature concerning several aspects of this disease in the elderly (e.g., epidemiology, etiopathogenesis, clinical aspects, association with co-morbidities, efficacy and safety profiles of treatments, and management strategies). This is an obvious deficiency in the data, as this disease causes a deterioration in quality of life, affecting the quality of sleep, everyday life habits and activities, and inducing severe disability. Chronic spontaneous urticaria (CSU) can also be associated with internal, infectious, autoimmune, or neoplastic diseases. It is therefore necessary to pay particular attention to these clinical issues through appropriate clinical examinations. At the same time, the specific features of medications used to treat CSU in the elderly should be carefully evaluated, as its pharmacological treatment raises a number of problems related both to the clinical condition of the patient and to concomitant diseases, as well as to the polypharmacotherapy, which is common in older subjects and may cause safety problems because of the drug interactions. Non-sedating new-generation antihistamines are the mainstay treatment of CSU for the elderly. The efficacy and safety of alternative treatment options have not been assessed in the geriatric population with CSU; corticosteroids and cyclosporine (ciclosporin) should be used by this population with extreme caution. Similarly, there are no data regarding the actual safety profile of the new-generation antihistamines at higher doses than those recommended in elderly patients.

NEW APPROACH IN URTICARIA TREATMENT

The article presents the European Guidelines for the Diagnostics and Management of Urticaria (revised in 2013) and new data on the physiopathology of urticaria related to the role of the platelet-activating factor (PAF) activating mast cells, attracting eosinophils and neutrophils, improving vascular permeability (it is more potent than histamine by 1,000 times) and mucosal edema, and increasing the level of pro-inflammatory cytokines. The data promoted the creation of a new rupatadine molecule, which blocks histamine and PAF receptors at the same time improving the therapeutic effect during urticaria treatment as compared to other antihistamine drugs. The author presents the study results confirming the efficacy and safety of rupatadine.

Las directrices mexicanas sobre urticaria

En nombre del grupo de expertos y de las sociedades fundadoras de las guías internacionales sobre urticaria, quisiéramos congratularles por la finalización de las guías mexicanas para la urticaria. Este documento es un hito para la mejora del manejo de urticaria en México, ya que se basa en perfiles de evidencia desarrollados durante la generación de varios documentos de posición, parámetros para la práctica clínica y las guías EAACI/GA²LEN/EDF/WAO. Utilizando esta información como base, los autores han realizado una investigación independiente y han considerado factores que son específicos para el manejo de la urticaria en México. Esto ha dado como resultado la generación de recomendaciones, muy prácticas, pero al mismo tiempo basadas en evidencia que ahora forman la parte medular de las guías mexicanas

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

This methods report describes the process of guideline development in detail. It is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS) and is published in Allergy 2014; 69:868-887.

Management of urticaria in children

Urticaria is a common condition in children for which physicians are consulted. The management of childhood urticaria is similar as in adults; however, there are pediatric-specific features that must be taken into account for better management of childhood urticaria.

Comparative efficacy of non-sedating antihistamine updosing in patients with chronic urticaria

Urticaria and angioedema lasting more than 6 weeks have been designated as chronic urticaria (CU). It encompasses two major subtypes: chronic spontaneous urticaria (CSU) (previously known as chronic idiopathic urticaria) (CIU) and chronic inducible urticaria. CSU has been defined as wheals and/or angioedema that are endogenous and independent of any external physical stimulus. It affects 0.5 to 1% of the population [1]. In 40 to 45% of patients with CSU autoantibodies to the high affinity IgE receptor (FcϵRI) or to IgE itself are thought to play a psathogenic role, whereas 55 to 60% of cases are considered idiopathic [2]. Inducible urticarias include all forms of physical urticarias (cold-induced, heat-induced, solar, and pressure urticaria). According to the International Guidelines for the management of urticaria and angioedema non-sedating, second generation antihistamines (NSAHs) are recommended for the treatment of CU [3]. Nevertheless, a considerable proportion of patients do not respond sufficiently to NSAHs. According to Humphreys and Hunter up to 40% of patients with CU may not achieve good control with antihistaminic therapy [4]. They reported that out of 390 CU patients who were treated with antihistamines 44% responded well, 29% became asymptomatic, and 15% showed partial improvement. In a recent paper from Japan it was observed that the improvement rates (defined as a urticaria symptom score UAS ≤ 3) in 117 CU patients who received standard doses of AHs were 36.6% at 12 months, 51.2% at 24 months, and 66.1% at 60 months, while the remission rates were 11.5%, 13.9%, and 27.7%, respectively [5]. In patients that do not respond to standard doses, the next step in guideline-based therapy is to increase AH doses up to 4 times [3]. Investigations assessing the response to various NSAHs have demonstrated that up-dosing is significantly more effective in reducing symptoms of CU than standard-dose treatment [6]. According to Kaplan, high-dose antihistamines are effective in 45-60% of patients with CSU [7], while about one third are antihistamine resistant regardless of which dose is used [8, 9]. The present article is a review of the literature on the treatment of CU with increased doses of NSAHs in order to investigate if there are differences in efficacy between the various second generation AHs that have been studied in controlled protocols. It must be noticed, however, that it is difficult to find clinical investigations that strictly follow the criteria recommended by the guidelines on the management of urticaria, and therefore studies included in this review were those in which higher doses of NSAHs were used regardless of the clinical response to conventional doses. AHs included in this review are desloratadine, levocetirizine, fexofenadine, and the recently introduced NSAHs rupatadine and bilastine. Bilastine belongs to the piperidine class of antihistamines as do loratadine, desloratadine, and fexofenadine. Like other antihistamines bilastine is an H1 receptor inverse agonist. In vitro studies have shown that bilastine has a high specific affinity for the H1-receptor but it has no or very low affinity for 30 other tested receptors. The affinity for the H1 receptor is 3 and 6 times higher than for cetirizine and fexofenadine, respectively [10, 11]. Rupatadine fumarate is a new potent, long acting, orally active dual antagonist of both histamine H1 and Platelet-Activating Factor (PAF) receptors. In in vivo and in vitro studies rupatadine was as potent or even more potent than other second generation antihistamines (loratadine, terfenadine and cetirizine) or selective PAF antagonists [12].

Ketotifen in the management of chronic urticaria: resurrection of an old drug

Ketotifen is an oral antiallergic drug developed in 1970 by Sandoz Pharmaceuticals of Switzerland. It is a benzocycloheptathiophene derivative and was initially marketed as an inhibitor of anaphylaxis.1 The pharmacodynamic properties of ketotifen are many, because it is an inhibitor of the release and/or activity of mast cell and basophil mediators, including histamine, neutrophil, and eosinophil chemotactic factors, arachidonic acid metabolites, prostaglandins, and leukotrienes.2 Thus, it inhibits the bronchial response to inhaled histamine, allergen, or aspirin. In addition, the ocular, nasal, and dermal responses to applied allergen in sensitized patients are attenuated with use of ketotifen.3 It also has been found to have some calcium antagonist activity and to inhibit responses to platelet-activating factor from proinflammatory cells, such as eosinophils.2 Additional possible modes of action include its ability to reverse b2-agonisteinduced decreases in b-adrenoreceptor density and to alter the affinity of these receptors and increase intracellular concentrations of cyclic adenosine monophosphate.3 Ketotifen has a chemical structure similar to some first-generation antihistamines, such as cyproheptadine and azatidene.2 With regard to the pharmacokinetic properties of ketotifen, it is readily absorbed from the gastrointestinal tract after oral administration and achieves peak plasma concentrations within 2 to 4 hours of administration. Clearance of the drug from plasma is biphasic, with a half-life of distribution of 3 hours and a half-life of elimination of 22 hours in adults.3 However, the onset of action of ketotifen is slow, and it may take 4 to 6 weeks to achieve full prophylactic value under certain conditions.4 Ketotifen was originally patented by Sandoz in the 1970s. It became very popular for management of asthma in Japan and clinical trials were initiated in the United States in the 1980s for management of asthma and other allergic conditions. One author served on the Food and Drug Administration (FDA) Pulmonarye Allergy Drugs Advisory Committee and chaired that group from 1984 to 1986. Approval for treatment of asthma was not granted, but FDA staff did recommend more extensive evaluations for management of urticaria. Unfortunately, the latter studies have not been performed in a robust fashion. However, oral ketotifen has been used in patients with asthma, allergic rhinitis, allergic conjunctivitis, atopic dermatitis, chronic urticaria, cold-induced urticaria, cholinergic urticaria, exercise-induced urticaria, mastocytosis, and food allergy in Canada, Europe, and Mexico. Approval was granted for ocular administration in the United States for allergic conjunctivitis and later the drug became available over the counter. A review of clintrials.gov shows evaluations of ketotifen by oral administration for fibromyalgia, atopic dermatitis, attenuation of reactions during peanut desensitization, allergic rhinitis, asthma, and post-traumatic joint contractures. The authors became aware that ketotifen could be obtained in the United States from compounding pharmacies and began prescribing it more extensively in their clinics for severe urticaria in 2011. For adults and older children with asthma or allergic disease, the recommended dose of ketotifen is 1 mg twice daily. For young children 6 months to 3 years old, the recommended dose is 0.5 mg twice daily.3 It must be noted that oral ketotifen can be safely compounded in the United States. Pharmacy compounding is a practice in which a licensed pharmacist combines, mixes, or alters ingredients in response to a prescription to create a medication tailored to the medical needs of an individual patient. Pharmacy compounding, if performed properly, can serve an important public health need if a patient cannot be treated with an FDA-approved medication. The issue of safety of compounded drugs in the FDA Compliance Policy for Pharmacy Compounding is primarily for injectable drugs and does not relate to oral compounded drugs. This policy does include a select list of compounding drugs that were withdrawn or Reprints: Kristin C. Sokol, MD, MS, MPH, Division of Allergy and Immunology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555; E-mail: Kcsokol@utmb.edu. Disclosures: Authors have nothing to disclose. Funding Sources: This study was conducted with the support of the Institute for Translational Sciences at the University of Texas Medical Branch, supported in part by a Clinical and Translational Science Award (UL1T71) from the National Center for Advancing Translational Sciences, National Institutes of Health.

Omalizumab is an effective and rapidly acting therapy in difficult-to-treat chronic urticaria: A retrospective clinical analysis

BackgroundOmalizumab (anti-IgE) therapy is effective and safe in chronic urticaria (CU) in placebo-controlled clinical trials but real life clinical data are scarce. ObjectiveTo better understand the effects of omalizumab in CU patients treated outside of clinical trials. MethodsIn this retrospective clinical analysis, we assessed responder rates, optimal dosage, response to up-/downdosing, time to relief of symptoms, rates of return and time of relapse after omalizumab administration, and safety in 51 CU patients, 20 with chronic spontaneous urticaria (CSU) alone, 21 with different forms of chronic inducible urticaria (CindU) and 10 with both. ResultsOmalizumab treatment led to complete remission in 83% of CSU and 70% of CindU patients. When starting with 150mg omalizumab 4 weekly, only 2/15 CSU and 7/17 CindU patients required updosing to achieve complete remission. In CSU, 57% of complete responses occurred within week one, all on the first day. Relapses were 2–8 weeks in all but six patients, where they were <4 months. Omalizumab was safe. Efficacy was not correlated to baseline IgE levels. ConclusionClinical experience from more than 1250 injections in 51 patients over four years indicates that omalizumab is a rapidly acting, highly effective and safe drug in CSU and CindU patients. Our observations in a real life clinical setting support the recommendation of current EAACI/GA2LEN/EDF/WAO guideline for the management of urticaria to use omalizumab to treat urticaria patients.

Diagnosing rashes, part 5: Itchy rashes

Practice NursingVol. 24, No. 9 DermatologyDiagnosing rashes, part 5: Itchy rashesJean WatkinsJean WatkinsSearch for more papers by this authorJean WatkinsPublished Online:29 Sep 2013https://doi.org/10.12968/pnur.2013.24.9.438AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferences DermNet NZ (2013) Fungal nail infections (onychomycosis). http://tinyurl.com/njblvm9 (accessed 2 August 2013) Google Scholar Grattan CE, Humphreys F; British Association of Dermatologists Therapy Guidelines and Audit Subcommittee (2007) Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol 157(6): 1116–23 Crossref, Google Scholar Health Protection Agency (2010) Guidance on infection control in schools and other childcare settings. http://tinyurl.com/7abl364 (accessed 2 August 2013) Google Scholar Hogan D, Bower S, Mason SM, Mason SH (2012) Prurigo nodularis. http://tinyurl.com/qcrjx2z (accessed 5 August 2013) Google Scholar Lesher J (2012) Tinea corporis. http://tinyurl.com/ogueh4v (accessed 2 August 2013) Google Scholar Mayo Clinic (2012) Dermatographia. http://tinyurl.com/beptyk (accessed 5 August 2013) Google Scholar National Institute for Health and Care Excellence (2011) Scabies. Clinical Knowledge http://cks.nice.org.uk/scabies (accessed 2 August 2013) Google Scholar Scheinfield N (2013) Delusions of parasitosis. http://tinyurl.com/y58449w (accessed 2 August 2013) Google Scholar Watkins J (2013) Skin rashes, part 3: localized rashes. Practice Nursing 24(5): 235–41 Link, Google Scholar Wong H, Najib U, Sheikh J (2011) Acute urticaria. http://tinyurl.com/m9489kw (accessed 5 August 2013) Google Scholar FiguresReferencesRelatedDetails 1 September 2013Volume 24Issue 9ISSN (print): 0964-9271ISSN (online): 2052-2940 Metrics History Received 3 June 2013 Accepted 29 July 2013 Published online 29 September 2013 Published in print 1 September 2013 Information© MA Healthcare LimitedKeywordsItchy rashesInfectionsInfestationsSymptomsDiagnosisPDF download

Allergic diseases of the skin and drug allergies – 2022. Consensus statement on management of urticaria in India

Background Urticaria, a heterogeneous group of diseases, often cannot be recognized by its morphology. Due to non-specific and non-affordable diagnosis, management of urticaria, especially chronic urticaria, is very challenging. This guideline includes definition, causes, classification and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is identification and elimination of the underlying cause(s) and/or eliciting trigger (s), while the second one is treatment aimed at providing symptomatic relief. This guideline recommends use of second-generation non-sedating H1 antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the cost. First-generation antihistamines can interfere with rapid eye movement (REM) sleep and impact on learning and performance. New GA²LEN/EDF/EAACI/WAO guidelines do not recommend the use of these sedating antihistamines for the routine management of CU as the firstline agents. Second-generation antihistamines should be considered as the first-line symptomatic treatment for urticaria because of their good safety and tolerability pro

Omalizumab in chronic urticaria

The current EAACI/GA²LEN/EDF/WAO treatment guidelines for the management of urticaria recommend omalizumab as fourth-line therapy. Within the last year, many reports of omalizumab treatment in chronic urticaria have been published. Two multicenter, randomized, placebo-controlled trials in chronic spontaneous urticaria have shown excellent efficacy of omalizumab. Furthermore, in various case series and case reports, omalizumab has been shown to be effective also in inducible urticarias; however, no randomized placebo-controlled trial has been performed yet to thoroughly investigate the efficacy of omalizumab in inducible urticarias. In this review, all published information on the use of omalizumab in urticaria will be summarized and discussed with special emphasis on reports published within the last year. The available data indicate that omalizumab is an effective and well tolerated drug in antihistamine-resistant chronic urticaria.

Asia Pacific Allergy: a successful first year and the future

Let's celebrate the first anniversary of Asia Pacific Allergy (AP Allergy), the official journal of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI)! Since the launching ceremony on November 6, 2010 and its inaugural issue release on April 30, 2011, AP Allergy had a very successful first year. AP Allergy has published twenty three review articles which were recruited from Australia (3), India (3), Japan (2), Korea (7), Malaysia (1), Singapore (4), Sri Lanka (1), Sweden (1) and Thailand (1). A total of sixteen original articles from Australia (1), Indonesia (1), Iran (1), Japan (3), Korea (4), Philippines (4), Sri Lanka (1) and Thailand (1) have been published. Four case reports from Indonesia (1), Korea (2), and UK (1) have been published. After the launching of e-submission system, the submission of the original articles is increasing week by week. AP Allergy is an open access journal and now indexed/tracked/covered by PubMed, PubMed Central, CAB Abstracts, Global Health, CrossRef and Google Scholar databases. Especially, it took just 6 months from the release of the inaugural issue to be indexed by PubMed and PubMed Central in November 2011. Everything started when I received a phone call from professor Sang-il Lee, the founding editor and the Editor-in-Chief, in June 2010. Since then task force team was organized and we worked very hard on the launch of the journal. This journal could be managed with many splendid and wonderful persons, especially professor Choon-Shil Lee from Sookmyung Women's University, Korea who is my mentor, Mr. Inkwon Hwang from Inkwon and Partners who designed this beautiful journal cover and layout, Ms. Jung-min Nam, the manuscript editor, Ms. Nan-Kyeong Woo, and Ms. Hye-sook Jang who worked enormously hard for the manuscript editing, the publication of printed copies, and the on-line publication. I'd like to the entire editorial team for their enormous efforts and contribution (Fig. 1). Fig. 1 The editorial team with the inaugural issue of Asia Pacific Allergy in April 2011. I must the executive committee members of APAAACI and the editorial board members who strongly supported this journal. I'd like to especially professor Hiok Hee Chng, professor Bee Wah Lee, professor Bernard Thong from Singapore, professor Ashok Shah from India, professor Connie H. Katelaris, A/professor Frank Thien from Australia, professor Pakit Vichyanond, Thailand, professor Donald Leung, USA, professor Jiu-Yao Wang, Taiwan, professor Akihiro Morikawa, professor Hirohisa Saito, professor Naoki Shimojo, professor Ruby Pawankar from Japan, professor Zakiudin Munasir, Indonesia, professor Shahd Abbas, Pakistan, professor Hee-Bom Moon, professor Kyu-Earn Kim, professor Sang-Heon Cho and professor Kangmo Ahn from Korea. This issue of AP Allergy features important issues on allergic rhinitis in school going children [1], elderly asthma [2], the role of tiotropium in asthma management [3], and the management of urticaria [4] in review articles. Readers of this journal will also find original articles on the effect of olopatadine ophthalmic solution in the conjunctivitis models [5], the impact of helminth infection on allergic diseases from Sri Lanka [6], the prevalence of allergic rhinitis in Filipino adults based on the national survey [7], and IgE binding reactivities of natural pollen grain extracts from grass species in the Philippines [8]. Readers may have a new idea how to set up a birth cohort: the methodology of the GUSTO Cohort Study from Singapore is revealed in this issue [9]. This issue contains a very interesting case report of food-dependent exercise-induced anaphylaxis occurred only in a warm but not in a cold environment [10]. Readers will learn that the environmental factor played an essential role to induce anaphylaxis in the case. AP Allergy sends the electronic table of contents (eTOCs) of each issue with e-mails to more than 2,000 doctors. It now became a 'recognized' journal in the field of allergy and clinical immunology. The editorial team received many e-mails from readers, especially from the Asia Pacific region, to say thank you for the eTOCs and for publishing this journal. The editorial team appreciates this supports from readers very much. Lastly I'd like to all the authors very much for their interest and contribution. AP Allergy will continue to publish articles of good quality to communicate with physicians and researchers in the field of allergy and clinical immunology. Looking forward to another successful year!

Management of chronic urticaria in Asia: 2010 AADV consensus guidelines

This guideline is a result of a consensus reached during the 19th Asian-Australasian Regional Conference of Dermatology by the Asian Academy of Dermatology and Venereology Study Group in collaboration with the League of Asian Dermatological Societies in 2010. Urticaria has a profound impact on the quality of life in Asia and the need for effective treatment is required. In line with the EAACI/GA2LEN/EDF/WAO guideline for the management of urticaria the recommended first-line treatment is new generation, non-sedating H1-antihistamines. If standard dosing is ineffective, increasing the dosage up to four-fold is recommended. For patients who do not respond to a four-fold increase in dosage of non-sedating H1-antihistamines, it is recommended that therapies such as H2-antihistamine, leukotriene antagonist, and cyclosporine A should be added to the antihistamine treatment. In the choice of second-line treatment, both their costs and risk/benefit profiles are the most important considerations.

Diagnosis and Treatment of Urticaria and Angioedema: A Worldwide Perspective

Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.

Chronic urticaria and use of statins

To the Editor, I read with interest the consensus guidelines on chronic urticaria by Steven KW Chow and colleagues [1] but have reservations with the statement that angiotensin converting enzyme inhibitors (ACEIs) should usually be avoided in chronic urticaria with or without angioedema. Although the EAACI/GA2LEN/EDF/WAO position paper does allude to the fact that ACEIs come second to non-steroidal anti-inflammatory drugs in eliciting and aggravating urticaria [2], the level of evidence to support this statement was not provided. Yet another consensus statement on the management of urticaria by Godse KV et al. [3] does not mention ACEIs as a possible trigger for urticaria. The incidence of urticaria to the ACEI drug enalapril was reported at 0.3% (32 of 12,543 patients) in a 12 months post-marketing surveillance study, but the report also mentioned that this necessitated withdrawal of the drug only in 5 cases and 6 other cases of urticaria were not attributed to enalapril [4]. Dr. Pfeiffer [5] referenced the above paper in a correspondence to a review by Dr. Allen P Kaplan [6] on chronic urticaria and angioedema in The New England Journal of Medicine, but that ACEI drugs can elicit urticaria was not entirely accepted by Dr. Kaplan in his reply [5]. A more commonly prescribed class of drugs that have a higher incidence of urticaria are lipid lowering statins. Manufacturers of statin drugs report the combined incidence of rash and allergic reactions to be 7.7% (data on file; Parke-Davis, USA) that is much higher than that for ACEIs [see Table 1 for published reports; MEDLINE from PubMed, EMBASE, BNI, CINAHL with search terms: 'statin', 'urticaria']. A recently published 10-year study from the French PharmacoVigilance Database reported 7.3% of systemic lupus erythematosus cases associated with statin use [with reporting odds ratio at 1.67 (95% CI 1.02-2.74)] [7]. The mechanisms of statin-induced (autoimmune) urticaria/systemic lupus erythematosus may be related to (1) the proapoptotic nature of the drug (at least the second generation statins) that may release otherwise unaccessible nuclear antigens and subsequent generation of autoantibodies; and (2) statins have been shown to promote a shift from T helper 1 (Th1) to Th2 immune responses that leads to B-cell reactivity and the production of pathogenic autoantibodies [8-10]. Table 1 Reports of statin use with development of urticaria With several consensus guidelines from various clinical groups recommending prophylactic statin therapy, clinicians should be aware of all side effects with these widely prescribed medications.

Selected urticaria patients benefit from a referral to tertiary care centres – results of an expert survey

Urticaria is a frequent reason for consultations. Recently, it has been demonstrated that the management of chronic spontaneous urticaria (csU) in the practice setting does not fully comply with published guidelines. In addition, it was shown that one of four csU patients is referred to specialized centres. To analyse the management of urticaria patients in tertiary referral centres. During a standardized expert-to-expert interview, 41 specialists from German tertiary care centres were asked for different aspects of urticaria patient care with a special focus on csU. On average, the participating centres saw 25 csU patients per month. All ran programmes for the identification of underlying causes with an average success rate of 45 ± 3% which is considerably higher as has been found in the practice setting. In those patients where an identification succeeds, infections, drugs, intolerance and autoreactivity were reported to be causes in 41%, 20%, 17% and 16%. In their symptomatic treatment the majority of centres (71%) followed the guidelines by using regular dosed non-sedating H(1)-antihistamines as first line and higher doses (61%) as second line option. In contrast to the practice setting, meaningful experience also existed for alternative therapies in antihistamine-resistant patients, such as dapsone, cyclosporin and omalizumab. The expenditure of time, laboratory costs and frequency of follow-up visits was reported to be above average in case of csU. This study indicates that some urticaria patients, especially those with unknown causes or with an H(1)-antihistamine-resistant disease, may benefit from a referral to tertiary care centres.

An approach to urticaria in the elderly patients

The guidelines for the management of urticaria in adults and children have been published in outstanding position papers. By contrast, the onset of urticaria in the elderly has not yet had a clear definition. In order to approach diagnosis and treatment in a population of elderly patients, we have performed an epidemiological study on a population of elderly people observed in the Immuno Allergology Unit in Bari University Hospital. The patients underwent skin prick test for food allergy and laboratory and instrumental tests. From the data it resulted that 49% of cases have had urticaria because of adverse drug reactions (ADRs), 16% of cases were positive to food, while in 21% of cases systemic and metabolic diseases (SMDs) have been diagnosed. If we consider the young controls, urticaria for ADR was present in 48% of cases; however, in 28% it was possible to make the diagnosis of food allergy, 12% cases had a SMD. Our results show that the main cause of urticaria in the elderly is related to drug assumption because of the high number of drugs taken, followed by internal pathologies correlated to the typical immune and metabolic changes of the elderly. Furthermore, from the observation of our data it was possible to give guidelines for the treatment of urticaria in geriatric age.