Management Of Urticaria Research Articles

Urticaria and angioedema

Urticaria (hives) is a common disorder that often presents with angioedema (swelling that occurs beneath the skin). It is generally classified as acute, chronic or physical. Second-generation, non-sedating H1-receptor antihistamines represent the mainstay of therapy for both acute and chronic urticaria. Angioedema can occur in the absence of urticaria, with angiotensin-converting enzyme (ACE) inhibitor-induced angioedema and idiopathic angioedema being the more common causes. Rarer causes are hereditary angioedema (HAE) or acquired angioedema (AAE). Although the angioedema associated with these disorders is often self-limited, laryngeal involvement can lead to fatal asphyxiation in some cases. The management of HAE and AAE involves both prophylactic strategies to prevent attacks of angioedema (i.e., trigger avoidance, attenuated androgens, tranexamic acid, and plasma-derived C1 inhibitor replacement therapy) as well as pharmacological interventions for the treatment of acute attacks (i.e., C1 inhibitor replacement therapy, ecallantide and icatibant). In this article, the authors review the causes, diagnosis and management of urticaria (with or without angioedema) as well as the work-up and management of isolated angioedema, which vary considerably from that of angioedema that occurs in the presence of urticaria.

Clinical utility of testing for autoimmunity in chronic idiopathic urticaria

Positive autoimmune testing in patients with chronic idiopathic urticaria (CIU) has previously been associated with more severe disease. We sought to determine whether patients with CIU and a positive autoimmune urticaria test finding were more difficult to treat clinically. In this retrospective study, 428 patients seen by physicians of the Department of Dermatology, University of Pittsburgh between January 2007 and March 2010 were identified by International Classification of Diseases, Ninth Revision code 708.9 for urticaria. Included individuals met clinical criteria for CIU and had an autoimmune urticaria test (chronic urticaria index or CD203 expression test) result in their medical record. Twenty patients met the study criteria set forth and positive autoimmune urticaria test results occurred in 8 of the 20 patients. In all, 75% of patients in each group (positive and negative autoimmune test findings) were more than 75% clear of disease (P = 1) by the last visit. Mean number of distinct medications prescribed for urticaria management in the positive and negative autoimmune groups was 6.9 and 8.4, respectively (P = .4). No significant difference was detected between the various medications that led to more than 75% disease clearance in either group. The mean number of patient clinic visits over the study period was 3.1 and 4.8, respectively, for positive and negative groups (P = .5). This was a retrospective study with a small sample size. A positive autoimmune urticaria test finding in the setting of CIU is not indicative of a more complicated clinical course.

Consensus statement on the management of urticaria

This consensus statement was developed by Special Interest Group – Urticaria (IADVL). 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.

TREATMENT OF URTICARIA: TODAY AND TOMORROW

Urticaria is a common disorder with diverse clinical presentations. Correct recognition of the different clinical patterns helps clinical assessment and treatment. The management of urticaria involves recognition of relevant disease associations, treatment of any identifiable external causes including infection, avoidance of drug, food and physical triggers and the appropriate use of pharmacological therapies. These can be divided into first, second and third line approaches. The choice of treatment will be influenced by many factors including drug licensing, safety, pattern of disease, its severity, pharmacoeconomic considerations and patient preference. Possible new therapeutic approaches on the horizon include new H1 antihistamines, H4 receptor antagonists, a histidine decarboxylase inhibitor under development and biological agents that target histamine - releasing autoantibody production and function.

Effectiveness of Helicobacter pylori eradication in chronic urticaria: evidence-based analysis using the Grading of Recommendations Assessment, Development, and Evaluation system

Chronic urticaria is a common and often frustrating condition that physicians encounter in the outpatient setting. Its management continues to be a challenge, and an exogenous cause for chronic urticaria is only found rarely. Helicobacter pylori has been implicated as a factor for many disorders and proposed as an etiologic factor for chronic urticaria. We aim to provide a comprehensive review of the data on H. pylori eradication for treatment of chronic urticaria by utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to analyze and determine the quality of evidence for this proposed therapy. Although H. pylori eradication has been recommended as part of routine chronic urticaria management by multiple authors, the trials of H. pylori eradication in the treatment of chronic urticaria have yielded conflicting results and suffer from substantial methodological limitations. Our critical appraisal of the 10 trials showing the benefit of H. pylori eradication in patients with chronic urticaria leads to an overall very low grade for this intervention. Appraisal of nine studies in which H. pylori eradication showed no benefit in the course of chronic urticaria also leads to an overall very low grade. The evidence that H. pylori eradication leads to improvement of chronic urticaria outcomes is weak and conflicting; this leads to a weak recommendation for routine H. pylori eradication for patients with chronic urticaria. For this reason, a decision to proceed with this management should be considered carefully in the context of relative harms/burdens and benefits, as well as patient values and preferences.

Urtikaria – die häufigste dermatologische Erkrankung

Urticaria is a very frequent disease. The life time risk to experience at least one episode of urticaria is around 15 - 25 %. This article summarizes the most important definitions, classifications and diagnostic procedures in urticaria, as well as the evidence based management of urticaria. The recommendations given in this article are in accordance with two recent position papers by the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA2LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO).

Therapeutic Hotline: Cysteinyl leukotriene receptor antagonist montelukast in the treatment of atopic dermatitis

Leukotrienes are potent proinflammatory mediators derived from arachidonic acid through the 5-lipoxygenase pathway. Experimental data suggest a role for cysteinyl leukotrienes in the pathogenesis of atopy giving a rationale for its use in asthma, allergic rhinitis, and chronic urticaria management. A few clinical observations and small trials suggest that montelukast may be used in an adjunctive manner as an effective therapeutic option for all age categories affected by moderate-to-severe atopic dermatitis. Our own observations proved that montelukast as a prospective corticosteroid-sparing option in the complex therapeutic strategy of corticosteroid-dependent atopic dermatitis patients, even in the severe erythrodermic cases.

Treatment of urticaria: today and tomorrow

Urticaria is a common disorder with diverse clinical presentations. Correct recognition of the different clinical patterns helps clinical assessment and treatment. The management of urticaria involves recognition of relevant disease associations, treatment of any identifiable external causes including infection, avoidance of drug, food and physical triggers and the appropriate use of pharmacological therapies. These can be divided into first, second and third-line approaches. The choice of treatment will be influenced by many factors including drug-licensing, safety, pattern of disease, its severity, pharmaco-economic considerations and patient preference. Possible new therapeutic approaches on the horizon include new H1 antihistamines, H4 receptor antagonists, a histidine decarboxylase inhibitor under development and biological agents that target histamine-releasing autoantibody production and function.

EAACI/GA2LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria

This guideline, together with its sister guideline on the management of urticaria [Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: Management of urticaria. Allergy, 2009; 64:1427-1443] is the result of a consensus reached during a panel discussion at the 3rd International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology 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). Urticaria is a frequent disease. The life-time prevalence for any subtype of urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria do not only cause a decrease in quality of life, but also affect performance at work and school and, as such, are members of the group of severe allergic diseases. 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 approaches for different subtypes of urticaria. The correct management of urticaria, which is of paramount importance for patients, is very complex and is consequently covered in a separate guideline developed during the same consensus meeting. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

EAACI/GA²LEN/EDF/WAO guideline: management of urticaria

This guideline, together with its sister guideline on the classification of urticaria (Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: definition, classification and diagnosis of urticaria. Allergy 2009;64: 1417-1426), is the result of a consensus reached during a panel discussion at the Third International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology 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). As members of the panel, the authors had prepared their suggestions regarding management of urticaria before the meeting. The draft of the guideline took into account all available evidence in the literature (including Medline and Embase searches and hand searches of abstracts at international allergy congresses in 2004-2008) and was based on the existing consensus reports of the first and the second symposia in 2000 and 2004. These suggestions were then discussed in detail among the panel members and with the over 200 international specialists of the meeting to achieve a consensus using a simple voting system where appropriate. Urticaria has a profound impact on the quality of life and effective treatment is, therefore, required. The recommended first line treatment is new generation, nonsedating H(1)-antihistamines. If standard dosing is not effective, increasing the dosage up to four-fold is recommended. For patients who do not respond to a four-fold increase in dosage of nonsedating H(1)-antihistamines, it is recommended that second-line therapies should be added to the antihistamine treatment. In the choice of second-line treatment, both their costs and risk/benefit profiles are most important to consider. Corticosteroids are not recommended for long-term treatment due to their unavoidable severe adverse effects. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Dermatological Emergencies

Acute dermatological problems are seen regularly by physicians. This review aims to provide a framework for the diagnosis and management of urgent dermatological conditions. Cutaneous drug reactions are commonly seen and the different clinical presentations are discussed including the less common but important drug reactions Stevens- Johnson syndrome and toxic epidermal necrolysis. Erythrodermic patients also require prompt evaluation and management. Current guidelines for the management of urticaria and the common acquired autoimmune bullous disorders will be discussed. Patients with complications of eczema and psoriasis frequently require urgent in-patient management and patients with cellulitis and leg ulcers are also seen regularly on acute medical receiving units often requiring both medical and dermatological input.

The use of a responder analysis to identify clinically meaningful differences in chronic urticaria patients following placebo- controlled treatment with rupatadine 10 and 20 mg

According to the EAACI/GA(2)LEN/EDF guidelines for urticaria management, modern non-sedating H1-antihistamines are the first-line symptomatic treatment for chronic urticaria. Two previous randomized clinical trials demonstrated rupatadine efficacy and safety in chronic urticaria treatment. However, a responder analysis to identify clinically meaningful differences in patients with chronic urticaria has not yet been performed. This analysis includes the pooled data from two randomized, double-blind, placebo-controlled, multicentre studies in which chronic urticaria patients were treated with rupatadine at different doses. Responder rates were defined as the percentage of patients after 4 weeks of treatment who exhibited a reduction of symptoms by at least 50% or 75% as compared to baseline. The variables analysed were as follows: Mean Pruritus Score (MPS), Mean Number of Wheals (MNW), and Mean Urticaria Activity Score (UAS). A total of 538 patients were included. This responder analysis, using different response levels, shows that the efficacy of rupatadine 10 mg and 20 mg is significantly better as compared to placebo in the treatment of chronic urticaria patients. Notably, treatment with rupatadine 20 mg daily resulted in a higher percentage of patients with response of 75% symptom reduction or better than rupatadine 10 mg. Our results support the use of higher than standard doses of non sedating antihistamines in chronic urticaria. We strongly recommend performing and reporting responder analyses for established and new drugs used by patients with chronic urticaria.

Office-Based Management of Urticaria

Urticaria is a common pruritic skin disorder that is often seen in the office and varies in severity and chronicity. The etiologic cause is frequently not identifiable. Urticaria may be associated with physical factors and triggers, including foods or medications. A significant percentage of patients with chronic urticaria have circulating autoantibodies directed toward immunoglobulin-E or the high-affinity receptor for immunoglobulin-E (FcεRI), or have antithyroid antibodies that might play a role in the activation of the final common pathway in urticaria: mast cell activation and degranulation. Management begins with a careful investigation and elimination of eliciting factors when identified, followed by treatment of underlying disease. Antihistamines are the current mainstay of pharmacotherapy for urticaria, which provide symptomatic relief in most cases. In severe cases, corticosteroids, hydroxychloroquine sulfate (Plaquenil; Sanofi-Synthelabo, New York, NY), and immunosuppressive agents, including cyclosporin, are sometimes used by specialists.

Current advances in the management of urticaria

Urticaria is a relatively common autoimmune/autoreactive skin disorder that may severely impair quality of life. Although rarely life-threatening, widespread urticaria and its associated angioedema can be an extremely disabling and difficult-to-treat condition. Patients may suffer symptoms such as pruritus and disfigurement due to wheals for years or decades. Urticaria is caused by cutaneous mast-cell degranulation attributed to immunological, non-immunological, and idiopathic causes. The last decade has seen some notable advances in the understanding of the etiology and pathogenesis of common forms of urticaria and their management. Furthermore, the wide diversity in urticaria subtypes has been identified and this reflects a partial understanding of the causes or factors that trigger it as well as the molecular and cellular mechanisms that are involved in its physiopathology. In addition, new instruments for diagnosing urticaria variants and for assessing quality of life in urticaria patients have been developed. Finally, several clinical trials have demonstrated the efficacy of novel treatment approaches for urticaria, while other therapeutic concepts are under development. The objective of this article was to review the literature to be able to offer the readers comprehensive and updated information on the basic etiological and physiopathological mechanisms and to make special emphasis on the current management of urticaria, thus promoting continuous medical education.

Guidelines for evaluation and management of urticaria in adults and children

Appropriate management of urticaria depends on the correct evaluation of clinical patterns and causes where these can be identified. Guidance for treatment is presented, based on the strength of evidence available at the time of preparation. As many of the recommendations relate to the off-licence use of drugs, it is particularly important that clinicians should be familiar with dosing and side-effects of treatment in the context of managing urticaria.

5: Allergy and the skin: eczema and chronic urticaria

Eczema is common, occurring in 15%-20% of infants and young children. For some infants it can be a severe chronic illness with a major impact on the child's general health and on the family. A minority of children will continue to have eczema as adults. The exact cause of eczema is not clear, but precipitating or aggravating factors may include food allergens (most commonly, egg) or environmental allergens/irritants, climatic conditions, stress and genetic predisposition. Management of eczema consists of education; avoidance of triggers and allergens; liberal use of emollients or topical steroids to control inflammation; use of antihistamines to reduce itch; and treatment of infection if present. Treatment with systemic agents may be required in severe cases, but must be supervised by an immunologist. Urticaria ("hives") may affect up to a quarter of people at some time in their lives. Acute urticaria is more common in children, while chronic urticaria is more common in adults. Chronic urticaria is not life-threatening, but the associated pruritus and unsightly weals can cause patients much distress and significantly affect their daily lives. Angioedema coexists with urticaria in about 50% of patients. It typically affects the lips, eyelids, palms, soles and genitalia. Management of urticaria is through education; avoidance of triggers and allergens (where relevant); use of antihistamines to reduce itch; and short-term use of corticosteroids when antihistamine therapy is ineffective. Referral is indicated for patients with resistant disease.

The etiology of different forms of urticaria in childhood.

Urticaria is a common disease in children. In contrast to the ease of its diagnosis, etiologic factors are often difficult to determine. In order to study whether differences exist among various forms of urticaria in childhood and whether the patterns of different types of urticaria differ between adults and children, we extensively studied the possible causes of urticaria in children. Fifty-four children (23 girls and 31 boys; ages 1-19 years) with various forms of urticaria were included in the study. In all cases, questions about food allergies, food additive intolerance, drug intake, signs of infection, causes of physical urticaria, insect bites, and personal and family history of atopy were asked. Clinical characteristics of the disease, such as duration, recurrence, and associated angioedema and symptoms of anaphylaxis were also investigated. Detailed laboratory tests, including serologic, autoimmune, and allergic analyses, were conducted to reveal the probable etiologies of urticaria. Of the study patients, 68.5% and 31.5% were diagnosed as having acute and chronic urticaria, respectively. The patient group with chronic urticaria was older and included more boys than the acute group. In the acute urticaria group, infection was the most frequently documented cause (48.6%), followed by drugs (5.4%), and food allergies (2.7%), whereas in chronic urticaria, physical factors were the leading cause (52.94%). The most frequently documented infection was urinary tract infection, followed by serologically determined infections of Chlamydia pneumoniae and Helicobacter pylori. In this study we found indications that infections were frequently associated with urticaria, which suggests that urticaria management should include a survey of certain infectious agents in addition to a detailed history.

Antihistamines and steroids in pediatric dermatology

Histamine-receptor antagonists, or antihistamines, compete with histamine for receptors in various tissues and are classified into H1and H2-antihistamines. The principal actions of H1-antihistamines are on vasodilatation and increased vascular permeability. They reduce whealing and suppress the wheal-and-flare reaction of the axon reflex in acute urticaria as well as the associated itching. H2-antihistamines are mainly used in peptic ulcer disease, but the presence of H2-receptors in the cutaneous microvasculature has prompted their use in dermatology, too. It seems that an H2-antihistamine given concurrently with an H1-antihistamine may modestly improve itching and wheal formation in some patients with urticaria refractory to treatment with an H1-antihistamine alone, but the available evidence does not justify the routine use of H2-antihistamines in urticaria management. H1-antihistamines are further classified into firstand second-generation agents. First-generation antihistamines include diphenhydramine, chlorpheniramine, and hydroxyzine and may cause sedation due to their property of crossing the blood-brain barrier. Secondgeneration, or low-sedating, H1-antihistamines include terfenadine, astemizole, cetirizine, loratadine, fexofenadine, and mizolastine.

State of the art management of urticaria and allergic skin disease (BSACI session)

ImmunologyVolume 107, Issue s1 p. 73-73 Free Access State of the art management of urticaria and allergic skin disease (BSACI session) First published: 09 December 2002 https://doi.org/10.1046/j.1365-2567.107.s1.68.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume107, Issues1December 2002Pages 73-73 RelatedInformation

Parameters for the treatment of urticaria and angioedema.

This month's CPG column reviews "The Diagnosis and Management of Urticaria: a Practice Parameter Part I: Acute Urticaria/Angioedema and Part II: Chronic Urticaria/Angioedema." As many as 15%-24% of the U.S. population may experience at least one episode of urticaria and/or angioedema in their lifetime. Evaluation and treatment is dependent on whether the urticaria/angioedema is acute or chronic because they are fundamentally different disorders. Acute urticaria is frequently self-limited and usually caused by an allergic reaction to an identifiable agent. Chronic urticaria is usually due to an endogenous cause, one that is difficult to identify and to treat. Due to the magnitude, potential seriousness and chronicity of urticaria and angioedema, this CPG should be quite useful to nurse practitioners in a variety of settings.