Chronic Idiopathic Urticaria and Thyroid Autoimmunity: Perplexing Association

Background:

Autologous serum skin test (ASST) is the most commonly used laboratory test to differentiate chronic autoimmune urticaria patients from chronic idiopathic urticaria patients without autoantibodies. Thyroid autoimmunity is the original paradigm for autoimmune disease in general and many previous studies show increased prevalence of thyroid autoantibodies and deranged thyroid hormone profile in chronic idiopathic urticaria patients.

Aim:

To find the association between thyroid autoimmunity and chronic autoimmune urticaria, if any.

Materials and Methods:

The chronic idiopathic urticaria patients were divided into two subgroups based on autologous serum skin test. Thyroid autoantibodies were estimated in 40 patients each of ASST positive and ASST negative groups. Further, thyroid hormone profile was done in cases with significant titers of thyroid autoantibodies. Forty patients, who had never suffered from urticaria, represented the control group.

Results:

The prevalence of thyroid autoantibodies did not differ significantly among the ASST positive (20%) and ASST negative patients (15%). The control group had low prevalence of these autoantibodies (5%).

Conclusion:

The almost equal prevalence of thyroid autoantibodies in two subgroups of chronic idiopathic urticaria patients suggests possibly the same etiopathogenesis of the two subgroups. The two subgroups probably form a continuum, or even may be the same entity.     

Classification of Urticaria

Classification is based on GA²LEN/EAACI/WAO/EDF guidelines (2009). These guidelines classify urticaria according to clinical manifestations. Urticaria is mediated by mast cells. According to level of mast cell degranulation clinical signs are superficial (Urticaria) or deep swelling (Angioedema).     

Updosing of Nonsedating Anti-histamines in Recalcitrant Chronic Urticaria

Chronic urticaria (CU) is a persistent, debiliating condition that causes severe impairment on the quality of life (QoL) of patient by interrupting work productivity. Current guidelines recommend second-generation (nonsedating) anti-histamines for the treatment for all forms of urticaria. In patients who do not respond adequately to conventional doses of anti-histamines, it is recommended to increase the dose to up to four times to obtain control. But there are only few controlled studies that have assessed the efficacy and safety of nonsedating anti-histamines. Though sedating histamines are frequently used as an add-on therapy in severe cases, they have a negative impact on QoL by compromising sleep and performance. The use of other suggested therapeutic options (omalizumab, cyclosporine A, montelukast and dapsone) is also limited by paucity of data on their efficacy and adverse effect profile. Second-generation anti-histamines which are relatively safer require more proven data to support their judicious use to improve disease in patients with CU.     

Autologous Serum Therapy in Chronic Urticaria: A Promising Complement to Antihistamines

Background:

Chronic urticaria (CU) is a vexing problem and patients of CU suffer from the morbidity that arise from irritable itch and weals and are also subjected to a huge antihistamine pill burden. The symptoms are more in autoreactive urticaria (AU) where auto-antibodies in blood flares-up the condition. Search for newer effective modalities which can reduce pill burden is a felt need.

Aims:

This study evaluates the effectiveness of autologous serum therapy (AST) in CU and also determines its usefulness in AU.

Materials and Methods:

Double blind, parallel group, randomized, controlled study. Fifty four patients were given AST and 57 patients were given injection normal saline (placebo), along with cetirizine in an on-demand basis in both groups. AST/Placebo was given weekly for nine weeks and followed-up for a total period of 24 weeks. AU was diagnosed by autologous serum skin test. Urticaria total severity score (TSS), Urticaria activity score (UAS), Dermatologic life quality index (DLQI) was used as primary effectiveness variables. Safety parameters assessed were the spontaneously reported adverse events and laboratory parameters.

Results:

TSS showed significant improvement from baseline, 7^th week and 8^th week onwards in AST group and placebo group respectively. Group comparison showed significant improvement 4^th week onwards. UAS showed similar results. DLQI showed significant improvement in AST group compared to placebo at the end of study. Both AU and non-AU patients showed comparable improvement of TSS.

Conclusion:

AST shows promise in treatment of urticaria regardless of the autoreactive nature.     

Role of Nasal Carriage of Staphylococcus aureus in Chronic Urticaria

Aim:

To evaluate the role of nasal carriage of Staphylococcus aureus in patients suffering from chronic urticaria.

Method:

All total 82 patients were included for this study. Study group comprised 57 patients with chronic urticaria and the control group comprised 25 healthy volunteers. Nasal swab specimens were taken from all the 82 patients for bacterial culture and antimicrobial sensitivity. Patients with chronic urticaria who had positive growth for S. aureus were treated with sensitive antimicrobial agent. Nasal swab specimens were taken again from all the patients who received antimicrobial therapy to ensure complete eradication of S. aureus. All patients were followed up for a period of 6 weeks after the treatment. Urticarial activity was measured with the help of urticarial activity score.

Results:

S. aureus was detected in swab specimens from the nasal cavity in 32 patients in the study group and 7 patients in the control group. In the study group, after the antimicrobial treatment, 9 patients (28.12%) had complete recovery from urticaria during the follow-up period; 4 patients (12.5%) showed partial recovery from urticaria while the remaining patients (59.37%) continued to suffer from urticaria.

Conclusion:

This study showed that nasal carriage of S. aureus can act as an etiological factor in chronic urticaria.     

Treatment of Chronic Spontaneous Urticaria with a Single Dose of Omalizumab: A Study of Four Cases

Background:Chronic spontaneous urticaria (CSU) has a detrimental effect on patients’ emotional and physical quality of life. Omalizumab, an anti-immunoglobulin E humanized monoclonal antibody, has been shown to be very effective in the treatment of refractory chronic urticaria patients but may not be an economically viable option for all CSU patients. However, we present a case series where a single dose of omalizumab gave sustained relief of symptoms in patients with CSU, which may be an economical option.Aims:The aim of this study is to assess the efficacy of a single dose of omalizumab in the treatment of CSU. Materials and Methods: Four patients of CSU whose disease was not controlled with four times the licensed dose of tablet fexofenadine 180 mg were exhibited one subcutaneous injection of omalizumab and were followed up at 4 weekly intervals for 24 weeks for Weekly Urticaria Activity Score 7 (UAS7) and Dermatology Life Quality Index (DLQI).Results:A sharp decline in UAS7 and DLQI was documented in 7–10 days. The decline was maintained up to 16 weeks in one case and 20 weeks in the other three cases. Both the scores at the end of the follow-up period of 24 weeks were better than the pre-omalizumab scores.Conclusion:The results of this case series indicate the efficacy of a single-dose omalizumab in treating moderate to severe refractory CSU. Further studies are required to identify the minimum frequency of administering omalizumab to effectively control CSU. This would greatly reduce the cost of this novel therapy.     

Comparison of Efficacy,Safety and Cost-effectiveness of Rupatadine and Olopatadine in Patients of Chronic Spontaneous Urticaria: A Randomized,Double-blind,Comparative, Parallel Group Trial

Objective:To compare efficacy, safety and cost-effectiveness of rupatadine and olopatadine in patients of chronic spontaneous urticaria.Results:Both the drugs significantly reduced the MTSS, number of wheals, size of wheal, scale for interference of wheals with sleep, but olopatadine was found to be superior. In olopatadine group, there was significantly higher reduction in MTSS (p = 0.01), Number of wheals (P < 0.05), Size of wheals (p < 0.05), Scale for intensity of erythema (p < 0.05) and change in eosinopils count (p = 0.015) than that of rupatadine. Incidence of adverse effects was found to be less in olopatadine group when compared with rupatadine group. Cost effectiveness ratio was less in olopatadine group as compared to rupatadine group throughout the treatment.Conclusions:Olopatadine is a better choice in chronic spontaneous urticaria in comparison to rupatadine due to its better efficacy, safety and cost effectiveness profile.     

Autologous Serum Therapy in Chronic Urticaria

Autologous serum therapy is a promising therapy for treatment resistant urticaria. This is useful in developing countries as this is economical option. Minimum instruments like centrifuge, syringe and needles are required for the procedure.     

Chronic urticaria

Chronic urticaria (CU) is a disturbing allergic condition of the skin. Although frequently benign, it may sometimes be a red flag sign of a serious internal disease. A multitude of etiologies have been implicated in the causation of CU, including physical, infective, vasculitic, psychological and idiopathic. An autoimmune basis of most of the 'idiopathic' forms is now hypothesized. Histamine released from mast cells is the major effector in pathogenesis and it is clinically characterized by wheals that have a tendency to recur. Laboratory investigations aimed at a specific etiology are not always conclusive, though may be suggestive of an underlying condition. A clinical search for associated systemic disease is strongly advocated under appropriate circumstances. The mainstay of treatment remains H1 antihistaminics. These may be combined with complementary pharmacopeia in the form of H2 blockers, doxepin, nifedipine and leukotriene inhibitors. More radical therapy in the form of immunoglobulins, plasmapheresis and cyclophosphamide may be required for recalcitrant cases. Autologous transfusion and alternative remedies like acupuncture have prospects for future. A stepwise management results in favorable outcomes. An update on CU based on our experience with patients at a tertiary care centre is presented.     

Allergic Urticaria: A Case Report of Rare Skin Allergy with a Common Mouthwash

Chlorhexidine is a widely used antiseptic and disinfectant in medical and non-medical environments. Compared to its ubiquitous use, allergic contact dermatitis from chlorhexidine has rarely been reported and so its sensitization rate seems to be low. Chlorhexidine has been used for more than 50 years but it was only in the last two decades, that reports of immediate- type reactions to chlorhexidine were seen. Reactions ranging from localized urticaria to anaphylactic shock and hypersensitivity reactions, including delayed hypersensitivity reactions such as contact dermatitis, fixed drug eruptions, and photosensitivity reactions, began to appear more frequently. However the prevalence of contact urticaria and anaphylaxis due to chlorhexidine remains to be unknown. In this case report we have reported a case of urticaria due to oral use of chlorhexidine. The adverse reaction was confirmed by a skin prick test.     

CHRONIC AUTOIMMUNE URTICARIA: WHERE WE STAND?

It is well-recognized that 30-40% of chronic idiopathic urticaria is autoimmune in nature. Chronic autoimmune urticaria is caused by anti-FcεRI and less frequently, by anti-IgE autoantibodies that lead to mast cell and basophil activation, thereby giving rise to the release of histamine and other proinflammatory mediators. Activation of the classical complement pathway and formation of C5a are important in dermal mast cell activation. C5a is also a neutrophil and eosinophil chemoattractant. Chronic autoimmune urticaria has been found to be associated with autoimmune thyroid disease. The autologous serum skin test is used as a screening test for chronic autoimmune urticaria and has a sensitivity and specificity of about 70 and 80%, respectively. The current gold standard diagnostic test is the basophil histamine release assay. The treatment of chronic autoimmune urticaria, as in chronic idiopathic urticaria, is with H1 antihistamines. Oral corticosteroids may be used during acute flares. Refractory cases have been shown to respond to cyclosporine and other immunomodulators. The prevalence of chronic autoimmune urticaria in Singapore is similar to that reported in Western countries at about 42%. The presence of thyroid autoimmunity appears to be higher than reported, with 22.5% of patients with chronic idiopathic urticaria here, exhibiting presence of thyroid autoantibodies.     

MANAGEMENT OF DIFFICULT URTICARIA

Chronic urticaria, a major health problem causing patient''s distress, induces often physicians'' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.     

Clinical and Investigative Assessment of Patients with Positive Versus Negative Autologous Serum Skin Test: A Study of 80 South Indian Patients

Background:

Chronic urticaria (CU) is defined as urticaria persisting daily as or almost daily for more than 6 weeks and affecting 0.1% of the population. Mast cell degranulation and histamine release is of central importance in the pathogenesis of CU. About 40-50% of the patients with chronic idiopathic urticaria demonstrate an immediate wheal and flare response to intra-dermal injected autologous serum. This led to the concept of autoimmune urticaria.

Aims:

To determine the occurrence, clinical features, associated clinical conditions, comorbidities of autoimmune urticaria and to compare this with chronic spontaneous urticaria. This study aimed to find the frequency of autologous serum skin test (ASST) positive patients among patients with CU and to identify the clinical and laboratory parameters associated with positive ASST.

Materials and Methods:

Prospective correlation study was done on 80 chronic urticaria patients, more than 6 weeks duration, attending outpatient department of dermatology during a period of November 2007 to January 2010. Patients were subjected to ASST, complete blood count, urine routine examination, liver function tests, renal function tests, thyroid function tests, H. pylori antibody tests, C3 and C4 complement level estimation, antinuclear antibody, and urine analysis.

Results:

ASST was positive in 58.75% and negative in 41.25% of the patients, respectively. Out of 33 patients with history of angioedema, 9 (27.3%) patients were in ASST negative group and 24 were in positive group, this was statistically significant. Both groups showed no statistically significant difference for epidemiological details.

Conclusion:

ASST is considered a screening test for an autoimmune urticaria, which decreases the rate of diagnosis of “idiopathic” form of chronic urticaria. Patients with an autoimmune urticaria have more severe urticaria, more prolonged duration, more frequent attacks, and angioedema. Identification of autoimmune urticaria may permit the use of an immunotherapy in severe disease unresponsive to anti-histamine therapy.     

Skin Prick Test in Patients with Chronic Allergic Skin Disorders

Background:

Chronic allergic skin disorders are the inflammatory and proliferative conditions in which both genetic and environmental factors play important roles. Chronic idiopathic urticaria (CIU) and atopic dermatitis (AD) are among the most common chronic allergic skin disorders. These can be provoked by various food and aeroallergens. Skin prick tests (SPTs) represent the cheapest and most effective method to diagnose type I hypersensitivity. Positive skin tests with a history suggestive of clinical sensitivity strongly incriminate the allergen as a contributor to the disease process.

Aims and Objectives:

To determine the incidence of positive SPT in patients with chronic allergic skin disorders and to identify the various allergens implicated in positive SPT.

Methods:

Fifty patients of chronic allergic disorders were recruited in this study. They were evaluated by SPT with both food and aeroallergens.

Results:

In our study, SPT positivity in patients of CIU was 63.41% and in AD was 77.78%. Out of the 41 patients of CIU, the most common allergen groups showing SPT positivity were dust and pollen, each comprising 26.83% patients. SPT reaction was positive with food items (21.6%), insects (17.07%), fungus (12.20%), and Dermatophagoides farinae, that is, house dust mite (HDM) (7.32%). The allergen which showed maximum positivity was grain dust wheat (19.51%). Among nine patients of AD, maximum SPT positivity was seen with Dermatophagoides farinae, pollen Amaranthus spinosus, grain dust wheat, and cotton mill dust; each comprising 22.22% of patients.

Conclusion:

Our study showed that a significant number of patients of CIU and AD showed sensitivity to dust, pollen, insects, Dermatophagoides farinae, and fungi on SPT. Thus, it is an important tool in the diagnosis of CIU and AD.     

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.     

CONTACT URTICARIA: PRESENT SCENARIO

Immunological contact urticaria is a hypersensitivity reaction that appears on the skin following contact with an eliciting substance. Recent advances in our understanding of the molecular mechanism and pathogenesis of this reaction have altered its classification, diagnosis, and treatment. We discuss classification, epidemiology, diagnosis, testing, and treatment options that are available to patients with contact urticaria.     

CHRONIC URTICARIA AND TREATMENT OPTIONS

Chronic urticaria has a wide spectrum of clinical presentations and causes. Still, despite our best efforts no cause may be found in the majority of cases. The treatment options are: Primary prevention in the form of avoidance of aggravating factors; counseling; antihistamines; leukotriene receptor antagonists; prednisolone; sulfasalazine and a host of immunosuppressives like methotrexate, cyclosporine, omalizumab etc.     

Epidemiological Study of Insect Bite Reactions from Central India

Introduction:

The physical effects of the arthropod bites on human skin receive less attention, especially in the rural areas where the per capita income is less. Ours is a rural-based hospital, the vicinity having more of plants, trees, and forests; we undertook the study to find out the relation of insect bite dermatitis in a rural area.

Materials and Methods:

The study was carried out in the Dermatology outpatient department of our institute on 100 subjects of insect bite dermatitis who were questioned retrospectively about the sequence of events besides their environmental and living conditions. They were examined thoroughly and the relevant clinical findings were noted, also taking into account the prior treatment taken by them, if any.

Results and Conclusions:

It was found that insect bite dermatitis has no age or gender preponderance, and the protective factors for the same are use of full sleeve clothes and keeping the doors and windows closed at night. On the contrary, the risk factors are residence in areas of heavy insect infestation, use of perfumes and colognes, warm weather in spring and summer and the lack of protective measures. However, there was no direct association of atopy with increased risk of developing insect bite dermatitis.     

AUTOLOGOUS SERUM SKIN TEST IN CHILDREN

Chronic urticaria in children occurs less often than adults. Out of 17 children (age group 6-16 years,

Recurrent facial urticaria following herpes simplex labialis

We describe recurrent acute right-sided facial urticaria associated with herpes labialis infection in a middle-aged female patient. Antiviral medications and antihistamines not only successfully cleared the herpes infection and urticaria but also prevented further recurrences.