Antihistamines and alternatives in physical urticaria

ABSTRACT: The mainstay of management of physical urticaria is symptomatic therapy with H₁-type antihistamines, with preference being given to the nonsedating drugs. Patients vary in their responsiveness, in dependence of the type of physical urticaria. If even higher doses of H₁ blockers fail, dapsone, sulfazalazine, chloroquine, and danazol may be tried as alternatives. Corticosteroids, though highly effective, are contraindicated because of long-term adverse effects. Patients should also be advised to avoid eliciting stimuli or to use exposure only to induce the so-called hardening, under medical supervision. Physicians should exclude sustaining diseases or drug intake. In cold urticaria, a trial with antibiotics is worthwhile. If all these possibilities are utilized to the advantage of the individual patient, physical urticaria is a generally well-managed disease.     

雷公藤多苷联合抗组胺药治疗慢性荨麻疹临床疗效及生活质量的观察

目的 临床观察雷公藤多苷联合不同的第二代抗组胺药治疗慢性荨麻疹的临床疗效及对患者生活质量的影响.方法 360例慢性荨麻疹患者,随机分为六组.治疗组为雷公藤多苷联合不同的抗组胺药(氯雷他定、西替利嗪、咪唑斯汀)各一组,以及仅使用不同抗组胺药(氯雷他定、西替利嗪、咪唑斯汀)各一组作为对照组的治疗方案.六组于治疗前后记录荨麻疹症状评分以及皮肤病生活质量评分表.结果 治疗4周后,雷公藤多苷和抗组胺药联合应用的治疗组的症状评分均低于仅使用抗组胺药物的对照组(P＜0.001),有效率治疗组也高于对照组(P＜0.05).在生活质量方面,治疗组的DLQI评分在用药2周与4周后均显著低于对照组(P＜0.05,P＜0.001)结论 使用雷公藤多苷联合抗组胺药(尤其是咪唑斯汀)能够更快的减轻患者症状,提高患者的生活质量.     

Camouflage technique for alopecia areata: What is a patient to do?

Alopecia areata is a devastating condition for any patient as hair is a prized component of human beauty. Poems and folktales have been written about long, luxuriant, female, golden, and chestnut hair, and even the Bible discusses the diminishment of male power when hair is lost. The question arises as to whether anyone can be beautiful without hair. The answer is a definite yes. No one can dispute the virility of a shaved male head, indicating the absence of hair can make a strikingly beautiful fashion statement. This is sadly not the case for women. With hair loss, the decision can be made to readjust to a personal image devoid of hair, yet there are those who require hair for self-confidence or simply to fit in with the rest of society. This article discusses the currently available options for those who wish to pursue camouflage of hair loss involving the scalp, eyebrows, and eyelashes.     

Contact urticaria from peanut butter

A patient with multiple atopic allergies, atopic facial dermatitis, and a generalized atopic skin diathesis developed (i) angioedema of the lips and tongue following ingestion of peanut butter, and (ii) localized urticarial reactions following direct skin contact. Open testing with peanut butter demonstrated probable immunologic contact urticaria. The relationship of contact urticaria to the atopic skin diathesis is discussed.     

Second- and third-generation antihistamines in the treatment of urticaria

ABSTRACT: Chronic urticaria is mainly idiopathic in nature and can be difficult to treat. While less responsive to antihistamine therapy than acute urticaria, antihistamines still play a key role in the management of symptomatology. While many of the antihistamines still commonly used to treat urticaria are first generation H₁ antagonists (e.g., diphenhydramine, hydroxyzine), the more recently developed second-generation agents (e.g., loratadine, cetirizine) and their metabolites—the third-generation antihistamines (e.g., fexofenadine, norastemizole, descarboxyloratadine)—possess many of the desirable clinical effects of the first-generation agents with a more tolerable side effect profile. This review discusses the advantages and disadvantages of each of the various second- and third-generation agents available, and presents some of the data showing the differences among these agents in the treatment of chronic urticaria.     

Comparative study of the impact of chronic urticaria, psoriasis and atopic dermatitis on the quality of life

BACKGROUND: A better management of chronic skin disorders (CSDs) requires a knowledge of their impact from the patient's point of view. OBJECTIVES: To determine which aspects of the patient's life are mainly impaired in the different CSDs, and provide comparative references to estimate better the real impact of the different CSDs. PATIENTS AND METHODS: A prospective cross-sectional and matched study of 1356 adult outpatients to compare the health-related quality of life (HRQL) profile in chronic urticaria (466 CU), psoriasis (464 PSO) and atopic dermatitis (426 AD), using the VQ-Dermato, a multidimensional instrument in French validated for CSDs. RESULTS: After adjustment for confounders, HRQL dimensions were differently affected in the three CSDs. The 'physical discomfort' dimension was more degraded in AD and CU than in PSO (P < 0.001), and 'leisure activities' more in PSO than in CU (P < 0.001). 'Self-perception' and 'treatment-induced restrictions' dimensions were much less affected in CU than in PSO and AD (P < 0.001). In PSO, the 'daily living activities' dimension was much less impaired than in CU and AD (P < 0.001). No aspect of HRQL was really spared in AD. CONCLUSIONS: The comparison shows that CU, PSO and AD are characterized by completely different qualitative profiles of impact on HRQL, which are influenced by their clinical characteristics and usual treatment options. It underlines the severe impairment of CU which is often underestimated.     

Interrelationship between biliary dyskinesia and chronic urticaria, chronic eczema and atopic dermatitis

Interrelationships between biliary dyskinesia and chronic urticaria, chronic eczema and atopic dermatitis have been studied in 210 biliary dyskinesia patients and 60 normal subjects. Incidences of chronic urticaria, chronic eczema and atopic dermatitis were found more frequently in biliary dyskinesia patients than normal subjects. Skin symptoms of these chronic urticaria, chronic eczema and atopic dermatitis cases showed significant normalization with improved gallbladder contraction rate. COMT inhibitor therapy and fat restriction were more effective for the skin symptoms and for prolonging the interval before recidivation or exacerbation of these allergic diseases than conservative therapy.     

Use and safety of antihistamines in children

ABSTRACT: Although first-generation antihistamines remain popular for the treatment of seasonal allergic rhinitis, atopic dermatitis, and urticaria in children, second- and third-generation antihistamines hold clear advantages over the first-generation agents, especially for the pediatric patient. The less frequent dosing schedule of the second- and third-generation agents makes administration easier for the parent. With less sedation and lower risk of adverse effects, the safety profile of second- and third-generation agents appears superior to that of first-generation agents. After briefly discussing the use of first-generation antihistamines, the pharmacokinetics, safety, and use of the newer antihistamines loratadine, cetirizine, and fexofenadine in the pediatric patient are reviewed.     

Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema

BACKGROUND: Epidemiological studies indicate that occupational hand eczema (OHE) often is associated with persistent dermatitis and prolonged sick leave, which may lead to unemployment. Previous studies suggest that OHE caused by allergic contact dermatitis and atopic dermatitis (AD) carries the worst prognosis. OBJECTIVES: To evaluate and compare the severity and consequences of recognized OHE in different diagnostic and subdiagnostic groups. METHODS: Between October 2001 and November 2002, all new cases of recognized OHE were identified from the Danish National Board of Industrial Injuries Registry (758 cases). Severity was graded from 0 to 2 depending on the intensity of skin response and the frequency of relapse. To supplement the information from the Registry, we surveyed the study population using a postal questionnaire which included questions about disease duration, sick leave, current occupation and loss of job. RESULTS: The overall response rate to the questionnaire was 82%. We observed substantially greater severity among those with occupational irritant contact dermatitis (ICD) and AD than for any other diagnoses. Age above 50 years was also associated with increased severity of OHE. Prolonged sick leave due to OHE was reported by 19.9% and was associated with AD and severe OHE. We found a higher proportion of prolonged sick leave among those in food-related occupations (27.2%) compared with those in wet occupations (20.1%) and other occupations (16.5%). Twenty-three per cent reported that they had lost their job at least once during the past 12 months due to OHE. The only strong association with loss of job was food-related occupations. CONCLUSIONS: Occupational ICD and AD appear to be strongly associated with severity of OHE. AD and severity of OHE were independently associated with prolonged sick leave. Having a food-related occupation appears to be associated with increased risk of loss of job.     

Sweat antigen induces histamine release from basophils of patients with cholinergic urticaria associated with atopic diathesis

Background  We previously demonstrated that the semipurified human sweat antigen causes skin reactions and histamine release from basophils via specific IgE in patients with atopic dermatitis (AD). Patients with cholinergic urticaria (ChU) also develop skin reactions and histamine release of basophils in response to autologous sweat.
Objectives  To study whether or not patients with ChU share sensitivity for the sweat antigen with patients with AD and to study the clinical characteristics among patients with ChU and the relationship with histamine-release activity of basophils.
Methods  The sweat antigen that induces histamine release from basophils of patients with AD was prepared by Con-A, anion-exchange and reverse-phase chromatography. Relationships between histamine-release activity against the sweat antigen and clinical features of patients with ChU were analysed.
Results  Twenty-three of 35 patients with ChU showed > 5% net histamine release in response to the semipurified sweat antigen, whereas none of healthy controls did so. In patients with ChU, histamine release in response to semipurified sweat antigen significantly correlated with the level of serum IgE and eosinophil numbers in peripheral blood. Incidence of each atopic disease in patients with ChU tended to be higher than in the general Japanese population. When the patients were categorized according to their responses in the histamine release test, the positive group tended to show a higher incidence of AD and bronchial asthma compared with the negative group.
Conclusions  ChU and AD may share hypersensitivity to common antigens in sweat. The sweat allergy and atopic diathesis are associated with each other.     

Urticaria

Urticaria and angioedema are common and, if chronic, often persist for years with significant impact on quality of life and occupational ability. To achieve a better understanding of disease etiology and pathogenesis and to compare clinical trials, there is a clear need for cross‐specialty and international agreement of the nomenclature and diagnostic classification of urticaria and angioedema. At least in part this has been achieved by two recently published European guidelines. After the urticaria subtype is defined, potential triggers should be sought including persistent bacterial infections (Helicobacter pylori, streptococci, staphylococci, Yersinia, parasites) pseudoallergic reactions (acetylsalicylic acid, rarely food additives) and/or autoreactive mechanisms (autologous serum test). Identified trigger factors should be avoided or eradicated, as this is the most successful therapeutic approach. Treatment of most urticaria subtypes is difficult and besides H1 antihistamines neither standardized nor evidence‐based. Low‐sedating H1 antihistamines represent the mainstay of treatment, as they have a better therapeutic index and pharmacodynamic properties than older agents. In severe cases their dose has to be increased which is off‐label use. The evidence base for treatment alternatives is totally insufficient and the risk‐benefit profile of each off‐label used drug should be carefully considered.     

Treatments for chronic pruritus outside of the box

Patients with chronic pruritus are in desperate need of novel treatment options, as current therapeutic possibilities are often not effective, have a poor level of evidence and are mostly off‐label. In recent years, much effort has been put into the identification of potential targets for the treatment of chronic pruritus. More importantly, a number of promising new drugs that are aimed at treating pruritus in different conditions are currently in advanced stages of clinical trials. Here, current pharmacological developments leading to potential new drugs for the treatment of chronic pruritus within various conditions are summarized. Hopefully, these new approaches will result in effective and safe therapies for our patients with chronic pruritus associated with dermatological or non‐dermatological diseases in the near future.     

Stanozolol in chronic urticaria: a double blind, placebo controlled trial

H1-type antihistamine drugs are mainstays in the management of chronic urticaria. For patients with refractory, chronic, idiopathic urticaria who have failed to benefit from conventional therapy, other safe therapeutic modalities are required. To evaluate the role of stanozolol as an adjunctive therapeutic agent with H1-antihistamine in refractory chronic idiopathic urticaria, we conducted this study. Fifty-eight patients with chronic refractory urticaria were enrolled in this trial and were randomly assigned to two groups (A and B). Patients in group A received 2 mg stanozolol twice daily along with cetrizine 10 mg daily. Patients in group B received cetrizine 10 mg daily and placebo tablets twice daily. The improvement was monitored by estimation of severity score. Of the 58 patients, 26 in group A and 24 in group B could be evaluated. At the end of 12 weeks, 17 patients in group A showed marked to complete resolution as compared to 7 patients in group B (chi-square p<0.01). The intention to treat analysis p value was a found to be <0.007. There was a highly significant decrease in mean severity score at 12 weeks (p<0.001) in group A patients. The present study demonstrated that stanozolol is an effective and safe adjuvant therapy for treatment of chronic refractory urticaria.