Urticaria and Angioedema
Pudupakkam K Vedanthan, Harold S Nelson, Shripad N Agashe, PA Mahesh, Rohit Katial in Textbook of Allergy for the Clinician, 2021
Chronic urticaria is characterized by hives that occur daily or almost daily for 6 weeks or more. Chronic Spontaneous Urticaria (CSU) is the most common type of chronic urticaria. CSU was previously called Chronic ‘Idiopathic’ Urticaria (CIU), but recent nomenclature has shifted to the term ‘spontaneous’ to reflect that urticaria occurs spontaneously without an apparent trigger. This lack of an identifiable cause of urticaria is sometimes difficult for both patients and health care providers to accept. Search for a cause of CSU can lead to expensive, potentially invasive and often fruitless investigations (Tarbox et al. 2011). The best diagnostic tool in the evaluation of chronic spontaneous urticaria is a thorough history and physical, performed by a board certified specialist knowledgeable in urticarial disease. Figure 24.3 outlines a diagnostic algorithm for chronic urticaria.
Monographs of fragrance chemicals and extracts that have caused contact allergy / allergic contact dermatitis
Anton C. de Groot in Monographs in Contact Allergy, 2021
In a study in the mid-1970’s in Sweden, closed patch tests with BP in concentrations ranging from 1.56% to 50% and 11 of its components (benzoic acid 5%, benzaldehyde 5%, cinnamal 2% [not an ingredient of MP], cinnamyl alcohol 2%, cinnamic acid 5%, methyl cinnamate 0.5%, benzyl benzoate 5%, benzyl salicylate 2%, benzyl cinnamate 5%, eugenol 5%, vanillin 10%) were applied to the upper part of the back for a period of 30 minutes. The result was read immediately after removal and after every hour until the reaction disappeared. The tests were performed on 121 patients with different dermatoses and on 57 patients with chronic urticaria, the components only in 5 patients (not specified). MP gave rise to 9/121 (7.4%) and 16/57 (28%) patients, respectively. Most reactions were caused by the higher concentrations, with 12.5% < 25% < 50% pet. The reaction appeared earliest 10 minutes after application of MP and normally after 20 minutes and would fade within 2 hours. Conventional patch tests were negative.
Dermatology
John D Firth, Professor Ian Gilmore in MRCP Part 1 Self-Assessment, 2017
A precipitant is identified in about 50% of patients with chronic urticaria, but IgE-mediated chronic urticaria is a relatively minor cause. It is not associated with internal malignancy, but can rarely be associated with systemic vasculitides although in the vast majority of cases there are no vasculitic changes on biopsy. H1-antagonists can be very helpful and H2-antagonists can help some patients. Most patients with chronic urticaria will have improved within a year, but relapses are not infrequent. For uncomplicated chronic urticaria with no clear clues from the history or examination of systemic disease or an exogenous precipitant, the current UK guidelines (2003) recommend full blood count, ESR and antinuclear antibodies as reasonable screening investigations for those with moderate-severe disease. Non-steroidals are a common cause of exacerbation of urticaria.
Haematological parameters in patients with chronic spontaneous urticaria
Published in Cutaneous and Ocular Toxicology, 2020
Chronic urticaria is a common skin disorder defined by recurrent wheals and pruritus of at least a 6-week duration2. Previous studies have deemed chronic spontaneous urticaria to be associated with an altered immune response related to chronic systemic inflammation3,4. Moreover, these studies have demonstrated the infiltration of eosinophils, neutrophils, monocytes and T cells in the skin of patients with chronic spontaneous urticaria5. As you mentioned in the study, in recent years, haematological parameters have been used as inflammatory markers in various diseases. It is known that monocytes increase in diseases in which inflammatory response is involved such as psoriasis and urticaria. In addition, these cells decrease with suppression of inflammation after treatment. In the present study authors found a significant decrease in the neutrophil/monocyte ratio due to increased monocyte count after omalizumab treatment. However, both neutrophils and monocytes are expected to decrease after treatment. This unexpected increase in the count of monocytes may be due to other possible causes. Moreover, neutrophil/monocyte ratio was not shown as an inflammatory parameter in previous studies. Therefore, I think that neutrophil/monocyte ratio decreases by chance after the treatment, and should not be shown as an inflammatory marker. The clinical relevance should be validated in more rigorous studies with larger participant numbers.
Recurrent oedema of the uvula in a patient with chronic spontaneous urticaria successfully treated with omalizumab
Published in Journal of Dermatological Treatment, 2018
Urticaria is a disease characterized by itching wheals, and sometimes angioedema. According to EAACI/GA2LEN/EDF/WAO (European Academy of Allergy and Clinical Immunology, Global Allergy and Asthma European Network, European Dermatology Forum, World Allergy Organization) guidelines, urticaria is considered chronic when it lasts longer than 6 weeks (3). Chronic urticaria is spontaneous when the etiology is unknown. Chronic urticaria may be disabling and difficult to treat, with a bad impact on the patient’s quality of life. A first line therapy with second generation antihistamine drugs is recommended for chronic urticaria, titrating the dosage up to fourfold the usual dose (second line treatment). Omalizumab administration is suggested for refractory patients as add-on therapy to the antihistamines, in a third line treatment (3). According to Italian regulatory, omalizumab may be used for the treatment of spontaneous chronic urticaria in patients older than 12 years, refractory to antihistamines, with UAS >3 and UAS7 > 16.
Emerging treatments for chronic urticaria
Published in Expert Opinion on Investigational Drugs, 2022
For patients and clinicians, the pipeline for the treatment of chronic urticaria is very promising. While omalizumab biosimilars are investigated in clinical trials, the expected approval of ligelizumab will soon expand the so far very effective and safe anti-IgE approach observed with omalizumab. For other anti-IgE mAbs like UB-221, the development is considerably behind. Data are too limited so far to clearly define the role of anti-cytokine and anti-cytokine receptor biologics such as dupilumab, tezepelumab, mepolizumab, benralizumab and CDX-0159, of which only dupilumab is actually investigated in phase 3. Regarding small molecules, three selective oral BTK inhibitors are considered in CU, remibrutinib, rilzabrutinib, and fenebrutinib, of which the development of remibrutinib is most advanced, namely in phase 3. As the pipeline interventions address different targets, the results of the studies will give new insights into the pathomechanism of CSU and of CINDU and might identify additional endotypes. It is welcome that for the first time, CINDU subtypes are addressed in RCTs. Hopefully, in the next future, we will have additional approved and also more targeted approaches to adequately treat chronic urticaria.
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