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urticaria archivos - Bilastina

The challenges of chronic urticaria part 2: Pharmacological treatment, chronic inducible urticaria, urticaria in special situations

By | New, Selected articles

Mario Sanchez-Borges, Ignacio J. Ansotegui, Ilaria Baiardini, Jonathan Bernstein, Giorgio Walter Canonica, Motohiro Ebisawa, Maximiliano Gomez, Sandra Nora Gonzalez-Diaz, Bryan Martin, Mario Morais-Almeida and Jose Antonio Ortega Martell

World Allergy Organ J . 2021 Jun 3;14(6):100546. doi: 10.1016/j.waojou.2021.100546. eCollection 2021 Jun.

Chronic spontaneous urticaria consists in the occurrence of wheals, angioedema, or both more than 6 weeks, and 1-2% of the population is affected. It is more prevalent in women and frequently compromises quality of life and the costs for national health systems can be considerable.

The World Allergy Organization (WAO) has reviewed a position paper published in 2012 regarding diagnosis and treatment of urticaria and angioedema. Since then, there have been advances in the knowledge of urticaria mechanism of action, and new treatments (biologics) have been released for severe refractory disease.

This is the second part of an update from the WAO, which intention is to provide an updated guidance for urticaria, especially in special situations such as childhood and pregnancy.

Second generation H1 antihistamines are recommended in major guidelines as the first line treatment for urticaria, as they are effective and safe. Some guidelines include first generation antihistamines for non responders. The dose can also be increased up to 4 times to improve efficacy (and without compromising safety). Combination of antihistamines does not seem to induce better effects, and patients who are refractory to antihistamines are candidates to omalizumab or cyclosporin-A. Omalizumab is the only biological approved for the treatment of antihistamine-refractory patients with moderate to severe urticaria. Cyclosporin-A is an immunosuppressing drug that inhibits T helper cells by blocking the production of inflammatory cytokines.

Special conditions associated with urticaria include autoinflammatory syndromes and various forms of urticarial vasculitis, which are treated with second generation antihistamines and systemic glucocorticoids, and alternatively immunomodulators and immunosuppressors.

 

Specialists are recommended to follow the guidelines, use validated PRO instruments and use effective and safe medications.

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The challenges of chronic urticaria part 1: Epidemiology, immunopathogenesis, comorbidities, quality of life, and management

By | New, Selected articles

Mario Sanchez-Borges, Ignacio J. Ansotegui, Ilaria Baiardini, Jonathan Bernstein, Giorgio Walter Canonica, Motohiro Ebisawa, Maximiliano Gomez, Sandra Nora Gonzalez-Diaz, Bryan Martin, Mario Morais-Almeida and Jose Antonio Ortega Martell World Allergy Organ J. 2021 Jun 1;14(6):100533. doi: 10.1016/j.waojou.2021.100533. eCollection 2021 Jun.

Chronic spontaneous urticaria consists in the occurrence of wheals, angioedema, or both more than 6 weeks, and 1-2% of the population is affected. It is more prevalent in women and frequently compromises quality of life and the costs for national health systems can be considerable.

The World Allergy Organization (WAO) has reviewed a position paper published in 2012 regarding diagnosis and treatment of urticaria and angioedema. Since then, there have been advances in the knowledge of urticaria mechanism of action, and new treatments (biologics) have been released for severe refractory disease. Urticaria pathological mechanisms include different cell types, mainly mast cells, basophils, eosinophils, T and B lymphocytes and epithelial and endothelial cells. The dysregulation of intracellular signaling pathways and autoimmune mechanisms have an important role in the activation of mast cells/basophils, which leads to the release of inflammatory mediators resulting in wheals and angioedema.

This is the first part of an update from the WAO, which intention is to provide an updated guidance for urticaria.

Biomarkers have been identified for the prognosis of chronic urticaria (total IgE, CRP, ASST, Anti-TPO, IL-17, IL-31, IL-33) and the assessment of the response of different therapies. Specialists are recommended to follow the guidelines, use validated PRO instruments and use effective and safe medications.

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Real-Life Experience of Efficacy and Safety of Bilastine in the Refractory Cases of Chronic Spontaneous Urticaria and its Effect on the Quality of Life of Patients

By | Articles about Bilastine, New

Abhishek De, Kiran Godse, Dhiraj Dhoot, and Aarti Sarda

Indian J Dermatol . Mar-Apr 2021;66(2):159-164. doi: 10.4103/ijd.IJD_771_20.

Chronic spontaneous urticaria is a skin condition with wheals and angioedema, for more than six weeks. Second-generation H1-antihistamines are the first line treatment for these allergic conditions, namely bilastine. The aim of this study was to assess long-term efficacy and tolerability of bilastine in patients with chronic spontaneous urticaria in India.

This was a retrospective analysis that identified patients with urticaria who were prescribe bilastine between May, 1, 2019 to March, 20, 2020 from analysis of electronic medical records. Patients with unsatisfactory response to previous treatment were also included. Unsatisfactory treatment was assessed as per Urticaria Activity Score 7 (UAS7). The efficacy of the treatment was evaluated by revising their UAS7 score ate weeks 4, 8, 12, 16, 20. DLQI was also evaluated and compared at baseline and week 24.

The study included 49 patients. At 24 weeks, 51% of them had achieved treatment response (UAS = 0) and the remaining 49% had a well-controlled urticaria (UAS <6). At 24 weeks, mean UAS7 was statistically significant compared to baseline values (1,35 ± 1,61 vs. 20,2 ± 5,73), and mean DLQI score also decreased to 1,63 ± 1,18, compared to 8,39 ± 2,49 at baseline.

In conclusion, this study demonstrated that patients who usually had an inadequate response with commonly used antihistamines, when switched to bilastine had their quality of life and symptoms improved.

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Cold Agglutinins and Cryoglobulins Associate with Clinical and Laboratory Parameters of Cold Urticaria

By | Selected articles

Mojca Bizjak, Mitja Kosnik, Dorothea Terhorst-Molawi, Dejan Dinevski, Marcus Maurer

Front Immunol. 2021 Apr 29;12:665491. doi: 10.3389/fimmu.2021.665491. eCollection 2021

Cold urticaria is a condition characterized by wheals and/or angioedema in response to cold. It is usually diagnosed after provocation testing, and trigger thresholds measure its activity. Just as “common” urticaria, cold urticaria is also a mast-cell driven condition, where cold is an activating signal which causes a release of histamine from dermal mast cells. Cold agglutinins and cryoglobulins were designated as elements related to cold urticaria. The objective of this study was to understand the impact of cold agglutinins and cryoglobulins on the molecular level and evaluate strategies for cold urticaria.

This was a single-center prospective cohort study that included 35 participants with cold urticaria. They were analyzed for cold agglutinins and cryoglobulin, demographics, history data, cold stimulation test results, complete blood count values, C-reactive protein, total immunoglobulin E levels, and basal serum tryptase levels.

Sixteen (46%) of the 35 participants tested positive for cold agglutinin, and 9 (27%) of 33 tested participants had a positive cryoglobulin test. There was no gender association for cryoglobulin. However, a positive cold agglutinin was mainly in female participants. Also, a positive cold agglutinin test showed a higher rate of reactions triggered by cold ambient air, immersion in cold water, and aggravated by summer humidity. These participants also had more angioedema triggered by cold foods or drinks.

Cold agglutinin serum levels correlated with erythrocyte and monocyte counts. Cryoglobulin concentrations associated with basal serum tryptase levels and cold urticaria duration.

In conclusion, this study suggests that cold agglutinins and cryoglobulins are related to the course and pathogenesis of cold urticaria. More studies are encouraged to explore mechanisms of action, treatment, and use as biomarkers.

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Effects of Serum Vitamin D Levels and Vitamin D Supplementation on Urticaria: A Systematic Review and Meta-Analysis

By | Selected articles

Yajia Li, Ziqin Cao, Jia Guo, Qiangxiang Li, Juan Su

Int J Environ Res Public Health. 2021 May 5;18(9):4911. doi: 10.3390/ijerph18094911.

Urticaria is characterized by itchy wheals and/or angioedema. It is a common condition with an impact on the quality of life driven by mast cells. Numerous studies have demonstrated that serum levels of 25-hydroxyvitamin D can impact urticaria. However, the relation between vitamin D and urticaria is not well recognized. The objective of this study was to systematically synthesize the associations of vitamin D and urticaria published until March 2021.

A systematic search was done in PubMed, EMBASE, Web of Science, and Cochrane. Observational studies with the comparisons of vitamin D and people with urticaria and clinical studies were included.

A meta-analysis of 17 studies of urticaria patients compared to controls demonstrated a mean difference of -9.35 ng/mL in vitamin D, which complied with the association of urticaria with a deficiency in vitamin D. Studies with supplementation of vitamin D also demonstrated a significant reduction in clinical urticarial score in people supplemented with vitamin D.

In conclusion, people with urticaria may have a lower level of serum vitamin D, and vitamin D supplementation may reduce urticaria symptoms and exacerbations and improve quality of life due to vitamin D immunomodulatory and anti-inflammatory properties. However, more studies are needed to assess the clinical benefits and mechanisms of action of vitamin D in urticaria.

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Triggers of Exacerbation in Chronic Urticaria and Recurrent Angioedema-Prevalence and Relevance

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Anete Sevciovic Grumach, Petra Staubach-Renz, Ricardo Cardona Villa, Susana Diez-Zuluaga, Imke Reese, William R. Lumry

J Allergy Clin Immunol Pract . 2021 Jun;9(6):2160-2168. doi: 10.1016/j.jaip.2021.04.023

 

The causes of urticaria vary with patients, with hives mainly characterizing most of them. Urticaria can be classified as acute or chronic according to its duration. Most patients have triggers that cause exacerbations, which should be avoided to help control the disease. This review aims to describe the factors that may trigger chronic urticaria and angioedema, highlighting its mechanisms.

The major drug groups that may trigger urticaria include nonsteroidal anti-inflammatory drugs, antibiotics (especially beta-lactams), vaccines, bupropion, antidepressants, antihypertensives, H2 antihistamines, antifungals, and H1 antihistamines. Other drugs that decrease the degradation of bradykinin (from the mast cell degranulation cascade) lead to angioedema and include angiotensin-converting enzyme inhibitors, neutral endopeptidase, and dipeptidyl peptidase-4 inhibitors, resulting in the accumulation of bradykinin, followed by localized vasodilation and then angioedema.

Food and food components may also trigger urticaria or angioedema, such as food additives and naturally occurring substances (biogenic amines and aromatic compounds).

Other triggers of angioedema without urticaria include emotional distress, physical exertion, mechanical trauma, infection, menstruation, pregnancy, medical procedures, weather changes, alcohol ingestion, and some medicinal products.

In conclusion, patients with urticaria or angioedema must know trigger factors to introduce changes in their lifestyle and an individualized approach to treatment.

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Effects of pregnancy on chronic urticaria: Results of the PREG-CU UCARE study

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Emek Kocatürk, et al.

Allergy. 2021 May 22. doi: 10.1111/all.14950. Online ahead of print.

Chronic urticaria is an inflammatory condition characterized by wheals, angioedema, or both for more than six weeks. Women are more affected, and it is thought that sex hormones have a modulation capacity in women with urticaria. The objective of this study was to assess the evolution and characteristics of chronic urticaria during pregnancy.

PREG-CU was an international, multicenter study of the Urticaria Centers of Reference and Excellence (UCARE) network that included 288 women with chronic urticaria who became pregnant within the last three years and completed a 47-item questionnaire.

A total of 288 pregnancies of 288 women with chronic urticaria from 13 countries were analyzed. Half of the women reported their chronic urticaria had improved, 29% reported worsening, and 20% didn’t notice changes. Urticaria exacerbations happened mainly in the first or third trimester (22,8% and 27,6%, respectively). The risk factors were: mild disease and no angioedema before pregnancy, no treatment before pregnancy, exacerbation in a previous pregnancy, treatment during pregnancy, and stress. After giving birth, 44% of the women reported no changes in the disease, 37% reported worsening, and 18% improved.

In conclusion, pregnancy impacts the course of urticaria, and counsel and management should be done on a one-to-one basis. More prospective studies are needed to assess the importance and reliability of urticaria risk factors during pregnancy.

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Advanced Biomarkers: Therapeutic and Diagnostic Targets in Urticaria

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Yue Zhang, Hanyi Zhang, Shengyi Du, Siyu Yan, Jinrong Zeng

Int Arch Allergy Immunol . 2021 Apr 29;1-15. doi: 10.1159/000515753. Online ahead of print.

Urticaria is a skin disease characterized by rapid onset of hives (superficial dermis edema, erythema, pruritus, or burning sensation), which can be worsened by angioedema (edema of the deep dermis, fat tissue, and gastrointestinal tract). It reduces the quality of life of people and can consist of recurrent attacks. It can be considered acute urticaria or chronic urticaria if it takes longer than six weeks.

Chronic spontaneous urticaria is the most common and can be induced by autoreactivity or other causes. The diagnosis of chronic urticaria is usually complex and requires the exclusion of recurrent angioedema or hereditary angioedema, so biomarkers are essential to diagnose urticaria patients.

Currently, the assessment of chronic urticaria activity depends on the Urticaria Activity Score (UAS), with few evaluation indicators. Consistent biomarkers are needed to assess urticaria.

This article summarizes advanced biomarkers and related pathogenic pathways recently discovered, such as the cell adhesion/chemotaxis pathway, interleukin (IL)-6/Janus tyrosine kinase/STAT pathway, IL-17/IL-23 pathway, basophil- and mast cell-related pathway, coagulation/fibrinolysis-related pathways, single-nucleotide polymorphism, and some other pathways.

This review aims to discover adequate biomarkers to assess disease activity, find novel therapeutic targets, and predict the patients’ response to therapeutic agents (table 1).

 

Table 1. Biomarkers uses in urticaria

 

IL-18BP

IL-6 IL-33

Dimeric TCTP

IL-17

CRP

Siglec-8 IL-23

D-dimer

BDNF

CD203c

5-HT transporter protein

Syk

Vitamin D3/VDBP SSA

CCL17

Substance P

PAF

Keratin86; desmocollin 1; lectin, galactoside-binding, soluble, 7; lactotransferrin; keratin, type II cytoskeletal 4; keratin 31; keratin 80; premature ovarian failure, 1B; plakophilin 1; defensin, alpha 3, and neutrophil-specific

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The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

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Martin Metz

J Allergy Clin Immunol Pract . 2021 Apr 20;S2213-2198(21)00435-9. doi: 10.1016/j.jaip.2021.03.049. Online ahead of print.

Chronic spontaneous urticaria (CSU) consists of wheals, angioedema, or both for longer than six weeks. Guidelines have limited procedures during the routine workup; however, some patients might need additional investigations. The objective of this article is to propose recommendations for the diagnostic and evaluation of some urticaria patients.

An extensive literature search was performed to identify important questions that should define diagnostic procedures based on expert consensus and published evidence.

The authors proposed seven questions for all chronic spontaneous urticaria patients: Confirm (rule out a differential diagnosis); Cause (look for indications of CSU); Cofactors (identify potential triggers, aggravators); Comorbidities (check for chronic inducible urticaria, autoimmunity, and mental health); Consequences (identify problems with sleep, distress, sexual health, work, and social performance); Components (assess potential biomarkers or predictors of treatment response); Course (monitor CSU activity, impact, and control).

Also, a complete medical history should be conducted in the assessment of the patient. CSU should be confirmed in all patients through a differential diagnosis, including blood testing for CRP and/or erythrocyte sedimentation rate and complete blood count with differential.

In conclusion, based on the answers, a decision for or against more diagnostic tests should be conducted by the specialist to prevent unnecessary and expensive testing and increase treatment effectiveness.

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Immunological Responses and Biomarkers for Allergen-Specific Immunotherapy Against Inhaled Allergens

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Mohamed H. Shamji, Janice A. Layhadi, Hanisah Sharif, Martin Penagos, Stephen R. Durham

J Allergy Clin Immunol Pract. 2021 Mar 27:S2213-2198(21)00363-9. doi: 10.1016/j.jaip.2021.03.029.

Patients with IgE-mediated rhinoconjunctivitis and/or bronchial asthma who do not respond to symptomatic treatment or have severe side effects are often recommended allergen immunotherapy. Prolonged treatment has shown long-term benefits in patients with moderate to severe allergic rhinitis. The long-term efficacy from allergen immunotherapy represents a decrease in IgE activation of mast cells and tissue eosinophilia, which is accompanied by early induction of regulatory T cells, immune deviation in favor of TH1 responses, and induction of local and systemic IgG and IgA antibodies. These antibodies, whose primary function is to be protective, can prevent the formation of allergen-IgE complex and subsequent activation of the mast cells and TH2 facilitated by IgE.

Some studies demonstrate the importance of innate responses mediated by type 2 dendritic cells and innate lymphoid cells in allergic inflammation. Type 2 dendritic cells and lymphoid cells are regulated by cytokines derived from the respiratory epithelium. New subsets of regulatory cells induced by immunotherapy include:

  • IL-35-producing regulatory T cells,
  • Regulatory B cells,
  • A subset of T follicular regulatory cells, and
  • IL-10-producing group 2 innate lymphoid cells.

These regulatory cells may represent biomarkers that will predict the clinical response to immunotherapy and evaluate the efficacy, safety, and long-term tolerance.

More studies are required to identify candidate biomarkers as a routine immune-monitoring tool for assessing allergen immunotherapy response.

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Chronic Spontaneous Urticaria

The Pathogenesis of Chronic Spontaneous Urticaria: The Role of Infiltrating Cells

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Ana M. Giménez-Arnau, Laurence DeMontojoye, Riccardo Asero, Massimo Cugno, Kanokvalai Kulthanan, Yuhki Yanase, Michihiro Hide, Allen P. Kaplan

J Allergy Clin Immunol Pract. 2021 Apr 3:S2213-2198(21)00374-3. doi: 10.1016/j.jaip.2021.03.033. Epub ahead of print.

In chronic spontaneous urticaria, cutaneous mast cells are activated to initiate the process. There are different triggers, including the hypothesis that it is an autoimmune disease not driven by exposure to an exogenous agent.

It is characterized by a perivascular non-necrotizing cellular infiltrate around small venules of the skin. These infiltrates include CD4+ lymphocytes, Th2 and Th1 subtypes, Th17 cell-derived cytokines, neutrophils, eosinophils, basophils and monocytes, which contribute to the pathogenesis and responsiveness to steroid

This review focuses on each cell’s contribution to the inflammatory response and a view toward developing therapeutic options.

Immunohistochemistry can help reveal the function of each cell within the perivenular infiltrate. Rituximab efficacy is probably due to the prevention of autoantibody synthesis. Corticosteroids inhibit the function of T lymphocytes and eosinophils and prevent egress of most cell types from the bloodstream into tissues.

In the future, there may be studies that include drugs with increasing specificity in the course of urticaria, such as secukinumab (targets IL-17), dupilumab (targets TH-2 dependent cytokines, IL-4 and IL-3), mepolizumab, reslizumab and benralizumab (target TH2 and eosinophil-dependent cytokines), avdoralimab (complement C5a receptor) and lirentelimab (targets Siglec-8 on the surface of mast cells and eosinophils).

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Biologics for the Use in Chronic Spontaneous Urticaria: When and Which

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Marcus Maurer, David A. Khan, Daniel Elieh Ali Komi, Allen P. Kaplan

J Allergy Clin Immunol Pract . 2021 Mar;9(3):1067-1078. doi: 10.1016/j.jaip.2020.11.043.

Urticaria treatment has evolved a lot during the past decade. Current guidelines for the treatment of chronic spontaneous urticaria recommend the use of omalizumab, an IgE-targeted biologic. IgE has high-affinity to the receptor FcεRI, and degranulate skin mast cells, which are responsible for the development of signs and symptoms of urticaria, itchy wheals and angioedema. This study aims to review the existing understanding of the pathogenesis of chronic urticaria and its autoimmune endotypes.

Omalizumab is the only licensed biologic for use in chronic urticaria from 12 years old age. It is recommended as the third step of the therapy in patients who have failed standard or high-dose second-generation antihistamines and is generally well tolerated. Omalizumab has multiple potential mechanisms of action in chronic urticaria, with effects on mast cells and basophils, reducing mediators’ release and decreasing FcεRI expression. It has been approved for chronic urticaria at doses of 150 or 300 mg every 4 weeks. Poor responders may benefit from shortening the dosing interval to every 2 or 3 weeks or by adjunctive therapy with cyclosporine 3 mg/kg/day for 4 months each.

Some other biologic drugs used as off-label in chronic urticaria include dupilumab, benralizumab, mepolizumab, reslizumab, and secukinumab. New biologics under development aim to reduce mast cell activation by blocking activating pathways or engaging inhibitory receptors or mast cell numbers. These include ligelizumab and GI-301, avdoralimab, tezepelumab, lirentelimab, LY3454738, and CDX-0159 at different stages of development.

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Differences in gut microbiota between allergic rhinitis, atopic dermatitis, and skin urticaria: A pilot study

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Yu-Jih Su, Sheng-Dean Luo, Chung-Yuan, Ho-Chang Kuo

Medicine (Baltimore) . 2021 Mar 5;100(9):e25091. doi: 10.1097/MD.0000000000025091.

Allergic rhinitis and urticaria prevalence are increasing. The intestinal flora or microbiota may influence their pathogeneses. This study aimed to compare differences between the gut microbiota of people with atopic dermatitis, allergic rhinitis, and chronic urticaria.

The study included 19 participants with eczema, nine with urticaria, and 11 with allergic rhinitis. The microbiota was compared by examining participants’ fecal samples using 16S ribosomal ribonucleic acid amplicon sequencing and bioinformatics and statistical analysis.

All three groups of patients had similar clinical data. The microbiota was substantially different between participants with atopic dermatitis, allergic rhinitis, and chronic urticaria, demonstrating gut-skin and gut-nose axes. Bacteroidales species were found in skin allergies more than in allergic rhinitis. This may represent a link between gut flora and skin allergy because gut flora colonies differ significantly between them.

In conclusion, different conditions have heterogeneous microbiota. Bacteroidales species could represent a link between gut flora and skin allergy, with Bacteroids Plebeius DSM 17135 being significantly associated with urticaria. Ruminococcaceae is also associated with allergic diseases.

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Exaggerated neurophysiological responses to stressor in patients with chronic spontaneous urticaria

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Engel-Yeger B, Maurer M, Hawro T, Zubedat S, Avital A, Kessel A

Clin Exp Allergy. 2021 Feb 22. doi: 10.1111/cea.13854. Versión digital previa a la impresión.

Chronic spontaneous urticaria impacts the quality of life and emotional well-being of people suffering from it. People with chronic spontaneous urticaria have increased emotional distress, anxiety, depression, somatoform disorders, and stress, which correlates with the activity of urticaria.

People with chronic spontaneous urticaria may be more susceptible to stressors and thus have increased stress responses. Stress responses may lead to the secretion of neuropeptides from sensory skin nerves, interacting with mast cells and releasing histamine, causing chronic spontaneous urticaria attacks.

This study compared the stress responses to acoustic startle and stress levels between 47 people with chronic spontaneous urticaria and 56 healthy volunteers. Stress levels were evaluated with the Perceived Stress Scale.

The stressor exposure session was three minutes long. Participants were exposed to 40 randomly spaced auditory startle stimuli. Responses to the stimuli were measured by electromyography assessment of the contraction amplitude of the orbicularis oculi muscle for each startle stimulus and the number of eye blinks.

People with chronic spontaneous urticaria had stronger responses to acoustic startles with high mean electromyography values and a higher number of eye blinks than healthy volunteers. People with urticaria also had longer stress responses and stress levels, as assessed by the Perceived Stress Scale.

In conclusion, people with urticaria have increased stress responses using objective and subjective measures. Underlying neuroimmune mechanisms should be studied further, as it is possible that stress predisposes to chronic spontaneous urticaria and that chronic spontaneous urticaria increases stress, forming a disease amplification loop.

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Predictors of treatment response in chronic spontaneous urticaria

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Jie Shen Fok, Pavel Kolkhir, Martin K. Church, Marcus Ma

Allergy . 2021 Feb 4. doi: 10.1111/all.14757. Online ahead of print.

Chronic spontaneous urticaria consists of wheals, angioedema, or both for more than six weeks. Patients with chronic urticaria have an impaired quality of life that impacts their relationships, work, and sleep. Existing treatment guidelines recommend a treatment escalation from second-generation H1-antihistamines to omalizumab and cyclosporine until complete response.

This review aimed to evaluate the predictors of response and nonresponse to these treatments in chronic spontaneous urticaria.

A systematic search was executed using the PubMed/MEDLINE database, and 73 studies were included. Different levels of evidence were categorized as strong (robust predictors), weak (emerging predictors), or not associated.

High disease activity, high C-reactive protein levels, and D-dimer are robust predictors of a poor or no response to H1-antihistamines. Low serum levels of total IgE may predict omalizumab response. Cyclosporine response may be predicted by a positive basophil histamine release assay, while low total IgE is an emerging predictor.

In conclusion, there are clinical and biochemical predictors of nonresponse to H1-antihistamines and omalizumab, as well as predictors of response to cyclosporine. These predictors can help specialists counsel patients and prioritize patients at risk of nonresponse to be assessed and switched to more effective treatments.

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