Urticaria is a common condition that occurs in both children and adults. Most cases have no specific allergic trigger and the aetiology of urticaria remains idiopathic and occasionally spontaneous in nature. Inappropriate advice such as avoidance of foods (milk, egg, prawn, and brinjal) is common place in certain sections of India mostly by nonspecialists that should not be routinely recommended. It is important to look for physical urticarias such as pressure urticaria in chronic cases, which may be present either alone or in combination with other causes. Autoimmune causes for chronic urticaria have been found to play an important role in a significant proportion of patients. Long-acting nonsedating antihistamines at higher than the standard doses is safe and effective. Quality of life is affected adversely in patients with chronic symptomatic urticaria and some may require multidisciplinary management. 1. Background Urticaria is a common condition and the chronic form usually has no allergic trigger. Longacting non-sedating antihistamines at higher than the standard doses is safe and effective. Urticaria is characterized by itchy, red, raised (wheal), and flared skin reactions that last usually for a few hours (typically <24 hours). It is classified as chronic urticaria (CU) if it lasts for more than 6 weeks. The chronic spontaneous form of urticaria does not need any stimulus and sometimes it is also referred to as chronic idiopathic urticaria (CIU) [1–6]. It is now well recognized that CIU consists of a myriad group of diseases and development of skin lesions and/or angioedema is seen in all different types and subtypes [4–6]. The terms CIU and CU have been used interchangeably in the article, although strictly CIU would refer to patients without a proven autoimmune component to the urticaria [5–9]. The wheal has a central swelling surrounded by a reflex erythema that is itchy while the angioedema is associated with pronounced swelling of the lower dermis and subcutaneous tissue with the occasional involvement of mucous membranes (lips, tongue) in some patients. Acute urticaria appears more commonly in children and young adults of which common causes are infections, food, drugs (intravenous more than oral forms), and insect stings. It is important to take a detailed clinical history to identify whether the urticaria is chronic (or acute or chronic), as occasionally a patient may be wrongly labeled as drug allergic when it may be that the urticaria was present before the drug was started [1–3]. There are some drugs, however, that are notorious in
References
[1]
T. Zuberbier, R. Asero, C. Bindslev-Jensen et al., “EAACI/GA2LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria,” Allergy, vol. 64, no. 10, pp. 1417–1426, 2009.
[2]
T. Zuberbier, R. Asero, C. Bindslev-Jensen, et al., “EAACI/GA2LEN/EDF/WAO guideline: management of urticaria,” Allergy, vol. 64, pp. 1427–1443, 2009.
[3]
M. Maurer, K. Weller, C. Bindslev-Jensen et al., “Unmet clinical needs in chronic spontaneous urticaria. A GA2LEN task force report,” Allergy, vol. 66, no. 3, pp. 317–330, 2011.
[4]
L. Fromer, “Treatment options for the relief of chronic idiopathic urticaria symptoms,” Southern Medical Journal, vol. 101, no. 2, pp. 186–192, 2008.
[5]
K. Godse, V. Zawar, D. Krupashankar et al., “Consensus statement on the management of urticaria,” Indian Journal of Dermatology, vol. 56, no. 5, pp. 485–489, 2011.
[6]
G. N. Konstantinou, R. Asero, M. Ferrer et al., “EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria,” Allergy, vol. 68, pp. 27–36, 2013.
[7]
S. Pastore, I. Berti, and G. Longo, “Autoimmune chronic urticaria: transferability of autologous serum skin test,” European Journal of Pediatrics, vol. 172, p. 569, 2013.
[8]
L. Brunetti, R. Francavilla, V. L. Miniello et al., “High prevalence of autoimmune urticaria in children with chronic urticaria,” Journal of Allergy and Clinical Immunology, vol. 114, no. 4, pp. 922–927, 2004.
[9]
K. S. Wan and C. S. Wu, “The essential role of anti-thyroid antibodies in chronic idiopathic urticaria,” Endocrine Research, vol. 38, pp. 85–88, 2013.
[10]
T. Takeda, Y. Sakurai, S. Takahagi et al., “Increase of coagulation potential in chronic spontaneous urticaria,” Allergy, vol. 66, no. 3, pp. 428–433, 2011.
[11]
Z. Huilan, L. Runxiang, L. Bihua, and G. Qing, “Role of the subgroups of T, B, natural killer lymphocyte and serum levels of interleukin-15, interleukin-21 and immunoglobulin e in the pathogenesis of urticaria,” Journal of Dermatology, vol. 37, no. 5, pp. 441–447, 2010.
[12]
U. Raap, D. Wieczorek, M. Gehring et al., “Increased levels of serum IL-31 in chronic spontaneous urticaria,” Experimental Dermatology, vol. 19, no. 5, pp. 464–466, 2010.
[13]
A. Lopes, D. Machado, S. Pedreiro, et al., “Different frequencies of tc17/tc1 and th17/th1 cells in chronic spontaneous urticaria,” International Archives of Allergy and Immunology, vol. 161, pp. 155–162, 2013.
[14]
J. C. dos Santos, M. H. Azor, V. Y. Nojima et al., “Increased circulating pro-inflammatory cytokines and imbalanced regulatory T-cell cytokines production in chronic idiopathic urticaria,” International Immunopharmacology, vol. 8, no. 10, pp. 1433–1440, 2008.
[15]
W.-C. Chen, B.-L. Chiang, H. E. Liu, S.-J. Leu, and Y.-L. Lee, “Defective functions of circulating CD4+CD25+ and CD4+CD25？ T cells in patients with chronic ordinary urticaria,” Journal of Dermatological Science, vol. 51, no. 2, pp. 121–130, 2008.
[16]
F. D. Louren？o, M. H. Azor, J. C. Santos et al., “Activated status of basophils in chronic urticaria leads to interleukin-3 hyper-responsiveness and enhancement of histamine release induced by anti-IgE stimulus,” British Journal of Dermatology, vol. 158, no. 5, pp. 979–986, 2008.
[17]
M. Caproni, B. Giomi, L. Melani et al., “Cellular infiltrate and related cytokines, chemokines, chemokine receptors and adhesion molecules in chronic autoimmune urticaria: comparison between spontaneous and autologous serum skin test induced wheal,” International Journal of Immunopathology and Pharmacology, vol. 19, no. 3, pp. 507–515, 2006.
[18]
A. Puccetti, C. Bason, S. Simeoni et al., “In chronic idiopathic urticaria autoantibodies against FcεRII/CD23 induce histamine release via eosinophil activation,” Clinical and Experimental Allergy, vol. 35, no. 12, pp. 1599–1607, 2005.
[19]
A. Kasperska-Zajac, Z. Brzoza, and B. Rogala, “Increased concentration of platelet-derived chemokinesin serum of patients with delayed pressure urticaria,” European Cytokine Network, vol. 19, no. 2, pp. 89–91, 2008.
[20]
M. Caproni, B. Giomi, W. Volpi et al., “Chronic idiopathic urticaria: infiltrating cells and related cytokines in autologous serum-induced wheals,” Clinical Immunology, vol. 114, no. 3, pp. 284–292, 2005.
[21]
M. Caproni, C. Cardinali, B. Giomi et al., “Serological detection of eotaxin, IL-4, IL-13, IFN-γ, MIP-1α, TARC and IP-10 in chronic autoimmune urticaria and chronic idiopathic urticaria,” Journal of Dermatological Science, vol. 36, no. 1, pp. 57–59, 2004.
[22]
J. C. Santos, C. A. de Brito, E. A. Futata et al., “Up-regulation of chemokine C-C ligand 2 (CCL2) and C-X-C chemokine 8 (CXCL8) expression by monocytes in chronic idiopathic urticaria,” Clinical and Experimental Immunology, vol. 167, no. 1, pp. 129–136, 2012.
[23]
F. Bossi, B. Frossi, O. Radillo et al., “Mast cells are critically involved in serum-mediated vascular leakage in chronic urticaria beyond high-affinity IgE receptor stimulation,” Allergy, vol. 66, no. 12, pp. 1538–1545, 2011.
[24]
M. Ferrer, J. M. Nu？ez-Córdoba, E. Luquin et al., “Serum total tryptase levels are increased in patients with active chronic urticaria,” Clinical and Experimental Allergy, vol. 40, no. 12, pp. 1760–1766, 2010.
[25]
J.-I. Kashiwakura, T. Ando, K. Matsumoto et al., “Histamine-releasing factor has a proinflammatory role in mouse models of asthma and allergy,” Journal of Clinical Investigation, vol. 122, no. 1, pp. 218–228, 2012.
[26]
R. Asero, M. Lorini, S. U. Chong, T. Zuberbier, and A. Tedeschi, “Assessment of histamine-releasing activity of sera from patients with chronic urticaria showing positive autologous skin test on human basophils and mast cells,” Clinical & Experimental Allergy, vol. 34, pp. 1111–1114, 2004.
[27]
K.-L. Chang, Y.-H. Yang, H.-H. Yu, J.-H. Lee, L.-C. Wang, and B.-L. Chiang, “Analysis of serum total IgE, specific IgE and eosinophils in children with acute and chronic urticaria,” Journal of Microbiology, Immunology and Infection, vol. 46, no. 1, pp. 53–58, 2013.
[28]
T. Zuberbier, “The role of allergens and pseudoallergens in urticaria,” Journal of Investigative Dermatology Symposium Proceedings, vol. 6, no. 2, pp. 132–134, 2001.
[29]
K. Kulthanan and C. Wachirakahan, “Prevalence and clinical characteristics of chronic urticaria and positive skin prick testing to mites,” Acta Dermato-Venereologica, vol. 88, no. 6, pp. 584–588, 2008.
[30]
P. A. Mahesh, P. A. Kushalappa, A. D. Holla, and P. K. Vedanthan, “House dust mite sensitivity is a factor in chronic urticaria,” Indian Journal of Dermatology, Venereology and Leprology, vol. 71, no. 2, pp. 99–101, 2005.
[31]
Z. Caliskaner, S. Ozturk, M. Turan, and M. Karaayvaz, “Skin test positivity to aeroallergens in the patients with chronic urticaria without allergic respiratory disease,” Journal of Investigational Allergology and Clinical Immunology, vol. 14, no. 1, pp. 50–54, 2004.
[32]
A. F. Finn Jr., A. P. Kaplan, R. Fretwell, R. Qu, and J. Long, “A double-blind, placebo-controlled trial of fexofenadine HCl in the treatment of chronic idiopathic urticaria,” Journal of Allergy and Clinical Immunology, vol. 104, no. 5, pp. 1071–1078, 1999.
[33]
H. S. Nelson, R. Reynolds, and J. Mason, “Fexofenadine HCl is safe and effective for treatment of chronic idiopathic urticaria,” Annals of Allergy, Asthma and Immunology, vol. 84, no. 5, pp. 517–522, 2000.
[34]
C. Weber-Schoendorfer and C. Schaefer, “The safety of cetirizine during pregnancy. A prospective observational cohort study,” Reproductive Toxicology, vol. 26, no. 1, pp. 19–23, 2008.
[35]
M. S. Blaiss and ACAAI-ACOG(American College of Allergy, Asthma, and Immunology and American College of Obstetricians and Gynecologists), “Management of rhinitis and asthma in pregnancy,” Annals of Allergy, Asthma and Immunology, vol. 90, pp. 16–22, 2003.
[36]
D. R. Weldon, “Quality of life in patients with urticaria,” Allergy and Asthma Proceedings, vol. 27, no. 2, pp. 96–99, 2006.
[37]
E. Poon, P. T. Seed, M. W. Greaves, and A. Kobza-Black, “The extent and nature of disability in different urticarial conditions,” British Journal of Dermatology, vol. 140, no. 4, pp. 667–671, 1999.
[38]
J.-J. Grob and C. Gaudy-Marqueste, “Urticaria and quality of life,” Clinical Reviews in Allergy and Immunology, vol. 30, no. 1, pp. 47–51, 2006.
[39]
P. Staubach, A. Eckhardt-Henn, M. Dechene et al., “Quality of life in patients with chronic urticaria is differentially impaired and determined by psychiatric comorbidity,” British Journal of Dermatology, vol. 154, no. 2, pp. 294–298, 2006.
[40]
Y. M. Ye, J. W. Park, S. H. Kim, et al., “Clinical evaluation of the computerized chronic urticaria-specific quality of life questionnaire in Korean patients with chronic urticaria,” Clinical and Experimental Dermatology, vol. 37, pp. 722–728, 2012.
[41]
A. M？ynek, M. Magerl, M. Hanna et al., “The German version of the chronic urticaria quality-of-life questionnaire: factor analysis, validation, and initial clinical findings,” Allergy, vol. 64, no. 6, pp. 927–936, 2009.
[42]
P. Staubach, M. Dechene, M. Metz et al., “High prevalence of mental disorders and emotional distress in patients with chronic spontaneous urticaria,” Acta Dermato-Venereologica, vol. 91, no. 5, pp. 557–561, 2011.
[43]
S. Fukuda, T. Shimoyama, N. Umegaki, T. Mikami, H. Nakano, and A. Munakata, “Effect of Helicobacter pylori eradication in the treatment of Japanese patients with chronic idiopathic urticaria,” Journal of Gastroenterology, vol. 39, no. 9, pp. 827–830, 2004.
[44]
M. K. Yadav, J. P. Rishi, and S. Nijawan, “Chronic urticaria and Helicobacter pylori,” Indian Journal of Medical Sciences, vol. 62, no. 4, pp. 157–162, 2008.
[45]
E. Magen, J. Mishal, M. Schlesinger, and S. Scharf, “Eradication of Helicobacter pylori infection equally improves chronic urticaria with positive and negative autologous serum skin test,” Helicobacter, vol. 12, no. 5, pp. 567–571, 2007.
[46]
A. Campanati, R. Gesuita, M. Giannoni, et al., “Role of small intestinal bacterial overgrowth and Helicobacter pylori infection in chronic spontaneous urticaria: a prospective analysis,” Acta Dermato-Venereologica, vol. 93, pp. 161–164, 2013.
[47]
G. W. Scadding and G. K. Scadding, “Recent advances in antileukotriene therapy,” Current Opinion in Allergy and Clinical Immunology, vol. 10, no. 4, pp. 370–376, 2010.
[48]
B. J. Lipworth, “Leukotriene-receptor antagonists,” The Lancet, vol. 353, no. 9146, pp. 57–62, 1999.
[49]
G. E. Rovati and V. Capra, “Cysteinyl-leukotriene receptors and cellular signals,” The Scientific World Journal, vol. 7, pp. 1375–1392, 2007.
[50]
Z. Erbagci, “The leukotriene receptor antagonist montelukast in the treatment of chronic idiopathic urticaria: a single-blind, placebo-controlled, crossover clinical study,” Journal of Allergy and Clinical Immunology, vol. 110, no. 3, pp. 484–488, 2002.
[51]
M. Kosnik and T. Subic, “Add-on montelukast in antihistamine-resistant chronic idiopathic urticaria,” Respiratory Medicine, vol. 105, no. 1, pp. S84–S88, 2011.
[52]
K.-S. Wan, “Efficacy of leukotriene receptor antagonist with an anti-H1 receptor antagonist for treatment of chronic idiopathic urticaria,” Journal of Dermatological Treatment, vol. 20, no. 4, pp. 194–197, 2009.
[53]
G. di Lorenzo, A. D'Alcamo, M. Rizzo et al., “Leukotriene receptor antagonists in monotherapy or in combination with antihistamines in the treatment of chronic urticaria: a systematic review,” Journal of Asthma and Allergy, no. 2, pp. 9–16, 2009.
[54]
S. Khan and N. Lynch, “Efficacy of montelukast as added therapy in patients with chronic idiopathic urticaria,” Inflammation and Allergy, vol. 11, no. 3, pp. 235–243, 2012.
[55]
E. di Leo, E. Nettis, A. M. Aloia et al., “Cyclosporin-A efficacy in chronic idiopathic urticaria,” International Journal of Immunopathology and Pharmacology, vol. 24, no. 1, pp. 195–200, 2011.
[56]
C. Boubouka, C. Charissi, D. Kouimintzis, D. Kalogeromitros, P. Stavropoulos, and A. Katsarou, “Treatment of autoimmune urticaria with low-dose cyclosporin a: a one-year follow-up,” Acta Dermato-Venereologica, vol. 91, no. 1, pp. 50–54, 2011.
[57]
A. Kessel and E. Toubi, “Cyclosporine-A in severe chronic urticaria: the option for long-term therapy,” Allergy, vol. 65, no. 11, pp. 1478–1482, 2010.
[58]
H. Serhat Inaloz, S. Ozturk, C. Akcali, N. Kirtak, and M. Tarakcioglu, “Low-dose and short-term cyclosporine treatment in patients with chronic idiopathic urticaria: a clinical and immunological evaluation,” Journal of Dermatology, vol. 35, no. 5, pp. 276–282, 2008.
[59]
K. V. Godse, “Cyclosporine in chronic idiopathic urticaria with positive autologous serum skin test,” Indian Journal of Dermatology, vol. 53, no. 2, pp. 101–102, 2008.
[60]
S. M. Hollander, S. S. Joo, and H. J. Wedner, “Factors that predict the success of cyclosporine treatment for chronic urticaria,” Annals of Allergy, Asthma and Immunology, vol. 107, no. 6, pp. 523–528, 2011.
[61]
S. Darras, M. Ségard, L. Mortier, A. Bonnevalle, and P. Thomas, “Treatment of solar urticaria by intravenous immunoglobulins and PUVAtherapy,” Annales de Dermatologie et de Venereologie, vol. 131, no. 1, pp. 65–69, 2004.
[62]
K. Aydogan, S. K. Karadogan, S. Tunali, and H. Saricaoglu, “Narrowband ultraviolet B (311nm, TL01) phototherapy in chronic ordinary urticaria,” International Journal of Dermatology, vol. 51, no. 1, pp. 98–103, 2012.
[63]
B. Engin, M. ？zdemir, A. Balevi, and I. Mevlito？lu, “Treatment of chronic urticaria with narrowband ultraviolet B phototherapy: a randomized controlled trial,” Acta Dermato-Venereologica, vol. 88, no. 3, pp. 247–251, 2008.
[64]
G. Monfrecola, A. de Paulis, E. Prizio et al., “In vitro effects of ultraviolet A on histamine release from human basophils,” Journal of the European Academy of Dermatology and Venereology, vol. 17, no. 6, pp. 646–651, 2003.
[65]
A. C. Lefévre, M. Deleuran, and C. A. Vestergaard, “A long term case series study of the effect of omalizumab on chronic spontaneous urticaria,” Annals of Dermatology, vol. 25, pp. 242–245, 2013.
[66]
M. Maurer, K. Rosén, H. J. Hsieh, et al., “Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria.,” The New England Journal of Medicine, vol. 368, pp. 924–935, 2013.
[67]
C. H. Song, S. Stern, M. Giruparajah, N. Berlin, and G. L. Sussman, “Long-term efficacy of fixed-dose omalizumab for patients with severe chronic spontaneous urticaria,” Annals of Allergy, Asthma & Immunology, vol. 110, pp. 113–117, 2013.
[68]
L. S. Cox, “How safe are the biologicals in treating asthma and rhinitis?” Allergy, Asthma and Clinical Immunology, vol. 5, no. 4, article 4, 2009.
[69]
P. J. Cooper, G. Ayre, C. Martin, J. A. Rizzo, E. V. Ponte, and A. A. Cruz, “Geohelminth infections: a review of the role of IgE and assessment of potential risks of anti-IgE treatment,” Allergy, vol. 63, no. 4, pp. 409–417, 2008.
[70]
S. K. Chow, “Management of chronic urticaria in Asia: 2010 AADV consensus guidelines,” Asia Pacific Allergy, vol. 2, pp. 149–160, 2012.
