KAAACI Work Group report on the management of chronic urticaria

Young-Min Ye; Gwang Cheon Jang; Sun Hee Choi; Jeongmin Lee; Hye-Soo Yoo; Kyung Hee Park; Meeyong Shin; Jihyun Kim; Suh-Young Lee; Jeong-Hee Choi; Youngmin Ahn; Hae-Sim Park; Yoon-Seok Chang; Jae-Won Jeong; Sooyoung Lee

doi:10.4168/aard.2015.3.1.3

Journal List > Allergy Asthma Respir Dis > v.3(1) > 1059117

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Ye, Jang, Choi, Lee, Yoo, Park, Shin, Kim, Lee, Choi, Ahn, Park, Chang, Jeong, Lee, and Korean Academy of Asthma, Allergy and Clinical Immunology Work Group of Anaphylaxis, Urticaria and Angioedema: KAAACI Work Group report on the management of chronic urticaria

Review

Allergy, Asthma & Respiratory Disease 2015; 3(1): 3-14.

Published online: 31 January 2015

DOI: https://doi.org/10.4168/aard.2015.3.1.3

KAAACI Work Group report on the management of chronic urticaria

Young-Min Ye^1,^*, Gwang Cheon Jang^2,^*, Sun Hee Choi³, Jeongmin Lee⁴, Hye-Soo Yoo⁵, Kyung Hee Park⁶, Meeyong Shin⁷, Jihyun Kim⁸, Suh-Young Lee⁹, Jeong-Hee Choi¹⁰, Youngmin Ahn¹¹, Hae-Sim Park¹

, Yoon-Seok Chang⁹

, Jae-Won Jeong¹², Sooyoung Lee^5,¹³; Korean Academy of Asthma, Allergy and Clinical Immunology Work Group of Anaphylaxis, Urticaria and Angioedema

¹Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.

²Department of Pediatrics, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea.

³Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea.

⁴Maeil Central Research Laboratory, Pyeongtaek, Korea.

⁵Suwon Center for Environmental Disease and Atopy, Suwon, Korea.

⁶Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.

⁷Department of Pediatrics, Soonchunhyang University College of Medicine, Cheonan, Korea.

⁸Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea.

⁹Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.

¹⁰Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea.

¹¹Department of Pediatrics, Eulji University School of Medicine, Daejeon, Korea.

¹²Department of Internal Medicine, Inje University College of Medicine, Busan, Korea.

¹³Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea.

Correspondence to: Sooyoung Lee. Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 443-380, Korea. Tel: +82-31-219-5164, Fax: +82-31-219-5169, jsjs87@ajou.ac.kr

Equal contributor:

*These authors contributed equally to this study and should be considered co-first authors.

Received 19 December 2014 Revised 22 December 2014 Accepted 22 December 2014

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).

Abstract

Chronic urticaria (CU) is defined by the presence of urticaria that has been continuously or intermittently for a period of 6 weeks or longer. The prevalence of CU in the general population has been estimated to range from 0.5% to 5%. Correct diagnosis and proper management for CU is essential to improve the quality of care. To date, several practical guidelines have been available for practitioners. In this article, we reviewed and summarized the epidemiology, pathogenesis, diagnosis, and management based on case reports and studies of CU from Korea and the other part of world, and recently published guidelines. Although there are many controversies, this report for CU would provide a clinical guidance for healthcare professionals in Korea.

Keywords: Urticaria, Chronic, Etiology, Diagnosis, Treatment

Figures and Tables

Fig. 1

Stepwise approach to the treatment for chronic urticaria in the American guideline. ^*Recommended by the European guideline. ^†Leukotriene receptor antagonist is included in the 3rd line treatment with omalizumab and cyclosporine of the European guideline. Adapted from Bernstein JA, et al. J Allergy Clin Immunol 2014;133:1270-7, with permission from Elsevier Inc.5)

Table 1

Definition of urticaria and angioedema

Table 2

Classification of chronic urticaria

Table 3

History taking for the diagnosis of urticaria

Table 4

Recommended diagnostic tests in chronic urticaria

Table 5

The assessment of urticaria disease activity using UAS7 (Urticaria Activity Score 7)

Table 6

Pharmacologic effects of H1 antihistamines

NA, not available.

Adapted from Simons FE, et al. J Allergy Clin Immunol 2011;128:1139-50.e4, with permission from Elsevier Inc.68)

Notes

This work was supported by the Korean Academy of Asthma, Allergy and Clinical Immunology.

References

1. Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau A, et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy. 2009; 64:1417–1426.

2. Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau AM, et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy. 2009; 64:1427–1443.

3. Zuberbier T. A summary of the New International EAACI/GA2LEN/EDF/WAO guidelines in urticaria. World Allergy Organ J. 2012; 5:Suppl 1. S1–S5.

4. Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, et al. The EAACI/GA(2) LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014; 69:868–887.

5. Bernstein JA, Lang DM, Khan DA, Craig T, Dreyfus D, Hsieh F, et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014; 133:1270–1277.

6. Powell RJ, Du Toit GL, Siddique N, Leech SC, Dixon TA, Clark AT, et al. BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy. 2007; 37:631–650.

7. Ye YM, Park JW, Kim SH, Choi JH, Hur GY, Lee HY, et al. Clinical evaluation of the computerized chronic urticaria-specific quality of life questionnaire in Korean patients with chronic urticaria. Clin Exp Dermatol. 2012; 37:722–728.

8. Kim S, Baek S, Shin B, Yoon SY, Park SY, Lee T, et al. Influence of initial treatment modality on long-term control of chronic idiopathic urticaria. PLoS One. 2013; 8:e69345.

9. Church MK, Weller K, Stock P, Maurer M. Chronic spontaneous urticaria in children: itching for insight. Pediatr Allergy Immunol. 2011; 22(1 Pt 1):1–8.

10. Maurer M, Weller K, Bindslev-Jensen C, Gimenez-Arnau A, Bousquet PJ, Bousquet J, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report. Allergy. 2011; 66:317–330.

11. Zuberbier T, Balke M, Worm M, Edenharter G, Maurer M. Epidemiology of urticaria: a representative cross-sectional population survey. Clin Exp Dermatol. 2010; 35:869–873.

12. Kang HS, Shin MY. Clinical aspects of chronic urticaria in children. Korean J Pediatr. 2009; 52:205–212.

13. Choi SY, Park HY, Ahn YM. Chronic urticaria in childhood: etiology and outcome. Pediatr Allergy Respir Dis. 2007; 17:38–47.

14. Saini SS. Chronic spontaneous urticaria: etiology and pathogenesis. Immunol Allergy Clin North Am. 2014; 34:33–52.

15. Zazzali JL, Broder MS, Chang E, Chiu MW, Hogan DJ. Cost, utilization, and patterns of medication use associated with chronic idiopathic urticaria. Ann Allergy Asthma Immunol. 2012; 108:98–102.

16. Confino-Cohen R, Chodick G, Shalev V, Leshno M, Kimhi O, Goldberg A. Chronic urticaria and autoimmunity: associations found in a large population study. J Allergy Clin Immunol. 2012; 129:1307–1313.

17. Suh YJ, Jeung CK, Lee SJ, Kim SS, Lee SK, Nahm DH, et al. The clinical significance of thyroid auto-antibodies in patients with chronic idiopathic urticaria. J Asthma Allergy Clin Immunol. 2000; 20:535–544.

18. Lee SY, Song WJ, Jung JW, Park HW, Cho SH, Min KU, et al. Thyroid autoantibodies and the prognosis of chronic idiopathic urticaria. Allergy Asthma Respir Dis. 2013; 1:151–156.

19. Ye YM, Jin HJ, Hwang EK, Nam YH, Kim JH, Shin YS, et al. Co-existence of chronic urticaria and metabolic syndrome: clinical implications. Acta Derm Venereol. 2013; 93:156–160.

20. Lindelof B, Sigurgeirsson B, Wahlgren CF, Eklund G. Chronic urticaria and cancer: an epidemiological study of 1155 patients. Br J Dermatol. 1990; 123:453–456.

21. Chen YJ, Wu CY, Shen JL, Chen TT, Chang YT. Cancer risk in patients with chronic urticaria: a population-based cohort study. Arch Dermatol. 2012; 148:103–108.

22. Gaig P, Olona M, Munoz Lejarazu D, Caballero MT, Dominguez FJ, Echechipia S, et al. Epidemiology of urticaria in Spain. J Investig Allergol Clin Immunol. 2004; 14:214–220.

23. Chansakulporn S, Pongpreuksa S, Sangacharoenkit P, Pacharn P, Visitsunthorn N, Vichyanond P, et al. The natural history of chronic urticaria in childhood: a prospective study. J Am Acad Dermatol. 2014; 71:663–668.

24. Khakoo G, Sofianou-Katsoulis A, Perkin MR, Lack G. Clinical features and natural history of physical urticaria in children. Pediatr Allergy Immunol. 2008; 19:363–366.

25. Sahiner UM, Civelek E, Tuncer A, Yavuz ST, Karabulut E, Sackesen C, et al. Chronic urticaria: etiology and natural course in children. Int Arch Allergy Immunol. 2011; 156:224–230.

26. Uguz F, Engin B, Yilmaz E. Axis I and Axis II diagnoses in patients with chronic idiopathic urticaria. J Psychosom Res. 2008; 64:225–229.

27. Ferrer M. Epidemiology, healthcare, resources, use and clinical features of different types of urticaria. Alergológica 2005. J Investig Allergol Clin Immunol. 2009; 19:Suppl 2. 21–26.

28. Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol. 2006; 155:145–151.

29. O'Donnell BF. Urticaria: impact on quality of life and economic cost. Immunol Allergy Clin North Am. 2014; 34:89–104.

30. Caffarelli C, Cuomo B, Cardinale F, Barberi S, Dascola CP, Agostinis F, et al. Aetiological factors associated with chronic urticaria in children: a systematic review. Acta Derm Venereol. 2013; 93:268–272.

31. Jirapongsananuruk O, Pongpreuksa S, Sangacharoenkit P, Visitsunthorn N, Vichyanond P. Identification of the etiologies of chronic urticaria in children: a prospective study of 94 patients. Pediatr Allergy Immunol. 2010; 21:508–514.

32. Ying S, Kikuchi Y, Meng Q, Kay AB, Kaplan AP. TH1/TH2 cytokines and inflammatory cells in skin biopsy specimens from patients with chronic idiopathic urticaria: comparison with the allergen-induced late-phase cutaneous reaction. J Allergy Clin Immunol. 2002; 10:694–700.

33. Kaplan AP, Horakova Z, Katz SI. Assessment of tissue fluid histamine levels in patients with urticaria. J Allergy Clin Immunol. 1978; 61:350–354.

34. Claveau J, Lavoie A, Brunet C, Bedard PM, Hebert J. Chronic idiopathic urticaria: possible contribution of histamine-releasing factor to pathogenesis. J Allergy Clin Immunol. 1993; 92(1 Pt 1):132–137.

35. Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. 2009; 39:777–787.

36. Tedeschi A, Kolkhir P, Asero R, Pogorelov D, Olisova O, Kochergin N, et al. Chronic urticaria and coagulation: pathophysiological and clinical aspects. Allergy. 2014; 69:683–691.

37. Chandrashekar L, Rajappa M, Sundar I, Munisamy M, Ananthanarayanan PH, Thappa DM, et al. Platelet activation in chronic urticaria and its correlation with disease severity. Platelets. 2014; 25:162–165.

38. Piconi S, Trabattoni D, Iemoli E, Fusi ML, Villa ML, Milazzo F, et al. Immune profiles of patients with chronic idiopathic urticaria. Int Arch Allergy Immunol. 2002; 128:59–66.

39. Eckman JA, Hamilton RG, Gober LM, Sterba PM, Saini SS. Basophil phenotypes in chronic idiopathic urticaria in relation to disease activity and autoantibodies. J Invest Dermatol. 2008; 128:1956–1963.

40. Ye YM, Yang EM, Yoo HS, Shin YS, Kim SH, Park HS. Increased level of basophil CD203c expression predicts severe chronic urticaria. J Korean Med Sci. 2014; 29:43–47.

41. Wedi B, Raap U, Wieczorek D, Kapp A. Urticaria and infections. Allergy Asthma Clin Immunol. 2009; 5:10.

42. O'Donnell BF, O'Neill CM, Francis DM, Niimi N, Barr RM, Barlow RJ, et al. Human leucocyte antigen class II associations in chronic idiopathic urticaria. Br J Dermatol. 1999; 140:853–858.

43. Cho CB, Stutes SA, Altrich ML, Ardoin SP, Phillips G, Ogbogu PU. Autoantibodies in chronic idiopathic urticaria and nonurticarial systemic autoimmune disorders. Ann Allergy Asthma Immunol. 2013; 110:29–33.

44. Bailey E, Shaker M. An update on childhood urticaria and angioedema. Curr Opin Pediatr. 2008; 20:425–430.

45. Smith CH, Kepley C, Schwartz LB, Lee TH. Mast cell number and phenotype in chronic idiopathic urticaria. J Allergy Clin Immunol. 1995; 96:360–364.

46. Jacques P, Lavoie A, Bedard PM, Brunet C, Hebert J. Chronic idiopathic urticaria: profiles of skin mast cell histamine release during active disease and remission. J Allergy Clin Immunol. 1992; 89:1139–1143.

47. Christensen CU, Vestergaard C, Hoffmann HJ. Activation Markers CD63 and CD203c Are Upregulated in Chronic Urticaria. Ann Dermatol. 2013; 25:522–523.

48. Grattan CE, Dawn G, Gibbs S, Francis DM. Blood basophil numbers in chronic ordinary urticaria and healthy controls: diurnal variation, influence of loratadine and prednisolone and relationship to disease activity. Clin Exp Allergy. 2003; 33:337–341.

49. Juhlin L, Michaelsson G. Cutaneous reactions to kallikrein, bradykinin and histamine in healthy subjects and in patients with urticaria. Acta Derm Venereol. 1969; 49:26–36.

50. Maxwell DL, Atkinson BA, Spur BW, Lessof MH, Lee TH. Skin responses to intradermal histamine and leukotrienes C4, D4, and E4 in patients with chronic idiopathic urticaria and in normal subjects. J Allergy Clin Immunol. 1990; 86:759–765.

51. Smith CH, Atkinson B, Morris RW, Hayes N, Foreman JC, Lee TH. Cutaneous responses to vasoactive intestinal polypeptide in chronic idiopathic urticaria. Lancet. 1992; 339:91–93.

52. Kasperska-Zajac A, Sztylc J, Machura E, Jop G. Plasma IL-6 concentration correlates with clinical disease activity and serum C-reactive protein concentration in chronic urticaria patients. Clin Exp Allergy. 2011; 41:1386–1391.

53. Tedeschi A, Asero R, Lorini M, Marzano AV, Cugno M. Plasma levels of matrix metalloproteinase-9 in chronic urticaria pat ients correlate with disease severity and C-reactive protein but not with circulating histamine-releasing factors. Clin Exp Allergy. 2010; 40:875–881.

54. Tedeschi A, Lorini M, Suli C, Asero R. Serum interleukin-18 in patients with chronic ordinary urticaria: association with disease activity. Clin Exp Dermatol. 2007; 32:568–570.

55. Rabelo-Filardi R, Daltro-Oliveira R, Campos RA. Parameters associated with chronic spontaneous urticaria duration and severity: a systematic review. Int Arch Allergy Immunol. 2013; 161:197–204.

56. Sackesen C, Sekerel BE, Orhan F, Kocabas CN, Tuncer A, Adalioglu G. The etiology of different forms of urticaria in childhood. Pediatr Dermatol. 2004; 21:102–108.

57. Mathelier-Fusade P. Drug-induced urticarias. Clin Rev Allergy Immunol. 2006; 30:19–23.

58. Kowalski ML, Makowska JS, Blanca M, Bavbek S, Bochenek G, Bousquet J, et al. Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) - classification, diagnosis and management: review of the EAACI/ENDA(#) and GA2LEN/HANNA^*. Allergy. 2011; 66:818–829.

59. Sanchez-Borges M, Capriles-Hulett A. Atopy is a risk factor for non-steroidal anti-inflammatory drug sensitivity. Ann Allergy Asthma Immunol. 2000; 84:101–106.

60. Jenkins C, Costello J, Hodge L. Systematic review of prevalence of aspirin induced asthma and its implications for clinical practice. BMJ. 2004; 328:434.

61. Shakouri A, Compalati E, Lang DM, Khan DA. Effectiveness of Helicobacter pylori eradication in chronic urticaria: evidence-based analysis using the Grading of Recommendations Assessment, Development, and Evaluation system. Curr Opin Allergy Clin Immunol. 2010; 10:362–369.

62. Wedi B, Raap U, Kapp A. Chronic urticaria and infections. Curr Opin Allergy Clin Immunol. 2004; 4:387–396.

63. Magerl M, Pisarevskaja D, Scheufele R, Zuberbier T, Maurer M. Effects of a pseudoallergen-free diet on chronic spontaneous urticaria: a prospective trial. Allergy. 2010; 65:78–83.

64. Akoglu G, Atakan N, Cakır B, Kalayci O, Hayran M. Effects of low pseudoallergen diet on urticarial activity and leukotriene levels in chronic urticaria. Arch Dermatol Res. 2012; 304:257–262.

65. Hide M, Hiragun T. Japanese Dermatological Association. Japanese guidelines for diagnosis and treatment of urticaria in comparison with other countries. Allergol Int. 2012; 61:517–527.

66. Grob JJ, Auquier P, Dreyfus I, Ortonne JP. How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily vs PRN and quality of life. Allergy. 2009; 64:605–612.

67. Church MK, Maurer M, Simons FE, Bindslev-Jensen C, van Cauwenberge P, Bousquet J, et al. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy. 2010; 65:459–466.

68. Simons FE, Simons KJ. Histamine and H1-antihistamines: celebrating a century of progress. J Allergy Clin Immunol. 2011; 128:1139–1150.e4.

69. Gimenez-Arnau A, Izquierdo I, Maurer M. The use of a responder analysis to identify clinically meaningful differences in chronic urticaria patients following placebo-controlled treatment with rupatadine 10 and 20 mg. J Eur Acad Dermatol Venereol. 2009; 23:1088–1091.

70. Siebenhaar F, Degener F, Zuberbier T, Martus P, Maurer M. High-dose desloratadine decreases wheal volume and improves cold provocation thresholds compared with standard-dose treatment in patients with acquired cold urticaria: a randomized, placebo-controlled, crossover study. J Allergy Clin Immunol. 2009; 123:672–679.

71. Staevska M, Popov TA, Kralimarkova T, Lazarova C, Kraeva S, Popova D, et al. The effectiveness of levocetirizine and desloratadine in up to 4 times onventional doses in difficult-to-treat urticaria. J Allergy Clin Immunol. 2010; 125:676–682.

72. Weller K, Ardelean E, Scholz E, Martus P, Zuberbier T, Maurer M. Can on-demand non-sedating antihistamines improve urticaria symptoms? A double-blind, randomized, single-dose study. Acta Derm Venereol. 2013; 93:168–174.

73. Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med. 1995; 26:547–551.

74. Kaplan AP. Treatment of chronic spontaneous urticaria. Allergy Asthma Immunol Res. 2012; 4:326–331.

75. Maurer M, Magerl M, Metz M, Zuberbier T. Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. J Dtsch Dermatol Ges. 2013; 08. 19. [Epub]. http://dx.doi.org/10.1111/ddg.12194.

76. Maurer M, Rosen K, Hsieh HJ, Saini S, Grattan C, Gimenez-Arnau A, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013; 368:924–935.

77. Kaplan A, Ledford D, Ashby M, Canvin J, Zazzali JL, Conner E, et al. Omalizumab in patients with symptomatic chronic idiopathic/spontaneous urticaria despite standard combination therapy. J Allergy Clin Immunol. 2013; 132:101–109.

78. Kaplan AP, Popov TA. Biologic agents and the therapy of chronic spontaneous urticaria. Curr Opin Allergy Clin Immunol. 2014; 14:347–353.

79. Loria MP, Dambra PP, D'Oronzio L, Nettis E, Pannofino A, Cavallo E, et al. Cyclosporin A in patients affected by chronic idopathic urticaria: a therapeutic alternative. Immunopharmacol Immunotoxicol. 2001; 23:205–213.

80. Morgan M, Khan DA. Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1. Ann Allergy Asthma Immunol. 2008; 100:403–411.

81. Toubi E, Blant A, Kessel A, Golan TD. Low-dose cyclosporin A in the treatment of severe chronic idiopathic urticaria. Allergy. 1997; 52:312–316.

82. Asero R, Tedeschi A, Cugno M. Treatment of chronic urticaria. Immunol Allergy Clin North Am. 2014; 34:105–116.

83. de Silva NL, Damayanthi H, Rajapakse AC, Rodringo C, Rajapakse S. Leukotriene receptor antagonists for chronic urticaria: a systematic review. Allergy Asthma Clin Immunol. 2014; 10:24.

84. Laurberg G. Tranexamic acid (Cyklokapron) in chronic urticaria: a double-blind study. Acta Derm Venereol. 1977; 57:369–370.

85. Thormann J, Laurberg G, Zachariae H. Oral sodium cromoglycate in chronic urticaria. Allergy. 1980; 35:139–141.

TOOLS

ORCID iDs

Hae-Sim Park
https://orcid.org/http://orcid.org/0000-0003-2614-0303

Yoon-Seok Chang
https://orcid.org/http://orcid.org/0000-0003-3157-0447

Similar articles