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Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines

  • Allergic Skin Diseases (L Fonacier, Section Editor)
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Abstract

Urticaria can present acutely and be self-limiting or become chronic and persist for weeks, months, or years. In either case, the condition may have a significant impact on the patient’s quality of life. Two major consensus groups, the EAACI/WAO and the AAAAI/ACAAI Joint Task Force, have written guidelines on the diagnosis and management of urticaria. While both agree on most points regarding the definition, general evaluation, and treatment, there are some differences which exist. The guidelines, which are written to assist both primary practitioners and specialists in managing their patients with urticaria, have been developed based on scientific evidence, and when insufficient evidence is available, then recommendations are based on expert consensus opinion. The majority of the differences between the two guidelines pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these two groups, highlighting the key similarities and differences.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Zuberbier T, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, Church MK, et al. The EAACI/GA2LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014;69:868–87. This is the document outlining the European guidelines for urticaria.

    Article  CAS  PubMed  Google Scholar 

  2. 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 US Am Acad Allergy Asthma Immunol. 2014;133:1270–7. Published by Mosby, Inc. This is the document outlining the American guidelines for urticaria.

    Google Scholar 

  3. Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau A, et al. EAACI/GA2LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy Eur J Allergy Clin Immunol. 2009;64:1417–26.

    Article  CAS  Google Scholar 

  4. Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, et al. Methods report on the development of the 2013 revision and update of the EAACI/GA(2) LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. 2014;69:e1–e29.

    Article  CAS  PubMed  Google Scholar 

  5. Shocket AL. Chronic urticaria: pathophysiology and etiology, or the what and why. Allergy Asthma Proc. 2006;27:90–5.

    Google Scholar 

  6. 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. 2012;129:1307–13. ImmunolAllergy Clin Immunol Unit, Meir Medical Center, Kfar Saba, Israel. ronitco@clalit.org.il: American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc.

    Article  Google Scholar 

  7. 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;37:631–50. Clinical Immunology Unit, Queen’s Medical Centre, Nottingham, UK.

    Article  CAS  PubMed  Google Scholar 

  8. Ap K. Chronic urticaria: pathogenesis and treatment. J Allergy Clin Immunol. 2004;114:465–74.

    Article  Google Scholar 

  9. 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;71:663–8. The natural history of chronic urticaria in childhood: a prospective study. Division of Allergy and Immunology, Department of Pediatrics, Srinakarinwirot University, Bangkok, Thailand; Division of Allergy and Immunology, Department of Pediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of All (TRUNCATED: American Academy of Dermatology, Inc. Published by Elsevier Inc.

    Article  PubMed  Google Scholar 

  10. Volonakis M, Katsarou-Katsari A, Stratigos J. Etiologic factors in childhood chronic urticaria. Ann Allergy. 1992;69:61–5.

    CAS  PubMed  Google Scholar 

  11. Kauppinen K, Juntunen K, Lanki H. Urticaria in children. Retrospective evaluation and follow-up. Allergy. 1984;39:469–72.

    Article  CAS  PubMed  Google Scholar 

  12. Greenberger PA. Chronic urticaria: new management options. World Allergy Organ J. 2014;7:31–4551 – 7–31. eCollection 2014. Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 676 N. St. Clair Street, # 14108, 60611 Chicago, IL USA.

  13. Erbagci Z. The leukotriene receptor antagonist montelukast in the treatment of chronic idiopathic urticaria: a single-blind, placebo-controlled, crossover clinical study. J Allergy Clin Immunol. 2002;110:484–8. Department of Dermatology, Gaziantep University Medical Faculty, Turkey.

    Article  CAS  PubMed  Google Scholar 

  14. Grattan CE, O’Donnell BF, Francis DM, Niimi N, Barlow RJ, Seed PT, et al. Randomized double-blind study of cyclosporin in chronic “idiopathic” urticaria. Br J Dermatol. 2000;143:365–72. Dermatology Centre, West Norwich Hospital, Norwich NR2 3TU, UK. clive.grattan@norfolk-norwich.thenhs.com.

    Article  CAS  PubMed  Google Scholar 

  15. Mlynek A, Zalewska-Janowska A, Martus P, Staubach P, Zuberbier T, Maurer M. How to assess disease activity in patients with chronic urticaria? Allergy. 2008;63:777–80. Department of Dermatology and Allergy, Charite-Universitatsmedizin Berlin, Berlin, Germany.

    Article  CAS  PubMed  Google Scholar 

  16. Baiardini I, Pasquali M, Braido F, Fumagalli F, Guerra L, Compalati E, et al. A new tool to evaluate the impact of chronic urticaria on quality of life: chronic urticaria quality of life questionnaire (CU-QoL). Allergy. 2005;60:1073–8.

    Article  CAS  PubMed  Google Scholar 

  17. Mathias SD, Crosby RD, Zazzali JL, Maurer M, Saini SS. Evaluating the minimally important difference of the urticaria activity score and other measures of disease activity in patients with chronic idiopathic urticaria. Ann Allergy Asthma Immunol. 2012;108:20–4.

    Article  PubMed  Google Scholar 

  18. Saini S, Rosen KE, Hsieh HJ, Wong DA, Conner E, Kaplan A, et al. A randomized, placebo-controlled, dose-ranging study of single-dose omalizumab in patients with H1-antihistamine-refractory chronic idiopathic urticaria. J Allergy Clin Immunol. 2011;128:567–73.e1. Johns Hopkins Asthma and Allergy Center, Baltimore, MD 21224, USA. ssaini@jhmi.edu: American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc.

    Article  CAS  PubMed  Google Scholar 

  19. Młynek A, Magerl M, Hanna M, Lhachimi S, Baiardini I, Canonica GW, et al. The German version of the Chronic Urticaria Quality-of-Life Questionnaire: factor analysis, validation, and initial clinical findings. Allergy. 2009;64:927–36.

    Article  PubMed  Google Scholar 

  20. Valero A, Herdman M, Bartra J, Ferrer M, Jáuregui I, Dávila I, et al. Adaptation and validation of the Spanish version of the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL). J Investig Allergol Clin Immunol [Internet]. 2008;18:426–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19123433.

  21. Platzer MH, Grattan CEH, Poulsen LK, Skov PS. Validation of basophil histamine release against the autologous serum skin test and outcome of serum-induced basophil histamine release studies in a large population of chronic urticaria patients. Allergy Eur J Allergy Clin Immunol. 2005;60:1152–6.

    Article  CAS  Google Scholar 

  22. Konstantinou GN, Asero R, Maurer M, Sabroe RA, Schmid-Grendelmeier P, Grattan CE. EAACI/GA(2)LEN task force consensus report: the autologous serum skin test in urticaria. Allergy. 2009;64:1256–68. Allergy and Clinical Immunology Department, NIMTS, Army Hospital and Allergy Research Center National & Kapodistrian University of Athens, Greece.

    Article  CAS  PubMed  Google Scholar 

  23. Maurer M, Weller K, Bindslev-Jensen C, Gimenez-Arnau A, Bousquet PJ, Bousquet J, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA(2)LEN task force report. Allergy. 2011;66:317–30. Department of Dermatology and Allergy, Charite- Universitatsmedizin Berlin, Berlin, Germany. marcus.maurer@charite.de: John Wiley & Sons A/S.

    Article  CAS  PubMed  Google Scholar 

  24. Quaranta JH, Rohr AS, Rachelefsky GS, Siegel SC, Katz RM, Spector SL, et al. The natural history and response to therapy of chronic urticaria and angioedema. Ann Allergy. 1989;62:421–4. United States.

    CAS  PubMed  Google Scholar 

  25. Kozel MM, Mekkes JR, Bossuyt PM, Bos JD. Natural course of physical and chronic urticaria and angioedema in 220 patients. J Am Acad Dermatol. 2001;45:387–91. Department of Dermatology, Academic Medical Center, University of Amsterdam, The Netherlands.

    Article  CAS  PubMed  Google Scholar 

  26. Amin P, Levin L, Holmes SJ, Picard J, Bernstein JA. Investigation of patient-specific characteristics associated with treatment outcomes for chronic urticaria. J Allergy Clin Immunol Pr. 2015. doi:10.1016/j.jaip.2014.12.007.

  27. Ring J, Hein R, Gauger A, Bronsky E, Miller B. Once-daily desloratadine improves the signs and symptoms of chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled study. Int J Dermatol [Internet]. 2001;40:72–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11277962\nhttp://apps.isiknowledge.com/full_record.do?product=UA&search_mode=GeneralSearch&qid=8&SID=T2FFQ4fEGczccZ8jE6Z&page=9&doc=419.

  28. 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 conventional doses in difficult-to-treat urticaria. J Allergy Clin Immunol. 2010;125:676–82. Evidence supporting step 2 of both the JTF and EAACI guidelines to increase 2nd generation antihistamines up to 4 times the conventional dose. This is generally very effective, safe and easy to manage for many patients.

    Article  CAS  PubMed  Google Scholar 

  29. Nettis E, Dambra P, D’Oronzio L, Loria MP, Ferrannini A, Tursi A. Comparison of montelukast and fexofenadine for chronic idiopathic urticaria. Arch Dermatol. 2001;137:99–100. United States.

    CAS  PubMed  Google Scholar 

  30. Sanada S, Tanaka T, Kameyoshi Y, Hide M. The effectiveness of montelukast for the treatment of anti-histamine-resistant chronic urticaria. Arch Dermatol Res. 2005;297:134–8. Department of Dermatology, Programs for Biomedical Research, Division of Molecular Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan.

    Article  CAS  PubMed  Google Scholar 

  31. Nettis E, Colanardi MC, Paradiso MT, Ferrannini A. Desloratadine in combination with montelukast in the treatment of chronic urticaria: a randomized, double-blind, placebo-controlled study. Clin Exp Allergy. 2004;34:1401–7. Department of Medical Clinic, Immunology and Infectious Diseases, Section of Allergy and Clinical Immunology, University of Bari, Bari, Italy. e.nettis@allergy.uniba.it.

    Article  CAS  PubMed  Google Scholar 

  32. Bagenstose SE, Levin L, Bernstein JA. The addition of zafirlukast to cetirizine improves the treatment of chronic urticaria in patients with positive autologous serum skin test results. J Allergy Clin Immunol. 2004;113:134–40.

    Article  CAS  PubMed  Google Scholar 

  33. Presta LG, Lahr SJ, Shields RL, Porter JP, Gorman CM, Fendly BM, et al. Humanization of an antibody directed against IgE. J Immunol. 1993;151:2623–32.

    CAS  PubMed  Google Scholar 

  34. 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;368:924–35. Highlights the most efficacious dose of omalizumab (300 mg SC every 4 weeks) and the use of the UAS7 score to quantify response to treatment. Department of Dermatology and Allergy, Charite-Universitatsmedizin, Berlin.

    Article  CAS  PubMed  Google Scholar 

  35. Strunk RC, Bloomberg GR. Omalizumab for asthma. N Engl J Med. 2006;354:2689–95. Department of Pediatrics, Washington University School of Medicine, St. Louis, USA.

    Article  CAS  PubMed  Google Scholar 

  36. Corren J, Casale TB, Lanier B, Buhl R, Holgate S, Jimenez P. Safety and tolerability of omalizumab. Clin Exp Allergy. 2009;39:788–97. Allergy Research Foundation, Los Angeles, CA 90025, USA. jcorren@ucla.edu.

    Article  CAS  PubMed  Google Scholar 

  37. Chiang DT, Clark J, Casale TB. Omalizumab in asthma: approval and postapproval experience. Clin Rev Allergy Immunol. 2005;29:3–16. Division of Allergy and Immunology, Creighton University Medical Center, Omaha, NE, USA.

    Article  CAS  PubMed  Google Scholar 

  38. Kar S, Krishnan A, Preetha K, Mohankar A. A review of antihistamines used during pregnancy. [Internet]. J. Pharmacol Pharmacother. 2012. p. 105–8. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3356948&tool=pmcentrez&rendertype=abstract

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Conflict of Interest

Jonathan A. Bernstein reports speaker fees from Genentech and clinical trial and IIS grants from Genentech/Novartis. Lauren M. Fine declares no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Correspondence to Jonathan A. Bernstein.

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This article is part of the Topical Collection on Allergic Skin Diseases

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Fine, L.M., Bernstein, J.A. Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines. Curr Allergy Asthma Rep 15, 30 (2015). https://doi.org/10.1007/s11882-015-0535-z

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  • DOI: https://doi.org/10.1007/s11882-015-0535-z

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