Clinical Characteristics, Investigations and Treatment in Children with Chronic Urticaria: An Observational Study.

Background and Objectives: The guidelines for chronic urticaria in children contain recommendations that are often based on adult studies. The diagnostic pathway has not been standardized and the effectiveness of anti-H1, omalizumab, montelukast, and systemic glucocorticoids is rarely reported in the pediatric population. There is a wide variation in the rate of remission of chronic urticaria between studies. The aim of this study is to enhance our understanding of pediatric chronic urticaria. Materials and Methods: This study enrolled 37 children with chronic urticaria aged from 0 to 18 years. Demographic parameters, medical history, clinical features, laboratory data and treatment information were collected. Children were treated with the recommended dosage of second-generation H1-antihistamines, which was increased by up to twofold. Omalizumab was added for refractory anti-H1 patients. A three-day course with systemic glucocorticoids was administered for severe exacerbations. Montelukast was administered to some children. Results: Wheals without angioedema were common. Chronic urticaria was spontaneous in 32 children (86.48%), inducible in 2 (5.41%), induced by a parasite in 1 and vasculitic in 2. Treatment of the potential causes of chronic urticaria was of no benefit, except for eradication of Dientamoeba fragilis. Chronic urticaria was resolved within three years in 45.9% of cases. Allergic diseases were present in nine children (24.32%) and autoimmune diseases were present in three (8.11%). All children were treated with anti-H1 at the licensed dose or at a higher dose. A partial or complete response to anti-H1 was observed in 29 (78.38%) patients. Montelukast showed no benefit. All children treated with omalizumab responded. Systemic glucocorticoids were successfully used to treat exacerbations. Conclusions: Our findings indicate that laboratory tests should not be routinely performed in children with chronic urticaria without clinical suspicion. However, comorbidities such as thyroid autoimmune disease and coeliac disease are suggested to be monitored over the chronic urticaria course. These clinical conditions could be diagnosed from the diagnostic framework of chronic urticaria. Increasing the dosage of anti-H1 and omalizumab was effective in children resistant to standard treatment but we still need further studies to generate a standard patient-centered treatment.

Chronic urticaria in the real-life clinical practice setting in Portugal: 2-years results from the non-interventional multicenter AWARE study.

INTRODUCTION: Information regarding chronic urticaria patients in the real-world setting is scarce. This analysis reports the two-year results of Portuguese patients included in the AWARE study. MATERIAL AND METHODS: Non-interventional cohort study. Adult patients with a diagnosis of chronic urticaria with symptoms for at least two months, refractory to H1-antihistamines, consulting one of the 10 participating urticaria centers throughout Portugal, from the 31st October 2014 to 31st July 2015, have been included in the study. Clinical parameters, medicines taken for urticaria symptom relief, weekly urticaria activity score, and dermatology quality of life index have been collected throughout the two years of the study. RESULTS: Seventy-six patients were enrolled in the study. Results showed that the proportion of patients with omalizumab therapy almost duplicated after two years of the AWARE study, which was accompanied by the decrease of medical resources use and absenteeism. Moreover, urticaria severity and impact on quality of life both decreased after one year and continued to decrease at two years, although decreased severity was significant at both time points and quality of life was only significant at two years. At the end of two years, 79.0% of patients had their disease controlled compared to 29.3% at baseline (p < 0.001). DISCUSSION: At the end of the AWARE study a significant proportion of patients had their disease controlled allowing for decreased use of medical resources. CONCLUSION: Chronic urticaria still has a significant impact on quality of life and therefore there is opportunity for further therapy optimization.

Introdução: A informação disponível sobre doentes com urticária crónica em contexto da prática clínica real é escassa. Esta análise reporta os resultados a dois anos dos doentes portugueses incluídos no estudo AWARE. Material e Métodos: Estudo de coorte, observacional, prospectivo, de doentes adultos com diagnóstico de urticária crónica, com sintomas há pelo menos dois meses, refratários a antihístamínicos-H1 na dose aprovada, seguidos em 10 centros de urticária em Portugal, incluídos entre 31 de outubro de 2014 e 31 de julho de 2015. Ao longo dos dois anos do estudo AWARE foram avaliados parâmetros clínicos, medicação utilizada para alívio dos sintomas de urticária, o Weekly Urticaria Activity Score e o índice de qualidade de vida dermatológico. Resultados: Foram incluídos setenta e seis doentes. Após dois anos do estudo AWARE, a percentagem de doentes sob terapia com omalizumab quase duplicou, sendo acompanhada por uma diminuição da utilização de recursos médicos e absenteísmo. A gravidade da urticária e o impacto na qualidade de vida diminuíram após um ano e continuaram a diminuir aos dois anos, embora o aumento da qualidade de vida apenas tenha atingido significado estatístico no segundo ano. A percentagem de doentes com patologia controlada aumentou de 29,3% no início do estudo para 79,0% (p < 0,001). Discussão: No final do estudo AWARE, uma percentagem significativa de doentes apresentou a patologia controlada, permitindo uma diminuição na utilização dos recursos médicos. Conclusão: A urticária crónica tem impacto na qualidade de vida da população, mostrando que a terapêutica ainda poderá ser otimizada.

A European survey of management approaches in chronic urticaria in children: EAACI pediatric urticaria taskforce.

BACKGROUND: Although well described in adults, there are scarce and heterogeneous data on the diagnosis and management of chronic urticaria (CU) in children (0-18 years) throughout Europe. Our aim was to explore country differences and identify the extent to which the EAACI/GA²LEN/EDF/WAO guideline recommendations for pediatric urticaria are implemented. METHODS: The EAACI Task Force for pediatric CU disseminated an online clinical survey among EAACI pediatric section members. Members were asked to answer 35 multiple choice questions on current practices in their respective centers. RESULTS: The survey was sent to 2,773 physicians of whom 358 (13.8%) responded, mainly pediatric allergists (80%) and pediatricians (49.7%), working in 69 countries. For diagnosis, Southern European countries used significantly more routine tests (eg, autoimmune testing, allergological tests, and parasitic investigation) than Northern European countries. Most respondents (60.3%) used a 2nd -generation antihistamine as first-line treatment of whom 64.8% updosed as a second line. Omalizumab was used as a second-line treatment by 1.7% and third line by 20.7% of respondents. Most clinicians (65%) follow EAACI/WAO/GA2LEN/EDF guidelines when diagnosing CU, and only 7.3% follow no specific guidelines. Some clinicians prefer to follow national guidelines (18.4%, mainly Northern European) or the AAAAI practice parameter (1.7%). CONCLUSIONS: Even though most members of the Pediatric Section of EAACI are familiar with the EAACI/WAO/GA2LEN/EDF guidelines, a significant number do not follow them. Also, the large variation in diagnosis and treatment strengthens the need to re-evaluate, update, and standardize guidelines on the diagnosis and management of CU in children.