Recomendaciones para el diagnóstico y tratamiento de la urticaria en pediatría / Recommendations for the diagnosis and treatment of urticaria in children

La urticaria es una de las afecciones cutáneas más comunes en niños. Se define urticaria aguda cuando persiste hasta 6 semanas, y crónica, cuando la duración es mayor. Afecta al 25 % de la población. La forma aguda es la más frecuente. La crónica representa el 0,1 %, con mayor predominio en mujeres (el 60 %). Se subdivide en urticaria crónica inducible cuando hay un desencadenante externo específico y urticaria crónica espontánea si este no está presente.Aunque la fisiopatología es compleja, la degranulación del mastocito se considera un evento clave. Los antihistamínicos anti-H1 de segunda generación son la primera línea de tratamiento tanto en la urticaria aguda como en la crónica. En pacientes no respondedores, se considerarán otras terapias.Se hará énfasis en urticaria crónica dada la dificultad en su diagnóstico, el aumento de su prevalencia y la gran afectación que produce en la calidad de vida de los niños.

Urticaria is one of the most common skin disorders in children. We define acute urticaria when it persists for less than 6 weeks, and chronic urticaria (CU), when it persists longer. Urticaria affects 25 % of the population; in most cases, it is acute urticaria. CU represents 0.1 %, with higher prevalence in women (60 %). CU is subclassified in chronic inducible urticaria when there is a specific external trigger and chronic spontaneous urticaria if it is not present.Although the pathophysiology is complex, mast cell degranulation is recognized as a key event. Second-generation H1 antihistamines are the first line of treatment in both, acute urticaria and CU. In unresponsive patients, other therapies will be considered.We will emphasize in CU due to the difficulty in its diagnosis, the increase in its prevalence and the severe impairment it causes in children ́s quality of life.

High waist circumference rather than high body mass index may be a predictive risk factor for the longer disease duration of chronic spontaneous urticaria.

In a previous study, we found that higher waist circumference (WC) and higher body mass index (BMI) both increase the risk of chronic spontaneous urticaria (CSU). The aim of this study was to determine whether WC and BMI also increase the duration of CSU. We used multivariable Cox proportional hazards models to determine the hazard ratio (HR) for longer disease duration (longer than 3 years) according to WC and BMI. A total of 52,667 subjects were enrolled and their mean age was 54.5. After adjustments for other confounding variables the high WC/high BMI group had 1.062 times higher HR (95% CI, 1.028-1.098) than the normal WC/normal BMI group. Interestingly, the high WC/normal BMI group showed a significantly higher HR (1.053; 95% CI, 1.008-1.101) than the normal WC/normal BMI group, but not the normal WC/high BMI group (0.998; 95% CI, 0.951-1.046). Taken together, our results suggest that high WC rather than high BMI is a predictive risk factor for the longer disease duration of CSU.

Rotational Thromboelastometry Profile in Children With Chronic Spontaneous Urticaria.

The pathogenesis of chronic spontaneous urticaria (CSU) is incompletely understood. There is a growing interest in the role of the coagulation cascade in chronic urticaria. Rotational thromboelastometry (ROTEM) assay enables the global assessment of coagulation status. In the present study, we aimed to test the coagulation profile in children with CSU using ROTEM and correlate these parameters with those of a healthy group. A total of 24 children with active CSU (11 girls and 13 boys) 8 to 17 years of age and age-matched and sex-matched 30 healthy control participants were enrolled in the study. ROTEM assays (intrinsic thromboelastometry and extrinsic thromboelastometry) were used to measure and analyze coagulation time, clot formation time, and maximum clot firmness. The CSU patients and controls did not differ in age, sex, erythrocyte, neutrophil, and platelet counts. Also, ROTEM parameters did not show any difference between the 2 groups. ROTEM is increasingly being used as a tool for monitoring coagulation status. In this study, ROTEM parameters did not show any difference between CSU patients and the healthy group. Further studies are needed to confirm our findings on a larger number of CSU patients.

Validity, reliability, and interpretability of the Brazilian urticaria control test.

Background: The urticaria control test (UCT) is a patient-reported outcome measure designed to determine the current level of disease control in patients with chronic urticaria (CU). Recently, a Brazilian UCT was developed, but its validity and reliability are unknown. Method: The clinimetric properties of the Brazilian UCT short form (UCTsh) and its long form (UCTlg) were determined in 130 patients with CU. In parallel, the urticaria activity scores (UAS) that covers 7 days (UAS7) and 28 days (UAS28) were used to assess disease activity. Subsequently, the results were analyzed statistically to determine the validity, reliability, and interpretability of the Brazilian UCT versions. Results: A total of 107 female (82%) and 23 male patients with CU completed both versions of the Brazilian UCT. Both of the Brazilian UCT versions showed excellent internal consistency reliability. In addition, the Brazilian UCT results showed strong correlations with UAS7 and UAS28 results, which indicated high levels of convergent validity. The test-retest reliability was examined in a subsample of 27 patients with CU and was found to be excellent. Notably, the results of both Brazilian UCT versions correlated extensively, which suggested that the UCTsh can replace the UCTlg without changing the UCT results. Conclusion: The Brazilian UCT is a valid and reliable tool for assessing disease control. To facilitate the use of the Brazilian UCT in global studies and to put a stronger focus on the specificity, we propose that the same cutoff values for well-controlled disease should be used as identified in the original publication of the UCT, i.e., ≥12 points for the UCTsh.

Efficacy and safety of acupuncture for patients with chronic urticaria: study protocol of a randomized, sham-controlled pilot trial.

BACKGROUND: Chronic urticaria (CU) is a refractory skin disease with long duration and a high recurrence rate. Acupuncture has been widely used for the treatment of CU in clinical practice in China. However, until now, there has been no appropriately designed randomized controlled trial (RCT) to provide explicit evidence about the effectiveness of acupuncture for the treatment of CU worldwide. Therefore, we plan to conduct a pilot study to explore its effectiveness and safety and determine the feasibility of studying acupuncture in a future, full-scale, RCT of CU. METHODS/DESIGN: This randomized, sham-controlled, participant-blinded and assessor-blinded pilot trial is underway in China. A total of 60 participants with CU will be randomly assigned to two groups in a 1:1 ratio: one treated with real acupuncture and the other with sham acupuncture, for 10 sessions over 2 weeks. The experimental group will receive acupuncture on a fixed prescription of acupoints, whereas the control group will receive sham acupuncture, namely minimal acupuncture on non-acupuncture points. The primary outcome will be the urticaria activity score (UAS). The secondary outcomes will include a visual analogue scale (VAS) score for itching intensity, the Dermatology Life Quality Index (DLQI), the Hamilton Depression Scale (HAMD), the Hamilton Anxiety Scale (HAMA), the humoral immunity index, serum total IgE, and adverse events. The UAS, VAS for itching and the DLQI will be conducted at baseline and at 1, 2, 3, and 4 weeks after randomization. The HAMD, HAMA, humoral immunity index, and serum total IgE will be assessed at baseline and at 2 weeks after randomization. Adverse events will be summarized at 1 week and 2 weeks after randomization. DISCUSSION: The pilot study mainly aims to investigate trial feasibility, and confirm basic information about its effects and safety. Results of this trial will help clarify whether the acupuncture treatment is beneficial for symptom improvement in patients with CU. The finding of this study will provide preliminary evidence on the effectiveness and safety of acupuncture for CU. TRIAL REGISTRATION: Acupuncture-Moxibustion Clinical Trial Registry, AMCTR-ICR-18000190 . Registered on 19 June 2018.

[Thyroid disorders in spontaneous chronic urticaria]. / Alteraciones tiroideas en urticaria crónica espontánea.

BACKGROUND: Chronic spontaneous urticaria (CSU) is linked to thyroid disease in up to 54%, with predominance of hypothyroidism. OBJECTIVE: To describe the impairments of the thyroid function in patients with CSU in a third level of care. METHODS: A cross-sectional, observational, and descriptive study in which we have included men and women over 18-year-old with CSU; in which TSH and free T4 were quantified. According to the results, they were classified as euthyroid, hyperthyroid, and hypothyroid; in the latter ones, the presence of antithyroid antibodies was intentionally sought. The demographic and biochemical characteristics of the results were assessed. RESULTS: The clinical characteristics of 127 patients with CSU were analyzed. Women accounted for 78%. The average age was 44.5 ± 15.1 years. Impairments of the thyroid function were identified in 50 patients (39%), and subclinical hypothyroidism (SH) occurred in 41 (82%) of them; patients with hyperthyroidism were not found. Of the patients with hypothyroidism, 14 (28%) presented positive antibodies; all of them were women. CONCLUSIONS: More than a third of the analyzed patients with CSU presented impairments of the thyroid function; subclinical hypothyroidism (SH) was more common. The importance of identifying this entity lies in the possibility of a multidisciplinary treatment with endocrinology. Subsequent studies may establish whether the presence of hypothyroidism influences the activity of CSU.

Antecedentes: La urticaria crónica espontánea (UCE) se asocia con enfermedad tiroidea hasta en 54 %, con predominio de hipotiroidismo. Objetivo: Describir las alteraciones de la función tiroidea en pacientes con UCE en un tercer nivel de atención. Métodos: Estudio trasversal, observacional y descriptivo en el que se incluyeron hombres y mujeres mayores de 18 años de edad con UCE en quienes se cuantificó TSH y T4 libre. De acuerdo con los resultados, fueron clasificados como eutiroideos, hipertiroideos e hipotiroideos, en estos últimos se buscó intencionadamente anticuerpos antitiroideos. Se evaluaron las características demográficas y bioquímicas de los resultados. Resultados: Se analizaron las características clínicas de 127 pacientes con UCE. Las mujeres representaron 78 %. La media de edad fue de 44.5 ± 15.1 años. Se identificaron alteraciones de la función tiroidea en 50 pacientes (39 %); hipotiroidismo subclínico (HS) en 41 (82%) y ninguno con hipertiroidismo. De los pacientes con hipotiroidismo, 14 (28%) presentaron anticuerpos positivos; todas eran mujeres. Conclusiones: Más de un tercio de los pacientes con UCE analizados presentaron alteraciones de la función tiroidea; fue más común el hipotiroidismo subclínico. La importancia de identificar esta entidad radica en la posibilidad de tratamiento multidisciplinario con el servicio de endocrinología. Estudios posteriores podrán establecer si el hipotiroidismo influye en la actividad de la UCE.