Diet in dermatology: Part II. Melanoma, chronic urticaria, and psoriasis.

The roles of dietary factors in aggravating, preventing, or treating skin diseases are common questions encountered in dermatology practice. Part II of this two-part series reviews dietary modifications that can potentially be utilized in the management of melanoma, chronic urticaria, and psoriasis patients. Specifically, we examine the effect of alcohol consumption and supplementation with vitamins D and E, polyunsaturated fatty acids, selenium, green tea, resveratrol, and lycopene on melanoma risk. The relationships between chronic urticaria symptoms and dietary pseudoallergens, gluten, and vitamin D are analyzed. We explore weight loss, reduced alcohol consumption, and gluten avoidance as means of reducing psoriasis-associated morbidity, as well as the possible utility of supplementation with polyunsaturated fatty acids, folic acid, vitamin D, and antioxidants. With proper knowledge of the role of diet in these cutaneous disease processes, dermatologists can better answer patient inquiries and consider implementation of dietary modifications as adjuncts to other treatments and preventative measures.

Eosinophilic esophagitis, celiac disease, and immunoglobulin E-mediated allergy in a 2-year-old child.

Celiac disease, eosinophilic esophagitis, and urticaria are 3 manifestations of food allergy with different pathogenic mechanisms. We report the case of a 2-year-old child with digestive symptoms, slow growth, and severe asthma. The results of skin prick tests were positive to several foods. Endoscopy revealed eosinophilic esophagitis and celiac disease. Treatment consisted of a gluten-free diet and a 1-month course of oral corticosteroids. Endoscopy and biopsy findings were normal at 5 years of age. A gluten-free diet is the basis of treatment of celiac disease, but the role of an elimination diet in eosinophilic esophagitis is not well established. Our patient also developed urticaria when exposed to milk and egg.We present, to our knowledge, the first report of a patient with celiac disease, eosinophilic esophagitis, and immediate-type immunoglobulin E-mediated food allergy.

Urticaria: an evidence-based update. Conference report.

Summary Evidence-based update meetings are held annually by the Centre of Evidence Based Dermatology, University of Nottingham. Topics are chosen by delegates at the previous year's conference and in the past have included blistering disorders, psoriasis, hair disorders and skin cancers. Once the topic is identified, a trials database search is undertaken with the aim of including speakers who are actively involved in trials that address the subject in question. This year, the eighth Evidence Based Update meeting focused on urticaria and took place in Loughborough University on 14 May 2009. The latest data on the diagnosis and management of acute and chronic urticaria, including cold and solar urticaria, and the impact of food intolerance on chronic urticaria, were presented by an international panel of renowned speakers, who sometimes expressed different viewpoints. The highlights of the meeting included an informal atmosphere, an international perspective, and a practical question and answer session. Over 70% of the delegates stated that they would be changing their clinical practice following on from the meeting. The evidence-based update meeting in 2010 will be devoted to eczema.

Usefulness of the CD63 basophil activation test in detecting Anisakis hypersensitivity in patients with chronic urticaria: diagnosis and follow-up.

BACKGROUND: The basophil activation test (BAT) has been recently described as a useful in vitro tool for diagnosis of allergy to Anisakis species in patients with acute urticaria. AIM: To evaluate the relationship between sensitization to Anisakis simplex and chronic urticaria (CU), using flow cytometry analysis of in vitro BAT. Methods. A. simplex sensitization was evaluated in patients with CU (n = 57) and in atopic (n = 22) and healthy controls (n = 20) by means of skin prick test (SPT), specific IgE and Anisakis-induced BAT using a triple-labelled strategy with anti-CD123, anti-human leucocyte antigen DR and anti-CD63 antibodies. During a follow-up period of 6 months in 10 patients with CU who accepted a fish-free dietary regimen, the diagnostic performance of the in vivo and in vitro methods was calculated, and changes in specific IgE and BAT were evaluated with respect to clinical response. RESULTS: A significant association between CU and A. simplex sensitization was found, with an overall prevalence of 75.4% in patients with CU (43/57) compared with 18% (4/22) and 10% (2/20) of the atopic and healthy controls, respectively (P < 0.0001). BAT (cut-off > 13%) had the highest sensitivity and specificity, with significantly better ability than specific IgE testing for the identification of A. simplex sensitization in patients with CU. During the 6-month follow-up, clinical improvement was seen in all patients, and specific IgE and BAT results decreased to normal values in 6/10 (60%) and 10/10 (100%) patients, respectively. CONCLUSIONS: BAT can be considered a reliable new in vitro method to evaluate A. simplex hypersensitivity in patients with CU, supplementing standardized procedures in both diagnosis and follow-up.

Italian position paper on urticaria. Italian Board on Urticaria.

The Italian Board on Urticaria has prepared a document focusing on the definition and classification of urticaria, taking into account the recent progress in identifying the causes, eliciting factors, and pathomechanisms of this disease. As urticaria has a profound impact on the quality of life, effective treatment is important. Therefore, specific treatment options for the management of urticaria are evaluated on the basis of the recent literature. Non-sedating H(1) antihistamines are recommended as the first-line treatment as they have proven effective in several randomized double-blind controlled studies. Dosages higher than those recommended may be necessary in some cases. However, additional or alternative therapies may be required for different urticaria subtypes and in view of individual variations in the course of the disease and response to treatment. Immunosuppressive drugs such as corticosteroids are not recommended for long-term treatment due to unavoidable, severe adverse effects.

Chronic urticaria: a cutaneous manifestation of celiac disease.

Celiac disease, or gluten-sensitive enteropathy, is an immune-mediated disease of the small bowel that results in malabsorption. It classically presents with gastrointestinal symptoms including chronic diarrhea, weight loss, abdominal bloating and anorexia. It is becoming more frequently identified in asymptomatic patients with a diagnosis of deficiencies related to malabsorption of iron, folic acid, vitamin B12 and vitamin D. It is increasingly identified as a cause for early or refractory osteoporosis. Occasionally, celiac disease presents with cutaneous manifestations alone. Dermatitis herpetiformis is a well-recognized cutaneous manifestation of celiac disease. Other cutaneous manifestations include alopecia, angular stomatitis and aphthous ulcerations. Described here is a case of a 24-year-old woman who presented with intermittent urticaria and gastrointestinal complaints. She was found to have celiac disease on small-bowel biopsy. Both her gastrointestinal symptoms and urticaria resolved when she was put on a gluten-free diet, suggesting that her urticaria was a cutaneous manifestation of celiac disease.

Chronic urticaria and associated coeliac disease in children: a case-control study.

UNLABELLED: Celiac disease (CD) and chronic urticaria (CU) are both sustained by immune mechanisms, but there are so far few data on their clinical association. We performed a case-control study to determine the occurrence of CD in urticaria and matched control children, and to assess the clinical relevance of this association. Children and adolescents were diagnosed to have severe chronic idiopathic urticaria in the presence of hives for more than 6 wk poorly or not responsive to oral antihistamines. Other known causes of urticaria had to be excluded. A matched control group without urticaria was enrolled. In both groups, the presence of CD was searched by assaying antitransglutaminase and antiedomysial antibodies, and confirmed with endoscopic intestinal biopsy. Results. CD was diagnosed and confirmed in 4/79 (5.0%) of children with CU and in 17/2545 (0.67%) of the controls (p = 0.0003). In the four children with urticaria and CD the gluten free diet (GFD) lead to complete remission of urticaria within 5-10 wk, whereas the disappearance of serological markers occurred in longer times (5-9 months). CONCLUSIONS: The presence of CD in children with CU was significantly more frequent than in controls. GFD resulted in urticaria remission. CD may be regarded in such subjects as a cause of CU.

Is Anisakis simplex responsible for chronic urticaria?

The association of chronic urticaria (CU) to parasitic infestations has been poorly studied. Recently, sensitization to the parasite larva Anisakis simplex has been described as the cause of acute urticaria and anaphylaxis. The aim of this work was to study the relationship between sensitization to A. simplex and CU. One hundred one patients with CU were studied. Data of possible contacts with A. simplex were collected and the usual CU study was performed. Furthermore, total and specific immunoglobulin E (IgE; Pharmacia CAP system IGE fluorescence enzyme immunoassay: CAP) to A. simplex, Ascaris lumbricoides, Echinococcus granulosus, and Toxocara canis were determined as well as skin-prick test with A. simplex and serology to E. granulosus. In accordance with the results of the CAP to A. simplex, the patients were divided into two groups, positive and negative, and, subsequently, subdivided into two other subgroups that were alternatively told to stop eating fish or seafood in their diet or to continue with their normal diet. Checkups were performed at 6, 12, and 18 months. Thirty-five percent of the patients had positive skin tests to A. simplex, and CAP to A. simplex was positive in 55%. The fish-eating habits, acute or chronic gastrointestinal disease, and the background of abdominal surgery were not related to the results of the CAP and/or skin test to A. simplex. A total of 21.8% of all the patients had detectable CAP to A. lumbricoides, 91% of whom had positive CAP to A. simplex. Three patients had specific IgE to T. canis and five patients had specific IgE to E. granulosus, in the absence of positive serology. All had specific IgE to A. simplex. Present infestation could not be proved in any of them. The clinical evolution and variations of CAP to A. simplex and of total IgE were not statistically different among the groups during the 6, 12, and 18 months of the study. The percentage of sensitization to A. simplex in patients with CU is elevated and determines the sensitization to other parasites because of cross-reactivity. We have not found any causal relationship between the presence of specific IgE to A. simplex and CU. The clinical importance of this finding in this disease is still undetermined.

Chronic urticaria exacerbated by the antioxidant food preservatives, butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT).

Two patients with chronic idiopathic urticaria in whom remissions were achieved with dye- and preservative-elimination diet had exacerbations of their urticaria when they were challenged under double-blind, placebo-controlled conditions with butylated hydroxyanisole and butylated hydroxytoluene. After elimination of butylated hydroxyanisole and butylated hydroxytoluene from their diets, there was marked abatement of the frequency, severity, and duration of their urticaria. These antioxidants appear capable of aggravating symptoms in certain patients with chronic urticaria.

An allergist looks at urticaria.

Some etiologic possibilities which must be considered are foods, drugs, infection, inhalant sensitivity, psychic factors, physical agents, underlying connective tissue disease or neoplasm, insect bite or stings and genetic abnormalities. A painstaking history and a complete physical examination are, of course, mandatory. These are followed by appropriate studies for whatever etiologic factors are suggested by the history and physical examination. Certain routine or more sophisticated studies might be indicated including a complete blood count, urinalysis, stools for ova and parasites, antinuclear antibody titer, complete complement, sedimentation rate, sinus, chest and dental X rays and any other specified test depending on where the clues lead. O'Loughlin described a practical approach in the use of laboratory studies for the diagnosis of chronic urticaria. Skin tests can be helpful especially for inhalants, but food tests are usually not reliable in the diagnosis of chronic urticaria. The acute urticaria reaction to a food is clinically obvious and this type of patient does not usually seek medical attention or need extensive investigation. Treatment includes a few basic medications. Hydroxyzine (Atarax, Vistaril), which combines tranquilizer and antihistamine action, is frequently effective. Cyproheptadine HCL (Periactin) both a serotonin and histamine antagonist with anticholinergic effect, is also helpful--especially in combination with hydroxyzine. Antihistamines, ephedrine, epinephrine, aminophyllin and occasionally corticosteroids are helpful. Immunotherapy with inhalants is occasionally indicated. Eliminating possible offending foods, dyes or drugs has been previously discussed. Anti-candidal therapy and low yeast diet is effective when indicated. The final aspect of the investigation and treatment process might best be described as "patient support"--patience on the part of the physician. It should be realized that in 75% of the cases of chronic urticaria, no convincing etiology is found. It should also be realized that urticaria all too frequently "settles down" due as much to the natural course as to the careful ministrations of the physician.