Consensus Statement for the Diagnosis and Treatment of Urticaria: A 2017 Update.

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab.

A Real-World Study to Assess the Effectiveness of Itolizumab in Patients with Chronic Plaque Psoriasis.

BACKGROUND: While clinical trial data on the efficacy of itolizumab in the management of psoriasis is relatively well documented, data on the effectiveness of this humanized IgG1 monoclonal antibody in real-world settings is sparse. AIMS: The current study assessed the effectiveness of itolizumab in real-world settings. MATERIALS AND METHODS: This study assessed psoriasis area severity index (PASI), dermatology quality of life index (DLQI), safety, and tolerability data from a registry of itolizumab maintained by Syngene International, Bangalore. Registry data of 155 patients who were prescribed itolizumab at a dose of 1.6 mg/kg every 2 weeks for the first 12 weeks followed by 1.6 mg/kg every 4 weeks for up to 24 weeks for chronic plaque psoriasis. RESULTS: In the study, 35.48% completed itolizumab for 12 weeks and 76.59% of these patients achieved PASI 75. Furthermore, 24.51% patients completed the full Itolizumab regimen for 24 weeks, of whom 92.01% patients achieved PASI 75. The mean percent change in DLQI scores at weeks 12 and 24 were 60.19 and 82.72, respectively. Adverse events and infusion reactions noted in the study were generally of mild to moderate severity. CONCLUSION: Itolizumab is a safe and effective option in treatment-compliant patients with chronic plaque psoriasis. Effects of putative compliance-modulators such as cost, route of administration, and delayed onset of action warrant further investigation.

Efficacy and safety of itolizumab, a novel anti-CD6 monoclonal antibody, in patients with moderate to severe chronic plaque psoriasis: results of a double-blind, randomized, placebo-controlled, phase-III study.

BACKGROUND: Itolizumab, a humanized monoclonal antibody to CD6, is a novel therapeutic agent evaluated in chronic plaque psoriasis. OBJECTIVE: We sought to assess the safety and efficacy of itolizumab in moderate to severe chronic plaque psoriasis. METHODS: A total of 225 patients were randomized (2:2:1) to 2 different itolizumab arms (A or B; A = 4-week loading dose of 0.4 mg/kg/wk followed by 1.6 mg/kg every 2 weeks; B = 1.6/mg every 2 weeks) or placebo. At week 12, the placebo arm was switched to 1.6 mg/kg itolizumab every 2 weeks. The primary end point was the proportion of patients with at least 75% improvement in Psoriasis Area and Severity Index score at week 12. RESULTS: At week 12, 27.0% in arm A (P = .0172 vs placebo), 36.4% in B (P = .0043 vs placebo), and 2.3% in the placebo arm had at least 75% improvement in Psoriasis Area and Severity Index score. At week 28, the proportion with at least 75% improvement in Psoriasis Area and Severity Index score was comparable: 46.1%, 45.5%, and 41.9% for A, B, and placebo, respectively. In weeks 1 to 12, the incidence of all adverse events was comparable across arms (A, 43%; B, 38%; placebo, 47%) and the incidence of infections was not greater than placebo (11.1%, 8.9%, and 18.6% for A, B, and placebo). LIMITATIONS: No active comparator is a limitation. CONCLUSIONS: Itolizumab is an effective and well-tolerated novel biological therapy in moderate to severe psoriasis.

Clinical and investigative assessment of patients with positive versus negative autologous serum skin test: a study of 80 South Indian patients.

BACKGROUND: Chronic urticaria (CU) is defined as urticaria persisting daily as or almost daily for more than 6 weeks and affecting 0.1% of the population. Mast cell degranulation and histamine release is of central importance in the pathogenesis of CU. About 40-50% of the patients with chronic idiopathic urticaria demonstrate an immediate wheal and flare response to intra-dermal injected autologous serum. This led to the concept of autoimmune urticaria. AIMS: To determine the occurrence, clinical features, associated clinical conditions, comorbidities of autoimmune urticaria and to compare this with chronic spontaneous urticaria. This study aimed to find the frequency of autologous serum skin test (ASST) positive patients among patients with CU and to identify the clinical and laboratory parameters associated with positive ASST. MATERIALS AND METHODS: Prospective correlation study was done on 80 chronic urticaria patients, more than 6 weeks duration, attending outpatient department of dermatology during a period of November 2007 to January 2010. Patients were subjected to ASST, complete blood count, urine routine examination, liver function tests, renal function tests, thyroid function tests, H. pylori antibody tests, C3 and C4 complement level estimation, antinuclear antibody, and urine analysis. RESULTS: ASST was positive in 58.75% and negative in 41.25% of the patients, respectively. Out of 33 patients with history of angioedema, 9 (27.3%) patients were in ASST negative group and 24 were in positive group, this was statistically significant. Both groups showed no statistically significant difference for epidemiological details. CONCLUSION: ASST is considered a screening test for an autoimmune urticaria, which decreases the rate of diagnosis of "idiopathic" form of chronic urticaria. Patients with an autoimmune urticaria have more severe urticaria, more prolonged duration, more frequent attacks, and angioedema. Identification of autoimmune urticaria may permit the use of an immunotherapy in severe disease unresponsive to anti-histamine therapy.

Prevalence and relevance of secondary contact sensitizers in subjects with psoriasis.

BACKGROUND: Psoriasis may be complicated by contact dermatitis due to an impaired cutaneous barrier. Patch testing helps elucidate sensitizers if any. AIMS: To determine the prevalence and relevance of secondary contact dermatitis in subjects with psoriasis. MATERIALS AND METHODS: Patch testing with Indian Standard Series was done and readings interpreted after 48 and 96 hours. RESULTS: Among 110 subjects 47 (42.7%) showed reactions to at least one antigen. Fifteen (13.6%) reacted to fragrance mix, 10 (9.1%) to nickel sulfate, seven (6.4%) to parthenium, and six (5.5%) to balsam of Peru. Palmoplantar psoriasis was the commonest type of psoriasis patch tested. Fragrance mix was the commonest antigen showing 100% current relevance as an aggravating factor of psoriasis. Cosmetics, beauty preparations, skin and healthcare products followed by topical medications were found to be the most common sources of the patch test positivity. CONCLUSIONS: Secondary contact dermatitis is common in patients with psoriasis. Patch testing is necessary to determine the triggering or aggravating antigens in these patients to avoid sensitizers and improve quality of life.

Fractional lasers in dermatology--current status and recommendations.

INTRODUCTION: Fractional laser technology is a new emerging technology to improve scars, fine lines, dyspigmentation, striae and wrinkles. The technique is easy, safe to use and has been used effectively for several clinical and cosmetic indications in Indian skin. DEVICES: Different fractional laser machines, with different wavelengths, both ablative and non-ablative, are now available in India. A detailed understanding of the device being used is recommended. INDICATIONS: Common indications include resurfacing for acne, chickenpox and surgical scars, periorbital and perioral wrinkles, photoageing changes, facial dyschromias. The use of fractional lasers in stretch marks, melasma and other pigmentary conditions, dermatological conditions such as granuloma annulare has been reported. But further data are needed before adopting them for routine use in such conditions. PHYSICIAN QUALIFICATION: Any qualified dermatologist may administer fractional laser treatment. He/ she should possess a Master's degree or diploma in dermatology and should have had specific hands-on training in lasers, either during postgraduation or later at a facility which routinely performs laser procedures under a competent dermatologist or plastic surgeon with experience and training in using lasers. Since parameters may vary with different systems, specific training tailored towards the concerned device at either the manufacturer's facility or at another center using the machine is recommended. FACILITY: Fractional lasers can be used in the dermatologist's minor procedure room for the above indications. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects and possible postoperative complications should be provided to the patient. The patient should be provided brochures to study and also adequate opportunity to seek information. A detailed consent form needs to be completed by the patient. Consent form should include information on the machine, possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing. A close-up front and 45-degree lateral photographs of both sides must be taken. LASER PARAMETERS: There are different machines based on different technologies available. Choice parameters depend on the type of machine, location and type of lesion, and skin color. Physician needs to be familiar with these requirements before using the machine. ANESTHESIA: Fractional laser treatment can be carried out under topical anesthesia with eutectic mixture of lidocaine and prilocaine. Some machines can be used without any anesthesia or only with topical cooling or cryospray. But for maximal patient comfort, a topical anesthetic prior to the procedure is recommended. POSTOPERATIVE CARE: Proper postoperative care is important in avoiding complications. Post-treatment edema and redness settle in a few hours to a few days. A sunscreen is mandatory, and emollients may be prescribed for the dryness and peeling that could occur.

Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing.

UNLABELLED: Resurfacing is a treatment to remove acne and chicken pox scars, and changes in the skin due to ageing. MACHINES: Both ablative and nonablative lasers are available for use. CO 2 laser is the gold standard in ablative lasers. Detailed knowledge of the machines is essential. INDICATIONS FOR CO 2 LASER: Therapeutic indications: Actinic and seborrheic keratosis, warts, moles, skin tags, epidermal and dermal nevi, vitiligo blister and punch grafting, rhinophyma, sebaceous hyperplasia, xanthelasma, syringomas, actinic cheilitis angiofibroma, scar treatment, keloid, skin cancer, neurofibroma and diffuse actinic keratoses. CO 2 laser is not recommended for the removal of tattoos. AESTHETIC INDICATIONS: Resurfacing for acne, chicken pox and surgical scars, periorbital and perioral wrinkles, photo ageing changes, facial resurfacing. PHYSICIANS' QUALIFICATIONS: Any qualified dermatologist (DVD or MD) may practice CO 2 laser. The dermatologist should possess postgraduate qualification in dermatology and should have had specific hands-on training in lasers either during postgraduation or later at a facility which routinely performs laser procedures under a competent dermatologist/plastic surgeon, who has experience and training in using lasers. For the use of CO 2 lasers for benign growths, a full day workshop is adequate. As parameters may vary in different machines, specific training with the available machine at either the manufacturer's facility or at another centre using the machine is recommended. FACILITY: CO 2 lasers can be used in the dermatologist's minor procedure room for the above indications. However, when used for full-face resurfacing, the hospital operation theatre or day care facility with immediate access to emergency medical care is essential. Smoke evacuator is mandatory. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects, possible postoperative complications, should be discussed with the patient. The patient should be provided brochures to study and also given adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. Consent forms should include information on the machine used; possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing. Choice of the machine and the parameters depends on the site, type of lesion, result needed, and the physician's experience. ANESTHESIA: Localized lesions can be treated under eutectic mixture of local anesthesia (EMLA) cream anesthesia or local infiltration anesthesia. Full-face resurfacing can be performed under general anesthesia. Proper postoperative care is important to avoid complications.

Suction blister grafting for stable vitiligo using pulsed erbium:YAG laser ablation for recipient site.

BACKGROUND: Suction blister grafting was performed via a modified simple technique using a 20-mL syringe to create the donor graft and pulsed erbium:YAG laser ablation of the recipient site. METHODS: Two patients with stable vitiligo and one with postinflammatory depigmentation were studied. RESULTS: The grafts took well in all three patients and pigmentation was retained at 20 weeks. No complications occurred. CONCLUSIONS: The erbium:YAG laser is an ideal tool for creating graft recipient sites, given its precision in terms of width and depth of ablation. A 20-mL syringe can be used to create a blister of adequate size.

Flare up of Nickel Contact Dermatits Following Oral Challenge.

A patient having contact dermatitis due to nickel on the wrist, sides of neck, thighs and legs, confirmed by patch tests with nickel sulphate, showed aggravation of the dermatitis following oral provocation with 25 mg nickel sulphate.

Allergenic agent in contact dermatitis from Holigarna ferruginea.

9 of 10 patients who developed dermatitis following contact with Holigarna ferruginea and 5 of 35 asymptomatic volunteers showed a positive patch test reaction to 2% W/V acetone extract of the plant's resinous exudate. 6 albino rats were sensitized following 3 weekly applications of the same extract. Laccol (3-heptadecadienyl catechol) was identified as the active principle in the exudate.

Absence of Nickel in Detergents Confirmed by Dimethylglyoxime Spot Test.

Reports differ greatly as to the significance of nickel in detergents as a cause of dermatitis. Dimethylglyoe spot test was negative for nickel with various detergents. It seems therefore that nickel is not an important cause of detergent induced dermatitis in India.