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      Clinical features of elderly chronic urticaria

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          Abstract

          Background/Aims

          Chronic urticaria (CU) is defined as itchy wheals lasting 6 weeks or more. As the aged population increases worldwide, it is essential to identify the specific features of this disease in the elderly population.

          Methods

          We investigated the prevalence and clinical features of CU in elderly patients. Medical records of 837 CU patients from the outpatient Allergy Clinic of Ajou University Hospital, Korea were analyzed retrospectively. Patients with chronic spontaneous urticaria according to the EAACI/GA2LEN/EDF/WAO guidelines were included. Patients older than 60 years were defined as elderly.

          Results

          Of the 837 patients, 37 (4.5%) were elderly. In elderly versus nonelderly CU patients, the prevalence of atopic dermatitis (AD) was significantly higher (37.8% vs. 21.7%, respectively; p = 0.022), while that of aspirin intolerance was lower (18.9% vs. 43.6%, respectively; p = 0.003) in terms of comorbid conditions. The prevalences of serum specific immunoglobulin E antibodies to staphylococcal enterotoxin A and staphylococcal enterotoxin B were considerably higher in elderly CU patients with AD than in those without AD (37.5% vs. 0%, respectively).

          Conclusions

          Elderly patients with CU had a higher prevalence of AD. Therefore, there is a need to recognize the existence of AD in elderly CU patients.

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          EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria.

          T Zuberbier, R Asero, C. Bindslev-Jensen … (2009)
          This guideline, together with its sister guideline on the classification of urticaria (Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: definition, classification and diagnosis of urticaria. Allergy 2009;64: 1417-1426), is the result of a consensus reached during a panel discussion at the Third International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO). As members of the panel, the authors had prepared their suggestions regarding management of urticaria before the meeting. The draft of the guideline took into account all available evidence in the literature (including Medline and Embase searches and hand searches of abstracts at international allergy congresses in 2004-2008) and was based on the existing consensus reports of the first and the second symposia in 2000 and 2004. These suggestions were then discussed in detail among the panel members and with the over 200 international specialists of the meeting to achieve a consensus using a simple voting system where appropriate. Urticaria has a profound impact on the quality of life and effective treatment is, therefore, required. The recommended first line treatment is new generation, nonsedating H(1)-antihistamines. If standard dosing is not effective, increasing the dosage up to four-fold is recommended. For patients who do not respond to a four-fold increase in dosage of nonsedating H(1)-antihistamines, it is recommended that second-line therapies should be added to the antihistamine treatment. In the choice of second-line treatment, both their costs and risk/benefit profiles are most important to consider. Corticosteroids are not recommended for long-term treatment due to their unavoidable severe adverse effects. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).
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            Pathogenesis of chronic urticaria.

            Lara M. Greaves, Celia Kaplan (2009)
            Chronic urticaria is defined as the presence of urticaria (hives) for at least 6 weeks with the assumption that it occurs daily or close to it. If we eliminate physical urticarias and urticarial vasculitis from consideration, the remainder can be divided into autoimmune chronic urticaria (45%) and idiopathic chronic urticaria (55%). The autoimmune subgroup is associated with the IgG anti-IgE receptor alpha subunit in 35-40% of patients and IgG anti-IgE in an additional 5-10%. These autoantibodies have been shown to activate blood basophils and cutaneous mast cells in vitro with augmentation of basophil activation by complement and release of C5a, in particular. Binding methods (immunoblot and ELISA) yield positives in many autoimmune diseases as well as occasional normal subjects or patients with other forms of urticaria but most such sera are non-functional. Activation of basophils or mast cells causing histamine release is quite specific for chronic urticaria and defines the autoimmune subgroup. Although pathogenicity is not formally proven, the antibodies cause wealing upon intradermal injection, and removal of the autoantibody leads to remission. A cellular infiltrate is seen to be characterized by mast cell degranulation and infiltration of CD4+ T lymphocytes, monocytes, neutrophils, eosinophils, and basophils. The intensity of the infiltrate and clinical severity of the disease (including accompanying angio-oedema) is more severe in the autoimmune subpopulation. This latter group also has a higher evidence of human leucocyte antigen DR alleles associated with autoimmunity and a 25% incidence of antithyroid antibodies with diagnosed hypothyroidism in some. Hypo-responsiveness of patients' basophils to anti-IgE and hyperresponsiveness to serum defines another subpopulation (at least 50%) that overlaps the idiopathic and autoimmune subgroups. Hypo-responsiveness to anti-IgE has been shown to be associated with elevated levels of cytoplasmic phosphatases that inhibit degranulation. Reversal of the abnormality is seen with disease remission. Further work will be needed to distinguish whether this is a cause or a consequence of persistent urticaria and to further assess the relationship (or lack thereof) of altered responsiveness (decreased or increased) with the presence or absence of activating autoantibodies.
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              Structural characteristics of the aging skin: a review.

              Howard Maibach, Miranda A. Farage, Kenneth W. Miller … (2007)
              As life expectancy in industrialized countries increases, appropriate care of elderly skin looms as a dermatologic priority. Skin aging is a complex, multifactorial process whose baseline rate is genetically determined but that may be accelerated by environmental, mechanical, or socioeconomic factors. The intrinsic structural changes that occur with the aging of the skin increase skin fragility, decrease the ability of the skin to heal, increase risk for toxicological injuries, promote the development of various cutaneous disorders, and produce aesthetically undesirable effects like wrinkling and uneven pigmentation. As aged patients represent a larger segment of the population, increased attention to the problems of the aged skin, both cosmetic and beyond, will be necessary and should build on currently successful interventions to improve their quality of life.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Intern Med
                Journal ID (iso-abbrev): Korean J. Intern. Med
                Journal ID (publisher-id): KJIM
                Title: The Korean Journal of Internal Medicine
                Publisher: The Korean Association of Internal Medicine
                ISSN (Print): 1226-3303
                ISSN (Electronic): 2005-6648
                Publication date (Print): November 2014
                Publication date (Electronic): 31 October 2014
                Volume: 29
                Issue: 6
                Pages: 800-806
                Affiliations
                Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
                Author notes
                Correspondence to Hae-Sim Park, M.D. Department of Allergy and Clinical Immunology, Ajou University School of Medicine, 206 World cup-ro, Yeongtong-gu, Suwon 443-721, Korea. Tel: +82-31-219-5150, Fax: +82-31-219-5154, hspark@ 123456ajou.ac.kr
                Author information
                http://orcid.org/0000-0003-2614-0303
                Article
                DOI: 10.3904/kjim.2014.29.6.800
                PMC ID: 4219970
                SO-VID: c2548f1f-e33f-4d74-acbf-32d6789ab702
                Copyright © Copyright © 2014 The Korean Association of Internal Medicine
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 December 2013
                Date revision received : 26 June 2014
                Date accepted : 28 July 2014
                Funding
                Funded by: Ministry of Health and Welfare
                Award ID: HI14C006
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Internal medicine
                Keywords: chronic urticaria,aged,dermatitis, atopic,specific ige to staphylococcal superantigen
                Data availability:
                ScienceOpen disciplines: Internal medicine
                Keywords: chronic urticaria, aged, dermatitis, atopic, specific ige to staphylococcal superantigen

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