Prevelance and diagnostics of Urticaria and its therapeutic considerations
Urticaria is a heterogeneous skin disorder, which is characterized by the development of wheels on the skin followed by Angioedema. This can appear in any part of the body. Symptoms of the Urticaria are:
- raised skin,
- itchy bumps,
- blanching (when pressed the centre of red hive turns white).
Furthermore, scratching, exercise, emotional stress may worsen it.
The main cause of Urticaria are:
- blood transfusion,
- viral infection,
- some foods such as peanuts,
- nuts (Powell, Leech, Till, & Huber, 2015).
The three major categories of Urticaria are:
- Spontaneous occurrence of wheels (cause acute and chronic Urticarial).
- Wheels and angioedema elicited by physical Urticaria.
- Exercise-induced Urticaria.
Prevalence of Urticaria
Urticaria occurs frequently with a lifetime prevalence of around 20%. The global prevalence for the disease is around 8.8%. In terms of gender, it is found to be more prevalent among females in comparison to males (Zuberbier, Balke, Worm, Edenharter, & Maurer, 2010). Furthermore, in terms of age, 20-30 years old are more affected by the disease with affecting percentage reduced to 5% in 30 years and above.
In terms of case countries, this disease affects 15% of the US population. Food is the most common cause of the disease (Allergies: NWHIC, 2017). Furthermore, 64% of the patients were found to be suffering from the disease due to house dust mite (Mahesh, Kushalappa, Holla, & Vedanthan, 2005). It is also reported that in nearly 1/4th of the population, the exact reason for the allergy remains unknown.
Much as the US, Australia also reflects 15% prevalence, wherein peanut allergy is a common cause for the disease. A recent study reveals that; an increase in hospital admission in Australia is 5.7% per year between 5-34 years of age (Sánchez-Borges et al., 2012a). It is most noteworthy that, this rate of hospitalisation is an alarming indication.
Most of all in the UK, the percentage is even higher with 30-40% of the population suffering (Vonakis et al., 2007). As compared to the UK, the percentage is even higher in Japan with 200 out of 260 (76.9%) patients were suffering from Idiopathic Urticaria. Also out sample population of 260, 38.8 % of the patients showed more than one type of Urticaria (Tanaka, 2006). In Africa, it affects about 35% of the entire population. The most common cause of the Urticaria was less hygiene among the population.
Furthermore, 20-30% of the Indian population is suffering from this disease. The common causes found for the disease include:
- food (35%),
- bacterial infection (10%),
- drug-induced (6%) and
- insect bite (3%).
However, the most common cause was found to be a worm infection (Kataria & Chhillar, 2015).
Diagnosis of Urticaria
Except for acute Urticaria (defined by the maximum duration of 6 weeks), the diagnosis of Urticaria is difficult with common tests. Much as other forms of allergies, skin prick test and the blood test is performed to detect the antibodies in the bloodstream for Urticaria. The diagnosis can be done by the examination of size, shape, distribution, an appearance of rashes. In addition, family and personal history of the patient and the effect of the food and the stress (Sánchez-Borges et al., 2012b) are also used for detection.
In USA and Australia, Autologous Skin Serum Test (ASST) method is commonly used for the diagnosis of Urticaria (Schoepke, Doumoulakis, & Maurer, 2013). Furthermore:
- Patch testing,
- skin biopsy,
- elicit dermatographism,
- cold provocation testing,
- pressure testing,
- UV lighting,
- dietary testing and
- thyroid autoantibodies
are among other tests to detect complex forms of Urticarial. Most of all these tests are used in special cases when the autoimmune mechanism is suspected (Zuberbier et al., 2009). While in the UK, a basophile test is offered. This is the only available test to screen autoimmune antibodies against the IgE receptor in the serum skin test (Grattan et al., 2007).
Management of Urticaria is mainly focused on treating the symptoms and not related to the causes of the disease. The primary treatment of Urticaria is to avoid the trigger substance that causes the disease. Recommended treatment algorithm for Urticaria is a three-step process wherein;
- While the first line of treatment involves modern second-generation anti-histamines rather general anti-histamines are preferred. This is because they show an adverse effect in the Central nervous system leading to hypnotics, sedatives and mood-elevations (Khan et al., 2013).
- Furthermore, if the symptoms persist for 2 weeks then the second line of treatment is initiated wherein the dosage is increased and Montelukast is further added to the treatment.
- If the symptoms persist for 1-4 weeks then along with the second line of treatment Montelukast, Omalizumab or Cyclosporin A is also included. Among these, Omalizumab is the most promising therapeutic drug which costs USD 10000 in India.
Also, the short course of corticosteroids is conducted for the treatment of exacerbations (Zuberbier et al., n.d.). In non-pharmacological responses methanol or calamine lotion or cream, crotamiton lotion is used to treat the symptoms. Furthermore, phototherapy with ultraviolet light is used in case of Chronic urticaria. 60% of the people respond well for anti-histamines but remaining 40% do not (Mahesh et al., 2005).
Need for further research for more severe forms
Urticaria is a complex and frequently occurring disease affecting 20% of the global population. Although diagnostic procedures for acute urticarial are present, there is a lack of procedures for chronic and severe forms of the disease. Avoidance of factors which causes or which stimulate the allergens is recommended with anti-histamines as a licensed treatment procedure. If left untreated, the disease can adversely affect the quality of life, leading to lost productivity which grossly outweighs the treatment cost.
- Allergies: NWHIC. (2017). America. Retrieved from http://www.rightdiagnosis.com/artic/allergies_nwhic.htm.
- DeLong, L. K., Culler, S. D., Saini, S. S., Beck, L. A., & Chen, S. C. (2008). Annual Direct and Indirect Health Care Costs of Chronic Idiopathic Urticaria. Archives of Dermatology, 144(1), 35–9. https://doi.org/10.1001/archdermatol.2007.5.
- Grattan, C. E. H., Humphreys, F., Bell, H., Mitchell, D., Bull, R., Tidman, M., … Wagle, S. (2007). Guidelines for evaluation and management of urticaria in adults and children on behalf of the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. London. https://doi.org/10.1111/j.1365-2133.2007.08283.x.
- Mahesh, P. A., Kushalappa, P. A., Holla, A. D., & Vedanthan, P. K. (2005). House dust mite sensitivity is a factor in chronic utricaria. Indian J Dermatol Venereol Leprol, 71(2), 1–3. Retrieved from https://tspace.library.utoronto.ca/bitstream/1807/5484/1/dv05031.pdf.
- Overview of Chronic Urticaria. (2016). National Medicines Information Centre, 22(2), 2–6. Retrieved from
- Powell, R. J., Leech, S. C., Till, S., & Huber, P. A. J. (2015). BSACI guideline for the management of chronic urticaria and angioedema. Clinical and Experimental Allergy, 45, 547–565.
- Sánchez-Borges, M., Asero, R., Ansotegui, I. J., Baiardini, I., Bernstein, J. A., Canonica, G. W., … WAO Scientific and Clinical Issues Council, the W. S. and C. I. (2012a). Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. The World Allergy Organization Journal, 5(11), 125–47. https://doi.org/10.1097/WOX.0b013e3182758d6c.
- Sánchez-Borges, M., Asero, R., Ansotegui, I. J., Baiardini, I., Bernstein, J. A., Canonica, G. W., … WAO Scientific and Clinical Issues Council, the W. S. and C. I. (2012b). Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. The World Allergy Organization Journal, 5(11), 125–47. https://doi.org/10.1097/WOX.0b013e3182758d6c.
- Schoepke, N., Doumoulakis, G., & Maurer, M. (2013). Diagnosis of urticaria. Indian Journal of Dermatology, 58(3), 211–8. https://doi.org/10.4103/0019-5154.110831.
- Zuberbier, T., Asero, R., Bindslev-Jensen, C., Canonica, G. W., Church, M. K., Gimønez-Arnau, A. M., … Schünemann, H. (n.d.). EAACI/GA 2 LEN/EDF/WAO guideline: management of urticaria. https://doi.org/10.1111/j.1398-9995.2009.02178.x.
- Zuberbier, T., Balke, M., Worm, M., Edenharter, G., & Maurer, M. (2010). Epidemiology of urticaria: a representative cross-sectional population survey. Clinical and Experimental Dermatology, 35(8), 869–873. https://doi.org/10.1111/j.1365-2230.2010.03840.