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This update and revision of the international guideline for urticaria was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GALEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), the European Dermatology Forum (EDF; EuroGuiDerm), and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology with the participation of 64 delegates of 50 national and international societies and from 31 countries. The consensus conference was held on 3 December 2020. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast-cell-driven disease that presents with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic urticaria, i.e. chronic spontaneous urticaria and chronic inducible urticaria, is disabling, impairs quality of life, and affects performance at work and school. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This article is protected by copyright. All rights reserved.

In this autobiographical case report, the physician-author-patient is documenting the remission of his own severe chronic spontaneous urticaria (CSU) in response to caloric restriction and subsequent weight loss. To my knowledge, this is the first reported case of CSU remission secondary to weight loss in the literature. CSU is a common debilitating pruritic skin condition that carries a significant economic and psychological burden. Currently, the mainstay of CSU treatment is symptom control, rather than seeking to achieve complete remission. Despite some recent retrospective studies reporting an association between obesity and CSU, there is a paucity of interventional research testing the impact of obesity management on CSU. The case reported herein highlights the need for research able to test the hypothesized association between obesity, particularly visceral obesity, and CSU.

Public health efforts over the past few months have been aimed at vaccinating young adults. Moderna and Pfizer COVID-19 vaccines are widely available options. Cutaneous reactions to these vaccines have been described as self-limiting and relatively immediate after vaccine administration. In this case report, we present a young adult who received the Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine and developed chronic, spontaneous urticaria.

Background: Up to 1% of the general population in the USA and Europe suffer from chronic urticaria (CU) at some point in their lifetime. CU has an adverse effect on the quality of life. Objectives: This study aims to provide an update on the epidemiology, pathogenesis, clinical manifestations, diagnosis, aggravating factors, complications, treatment and prognosis of CU. Methods: The search strategy included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term "chronic urticaria" at the following links: www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com. Results: CU is a clinical diagnosis, based on the episodic appearance of characteristic urticarial lesions that wax and wane rapidly, with or without angioedema, on most days of the week, for a period of six weeks or longer. Triggers such as medications, physical stimuli, and stress can be identified in 10 to 20% of cases. C-reactive protein/erythrocyte sedimentation rate, and complete blood cell count with differential are the screening tests that may be used to rule out an underlying disorder. The mainstay of therapy is reassurance, patient education, avoidance of known triggers, and pharmacotherapy. Secondgeneration H1 antihistamines are the drugs of choice for initial therapy because of their safety and efficacy profile. If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable, the dose of second-generation H1 antihistamines can be increased up to fourfold the manufacturer’s recommended dose (all be it off license). If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable after the fourfold increase in the dosage of second-generation H1 antihistamines, omalizumab should be added. If satisfactory improvement does not occur after 6 months or earlier if the symptoms are intolerable after omalizumab has been added, treatment with cyclosporine and second-generation H1 antihistamines is recommended. Short-term use of systemic corticosteroids may be considered for acute exacerbation of CU and in refractory cases. Recent patents for the management of chronic urticaria are also discussed. Complications of CU may include skin excoriations, adverse effect on quality of life, anxiety, depression, and considerable humanistic and economic impacts. On average, the duration of CU is around two to five years. Disease severity has an association with disease duration. Conclusion: CU is idiopathic in the majority of cases. On average, the duration of CU is around two to five years. Treatment is primarily symptomatic with second generation antihistamines being the first line. Omalizumab has been a remarkable advancement in the management of CU and improves the quality of life beyond symptom control.

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Chronic spontaneous urticaria is challenging to manage and substantially affects quality of life. This US, non-interventional qualitative study examined patients’ clinical journeys and emotional burden from symptom onset through disease management. Chronic spontaneous urticaria patients participated in interviews and completed diaries focusing on disease and treatment history/perspectives, impact on personal/family life, and relationships with physicians/other healthcare providers. Physicians were interviewed about their views on disease management and patient care. Twenty-five patients, previously or currently receiving chronic spontaneous urticaria treatment(s), and 12 physicians participated. Key stages following symptom onset were identified: Crisis (associated with feelings of torment/disorientation/shock); Searching for answers (puzzlement/frustration/anxiety); Diagnosis (relief/satisfaction/fear/isolation); and Disease management (frustration/hope/powerlessness). Findings revealed patients’ perceptions and experiences of chronic spontaneous urticaria, including living with a ‘skinemy’, experiencing their ‘own personal hell’ and feeling ‘like an experiment’. Awareness of unmet needs in patient care/management identified in this study may ultimately improve patient support and enhance physicians’ understanding of disease burden.

This guideline is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy 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) with the participation of delegates of 21 national and international societies. Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. the life-time prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria do not only cause a decrease in quality of life, but also affect performance at work and school and, as such, are members of the group of severe allergic diseases. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. in addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Charite, Allergy Ctr Charite, Dept Dermatol & Allergy, D-10117 Berlin, Germany Med Univ Graz, Dept Dermatol, Graz, Austria Clin San Carlo, Allergy Clin, Paderno Dugnano, MI, Italy Univ Southern Denmark, Odense Univ Hosp, Dept Dermatol & Allergy Ctr, Odense, Denmark Med Univ Silesia, Allergol & Clin Immunol Katowice, Dept Internal Dis, Zabrze, Poland Univ Genoa, IRCCS AOU SanMartino, Genoa, Italy Universidade Federal de São Paulo, Dept Clin Immunol & Allergy, São Paulo, Brazil Univ Autonoma Barcelona, Hosp Mar Parc Salut Mar, E-08193 Barcelona, Spain Dr DY Patil Med Coll & Hosp, Dept Dermatol, Navi Mumbai, India Fac Med, Dermatol Clin, Coimbra, Portugal Univ Hosp, Coimbra, Portugal Guys & St Thomas Hosp NHS Fdn Trust, St Johns Inst Dermatol, London, England Ctr Appl Res Allergy Quebec, Quebec City, PQ, Canada Hiroshima Univ, Inst Biomed & Hlth Sci, Dept Dermatol, Hiroshima, Japan Med Univ S Carolina, Dept Med, Div Pulm & Crit Care Med, Charleston, SC USA Hannover Med Sch, Dept Dermatol & Allergy, Hannover, Germany Pantai Hosp Kuala Lumpur, Dept Paediat, Kuala Lumpur, Malaysia Univ Hosp Tenon, Dept Dermatol & Allergy, Paris, France Johns Hopkins Asthma & Allergy Ctr, Baltimore, MD USA Ctr Medicodocente Trinidad, Allergy & Clin Immunol Dept, Caracas, Venezuela Univ Hosp, Dept Dermatol, Allergy Unit, Zurich, Switzerland Univ Manitoba, Dept Pediat & Child Hlth, Winnipeg, MB R3T 2N2, Canada Univ Manitoba, Dept Immunol, Winnipeg, MB, Canada Univ Med Ctr Mainz, Dept Dermatol, Mainz, Germany Univ Toronto, Div Allergy & Clin Immunol, Toronto, ON, Canada Technion, Fac Med, Bnai Zion Med Ctr, Haifa, Israel Univ Bari, Dept Biomed Sci & Human Oncol, Unit Dermatol & Venereol, Bari, Italy Peking Univ, Hosp 1, Dept Dermatol, Beijing 100871, Peoples R China Universidade Federal de São Paulo, Dept Clin Immunol & Allergy, São Paulo, Brazil Web of Science

Both spontaneous and inducible forms of chronic urticaria pose a significant economic burden and have an adverse effect on patients’ quality of life. The international guidelines and US practice parameters for the diagnosis and management of chronic urticaria both recommend performing a thorough patient history and physical examination, conducting limited routine laboratory testing, and taking a stepwise approach to treatment. These documents differ in several areas, such as the order of diagnostic procedures and the treatment for patients non-responsive to standard dose H1-antihistamines. Patients with chronic urticaria who visit a specialist have typically been treated with second-generation H1-antihistamines – the recommended first-line treatments. The advantages and disadvantages of each treatment option should be taken into consideration when selecting therapies beyond H1-antihistamines. Greater awareness of the international guidelines and US practice parameters will likely improve the quality of care for patients with chronic urticaria.

Urticaria is a relatively common condition that if chronic can persist for weeks, months or years and affect quality of life significantly. The etiology is often difficult to determine, especially as it becomes chronic. Many cases of chronic urticaria are thought to be autoimmune, although there is no consensus that testing for autoimmunity alters the diagnostic or management strategies or outcomes. Many times, urticaria is easily managed with antihistamines and/or short courses of oral corticosteroids, but too often control is insufficient and additional therapies must be added. For years, immune modulating medications, such as cyclosporine and Mycophenolate Mofetil, have been used in cases refractory to antihistamines and oral corticosteroids, although the evidence supporting their efficacy and safety has been limited. Omalizumab was recently approved for the treatment of chronic urticaria unresponsive to H1-antagonists. This IgG anti-IgE monoclonal antibody has been well demonstrated to safely and effectively control chronic urticaria at least partially in approximately 2/3 of cases. However, the mechanism of action and duration of treatment for omalizumab is still unclear. It is hoped that as the pathobiology of chronic urticaria becomes better defined, future therapies that target specific mechanistic pathways will be developed that continue to improve the management of these often challenging patients.

GA2LEN EAACI This methods report describes the process of guideline development in detail. It is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy 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) with the participation of delegates of 21 national and international societies. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. in addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS) and is published in Allergy 2014; 69:868-887. Charite, Allergy Ctr Charite, Dept Dermatol & Allergy, Berlin, Germany Med Univ Graz, Dept Dermatol, Graz, Austria Clin San Carlo, Allergy Clin, Paderno Dugnano, Italy Odense Univ Hosp, Dept Dermatol, DK-5000 Odense, Denmark Odense Univ Hosp, Allergy Ctr, DK-5000 Odense, Denmark Univ Southern Denmark, Odense, Denmark Med Univ Silesia, Allergol & Clin Immunol Katowice, Dept Internal Dis, Katowice, Poland Univ Genoa, IRCCS AOU SanMartino, Genoa, Italy Universidade Federal de São Paulo, São Paulo, Brazil Univ Autonoma Barcelona, Hosp Mar Parc Salut Mar, E-08193 Barcelona, Spain Dr DY Patil Med Coll & Hosp, Dept Dermatol, Navi Mumbai, India Fac Med, Dermatol Clin, Coimbra, Portugal Univ Hosp, Coimbra, Portugal Guys & St Thomas Hosp NHS Fdn Trust, St Johns Inst Dermatol, London, England Ctr Appl Res Allergy Quebec, Quebec City, PQ, Canada Hiroshima Univ, Dept Dermatol, Inst Biomed & Hlth Sci, Hiroshima, Japan Med Univ S Carolina, Dept Med, Div Pulm & Crit Care Med, Charleston, SC 29425 USA Hannover Med Sch, Dept Dermatol & Allergy, Hannover, Germany Pantai Hosp Kuala Lumpur, Dept Paediat, Bangsar, Malaysia Univ Hosp Tenon, Dept Dermatol & Allergy, Paris, France Johns Hopkins Asthma & Allergy Ctr, Baltimore, MD USA Ctr Medicodocente Trinidad, Allergy & Clin Immunol Dept, Caracas, Venezuela Univ Hosp, Dept Dermatol, Allergy Unit, Zurich, Switzerland Univ Manitoba, Dept Pediat & Child Hlth, Winnipeg, MB R3T 2N2, Canada Univ Manitoba, Dept Immunol, Winnipeg, MB, Canada Univ Med Ctr Mainz, Dept Dermatol, Mainz, Germany Univ Toronto, Div Allergy & Clin Immunol, Toronto, ON, Canada Technion, Bnai Zion Med Ctr, Fac Med, Haifa, Israel Univ Bari, Dept Biomed Sci & Human Oncol, Unit Dermatol & Venereol, Bari, Italy Universidade Federal de São Paulo, EPM, São Paulo, Brazil Web of Science

Vitamin D plays an important role in the immune system; decreased serum vitamin D concentrations have been linked to dysregulated immune function. Low vitamin D status is probably associated with chronic spontaneous urticaria (CSU). We evaluated the prevalence of low vitamin D status, and the clinical response and quality of life following vitamin D supplementation, in a prospective case-control study with 60 CSU patients and 40 healthy individuals. Serum 25-hydroxy vitamin D (25(OH)D) concentrations were measured at baseline and after 6 weeks. For patients with 25(OH)D concentrations < 30 ng/ml, treatment included 20,000 IU/day of ergocalciferol (vitamin D2) and non-sedative antihistamine drugs for 6 weeks. Urticaria symptom severity and quality of life were assessed based on the Urticaria Activity Score over 7 days (UAS7) and the Dermatology Life Quality Index (DLQI). Of the 100 participants, 73% were female; the mean age was 39 ± 16 years. Vitamin D deficiency (measured as 25(OH)D < 20 ng/ml) was significantly higher in the CSU group than the control group. The median 25(OH)D concentration for the CSU group, 15 (7 - 52) ng/ml was significantly lower than for control group, 30 (25 - 46) ng/ml. Overall, 83% (50/60) of CSU patients (25(OH)D < 30 ng/ml) were treated with ergocalciferol (vitamin D2) supplementation; after 6 weeks, these patients showed significant improvements in UAS7 and DLQI scores compared with the non-vitamin D supplement group. This study revealed a significant association of lower serum 25(OH)D concentrations with CSU. Vitamin D supplements might improve symptoms and quality of life in CSU patients.

Objective. 7 cases of AHA syndrome (arthralgia, arthritis, hives, angioneuroticedema) in children described. Literature and own data are presented. Possible pathogenetic mechanisms, clinical symptoms and treatment are discussed.

Este trabalho objetivou detectar presença de esporos de Paenibacillus larvae subsp. larvae em produtos de um entreposto do interior do Estado do Rio Grande do Sul, a identificação de possíveis fontes de contaminação e a avaliação da possibilidade da transferência de esporos para colméias de apiários adjacentes a partir de produtos importados contaminados. Foram analisados mel e pólen importados disponíveis no entreposto, favo do ninho (crias, pólen e mel) colhido de uma colméia sadia, mel estocado em um dos apiários e abelhas adultas. Os resultados foram positivos em relação ao mel e pólen importados, a três grupos de abelhas adultas e ao mel do favo. The objective of this work was to detect the presence of Paenibacillus larvae subsp. larvae spores in products from a warehouse located in Rio Grande do Sul State, Brazil, the identification of possible contamination sources, and the assessment of spores transference possibility from contaminated imported products from the warehouse to apiaries located in the surrounding area. Samples of imported pollen and bulk honey stocked in the warehouse, and honeycomb (brood, honey and pollen) from a healthy hive, honey from one apiary and adult bees were analyzed. Imported honey and pollen, and three groups of adult bees and the honey collected from the honeycomb resulted positive.

Urticaria occurs commonly in children and young adults. In general, a younger and atopic population is usually involved and the lesions are acute, usually less than 6 weeks in duration and it is relatively easy to show a cause and effect, usually by history. The cause of chronic urticaria, which is defined as urticaria lasting longer than 6 weeks, is much more difficult to identify and 80–95% of patients are classified as idiopathic. Many of the patients react with a wheal and flare to their own serum or plasma indicating that they have a histamine-releasing agent in their own serum. Most of these subjects will have urticaria which clears with time but a small minority continue to have urticaria for the rest of their lives. Treatment for patients having known causes is to avoid the triggers and all patients with chronic urticaria need to be treated with H1 antihistamines. Sometimes an H2 antihistamine is added or a tricyclic 'tranquilizer' which has anti H1 and H2 blocking action needs to be used. Those patients who do not respond may need treatment with prednisone which should be reduced to the smallest dosage and discontinued as soon as possible. Patients with hereditary angioedema respond to danazol, stanozol or epislan-aminocaproic acid or tranexamic acid.