Impact of chronic urticaria on the quality of life of patients followed up at a university hospital *

BACKGROUND Chronic urticaria is a debilitating disease that considerably affects health-related quality of life, and the Chronic Urticaria Quality of Life Questionnaire is the only questionnaire specifically designed for its evaluation. OBJECTIVE To evaluate the quality of life of patients with chronic urticaria, using the Brazilian Portuguese version of the Chronic Urticaria Quality of Life Questionnaire. METHODS The Chronic Urticaria Quality of Life Questionnaire was self-administered in 112 chronic urticaria patients and disease activity was assessed through the Urticaria Activity Score. Clinical and socio-demographic characteristics of patients were studied, such as: age, sex, etiologic diagnosis of chronic urticaria, duration of disease and Urticaria Activity Score. RESULTS The population studied was composed 85.72% of women with a mean age of 46 years (18-90), while the median disease duration period was 10 years (3 months-60 years). Regarding the etiologic diagnosis, 48.22% had chronic spontaneous urticaria; 22.32% associated with inducible urticaria, 28.57% with chronic autoimmune urticaria, and 23.21% had physical urticaria alone. Disease activity evaluated using the Urticaria Activity Score was 1.04 ± 1.61 (0-6). The total score for the Chronic Urticaria Quality of Life Questionnaire was 36 (0-100) and dimension I (sleep/mental status/eating) had a greater impact on quality of life. The items with the highest mean scores were nervousness and shame over lesions, while the items with the lowest scores were lip swelling and limitations on sporting activities. CONCLUSIONS Chronic urticaria compromises patients' quality of life, mainly those with more severe disease or who are diagnosed with chronic autoimmune urticaria.


INTRODUCTION
Chronic urticaria (CU) is a debilitating allergic skin disease, which affects 0.5 to 1% of the population and is characterized by erythematous, papulous and ichty lesions of a fluctuating nature that persist for over six weeks. 1 It is highly complex in relation to its etiology and treatment is challenging, even for experts.
Quality of life (QoL) has become an important subject for society and especially for health professionals. It can be defined as the individual satisfaction or happiness with life in domains that the subject considers important. Several factors may affect a subject's well-being, such as work, housing and financial concerns. Health is but one of these factors. The expression "health-related quality of life" (HRQoL) was thus developed to refer to the disease's impact on and therapy in a patient's life, according to his/her perception.
Hence, it is a subjective evaluation from the patient regarding the impact of health status on his/her full ability of living. 2 In recent decades, the incorporation of patients' perceptions into decision-making over the handling of diseases has been an essential factor in improving the QoL of health assistance models. The incapacity of traditional clinical parameters to express what people feel and think has led to increased interest in the HRQoL field from the scientific community. 3 CU interferes with subjective well-being and daily life; some patients` health status is comparable to that of coronary artery disease and severe asthma patients. It also causes inconvenience in family structures, compromising performance at work, school, and negatively impacting on leisure activities. 4,5 Skin pruritus causes variable discomfort, as well as lesions, which, depending on their number and location, may harm an individual's physical appearance and social life. 6 Sleep disorders such as insomnia, fatigue and drowsinessdue to pruritus or side effects from antihistamines -are frequently observed. Patients complain of recurrent pain syndromes, including tension headaches and fibromyalgia, while the prevalence of psychiatric disorders, like depression, hysteria, hypochondria and post-traumatic stress disorder is high. [7][8][9] The degree to which quality of life is affected varies according to the chronic urticaria's etiology and severity. When CU is asso- The questionnaire refers to the preceding two weeks, and the patients indicate the intensity of each item separately, on a 5-point Likert scale, ranging from 1 = "not at all" to 5 = "very much". A score is calculated for each dimension, then a total index is calculated for all the dimensions. The score ranges from 0 to 100.
The higher the score, the worse the patient's perception of his/her quality of life is.
Urticaria severity was evaluated using the score proposed by Zurberbier et al. (2001); and disease severity was assessed via the UAS -Urticaria Activity Score. The score evaluates the number of lesions and pruritus intensity. The sum of scores obtained by evaluating urticaria and pruritus ranges from 0 to 6, where 0 corresponds to controlled disease, while 6 corresponds to high intensity disease. 20 The following clinical and socio-demographic characteristics of the patients were studied, such as: age (18- This study and the respective informed consent form were approved by the Hospital Ethics Committee.

RESULTS
The  Table 3).
The items with the highest mean scores were 15 (nervousness), followed by 18 (shame over lesions) and 1 (pruritus). The lowest scores were item 4 (lip swelling) and 22 (limtations on sporting activity) ( Table 4).
Seventy-five percent of the patients were not doing sporting activities and only 16% indicated chronic urticaria as the reason for this.
Of the 28 patients who played sports, 42.8% mentioned that urticaria interfered a little, somewhat, or too much in sporting activity-related quality of life. Of the 13 patients who were not practicing sports due to urticaria, 69% reported that urticaria affected much or very much.
ANOVA analysis showed that patients aged 41-60 years were patients with autoimmune urticaria were more impacted in dimension III, compared with patients suffering from chronic spontaneous urticaria and inducible urticaria alone. Women were more affected in all dimensions but not in a statistically significant manner. Patients with higher severity scores (group 3) experienced a greater impact on quality of life in the total score, and in dimensions II and III (Table 5).   The mean time to disease progression was 10.6 years (3 months-60 years). In the Baiardini et al. study, the time was shorter, around 1 year and 9 months (SD: 27.32 months). 10 Gaig et al. found that 50% of CU patients were asymptomatic in three months, and 80% in 12 months. However, 11% were affected for over five years. 28 In most cases, chronic urticaria typically remits after 1-5 years, though 10-20% of cases may last 5-10 years and some can persist for up to 50 years. Patients with severe urticaria at diagnosis usually experience longer durations. In our population, 61% of patients presented the disease for over five years. The authors believe that the high frequency of long-lasting cases in these series is due to the institution being a reference center, which tends to recruit severe and refractory cases.
Regarding the etiology of chronic urticaria, just like in the medical literature, a higher prevalence of CSU (48.21%) was observed, followed by CAU (28.56%), and physical urticaria alone (23.21%). 1 Nevertheless, when all patients with inducible urticaria (alone and associated) were considered, a prevalence of 66.95% was found. In the Spanish study, patients experienced chronic spontaneous urticaria in 68% of cases, and physical urticaria in 60%. 11 About half of the study population did not have an etiologic diagnosis despite having undergone a complete research protocol with challenge tests for physical urticaria and an autologous serum test.
Affected patients with chronic spontaneous urticaria suffer deep frustration because of the uncertainty about the cause of their disease, which reduces their quality of life.

The first application of the Brazilian Portuguese version
of CU-Q2oL showed that it is a useful tool to evaluate the disease more specifically. The questions "embarrassed by signs" and "pruritus" also revealed a great impact on quality of life, as the first question assesses patients feelings and the second, the main and most troublesome symptom of this disease, which interferes with daily activities and mental health.
The question on "lip swelling" had the lowest score, like in the Spanish study. 11 Sporting activities were not regarded as rele-  31 In another Brazilian study published in 2011, the patients had a mean score of 13.5 in the DLQI (0-30), the presence of angioedema was associated with higher scores (14.3; p < 0.01); women were more limited with respect to clothing and men with respect to work and study (p < 0.05). 34 In these studies, the presence of angioedema and being female were associated with a worse quality of life. This study highlights a tendency toward a worse quality of life in women. The difference between patients with and without angioedema was not assessed. There is a need for further studies to define the predictive factors that affect quality of life in the Brazilian population.

CONCLUSION
Chronic urticaria seriously compromises the quality of life of patients due to its debilitating symptoms that can last for years.
In this study, a major impairment was observed in patients with the highest severity and in those diagnosed with autoimmune urticar- ia. An evaluation of quality of life is fundamental to better assess disease progression and treatment efficacy, as per recommended by the GA 2 LEN. In the future, the Brazilian Portuguese version of the CU-Q 2 oL may enable multicenter studies to be performed, in addition to promoting an overall understanding of the impact of chronic urticaria.q