Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology

Criado, Paulo Ricardo; Maruta, Celina Wakisaka; Alchorne, Alice de Oliveira de Avelar; Ramos, Andréa Machado Coelho; Gontijo, Bernardo; Santos, Josemir Belo dos; Martins, Luis Eduardo Agner Machado; Rivitti-Machado, Maria Cecília; Silvares, Maria Regina Cavariani; Pires, Mario Cezar; Souza, Patricia Karla de; Orfali, Raquel Leão; Bonamigo, Renan Rangel; Bedrikow, Roberta Buense; Criado, Roberta Fachini Jardim; Oliveira, Zilda Najjar Prado de

doi:10.1590/abd1806-4841.2019940209

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URTICARIA • An. Bras. Dermatol. 94 (2 Suppl 1) • Mar-Apr 2019 • https://doi.org/10.1590/abd1806-4841.2019940209 copy

Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology^* * Work conducted at the Sociedade Brasileira de Dermatologia, Rio de Janeiro (RJ), Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Background:

Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous.

Objectives:

To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US).

Methods:

A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults.

Results:

Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence).

Conclusions:

Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Keywords:
Cyclosporine; Dapsone; Histamine antagonists; Methotrexate; Omalizumab; Urticaria; Urticaria/etiology; Urticaria/therapy

SCORE^* * Sum of scores (hives + pruritus) = (0-6).	HIVES	PRURITUS
0	No hives	No symptom
1	Mild (< 20 hives/24 hours)	Mild
2	Moderate (21-50 hives/24 hours)	Moderate
3	Severe (>50 hives/24 hours or large confluent areas of hives)	Intense

			% total de respostas
N patients attended		n<50	94%
SCU/ month		n>50	6%
Follow treatment based on		International	63%
published guidelines?		United States	13%
		Others/combination^* * 8/16 of specialists use a combination of treatment protocols.	50%^* * 8/16 of specialists use a combination of treatment protocols.
Most requested laboratory tests		Blood count, ESR, CRP, free T4, TSH	>50%
		Stool Parasitologic Examination, thyroid autoantibodies, D-dimer,	<50%
		hepatitis serologies, ANA, complement, IgE, hepatic enzymes
Indicates histopathological examination		Yes	94%
if urticaria vasculitis is suspected?		No	6%
Treatment (public service)	1^st. option	non-sedating AH (2nd generation)	81%
		sedative AH (1st generation)	19%
	2^nd option	non-sedative AH (2nd generation) with dose increased 1-4x	81%
		sedative AH	13%
		Methotrexate	6%
Treatment (private practice)	1^st. option	non-sedating AH (2nd generation)	94%
		sedative AH (1st generation)	6%
	2^nd option	non-sedative AH (2nd generation) with dose increase 1-4x	81%
		sedative AH	13%
		Omalizumab	6%

Sociedade Brasileira de Dermatologia Av. Rio Branco, 39 18. and., 20090-003 Rio de Janeiro RJ, Tel./Fax: +55 21 2253-6747 - Rio de Janeiro - RJ - Brazil
E-mail: revista@sbd.org.br

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[1] Mailing address: Paulo Ricardo Criado. E-mail: prcriado@uol.com.br

1. How much have you suffered from the physical symptoms of urticaria (itching, hives, or swelling) in the last 4 weeks?	( ) very much ( ) much ( ) somewhat ( ) a little ( ) not at all

2. How much has your quality of life been adversely affected by urticaria in the last 4 weeks?	( ) very much ( ) much ( ) somewhat ( ) a little ( ) not at all

3. How often was the treatment for your urticaria insufficient to control symptoms in the last 4 weeks?	( ) very much ( ) much ( ) somewhat ( ) a little ( ) not at all

4. Overall, how well have you had your urticaria under control in the last 4 weeks?	( ) very much ( ) much ( ) somewhat ( ) a little ( ) not at all

Interpretation of UCT	The questionnaire has 5 possible answers for each question: very much (a score of 0), much (1), somewhat (2), a little (3), and not at all (4). The total UCT score in this short version of the four questions ranges from a minimum of 0 (totally uncontrolled disease), to a maximum of 16 (best possible control of urticaria).

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Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology* * Work conducted at the Sociedade Brasileira de Dermatologia, Rio de Janeiro (RJ), Brazil.

Abstract:

Background:

Objectives:

Methods:

Results:

Conclusions:

Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology^* * Work conducted at the Sociedade Brasileira de Dermatologia, Rio de Janeiro (RJ), Brazil.