Older patients with chronic urticaria present with unique characteristics
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Key takeaways:
- 13.8% of older patients with chronic spontaneous urticaria also had malignancy.
- Specialist evaluation reduced risk for rescue treatment with systemic corticosteroids by 86%.
Older patients with chronic urticaria have characteristics that are unique compared with younger patients, such as high rates of autoimmunity and malignancy, according to a study.
However, improved awareness of chronic urticaria among these patients with prompt referrals to specialists may improve outcomes, Rasha Khaliliya, MD, allergy and clinical immunology unit, Meir Medical Center, and colleagues wrote in The Journal of Allergy and Clinical Immunology: In Practice.
The retrospective study involved 166 patients (72% women; mean age at presentation, 72 ± 5.9 years) aged 65 years and older with chronic spontaneous urticaria (CSU) as well as 15 patients with chronic inducible urticaria (CIndU).
The CSU group included 38 (22.9%) patients with an autoimmune disease — primarily hypothyroidism (n = 28; 74%) — as well as 23 (13.8%) with malignancy, including 17 (74%) with active disease, 18 (78%) with solid tumors, three with chronic lymphocytic leukemia and two with other hematologic malignancies.
Also, 19 (11.5%) patients in the CSU group reported atopic diseases, including 10 (53%) with asthma, seven (37%) with allergic rhinitis, and one (5%) with food allergy and atopic dermatitis.
The duration of CSU before an allergologist diagnosed and evaluated it was 22.8 ± 53 months (median, 6 months; range, 1.5-360 months), with 103 (62%) of patients presenting with urticaria as their sole complaint, 45 (27%) presenting with urticaria and angioedema and 18 (11%) presenting only with angioedema.
The researchers also analyzed basic lab results for 163 (98%) of the patients with CSU. Five (3.4%) of the patients had eosinophilia. Also, 49 (31%) had IgE testing, with 24 (46.6%) registering abnormally high values, the researchers said.
Testing included thyroid-stimulating hormone (TSH) for 154 (93%) of the patients with CSU, including 19 (12%) with high levels and one patient with low levels. Two of these patients (10.5%) had low T4 as well.
Additionally, the researchers found evidence of anti-thyroid peroxidase antibodies in five of 32 patients with CSU (15.6%) and antithyroglobulin antibodies in five of 30 patients (16.6%).
Among the 87 (52%) patients with CSU with antinuclear antibody results, eight (9%) had values of 1:160 or greater, which the researchers characterized as high. Also, 26 of 79 patients with CSU (33%) who were tested had increased C-reactive protein.
Before they were evaluated, 117 (70%) of the patients with CSU used antihistamines as needed, including 22 (13%) who used regular low doses and 14 (8.4%) using a medium or high dose, the researchers said. Thirteen (9%) patients did not use any antihistamines.
Also, 67 (40%) of the patients with CSU had used systemic corticosteroids at least once, including 11 (16%) who received them regularly and 56 (83.5%) who were on intermittent courses. These courses averaged 1.8 ± 1.05 per patient in the 6 months prior to evaluation.
Pre-evaluation treatment also included montelukast for two patients, cyclosporine for one patient and omalizumab (Xolair; Genentech, Novartis) for one patient.
Once patients saw an allergy specialist, the researchers said, there was an increase in regular antihistamine use and a decrease in as-needed antihistamine and corticosteroid use.
Specifically, 80 (48%) patients with CSU received as-needed antihistamines, with 49 (30%) receiving low doses, 26 (16%) receiving medium doses and 25 (15%) receiving high doses.
Also, 18 (11%) received montelukast, 12 (7%) received omalizumab and eight (5%) received intermittent systemic steroids.
None of the patients received regular systemic corticosteroids once they saw the specialist. In fact, the researchers said, the risk for rescue treatment with systemic corticosteroids fell by 86% (OR = 0.145; 95% CI, 0.079-0.268) after specialist evaluation.
Similarly, after evaluation, risk for hospitalizations fell by 90% (OR = 0.094; 95% CI, 0.012-0.748) and risk for ED visits fell by 86% (OR = 0.08; 95% CI, 0.079-0.347). There was a tendency toward fewer primary physician visits as well (P < .001). The researchers said that allergologist consultation had a moderate to strong effect on reductions in visits to the primary physician.
Patients with CIndU generally had many of the same characteristics as the patients with CSU, the researchers said. However, the researchers said the patients with CIndU had a tendency toward a longer interval between disease duration and diagnosis (32.4 vs. 22.8 months).
Also, the patients with CIndU had less abnormal IgE levels (22% vs. 46.6%) and abnormal TSH levels (100% vs. 12%).
Eleven of the patients with CIndU (73%) received as-needed antihistamine before and after evaluation, whereas one patient with CIndU needed steroid treatment before evaluation but not afterward.
Overall, the researchers noted that diagnosis of chronic urticaria generally is delayed among patients in this age group, whose comorbidities differ from other age groups but who also experience a significant beneficial effect from specialist intervention.
Late referrals to specialists indicate that there may be a lack of awareness of chronic urticaria among older patients, the researchers continued, with direct undesirable consequences. Providers should consider malignancies in diagnosing chronic urticaria due to their high prevalence among this population as well.
However, the researchers said, further research is necessary to better differentiate the causes of chronic urticaria and how it best would be treated in older patients.
Perspective
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Chronic urticaria is one of the most common diagnoses addressed by both dermatologists and allergists, yet the specific features of this condition in older adults were largely unknown prior to this study.
Of particular clinical significance, unique associated conditions were seen in this age group, including rates of active cancer that were higher than would be expected in the elderly population in general. This creates a call to action for physicians who diagnose chronic urticaria in older adults to ensure that their patients are obtaining recommended cancer screenings. It also leads to intriguing hypotheses regarding what causes chronic urticaria, including the possibility that it is related to an altered immune system in the setting of cancer for some patients.
As a dermatologist, I often am diagnosing patients with chronic urticaria and starting regular antihistamine use. But then that raises the big question of what other conditions to worry about, if any. In my practice, I sometimes refer these patients to my allergy colleagues for further workup.
Since the authors of this study examined treatments before and after allergy specialist evaluation, they were able to learn that specialist care leads to increased use of regular antihistamines and decreased use of corticosteroids. It is reassuring to see that the treatments used by allergists largely align with those used by dermatologists, as both types of specialists will frequently see patients with chronic urticaria in practice.
I rarely see older adults with chronic urticaria who also have atopy, but I sometimes do see that these patients have a history of malignancy. Thus, my experience reflects that of the authors, but I am pleased to see these associations more formally studied.
Future work assessing the differences between CSU and CIndU in older adults will provide additional guidance on what workup should be done for an individual patient. Studies like this are extremely useful to physicians as they diagnose patients with certain conditions and then need to think about what to look for next to ensure that their patients get comprehensive care.
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