To the Editor,
Acute urticaria (AU) in children is a common pathology for primary care
physicians1,2,3. However, there are difficulties in
diagnosis, indications for hospitalization, amount and composition of
emergency therapy. Moreover, there are lack of published data on the
duration, the severity, co-existed angioedema, response to treatment,
rate of becoming chronic and how they link to the different causes in
childhood AU. Analysis of existing guidelines4,5,6,
lack of National consensus on AU, arouse interest in the awareness of
pediatricians on the issues of
diagnosis and rational treatment approaches.
We therefore performed a retrospective analysis on 74 children treated
in the pediatric wards of the Ternopil City Children’s Hospital with a
diagnosis of AU in 2018-2020. Boys predominated in 58.1% among patients
(43 of 74). The age structure of the surveyed was represented by: 32
children (43.2%) of the first three years of life and of them 15 (46.
9%) of the first year; 14 (18.9%) preschoolers, 28 (37.9 %)
schoolchildren.
Attention was drawn to the concern of parents who in the first hours
after the appearance of urticaria in a child sought emergency medical
team (48.7%) or immediately attended to the emergency department
(17.6%) and all of them were hospitalized; while other 33.7% who had
acute respiratory infections and urticaria were referred for
hospitalization by family doctors on 2-3rd days (table 1). Among all
examined there were two groups of patients: 40 (54%) had skin symptoms
(urticaria, angioedema, itching, redness) without obvious cause and 34
(46%) initially developed acute respiratory viral infection, followed
by urticaria. It is noteworthy that with the typical symptoms of
urticaria, the diagnoses varied as: urticaria (42.3%), allergic
reaction (34.6%), atopic dermatitis (1.9%), food allergy (1.9%), bee
/ wasp stings (3.8%), acute respiratory viral infection along with
urticarial (13.5%).
In the vast majority of cases (66.2%), the urticarial rash appeared for
the first time in life. 31.1% of patients had a history of allergy,
mostly to food, insect, medications. Among triggers of AU certain foods
was found in 12.2%, insect in 8.1%, non-steroidal anti-inflammatory
drugs or antibiotics in 12.2%; while in 21.6% AU was idiopathic.
Our findings support the results of other scientific studies, that point
to the special role of infections in childhood
AU2,7,8, particularly herpes viruses, cytomegalovirus,
Epstein-Barr, enterovirus, hepatitis B, C.
It is disputable whether hospitalization in children with acute
urticaria was justified? Under these circumstances, the severity of
children’s urticaria and associated anxiety of parents should be
considered. The localization of urticarial rash in all observed children
was mostly common throughout the body and in only 13.5% of cases was
limited to face or scalp. In only one in four children urticaria was
accompanied by angioedema, and of them in a third (31.6%) was localized
on eyelids, lips, face. One child had throat angioedema, affecting
breathing. In terms of age, angioedema was more common in schoolchildren
(42.1%) and children in the first two years of life (36.8%). Analyses
of symptoms duration (table 1) showed that during the first or second
day, urticaria disappeared in 56.8% and angioedema in 68.4% of
children. This fact needs to be clearly defined in the indications for
hospitalization of children with AU. That will reduce the frequency of
unreasonable use of hospital resources.
The emergency treatment was provided to 36 patients.. Of them
corticosteroids were given to 29 (80.6%) (dexamethasone - 75.9%,
prednisolone - 20.7%), as a first line of treatment. Additionally, 11
patients (37.9%) were administered the first-generation antihistamines.
Of 34 children with acute
respiratory infections and urticaria 67.6% were given first generation
antihistamines, 56.8% - corticosteroids, 37.8% - second generation
antihistamines.
The dynamics traced the duration of skin rashes at 2.9 ± 2.3 days, while
angioedema additionally lasted 1.7 ± 1.4 more days. In 5 patients
(6.8%) there was a complete regression of symptoms after using only
standard dose of oral first-generation antihistamines. Meanwhile 21
children (28.4%) experienced recurrent episodes of rash with no effect
from oral antihistamines. Of them 16 (76.2%) underwent additionally
corticosteroids, 12 (57.1%) second-generation antihistamines and 4
(19.1%) first-generation antihistamines im/iv.
The main strengths of our study include the data on the duration of
urticaria and angioedema symptoms, the severity of symptoms, influence
of co-existed angioedema and response to treatment in children with
AU. Our findings showed a high
frequency of hospitalization in children with acute urticaria and
treatment of parents for help in emergency department.
Given that there are differences in the management of AU with existing
guidelines4,5,6, we think that some emphasis should be
made. The clinical implementation raised the fact that is crucial to
indicate the symptoms for hospitalization in children with AU, involving
other organ systems beyond the skin, such as the pulmonary (wheezing,
stridor), cardiovascular (tachycardia, hypotension, collapse),
gastrointestinal (diarrhoea, vomiting, abdominal pain) or nervous system
(dizziness, loss of consciousness).
The importance of adequate management and treatment of AU should be
noted. In accordance with the existing experience in the world, the
advantages in the first line treatment are given to second-generation
antihistamines; in the absence of effect, the dose should be doubled. At
the same time, there are caveats to their use in pediatrics: most are
allowed in children older than two years; however, individual molecules
are allowed from six months (levocetirizine) or from one year of age
under medical supervision (cetirizine)9,10; in the USA
cetirizine licensed for children aged over 6 months11.
Additionally, there are still limited and conflicting data for some
antihistamine agents regarding increasing dose in children. In severe
cases, corticosteroids such as prednisolone (0.5 to 1 mg per kg per day)
may be added for three to 10 days to control symptoms.
It is important to monitor for
subsequent recurrence of urticaria, as almost third of our patients had
recurrent rashes, with no effect from the first line of treatment. They
may be in a risk group for developing chronic urticaria. However, it was
a limitation of our observation, especially taking in the account
current Covid-19 pandemic situation.
Our study confirms that the issues of diagnosis and rational management
and treatment of acute urticaria in children should be unified and
justified. Clearly identified
indications for hospitalization and adequate treatment are designed to
ensure principles of good clinical practice and reduce the cost of
treatment of patients with AU and hospital resources using.
Further multicentral studies are required to investigate the rate of AU
becoming chronic and how they link to the different causes in children
with AU as well as to determine prognostic factors of recurrent
urticaria in children.
N. Banadyha1, A. Nakonechna2
1- I. Horbachevsky Ternopil National Medical University, Ternopil,
Ukraine
2- University of Liverpool, Department of Allergy, Clinical Immunology
Royal Preston Hospital, Liverpool, United Kingdom
E-mails: natalia-fpo@tdmu.edu.ua;allanak1@yahoo.com
Conflict of interest: the authors declare that there is no conflict of
interest.
Key words: children; acute urticariа; treatment.
References
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M, Tomás-Pérez M, Vilà-Nadal G, et al. Acute urticaria in the
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Accessed Dec 2019.
Table 1 Symptoms presentation and their duration