SEVERE CHRONIC URTICARIA TREATED WITH ORAL MINI-PULSE STEROID THERAPY

Sir,

Urticarial patients are treated with oral antihistamines and 50% respond well to this treatment[1] ; however, 50% do not respond to antihistamines and require a more aggressive approach, such as short or prolonged courses of oral corticosteroids[2] or cyclosporine.[3]

Approximately, 40–50% of patients with no apparent cause for their urticaria are believed to have an associated autoimmune profile that may play a pathogenetic role.

We report a small study of 10 patients treated with oral mini-pulse (OMP) therapy for severe chronic urticaria. We conducted a study to find the efficacy of OMP therapy with methylprednisolone and oral levocetirizine in the treatment of severe chronic urticaria. Ten patients (seven females and three males) in the age group of 20-60 years (Table 1 and mean age = 34 years) with severe chronic urticaria were enrolled in the study after an informed written consent. All 10 patients had severe chronic idiopathic urticaria of duration ranging from 3 months to 2 years (mean duration = 14.8 months) which was not controlled with more than one antihistamine. Fexofenadine, cetirizine, and hydroxyzine were tried in combination with minimal improvement. Urticarial vasculitis was excluded by clinical examination, and urticarial lesions disappeared in 24 hours. Exclusion criteria were physical urticaria, urticarial vasculitis, pregnant or lactating women, gastritis, a history of sensitivity to aspirin or NSAIDs, and a history of aggravation of symptoms by pressure. Routine investigations such as complete blood count, blood sugar, thyroid-stimulating hormone (TSH), and urine examination were performed to rule out infections. Autologous serum skin test could not be performed as antihistamines could not be stopped even for a single day in three patients. In remaining seven patients, Autologous Serum Skin Test (ASST) was performed which was positive in five patients (four females and one male). The test was performed by injecting 0.05 mL of the patient's own serum intradermally into the left flexor forearm 2 inch below the antecubital crease and a saline control two inches away from test site on the left forearm. A reading of the wheal was taken after 30 min. A wheal and flare of more than 1.5 mm diameter than that of the control was considered positive. Investigations revealed one patient with diabetes and two patients out of eight had raised TSH levels. Physician's opinion was taken for appropriate treatment with thyroid and metformin. Investigations such as IgE, cold agglutinin were not done due to high cost in a private clinic setup.

Table 1.

Age and sex distribution

Corticosteroids can be considered in chronic urticaria where antihistamines in high doses failed to show desired result. There are no large-scale, double-blind, placebo-controlled trials of long-term use of corticosteroids in chronic urticaria.[2] Pasricha and Khaitan et al. have devised a new therapeutic regime called OMP therapy for reducing the side effects of corticosteroids. The OMP regime had been primarily designed for treating patients having fast spreading/extensive vitiligo to achieve the therapeutic results with the minimum of side effects.[4] Similar therapy is used for treatment of lichen planus and alopecia totalis.[5,6]

We started treatment with methylprednisolone 16 mg tablet twice a week on Saturday and Sunday after breakfast for 2 months along with levocetirizine 5 mg tablet daily.

All patients were reviewed at 0, 2, 4, and 8 weeks with urticaria activity score. The urticaria activity score consisted of the sum of the wheal number score and the itch severity score.[7] The wheal numbers are graded from 0 to 3 as follows: 0, <10 small wheals (diameter, <3 cm); 1, 10-50 small wheals or <10 large wheals (diameter, >3 cm); 2, greater than 50 small wheals or 10-50 large wheals; and 3, almost the whole body is covered. The severity of the itching is graded from 0 to 3 (0, none; 1, mild; 2, moderate; and 3, severe). The blood pressure and weight were recorded initially and monitored every month. Patients were examined for side effects such as weight gain, hypertension, gastritis, acneiform eruption, striae, and Cushingoid features.

Out of 10 patients, two patients were lost to follow up. Mean urticaria activity score of urticaria in patients treated with mini-pulse was 4.35 at baseline. At the end of 4 weeks, mean scores (01.35) had a significant change compared to baseline. At the end of 8 weeks, mean urticaria activity score came down to 0.50.

Side effects as the result of treatment were seen in one patient in the form of weight gain and epigastric pain. One patient had worsening of symptoms after stopping steroids. Rest of six patients (five females and one male) was well controlled with levocetirizine and mini-pulse therapy. Effect was maintained for 1 month after stopping steroids, and levocetirizine was continued for control of urticaria. Drawbacks of this study were very small number of patients and short duration of study.

Other options in treatment of severe urticaria are methotrexate, cyclosporine, or omalizumab. All these therapies are expensive or with side effects. Corticosteroids in mini-pulse therapy can be used in Indian patients as a convenient approach in treatment of chronic urticaria.