Chronic urticaria -- “Agony of Hives” -- is the focus of World Allergy Week 2017 (2-8 April)

Understanding Chronic Urticaria Is the Focus of World Allergy Week 2017: World Allergy Organization says there is hope for the “Agony of Hives”.

From World Allergy Organization (WAO) press release (Milwaukee, WI. March 9, 2017):

WAO, together with its member societies around the world, will host World Allergy Week from April 2-8, 2017. The theme and educational focus will be: The Agony of Hives – What to do when hives and swelling will not go away.

Chronic urticaria is defined as episodic or daily hives lasting for at least six weeks and impairing quality of life. To date there is no cure for the disease and suffering can last several years. “Too many people with chronic urticaria give up hope when the symptoms don’t go away,” said Paul Greenberger, MD, of Northwestern University in Chicago. “But there is hope for controlling chronic urticaria with the aid of the allergist.”

During World Allergy Week 2017 experts will provide information to physicians and the general public about the importance of the role of the allergist in diagnosing and managing the disease. “There are multiple options available for treating chronic urticaria,” said Mario Sánchez Borges, MD, of Centro Médico Docente – La Trinidad, in Caracas, Venezuela, and President of the World Allergy Organization. “Allergists have the necessary expertise in the diagnosis and treatment of chronic urticaria including knowledge about medication options. They also are able to teach patients about the condition, which is important in improving quality of life.”

Up to 1.8% of the population currently has chronic urticaria. More research on the global prevalence of the disease is needed. World Allergy Week 2017 organizers plan to draw attention to this and other future needs regarding chronic urticaria.

“The World Allergy Organization has 97 member societies around the world and many of them will participate along with us in World Allergy Week 2017,” said Dr Sánchez Borges. “They will hold workshops for physicians, patient education events and other activities that will help to increase awareness of the disease itself and share information about how to get relief from symptoms that can often seem unbearable.”

Recently, a highly effective biologic therapy (anti-IgE therapy) has become available for chronic urticaria. Experts will discuss the disease and approaches to patient care during a webinar to be held on April 4.

For more information about World Allergy Week 2017 and chronic urticaria, visit: To find a member society of the World Allergy Organization in your country or region, visit:

Urticaria (hives): what is the cause? (click to enlarge the image).

Chronic Urticaria Treatment Options in 6 Steps (click to enlarge the image). En Español.

Laboratory Diagnosis of Chronic Urticaria (click to enlarge the image).

Anti-FceR1 autoantibodies in chronic autoimmune urticaria: IgG against FceRI (receptor for IgE) (click to enlarge the image).


Greenberger PA. Chronic urticaria: new management options. World Allergy Organ J. 2014; 7:31

Kocatürk E, Maurer M, Metz M, Grattan C. Looking forward to new targeted treatments for chronic spontaneous urticaria. Clin Transl Allergy 2017, 7:1.

Maurer M, Church MK, Goncalo M, Sussman G, Sanchez Borges M. Management and treatment of chronic urticaria. J Eur Acad Dermatol Venereol. 2015; 29(Suppl3): 16-32.

Maurer M, Rosén K, Hsieh HJ, Saini S, Grattan C et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013 Mar 7;368(10):924-35

Sanchez Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA et al. Diagnosis and treatment of urticaria and angioedema, a worldwide perspective. World Allergy Organ J. 2012; 5:125

Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z et al. The EAACI/GA²LEN/EDF/WAO Guideline for the definition, classification, diagnosis and management of Urticaria. The 2013 revision and update. Allergy 2014:69; 868-887

Image source: Urticaria, Wikipedia, public domain.

Should you stop steroid eye drops before a skin patch test for contact dermatitis?

No, is the simple answer.

Avoid using test sites to which topical glucocorticoids, antihistamines, immunosuppressants, or immunomodulators are applied. The use of topical steroids or immunosuppressants at or near potential test sites should be avoided from at least one week prior to patch testing through the conclusion of patch testing.

Oral steroids may cause false-negative results of patch testing.

The effect of concomitant systemic antihistamine administration on the performance of patch testing is
unknown. The current recommendation from AAAAI is not stop oral antihistamines.

Topical steroids, antihistamines and other immunosuppressants (e.g., tacrolimus) may be used on non-test areas, but should be avoided on potential patch test areas prior to and during testing.

Simple instructions: Preparing for the Test

- Your skin should be clear for 2 weeks before the test if possible.
- Avoid exposing your back to the sun for 1 week before the testing.
- Stop these medicines for 1 week before your appointment: topical steroids to the back

- Stop these medicines for 3-5 days before the test: Oral corticosteroids and Non-steroid anti-inflammatories (NSAIDs)

- Do not apply any ointments, creams or lotions to the back 4 hours before the appointment.

Contact Dermatitis - An Approach to Treatment (click to enlarge the image).


T.R.U.E. TEST Quick Reference Guide
Allergy Patch Skin Testing

AAAAI Tweetup! Meet the allergists who are updating Twitter with the latest allergy news from the #AAAAI17 meeting

Here is the list of the allergists who are planning to use Twitter to post updates from the #AAAAI17 meeting. The list is open for edit, please feel free to add your own info. It shows the availability of the allergists by date and if they are planning to attend the Tweetup (a meeting of people who use Twitter or are following the tweets). If interested in a real life meeting Tweetup during the #AAAAI17, sign up in the spreadsheet above. This will be the Sixth Annual Tweetup during AAAAI! We started in 2012.

Here is the Tweetup info - come meet us for a chat at:

#AAAAI17 Tweetup
Saturday, March 4, 2017: 2:30 PM-3:30 PM
Atlanta Marriott Marquis, Atrium Level, Room A702

This is a free, informal event, no ticket required. Suggested topics: how to tweet? why to tweet? who to follow? research projects using social media, Twitter for patient education, etc.

The Tweetup will be hosted by Dr. Matthew Bowdish @MatthewBowdish and Dr. Alexei Gonzalez @docalergias

The hashtag for the meeting is #AAAAI17

The hashtag for the 2017 annual meeting of the American Academy of Allergy, Asthma and Immunology (AAAAI) is #AAAAI17

Type #AAAAI17 in Twitter Search box to find all recent updates from  #AAAAI17

You can also find info about the #AAAAI6 hashtag on the website of Symplur:

How to use Twitter to post updates from #AAAAI17 meeting

See examples of best practice by @MatthewBowdish and @DrAnneEllis posted here: (tweets were summarized in a series of blog posts by me). For example, the tweets from 2012 AAAAI meeting reached more than 250,000 people.

I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Here is how to do it: Twitter for Physicians: How to use Twitter to keep track of the latest news and scientific meetings, and share information with colleagues and patients.

WAO TV Social Media Guide for Allergists

Here is WAO TV Social Media Guide for Allergists:

Dr Stukus: How to use Twitter to engage patients

Dr Bowdish: Best practices for Twitter use by allergists

Dr Bowdish: How to use Twitter during a scientific conference: AAAAI, ACAAI, etc.

Dr Ramirez: How allergists can use Facebook for patient education


The impact of social media on a major international emergency medicine conference -- Neill et al. -- Emergency Medicine Journal

PLOS ONE: Tweeting the Meeting: An In-Depth Analysis of Twitter Activity at Kidney Week 2011

Tweeting the Meeting: Investigating Twitter Activity At the 2012 AAAAI Conference - Disclaimer: I am one of the authors.

How to share up to 4 photos in a single Tweet - Great for conference posters - see example

How to Make the Most of A National Scientific Conference

Drug allergy - Twitter summary from #ACAAI16 meeting

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:

@dranneellis @drsilge @choirdoc

Presentation handouts are available from the ACAAI website:

"Practical Advice for the diagnosis/management of Drug Allergy".

First speaker is Dr. Aleena Banerji "Drug Intolerance or Drug Allergy: critical role of the Allergist".

Up to half of antibiotic use is unnecessary and inappropriate. Using the correct antibiotic, when indicated, is even more critical.

Impact of self-reported penicillin allergy is huge - longer hospital stay, increased C diff, MRSA and VRE due to broad spectrum use. Longer hospital stays and increased rate of C diff, VRE for those with history of penicillin allergy.

Adverse drug reactions - all unintended pharmacology effects of a drug, except therapeutic failures, overdose, or abuse. Hypersensitivity is only a subset of drug adverse reactions - immune response leading to adverse health effects. Drug intolerances do not involve an immune response - patient can continue to use the drug and 'put up' with side effects if needed.

Dr Banerji charges us to eliminate "penicillin allergy disease" - the fear of prescribing PCN to a patient with self-reported PCN allergy.

PCN skin testing is highly effective - negative predictive value is high and subsequent use of broad spectrum ABX is reduced.

Preventing drug allergy starts with our primary care colleagues. Use antibiotics only when needed brings less chance for misunderstood reactions. Many patients with a history of rash with PCN/Amoxicillin actually have a viral infection and the antibiotic wasn't needed in 1st place.

Graded challenge is the Gold Standard for evaluating drug allergy; it is performed when low likelihood of hypersensitivity exists. In low risk patients, reaction rate is the same between 1-2 step graded challenges to antibiotics vs 3-4 step. Reaction rate to a 1-2 step challenge was identical to a 3-4 step protocol; assuming a low risk patient, both are safe.

Dr Banerji calls penicillin the wonder drug. It's what gets prescribed when you wonder what's going on.

Blumenthal’s Ann Allergy Asthma Immunology 2015 - guideline based approach to PCN allergy led to decrease of broad spectrum ABx use. Establishing antibiotic guidelines for hospitals increased use of test doses, decreased use of broad spectrum antibiotics.

Allergists can play a significant role in “de-labeling” drug allergy. If you're an allergist using EHR, it's on us to remove allergies from med allergy list. No one else is going to do it.

Dr. Eric Macy presented on "Cost Effectiveness in approaching Drug Allergy" @EricMacyMD

PCN allergy skin testing is well established as an important part of an effective antibiotic stewardship program. Currently available in vitro PCN IgE test is not useful because results don't correlate to oral challenge reactions; high false positive rate.

Study of 'PCN allergic' inpatients had a 0.59 more hospital days compared to age/gender matched controls. Study from the Netherlands showed higher hospital readmission rate in those with unconfirmed penicillin allergy on chart.

Toronto study: 23% inpatients had a self-reported "allergy" but beta-lactam was prefered ABx in 76%, 35% did not get a beta-lactam. Patients who were given a beta-lactam did not have harms unlike those who were given vancomycin or a fluoroquinolone.

Testing 308 patients for penicillin allergy saved Kaiser Healthcare over a million dollars over 6 years.

Dr. Roland Solensky presented on "Cephalosporins are not Penicillins".

Dr Solensky showed a case report of 2 patients with PCN allergy having fatal reactions to cephalosporin published in JAMA 1964/74.

Yes, penicillin and cephalosporins both have a beta-lactam ring, but side chains are different.

Initial studies evaluating PCN/Cephalosporin cross-reactivity looked at IgG/IgM (it took place in 1968 before IgE discovered!). Dr Solensky reviewed 40-50 year old data that created concern regarding cross-reactivity between PCN and cephalosporins. More recent studies (2000s) reveal a dramatically lower risk of PCN/cephalosporin cross-reactivity.

Dr Solensky's study of 606 patients with self-reported PCN allergy who were given cephalosporins anyway had only 1 patient with eczema reaction. History of PCN allergy wasn't a predictor of cephalosporin-induced anaphylaxis. EMR based study; anaphylaxis reports hand-reviewed.

Important to remember that studies of giving cephalosporins are to unproven PCN allergy - 90% will not actually be PCN allergic. However, a summary slide of all cephalosporin challenges in patients with PCN positive SPT showed 2% overall rate of reactions. About 2% of patients with PCN allergy will react to cephalosporins.

Data mining/chart review showed that new cephalosporin allergy on chart was higher in those with PCN allergy. But anaphylaxis was no higher.

Once a patient has an allergic like event (ALE) to penicillin, this increases risk of ALEs to all antibiotics. Patients with allergy like event (ALE) to PCN were as likely to have a reaction to cephalosporin as they were to structurally unrelated sulfonamide.

It is important to watch for cephalosporins with identical side chains - cefadroxil and cefprozil have the same R1 side chain as Amoxicillin. When confirmed allergy to ampicillin or amoxicillin (but negative to PCN), patients will react - 25% rate of reactions to a cephalosporin with an identical side chain.

Selective allergy to amoxicillin (not all penicillins) is very low in US - 0.35% to 1% - prevalence is higher in Europe for whatever reason. Rate seems higher in European studies (up to 45%) for unclear reasons.

Anaphylaxis - Twitter summary from #ACAAI16 meeting

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:

Presentation handouts are available from the ACAAI website:

@dranneellis: Gearing up to moderate "Leading the Pack - Allergists as Anaphylaxis Experts" Hear from me, @DrStanFineman and @danavwallace!

Dr Wallace explains importance of being prepared to treat anaphylaxis:

@danavwallace recommends that all staff in Allergy clinic, including clerical staff take CPR courses. Allergy practices must run mock anaphylaxis drills to ensure all are prepared. Have an anaphylaxis protocol and post it in the office.

Have a standing order that RN can give first dose of epinephrine 4 anaphylaxis without requiring clearance from attending physician.

No need to fear the epinephrine use in anaphylaxis - only 4 fatalities in literature - all were overdoses and IV administration of epinephrine. There is NO absolute contraindication for epinephrine in the setting of anaphylaxis. Repeat after me.

Before prescribing immunotherapy, think - would this patient be able to survive anaphylaxis should it occur? For example, 2015 Anaphylaxis PP suggest a "cautious approach" for using inhalant AIT in patients on beta-blockers.

Glucagon 1 mg to 5 mg may be effective in the setting of beta-blockers leading to epinephrine resistance to anaphylaxis management. Glucagon kit should be in all our treatment trays.

The AAAAI survey showed that 14% of systemic reactions post AIT occurred after 30 minutes.

@DrStanFineman presented on Anaphylaxis Action Plans in Practice.

Only about 40% of patients prescribed an epinephrine autoinjector were also give a written action plan in one study.

In a European anaphylaxis registry for kids/adolescents, 46% events occurred at home. Epinephrine only used in 25%. Non health care personnel initiated treatment in 30% of anaphylaxis cases in that registry (likely parents). The rate of epinephrine autoinjector use increased 4 fold however from 2011 to 2015, indicating better awareness of best management.

Prevalence of children at risk for anaphylaxis increased 41% over a 6 year period in one Australian study. While rate of epinephrine autoinjector prescriptions significantly rose as well, rate of actual autoinjector use remained stable.

It is not necessary to meet full NIAID criterion for anaphylaxis to give epinephrine - giving earlier in anaphylaxis better.

"Show us your Epi". Ask your patients at each clinic visit to produce their autoinjector.

The @ACAAI has developed an anaphylaxis preparedness questionnaire to use as a discussion tool for patients at risk for anaphylaxis.

Dr Ann Ellis explained biphasic anaphylactic reactions:

Dr Ellis explained that delay in epi treatment can predispose to biphasic reaction.
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