Diagnosis, Severity, and Impact of Chronic Spontaneous Urticaria

EP: 1.Overview and Burden of Chronic Spontaneous Urticaria

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EP: 2.Diagnosis, Severity, and Impact of Chronic Spontaneous Urticaria

EP: 3.Chronic Spontaneous Urticaria Management and the Role of Patient Communication

EP: 4.Chronic Spontaneous Urticaria: Diagnosis and Treatment Strategies

Jane Mast, PhD, DMSc, MPAS, PA-C: Hello, and welcome back to this Dermatology Times Partner Perspectives video series on chronic spontaneous urticaria, or CSU. My name is Jane Mast. I'm a Novartis Medical Director of Dermatology and Allergy. And joining me today is Dr Jonathan Rodrigues, also a Novartis Medical Director of Dermatology and Allergy and a board-certified allergist. Thanks so much for being here with us today.

Jonathan Rodrigues, MD: Thank you, Jane.

Jane Mast, PhD, DMSc, MPAS, PA-C: In the first video, we talked about CSU epidemiology, clinical features, and pathophysiology. Now we're going to dive deep into a discussion regarding assessment and diagnosis of CSU as well as disease severity and its impact on patients. We know that diagnostic delays are common for patients with CSU. Can you talk about some of the factors that impact these delays?

Jonathan Rodrigues, MD: Patients with CSU can experience an average delay of 24 months from symptom onset to the time a diagnosis is established.¹ There are several factors that drive these diagnostic delays. Firstly, patients with CSU that are refractory to treatment are more likely to self-medicate with over-the-counter medications, see a PCP rather than a specialist, and can also experience a delay in referral to a CSU-treating specialist.^1,2 We have seen that about 48.7% of patients with CSU see a general practitioner, 29.6% see an allergist, and around 19.2% see a dermatologist.³ Another factor that impacts delays in diagnosis is unnecessary allergy or laboratory testing.⁴ We have seen that only 0.16% of tests actually contribute to an improvement in clinical outcomes.⁴ Screening tests are also not very cost- effective and can cost as high as $573 per patient.⁴ Poor compliance with treatment guidelines could also result in incorrect treatment patterns such as the prolonged use of corticosteroids or insufficient dosing of second-generation antihistamines.^5-8 Insufficient knowledge of CSU among health care providers in both primary and secondary care can also contribute to diagnostic delays.¹ Therefore, we believe that there is a role to be played by medical education and awareness in ensuring timely diagnosis of CSU patients.¹

Jane Mast, PhD, DMSc, MPAS, PA-C: So now let's discuss diagnosis. Can you tell us about best practices for diagnosis of CSU?

Jonathan Rodrigues, MD: A thorough history and a physical exam is usually the first step in ensuring an accurate diagnosis of CSU.⁵ We know that a typical presentation of CSU is wheals or hives and angioedema lasting for more than 6 weeks.⁵ Wheals or hives usually resolve in 30 minutes to 24 hours.⁵ Angioedema can be slower to resolve and can last up to 72 hours.⁵ Family history and a review of a patient's symptoms in its entirety are also very important to rule out other possible conditions.⁵ There is a CSU diagnostic algorithm that is available, and this tool allows physicians to explore the multiple pathways that can lead to a diagnosis of CSU and also exclude other differential diagnoses.⁵ Diagnostic testing for CSU beyond basic lab tests such as a CBC with differential, an ESR, or a CRP should be limited to patients with atypical findings.^5,9 Skin biopsies should be performed only when hives last for more than 24 hours and where we suspect a diagnosis of urticarial vasculitis.^5,9

Jane Mast, PhD, DMSc, MPAS, PA-C: Now that we've reviewed the diagnosis, let's shift gears and talk about how this disease impacts patients. Can you talk a little bit more about how CSU impacts patient quality of life?

Jonathan Rodrigues, MD: In a study of patients with CSU and those without CSU, patients with CSU reported an increased prevalence of depression, anxiety, and sleep difficulties.¹⁰ As a matter of fact, the prevalence of depression was as high as 48%.¹⁰ Findings also showed a negative impact on sexual function and work productivity in patients with CSU.¹⁰ In another study comparing patients with CSU to those with psoriasis, patients with CSU had an increased prevalence of anxiety, depression, and sleep difficulties.¹¹ CSU also affects work productivity and performance.¹ In a study of 604 patients with CSU, of which 56.5% were employed, participants reported a mean absenteeism of 6.1%, presenteeism of 25.2%, and overall work impairment of 26.9% over the previous 7 days.¹ CSU when accompanied with chronic inducible urticaria, or CIndU, has the greatest impact on quality of life as measured by the Dermatology Life Quality Index with a score of 9.1 as compared with 8.3 in patients with CSU alone and 7.6 in patients with CIndU alone.¹² About 20% of patients with CSU also suffer from chronic inducible urticaria, or CIndU. And CIndU is the most common comorbidity in antihistamine- resistant CSU. Therefore, patients with CSU should be assessed for symptoms of CIndU and vice versa.¹³

Jane Mast, PhD, DMSc, MPAS, PA-C: To help understand the impact of CSU on patients' quality of life, it's also important to understand the severity of the disease. Can you tell us about UAS7 and how that's calculated?

Jonathan Rodrigues, MD: Yes. The UAS7 is a patient-reported outcome or PRO that is commonly used in clinical trials and is evaluated by both patients and physicians.¹⁴ The UAS7 comprises the daily itch severity score and the daily hive severity score, both of which are scored from 0 to 3 corresponding with none to
severe.^14,15 The daily UAS is a sum of the daily itch severity score and the daily hive severity score, giving it a range of 0 to 6 points per day. The UAS7 is a sum of daily UAS scores for the last 7 days.^14,15 The UAS7 overall enables health care providers to assess and monitor the severity of CSU and can also help guide them in maintaining, escalating, or modifying therapy in patients with CSU.¹⁵

Jane Mast, PhD, DMSc, MPAS, PA-C: Thank you so much, Jonathan, for this great discussion on chronic spontaneous urticaria, and thank you to our viewers for watching.

References
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2. Gabriel S et al. J Allergy Clin Immunol. 2016;137(suppl 2 suppl):AB242.
3. Patil D et al. Poster presented at: American Academy of Dermatology Associate Annual Meeting; March 25-29, 2022, Boston, MA.
4. Shaker M et al. J Allergy Clin Immunol. 2020:8(7):2360-2369.
5. Zuberbier T et al. Allergy. 2022;77(3):734- 766.
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13. Bauer A et al. Allergo J Int. 2021;30(2):64-75.
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15. Mathias SD, et al. Ann Allergy Asthma Immunol. 2012;108(1):20-24.