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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 4-8

Implication of pollen sensitivity among patients suffering from chronic urticaria: Current scenario


1 Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India
2 Department of Community Medicine, SRM Medical College Hospital and Research Centre, Kancheepuram, Tamil Nadu, India
3 Department of Dermatology, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India

Date of Web Publication15-Apr-2014

Correspondence Address:
R Balaji
Department of Community Medicine, SRM Medical College Hospital and Research Centre, Kancheepuram, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.130597

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  Abstract 

Background: Studies have implicated house dust mites and foods sensitivity in chronic urticaria based on skin prick test (SPT) and in vitro analysis. There are no studies telling the importance of pollen sensitivity in these patients. Objective: To study the implication of pollen sensitivity in chronic urticaria patients along with foods and dust mite allergens using SPT method. Materials and Methods: This study was conducted in Allergy Clinic, Preventive Medicine Unit, Kempegowda Institute of Medical Sciences Hospital, Bangalore from January 2005 to March 2010. Totally 300 patients with confirmed clinical diagnosis of chronic urticaria were recruited and were subjected for SPT with 123 allergen extracts and the results were analyzed and interpreted. Results: Out of 300 chronic urticaria patients, 171 (57%) were in the age group of 20-39 years. One hundred and forty-six (48.67%) were males and 154 (51.33%) were females. One hundred and eighty-one (60.33%) were having only chronic urticaria. One hundred and forty (46.67%) of urticaria patients were having symptoms from 6 weeks to 1 year. Forty-four (14.67%) had a family history of atopy. Majority of urticaria patients (with or without comorbid conditions) were sensitive to food allergens (164, 54.66%) followed by pollens (92, 30.66%), dust mites (60, 20%), and others. Among food allergens, majority (15, 5%) were sensitive to masoor dal followed by almonds (14, 4.66%), ginger (13, 4.33%), and yeast (13, 4.33%). Among pollens, majority (32, 10.66%) were sensitive to Prosopis juliflora followed by Parthenium hysterophorus (17, 5.66%), Peltophorum pterocarpum (17, 5.66%), and Chenopodium album (16, 5.33%). Among dust mites, 42 (14%) and 39 (13%) were sensitive to D. farinae and D. pteronyssinus, respectively. Conclusion: Pollens sensitivity is also implicated in chronic urticaria patients along with foods and dust mite allergens.

Keywords: Chronic urticaria, pollen sensitivity, skin prick test


How to cite this article:
Parasuramalu B G, Balaji R, Sharath Kumar B C. Implication of pollen sensitivity among patients suffering from chronic urticaria: Current scenario. Int J Health Allied Sci 2014;3:4-8

How to cite this URL:
Parasuramalu B G, Balaji R, Sharath Kumar B C. Implication of pollen sensitivity among patients suffering from chronic urticaria: Current scenario. Int J Health Allied Sci [serial online] 2014 [cited 2019 Sep 20];3:4-8. Available from: http://www.ijhas.in/text.asp?2014/3/1/4/130597


  Introduction Top


Chronic urticaria is one of the perplexing problems faced by the clinicians. Chronic urticaria is defined as daily or almost daily occurrence of urticarial wheals for at least 6 weeks. [1] Numerous physical agents can trigger the onset of urticaria, such as cold, heat, the sun, vibrations, rubbing (dermographism), or pressure. Urticaria can also be caused by drugs, food, infection (viral, bacterial, parasitic, or fungal), insect stings, more rarely due to pneumoallergens. [2],[3] Rhinitis and asthma are other atopic diseases also affected by the above allergens. [4] Urticaria is a common disorder that affects as many as 20% of all people at some time during their lives. The pathogenesis is complex and not well known. [5] Studies [6],[7],[8],[9] implicated house dust mites and foods sensitivity in chronic urticaria based on skin prick test (SPT) and in vitro analysis. Pollens are also one of the major allergen inducing all forms of allergy. Very few studies implicate the role of pollens in causing chronic urticaria. Hence, we wanted to study the implication/role of pollen sensitivity in patients with chronic urticaria along with foods and dust mite allergens using SPT method which is the gold standard to diagnose the clinical sensitivity.


  Materials and Methods Top


After obtaining the institutional ethics committee approval, the present study was conducted in the Allergy Clinic, Preventive Medicine Unit, Kempegowda Institute of Medical Sciences Hospital and Research Center, Bangalore from January 2005 to March 2010. Totally 300 patients with confirmed clinical diagnosis of chronic urticaria (with a duration of more than 6 weeks), in the age group of 5-70 years who attended the Allergy Clinic were recruited for the study after obtaining the informed consent. Comorbid conditions such as allergic rhinitis (Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines), [10] bronchial asthma (Global Initiative for Asthma (GINA) guidelines), [11] and allergic conjunctivitis were also assessed. Patients with autoimmune diseases, serious chronic inflammatory diseases, malignant disease, severe asthma, emphysema, bronchiectasis, pregnancy, ischemic heart disease, high blood pressure, receiving immunosuppressive medications, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, and suspicion of alcohol abuse were excluded. In all cases, questions regarding food allergies, drug intake, signs of infection, causes of physical urticaria, insect bites, and personal and family history of atopy were asked. The clinical characteristics of the disease, such as duration, frequency and associated angioedema, and symptoms of anaphylaxis were also investigated. Routine investigations such as complete blood count and urine examination were done to rule out the focus of infection. The complete history was obtained and physical examination was done to rule out the systemic diseases. The patients who were subjected to SPT were instructed to stop drugs like antihistamines, beta-blockers, and theophylline 15 days prior to the test. SPTs were performed on 300 patients with 123 allergen extracts. The extracts included 19 pollens, five dusts, two dust mites, 10 fungi, 10 insects, three epithelia, and 74 food allergens. Allergen extracts for SPTs were obtained from Creative Drug Industries, Navi Mumbai.

Procedure of SPT

SPT was performed on the flexor side of upper arm and forearm after cleaning with isopropyl alcohol. A single drop of each allergen extract of 1:10 concentration was placed along with positive control (histamine) and negative control (saline).

Sterile lancet was used to prick by making a shallow lift (at an acute angle) for a second to allow adequate entry of antigen beneath the stratum corneum epidermis [Figure 1]. This was repeated for each allergen after wiping the lancet with dry cotton. The allergen was left in place for 20 min then the reading of wheal area (allergen), saline area, and histamine area diameter was taken with the help of measuring scale. [12],[13] Interpretation of test results was done according to Indian College of Allergy Asthma and Immunology criteria. [14] Allergens, which produced wheal areas more than 2+ (grade 2 and above) were considered as positives [Figure 2].
Figure 1: Performing skin prick test

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Figure 2: Skin prick test reaction to allergen

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  Results Top


Out of 300 chronic urticaria patients, the maximum (171, 57%) were in the age group of 20-39 years. Among them, 146 (48.67%) were males and 154 (51.33%) were females. Among males, maximum (49, 33.56%) were in the age group of 20-29 years; whereas, in females, maximum (43, 27.92%) were in the age group of 30-39 years. The mean age of chronic urticaria patients was 35.15 ± 12.96 years and the range was 8-72 years [Table 1].
Table 1: Age- and sex-wise distribution of chronic urticaria patients


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Majority (181, 60.33%) were having chronic urticaria alone. The other comorbid conditions associated with chronic urticaria were chronic urticaria with conjunctivitis among 43 (14.33%) patients followed by chronic urticaria with allergic rhinitis among 34 (11.33%) and chronic urticaria with conjunctivitis and rhinitis among 21 (7%) [Table 2].
Table 2: Distribution of chronic urticaria patients according to comorbid conditions (n=300)


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The average duration of chronic urticaria was 3.3 ± 4.2 years. Majority (140, 46.67%) patients were having symptoms from 6 weeks to 1 year, next highest (49, 16.33%) were having symptoms from 5 to 10 years, and the least (13, 4.33%) were having symptoms from 13 to 18 months.

Forty-four (14.67%) chronic urticaria patients had a family history of atopy. Among them, 19 (43.18%) had family history of atopy in mother, followed by 17 (38.64%) in siblings, eight (18.18%) in father, three (6.81%) in paternal side, and two (4.54%) in maternal side.

Majority of chronic urticaria patients (with or without comorbid conditions; 164, 54.66%) were sensitive to one or more food allergens, followed by pollens (92, 30.66%), dust mites (60, 20%), and others. In this study, those patients with history of angioedema (four) were not positive for any of the allergen [Table 3]a.

The sensitivity for pollen allergens is found to be more than dust mite allergens in chronic urticarial patients (with or without comorbid conditions) and the difference is found to be statistically significant [Table 3]b.
Table 3:

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Among food allergens, majority of patients (15, 5%) were sensitive to masoor dal, followed by almonds (14, 4.66%), ginger (13, 4.33%), yeast (13, 4.33%), and others [Table 4]a. Among pollens, majority (32, 10.66%) were sensitive to Prosopis juliflora, followed by Parthenium hysterophorus (17, 5.66%), Peltophorum pterocarpum (17, 5.66%), Chenopodium album (16, 5.33%), and others [Table 4].
Table 4: Distribution of chronic urticaria patients according to skin prick test positivity to allergens (n=300)


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Among dust mites, 42 (14%) and 39 (13%) were sensitive to Dermatophagoides farinae and Dermatophagoides pteronyssinus, respectively.

Among dusts, majority of patients (17, 5.66%) were sensitive to house dust, followed by paper dust (12, 4%), wheat dust (10, 3.33%), cotton dust (six, 2%), and hay dust (three, 1%).

Among fungi, majority of patients (11, 3.66%) were sensitive to Candida albicans, followed by Aspergillus fumigatus (10, 3.33%), Cladosporium herbarum (seven, 2.33%), Penicillium sp (six, 2%), and others (i.e., Alternaria alternata (five, 1.66%), Aspergillus flavus (four, 1.33%), Trichoderma (four, 1.33%), Curvularia lunata (two, 0.66%), Helminthosporum (one, 0.33%), and Aspergillus niger (one, 0.33%).

Among insects, majority of patients (21, 7%) were sensitive to housefly, followed by cockroach (10, 3.33%), mosquito (10, 3.33%), and others. Among epithelia, six (2%), five (1.66%), and four (1.33%) were sensitive to dog epithelia, buffalo dander, and sheep's wool, respectively.


  Discussion Top


In the present study, the mean age of chronic urticaria patients was 35.15 ± 12.96 years. This is in accordance with the findings of Priya et al., [7] where the mean age was 35.7 years.

In the present study, maximum (60.33%) were having chronic urticaria alone. The other comorbid conditions associated with chronic urticaria were chronic urticaria with conjunctivitis among 14.33% of patients followed by chronic urticaria with allergic rhinitis among 11.33% and chronic urticaria with conjunctivitis and rhinitis among 7%. This observation is in accordance with the findings of Priya et al., [7] where 54.9% of patients were having chronic urticaria alone, 22.4% had chronic urticaria and allergic rhinitis, and 23% had chronic urticaria with asthma.

Majority of chronic urticaria patients were having symptoms from 6 weeks to 1 year in the present study; whereas, majority of patients were having symptoms of chronic urticaria from 1 to 4 years in the study conducted by Priya et al. [7]

In the present study, 14.67% of chronic urticaria patients had a family history of atopy, which was lower than the findings of Anuradha et al., [15] where 31.8% of chronic urticaria patients had family history of atopy.

In chronic urticaria patients, rhinitis and asthma were other atopic diseases also affected by food allergens. [4] Similar findings was observed in the present study.

In the present study, majority (164, 54.66%) of the chronic urticaria patients (with or without comorbid conditions) were sensitive to food allergens. The most common foods for which they were sensitive were masoor dal, almond, ginger, and yeast. Whereas in the study conducted by Priya et al., [7] majority were sensitive to beans, mustard, cardamom, cashew, and ginger. In the study conducted by Por Alvarado and Perez, [16] the principal foods involved in allergic reactions were fruits (57.7%), tree nuts (23.9%), and crustaceans (12.7%) in adults and fruits (54.2%), tree nuts (20%), legumes (14.3%), and fish (14.3%) in children.

Majority of the patients were sensitive to Prosopis juliflora (10.66%), followed by Parthenium hysterophorus (5.66%), Peltophorum pterocarpum (5.66%) and Chenopodium album (5.33%). It differs from the study conducted by Anuradha et al., [15] where the predominant pollen allergens in urticaria were Sorghum vulgare (64.7%) followed by Pennisetum typhoides (56.7%) and Artemesia scoparia (51.9%). Though the studies [6],[7],[8],[9] implicated house dust mites and foods sensitivity in chronic urticaria based on SPT and in vitro analysis; in the present study, in addition to house dust mite and food sensitivity, majority of patients have also shown sensitivity to pollens.

In the present study, 14 and 13% of patients were sensitive to Dermatophagoides farinae and Dermatophagoides pteronyssinus, respectively. This is in accordance with the other studies. [6],[8],[9],[17] Studies [8],[9] have also shown a significant association between house dust mite sensitivity and chronic urticaria using intradermal and in vitro test.

The study conducted by Tanaka et al., [18] suggested the route of entry of the house dust mite allergens into the skin tissues to interact with specific IgE on mast cells. Numata et al., [9] has also discussed the hypothesis of Hannafin that the dust mite antigen could penetrate the stratum corneum based upon its molecular weight.

To conclude, this study suggests a possible association/role of pollen sensitivity with chronic urticaria in addition to foods and dust mites sensitivity. It is important to perform SPTs among patients suffering from chronic urticaria (with or without comorbidities) not only for food allergens but also for pollens, house dust mites, and other allergens for diagnosis and proper management. Since there seem to be geographical differences is the prevalence of allergens causing allergy, there is a need to carry out more such studies in different regions.

 
  References Top

1.Black AK, Champion RH. Urticaria. In: Champion RH, Burton JL, Burns DA, Breathnach SM, editors, Rook/Wilkinson/Ebling. Textbook of Dermatology. 6 th ed. London: Blackwell Science; 1998. p. 2113-39.  Back to cited text no. 1
    
2.Barlow RJ, Ross EL, Mac Donald DM, Kobza Black A, Greaves MW. Mast cells and T lymphocytes in chronic urticaria. Clin Exp Allergy 1995;25:317-22.  Back to cited text no. 2
    
3.Sveum RJ. Urticaria. The diagnostic challenge of hives. Postgrad Med 1996;100:77-8, 81-4.  Back to cited text no. 3
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6.Mahesh PA, Kushalappa PA, Holla AD, Vedanthan PK. House dust mite sensitivity is a factor in chronic urticaria. Indian J Dermatol Venereol Leprol 2005;71:99-101.  Back to cited text no. 6
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7.Priya HA, Anuradha B, Vijayalakshmi VV, Latha SG, Murthy KJR. Profile of food allergens in urticaria patients in Hyderabad. Indian J Dermatol 2006;51:111-14.  Back to cited text no. 7
    
8.Sumimoto A, Ishizu K, Takahashi H, Yamada S, Numata T, Yamamoto S, et al. Correlation between dermatophagoides pteronyssinus and dermatophagoides farinae House dust mites in chronic urticaria. Hiroshima J Med Sci 1981;30:247-50.  Back to cited text no. 8
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9.Numata T, Yamamoto S, Yamura T. The role of mite, house dust and candida allergens in chronic urticaria. J Dermatol 1980;7:197-202.  Back to cited text no. 9
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10.Antonicelli L, Micucci C, Voltolini S, Feliziani V, Senna GE, Di Blasi P, et al. Allergic rhinitis and asthma comorbidity: ARIA classification of rhinitis does not correlate with the prevalence of asthma. Clin Exp Allergy 2007;37:954-60.  Back to cited text no. 10
    
11.Bousquet J, Clark TJ, Hurd S, Khaltaey N, Lenfant C, O'bryne P, et al. GINA guidelines on asthma and beyond. Allergy 2007;62:102-12.  Back to cited text no. 11
    
12.Tripathi DM. Role of allergen testing and immunotherapy in the management of respiratory allergic diseases. Bombay Hosp J 2002;44:419-25.  Back to cited text no. 12
    
13.Tripathi DM. Status of skin testing and specific immunotherapy in management of Asthma. Bombay Hosp J 1994;36:164-71.  Back to cited text no. 13
    
14.Gaur SN, Singh BP, Singh AB, Vijayan VK, Agarwal MK. Guidelines for practice of allergen immunotherapy in India. Indian J Allergy Asthma Immunol 2009;23:1-21.  Back to cited text no. 14
    
15.Anuradha B, Vijayalakshmi VV, Latha SG, Priya HA, Murthy KJ. Profile of pollen allergies in patients with asthma, allergic rhinitis and urticaria in Hyderabad. Indian J Chest Dis Allied Sci 2006;48:221-2.  Back to cited text no. 15
    
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