10.5826/dpc.1301a56
Introduction: Chronic urticaria is a common disease, characterized by the development of wheals, angioedema, or both, which can be associated with several comorbidities. Most of the available studies have focused on specific common comorbidities and their association with CU, but have seldom reported the overall burden of comorbidities.
Objectives: This study aimed to investigate and analyze self-reported comorbidities in polish patients with CU.
Methods: An anonymous online survey consisting of 20 questions was conducted on a members of Urticaria group on social media platform — Facebook. A total of 102 people took part in this survey. The results were analyzed in Microsoft Excel 2016.
Results: In the group 95.1% were females and 4.9% males, with a mean age of 33.8 years. The most common diagnosed type of urticaria was spontaneous (52.9%). Angioedema accompanied urticaria in 68.6% of the respondents, mainly those with delayed pressure urticaria (86.4%). 85.3% of respondents reported comorbidities, most often atopic diseases and allergies (49%), chronic inflammation and infections (36.3%), thyroid (36.3%) and psychiatric disorders (25.5%). Moreover, in 30.4% of patients at least one autoimmune disease was noted. As compared to the patients without autoimmune urticaria, much more with autoimmune urticaria had coexisting autoimmune disease (50% vs. 23.7%). The family history of autoimmune diseases was positive in 42.2%, and the familial history of urticaria and atopy was positive in 7.8% and 25.5%, respectively.
Conclusions: The knowledge of comorbidities of chronic urticaria may support clinicians to manage and treat patients with this common condition.
text/xml
2160-9381
2577
en
Magdalena Trzeciak
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
angioedema
Characterization of Chronic Urticaria and Associated Conditions - A Web-Based Survey
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-05-07
2023-01-31
2023-02-27
e2023056
Dermatol Pract Concept
Introduction: Chronic urticaria is a common disease, characterized by the development of wheals, angioedema, or both, which can be associated with several comorbidities. Most of the available studies have focused on specific common comorbidities and their association with CU, but have seldom reported the overall burden of comorbidities.
Objectives: This study aimed to investigate and analyze self-reported comorbidities in polish patients with CU.
Methods: An anonymous online survey consisting of 20 questions was conducted on a members of Urticaria group on social media platform — Facebook. A total of 102 people took part in this survey. The results were analyzed in Microsoft Excel 2016.
Results: In the group 95.1% were females and 4.9% males, with a mean age of 33.8 years. The most common diagnosed type of urticaria was spontaneous (52.9%). Angioedema accompanied urticaria in 68.6% of the respondents, mainly those with delayed pressure urticaria (86.4%). 85.3% of respondents reported comorbidities, most often atopic diseases and allergies (49%), chronic inflammation and infections (36.3%), thyroid (36.3%) and psychiatric disorders (25.5%). Moreover, in 30.4% of patients at least one autoimmune disease was noted. As compared to the patients without autoimmune urticaria, much more with autoimmune urticaria had coexisting autoimmune disease (50% vs. 23.7%). The family history of autoimmune diseases was positive in 42.2%, and the familial history of urticaria and atopy was positive in 7.8% and 25.5%, respectively.
Conclusions: The knowledge of comorbidities of chronic urticaria may support clinicians to manage and treat patients with this common condition.
Magdalena Trzeciak
2023/01/31
10.5826/dpc.1301a56
e2023056
Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdansk, Poland
2160-9381
angioedema
en
e2023056
Gericke J, Metz M, Ohanyan T, et al. Serum autoreactivity predicts time to response to omalizumab therapy in chronic spontaneous urticaria. J Allergy Clin Immunol. 2017;139(3):1059-1061.e1. doi:10.1016/j.jaci.2016.07.047
Characterization of Chronic Urticaria and Associated Conditions - A Web-Based Survey
https://dpcj.org/index.php/dpc/article/download/2577/1958
           Characterization of Chronic Urticaria and
          Associated Conditions - A Web-Based Survey
                                         Weronika Zysk1, Magdalena Trzeciak2


1 Dermatological Students Scientific Association, Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical
  University of Gdansk, Poland
2 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdansk, Poland



Key words: chronic urticaria, autoimmune urticaria, comorbidity, angioedema
Citation: Zysk W, Trzeciak M. Characterization of Chronic Urticaria and Associated Conditions - A Web-Based Survey. Dermatol Pract
Concept. 2023;13(1):e2023056. DOI: https://doi.org/10.5826/dpc.1301a56
Accepted: May 28, 2022; Published: January 2023
Copyright: ©2023 Zysk et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Weronika Zysk, Dermatological Students Scientific Association, Department of Dermatology,
Venerology and Allergology, Faculty of Medicine, Medical University of Gdansk, 17 Smoluchowskiego St, 80-214 Gdansk, Poland.
E-mail: weronikazysk@gumed.edu.pl




  ABSTRACT             Introduction: Chronic urticaria is a common disease, characterized by the development of wheals,
                       angioedema, or both, which can be associated with several comorbidities. Most of the available ­studies
                       have focused on specific common comorbidities and their association with CU, but have seldom
                       ­reported the overall burden of comorbidities.
                       Objectives: This study aimed to investigate and analyze self-reported comorbidities in Polish patients
                       with CU.
                       Methods: An anonymous online survey consisting of 20 questions was conducted on members of an
                       Urticaria group on the social media platform Facebook. A total of 102 people took part in this survey.
                       The results were analyzed in Microsoft Excel 2016.
                       Results: In the group, 95.1% were females and 4.9% males, with a mean age of 33.8 years. The most
                       common diagnosed type of urticaria was spontaneous (52.9%). Angioedema accompanied urticaria
                       in 68.6% of the respondents, mainly those with delayed pressure urticaria (86.4%). 85.3% of respon-
                       dents reported comorbidities, most often atopic diseases and allergies (49%), chronic inflammation
                       and infections (36.3%), thyroid (36.3%) and psychiatric disorders (25.5%). Moreover, in 30.4% of
                       patients, at least one autoimmune disease was noted. As compared to the patients without autoim-
                       mune urticaria, many more with autoimmune urticaria had a coexisting autoimmune disease (50%
                       vs. 23.7%). Family history of autoimmune diseases was positive in 42.2%, and the familial history of
                       urticaria and atopy was positive in 7.8% and 25.5%, respectively.
                       Conclusions: The knowledge of comorbidities of chronic urticaria may support clinicians to manage
                       and treat patients with this common condition.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023056                                                                           1
Introduction                                                      scleroderma, diabetes mellitus type 1, Crohn’ disease and
                                                                  ulcerative colitis.
Chronic urticaria (CU), affecting 0.5%–1% of the general              A total of 102 people (97 women and 5 men) took part
population, is defined by the repeated occurrence of itchy        in this survey. The average age of patients was 33.8 years
hives, angioedema, or both, for 6 weeks or more. Accord-          (range, 9-57 years). The results were analyzed in Microsoft
ing to current guidelines, CU can be divided into chronic         Excel 2016 and presented on a percentage scale.
spontaneous urticaria (CSU) and chronic inducible urticaria           The study was approved by the Independent Bioethics
(CIndU) with several subgroups. Both CU types can occur           Committee for Scientific Research at the Medical University
concomitantly in the same patient [1]. CU develops more           of Gdansk (NKBBN/833/2021).
frequently in adults, in the third to fifth decade of life, and
females are affected at least twice as often as males [2].
                                                                  Results
    Several studies reported that patients with CU frequently
exhibit comorbidities. The association of CU with psychiat-       The majority of CU patients were 19–39 years old (59.8%),
ric disorders, including depression, anxiety and behavioral       followed by patients aged ≥40 years old (33.3%), while
problems, atopic disorders, autoimmune disorders, hyper-          a small proportion, 6.9% of patients were ≤18 years old.
tension, osteoporosis, and infections, has been reported pre-     The vast majority of the respondents (80.4%) lived in cit-
viously [3-7]. Most of these studies have focused on specific     ies, the remaining 19.6% lived in villages. More than half of
common comorbidities and their association with CU, but           the respondents (63.7%) reported higher education, 17.6%
have seldom reported the overall burden of comorbidities.         ­secondary, and 3.9% vocational. Nearly 16% of respondents
                                                                  were studying.

Objectives                                                            The mean age at disease onset was 27.5 years (range,
                                                                  3–55 years). Among all patients, the most frequent type of
This study aimed to investigate and analyze self-reported co-     CU was CSU, diagnosed in 78.4%. Autoimmune urticaria,
morbidities in Polish patients with CU.                           which is a subtype of CSU, was diagnosed in 25.5%. Among
                                                                  all patients with CU, 59.8% were diagnosed with CSU only,

Material and Methods                                              21.6% were diagnosed with isolated CIndU only and the re-
                                                                  maining 18.6% had a combination of both types. The most
The study was based on an anonymously filled online survey        common subtypes of CIndU were delayed pressure urticaria
prepared by the authors. Individuals with CU and parents          (21.6%), symptomatic dermographism (14.7%), and cholin-
of children with CU were recruited for participation in the       ergic urticaria (8.8%; fig 1).
study through closed membership CU support groups found               Angioedema symptoms were reported by 70 patients
on social media platforms (Facebook). Individuals interested      (68.6%) and occurred mainly in patients with delayed pres-
in participating in the survey were directed through an intro-    sure urticaria (86.4%; fig 2). Of the 70 patients who ex-
duction and implicit consent into Google Forms.                   perienced symptoms of angioedema, the most frequently
    The   questionnaire    consisted   of   20   questions:   7   reported locations for angioedema were non-facial body
single-choice and 13 multiple-choice. Single-choice ques-         areas (82.9%), most commonly the hands (68.6%), feet
tions concerned basic demographic information, presence of        (57.1%), over joints (35.7%), and trunk (5.7%). 17.1% of
angioedema, age of the first episode of CU, and frequency         patients reported experiencing swelling symptoms over the
of CU symptoms. Multiple-choice questions concerned in-           whole body. On the face, angioedema occurred in 68.6% of
formation about diagnosed types of CU, localization of            patients: the areas around the eyes were affected in 67.1%
angioedema, family history of urticaria and atopy, family         of cases, the lips in 65.7%, the oral mucosa in 12.9%, and
history of autoimmune diseases, the coexistence of connec-        the tongue in 11.4%.
tive tissue, thyroid gland, digestive system, inflammatory dis-       In more than half of the cases (59.8%), hives appear ev-
eases, metabolic and cardiovascular diseases, skin diseases,      ery day, in 16.7% several times a week, in 8.8% several times
allergic diseases, mental disorders, neoplasm diseases, and       a month, in 10.8% several times a year, and in 3.9% less
others that individuals could add in a designated place.          frequently.
    Data about family history of atopy was defined as the             We examined the prevalence of reported comorbid dis-
presence of asthma, eczema, allergic rhinitis, or rhino-­         eases by CU patients, grouping them into 10 disease catego-
conjunctivitis, whereas autoimmune diseases were defined          ries. The data presented in Table 1 summarize the comorbidity
as Hashimoto’s thyroiditis, systemic lupus erythematosus,         profile of CU patients. Of 102 CU patients, 85.3% had one
pernicious anemia, vitiligo, Graves’ disease, rheumatoid ar-      or more concomitant diseases. Almost 50% of patients had
thritis, celiac disease, alopecia areata, sclerosis multiplex,    at least one atopic disease or allergy and it was the most



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(1):e2023056
Figure 1. Percentage of patients with chronic urticaria (CU), divided by subtype (n=102).




Figure 2. Percentage of patients with concomitant angioedema, divided by subtype of chronic urticaria (CU).


commonly reported group of comorbidities, followed by                  many more with autoimmune urticaria had a coexisting au-
chronic inflammation and infections (36.3%), thyroid dis-              toimmune disease (50% vs. 23.7%).
orders (36.3%), psychiatric disorders (36.3%), skin diseases               Interestingly, in 43 patients (42.2%) with CU there was
(18.6%), gastrointestinal diseases (18.6%), cardiometabolic            a familial history of autoimmune disease, in 26 patients
diseases (10.8%), rheumatic diseases (6.9%), malignancies              (25.5%) familial history of atopy, and in 8 patients (7.8%)
(2.0%), and others included migraine, endometriosis, perni-            familial history of chronic urticaria.
cious anemia and epilepsy.
    Among all comorbidities reported by patients, we de-
                                                                       Discussion
termined autoimmune diseases. Of 102 CU patients, 31
(30.4%) had one or more comorbid autoimmune diseases                   In line with the findings of previous studies, CSU occurs with
(Table 2). The most prevalent were autoimmune thyroid                  a higher frequency than CIndU, with comorbid CIndU likely
diseases (24.5%, mostly HT in 22.5%). Other common au-                 in a fifth of the cases, despite heterogeneity in the regional
toimmune comorbidities included systemic lupus erythema-               distribution of CU and its phenotypes [8]. Symptomatic der-
tosus (2.9%) and rheumatoid arthritis (2.9%). Of the 31 CU             mographism has previously been reported to be the most
patients with a comorbid autoimmune disease, 74.2% had                 common of the physical urticarias [9]. We observed that de-
one, most often HT, 22.6% had 2, and 3.2% had 3 (Table 2).             layed pressure urticaria was the most commonly diagnosed
As compared to the patients without autoimmune urticaria,              CIndU subtype.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023056                                                                     3
                         Table 1. The Comorbidity Profile of Chronic Urticaria Patients.
                                  Diseases                                           Prevalence in all CU patients (n=102)
 Atopy and allergies                          Drug allergy                              21,6%
                                              Allergic rhinitis                         20,6%
                                              Food allergy                              17,6%
                                              Asthma                                    15,7%
                                                                                                                     49,0%
                                              Inhaled allergy                           12,7%
                                              Atopic dermatitis                         10,8%
                                              Rhino-conjunctivitis                        6,9%
                                              Insect venom allergy                        6,9%
 Chronic inflammation and infectious          Sinusitis                                 17,6%
                                              Gastritis                                 10,8%
                                              Urinary tract infection                     7,8%
                                              Helicobacter pylori                         6,9%
                                                                                                                     36,3%
                                              Periodontitis                               5,9%
                                              Otitis media                                2,0%
                                              Hepatitis B                                 1,0%
                                              Autoimmune hepatitis                        1,0%
 Thyroid disorders                            Hashimoto’s disease                       22,5%
                                              Hypothyroidism                            17,6%
                                              Hyperthyroidism                             2,9%                       36,3%
                                              Graves’ disease                             2,0%
                                              Goiter                                      1,0%
 Psychiatric disorders                        Depression                                16,7%
                                                                                                                     25,5%
                                              Anxiety disorders                         14,7%
 Skin diseases                                Allergic contact dermatitis                 9,8%
                                              Psoriasis                                   4,9%
                                              Vitiligo                                    2,0%                       18,6%
                                              Seborrheic dermatitis                       1,0%
                                              Alopecia areata                             1,0%
 Gastrointestinal diseases                    GERD                                      10,8%
                                              IBS                                         8,8%
                                                                                                                     18,6%
                                              Peptic ulcer                                2,9%
                                              Celiac disease                              1,0%
 Cardiometabolic diseases                     Arterial hypertension                       8,8%
                                              Ischemic stroke                             2,0%                       10,8%
                                              Diabetes mellitus type 2                    1,0%
 Connective tissue diseases                   SLE                                         2,9%
                                              RA                                          2,9%
                                                                                                                      6,9%
                                              MCTD                                        1,0%
                                              Polymyositis                                1,0%
 Neoplasm                                     Melanoma                                    1,0%
                                                                                                                      2,0%
                                              Carcinoid tumor                             1,0%
 Others                                       Migraine                                  12,7%
                                              Endometriosis                               5,9%
                                                                                                                     19,6%
                                              Pernicious anemia                           2,0%
                                              epilepsy                                    1,0%

CU = chronic urticaria; GERD = gastroesophageal reflux disease; IBS = irritable bowel syndrome; MCTD = mixed connective tissue disorder;
RA = rheumatoid arthritis; SLE = systemic lupus erythematosus.



4                                                                         Original Article | Dermatol Pract Concept. 2023;13(1):e2023056
   Table 2. The Number and Combination of Autoimmune Diseases in Chronic Urticaria Patients.
                                                  Prevalence in all CU patients with        Prevalence in all CU patients
                    AID, No.                                 AID (n=31)                               (n=102)
 Hashimoto’s disease, 23                                         74,2%                                 22,5%
 SLE, 3                                                          9,7%                                    2,9%
 RA, 3                                                           9,7%                                    2,9%
 Vitiligo, 2                                                     6,5%                                    2,0%
 Graves’ disease, 2                                              6,5%                                    2,0%
 Pernicious anemia, 2                                            6,5%                                    2,0%
 Autoimmune hepatitis, 1                                         3,2%                                    1,0%
 Celiac disease, 1                                               3,2%                                    1,0%
 Alopecia areata, 1                                              3,2%                                    1,0%
 MCTD, 1                                                         3,2%                                    1,0%
 Polymyositis, 1                                                 3,2%                                    1,0%
 Number of AID in CU
 One, 23                                                         74,2%                                 22,5%
 Two, 7                                                          22,6%                                   6,9%
 Three, 1                                                        3,2%                                    1,0%
 Combination of CU of two or more autoimmune diseases
 HT + pernicious anemia, 2                                       6,5%                                    2,0%
 HT + celiac disease, 1                                          3,2%                                    1,0%
 HT + vitiligo, 1                                                3,2%                                    1,0%
 HT + RA, 1                                                      3,2%                                    1,0%
 HT + SLE, 1                                                     3,2%                                    1,0%
 HT + SLE + RA, 1                                                3,2%                                    1,0%
 alopecia areata + SLE, 1                                        3,2%                                    1,0%

AID = autoimmune diseases; CU = chronic urticaria; HT = Hashimoto’s disease; RA = rheumatoid arthritis; SLE = systemic lupus
erythematosus.




    The available data suggest that 33–67% of all patients         most common were allergic rhinitis (19.9%) and asthma
with CU have concomitant angioedema [10]. We obtained              (10.8%). Zuberbier et al. [14] also concluded that atopy,
very similar results. Angioedema usually affects the skin on       mainly allergic rhinitis (41.9%), and atopic dermatitis
the face, mainly the lips and eyelids [11]. In contrast, our       (18.9%) were the most common. A Korean study also
results showed that non-facial body areas were the most fre-       highlighted the high burden of allergic rhinitis, drug al-
quent locations for angioedema, which may be related to the        lergies, and asthma [15]. In the Scandinavian AWARE
relatively high percentage of patients with delayed pressure       study, a follow up-study of patients with CU refractory to
urticaria in our study, which is characterized by erythema-        antihistamine treatment, the most common comorbidities
tous swelling of the skin 4 to 6 hours after the application       were atopic diseases including asthma, allergic rhinitis,
of pressure. The swelling of the hands and feet provoked by        food allergies, and atopic dermatitis. [16]. Our results are
pressure may be difficult to tell apart from swelling caused       similar to these past findings. Type-I auto-allergic CSU is
by angioedema [12].                                                quite common and possibly more likely associated with
    Most publications do not provide information on the            atopic comorbidities than type- IIb auto-immune driven
frequency of episodes of CU. The data mainly relate to the         CSU, which seemingly be the reason for the high fre-
duration of the disease, which is estimated at generally 1-5       quency of atopic comorbidities observed in the overall CU
years [10]. The frequency of urticaria symptoms in this study      population [17].
was estimated as: 59.8% daily, 16.7% several times a week,               On the other hand, the large registry study from Ger-
8.8% several times a month, and 14.7% irregularly.                 many demonstrated hypertensive diseases (43.5%), lipopro-
    Many researchers analyzed mainly allergic diseases ac-         tein metabolism disorders (32.1%), and affective disorders
companying urticaria. Shalom et al. [13] reported that the         (26.0%) as the most frequently reported comorbidities of


Original Article | Dermatol Pract Concept. 2023;13(1):e2023056                                                               5
special interest [18]. This is in contrast to our findings where   patients. We found the prevalence of thyroid diseases among
coexisting hypertension was reported by only 8.8% of pa-           CU patients was about 36.3%. Hashimoto’s thyroiditis
tients. A retrospective Danish cohort study that examined          was the most prevalent thyroid disease (22.5%), followed
the prevalence of cardiovascular diseases did not find any         by hypothyroidism (17.6%), hyperthyroidism (2.9%), and
increased risk of these in CU patients compared to the gen-        Graves’ disease (2.0%).
eral population [19]. However, an extended duration of CSU            The relationship of CU with autoimmune thyroid dis-
is more likely in patients with arterial hypertension [5]. In      eases has been underlined for many years and a large num-
the Taiwan study, among the four categories of comorbid-           ber of studies have been conducted worldwide [27]. It is
ities that were examined, inflammatory diseases (9.78%)            worth noting that most of the studies have analyzed the re-
were the most prevalent, followed by psychiatric disorders         lationship between CSU and thyroid autoimmunity. Little is
(8.53%), rheumatic diseases (2.48%), and thyroid disorders         known about whether CIndU is also linked to thyroid au-
(1.78%) [20].                                                      toimmunity. Our data showed that 26,3% of patients with
    Other studies have found that psychiatric comorbidities        isolated CSU had autoimmune thyroid disease, while with
were the most commonly recognized in CU patients, ranging          isolated CIndU only 13,6%.
up to 60%. Anxiety, depression, and somatoform disorders              The guidelines of the EAACI/GA2LEN/EDF/WAO rec-
have been reported to be the most prevalent mental disorders       ommend that physicians assess CU patients for family his-
in CU patients [21]. In our study, almost 26% of patients          tory of urticaria and atopy [1]. In our study, family history of
reported psychiatric disorders, most often depression.             urticaria and atopy was negative in the majority of patients,
    Many authors emphasize the possible role of parasitic in-      92.2 % in urticaria and 74.5% in atopy. On the other hand,
festations and inflammation in chronic urticaria [22]. In our      autoimmune disorders were common in family members.
analysis, none of the respondents reported parasitic infesta-         Our study has some limitations. First, respondents were
tions. Whereas among inflammatory diseases, the most com-          recruited through Facebook groups and there is a poten-
mon were sinusitis (17.6%), gastritis (10.8%), and urinary         tial sample selection bias. Our study population cannot be
tract infection (7.8%). Authors from Taiwan found peptic           representative of all chronic urticaria patients as the partic-
ulcer was the most prevalent inflammatory disease (4.83%),         ipation of men has been unrepresentative. We did not use
followed by hepatitis B/hepatitis C (1.64%) and periodonti-        any instrument for assessing urticaria severity therefore we
tis (2.82%) [20].                                                  do not know the severity of the disease in the respondents.
    The association between CU and neoplasm diseases is still      However, patients participating in urticaria groups typi-
controversial. One population-based study reported no asso-        cally have more severe and uncontrolled symptoms of the
ciation between CU and cancer [23]. A study from Taiwan            disease. In addition, women participate more actively in so-
demonstrated an increased risk of hematological malignant          cial networks and are looking for more information about
tumors, especially non-Hodgkin lymphoma, in patients with          the diseases they suffer from. Another limitation is the fact
CU [24]. A Korean study showed an increased risk of non-           that middle-aged patients are more likely to participate ac-
hematological tumors, especially stomach, thyroid, and liver       tively in social networks and online survey studies thus the
cancers in the case of CU, and thyroid, liver, and prostate        obtained data may not be representative of all age groups.
cancers in the case of CSU [15]. In our study, two patients        Most of our study population were patients between the ages
reported the presence of melanoma and carcinoid tumor.             of 19 and 39. Taking into account all of this, our data have
    A systematic review of the literature on autoimmune co-        over-represented young women and those who have more
morbidities in patients with CU showed that the most com-          severe chronic urticaria.
mon autoimmune comorbidities were autoimmune thyroid                  As mentioned above, young women and patients with
diseases and vitiligo [25]. Our results are similar, except that   severe diseases seek more information about the disease they
the next most common diseases after autoimmune thyroid             suffer from and are more active on social media. Such a pro-
diseases (24.5%) were rheumatoid arthritis (2.9%) and sys-         file of patients participating in our study may affect the per-
temic lupus erythematosus (2.9%).                                  centage of comorbidities which is relatively high compared
    Thyroid dysfunctions, especially autoimmunity, have            to other reported publications.
been most commonly found among CU patients, with the                  Finally, the high registration percentage of delayed pres-
reported prevalence ranging up to more than 50% depend-            sure urticaria in our study may be a result of the percentage
ing on the inclusion criteria. Association studies using the       of angioedema. Regarding the fact that it can be difficult for
presence of anti-thyroid antibodies as the criteria usually        patients to distinguish between swelling caused by pressure
obtained higher frequencies [26]. In this study, we defined        from swelling caused by angioedema they often confuse the
the presence of thyroid disorders based on self-reports by         two entities or report them in the same way.




6                                                                      Original Article | Dermatol Pract Concept. 2023;13(1):e2023056
Conclusions                                                                    Allergy Organ J. 2018;11(1):32. Published 2018 Nov 16.
                                                                               doi:10.1186/s40413-018-0216-1
In conclusion, CU significantly influences the quality of pa-             9.   Sánchez J, Amaya E, Acevedo A, Celis A, Caraballo D, Cardona R.
                                                                               Prevalence of Inducible Urticaria in Patients with Chronic Spon-
tients’ lives, which may be negatively affected by the associ-
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ation with a wide range of comorbidities. Our study found                      nol Pract. 2017;5(2):464-470. doi:10.1016/j.jaip.2016.09.029
that the most common comorbidities in CU include atopic                  10.   Maurer M, Weller K, Bindslev-Jensen C, et al. Unmet clinical
and allergic diseases, chronic inflammations, thyroid, and                     needs in chronic spontaneous urticaria. A GA²LEN task force
psychiatric disorders. This pattern of comorbidities seems to                  report. Allergy. 2011;66(3):317-330. doi:10.1111/j.1398-9995
be specific to CU. Our data suggest that patients with auto-                   .2010.02496.x
                                                                         11.   Nowicki RJ, Grubska-Suchanek E, Porêbski G, et al.
immune urticaria are more likely to have autoimmune co-
                                                                               Angioedema. Interdisciplinary diagnostic and therapeutic rec-
                                                                               ­
morbidities than patients without this subtype of CSU. This                    ommendations of the Polish Dermatological Society (PTD) and
may be explained by the known co-occurrence of multiple                        Polish Society of Allergology (PTA). Postepy Dermatol Alergol.
autoimmune phenomena and autoimmune diseases. There-                           2020;37(4):445-451. doi:10.5114/ada.2020.98226
fore, autoimmune comorbidities in patients with chronic                  12.   Lawlor F, Black AK. Delayed pressure urticaria. Immunol
urticaria may suggest the presence of an autoimmunologi-                       Allergy Clin North Am. 2004;24(2):247-vii. doi:10.1016/j.
                                                                               iac.2004.01.006
cal subtype of CSU, which is usually more severe and has a
                                                                         13.   Shalom G, Magen E, Dreiher J, et al. Chronic urticaria and atopic
significantly worse response to omalizumab treatment [28].                     disorders: a cross-sectional study of 11 271 patients. Br J Derma-
Knowledge of the comorbidities of CU may support clini-                        tol. 2017;177(4):e96-e97. doi:10.1111/bjd.15347
cians in appropriately managing and treating this condition.             14.   Zuberbier T, Balke M, Worm M, Edenharter G, Maurer M.
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