Iman Nasr

Chronic urticaria is a mast cell–driven inflammatory disease characterized by recurrent wheals, angioedema or both for more than 6 weeks, with substantial effects on sleep, quality of life, mental health and daily functioning. Type I autoallergic and type IIb autoimmune mechanisms represent major endotypes, but many patients show overlapping or mixed features, contributing to heterogeneous clinical courses and variable treatment responses. Current management relies on confirming the diagnosis, excluding differential diagnoses, identifying aggravating factors and comorbidities and monitoring disease activity and control using validated patient‐reported outcome measures. A limited, clinically guided diagnostic workup is preferred, with extended investigations reserved for selected cases based on history, examination, red flags or isolated angioedema. Second‐generation H1‐antihistamines remain the first‐line therapy, with up‐dosing recommended in insufficient responders. Omalizumab has transformed the treatment of antihistamine‐refractory disease, while newer options such as dupilumab and remibrutinib further expand the therapeutic landscape. Ciclosporin remains an effective option in selected patients, particularly those with severe or difficult‐to‐treat disease, but requires careful safety monitoring. In chronic inducible urticaria, provocation testing, threshold assessment, trigger counselling and individualized treatment are central to care. Despite recent advances, important unmet needs remain, including reliable biomarkers for endotyping, evidence‐based selection among emerging therapies, better data in children and other special populations, standardized definitions of remission and relapse and disease‐modifying strategies. Future management is expected to move towards biomarker‐driven, personalized care, enabling more precise treatment selection and sustained disease control.

Al-Tamemi et al. describe that autosomal recessive CGD represents a significant disease in the MENA region associated with significant morbidity and mortality. Regional challenges are related to universal newborn BCG vaccine, lack of newborn screening programs, and limitation of curative interventions such as hematopoietic stem cell transplantation and gene therapy.

Background and Objective Symptomatic dermographism (SD), the most common chronic inducible urticaria subtype, manifests as strip-shaped, pruritic wheals after skin friction. Conclusive data on its associated factors are limited, and direct comparisons between individuals with and without SD remain scarce. We aimed to identify factors associated with SD internationally. Methods The PREVALENCE-D (Prevalence Estimation of Dermographism) study was an international cross-sectional survey conducted from 2021 to 2024 across 19 countries. An expert-designed questionnaire diagnosed SD and assessed potential associated factors. SD participants were defined as those who self-reported chronic recurrent urticarial dermographism with itch. Factors associated with SD were identified by comparing participants with and without SD. Results Of 68,513 participants, 3101 had SD (female 73.3%). Their mean age was 40.2 ± 16.2 years. Key factors associated with SD included atopic dermatitis (adjusted odds ratio [aOR] 4.20, 95% confidence interval [CI] 3.62‒4.88) and allergic rhinitis (aOR 2.11, 95% CI 1.88‒2.37). Participants with at least one atopic condition (allergic rhinitis, atopic dermatitis, or asthma) were significantly more likely to have SD (aOR 2.70, 95% CI 2.47‒2.95). Those with all three atopic conditions had a further increased likelihood of SD (aOR 7.75, 95% CI 5.31‒11.29). Other associations included working and older age groups, female sex, dyslipidemia, and thyroid disease. Conclusions Atopic dermatitis and allergic rhinitis emerged as the strongest correlates of SD, especially those with all three atopic conditions. Thus, allergic comorbidities should be assessed in SD patients. Further research is needed to clarify the pathophysiological relationship between these conditions and SD. [Graphical abstract available online] Graphical Abstract

This update and revision of the international guideline for urticaria was developed in accordance with the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is an initiative of the Global Allergy and Asthma Excellence Network (GA ² LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), with the participation of 210 delegates from 107 national and international societies, from 59 countries. The consensus conference was held on December 6th, 2024. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell‐driven disease, defined by a rapid appearance of wheals, angioedema, or both. The lifetime prevalence of acute urticaria is estimated to be approximately 20%. Chronic urticaria, categorized as either chronic spontaneous urticaria or chronic inducible urticaria, is disabling, impairs quality of life, and affects performance at work and school, however, novel therapies are available. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert‐guided and evidence‐based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Background: The prevalence of symptomatic dermographism ( SD ) in the general population remains unclear. This study aimed to internationally estimate the prevalence of SD and two other dermographic subtypes—physiological red dermographism and simple urticarial dermographism—among adults worldwide. Methods: The PREVALENCE ‐D (Prevalence Estimation of Dermographism) study was the largest international, cross‐sectional, internet‐based investigation conducted by the Urticaria Centers of Reference and Excellence of the Global Allergy and Asthma Excellence Network from 2021 to 2024. A world expert‐designed questionnaire was completed by participants from 28 centers across 19 countries to diagnose SD . Participants were recruited into three age groups (18–24, 25–60, and > 60 years), with ≥ 1000 individuals per group per country. We calculated sex‐ and age‐adjusted prevalence estimates internationally and by country, with 95% confidence intervals. Results: Among 59,543 participants worldwide, those with SD had an adjusted point prevalence of 3.20% (95% confidence interval [ CI ] 2.68%–3.73%) and a lifetime prevalence of 5.94% (95% CI 5.32%–6.56%). The 25–60 years group presented the highest prevalence. Females had higher rates than males, with statistically significant differences across all age groups for both point and lifetime prevalence. Physiological red dermographism had an adjusted point prevalence of 10.02% (95% CI 9.48%–10.55%) and a lifetime prevalence of 33.47% (95% CI 32.01%–34.94%). Simple urticarial dermographism showed an adjusted point prevalence of 1.21% (95% CI 1.08%–1.35%) and a lifetime prevalence of 5.39% (95% CI 4.99%–5.79%). Conclusion: These findings provide comprehensive international estimates of dermographism, particularly SD , and emphasize the need for appropriate healthcare resource allocation and disease recognition.

Background: CRUSE® is an app that allows patients with chronic spontaneous urticaria (CSU) to monitor their daily disease activity through the use of visual analogue scales (VASs). We aimed to determine the concurrent validity, reliability, responsiveness and minimal important difference (MID) of CRUSE® VASs. Method s: We evaluated the properties of three daily VASs: VAS for how much patients were affected by their CSU (‘VAS urticaria’), VAS for the impact of urticaria on work/school productivity (‘VAS productivity’) and the VAS of EQ‐5D. Concurrent validity was assessed by measuring the association between each VAS and the Urticaria Activity Score (UAS). Intra‐rater reliability was determined based on the data of users providing multiple daily questionnaires within the same day. Test–retest reliability and responsiveness (ability to change), respectively, were tested in clinically stable and clinically unstable users. MIDs were determined using distribution‐based methods. Results: We included 5938 patients (67,380 days). Concurrent validity was high, with VAS urticaria being more strongly associated with the UAS score than the remaining VASs. Intra‐rater reliability was also high, with intraclass correlation coefficients (ICC) being above 0.950 for all VASs. Moderate‐high test–retest reliability and responsiveness were observed, with reliability ICC being highest for VAS EQ‐5D and responsiveness being highest for VAS urticaria. The MID for VAS urticaria was 17 (out of 100) units, compared to 15 units for VAS productivity and 11 units for VAS EQ‐5D. Conclusion: Daily VASs for CSU available in the CRUSE® app display high concurrent validity and intra‐rater reliability and moderate‐high test–retest reliability and responsiveness.

Background: Identifying immune cells involved in COVID-19 disease progression and predictors of poor outcomes is important to manage patients adequately. Methods: A prospective observational cohort study enrolled 53 mild non-hospitalized and 48 hospitalized confirmed COVID-19 patients to a tertiary hospital in Oman. Results: Hospitalized patients were older (58 years vs 36 years, p <0.001) and had more comorbid conditions like diabetes (65 % Vs 21% p<0.001). Hospitalized patients had significantly higher inflammatory markers (p<0.001); C-reactive protein (CRP) (114 vs 4 mg/L), Interleukin-6 (IL-6) (33 vs 3.71pg/ml), lactate dehydrogenase (LDH) (417 vs 214 U/L), ferritin (760 vs 196 ng/mL), fibrinogen (6 vs 3 g/L), D-dimer (1.0 vs 0.3 mcg/mL), disseminated intravascular coagulopathy (DIC) score (2 vs 0) and neutrophil/lymphocyte ratio (4 vs 1.1), (p<0.001). In multivariate regression analysis, statistically significant independent early predictors of ICU admission or death were higher levels of IL-6 (OR 1.03, p=0.03), frequency of large inflammatory monocytes (CD14+CD16+) (OR 1.117, p=0.010) and frequency of circulating naïve CD4+ T cells (CD27+CD28+CD45RA+CCR7+) (OR 0.476, p=0.03). Conclusion: IL-6, frequency of large inflammatory monocytes, and circulating naïve CD4 T cells can be used as independent immunological predictors of poor outcomes in COVID-19 patients to prioritize critical care and resources.

Objectives: Anaphylaxis is an acute, life-threatening allergic reaction involving multiple systems caused by the sudden release of mediators from mast cells. This study aims to assess the current practice of emergency management of adults and children diagnosed with anaphylaxis at the Royal Hospital, against the recommendations of the National Institute for Health and Clinical Excellence (NICE) guidelines. Methods: This is an observational study of all anaphylaxis cases which took place at the emergency department (ED) during a 5-year period. Results: Of 100 patients with a preliminary diagnosis of anaphylaxis, 49% were true-anaphylaxis cases based on the WAO definition. All the 49-patients with true-anaphylaxis received adrenaline intramuscularly at ED. 24 (48.9%) of them were referred to an immunologist: 8/24 (33.3%) were adults and 16/24 (66.6%) were children. 16-children were admitted, seen by an immunologist and received an adrenaline autoinjector when indicated. 25 of the 33 adult patients (75.7%) were discharged from the ED with no onward referral to a specialist. None of the adult patients received an adrenaline autoinjector prior to discharge from ED and no one had a tryptase level checked. Conclusion: The paediatric emergency department fulfilled all the criteria for anaphylaxis management in accordance with NICE guidelines except for measuring serum tryptase where appropriate. By contrast, the adult patients were discharged from ED without an adrenaline autoinjector as an interim measure until seen by an allergist or immunologist. Therefore, education is the best strategy to improve the management of this severe and possible fatal condition.