From the Guidelines
Yes, chronic spontaneous urticaria (CSU) can occur without wheal eruptions, as evidenced by the presence of angioedema with or without wheals in patients with CSU. According to the guidelines for chronic spontaneous urticaria, patients with CSU can experience angioedema with or without wheals, and the Angioedema Activity Score should be used to assess disease activity in these patients 1. The guidelines also recommend using the Angioedema Control Test (AECT) to assess disease control in patients with CSU who develop angioedema with or without wheals. This suggests that CSU can manifest without wheal eruptions, but with angioedema, and that treatment decisions should be guided by the results of the AECT.
Some key points to consider in the diagnosis and treatment of CSU without wheal eruptions include:
- The use of the AECT to assess disease control in patients with CSU who develop angioedema with or without wheals 1
- The importance of considering other conditions, such as pruritus or dermatographism, in patients who experience symptoms like itching without visible wheals
- The standard treatment for CSU, including non-sedating H1-antihistamines, which can be increased up to four times the standard dose if needed, and omalizumab for antihistamine-resistant cases
- The pathophysiology of CSU, which involves mast cell activation and release of histamine and other inflammatory mediators, leading to increased vascular permeability and fluid accumulation in the skin.
In terms of treatment, the guidelines recommend a step-wise approach, starting with non-sedating H1-antihistamines, and progressing to omalizumab or other treatments if necessary 1. The goal of treatment is to provide patients with complete control of their disease, and the AECT can be used to guide treatment decisions.
From the Research
Definition and Characteristics of Chronic Spontaneous Urticaria
- Chronic spontaneous urticaria (CSU) is characterized by recurring wheals that last 6 weeks or longer without an identifiable cause 2.
- It is defined as persistent symptoms of urticaria for 6 weeks or more, often associated with autoimmunity in approximately 45 percent of patients 3.
- CSU is an inflammatory skin disease associated with medical and psychiatric comorbidities and impaired quality of life 4.
Symptoms and Diagnosis
- Symptoms of CSU include intensely itchy wheals, angioedema, or both, which recur spontaneously on a near-daily basis over more than 6 weeks 5.
- Diagnosis is based on clinical presentation, including spontaneously recurring wheals, angioedema, or both 4.
- CSU can present with comorbidities, including chronic inducible urticaria, autoimmune thyroiditis, metabolic syndrome, anxiety, and depression 4.
Treatment and Management
- Second-generation H1 antihistamines are first-line treatment for CSU, with partial or complete response observed in approximately 40% of patients 4.
- The monoclonal anti-IgE antibody omalizumab is recommended as second-line treatment for antihistamine-refractory CSU 4.
- Cyclosporine can improve symptoms in approximately 54% to 73% of patients, especially those with autoimmune CSU and nonresponse to omalizumab, but has adverse effects such as kidney dysfunction and hypertension 4.
Occurrence of CSU without Wheal Eruption
- There is no direct evidence in the provided studies to suggest that CSU can occur without wheal eruption, as wheals are a characteristic symptom of the condition 5, 2, 4.
- However, it is possible that some patients may experience other symptoms, such as angioedema or itching, without visible wheals, but this is not explicitly stated in the provided studies.