Case and Research Letter
Refractory solar urticaria successfully treated with omalizumab with normalization of phototest
Urticaria solar refractaria tratada satisfactoriamente con omalizumab y normalización del fototest
A. Combalia
, C. Fernández-Sartorio, P. Aguilera
Corresponding author
Dermatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
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Combalia, C. Fernández-Sartorio, P. Aguilera" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Combalia" "email" => array:1 [ 0 => "andreacombalia@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Fernández-Sartorio" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Aguilera" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Dermatology Department, Hospital Clínic de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Urticaria solar refractaria tratada satisfactoriamente con omalizumab y normalización del fototest" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 996 "Ancho" => 990 "Tamanyo" => 67385 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Phototest before omalizumab (Waldman® UV 181 UVA) was positive for UVA, minimal urticarial dose 7<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>. (B) Phototest after omalizumab (Waldman® UV 181 UVA): no reaction occurred to UVA after 6 months of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Solar urticaria (SU) is a rare photodermatosis characterized by sudden onset of urticarial skin lesions, intense itching or burning on photo-exposed areas, occurring a few minutes after sun exposure with great impact on patients’ quality of life. It is considered a type I hypersensitivity reaction, and therefore, it is an immunoglobulin E (IgE)-mediated condition that may be accompanied by other systemic symptoms and signs, such as dizziness, headache and angioedema. The action of spectrum for SU includes ultraviolet A (UVA), ultraviolet B (UVB), visible light (VL) and some patients may be sensitive to multiple action spectra. Although the diagnosis is made by the characteristic clinical presentation, it can be confirmed by phototesting.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The treatment of choice consists in broad-spectrum sunscreens and high-dose H1-antihistamines; however, SU is often unresponsive to them. Other treatment options are leukotriene receptor antagonists, UV-hardening, cyclosporine A, antimalarial drugs, plasmapheresis and intravenous immunoglobulin (IVIG). Efficacy of these treatments is usually partial or transient and may induce several unwanted effects, i.e. anaphylaxis, immunosuppression and malignancy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Omalizumab is a humanized monoclonal IgG1-kappa antibody against IgE recently approved by the US Food and Drug Administration and the European Medicines Agency for antihistamine refractory patients with chronic spontaneous urticaria (CSU) who are at least 12 years of age.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Omalizumab binds to free IgE with a greater affinity than IgE itself binds to the high-affinity Fc¿RI receptors present on basophils. Thus, it reduces the availability of free IgE for binding and promotes down-regulation of Fc¿RI on the surface of mast cells and basophils preventing IgE-mediated histamine release.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We report a case of a previously healthy 21 year-old Caucasian female with a 4-year history of erythema, intense itch, swelling and hives after minimal sun exposure even through window glass. No history of asthma or food allergy was reported. Phototest performed on the patient's back (Waldman® UV 181 UVA and Waldman® UV 800 broad band UVB) was positive for UVA, minimal urticarial dose 7<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>, and showed no reaction to UVB (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Visible light was not tested. IgE serum levels were elevated (294<span class="elsevierStyleHsp" style=""></span>kU/L) and other blood test determinations fell within normal limits; cell count, porphirins, antinuclear antibodies, liver and renal function panel, and serum triptase. She was diagnosed with Solar Urticaria (SU) induced by UVA, and partially achieved to control symptoms with antihistamines (Fexofenadine hydrochloride 180<span class="elsevierStyleHsp" style=""></span>mg/day) and broad-spectrum sunscreens.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Three years after diagnosis, her SU became unresponsive to first-line treatment with antihistamines, even updosing up to 4-fold. Her quality of life, as assessed by the Dermatology Quality of Life Index (DLQI 21) was seriously affected by SU. Thus, after careful consideration we decided to try experimental therapy with omalizumab. Following approval from our institution ethics committee for exceptional medical treatments, an initial dose of 300<span class="elsevierStyleHsp" style=""></span>mg of omalizumab was administered in April 2015, and antihistamines were gradually discontinued. Subsequent doses of 300<span class="elsevierStyleHsp" style=""></span>mg were administered monthly.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient reported a complete relief of symptoms within one day of the administration of the first dose (DLQI 0). She remained asymptomatic during the Spanish summer and no side effects were noted. However, a delay of omalizumab administration of one week brought back mild urticaria on one occasion. We repeated the phototest six months later to check treatment response and no reaction occurred to either UVA or UVB spectrum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). One year later, she is still on omalizumab and the effect is sustained.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment of SU with omalizumab is still off-label; however, management of SU with omalizumab has been proved effective on several occasions<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–9</span></a> and promising clinical results have recently been published.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On a recently published phase-II multicentric study,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> the response rate of SU to omalizumab appeared close to the mean proportion of patients with CSU achieving a urticarial activity score over 7 days of 6 or less with the same dose of omalizumab, and; similar to what is observed in CSU, the improvement in solar urticaria was rapidly lost when omalizumab was stopped.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Omalizumab seems to be a new well-tolerated effective agent in the treatment of severe SU and might be soon included in SU treatment guidelines as a third-line therapy in the same way it is done with CSU.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 996 "Ancho" => 990 "Tamanyo" => 67385 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Phototest before omalizumab (Waldman® UV 181 UVA) was positive for UVA, minimal urticarial dose 7<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>. (B) Phototest after omalizumab (Waldman® UV 181 UVA): no reaction occurred to UVA after 6 months of treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The clinical and photobiological characteristics of solar urticaria in 40 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N. Uetsu" 1 => "H. Miyauchi-Hashimoto" 2 => "H. Okamoto" 3 => "T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 9 | 19 |
| 2024 October | 65 | 31 | 96 |
| 2024 September | 68 | 18 | 86 |
| 2024 August | 98 | 52 | 150 |
| 2024 July | 82 | 41 | 123 |
| 2024 June | 85 | 38 | 123 |
| 2024 May | 85 | 41 | 126 |
| 2024 April | 70 | 31 | 101 |
| 2024 March | 74 | 31 | 105 |
| 2024 February | 56 | 26 | 82 |
| 2024 January | 48 | 38 | 86 |
| 2023 December | 44 | 18 | 62 |
| 2023 November | 51 | 27 | 78 |
| 2023 October | 51 | 24 | 75 |
| 2023 September | 53 | 33 | 86 |
| 2023 August | 49 | 19 | 68 |
| 2023 July | 64 | 32 | 96 |
| 2023 June | 40 | 19 | 59 |
| 2023 May | 51 | 24 | 75 |
| 2023 April | 41 | 29 | 70 |
| 2023 March | 38 | 20 | 58 |
| 2023 February | 44 | 25 | 69 |
| 2023 January | 27 | 24 | 51 |
| 2022 December | 42 | 37 | 79 |
| 2022 November | 22 | 31 | 53 |
| 2022 October | 35 | 23 | 58 |
| 2022 September | 22 | 39 | 61 |
| 2022 August | 29 | 35 | 64 |
| 2022 July | 16 | 35 | 51 |
| 2022 June | 20 | 24 | 44 |
| 2022 May | 49 | 42 | 91 |
| 2022 April | 50 | 35 | 85 |
| 2022 March | 59 | 41 | 100 |
| 2022 February | 49 | 23 | 72 |
| 2022 January | 54 | 30 | 84 |
| 2021 December | 36 | 37 | 73 |
| 2021 November | 40 | 44 | 84 |
| 2021 October | 46 | 51 | 97 |
| 2021 September | 36 | 33 | 69 |
| 2021 August | 21 | 32 | 53 |
| 2021 July | 19 | 27 | 46 |
| 2021 June | 35 | 25 | 60 |
| 2021 May | 39 | 51 | 90 |
| 2021 April | 77 | 84 | 161 |
| 2021 March | 55 | 38 | 93 |
| 2021 February | 45 | 29 | 74 |
| 2021 January | 29 | 15 | 44 |
| 2020 December | 36 | 23 | 59 |
| 2020 November | 25 | 21 | 46 |
| 2020 October | 24 | 12 | 36 |
| 2020 September | 29 | 19 | 48 |
| 2020 August | 34 | 16 | 50 |
| 2020 July | 26 | 22 | 48 |
| 2020 June | 29 | 45 | 74 |
| 2020 May | 17 | 16 | 33 |
| 2020 April | 28 | 12 | 40 |
| 2020 March | 20 | 12 | 32 |
| 2020 February | 3 | 0 | 3 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 6 | 0 | 6 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 2 | 0 | 2 |
| 2019 April | 2 | 0 | 2 |
| 2019 February | 3 | 0 | 3 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 3 | 0 | 3 |
| 2018 February | 12 | 4 | 16 |
| 2018 January | 20 | 3 | 23 |
| 2017 December | 47 | 6 | 53 |
| 2017 November | 16 | 8 | 24 |
| 2017 October | 14 | 15 | 29 |
| 2017 September | 19 | 13 | 32 |
| 2017 August | 38 | 20 | 58 |
| 2017 July | 39 | 27 | 66 |
| 2017 June | 5 | 1 | 6 |
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