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
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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" => 66330 ] ] "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" => 66330 ] ] "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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 9 | 15 |
| 2024 Octubre | 50 | 52 | 102 |
| 2024 Septiembre | 72 | 24 | 96 |
| 2024 Agosto | 77 | 52 | 129 |
| 2024 Julio | 55 | 29 | 84 |
| 2024 Junio | 67 | 49 | 116 |
| 2024 Mayo | 50 | 39 | 89 |
| 2024 Abril | 50 | 22 | 72 |
| 2024 Marzo | 56 | 27 | 83 |
| 2024 Febrero | 42 | 29 | 71 |
| 2024 Enero | 46 | 20 | 66 |
| 2023 Diciembre | 41 | 22 | 63 |
| 2023 Noviembre | 51 | 33 | 84 |
| 2023 Octubre | 52 | 23 | 75 |
| 2023 Septiembre | 44 | 26 | 70 |
| 2023 Agosto | 36 | 12 | 48 |
| 2023 Julio | 74 | 27 | 101 |
| 2023 Junio | 65 | 20 | 85 |
| 2023 Mayo | 54 | 27 | 81 |
| 2023 Abril | 56 | 27 | 83 |
| 2023 Marzo | 50 | 26 | 76 |
| 2023 Febrero | 45 | 30 | 75 |
| 2023 Enero | 41 | 30 | 71 |
| 2022 Diciembre | 53 | 31 | 84 |
| 2022 Noviembre | 35 | 30 | 65 |
| 2022 Octubre | 62 | 29 | 91 |
| 2022 Septiembre | 43 | 43 | 86 |
| 2022 Agosto | 47 | 46 | 93 |
| 2022 Julio | 52 | 35 | 87 |
| 2022 Junio | 58 | 26 | 84 |
| 2022 Mayo | 44 | 52 | 96 |
| 2022 Abril | 60 | 39 | 99 |
| 2022 Marzo | 57 | 39 | 96 |
| 2022 Febrero | 60 | 26 | 86 |
| 2022 Enero | 62 | 40 | 102 |
| 2021 Diciembre | 42 | 32 | 74 |
| 2021 Noviembre | 41 | 45 | 86 |
| 2021 Octubre | 55 | 62 | 117 |
| 2021 Septiembre | 28 | 35 | 63 |
| 2021 Agosto | 32 | 36 | 68 |
| 2021 Julio | 33 | 35 | 68 |
| 2021 Junio | 45 | 48 | 93 |
| 2021 Mayo | 43 | 57 | 100 |
| 2021 Abril | 78 | 83 | 161 |
| 2021 Marzo | 94 | 29 | 123 |
| 2021 Febrero | 62 | 36 | 98 |
| 2021 Enero | 40 | 38 | 78 |
| 2020 Diciembre | 35 | 19 | 54 |
| 2020 Noviembre | 30 | 34 | 64 |
| 2020 Octubre | 31 | 34 | 65 |
| 2020 Septiembre | 29 | 29 | 58 |
| 2020 Agosto | 27 | 26 | 53 |
| 2020 Julio | 37 | 21 | 58 |
| 2020 Junio | 35 | 30 | 65 |
| 2020 Mayo | 26 | 12 | 38 |
| 2020 Abril | 35 | 19 | 54 |
| 2020 Marzo | 26 | 16 | 42 |
| 2020 Febrero | 8 | 0 | 8 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 12 | 0 | 12 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 8 | 0 | 8 |
| 2019 Abril | 13 | 0 | 13 |
| 2019 Febrero | 5 | 0 | 5 |
| 2019 Enero | 4 | 2 | 6 |
| 2018 Diciembre | 7 | 2 | 9 |
| 2018 Noviembre | 4 | 2 | 6 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Febrero | 19 | 6 | 25 |
| 2018 Enero | 16 | 10 | 26 |
| 2017 Diciembre | 27 | 12 | 39 |
| 2017 Noviembre | 19 | 12 | 31 |
| 2017 Octubre | 4 | 15 | 19 |
| 2017 Septiembre | 13 | 18 | 31 |
| 2017 Agosto | 10 | 52 | 62 |
| 2017 Julio | 17 | 228 | 245 |
| 2017 Junio | 4 | 25 | 29 |
| 2017 Mayo | 0 | 7 | 7 |
| 2017 Abril | 0 | 29 | 29 |
| 2017 Marzo | 0 | 21 | 21 |
| 2017 Febrero | 0 | 35 | 35 |
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