Urticaria chronic spontaneous L50.8

Author: Prof. Dr. med. Peter Altmeyer

Our authors

Last updated on: 29.10.2020

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Synonym(s)

chronic spontaneous urticaria; chronic urticaria; Urticaria chronic; Urticaria chronica

Definition
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Urticaria existing for longer than 6 weeks (in many cases the clinical picture exists for > 5 years). A distinction is made according to the clinical course:

  • chronic-continuous spontaneous urticaria with daily attacks
  • Chronic recurrent spontaneous urticaria with relapsing episodes alternating with symptom-free intervals.

The term spontaneous or idiopathic urticaria refers to the unknown etiology and is in contrast to chronic inducible urticaria (causes known or easily determined e.g. physical urticaria see below). urticaria)

Classification
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S.u. Urticaria

Occurrence/Epidemiology
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Prevalence data vary between 0.1% and 0.6%. Cumulative prevalences (number of people who have experienced urticaria at some time in their lives) range from 9% to 25%.

Etiopathogenesis
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  • Up to 70% of diseases are idiopathic.
  • Positive history of atopy exists in about 1/4 of the patients. The total IgE is elevated in > 50% of cases.
  • The model of molecular mimicry of epitopes as a possible trigger of chronic urticaria is discussed repeatedly. The model is based e.g. on the temporary presence of various antibodies (e.g. thyroid autoantibodies TAK/TPO) as well as temporary or permanent susceptibility to non-immunological hypersensitivity reactions (e.g. intolerance reactions characterized by non-IgE-mediated histamine release ).
  • Depending on the type of urticaria, very different triggers are possible:
    • Drugs or foods (non-IgE-mediated; see also intolerance reactions; biogenic amines)
    • Food additives: colouring agents, benzoates, salicylates, sulphites, glutamates (non-IgE-mediated); the data situation is contradictory; causal for < 5% of the patents).
    • Acetylsalicylic acid: no association with salicylate-containing food (non-IgE-mediated)
    • Food (IgE-mediated allergic reactions) or contamination (e.g. residues of antibiotics in meat, etc.): such reactions are rather rare (< 1% in children and adults)
    • Bacterial infections (Helicobacter pylori [for this mode of infection there is the highest evidence], streptococci, staphylococci, Yersinia); for infections in the dental and ENT area there are no reliable correlations between therapy and the course of urticaria, although in individual cases these correlations are postulated.
    • Viral infections (there are reports of hepatitis virus infections and noro virus infections [so far no convincing evidence])
    • Parasites (lamblia, entamoeba, worm infections; trichomonads, trichinella, Toxocara canis)
    • Autoimmune processes (autologous serum test, thyroid autoantibodies - see autoreactive urticaria)
    • Rarely: tumours, hepatitis.

Manifestation
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Women are affected about twice as often as men. The frequency peak is between 30 and 40 years.

Clinical features
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Repeatedly or constantly occurring, raised, sharply defined, palpable, solitary or confluent, itchy, whitish to red, itchy, flat, volatile skin habits (wheals) of varying size (0.2-10.0 cm). In 52% of the cases there is a chronic recurrent course of the disease. There is evidence of an increased rate (depending on the literature, between 35% and 50% of the total) of psychiatric comorbidities, such as anxiety disorders, depression and somatoform disorders.

Laboratory
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Determination of RAST classes, possibly ANA, rheumatoid factors, thyroid gland antibodies (according to medical history).

Histology
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S.u. Urticaria.

Diagnosis
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Step-by-step programme for the diagnosis of chronic urticaria (according to Ring/Przybilla). Diagnosis of urticaria requires patience and consistent implementation of a clearly defined diagnostic program (discussed with the patient in advance) (see Table 1). When the patient is free of symptoms, the targeted provocation tests can be started. The following provocation diets can be recommended according to the patient's medical history and previous test results:

    • Advanced diet
    • Additiva rich diet
    • Salicylate-rich diet
    • Biogenic amines
    • Oral provocation test for idiosyncrasy (OPTI).
  • Pseudoallergic/intolerance reaction: About 20-50% of cases of chronic urticaria are caused by non-immunological i.e. as pseudoallergic reactions (especially acetylsalicylic acid). An antigen-antibody reaction does not take place in these reactions. IgE cannot be detected in increased quantities. RAST determinations in this sense are therefore not possible. Pseudo-allergic reactions can be triggered by various pathomechanisms, e.g. direct complement activation, direct mediator release, enzyme defects, Jarisch-Herxheimer reaction, neuro-psychogenic. The CAST (cellular antigen stimulation test) is available as a laboratory test for suspected pseudoallergic reactions. Provocation diets with biogenic amines can substantiate the suspicion.
  • Salicycylate: Acetylsalicylic acid is the most common substance that can trigger an intolerance reaction. The pathomechanism has not yet been clearly clarified. Inhibition of cyclooxygenase is being discussed, which leads to a lack of protective prostaglandins and to increased formation of lipoxygenase metabolites or can cause direct mediator release, direct complement activation and altered platelet reactivity. There are pronounced cross-reactions with pharmacologically similar acting agents, e.g. other NSA, but also with other chemicals such as food dyes (tartrazine) and preservatives. If an intolerance reaction to ASA is known, Coxibe (e.g. Celecoxib) can be given if necessary.

Differential diagnosis
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General therapy
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Elimination or avoidance of the triggering factors after careful anamnesis and diagnosis.

  • Focus search: Remediation of a chronic focus or treatment of the underlying disease (e.g. antibiotic or surgical treatment of dental and ENT foci [no reliable evidence]; eradication of Helicobacter pylori [high level of evidence], treatment of candida infections [no reliable evidence]; see also Candidosis, enteral and others).
  • In case of parasitic cause: adequate therapy.
  • Medication: Discontinuation or conversion of possibly causative medication (e.g. analgesics, antibiotics such as penicillin, acetylsalicylic acid, insulin, vaccinations).
  • If food or additives are possible triggers and other trigger factors are excluded, a standardised low-allergen basic diet (see table 4) should be followed for 4-6 months. 70% of patients show a marked improvement or no symptoms (placebo effect?). During the diet a food/complaint protocol including an assessment of urticaria severity should be performed. About 50% of the patients tolerate full food again after 6 months of diet.

External therapy
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Blande, itch-killing local therapy e.g. Optiderm Lotion, Tannolact Lotio, Lotio alba, Lotio Cordes, Zinc oxide emulsion LAW, if necessary with addition of 2-5% polidocanol (e.g. Thesit, rp. 200 rp. 196 ) or 1% menthol rp. 160 . If necessary topical glucocorticoids as lotio (e.g. Triamgalen Lotion, rp. 123 ) or cream (e.g. Triamgalen Cream, rp. 121 rp. 120 ). Alternatively gels containing antihistamines (e.g. Fenistil, Tavegil, Soventol).

Radiation therapy
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The use of UVA irradiation can lead to clinical improvement in individual cases. UVB therapy is more reserved for cholinergic urticaria and urticaria factitia.

Internal therapy
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Regarding evidence-based therapy, see below Urticaria (the therapy options listed here are based partly on smaller study results or personal experience).

  • Antihistamines: Oral administration of non-sedating antihistamines (H1-blockers) of the 2nd generation such as Loratadine (e.g. Lisino) once/day 1 tbl. p.o., Desloratadine (e.g. Aerius) once/day 1 tbl. p.o, Cetirizine (e.g. Zyrtec) 1 time/day 1 tbl. p.o. or Levocetirizine (Xusal) 1 time/day 1 tbl. p.o. In case of therapy failure (after 14 days) change to antihistaminic high-dose therapy:
  • Antihistaminic high-dose therapy: If the response is insufficient, individually adapted dose increases (e.g. desloratadine in increasing doses up to 4 times the standard dose) can be used. Fexofenadine (Telfast) should not be high-dosed due to possible cardiotoxic side effects.
  • Alternative: Combinations: The response to the different H1-blockers is individually very different, therefore the success of their combination has to be assessed differently. Different H1-blockers can be combined in twofold combinations (e.g. Levocetericin and Fexofenadin) or also in triple combinations (Levocetericin and Fexofenadin as well as Levocetericin in double standard dosage. Combinations with H2-receptor blockers such as cimetidine (e.g. Tagamet) 400-800 mg/day or ranitidine (e.g. Sostril) once/day 300 mg or twice/day 150 mg p.o. have also been successfully described.
  • Alternative: Omalizumab (Xolair): Approval for the treatment of chronic (therapy-resistant) spontaneous urticaria has been available since 2014. Dosage 300mg/s.c. every 28 days. The clinical efficiency has been proven in several studies (Staubach P et al. 2016)
  • Alternative: Sedating antihistamines (therapeutic principle is considered by many authors as outdated). Especially in hospitalised patients, night sedating antihistamines such as hydroxyzine (e.g. Atarax®) 1-3 tbl/day are a possibility.
  • Alternatively, antiallergics with antihistamine and PAF-blocking effect such as rupatadine (e.g. Rupafin) 10 mg/day p.o.
  • Alternatively, combinations of H1-blockers with a leukotriene antagonist (e.g. montelukast), especially in patients with concomitant angioedema.
  • Alternative: Combination of a H1-AH (e.g. desloratadine 10 mg/day) with dapsone (50-150 mg/day).
  • Alternative: Ciclosporin (good evidence) (2.5 mg/kg bw p.o. in 2 ED). However, Ciclosporin should only be used in severe, absolutely therapy-resistant chronic urticaria, if necessary in combination with H1-AH.
  • Casuistic: Dapson (low evidence):50-100 mg/day p.o. for 3-6 months. No longer mentioned in the latest guideline.
  • Mast cell stabilizers (low evidence): In case of additional intestinal intolerance reactions, success with disodium cromoglicic acid (4 times/day 200 mg or 400 mg 15-30 min before exposure) has been described.
  • Casuistic (low evidence): Successes with high-dose intravenous immunoglobulin therapy(IVIG) are described.
  • Casuistic: plasmapheresis/immune adsorption(low evidence): Chronic urticaria in its pronounced form, especially after failure of other therapeutic approaches, is an indication for plasmapheresis or immune adsorption. The method seems to be particularly successful in patients in whom the detection of autoantibodies against the highly affine part of the IgE (α chain) was successful. These AK cause degranulation and histamine release via binding to the IgE receptor, e.g. on the surface of basophils or mast cells. In addition, this finding offers the possibility of a cost-saving reduction of the costly diagnostics for a part of the patients. At the same time, the high costs of the procedure should be pointed out!
  • Not recommended for long-term therapy: Glucocorticoids (are no longer listed in the guidelines or are considered obsolete): In the case of pronounced findings and pronounced, therapy-resistant symptoms(pruritus), glucocorticoids in medium dosages are usually used very effectively. Glucocorticoids are indicated for intermittent shear activity. Prednisolone (e.g. Solu Decortin H) initial 40-60 mg/day i.v., gradual dose reduction to the lowest possible maintenance dose and switch to oral administration. Caution! The maintenance dose should be below the Cushing threshold. Gastric protection is required for oral use.
  • Therapy in pregnancy: There is no known damage to the fruit caused by H1-AH. If treatment is necessary for pregnant women or nursing mothers, loratadine or cetericine in the usual dosage should be used. Loratadine is the best solution. No safety data are available for H1-AH high-dose therapy.

Progression/forecast
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The course of chronic urticaria varies. If the clinical signs are only mild, the disease usually heals within 24 months. In moderate to severe cases, healing occurs in only 50% of cases. 30% of these patients suffer > 60 months from relapses of the disease.

Naturopathy
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Biological Urticaria Therapy:
  • Week 1:
    • Nystatin Drg. 3 times/day 2 Drg.
    • Ozovit powder: 2 times/day 2 measuring spoons.
  • Week 2-4:
    • Markalact powder: 2 times/day 3 teaspoons.
    • Amara drops Pascoe: 2 times/day 10 trp.
    • Hepar-Pasc 100: 2 times/day 2 tbl.
  • week 5-12:
    • Markalakt powder: 2 times/day 3 teaspoons.
    • Hepar-Pasc 100: 2 times/day 2 tbl.
    • Amara mixture: 2 times/day 30 trp. of the mixture of 25 ml Amara drops of Pascoe/20 ml Pascoepankreat Novo drops/20 ml Quassia Similiaplex drops.
    • MDS: 2 times/day 30 trp.

Tables
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Three-step programme of urticaria diagnostics

Level

Diagnostic measures

I

Basic examination with careful anamnesis

Recording of findings

General clinical examination and routine laboratory

Allergological test procedures

Atopy screening (cat, HST mite, grass)

Food Standard (Prick)

Physical provocation tests (cold, heat, pressure, exertion, dermographism, light staircase if necessary)

If necessary, skin biopsy with direct immunofluorescence

Urticaria-Basis-Diet: tea-potato-rice to exclude frequent food allergies

II

Intensive Care Unit

Diet diary

Infect allergic focus search (e.g. gastroscopy with Helicobacter pylori testing, C13 breath test)

III

Elimination diet and provocation testing

Elimination diet: Suspicious substances are removed one after the other and the clinical response is assessed.

Exploratory diet / provocation diet: Certain foods are given in sequence under control of the clinical findings. Reliable evaluation is only possible if the patient has been free of symptoms for at least 2 days before the test.

Oral provocation test for idiosyncrasy (OPTI)


Urticaria diagnostics (proposal for an in-patient diagnostic programme)

Physical causes

Dermographism

occurs O

positive O

negative O

Cold test/heat test

occurs O

positive O

negative O

Autologous serum test

occurs O

positive O

negative O

Print test

occurs O

positive O

negative O

Sweat test

occurs O

positive O

negative O

Doryl test (on the ward / allergy laboratory)

occurs O

positive O

negative O

(light stairs)

occurs O

positive O

negative O

Laboratory

BSG

occurs O

increased O

normal O

Leukocytes

occurs O

increased O

normal O

Eosinophils

occurs O

increased O

normal O

ASL

occurs O

increased O

normal O

RF

occurs O

increased O

normal O

ANA

occurs O

increased O

normal O

Complement (C3,C4, CH50,C1-esterase inhibitor)

occurs O

increased O

diminishedO

Total IgE

occurs O

increased O

normal O

SX-1

occurs O

positive O

negative O

RAST (Specific IgE)

occurs O

increased O

negative O

CAST

occurs O

increased O

normal O

CD 4/8 ratio

occurs O

pathol O

normal O

Thyroid hormones (T3, T4, TSH)

occurs O

increased O

normal O

SD-AK (MAK, TAK, TRAK, TPO)

occurs O

increased O

normal O

Hepatitis Serology

occurs O

positive O

negative O

Cryoglobulins

occurs O

increased O

normal O

Porphyrins

occurs O

increased O

normal O

Yersinia-KBR

occurs O

positive O

negative O

Candida AK

occurs O

positive O

negative O

Focal events

Imprint tongue e.g. oral candidiasis

occurs O

positive O

negative O

stool on yeasts, parasites, pathogenic germs

occurs O

positive O

negative O

Vaginal swab on yeast

occurs O

positive O

negative O

Gynaecological consultation

occurs O

Focus O

undetected. O

ENT-Consultation

occurs O

Focus O

undetected. O

Dental Consil

occurs O

Focus O

undetected. O

Urological consultation

occurs O

Focus O

undetected. O

Rö-NNH

occurs O

Focus O

undetected. O

Orthopantomogram

occurs O

Focus O

undetected. O

Rö-Thorax

occurs O

Focus O

undetected. O

Abdomen Sonography

occurs O

Focus O

undetected. O

Gastroscopy with Helicobacter rapid test

occurs O

Focus O

undetected. O

Skin tests (allergy laboratory)

After antihistamine free interval of 35 days

Prick test: inhalation allergens, food, additives, medicines

occurs O

positive O

negative O

Scratch test - food, medicines

occurs O

positive O

negative O

Friction test - food

occurs O

positive O

negative O

Intracutaneous test (not for Urticaria factitia)

occurs O

positive O

negative O

Multitest-Merieux

occurs O

conspicuous O

undetected. O

Exposure tests

Dyestuff mix

occurs O

conspicuous O

undetected. O

Preservative mix

occurs O

conspicuous O

undetected. O

Potassium metabisulphite

occurs O

conspicuous O

undetected. O

Indomethacin

occurs O

conspicuous O

undetected. O

Acetylsalicylic acid

occurs O

conspicuous O

undetected. O

Placebo

occurs O

conspicuous O

undetected. O

Paracetamol

occurs O

conspicuous O

undetected. O

Ibuprofen

occurs O

conspicuous O

undetected. O

Na-glutamate

occurs O

conspicuous O

undetected. O

p-Coumaric acid

occurs O

conspicuous O

undetected. O

Provocative diet

Additiva rich diet

occurs O

conspicuous O

undetected. O

Salicylate-rich diet

occurs O

conspicuous O

undetected. O


Urticaria basic diet (tea-potato-rice diet)

Allowed

Forbidden

Staple food

Rice wafers, rice crackers, wheat rolls (wheat flour type 405, fresh yeast, sugar, iodized salt, water, corn oil)

All other types of bread and cereals

Potato dishes

Boiled potatoes, fried potatoes, baked potatoes, potato rösti, potato cookies, potato pancakes, French fries

All not mentioned

Rice dishes

Husked rice, brown rice, wild rice, rice noodles

All not mentioned

Spices

iodized salt, sugar

No other

Grease

Corn oil, Becel diet margarine

No others, no butter

Beverages

Mineral water, black tea

No other


Oligo-Allergenic Basic Diet

Food

Products

Baked goods

100% rye bread, Wasa rye crispbread (green package), Hammermühle bread: chestnut bread, millet bread, Pfälzer white bread (gluten-free), corn wafers, wafer bread, Mondamin bread (own production)

Meat products

Lamb, turkey (only salted, roasted with maize-germ oil or cooked)

Vegetables

Potatoes (cooked), mashed potatoes, fried potatoes with corn oil or French fries, broccoli, cauliflower, carrots, kohlrabi, zucchini, cucumber without skin

Rice and noodles

Chicken egg-free and wheat-free noodles, corn and rice noodles, rice (long grain or brown rice), Humana apple porridge or children's semolina (milk-free) both based on corn or rice

Fruit

Cooked unsweetened pear, apple pulp

Greases

Vitagen margarine (from Vitaquell), maize germ oil (with high content of polyunsaturated fatty acids)

Sweetener

pear syrup, sugar beet juice

Beverages

Calcium-rich mineral water, Humana SL, Milupa SOM, apple juice (100% naturally cloudy from Dr. Koch's)

Egg replacement

Egg substitute powder (e.g. hammer mill)

Miscellaneous

Nestargel (locust bean gum), rice wafers, cornflakes (unsweetened), popcorn, pop rice


Build-up diet1

Food

Products

Dairy products

Buttermilk, young semi-hard cheese

Animal food

Meat: Cold cuts, roast beef, turkey

Fish: saithe, trout, plaice, cod

Eggs

Fruit

banana, ripe sweet pear, watermelon

Miscellaneous

Fresh herbs, herbal teas, pear juice, vegetable juice, sugar beet syrup (bread topping)


Provocation diet: Food rich in additives

Meal

Food/Products

Breakfast

Whole grain bread, multivitamin jam, large quantities of cocoa drink (Kaba, Nesquick)

Snack

fruit yoghurt, cocktail cherries, chewing gum (Hubba Bubba, Vivil Mash), chocolate bars (Mars, Nuts)

Noon

instant soup (bag/Knorr, Maggi), ham rolls with mayonnaise (preserved), instant mashed potatoes, delicatessen salad, beans, spinach, red gelatine with cocktail cherries

Coffee

orange juice (coloured), chocolate dragees, wine gum with colouring, chewing gum

Evening

wholemeal bread/grey bread (preserved), salami/ham, salmon substitute, fish semi-preserved, delicatessen salad, horseradish, 2 glasses of white or red wine

Night

raspberry syrup drink, chewing gum, tomato juice (ready-to-drink), camembert


Provocation diet - Salicylate-rich food: Without colouring, without seasoning

Meal

Food/Products

Breakfast

Rolls/bread of your choice, diet margarine, cream cheese without additives, edible quark, jam, nut nougat cream, muesli cup, apple, dried plums, peppermint tea with sugar and lemon, 0.2 l orange juice

Noon

Fresh vegetable soup (leek, carrots, celery, salt, spices, herbs, potatoes), roasted or cooked meat (without ready sauce), boiled potatoes, rice (all kinds), noodles, raw vegetables (chicory, endive, paprika, radish, cucumber fresh, peas fresh, kale, gherkin, courgette, olives

Dessert

Red currant, raspberries with sugar or cranberry, raspberry or blueberry compote

Afternoon

0.2 l grape juice, pastries with almonds, peppermint tea or coffee with canned milk and sugar

Dinner

Bread of your choice, diet margarine, cream cheese without additives, potatoes in the skin, quark, jam, gherkin, carrots, raw vegetables (apple, lemon, onion), 0.2 l orange juice or black currant juice


Provocation Day - Biogenic Amines

Biogenic amines

Food/Products

Histamine rich food

Tuna, mackerel, raw and long-life sausages, tomatoes, sauerkraut, red wine, cheese (Emmental)

Tyramine rich food

raspberries, banana, oranges, Chianti wine, fish, cheese (Camembert), chocolate, cocoa

Serotonin-rich foods

Banana, cheese (Gouda, Edam)


Oral provocation test for idiosyncrasy (OPTI)

Test day

Test Substances

Day 1 (dye mix I-II)

Tartrazine (E 102) 25 mg; quinoline yellow (E 104) 12.5 mg; sunset yellow (E 110) 12.5 mg; azorubine (E 122) 12.5 mg; amaranth (E123) 2.5 mg; cochineal red (E 124) 20 mg; erythrosine (E127) 10 mg, also possible: patent blue (E 131); indigotine (E132); brilliant black (E 151); iron oxide (E 127).

Day 2 (Preservative mix)

Sorbic acid (E 200) 50 mg: Has an antimycotic effect, no effect against yeasts, is contained in bread and cheese. 2,4 unsaturated fatty acid, occurs naturally in the saturated form as caproic acid in butter.

Na-benzoate (E 211) 50 mg: Benzoic acid occurs naturally in cranberries (in concentrations of 0.1-0.2%), has an antifungal and bacteriostatic effect.

PHB ester (p-OH-benzoic acid ethyl ester) (E 214) 50 mg: Ester is more antimycotic, acts even at higher pH, effective against coliform bacteria, staphylococci, streptococci, salmonella, klebsielles, proteus.

Day 3 (Potassium metabisulphite)

Especially for the preservation of wine, inhibits the growth of mould and yeast from 20 mg/l.

Day 4 (Indometacin)

(1:1000; 1:100; 1:10; original preparation)

Day 5 (Acetylsalicylic acid)

(Pseudoallergy, previously CAST to ASS). Dose-dependent reaction, beginning with 50 mg, increasing in hourly intervals to 100 mg, 250 mg, 500 mg, 1000 mg.

Day 6 (Possibly) Placebo

Day 7 (other)

E.g. paracetamol 1:1000, 1:100, 1:10, 1:1, ibuprofen 1:1000, 1:100, 1:10, 1:1, Na-glutamate (E 621) 124 Kps., p-coumaric acid 124 Kps.


Rules of thumb for differentiating between allergic and pseudoallergic reactions (according to Ring J, Applied Allergology, MMW)

Allergy

Pseudoallergy

Awareness raising

no sensitisation

rather rare (< 5%)

rather frequently (> 5%)

common clinical symptoms

often unspecific symptoms

inducing small doses

partly dose-dependent (e.g. infusions: speed)

Family history sometimes positive

Family history negative (exception: enzyme defect)

slight psychological influence

strong psychological influence


Low salicylate diet (with proven ASS intolerance)

Food *

Examples

Fruit

Apricots, oranges, blackberries, cherries, blueberries, gooseberries, cranberries, currants, nectarines, peaches, raspberries, strawberries, lemons

Vegetables

Aubergine, chicory, endive, paprika, pepperoni, radish, fresh cucumber, gherkin, zucchini

Seeds

Almonds

Beverages

aperitifs, beer, cognac, cola drinks, fruit juices from the above mentioned fruits, raspberry syrup, peppermint tea, wine


Low pseudoallergen diet

Allowed

Forbidden

Staple food

Bread, bread rolls without preservatives, semolina, millet, potatoes, rice, durum wheat noodles (without egg), rice wafers (only rice/salt)

e.g. noodle products, egg pasta, cakes, French fries

Greases

Butter, vegetable oils (cold pressing)

Margarine, mayonnaise etc.

Dairy products

Fresh milk, fresh cream, quark. natural yoghurt, unseasoned cream cheese, young Gouda

All other dairy products

Animal foodstuffs

Fresh meat, fresh minced meat

All processed animal food, eggs, fish, shellfish

Vegetables

lettuce, carrots, zucchini, Brussels sprouts, white cabbage, Chinese cabbage, broccoli, asparagus

Artichokes, peas, mushrooms, rhubarb, spinach, tomatoes and tomato products, olives, peppers

Fruit

No fruit

All kinds of fruit and fruit products, also dried, e.g. raisins

Spices

salt, chives, sugar, onions

All other spices, no garlic, no herbs

Sweets

None

All candy, sweetener, chewing gum

Beverages

milk, mineral water, coffee, black tea

All other drinks, herbal teas, alcohol. Drinks

Bread toppings

honey, curd cheese, unseasoned cream cheese, young Gouda

All rubbers not mentioned

Literature
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  3. Godse KV (2011) Omalizumab in treatment-resistant chronic spontaneous urticaria. Indian J Dermatol 56:444
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Last updated on: 29.10.2020