Author(s): I. Cherrez Ojeda1,2 , E. Vanegas1,2 , M. Felix2 , V. Mata2 , S. Cherrez3 , D. Simancas-Racines4 , L. Greiding5 , J. Cano1 , A. Cherrez2,6 and Juan Carlos Calderon1,2
Urticaria is defined by the presence of hives that appear and resolve within 24 h. Urticarial lesions can be circumscribed, raised, erythematous plaques, with central pallor. They can adopt different shapes and sizes (round, annular, or serpiginous), and are characterized by three main features: swelling and erythema; itching/burning sensation; spontaneous resolution within 24 h .
With regard to the duration of urticaria, it can be classified as "acute" (< 6 weeks) or "chronic" (> 6 weeks) . Among patients with chronic urticaria, [less than or equai to] 40% can have accompanying episodes of angioedema (defined as a sudden swelling of the deep dermis in well-circumscribed areas like the lips, periorbital area, extremities, and genitals) [3, 4].
According to its underlying etiology, chronic urticaria is classified in two main groups: (i) chronic spontaneous urticaria (formerly known as "chronic idiopathic urticaria"), and (ii) inducible urticaria (including cold, delayed pressure, solar, heat, vibratory, cholinergic, contact, and aquagenic) .
Despite recent updates to the management guidelines for urticaria, it remains a challenge for healthcare providers to diagnose and identify each subtype of chronic urticaria due to the broad spectrum of clinical manifestations, and the possibility that several subtypes of the disease coexist in the same patient [5, 6]. Among physicians in Ecuador, a recent study suggested a low awareness of existing guidelines, resulting in poor knowledge of how to diagnose and treat the disease. It seems that the limited time per consultation (specially in public hospitals due to the volume of patients), together with low participation in medical meetings and conferences, led to poor adherence and application of current guidelines. Thus, patients were less likely to receive the recent evidence based treatments and diagnostic approaches .
With regard to treatment, two major research teams have published guidelines based on the available evidence and expert opinion [5, 6]. The US Joint Task Force on Practice Parameters (JTFPP) promotes a four-step approach, whereas guidelines set by EAACI/GA2 LEN/EDF/WAO (European Academy of Allergology and Clinical Immunology, Global Allergy and Asthma European Network, European Dermatology Forum and World Allergy Organization) advocate a simplified three-step approach. Both guidelines agree on second-generation H1 antihistamines as the cornerstone and first-line therapy for chronic urticaria . Treatment failure can prompt a dose increase of up to fourfold according to European guidelines or, in the case of the US guidelines: addition of another second-generation antihistamine, combination therapy with a first- and second-generation H1 antihistamine, or the addition of a leukotriene receptor antagonist as the next step. Both guidelines also agree upon the inclusion of omalizumab, cyclosporine, corticosteroids, and immunosuppressants to treatment if the initial regimen fails [8, 9]. However, in developing countries, where access to omalizumab is not provided by medical insurance, the affordability is very low [10, 11].
Data regarding the prevalence, demographics, and clinical characteristics...