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. 2025 Jun 30:16:1584771.
doi: 10.3389/fimmu.2025.1584771. eCollection 2025.

Chronic inducible urticaria - having more than one is common and clinically relevant

Marina Lebedkina  1 , Elena Kovalkova  1 , Gerelma Andrenova  1 , Alexander Dushkin  1   2   3 , Anton Chernov  1 , Ekaterina Nikitina  1 , Alexander Karaulov  2   4 , Maryana Lysenko  1   5 , Marcus Maurer  6   7 , Emek Kocatürk  6   7   8 , Daria Fomina  1   2   9
Affiliations

Chronic inducible urticaria - having more than one is common and clinically relevant

Marina Lebedkina et al. Front Immunol. .

Abstract

Background: Chronic inducible urticaria (CIndU) is characterized by wheals and/or angioedema (AE) for 6 weeks or more in response to specific and definite triggers. Individual patients can have more than one type of CIndU. Reports on this come from single cases or small case series, most epidemiological studies did not assess whether these urticaria are standalone or mixed.

Objective: Determine the features of mixed CIndU and how they differ from standalone forms.

Methods: In a prospective cohort study we performed provocative testing in 210 patients with CIndU. A total of 188 patients were included (125 with the standalone CIndU and 63 with the mixed CIndU. Within each group, patients were divided into subgroups: symptomatic dermographism (SD), cold (ColdU) and cholinergic urticaria (CholU).

Results: Mixed CIndU most commonly were SD+ColdU (n=19, 30.2%), SD+CholU (n=15, 23.8%), SD+DPU (n=12, 19%) and ColdU+CholU (n=9, 14.3%). Comorbid chronic spontaneous urticaria (CSU) (50.8% vs 20.8, p<0.001) and AE (36.5% vs. 20%, p=0.014) were more common in patients with mixed CIndUs. In patients with mixed CIndUs, their onset time is more closely linked to each other (n=43; 68.2%) as compared to that of comorbid CSU (12 of 32, 37.5%). MixedSD patients are younger, show earlier onset of disease and have higher rates of AE and lower rates of atopic dermatitis (AtD), as compared to patients with standalone SD. MixedColdU patients have higher rates of comorbid CSU and lower rates of AtD, higher levels of total IgE and eosinophils. MixedCholU patients are older, have a high rate of comorbid CSU, a lower incidence of allergic disease.

Conclusion: This study shows for the first time that each combinations of mixed CIndU represent a distinct phenotype with its own features. These phenotypes require special attention of specialists.

Keywords: angioedema; cholinergic urticaria; chronic inducible urticaria; cold urticaria; symptomatic dermographism; urticaria; wheal.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Figures

Figure 1
Figure 1
Study design. CIndU, chronic inducible urticaria; SD, symptomatic dermographism; CholU, cholinergic urticaria; ColdU, cold urticaria; DPU, Delayed Pressure Urticaria.
Figure 2
Figure 2
Assessment of the onset of CIndU in mixedCIndU group (n=63). (A) among all patient in mixed CIndU (n=63) 68.2% had simultaneous onset of 2 urticaria, 31.8% non-simultaneous onset. (B) with non-simultaneous onset, ColdU was the first in 40.0% of patients, CholU in 35.0%, SD in 15%, DPU in 5%, and SolarU in 5%. SD, Symptomatic Dermographism; CholU, Cholinergic Urticaria; ColdU, Cold Urticaria; DPU, Delayed Pressure Urticaria; SolarU, Solar Urticaria.
Figure 3
Figure 3
Assessment of the first presented urticaria in sCIndU among patients with CSU (n=26). (A) among all patient with comorbid CSU in sCIndU group 42.4% has simultaneous onset of CSU plus CIndU, 30.7% has CSU as first urticaria and 26.9% has CIndU as first urticaria. (B) Evaluation of the onset of simultaneous CSU plus CIndU in each of the standalone groups with comorbid CSU (sSD (n=7), sColdU (n=1), sCholU (n=9)). In sSD and sCholU 43.45% and 44.4% of patients had simultaneous debut of CSU plus CIndU, in sColdU simultaneous debut occurred in 100% (only 1 patient in a group), p=0.545. CIndU, Chronic Inducible Urticaria; CSU, Chronic Spontaneous Urticaria; sSD, standalone Symptomatic Dermographism; CholU, standalone Cholinergic Urticaria; ColdU, standalone Cold Urticaria.
Figure 4
Figure 4
Assessment of the first presented urticaria in mixedCIndU among patients with CSU (n=32). (A) among all patient with comorbid CSU 37.5% has simultaneous onset of CSU+CIndU, 31.2% has CSU as first urticaria and 31.2% has CIndU as first urticaria. (B) In mixedSD (n=25) and mixedColdU (n=12) 44% and 43% of patients had simultaneous debut of CSU+CIndU, in mixedCholU (n=14) simultaneous debut occurred in 25%, p=0.514. CIndU, Chronic Inducible Urticaria; CSU, Chronic Spontaneous Urticaria; SD, Symptomatic Dermographism; CholU, Cholinergic Urticaria; ColdU, Cold Urticaria.
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References

    1. Magerl M, Altrichter S, Borzova E, Giménez-Arnau A, Grattan CE, Lawlor F, et al. The definition, diagnostic testing, and management of chronic inducible urticaria5/23/25 9:57:00 PMs - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision. Allergy. (2016) 71:780–802. doi: 10.1111/all.12884 - DOI - PubMed
    1. Zuberbier T, Abdul Latiff AH, Abuzakouk M, Aquilina S, Asero R, Baker D, et al. The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. (2022) 77:734–66. doi: 10.1111/all.15090 - DOI - PubMed
    1. Abajian M, Schoepke N, Altrichter S, Zuberbier T, Maurer M. Physical urticarias and cholinergic urticaria. Immunol Allergy Clin North Am. (2014) 34:73–88. doi: 10.1016/j.iac.2013.09.010 - DOI - PubMed
    1. Jain SV, Mullins RJ. Cold urticaria: a 20-year follow-up study. J Eur Acad Dermatol Venereol. (2016) 30:2066–71. doi: 10.1111/jdv.13841 - DOI - PubMed
    1. Kring Tannert L, Stahl Skov P, Bjerremann Jensen L, Maurer M, Bindslev-Jensen C. Cold urticaria patients exhibit normal skin levels of functional mast cells and histamine after tolerance induction. Dermatology. (2012) 224:101–5. doi: 10.1159/000336572 - DOI - PubMed