|Year : 2017 | Volume
| Issue : 2 | Page : 94-99
Autologous serum and plasma skin tests in chronic spontaneous urticaria: A reappraisal
Muthu Sendhil Kumaran, Sonia Mangal, Tarun Narang, Davinder Parsad
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||16-Mar-2017|
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The objective of this study was to assess autologous serum skin test (ASST) vs autologous plasma skin test (APST) response in chronic spontaneous urticaria (CSU) patients and study the significance of intensity of positive responses in relation to clinicoepidemiological parameters. Materials and Methods: One hundred CSU patients and 100 age and sex-matched controls were recruited. The demographic and clinical features were recorded in all patients and routine investigations were performed. ASST and APST tests were performed as per the standard guidelines. Results: The mean duration of illness was 4.85 ± 5.07 years, 90% patients were APST (+), 68% ASST (+), and 22 patients were only APST (+). Positive predictive value (PPV) of ASST and APST was 90.7% and 95.7%, respectively. A significant inverse association was seen between thyroid status and serum IgE levels with APST and ASST positivity. Conclusion: APST appears to have better PPV and high intensity of positive response on autologous tests, and correlates with ANA positivity and angioedema.
Keywords: Autoimmune, autologous plasma skin test, autologous serum skin test, chronic sponataneous urticaria
|How to cite this article:|
Kumaran MS, Mangal S, Narang T, Parsad D. Autologous serum and plasma skin tests in chronic spontaneous urticaria: A reappraisal. Indian Dermatol Online J 2017;8:94-9
|How to cite this URL:|
Kumaran MS, Mangal S, Narang T, Parsad D. Autologous serum and plasma skin tests in chronic spontaneous urticaria: A reappraisal. Indian Dermatol Online J [serial online] 2017 [cited 2018 Mar 23];8:94-9. Available from: http://www.idoj.in/text.asp?2017/8/2/94/202266
| Introduction|| |
Chronic spontaneous urticaria (CSU) is a common disorder with a complicated, incompletely fathomed etiopathogenesis. CSU is defined as daily or almost daily occurrence of wheals for at least 6 weeks with or without angioedema. It is commonly reported between 4th and 6th decades of life with a female preponderance. Despite the availability of a broad panel of diagnostic tests, identification of specific causative factor in CSU remains elusive.
Circulating mast cell-activating agents have been identified in blood of CSU patients; a subgroup of these patients has autoantibodies directed against the IgE receptor FcεRI or against IgE that functions as mast cell-activating signals. These autoantibodies have been shown to activate blood basophils and cutaneous mast cells in vitro. The presence of these autoantibodies may be clinically important in a group of severely affected, treatment-resistant patients, where immunomodulatory treatments may be valuable. Patients with autoantibodies have no distinctive diagnostic clinical features. Autoimmune and non-autoimmune cases are indistinguishable clinically and histologically. However, they do tend to have more severe urticaria.,,,,,,,,,,,
Autologous serum skin test (ASST) is a simple in-vivo clinical test for the detection of basophil histamine-releasing activity. Sabroe et al. found that ASST has a sensitivity of approximately 70% and a specificity of 80%, and it may be used as a reasonably predictive clinical test to indicate the presence of functional circulating autoantibodies. A positive ASST has been associated with prolonged disease that is poorly responsive to routine therapy. One important advantage of testing is to promote a more tailored prognostic counseling and earlier use of immunosuppressive drugs. Studies have also demonstrated a significant relation between chronic idiopathic urticaria (CIU) diagnosed by ASST and clinical parameters like frequency of attacks, duration of individual episodes, duration of wheals, regional involvement, and being less responsive to conventional antihistamine therapy., Albeit ASST is commonly usedin vivo validated test, which is positive in 30–67% of patients in CSU,, concerns have been raised regarding its interpretation and specificity.
The basophil histamine release assay is currently the gold standard for detecting functional autoantibodies in the serum of patients with chronic urticaria. However, this bioassay is difficult to standardize because it requires fresh basophils from healthy donors and it is also time consuming, hence it remains restricted to scientific research. Hence, ASST is considered to be a bedside clinical test that can detect the presence of autoimmunity in patients with CIU. Depending on the method of antibody detection, various studies have reported that the prevalence of ASST positivity in patients of chronic urticaria varies from 35% to 58%.
Asero et al. have reported that the autologous plasma skin test (APST) is more sensitive than ASST, but cannot be considered as a screening test for histamine-releasing autoantibodies. The prevalence of ASST positivity ranges from 42% to 68% whereas the prevalence of APST positivity varies from 14% to 97%. APST generates more positive responses than ASST because plasma contains coagulation factors and complements, which are consumed in the formation of clots in ASST, and hence, less positive results are seen. The demonstration of autoantibodies in only some patients with positive ASST and APST (25–50%) confirms that there are factors other than autoantibodies that play a role in the etiology of urticaria.
Although the literature includes various results, these variations depend on multiple factors, including methods of skin test, interpretation criteria of skin test results, type of anticoagulant, centrifuging blood specimen, and methods of serum separation. For example Asero et al. used ethylenediaminetetraacetic acid (EDTA) as an anticoagulant, and hence the positive results reported to be 97% of the cases., All relevant studies so far have reported that both the APST and ASST can be used for diagnostic purposes in patients with chronic autoimmune urticaria (CAU)., Which of these is more sensitive and whether or not their positivity correlates with the disease severity, varies between different studies and cannot be decisively concluded.
Although many studies have assessed these two investigations individually, there is scarcity of studies that have compared the two, and to our knowledge, no study has investigated the significance of responses in both these tests. Hence, we wanted to compare the results of ASST and APST in patients with CSU and correlated the intensity of response with various clinicoepidemiological parameters.
| Materials and Methods|| |
All patients of chronic urticaria attending the urticaria clinic at our institute were screened for 1 year; 150 chronic urticaria patients, aged >18 years, having a disease duration longer than 6 months were enrolled. CSU was defined as patients suffering from urticaria for more than 6 weeks duration. Those with a history of physical urticaria and pregnant and lactating women were excluded from the study; 100 age and sex-matched healthy controls were also studied to observe the distribution of ASST, APST, serum IgE levels, and thyroid profile among general population. The study was approved by the Institutional Ethics Committee, and a written informed consent was obtained from all patients and volunteers.
Medical history and physical examination was noted on a predesigned proforma. Laboratory investigations including complete blood count, metabolic panel, urine and stool analysis, serum IgE levels, ANA, and thyroid function tests (TFTs) were performed.
ASST and APST tests were performed as per standard guidelines., Patients were advised to stop antihistamines, doxepin, and steroids 2 days, 1 week, and 3 weeks prior to the test, respectively.
To obtain serum, venous blood (3 ml) was taken in a sterile glass tube without clotting accelerator and allowed to clot at room temperature for 30 minutes. Serum was separated by centrifugation at 500 g for 15 minutes.
To obtain plasma, 4 ml of venous blood was collected in a sterile vacutainer containing 0.5 ml of 0.105 mol/l sodium citrate. These samples were kept at room temperature for 15 minutes, and then centrifuged for 3 min at 1250 g to obtain plasma.
Histamine diphosphate 10 µg/ml and sterile physiological saline (0.9%) were used as positive and negative controls, respectively.
Fifty microlitres (two units of 40 units/1 ml insulin syringe) of each autologous plasma, serum, sterile physiological saline, and histamine were injected intradermally into the volar aspect of the left forearm keeping a gap of 3–5 cm. Areas known to be involved in whealing in previous 24 hours were avoided. Strict aseptic precautions were followed.
Wheal diameter was recorded at 30 minutes as the average of two maximum perpendicular diameters measured with the help of a measuring scale. ASST and APST were considered to be positive if the wheal induced by serum or plasma, respectively, was >2 mm in diameter than that induced by saline. The intensity of this positive response was graded arbitrarily:
- + (low intensity) = ≤3 mm with no peripheral surrounding erythema
- 2+ (moderate intensity) = 4–6 mm with mild peripheral erythema
- 3+ (high intensity) = >6 mm with bright red peripheral erythema.
For interpretation of the results, descriptive statistical methods (mean, standard deviation) as well as unpaired t-test for comparison of groups, Chi-square test, and odds ratio for comparing quantitative data were performed.
| Results|| |
Among 150 CSU patients screened, 100 were eligible, of which 48 were males and 52 were females (M:F = 1:1.08), with a mean age of 34.95 ± 11.96 years (mean age of females: 35.97 years; mean age of males: 33.35 years). The mean duration of illness was 4.85 ± 5.07 years. More than half of the study cohort had experienced >2 episodes of urticaria; 65% patients had only urticaria and remaining had urticaria with angioedema.
Autologous serum skin test vs autologous plasma skin test
On examining the response to autologous tests, among 100 patients, 68 were ASST (+) and 90 were APST (+). All ASST (+) patients were also positive for APST, and remaining 22 were only APST (+). The patients who were only APST (+) demonstrated a female predominance (F:18, M:4), <30 years of age, a refractory/resistant disease, and longer duration of disease (63.6% of them requiring immunosuppressive treatment methotrexate or cyclosporine in the past and the remaining patients required more than one antihistamines for disease controls). Those with only ASST (+) and both the autologous tests positive did not have any significant clinicoepidemiological details. Among controls, only 8% and 4% were found to be ASST (+) and APST (+), respectively. Comparison between the cohorts and controls for ASST/APST positivity was statistically significant, which was higher in patient population than controls (P < 001). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) are summarized in [Table 1].
|Table 1: Senstivity and specificity of ASST and APST on comparing cases with controls|
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Intensity of response analysis
The positive response on ASST and APST were further assessed for the intensity of response obtained; it was observed that in APST 63, 11, and 16 patients and in ASST 48, 16, and 14 patients had + (low), ++ (moderate) and +++ (high) positive response, respectively [Table 2]. Those with severe response (3+) complained of increased itching followed by burning sensation at the tested site, especially in patients with APST (+).
Additional features observed were:
- 3+ or high intensity response on ASST and APST was seen in 6/16 (37.5%) patients with angioedema who had respiratory difficulty during eruption (1 patient required hospital admission once)
- ANA was positive in 10 patients, 60% of them demonstrated 3+ or high intensity response on both ASST and APST; on further investigations, 4/6 patients also had dsDNA antibody positive along with low C3 and C4 complement levels, however, none manifested any signs and symptoms of collagen vascular disorder.
Sixteen patients demonstrated TFTs abnormalities, hypothyroidism (n = 15), and hyperthyroidism (n = 1). Hypothyroidism was encountered more in females (P< 0.01). Thyroid autoantibodies were seen in 13% of patients and 4% of controls. The distribution of anti-TPO antibodies among females and males, patients, and controls did not show any statistically significant variation. A significant inverse association was observed between TFTs and APST as 92.9% of those with normal TFTs were APST (+), (κ = −0.062 P = 0.029).
IgE levels were found to be raised in only 9% patients; they all had a positive family history for atopy (asthma in 6, allergic rhinitis in 3). The serum levels of IgE varied from 500 IU to 1200 IU; 8/9 (88.9%) patients demonstrated a moderate positive response only on APST. A significant inverse correlation was noted between IgE levels and ASST (+) as 84% of those with normal IgE levels were ASST (+) (κ = −0.141 P = 0.012).
The mean urticaria activity score (UAS) among all CSU patients was (4.2 ± 1.24); these scores did not significantly correlate with the intensity of positive response on either ASST or APST. Correlation between the intensity of positive response on autologous skin tests with regards to gender, duration of disease, and thyroid status of the study cohort did not bear any significance.
| Discussion|| |
Research is still underway to expound the enigmatic pathogenesis of CSU. Recent studies have incriminated platelets to play a vital role in various immune and inflammatory disorders such as allergic dermatitis (atopic dermatitis), psoriasis, urticaria, and inflammatory bowel disease.
Platelet activation factor-4 stimulates histamine release from rat mast cells. Cutaneous reaction following the intradermal injection of autologous serum and plasma in ASST and APST reflects autoreactivity in patients with chronic urticaria. ASST is a test for autoreactivity rather than a specific test for autoimmune urticaria with only moderate specificity as a marker for functional autoantibodies against IgE or the high affinity IgE receptor (FcεRI), detected by the basophil histamine release assay, however, with a high negative predictive value for CSU patients without them.
The extrinsic pathway of clotting cascade is involved in the pathogenesis of CSU and the disease severity is associated with the activation of coagulation cascade.,,, There are recent reports of APST to be more sensitive than ASST, thus it is predictable that APST generates more positive responses than ASST because plasma contains coagulation factors and complements.,,
The prevalence of APST positivity varies between 14% and 97% whereas that of ASST positivity ranges from 42% to 68%.,, In our study, the positive prevalence of autologous tests was 78% for ASST and 90% for APST, which is comparatively higher than most of the studies so far. Kocatürk et al., found that the specificity of ASST and APST was similar, whereas ASST was found to be more sensitive than APST in discriminating between CSU patients and controls. However, in our study we found APST to be more sensitive and specific than ASST with a higher positive predictive value, although it was not statistically significant. Twenty two patients in our study were positive only for APST and not vice versa; further analysis of these patients demonstrated a female preponderance, <30 years of age, longer disease duration, and resistant urticaria which was not improving with antihistamines with 63.6% of them requiring immunosuppressive treatment (methotrexate or cyclosporine).
False negative and positive results with ASST have been proposed owing to high amount of bradykinin generated during coagulation cascade leading to the release of proteinase enzymes that destroy C5a and the formation vasoactive mediators while the serum is being prepared leads to false positive results., Asero et al. described APST and suggested it to be more sensitive than ASST, which has been refuted by few researchers, claiming the higher rate of APST positivity in earlier studies being attributed to the failure to use negative control tests.,,,,,,, In our study, we found no significant correlations between ASST and APST positivity with respect to gender, disease duration, and personal or family history of atopy, which coincides with the findings of previous studies.,
We wanted to observe if there was any significance of the intensity of response during autologous skin tests in urticaria with regards to various clinico-epidemiological characteristics of patients. In the absence of any previous studies dealing with the intensity of positive response, we cannot compare our findings.
In our patients, an associated presence of angioedema demonstrated no significant correlation with ASST and APST outcome, as in earlier studies,,,,,,,, however, on assessing the intensity of positive response, 37.5% patients with severe angioedema demonstrated a high intensity response.
An increased prevalence of antithyroid autoantibodies among CSU patients have been cited by many researchers with prevalence ranging between 0 and 5.6%.,,,,, We found thyroid autoantibodies in 13% and 4% of our patients and controls respectively, which was not statistically significant. However, a statistically significant inverse association was noted between TFTs and APST; 92.9% of patients who were APST (+) had normal T3 and T4, TSH and anti TPO values (P = 0.029).
The relationship between atopy and chronic urticaria has been suggested by some authors, although some studies have observed no correlation between the two.,, Only 9 patients in our study provided a family history of atopy and not in the patient per se. All of them were found to have increased IgE levels, and 84% of patients with normal IgE levels were ASST (+) (P < 0.05).
ANA positivity was seen in 10 patients; 6/10 demonstrated 3+ or high intensity positive response on ASST and APST. Four out of these 6 patients had low complement (C3 and C4) levels and dsDNA positivity. Thus, a high intensity of response on autologous tests could signify a presence of underlying ANA positivity, in which case the patient needs to be followed up, along with monitoring for collagen vascular disorder. Since there are no studies assessing the intensity of positive response on autologous blood tests in CSU, we are unable to compare our preliminary results.
| Conclusion|| |
Our study exemplifies that APST is probably better than ASST in identifying autoreactivity in CSU owing to better PPV and the presence of high intensity response on ASST/APST, which could signify the presence of an underlying ANA positivity or a severe angioedema, as noted in our study. Additional studies are required to further clear the enigma between APST and ASST and confirm and augment our various preliminary findings.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Maurer M, Grabbe J. Urticaria. Its history-based diagnosis and etiologically oriented treatment. Dtsch Arztebl Int 2008;105:458-65.
Konstantinou GN, Asero R, Ferrer M, Knol EF, Maurer M, Raap U, et al
. EAACI taskforce position paper: Evidence for autoimmune urticaria and proposal for defining diagnostic criteria. Allergy 2013;68:27-36.
Hide M, Francis D, Grattan C, Hakimi J, Kochan JP, Greaves MW. Autoantibodies against the high-affinity IgE receptor as a cause of histamine release in chronic urticaria. N
Engl J Med 1993;328:1599-604.
Kikuchi Y, Kaplan A. Mechanisms of autoimmune activation of basophils in chronic urticaria. J Allergy Clin Immunol 2001;107:1056-62.
Tong L, Balakrishnan G, Kochan J, KoKinét JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol 1997;99:461-5.
Levy Y, Segal N, Weintrob N, Danon YL. Chronic urticaria: Association with thyroid autoimmunity. Arch Dis Child 2003;88:517-9.
Zauli D, Deleonardi G, Foderaro S, Grassi A, Bortolotti R, Ballardini G, et al
. Thyroid autoimmunity in chronic urticaria. Allergy Asthma Proc 2001;22:93-5.
Leznoff A, Josse RG, Denburg J, Dolovich J. Association of chronic urticaria and angioedema with thyroid autoimmunity. Arch Dermatol 1983;119:636-40.
Heymann WR. Chronic urticaria and angioedema associated with thyroid autoimmunity: Review and therapeutic implications. J Am Acad Dermatol 1999;40:229-32.
Kikuchi Y, Fann T, Kaplan AP. Antithyroid antibodies in chronic urticaria and angioedema. J Allergy Clin Immunol 2003;112:218.
O'Donnell BF, Francis DM, Swana GT, Seed PT, Kobza Black A, Greaves MW. Thyroid autoimmunity in chronic urticaria. Br J Dermatol 2005;153:331-5.
Turktas I, Gokcora N, Demirsoy S, Cakir N, Onal E. The association of chronic urticaria and angioedema with autoimmune thyroiditis. Int J Dermatol 1997;36:187-90.
Maurer M, Metz M, Magerl M, Siebenhaar F, Staubach P. Autoreactive urticaria and autoimmune urticaria. Hautarzt 2004;55:350-6.
Sabroe RA, Grattan CE, Francis DM, Barr RM, Kobza Black A, Greaves MW. The autologous serum skin test: A screening test for autoantibodies in chronic idiopathic urticaria. Br J Dermatol 1999;140:446-52.
Młynek A, Zalewska-Janowska A, Martus P, Staubach P, Zuberbier T, Maurer M. How to assess disease activity in patients with chronic urticaria?. Allergy 2008;63:777-80.
Konstantinou GN, Asero R, Maurer M, Sabroe RA, Schmid-Grendelmeier P, Grattan C. EAACI/GA(2)LEN task force consensus report: The autologous serum skin test in urticaria. Allergy 2009;64:1256-68.
Asero R, Lorini M, Chong SU, Zuberbier T, Tedeschi A. Assessment of histamine releasing activity of sera from patients with chronic urticaria showing positive autologous skin test on human basophils and mast cells. Clin Exp Allergy 2004;34:1111-4.
Asero R, Tedeschi A, Riboldi P, Cugno M. Plasma of patients with chronic urticaria shows signs of thrombin generation, and its intradermal injection causes wheal-and-flare reactions much more frequently than autologous serum. J Allergy Clin Immunol 2006;117:1113-7.
Asero R, Tedeschi A, Coppola R, Griffini S, Paparella P, Riboldi P, et al
. Activation of the tissue factor pathway of blood coagulation in patients with chronic urticaria. J Allergy Clin Immunol 2007;119:705-10.
Kocatürk E, Kavala M, Kural E, Sarıgul S, Zındancı I. Autologous serum skin test vs autologous plasma skin test in patients with chronic urticaria: Evaluation of reproducibility, sensitivity and specificity and relationship with disease activity, quality of life and anti-thyroid antibodies. Eur J Dermatol 2011;21:339-43.
Kasperka-Zajac A, Brzoza Z, Rogala B. Platelet function in cutaneous diseases. Platelets 2008;19:317-21.
Asero R, Riboldi P, Tedeschi A, Cugno M, Meroni P. Chronic urticaria: A disease at a crossroad between autoimmunity and coagulation. Autoimmun Rev 2007;7:71-6.
Ward PA, Hill JH. C5 chemotactic fragments produced by an enzyme in lysosomal granules of neutrophils. J Immunol 1970;104:535-43.
Asero R, Cugno M, Tedeschi A. Activation of blood coagulation in plasma from chronic urticaria patients with negative autologous plasma skin test. J Eur Acad Dermatol Venereol 2011;25:201-5.
Schaeffer RC Jr, Gong F, Bitrick MS Jr, Smith TL. Thrombin and bradykinin initiate discrete endothelial solute permeability mechanisms. Am J Physiol 1993;264:1798-809.
Cirino G, Cicala C, Bucci MR, Sorrentino L, Maraganore JM, Stone SR. Thrombin functions as an inflammatory mediator through activation of its receptors. J Exp Med 1996;183:821-7.
Razin E, Marx G. Thrombin induced degranulation of cultured bone marrow-derived mast cells. J Immunol 1984;133:3282-5.
Fusari A, Colangelo C, Bonifazi F, Antonicelli L. The autologous serum skin test in the follow-up of patients with chronic urticaria. Allergy 2005;60:256-8.
Altrich ML, Halsey JF, Altman LC. Comparison of the in vivo
autologous skin test with in vitro
diagnostic tests for diagnosis of chronic autoimmune urticaria. Allergy and Asthma Proceedings 2009;30:28-34.
Yıldız H, Karabudak O, Doğan B, Harmanyeri Y. Evaluation of autologous plasma skin test in patients with chronic idiopathic urticaria. Br J Dermatol 2011;165:1205-9.
Nettis E, Dambra P, D'Oronzio L, Cavallo E, Loria MP, Fanelli M, et al
. Reactivity to autologous serum skin test and clinical features in chronic idiopathic urticaria. Clin Exp Dermatol 2002;27:29-31.
Kulthanan K, Jiamton S, Gorvanich T, Pinkaew S. Autologous serum skin test in chronic idiopathic urticaria: Prevalence, correlation and clinical implications. Asian Pac J Allergy Immunol 2006; 24:201-6.
Sabroe RA, Francis DM, Barr RM, Black AK, Greaves MW. Anti-Fc (episilon) RI auto antibodies and basophil histamine release ability in chronic idiopathic urticaria. J Allergy Clin Immunol 1998;102:651-8.
Bakos N, Hillander M. Comparison of chronic autoimmune urticaria with chronic idiopathic urticaria. Int J Dermatol 2003;42:613-5.
Sajedi V, Movahedi M, Aghamohammadi A, Gharagozlou M, Shafiei A, Soheili H, et al
. Comparison between sensitivity of autologous skin serum test and autologous plasma skin test in patients with Chronic Idiopathic Urticaria for detection of antibody against IgE or IgE receptor (FcεRIα). Iran J Allergy Asthma Immunol 2011;10:111-7.
Sabroe RA, Seed PT, Francis DM, Barr RM, Black AK, Greaves MW. Chronic idiopathic urticaria: Comparison of the clinical features of patients with and without anti-FcepsilonRI or anti-IgE autoantibodies. J Am Acad Dermatol 1999;40:443-50.
Garmendia JV, Zabaleta M, Aldrey O, Rivera H, De Sanctis JB, Bianco NE, et al
. Immunophenotype characteristics of peripheral blood mononuclear leukocytes of chronic idiopathic urticaria patients. Invest Clin 2006;47:361-9.
De Swerdt A, Van Den Keybus C, Kasran A, Cadot P, Neyens K, Coorevits L, et al
. Detection of basophil activating IgG autoantibodies in chronic idiopathic urticaria by induction of CD 63. J Allergy Clin Immunol 2005;116:662-7.
Metz M, Giménez-Arnau A, Borzova E, Grattan CE, Magerl M, Maurer M. Frequency and clinical implications of skin autoreactivity to serum versus plasma in patients with chronic urticaria. J Allergy Clin Immunol 2009;123:705-6.
Godse KV. Autologous serum skin test v/s autologous plasma skin test. Ind J Dermatol Venereol Leprol 2008;74:496-7.
Gaig P, García-Ortega P, Enrique E, Richart C. Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity. J Invest Allergol Clin Immunol 2000;10:342-5.
Leznoff A, Sussman GL. Syndrome of idiopathic chronic urticaria and angioedema with thyroid autoimmunity: A study of 90 patients. J Allergy Clin Immunol 1989;84:66-71.
Nassif A. Is chronic urticaria an atopic condition? Eur J Dermatol 2007;17:545-6.
Kaplan AP. What the first 10,000 patients with chronic urticaria have taught me: A personal journey. J Allergy Clin Immunol 2009;123:713-7.
Augey F, Goujon-Henry C, Berard F, Nicolas JF, Gunera-Saad N. Is there a link between chronic urticaria and atopy? Eur J Dermatol 2008;18:348-9.
[Table 1], [Table 2]