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 Table of Contents  
Year : 2021  |  Volume : 41  |  Issue : 1  |  Page : 45-50

Prevalence of cholinergic urticaria among Egyptian students and its effect on quality of life

Department of Dermatology, Andrology and Venereology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission30-Mar-2020
Date of Acceptance08-May-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Manal A Sharara
Department of Dermatology, Andrology and Venereology, Faculty of Medicine, Ain Shams University, Cairo 11381
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejdv.ejdv_16_20

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Background Cholinergic urticaria (CholU) is a type of physical urticaria characterized by pinpoint, highly pruritic heat-associated wheals. The prevalence of CholU ranges in different regions of the world between 0.2 and 11%. The prevalence in Egypt has not been studied before.
Objective We aimed to study the prevalence and clinical characteristics of CholU among Egyptian students together with assessing the effect of this disease on their quality of life (QOL).
Patients and methods A total of 400 Egyptian students (20–28 years of age) were surveyed to assess prevalence of CholU among them. Two questionnaires were used, one to study clinical characteristics of the disease, and the other was the dermatology life quality index to assess the effect of this disease on their QOL. Diagnosis was confirmed by exercise provocation test.
Results The overall prevalence of CholU was 7.5% (30 of 400 students), with most of the affected persons being females (73.3%). In 83.3% of the patients, the disease started in their third decade. Exercise was the most exacerbating factor, with tingling/itching without wheals more commonly occurring on the back. A total of 19 (63.3%) patients reported exacerbation in winter and 20 (66.7%) reported decreased sweating. Overall, 11 (36.7%) patients had a family member with similar condition. Regarding the effect on QOL, 10 (33.3%) patients showed extreme large affection and 17 (56.7%) had large affection.
Conclusion The study showed a high prevalence of CholU among Egyptian students, and it basically affected their QOL.

Keywords: cholinergic urticaria, prevalence, quality of life

How to cite this article:
Abdallah MA, Swidan AM, Sharara MA. Prevalence of cholinergic urticaria among Egyptian students and its effect on quality of life. Egypt J Dermatol Venerol 2021;41:45-50

How to cite this URL:
Abdallah MA, Swidan AM, Sharara MA. Prevalence of cholinergic urticaria among Egyptian students and its effect on quality of life. Egypt J Dermatol Venerol [serial online] 2021 [cited 2022 Oct 1];41:45-50. Available from: http://www.ejdv.eg.net/text.asp?2021/41/1/45/304323

  Introduction Top

Cholinergic urticaria (CholU), first described by Duke [1], is a frequently occurring skin disorder characterized by unique clinical features. Pinpoint, highly pruritic wheals with surrounding erythema appear after sweating, induced by an increase in the core body temperature, which occurs in response to hot bathing, physical exercise, and/or emotional stress [2],[3]. Although the symptoms usually subside rapidly, commonly within 1 h, most patients with CholU complain that they feel stinging or tingling pain and/or itching at the onset of symptoms, and these feelings appear to disturb their quality of life (QOL) [4],[5].

Several reports are available about CholU in various countries and ethnicities [6],[7],[8],[9]; however, no previous Egyptian studies considered the prevalence and clinical characteristics of this disease among Egyptian population. Accordingly, this study aimed to outline the prevalence and clinical characteristics of CholU, together with the effect of this condition on QOL.

  Patients and methods Top

This cross-sectional study included 400 randomly selected students from two different faculties. Both sexes were included. The study protocol was in accordance with Helsinki declaration of human rights and was approved by the local Ethical Committee of Ain Shams University. The study was done between November and March. Sample size was calculated using PASS program, version 15 (PASS 15 Power Analysis and Sample Size Software (2017). NCSS, LLC, Kaysville, Utah, USA), setting the type-error (α) at 0.05 and margin of error of 3.5%. Result from previous study [6] showed that the prevalence of urticaria was 11%. Calculation according to these values produced a sample size of 385 cases, taking into account 20% dropout rate. The simple asymptotic confidence interval formula was used in calculation. Exclusion criteria included current or previous history of systemic diseases e.g. liver cirrhosis, biliary obstruction, organ transplant, and renal blood diseases.

In the studied group, eliciting factors, clinical signs, and symptoms were explained with photographs of patients with lesions of CholU in a 5-min presentation in the classroom. Then, a short-written questionnaire was given and answered to confirm the presence or absence of CholU in the presence of dermatologist to help with any queries. Those who were diagnosed with CholU based on history signed a consent to participate in the study. Students who recorded a positive history underwent 15 min of vigorous exercise followed by an examination for wheals and erythema. Each participant was given two questionnaires: a questionnaire of CholU to study the clinical characteristics of CholU (age, sex, age of onset, family history, symptoms, common sites, and eliciting factors) and the dermatology life quality index questionnaire to be also answered by the students to assess the effect of CholU on QOL [10].

Statistical analysis

The collected data were revised, coded, tabulated, and introduced to a PC using statistical package for social science (IBM Corp. Released 2011, IBM SPSS Statistics for Windows, Version 20.0.; IBM Corp., Armonk, New York, USA). Quantitative variables were expressed as mean and SD. Qualitative variables were expressed as frequencies and percent.

  Results Top

Sex, age, and time of onset

This study included 400 students: 180 (45%) females and 220 (55%) males, with an age range from 20 to 28 years, with a mean of 24.5±2.5 years. The overall prevalence of CholU was found to be 7.5% (30 of 400 students) as proved by exercise provocation test ([Figure 1]). Age range of students diagnosed with CholU was 20–28 years with a mean±SD of 23.7±1.89 years. They were 22 (73.3%) females and seven (26.7%) males. According to analysis of disease onset, five (16.7%) patients started the disease in their second decade (10–19 years) and 25 (83.3%) in their third decade (20–29) ([Table 1]).
Figure 1 Prevalence of cholinergic urticaria among students.

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Table 1 Demographic data of patients with cholinergic urticaria

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Exacerbating factors

Among cases, exercise was identified as the most common exacerbating factor in 22 (73.3%), followed by spicy food in 21 (70%), hot bath in 19 (63.3%), and cold weather in 11 (37.9%) ([Table 2]).
Table 2 Clinical features of patients with cholinergic urticaria

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Morphology, clinical symptoms, and distribution of lesions

A total of 22 (73.3%) cases had only tingling/itching sensation, and eight (26.7%) had tingling/itching accompanied by follicular wheals.

Regarding the distribution of lesions and symptoms, the back was the most common site in 27 (90%) cases, followed by the chest in 26 (86.7%), lower limbs in 16 (53.3%), upper limbs in 12 (40%), and face and neck in 10 (33.3%) ([Table 2] and [Figure 2]).
Figure 2 Site of symptoms among young adults with cholinergic urticaria.

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Seasonal exacerbation and reduced sweat secretion

A total of 19 (63.3%) patients reported exacerbation in winter, and 20 (66.7%) reported decreased sweating.

Family history

Overall, 11 (36.7%) patients have a family member with similar condition; seven (63.3%) had their father affected and four (36.4%) had their mother. However, 15 (50%) had no family history, and four (13.3%) were not sure ([Figure 3]).
Figure 3 Family history among young adults with cholinergic urticaria.

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Overall, 80% (24) of our patients did not receive treatment as they never sought medical advice and were not oriented by the condition until explained to them, whereas 20% (six) received treatment in the form of first- and second-generation antihistamines.

Quality of life in patients with cholinergic urticaria

Among the studied cases, 10 (33.3%) patients showed extreme large affection in their QOL, 17 (56.7%) had large affection, two (6.7%) had moderate affection, and one (3.3%) showed small affection ([Table 2] and [Figure 4]).
Figure 4 Dermatology life quality index in patients with cholinergic urticaria.

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  Discussion Top

CholU is a fairly common type of hives, comprising ∼30% of physical urticaria and ∼7% of chronic urticaria [11]. Zuberbier et al. [6], in their study, found a prevalence of 11.2% of CholU in the young German population. Prevalence is much lower in countries with hot and humid weather. The overall prevalence of CholU was reported as 4% (25 of 600 students) in India (seven), and six of 86 patients with physical urticaria had CholU in Thailand [8]. In our study, the prevalence was found to be relatively high (7.5%) compared with hot-humid countries; this may be attributed to the differences in genetic background, method of diagnosis, and climatic factor. Moreover, this relatively high prevalence could be attributed to stress factors that medical and engineering students are exposed to. However, to the best of our knowledge, no previous Egyptian studies looked at the prevalence of CholU among Egyptian population, and further larger studies on different age and broader group of population should be carried out to further clarify this point.

Commonest age of onset of CholU is in the second decade. A study by Kim et al. [9] found that 51% developed CholU in their teens. Another study by Kumaran et al. [12] reported that 47.3% had onset in their first decade. A Korean study by Kim and Lee [13] reported onset in second decade in 65% of the studied group. Our study demonstrated similar but slightly higher pattern, where 83.3% developed CholU in their third decade; however, as the study was a cross-sectional study, the data about the onset can be unreliable as we did not study individuals of higher age who could develop their disease at an older age.

Regarding sex distribution, there have been contradictory reports. Although some studies noted a male predominance [2],[9], others have found female predominance [6]. Our study demonstrated higher female predominance (73.3%).

In our study, exercise was the most common exacerbating factor (73.3%), followed by spicy food, hot bath, and then weather changes. Kim et al. [9] also reported exercise as the most common aggravating factor (64.1%), followed by a bath then hot or spicy food, and then psychological stress. Zuberbier et al. [6] found the most common exacerbating factor as hot shower followed by sweating and exercise.

Distribution of symptoms was greatest at the back (90%), chest (86.7%), lower limbs (53.3%), arms (40%), neck (23.3%), and face (10%). This is in accordance with the different studies which reported the trunk as the most commonly affected site [3],[6],[9],[13].

A total of 19 (63.3%) patients reported exacerbation in winter and 20 (66.7%) reported decreased sweating after hives. A previous study by Ramam and Pahwa [14], had also found symptoms limited to winter months (from October to January) in 62.5% patients, with 12.5% patients having increased frequency and severity of episodes during winters. Rho [15] reported that CholU symptoms can be aggravated owing to xerosis-induced sweat duct occlusion in winter. In their report, 64 (26.1%) of 245 patients showed symptom onset only in winter, and 17 complained of decreased perspiration. Kobayashi et al. [16] explained that the sweat pores in the epidermis are blocked by a widening of the keratin plug or sweat duct obstruction in patients with CholU, resulting in inflammatory substances contained in sweat being refluxed into the dermis causing urticaria wheals. Exacerbation of CholU in the winter suggests that sweating in the summer may prevent the formation of keratotic plugs and occlusion. Immediate-type hypersensitivity to unknown substances in sweat has also been suggested considering positive reactions induced by an intradermal injection of a patient’s own diluted sweat [17],[18]. Anti-immunoglobulin E therapy with omalizumab has been found to be effective in this population [19].

In our study, we reported 36.7% of patients with CholU to have a family member affected with similar condition; in 63.3%, the father was the one to be affected. According to Onn et al. [20], who reported the family history of CholU for the first time, only the father and the son developed CholU in a four-member family with an urticaria history.

The majority of our studied cases (73.3%) complained only from tingling or itching sensation, whereas 26.7% had follicular wheals accompanying the tingling/itching sensation. Zuberbier et al. [6] stated that most patients (76%) had only mild to moderate symptoms, with typical pinpoint wheals of short duration, invariably associated with pruritis. Kim et al. [9] found that 46.7% of the patients complained only of pruritis, 17.4% complained of soreness, and 35.9% complained of both. It is known that follicular and nonfollicular forms have different pathogenic mechanisms. It is hypothesized that hypersensitivity to autologous serum and sweat may be involved in the wheal formation of the former and the latter type, respectively [21].In this study, most patients (80%) did not receive any treatment and never sought medical advice for their condition; however, 20% were treated with first-generation and second-generation antihistamines. Available treatments for CholU include H1 receptor antagonists as a first-line therapy for patients with CholU, but many patients show only a mild to moderate response to standard doses. Increasing the dose in patients with CholU that is refractory to standard doses may improve the disease activity, but this occurs in fewer than half of all patients. The addition of an H2 receptor antagonists was reported to be effective in patients with refractory CholU that was unresponsive to up-dosing of an H1 receptor antagonists. Other studies have demonstrated the efficacy of scopolamine butylbromide (an anticholinergic agent); combinations of propranolol (a b2-adrenergic blocker), antihistamines, and montelukast; and treatment and injection with botulinum toxin. High doses of danazol (600 mg daily) are also reportedly effective, but the adverse effect profile of danazol restricts its use. Several studies have shown that omalizumab (a recombinant humanized IgG1 monoclonal antibody that binds to IgE) was effective for severe CholU [22].

Regarding the QOL affection among patients with CholU, our study demonstrated that 33.3% had extremely large affection, and 56.7% had large affection. No previous studies addressed the effect of CholU on the QOL, which is considered a very critical issue, as most eliciting factors of CholU are parts of everyday life activities. However, more recently, Ruft et al. [23] developed and validated the first disease-specific QOL instrument for patients with CholU, the Cholinergic Urticaria Quality-of-Life Questionnaire, which was not available at the time we performed our study.

  Conclusion Top

So, in conclusion, this study showed a high prevalence of CholU among Egyptian students, and it basically affected their QOL. It highlights the importance of increased awareness about this disease as many patients in our study did not seek medical advice before they were educated about the disease.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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