Original articleMechanisms of allergic and immune diseasesAssociation among stress, hypocortisolism, systemic inflammation, and disease severity in chronic urticaria
Introduction
Chronic urticaria (CU) is a disease characterized by short-lived but recurrent wheals, itching, and erythema lasting for more than 6 weeks. CU poses problems with respect to high prevalence, reduced quality of life, lack of long-term efficacy, and expense of current treatments for severe intractable symptoms. The pathogenesis of CU is poorly understood, but autoimmunity is considered one of the major underlying causes (30%–50%) of this disease, although other theories exist.1 There have been many reports suggesting that stress factors may be implicated in the pathogenesis.2 It has also been reported in previous studies that patients with CU experience secondary insomnia due to stress and itching caused by the disease before their disease onset, which may disturb the circadian rhythm of cortisol secretion and further precipitate CU.3 There are also reports of successful treatment of urticaria with selective serotonin reuptake inhibitors (SSRIs)4 and the whole-person treatment approach.2
In general, during acute stress, both the adrenocortical and medullary systems are activated, leading to increased release of cortisol and catecholamines. On the contrary, chronic stress causes hypothalamic-pituitary-adrenocortical (HPA) axis fatigue, resulting in reduced cortisol secretion and leading to increased secretion of inflammatory cytokines, such as interleukin (IL)-6 and IL-18, which are typically counterregulated by cortisol.5 Hence, we conducted this study to explore the association of disease and stress severity with markers of systemic inflammation and cortisol levels in patients with CU.
Section snippets
Methods
This cross-sectional study was performed in 45 patients with CU attending the Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, and 45 age- and sex-matched healthy controls conforming to the inclusion and exclusion criteria after obtaining written informed consent from the study participants. Ethical clearance was obtained from the Institute Ethics Committee (Human Studies), and written informed consent was obtained from all study participants
Results
In this cross-sectional study, the serum levels of cortisol, hs-CRP, and IL-18 and the PSLE and DHUS-R scores for stress were compared for 45 patients with CU and 45 age- and sex-matched controls. Baseline characteristics were comparable between cases and controls (Table 1). Of 45 patients with CU, 33 (73.3%) tested APST positive and 12 (26.7%) APST negative (Table 2). The median UAS of CU patients in our study was 5.0 (IQR, 4.0–6.0), and the median duration of the symptoms was 12.0 (IQR,
Discussion
Previous studies have proposed a role for psychological stress in CU[3], [12], [13] in a 2-way interaction, wherein CU heightens psychological distress and chronic stress may be a trigger of CU.12 There is evidence of the occurrence of stressful life events as precursors to the onset of CU. In a previous case-control study by Yang et al3 on patients with CU and the association between chronic idiopathic urticaria and stress from major life events, the investigators observed that patients with
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Disclosures: Authors have nothing to disclose.
Funding Source: This study was supported by intramural funds from the Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.