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August 19, 2020

Chronic Urticaria, Echinacea, Autohemotherapy

Question
Recently, I saw a 64-year-old female patient with chronic urticaria (longer than 2 years) who took Echinacea capsules for 2 weeks and cleared completely. How do you explain this improvement? Please also comment on Autohemotherapy for this entity that sometimes does work. Thank you.

Answer

Currently, antihistamines are the mainstay of treatment for patients with chronic spontaneous urticaria (CSU). However, up to 40% of patients do not improve significantly even with high (four-fold) daily doses of ‘modern’ antihistamines, requiring second-line therapies such as omalizumab and cyclosporine.

Due to the negative impact of antihistamine-resistant CSU on quality of life, and the high cost or low safety profile of second-line therapies, people are tempted to look for a variety of non-conventional interventions, which could be useful in some cases. However, convincing evidence for the overall efficacy of these interventions is generally lacking.

Autoimmune phenomena, including synthesis of immunoglobulin E (IgE) to self-antigens (‘autoallergens’) and IgG to the high-affinity IgE receptor or IgE itself, are considered to play an important role in the pathogenesis of CSU.  A complex network of inflammatory molecules mediates the appearance of wheals and hives. For example, interleukin 24 (IL-24) has recently been identified as a common, specific, and functional autoallergen recognized by IgE in patients with CSU. Additionally, Feng et al. propose that upregulation of IL-9 and IL-10 favors the development of CSU, while inhibition of JAK/STAT signaling pathway can effectively suppress the activity of the disease.

Echinacea, commonly called coneflowers, is a genus of herbaceous flowering plants traditionally used as herbal medicine. In particular, three species of Echinacea, namely E. purpurea, E. angustifolia and E. pallida, have been used as a treatment for cough, common cold, pharyngitis, and bronchitis. Echinacea is well known by its immunomodulatory and anti-inflammatory effects. I have not found significant research on the efficacy of Echinacea in the treatment of CSU. However, its immunologic effects could be related to the alleviation of the disease in your reported patient.

Autohemotherapy, that is, injection of autologous whole blood or serum, is commonly used to treat patients with antihistamine-resistant CSU in several countries throughout the world such as China, Germany, India, Iran, South Korea, Turkey, Mexico, and the United States. Autohemotherapy might have rapid and persistent beneficial effects in patients with ‘autoimmune’ CSU, related to a possible inhibitory action on autoantibodies. Yu et al. found that injection of autologous serum for eight weeks in patients with CSU reduced disease activity and serum anti-IL-24 IgE levels, although the study lacked a control group. There is still insufficient evidence to broadly recommend the use of autohemotherapy as an effective treatment for CSU, added to the fact that its mechanism of action is not well understood.

In conclusion, further research is needed to ascertain the relevance and mechanisms of the mentioned therapeutic interventions.

References

  1. Sharifi-Rad M, Mnayer D, Morais-Braga MFB, et al. Echinacea plants as antioxidant and antibacterial agents: From traditional medicine to biotechnological applications. Phytother Res. 2018;32(9):1653-1663. doi:10.1002/ptr.610
  2. Catanzaro M, Corsini E, Rosini M, Racchi M, Lanni C. Immunomodulators Inspired by Nature: A Review on Curcumin and Echinacea. Molecules. 2018;23(11):2778. Published 2018 Oct 26. doi:10.3390/molecules23112778
  3. Yu L, Buttgereit T, Stahl Skov P, et al. Immunological effects and potential mechanisms of action of autologous serum therapy in chronic spontaneous urticaria. J Eur Acad Dermatol Venereol. 2019;33(9):1747-1754. doi:10.1111/jdv.15640
  4. Chen Q, Zhong H, Chen WC, et al. Different expression patterns of plasma Th1-, Th2-, Th17- and Th22-related cytokines correlate with serum autoreactivity and allergen sensitivity in chronic spontaneous urticaria. J Eur Acad Dermatol Venereol. 2018;32(3):441-448. doi:10.1111/jdv.14541
  5. Feng H, Feng J, Zhang Z, et al. Role of IL-9 and IL-10 in the pathogenesis of chronic spontaneous urticaria through the JAK/STAT signalling pathway. Cell Biochem Funct. 2020;38(4):480-489. doi:10.1002/cbf.3481

Answered By:
Iris E. Hidalgo Nicho, MD
Allergy and Clinical Immunology


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