Dietary Modifications for Chronic Urticaria

August 31, 2020
Dietary Modifications for Chronic Urticaria

Question
I am an allergist in Australia where low food-chemical diets are often tried in chronic urticaria. Many academic publications from the USA state that such diets have a limited role in this condition. These diets are often use in Europe, where they often called “pseudo-allergen diets”- are there any RCT studies on this intervention? Can you advise on this diet´s role in chronic urticaria?

Answer
The efficacy of dietary modifications to alleviate chronic spontaneous urticaria (CSU) is controversial. To my best knowledge, there are no systematic reviews and meta-analysis of double-blind, placebo-controlled, randomized clinical trials englobing a sufficient population to provide meaningful conclusions. Nevertheless, some lower-evidence studies performed worldwide propose significant benefit of particular diets in patients with chronic hives and wheals.

Suggested dietary modifications for subjects with CSU include pseudo-allergen-free (e.g., food additives), low-histamine, gluten-free, and specific-food-free (e.g., fish) diets.

Food additives can be recognized as antigens by the immune system, leading to the exacerbation of inflammatory symptoms, not only in patients with CSU, but also eosinophilic esophagitis, bronchial asthma, atopic dermatitis, and anaphylaxis. Clinical history and food challenges are essential to recognize sensitization to food additives.

Histamine generates itch, wheals and hives. Low-histamine diets could lead to reduced plasma histamine levels and diminished symptoms in subjects with CSU, especially those patients with extra-cutaneous histamine-mediated inflammatory symptoms (e.g., diarrhea, headache). It is mandatory to first exclude other inflammatory diseases.

On the other hand, unnecessary dietary restrictions might have a detrimental effect on the nutritional condition and quality of life of patients with CSU.

In summary, I recommend a thorough clinical history and, if necessary, personalized food challenges to stablish the relevance of ingested molecules in each individual with CSU. This approach can lead to the suggestion of a particular diet in some patients.

References

1. Anvari S, Miller J, Yeh C-Y, Davis CM. IgE-Mediated Food Allergy. Clin Rev Allergy Immunol. octubre de 2019;57(2):244-60.
2. 2. Son JH, Chung BY, Kim HO, Park CW. A Histamine-Free Diet Is Helpful for Treatment of Adult Patients with Chronic Spontaneous Urticaria. Ann Dermatol. 2018;30(2):164.
3. Wagner N, Dirk D, Peveling-Oberhag A, Reese I, Rady-Pizarro U, Mitzel H, et al. A Popular myth - low-histamine diet improves chronic spontaneous urticaria - fact or fiction? J Eur Acad Dermatol Venereol. abril de 2017;31(4):650-5.
4. Jaros J, Shi VY, Katta R. Diet and Chronic Urticaria: Dietary Modification as a Treatment Strategy. Dermatol Pract Concept. 31 de diciembre de 2019;e2020004.
5. Murzaku EC, Bronsnick T, Rao BK. Diet in dermatology. J Am Acad Dermatol. diciembre de 2014;71(6):1053.e1-1053.e16.
6. Cornillier H, Giraudeau B, Samimi M, Munck S, Hacard F, Jonville-Bera A, et al. Effect of Diet in Chronic Spontaneous Urticaria: A Systematic Review. Acta Derm Venereol. 2019;99(2):127-32.
7. Magerl M, Pisarevskaja D, Scheufele R, Zuberbier T, Maurer M. Effects of a pseudoallergen-free diet on chronic spontaneous urticaria: a prospective trial: Effects of a pseudoallergen-free diet on urticaria. Allergy. enero de 2010;65(1):78-83.
8. Velázquez-Sámano G, Collado-Chagoya R, Cruz-Pantoja RA, Velasco-Medina AA, Rosales-Guevara J. Reacciones de hipersensibilidad a aditivos alimentarios. Rev Alerg México. 27 de junio de 2019;66(3):329.
9. Stephen-Victor E, Chatila TA. Regulation of oral immune tolerance by the microbiome in food allergy. Curr Opin Immunol. octubre de 2019; 60:141-7.

Paula Mazuelos-Weyrauch, MD
Allergy and Clinical Immunology

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