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REVIEW ARTICLE
Effect of Diet in Chronic Spontaneous Urticaria: A Systematic
Review
Hélène CORNILLIER 1 , Bruno GIRAUDEAU 2 , Mahtab SAMIMI 1 , Stéphane MUNCK 3 , Florence HACARD 4 , Annie-Pierre JONVILLE-
BERA 2,5 , Marie-Hélène JEGOU 6 , Gwenaëlle D’ACREMONT 7 , Bach-nga PHAM 8 , Olivier CHOSIDOW 9 and Annabel MARUANI 1,2 ;
CENTRE DE PREUVES EN DERMATOLOGIE
1
Department of Dermatology, University François Rabelais Tours, CHRU Tours, Tours, 2 SPHERE - INSERM 1246. University of Tours and
Nantes, 3 Department of Teaching and Research in General Practice, University Nice Sophia Antipolis, Nice, 4 Department of Allergology and
Immunology, University Hospital Center of Lyon, Lyon, 5 Department of Clinical Pharmacology, CHRU Tours, Tours, 6 Dermatology Office,
Blanquefort, 7 Pediatric Office, Paris, 8 Laboratory of Immunology, University Hospital Centre of Reims, Reims, and 9 EA 7379 EpiDermE and
CIC INSERM 1430, AP-HP, Hospital Henri Mondor, UPEC, Créteil, France
Strategies for diets in chronic spontaneous urticaria
(CSU) are controversial. This systematic review asses-
sed the interest in diet for managing CSU. We sear-
ched for original reports in MEDLINE, EMBASE, CEN-
TRAL and LILACS. Among the 278 reports screened, 20
were included, involving 1,734 patients. Reports des-
cribed 3 types of systematic diet: pseudoallergen-free
diet (n = 1,555 patients), low-histamine diet (n = 223)
and diet without fish products (n = 47), which induced
complete remission in 4.8%, 11.7% and 10.6% of pa-
tients, respectively, and partial remission in 37.0%,
43.9% and 4.3%. Eight reports described personalized
exclusion diets (66 patients) adapted to symptoms/
allergological test results and led to complete remis-
sion in 74.6% of patients, although the diagnosis of
CSU was doubtful. No comparative randomized studies
of diets were available. The only randomized studies
were based on oral provocation tests with the suspec-
ted responsible diet. Population and outcomes were
heterogeneous. In conclusion, there is evidence for
the benefit of diets in CSU only in individual patients
with clinical symptoms. However, the level of evidence
is low for the benefit of systematic diets in CSU be-
cause systematic double-blind controlled trials of diet
are lacking.
Key words: chronic urticaria; spontaneous urticaria; diet; food;
allergological tests.
Accepted Aug 7, 2018; E-published Aug 7, 2018
Acta Derm Venereol 2019; 99: 127–132.
Corr: Hélène Cornillier, Department of Dermatology, CHRU Tours – Hospi-
tal Trousseau, Avenue de la République, FR-37044, Tours Cedex 9, Tours,
France. E-mail: [email protected]
C
hronic urticaria is an inflammatory skin and mucosa
dermatitis, defined as the occurrence of spontaneous
wheals, angioedema, or both, for more than 6 weeks.
The guidelines of the European Academy of Allergy and
Clinical Immunology, Global Allergy and Asthma Euro-
pean Network, European Dermatology Forum and World
Allergy Organization (EAACI/GA 2 LEN/EDF/WAO)
divide chronic urticaria into 2 groups: chronic inducible
urticaria and chronic spontaneous urticaria (CSU) (1).
Chronic inducible urticaria includes symptomatic dermo-
SIGNIFICANCE
Chronic spontaneous urticaria is an inflammatory skin and
mucosa disease, defined as the occurrence of spontaneous
wheals or oedema for more than 6 weeks. Chronic sponta-
neous urticaria treatment frequently includes H1-antihista-
mine drugs as first-line treatment. Strategies for diets are
controversial. A systematic review was performed to assess
the value of diets in managing chronic spontaneous urtica-
ria. The review shows that the level of scientific evidence is
low because controlled studies of diets and of allergological
tests in chronic spontaneous urticaria are lacking. However,
the data suggest no benefit of systematic diets in chronic
spontaneous urticaria, but benefit of personalized diets in
individual patients with clinical symptoms.
graphism, cold urticaria, delayed pressure urticaria, solar
and heat urticaria, vibratory angiooedema, cholinergic
urticaria, contact urticaria and aquagenic urticaria. The
causes of CSU are frequently unknown. CSU might oc-
cur at any age, but is more frequent in young adults and
has a female predominance.
CSU is the consequence of mast cell activation.
Activated mast cells release histamine first, then other
mediators, such as platelet-activating factor, leukotrienes
and prostaglandins that induce sensory nerve activation,
vasodilatation, and plasma extravasation. These effects
are responsible for dermal oedema, whose clinical fea-
tures are urticarial characteristic lesions. In CSU, mast
cells are pre-activated via an immunological pathway
(IgE, IgG, complement) or non-immunological pathway
by transmembrane receptors or intracellular signals (2).
Complete mast cell activation is triggered by other mul-
tiple signals, including infections, drugs, stress, foods
and other agents.
Foods might be responsible for urticaria if they are
rich in histamine or are able to activate mast cells via
the non-immunological pathway and induce histamine
release. Foods that might be involved include cheese,
fish, vegetables, fruits, chocolate and alcohol (this is a
non-exhaustive list). Contrary to acute urticaria being
linked to food allergy, the mechanism of CSU is not
an IgE-mediated type I reaction, but is rather dose-
dependent, usually a delayed pseudoallergic reaction
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.
doi: 10.2340/00015555-3015
Acta Derm Venereol 2019; 99: 127–132