PRACA ORYGINALNA

ORIGINAL ARTICLE

COMBINED DIFFERENTIATED THERAPY IN PATIENTS WITH URTICARIA

Оrysya О. Syzon, Tetyana I. Rudnyk, Marianna O. Dashko

Danylo Halytsky Lviv National Medical University, Lviv, Ukraine

ABSTRACT

Introduction: The necessity of the study of urticaria is called for by its high specific gravity in the structure of dermatoses, lack of effective therapies and, consequently, negative impact on the quality of life of patients and members of their families.

Among the factors that initiate clinical manifestations of urticaria are autoimmune disorders, diseases of the gastrointestinal tract, nervous system, bacterial and viral infections, helminth infestation. However, the state of the internal secretion glands in such patients is understudied. Although, it is recognised that thyroid gland plays an important role in the development of allergic dermatitis, but its role in the formation of autoimmune processes at urticaria is still unclear. Such diversity of mechanisms of urticaria development considerably complicates the choice of rational ways of effective therapy. In particular, traditional agents (antihistamine and other hyposensitizing ones) often do not have the desired effect. Due to such complicated current condition of treatment of patients with urticaria, non-medicated methods of treatment seem to be getting more and more prospective.

The aim:To develop differentiated treatment of urticaria patients, taking into account the functional state of the thyroid gland and its participation in the formation of autoimmune processes.

Materials and methods: We had been supervising 127 patients with chronic idiopathic urticaria (49 men and 78 women) of the age range from 15 to 67 years old with the disease duration from 5 months to 29 years. The control group consisted of 20 healthy individuals. The mild degree of severity of dermatosis was diagnosed in 43 (33.9%) patients, the average degree of the disease severity – in 41 (32.2%), and severe form of the disease was observed in 43 (33.9%) patients.

The functional state of thyroid gland was evaluated by determining the level of thyroxine, triiodothyronine, thyroglobulin, and autoantibodies to thyroperoxidase and thyroglobulin in serum.

Results: It was discovered that in patients with urticaria, dysfunctional state of thyroid gland is observed, which is manifested by a probable increase in thyroxine content up to 107.52±4.20 nmol/l (in healthy individuals 78.13±3.65 nmol/l; p<0.05) and thyroglobulin – up to 29.73±2.51 ng/ml (in healthy individuals – 20.16±1.34 ng/ml; p<0.05), which is associated with a decrease in the level of triiodothyronine – up to 1.33±0.06 nmol/l (in healthy individuals – 1.52±0.04 nmol/l; p<0.05).

In order to evaluate the effectiveness of this approach, all patients were divided into 4 groups. The first group, with the total amount of 32 patients were prescribed only traditional standard treatment, according to the guidelines. The pations of second group (31 patients) were prescribed specific phototherapy (once a week, 6-8 sessions) after traditional medication and afterward absence of clinical manifestations of pathological process. 31 рatients of the third group were prescribed balneo- and halotherapy after traditional medication and no afterward clinical manifestations of urticaria. The fourth group (33 patients) prescribed combined treatment in the way of combined application of specific therapy, phototherapy, balneotherapy and halotherapy, after the elimination of clinical manifestations of dermatosis by means of 2 month traditional medication.

It was established that patients with mild dermatosis were exposed to a probable correction of the functional state of the thyroid gland, improved clinical course and quality of life after medication, balneo- and halomethods of treatment, patients with moderate and severe degree – after combined application of medication, specific photo-, balneo- and halotherapy

Conclusions: Thus, the therapy of patients with urticaria requires a differentiated approach. Patients with mild dermatosis, after traditional medication, should be prescribed balneo- and halomethods of treatment. Patients with moderate to severe degree of the disease require more intensive medical intervention. They should be prescribed a combined application of specific photo-, balneo- and halotherapy. This approach allows eliminating the pathological process.

KEY WORDS: urticaria, thyroid gland, autoimmune disorders, therapy

Wiad Lek 2019, 72, 4, 589-594

Introduction

The necessity of the study of urticaria is called for by its high specific gravity in the structure of dermatoses, lack of effective therapies and, consequently, negative impact on the quality of life of patients and members of their families [1-4].

Among the factors that initiate clinical manifestations of urticaria are autoimmune disorders, diseases of the gastrointestinal tract, nervous system, bacterial and viral infections, helminth infestation [5]. However, the state of the internal secretion glands in such patients is understudied. Although, it is recognised that thyroid gland plays an important role in the development of allergic dermatitis [6,7], but its role in the formation of autoimmune processes at urticaria is still unclear.

Such diversity of mechanisms of urticaria development considerably complicates the choice of rational ways of effective therapy. In particular, traditional agents (antihistamine and other hyposensitizing ones) often do not have the desired effect [8,9].

Due to such complicated current condition of treatment of patients with urticaria, non-medicated methods of treatment seem to be getting more and more prospective. In particular, it is believed that recurrence of clinical manifestations of dermatosis and the elimination of functional disorders of the macroorganism in general, and of the skin in particular may be faster under the influence of balneological and climatic procedures than under the influence of allopathic remedies [10]. It is known [11, 12] that mineral baths have undoubted therapeutic properties. They affect macroorganism by a combination of factors. To their non-specific effects refer: hydrostatic (promoting blood to heart), mechanical (the effect of which is particularly perceptible while applying shower or shower with massage), temperature (having an effect on skin receptors area and processes of thermoregulation). The specific factors of balneotherapy are manifested by selective influence of procedures on different systems of macroorganism, depending on physical, chemical and other properties of mineral water. The significance of the latter is determined by its mineral and ionic composition, presence of gases and gas saturation, content of organic compounds and microelements with bio-and radioactivity, Ph, temperature [10,12].

In particular, expediency of including balneotherapy in the basic program of rehabilitation of such patients it is indicated [10] (sodium chloride baths of small or medium mineralization at the t 36-38°С, for 15 minutes; hydrogen sulfide baths with the ions concentration 80-120 mg at the t 36-37°С for 5 minutes; radon baths of small and medium concentrations at the t 36°С for 10-15 minuntes). However, the data on the effectiveness of balneotherapy for patients with urticaria are quite controversial.

Significant attention in the treatment of patients with allergic dermatoses is paid to UVR. Its influence can be direct, humoral, and reflexive [13]. The antiproliferative effect of the UVR on the skin lies in reduction of the amount of Langerhans antigen-presenting cells in the dermis and epidermis, by interacting with T-lymphocytes, which leads to suppression of functional activity of the cellular elements and causes skin activity decrease in reactions to contact hypersensitivity. It has been proved that UVR not only depresses the functionality of lymphocytes, but it can also destroy them. In addition, the activity of these immunocompetent cells decreases due to the elimination of the epidermis associated macrophages. Also, UVR leads to the formation of dendritic cells in the skin, which are more resistant to the effects of damaging factors. Having direct suppressing effects on the synthesis of nuclear DNA of keratinocytes, UVR reduces their mitotic activity. Moreover, UVR is characterized by dermotropism which depends on the wave length. Several variants of phototherapy of patients with skin pathology have been developed so far, for instance: selective, embodying the combination of UVB (295-330 nm) and UVA; photochemotherapy (PUVA), narrow-wave UVB with a wave length of 311 nm, and phototherapy with the appointment of UVA narrow spectrum (370 nm). The most expedient in terms of efficiency, convenience and safety is the use of UVB with the length of 311 nm [14-16]. However, there is no data available as to their appointment to patients with urticaria.

Thus, all the above facts testify a number of unexplained pathogenetic mechanisms of urticaria aas well as ways of treatment of such patients. There are no targeted studies concerning the role of thyroid gland in the development of dermatosis.

The aim

Тo develop differentiated treatment of urticaria patients, taking into account the functional state of the thyroid gland and its participation in the formation of autoimmune processes.

Materials and methods

We had been supervising 127 patients with chronic idiopathic urticaria (49 men and 78 women) of the age range from 15 to 67 years old with the disease duration from 5 months to 29 years. The control group consisted of 20 healthy individuals. The mild degree of severity of dermatosis was diagnosed in 43 (33.9%) patients, the average degree of the disease severity – in 41 (32.2%), and severe form of the disease was observed in 43 (33.9%) patients (figure 1).

The functional state of thyroid gland was evaluated by determining the level of thyroxine, triiodothyronine, thyroglobulin, and autoantibodies to thyroperoxidase and thyroglobulin in serum. The content of thyroxine was studied using the test kit RIO-T4-IOP (Republic of Belarus), and triiodothyronine – using the test kit RIO-T3-IPR (Republic of Belarus). The results were expressed in nmol/l. The level of thyroglobulin was detected using the test kit RІО-TG125І, with employment of thyroglobulin labeled with iodine 125 (Republic of Belarus). The results were expressed in ng/ml. The research was carried out on the radio-immunoassay “Gamma-12”.

The autoantibodies to thyroperoxidase and thyroglobulin were determined using the sandwich method of the solid phase enzyme-linked immunosorbent assay using reagent kits, AT-TPO-IFA and AT-TG-IFA respectively, and their values were expressed in MO/ml.

Results and discussion

Among the factors that initiate clinical manifestations of urticaria are some internal disease[1,5]. Also in some literary data there information about thyroid gland and there role in the development of allergic dermatitis[4]. It was discovered that in patients with urticaria, dysfunctional state of thyroid gland is observed, which is manifested by a probable increase in thyroxine content up to 107.52±4.20 nmol/l (in healthy individuals ‒ 78.13±3.65 nmol/l; p<0.05) and thyroglobulin ‒ up to 29.73±2.51 ng/ml (in healthy individuals ‒ 20.16±1.34 ng/ml; p<0.05), which is associated with a decrease in the level of triiodothyronine ‒ up to 1.33±0.06 nmol/l (in healthy individuals ‒ 1.52±0.04 nmol/l; p<0.05). However, the degree of severity of dermatosis did not differ significantly in terms of statistic changes from the average values of the entire number of patients.

However, we can not omit the fact of the lack of dependence of the content of thyroxin, thyroglobulin and triiodothyronine on the course of the pathological process. Quite a different situation was observed while analysing the effect of the duration of the last clinical remission at the level of these compounds. So, at the absence of remissions and their duration up to 3 months, the thyroxine content increased significantly, in comparison with the average values of the entire number of patients up to ‒ 114.75±1.32 nmol/l (p<0,05) and up to ‒ 113.98±1.45 nmol/l (p<0.05) respectively. The levels of triiodothyronine in these groups of patients decreased up to ‒ 1.15±0.03 nmol/l (p<0.05) and up to ‒ 1.20±0.04 nmol/l (p<0.05) respectively. The content of thyroglobulin increased significantly only in the absence of remissions – up to 35.49±1.65 ng/ml (p<0.05).

Investigating the role of thyroid gland in the development of autoimmune processes at urticaria has made it possible to calculate the probable increase in the levels of autoantibodies to thyroperoxidase and thyroglobulin in such patients: to 27,18±2,23 mo/ml (in healthy individuals ‒ 14.47±0.55 mo/ml, p<0.05) and up to 159.70±8.05 mo/ml (in healthy individuals ‒ 76.12±3.42 mo/ml, p<0.05) respectively. In addition, an essential dependence of the content of these compounds on the clinical manifestations of the pathological process has been established. In particular, if, at a mild degree of dermatosis, the values of autoantibodies to thyroperoxidase and thyroglobulin were significantly reduced, compared to the average values the entire number of patients, and were, corresponding up to 20.35±1.14 mo/ml (p<0,05) and to 126.94±4.83 mo/ml (p<0.05), at moderate level they were within their norms, i.e. 26.73 mo/ml (p>0.05) and 149.08±6.12 mo/ml (p> 0.05) respectively. Severe urticaria was characterized by a significantly high content of autoantibodies to thyroperoxidase and thyroglobulin, compared with average value of the entire number of patients – up to 34.13±1.35 mo/ml (p<0.05) and 197.65±7,94 mo/ml (p<0,05) respectively.

The dependence of the levels of these compounds on the duration of the pathological process was not detected. However, there was a certain dependence in case of the duration of the process up to 3 months the content of autoantibodies to thyroperoxidase significantly exceeded the average values of the entire number of patients, reaching 35.04±1.19 mo/ml (p<0.05) and 33.74±0.89 mo/ml (p<0.05). The level of autoantibodies to thyroglobulin was obviously increasing, comparing with the average values of the entire number of patients, only in the absence of remissions, up to 174.38±5.67 mo/ml (p<0.05).

The study of the interrelation between the functional state of the thyroid gland and the autoimmune linkage of urticaria revealed the greatest association between the levels of thyroxine and thyroglobulin and the content of autoantibodies to thyroperoxidase, which is characterized by r = + 0.62 and + 0.60, respectively.

We have resorted to the combined use of narrow-spectral phototherapy, balneotherapy and microclimate chambers, which have a multidirectional effect on the course of the pathological process, as a method of treatment that corrects the functional state of the thyroid gland, autoimmune disorders and clinical manifestations of urticarial. In order to evaluate the effectiveness of this approach, all patients were divided into 4 groups (3 comparative groups and 1 main group).

The first group, with the total amount of 32 patients, included 10 people with mild degree of urticaria, 11 – with moderate degree, and 11 – with severe degree. The second group, with the total number of 31 patients, included, respectively, 10, 10 and 11 patients. In the third group (consisting of 31 patients), 11 patients were with mild degree of dermatosis, 10 – with moderate, 10 – with severe urticaria. The fourth group (33 patients) consisted of 12, 10 and 11 patients, respectively.

The first group of patients were prescribed only traditional standard treatment, according to the guidelines: antihistamines and hypoxibles, and enterosorbents. In special cases of severe, resistant to the above mentioned medications, pathological process, systemic glucocorticosteroids were recommended. Duration of the treatment was 2-4 weeks.

In patients of the first group of comparison, absence of probable correction of the functional state of thyroid gland was observed. The content of autoantibodies to thyroperoxidase and thyroglobulin was statistically significantly suppressed, regardless of the degree of urticaria severit, but remained outside the limits of physiological values. The quality of life of patients of this group has not significantly improved.

Patients of the second group of comparison were prescribed specific phototherapy (once a week, 6-8 sessions) after traditional medication and afterward absence of clinical manifestations of pathological process. It has been shown that in these patients, the functional state of thyroid gland was likely to improve, but only in case of mild urticaria. However, if the content of triiodothyronine and thyroglobulin was within the range of control deviations, reaching 1.49±0.02 nmol/l (1.38±0.07 nmol/l, p<0.05) and 21.74±0.92 ng/ml (before treatment ‒ 25.42±1.73 ng/ml, p<0.05; in healthy individuals ‒ 20.16±1.34 ng/ml; p>0.05) then the level of thyroxin remained outside its limits 91.25±3.73 nmol/l (before treatment ‒ 103.04±2.80 nmol/l; p<0.05; in healthy individuals ‒ 78.43±3.65 nmol/l; p>0.05). More emphasis was paid to the depressing effect of narrow-spectral phototherapy on autoimmune processes. In particular, at mild degree of dermatosis, the values of autoantibodies to thyroperoxidase and thyroglobulin decreased to physiological ones, i.e., corresponding to 15.32±0.63 mo/ml (before treatment ‒ 20.35±1.14 mo/ml, p<0.05; in healthy individuals ‒ 14.47±0.55 mo/ml; p>0.05) and to 79.80±2.61 mo/ml (before treatment ‒ 126.96±4.83 mo/ml, p<0.05; in healthy individuals – 76.12±3.42 mo/ml; p>0.05); and at the average, respectively, up to 16.01±2.13 mo/ml (before treatment 26.73 ± 1.28 mo/ml, p<0.05, in healthy individuals ‒ 14.47±0.55 mo/ml; p>0.05) and to 81.37±5.92 mo/ml (before treatment ‒ 143.08±6.12 mo/ml; p<0.05; in healthy individuals ‒ 76.12±3.42 mo/ml; p>0.05). At a severe degree of the disease, the values were beyond the index of control deviations, reaching correspondingly 23.54±1.89 mo/ml (before treatment ‒ 34.13±1.35 mo/ml, p<0.05, in healthy individuals ‒ 14.47±0.55 mo/ml; p>0.05) and 118.14±6.18 mo/ml (before treatment ‒ 197.65±7.94 mo/ml; p<0.05; in healthy individuals ‒ 76.12±3.42 mo/ml, p>0.05). The quality of life of patients of the second group of comparison was likely to improve at mild and moderate degrees of urticaria, forming, respectively, dermatology life quality index (DLQI) 7.5±0.3 points (before treatment ‒ 10.2±1.9 points p< 0,05) and 9,2±0,6 points (before treatment ‒ 14.3±2.1 points, p< 0,05). At severe urticarial the DLQI was characterized by an unreliable correction 17.9±1.2 points (before treatment ‒ 19.7±1.6 points, p<0,05).

Patients of the third group of comparison were prescribed balneo- and halotherapy after traditional medication and no afterward clinical manifestations of urticaria. We recommended low-mineralized chloride-sodium baths and a chamber of artificial microclimate 1 time a week. The course of therapy lasted 1.5 – 2 months. It was ascertained that these patients feel significant correction and improvement of the functional of thyroid gland. In particular, at mild to moderate degrees of dermatosis, its values were reaching the physiological limits. In particular, the thyroxin content was 82.17±4.01 nmol/l (before treatment ‒ 103.04±2.80 nmol/l, p<0.05; in healthy individuals ‒ 78.43±3.65 nmol/l; р>0,05) and 84.27±5.16 nmol/l (before treatment ‒ 106.38±3,94 nmol/l; p<0,05; in healthy individuals ‒ 78.43±3.65 nmol/l; p>0.05), triiodothyronine ‒ 1.53±0.03 nmol/l (before treatment ‒ 1.38±0.07 nmol/l; p<0.05; in healthy individuals ‒ 1.52±0.04 nmol/l; p>0,05) and 1.48±0.06 nmol/l (before treatment ‒ 1.30±0.05 nmol/l; p<0.05; in healthy individuals – 1.52±0.04 nmol/l; p>0,05); tireoglobulin – 20.95±1.87 nmol/l (before treatment ‒ 25.42±1.73 nmol/l; p<0.05; in healthy individuals ‒ 20.16±1.34 nmol/l; p>0.05), 22.05±1.96 nmol/l (before treatment ‒ 28.91±2.27 nmol/l; p<0.05; in healthy individuals ‒ 20.16±1.34 nmol/l ; p>0.05). The values changed slightly differently at severe degree of urticaria. Thus, if the levels of thyroxine and thyroglotin were decreasing correctly, they were not included in the control data range, as congruent to 93.19±2.97 nmol/l (before treatment ‒ 109.87±4.15 nmol/l; p<0.05; in healthy individuals ‒ 78.43±3.65 nmol/l; p>0,05) and up to 25.00±1.50 nmol/l (before treatment ‒ 31.06±2.42 nmol/l; p<0,05; in healthy individuals ‒ 20.16±1.34 ng/ml; p>0.05), no significant increase in the content of triiodothyronine was observed – 1.41±0.03 nmol/l (before treatment ‒ 1.35±20.08 nmol/l; p>0.05; in healthy individuals ‒ 1.52±0.04 ng/ml; p<0.05). The levels of autoantibodies to thyroperoxidase and thyroid glands were probably suppressed in patients of this group, regardless of the clinical course of pathological process, and were included into the amplitude of physiological oscillations. The quality of life in these patients also obviously improved, reaching at mild urticaria the DLQI 5.0±0.4 points (before treatment 10.2±1.9 points p<0.05), at average urticarial – 8.5±0.5 points (before treatment ‒ 14.3±2.1 points, p<0.05) and at severe degree of the disease – 15.1±0.7 points (before treatment ‒ 19.7±1.6 points, p<0,05 )

Taking into account the results of the rehabilitation of patients of the three groups of comparison, patients of the main group were prescribed combined treatment in the way of combined application of specific therapy, phototherapy, balneotherapy and halotherapy, after the elimination of clinical manifestations of dermatosis by means of 2 month traditional medication. These patients proved to feel obvious improvement in the functional of thyroid gland. With mild to moderate degrees of urticaria, it reached its physiological limits. In particular, the thyroxin content was 83.22±5.31 nmol/l (before treatment – 103.04±2.80 nmol/l, p<0.05, in healthy sindividuals ‒ 78.43±3.65 nmol/l; p>0.05) and 80.75±4.90 nmol/l (before treatment ‒ 106.23±3.94 nmol/l; p<0.05; in healthy individuals – 78.43±3.65 ng/ml; p>0.05), triiodothyronine ‒ 1.55±0.02 nmol/l (before treatment ‒ 1.38±0.07 nmol/l; p<0.05; in healthy individuals – 1.52±0.04 ng/ml; p>0.05) and 1.49±0.09 nmol/l (before treatment ‒ 1.30±0.05 nmol/l; p<0.05; in healthy individuals ‒ 1.52±0.04 nmol/l; p>0.05), thyroglobulin ‒ 19.13±1.32 ng/ml (before treatment ‒ 25.42±1.73 ng/ml; p<0.05; in healthy individuals ‒ 20.16±1.34 ng/ml; p>0,05) and 22.04±2.14 ng/ml (before treatment ‒ 22.91±2.27 ng/ml; p<0.05; in healthy individuals ‒ 20.16±1.34 ng/ml; p>0.05). At severe degree of dermatosis, despite probable correction, the values remained outside the range of control deviations. Thus, the level of thyroxine was 95.19±3.08 nmol/l (before treatment ‒ 109.87±4.15 nmol/l; p<0.05; in healthy individuals ‒ 78.43±3.65 nmol/l ; p>0.05) of triiodothyronine ‒ 1.45±0.01 nmol/l (before treatment ‒ 1.35±0.08 nmol/l; p<0.05; in healthy individuals ‒ 1.52±0.04 ng/ml; p>0.05) thyroglobulin ‒ 26.53±1.2 ng/ml (before treatment ‒ 31.06±2.42 ng/ml; p<0.05; in healthy individuals – 20.16±1.34 ng/ml; p>0.05). The content of autoantibodies to thyroperoxidase and thyroglobulin in such patients was probably suppressed and included in the amplitude of physiological oscillations, regardless of clinical manifestations of pathological process, namely: at mild urticaria, it was 15.19±0.75 mo/ml (before treatment ‒ 20.35±1.14 mo/ml; p<0.05; in healthy individuals ‒ 14.47±0.55 mo/ml; p>0.05) and 78.61±4.22 mo/ml (before treatment – 126.96±4.83 mo/ml, p<0.05; in healthy individuals ‒ 76.12±3.42 mo/ml; p>0.05) respectively; at moderate degree of urticaria ‒ 13.02±1.30 mo/ml (before treatment 26.73±1.28 mo/ml, p<0.05, in healthy individuals ‒ 14.47±0.55 mo/ml p>0.05) and 80.35±5.19 mo/ml (before treatment ‒ 149.08±6.12 mo/ml, p<0.05; in healthy individuals ‒ 76.12±3.42 mo/ml; p>0.05); and at severe urticaria ‒ 16.04±1.97 mo/ml (before treatment ‒ 34.13±1.35 ng/ml; p<0.05; in healthy individuals ‒ 14.47±0.55 mo/ml; p>0.05) and 81.72±6.15 mo/ml (before treatment ‒ 197.65±7.94 mo/ml; p<0.05, in healthy individuals ‒ 76.12±3.42 mo/ml, p>0.05). The quality of life of these patients has also improved, regardless of the clinical manifestations of dermatosis. Thus, at mild urticaria the DLQI decreased to 4.9±0.3 points (before treatment ‒ 10.2±1.9 points p<0.05), at moderate degree of disease – to 7.8±0.6 points (before treatment ‒ 14.3 ± 2.1 points, p<0.05), and at severe urticaria – to 14.2±0.5 points (before treatment ‒ 19.7±1.6 points, p<0.05).

Clinical effectiveness of therapy in all groups of patients had been evaluating for 1.5 years, in the course of patients monitoring. The criteria were considered as following: duration of clinical remission and severity of relapses. If the duration of remission did not exceed a month, then the treatment was evaluated as non-effective. If the duration of remission was from 6 to 12 months, such condition was regarded as an unstable clinical remission, and if it was more than 12 months – as stable clinical remission. The results are presented in figure 2.

The severity of relapse did not significantly change before and after treatment in patients of group 1, but in patients of group 2 it was significantly suppressed by reducing the number of blisters (per 4-35 elements) and their size (not exceeding 3-5 cm), in the third group of reduction comparison, the severity of relapse was observed only in patients with mild degree of dermatosis, and only in patients from the main group relapses were characterized by a significant severity decrease.

Conclusions

Thus, the therapy of patients with urticaria requires a differentiated approach. Patients with mild dermatosis, after traditional medication, should be prescribed balneo- and halomethods of treatment. Patients with moderate to severe degree of the disease require more intensive medical intervention. They should be prescribed a combined application of specific photo-, balneo- and halotherapy. This approach allows eliminating the pathological process.

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Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Marianna Dashko

Department of Dermatology, Venereology

Danylo Halytsky Lviv National Medical University

Konovalets str., 1, 79014, Lviv, Ukraine

tel: +380677691977

e-mail: mariannadashko@gmail.com

Received: 01.03.2019

Accepted: 02.04.2019

Figure 2. Clinical efficacy of treatment the patients with urticaria

Figure 1. Distribution of patients with different degree of urticaria severity