Journal of the American Academy of Dermatology Volume 34, Number 4
Brief communications 685 II
Helicobacter pylori infection and chronic urticaria Beate Tebbe, MD, a Christoph C. Geilen, MD, PhD, a JSrg-Dieter Schu!zke, MD, b Christian Bojarski, b Michael Radenhausen,a and Constantin E. Orfanos, MD a
Berlin, Germany
Together with antihistamines, various antibiotics including penicillin, tetracycline, and others have been empirically used to treat chronic urticaria in an attempt to eliminate an underlying focal infection. On the basis of this knowledge, we posed the question as to whether Helicobacter pylori infection could be an underlying cause of chronic urticaria. H. pylori infection can easily be diagnosed with high sensitivity and specificity with the [13C]-urea breath test.l, 2 The present study was performed to investigate the possible role of H. pylori in patients with chronic urticaria. We screened an unselected series of patients for infection and investigated whether specific treatment against the pathogen could cure the urticaria. METHODS
Twenty-five unselected patients with chronic urticaria seen consecutively from April 1994 to April 1995 were included. Ages of the patients ( 11 male, 14 female) ranged from 10 to 65 years and reported persistence of the disease for more than 6 months. Each patient was asked about the frequency of flares, the occurrence of angioedema, the presence of any concomitant gastrointestinal disease or complaints, and a history of atopic diseases, food allergy, and drug intake. Blood examinations included tests for polyclonal IgE and the antistreptolysin titer. Urticarial vasculitis or other autoimmune diseases or inflammatory foci in various locations (teeth, upper respiratory, gastrointestinal, and urogenital tracts) were also excluded. Each patient was tested for physical urticaria. All patients were examined for H. pylori infection with the [13C]-urea breath test2 and a commercially available From the Departmentsof Dermatologya and Gastroenterology?University Medical Center BenjaminFranklin,The Free Universityof Berlin. Reprintrequests:Beate Tebbe,MD, Dept. of Dermatology,University Medical Center BenjaminFranklin,The Free Universityof Berlin, Hindenburgdamm30, 12200 Berlin, Germany. J AM ACADDERMATOL1996;34:685-6. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0 16/54/70847
enzyme-linked immunosorbent assay for specific IgG antibodies against the bacterium (Bios, ~ g e n , Germany). If both tests were positive, g~troscopy with mucosal biopsy was proposed to the patients to verify the presence of H. pylori. Each patient was informed about the study and consented to participate. Patients with H, pylori infection were treated orally with (1) amoxicillin, 4 x 500 mg/day; or (2) clarithromytin, 2 x 500 mg/day; or (3) tetracycline, 4 x 500 mg/day; or (4) tetracycline, 500 rag/day 4>< plus metronidazole, 3 x 400 mg/day, and 3 x bismuth salicylate, 600 mg/day. Each of these schedules was combined with oral omeprazole, 40 mg/day, over a period of 2 weeks, followed by omeprazole alone for another 2 weeks.
RESULTS
H. pylori infection was diagnosed in 17 of 25 patients with chronic urticaria who had a positive [13C]-~ breath test and circulating specific IgG antibodies against the pathogen; both tests were negative in eight patients. Twelve patients accepted gastroscopy and biopsy of the gastric mucosa. In all patients, the presence of the pathogen was confirmed by histologic examination. Gastrointestinal symptoms were present in 10 of 17 patients with H. pylori infection. In contrast, none of the eight patients without evidence of H. pylori infection mentioned gastrointestinal symptoms. Laboratory tests revealed no significant evidence of another underlying disease in the entire group. A moderate elevation of IgE was found in 12 of 15 patients, positive antistreptolysin titers in 5 o f 25, and a slightly elevated antinuclear antibody titer in three patients. Nb other underlying focus of infection was found, and none of the patients had a food allergy or any drug intake suspected to cause chronic urticaria. None had physical urticaria. Therapy for H. pylori infection was given to the 17 patients with positive test results. All patients treated were observed for 6 to 10 weeks thereafter. All patients completed the 4-week treatment. The overall results were evaluated and documented as
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Brief communications
remission (>75% improvement), partial remission (50% to 75% improvement), no significant change, or aggravation. At the posttreatment evaluation, 8 of 17 patients showed remission and 6 o f 17 partial remission; in 14 patients, the [13C]-urea breath test had also become negative (14 o f 17). T w o o f the remaining three patients showed no significant change in their urticaria, and one was worse. H. pylori infection was still detectable by the [13C]-urea breath test in each of them. The disease remained unchanged in the 8 of 25 patients with chronic urticaria who did not have any indication o f H . pylori infection and received no oral treatment. DISCUSSION
Although this study was performed in a limited number o f patients with chronic urticaria, it provides substantial evidence that otherwise unexplained cases m a y be associated with H. pylori infection. Eradication of the pathogen in 17 patients with chronic urticaria was accompanied by clinical remission in 14 o f the cases. These results confirm our preliminary findings and those of another group), 4
Journal of the American Academy of Dermatology April 1996
The pathogenetic mechanisms that m a y exist between chronic urticaria and H. pylori infection remain unknown. However, there is increasing evidence that H. pylori may also be involved in other dermatologic diseases. Clinical associations between H. pylori and rosacea and Sjfgren's syndrome have been described. 5, 6 REFERENCES
I. Graham DY, Klein PD, Evans DR Jr, et al. Campylobacter pylori detected noninvasively by the 13C-ure~ breath test. lancet 1987;1:1174-7. 2. Eggers RH, Kutp A, Tegeler R, et al. A methodological analysis of the laC-urea breath test for detection of Helicobacter pylori infections: high sensitivity and specificity within 30 min using 75mg of 13C-urea. Eur J Gastroenterol 1990;2:437-44. 3. Kolibfisov~iK, Cervenkov~iD, Hegyi E, et al. Helicobacter pylori: ein m~Sglicher~itiologischerFaktor der chronischen Urticaria. Derrnatosen 1994;42:235-6. 4. Geilen CC, Tebbe B, Schulzke JD, et al. Helicobacter pylori-Infekfion--Ursache einer rezidivierenden Urfikaria? report on the 38. Congress of the German Dermatological Society, Berlin, 29.04.-03.05.1995. 5. Rebora A, Drago F, Picciotto A. Helicobacterpylori in patients with rosacea. Am J Gastroenterol 1994;89:1603-4. 6. Figura N, Giordano N, Burroni D, et al. Sj0gren's syndrome and Helicobacter pylori infection. Eur J Gastroenterol Hepatoi 1994;6:321-2.
Transient reactive papulotranslucent acrokeratoderma C P T Joseph C. English IN, MC, USA, and L T C Martha L. McCollough, MC, U S A
Fort Sam Houston, Texas
An unusual presentation of transient reactive palmar papulotranslucent acrokeratodermal lesions in two siblings is described. This condition m a y represent a variant of hereditary papulotmnslucent acrokeratoderma as described by Onwukwe, Mihm, and Toda 1 or a new clinical entity.
From the DermatologyService,BrookeArmyMedicalCenter. Reprint requests: Joseph C. English111,MD, DermatologyService, BAMC, Bldg. 1053, Ft. Sam Houston,TX 78234. The opinionsand assertionscontainedhereinare the privateviewsof the authorsand are not to be construedas officialor as reflectingthe views of the Deparanentof the Armyand Departmentof Defense. J AMACADDERMATOL1996;34:686-7. 16/54/68952
CASE REPORT
A 20-year-old white woman had a 3- to 4-year history of transient nonpruritic symmetric thickening on the palms and lateral fingers that developed a whitish discoloration after exposure to water. The disorder occurred 3 to 5 minutes after exposure to water and resolved after a variable drying period to residual hyperkeratotic areas that were flesh-colored to white. This was associated with a tightening sensation. On re,exposure to water, the hyperkeratotic areas evolved to Wanslucent white confluent papules with dilated puncta (Fig. 1), The patient noticed that the disorder began on her right hand but later became bilateral. She described periods in which there was complete resolution of the eruption and immersion of her hands in water did not produce changes. The patient has been examined in both states and physical findings were