Urticaria crónica en niños atendidos en un hospital básico privado de la ciudad de Portoviejo J. Adv. Educ. Sci. Humanit. (January - June 2025) 3(1): 1-7 https://doi.org/10.5281/zenodo.14816598 ISSN: XXXX-XXXX ORIGINAL ARTICLE Chronic urticaria in children treated in a private basic hospital in the city of Portoviejo  Nancy Toledo nancy.toledo@utm.edu.ec Received: 11 September 2024 / Accepted: 27 December 2024 / Published online: 31 January 2025 © The Author(s) 2025 Yuliana C. Mera · Freddy A. Bravo · Nancy Toledo Abstract Chronic urticaria is defined as spontaneously ap- pearing hives, daily or almost daily, for most days for more than 6 weeks. This study, carried out at the Private Basic Hos- pital “Clínica Dei Bambini” in Portoviejo between February 2023 and February 2024, analyzed this condition’s clinical and epidemiological profile in pediatric patients. Thirty-two patients between 1 and 18 years of age were included, whose anonymized medical records were reviewed. The observa- tional, descriptive, and cross-sectional study used theoreti- cal and empirical methods and applied descriptive statistics to process the data. The results indicated that most cases corresponded to children aged 1 to 10 years, predominant- ly males, living in urban areas and with parents of middle socioeconomic level and basic or secondary education. In most cases, urticaria was classified as “unspecified”, with no family history of the disease. Food was the most common trigger, followed by exposure to chemicals and medications. The most common symptoms included hives, itching, fever, and shortness of breath. The average duration of episodes was 6 to 8 weeks, and the most commonly used treatment was first-line second-generation H1 antihistamines, mainly loratadine. Keywords chronic urticaria, chronic spontaneous urticar- ia, epidemiology, clinical manifestations. Resumen La urticaria crónica se define como la presencia de habones de aparición espontánea, diarios o casi diarios, durante la mayoría de los días por más de 6 semanas. Este estudio, realizado en el Hospital Básico Privado “Clínica Dei Bambini” en Portoviejo, entre febrero de 2023 y febrero de 2024, analizó el perfil clínico y epidemiológico de esta con- dición en pacientes pediátricos. Se incluyeron 32 pacientes de entre 1 y 18 años, cuyas historias clínicas anonimizadas fueron revisadas. El estudio, de tipo observacional, descripti- vo y transversal, utilizó métodos teóricos y empíricos y apli- có estadística descriptiva para procesar los datos. Los resul- tados indicaron que la mayoría de los casos correspondieron a niños de 1 a 10 años, predominantemente varones, residen- tes en áreas urbanas y con padres de nivel socioeconómico medio y educación básica o secundaria. En la mayoría de los casos, la urticaria fue clasificada como “no especificada”, sin antecedentes familiares de la enfermedad. Entre los factores desencadenantes, destacaron los alimentos, seguidos por la exposición a químicos y medicamentos. Los síntomas más comunes incluyeron habones, prurito, fiebre y dificultad res- piratoria. La duración promedio de los episodios fue de 6 a 8 semanas, y el tratamiento más utilizado fue el de primera línea, con antihistamínicos H1 de segunda generación, prin- cipalmente loratadina. Palabras clave urticaria crónica, urticaria crónica espontá- nea, epidemiología, manifestaciones clínicas. How to cite Mera, Y. C., Bravo, F.A., & Toledo, N. (2025). Chronic urticaria in children treated in a private basic hospital in the city of Portoviejo. Journal of Advances in Education, Sciences and Humanities, 3(1), 1-7. https://doi.org/10.5281/zenodo.14816598 Facultad de Ciencias de la Salud, Universidad Técnica de Manabí, Portoviejo, Ecuador.

J. Adv. Educ. Sci. Humanit. (January - June 2025) 3(1): 1-7 2 Introduction Urticaria was described as a skin disorder whose charac- teristic lesion was the wheal, defined as a central edematous area surrounded by erythema that disappeared with pressure and caused pruritus. Angioedema (AE) sometimes accom- panies urticaria, manifesting as edema affecting the deeper layers of the skin or mucous membranes. Urticaria, classi- fied as acute or chronic, particularly chronic urticaria (CU), represented a significant socioeconomic burden globally. However, its worldwide epidemiology and geographical and temporal trends have not yet been fully explored (Coronado et al., 2021). CU was characterized by the recurrent presence of hives or wheals (Zamitiz-Hernández et al., 2021; Sedó-Mejía et al., 2015), frequently accompanied by pruritus, lasting lon- ger than six weeks. Its distinctive feature was erythema and edema of the superficial layer of the skin or mucous mem- branes (Zuberbier et al., 2018). Occasionally, this condition appeared alongside AE (Kanani et al., 2018). According to the latest international guidelines from the European Aca- demy of Allergy & Clinical Immunology, the World Allergy Organization (EAACI/GA1LEN/EDF/WAO), and the Mexi- can Urticaria Guide, it was defined as the presence of hives, angioedema, or both, characterized by three distinctive ele- ments: a central wheal of variable size, generally surrounded by fixed erythema, accompanied by intense pruritus or bur- ning; the eruptions tended to move across the body, reaching their peak between 8 and 12 hours, and the skin returned to its normal state in less than 24 hours (Zuberbier et al., 2018). The triggering factors varied according to the type of urti- caria, with the most common subtypes being spontaneous urticaria, papular urticaria, drug-induced urticaria, and der- mographic urticaria (Kanani et al., 2018). Various studies indicated that CU was more common in adults; however, its incidence in the pediatric population has increased in recent years. The estimated prevalence of all forms of urticaria in children ranged between 3 and 6%. Some reports estimated that between 15 and 23% of the ge- neral population would experience an episode of urticaria at some point in their lives (López et al., 2020). CU had a sig- nificant impact on quality of life, causing physical and social discomfort as well as psychological disorders in those who suffered from it (Arias-Cruz et al., 2018). In CU cases, wheals or angioedema appeared daily or al- most daily for six or more consecutive weeks (Mora, 2022). Urticarial wheals, surrounded by erythema, were frequently accompanied by pruritus, although they were sometimes as- sociated with a burning sensation. The most common form of CU was spontaneous, and approximately 50% of cases was resolved within five years. This condition was not clas- sified as allergic, so extensive blood or skin tests were not routinely recommended. Studies indicated that 40% of chil- dren presented only wheals, 10% only AE, and 50% both. The prognosis was more favorable in children than adults (Zamitiz-Hernández et al., 2021). Chronic urticaria represents a diagnostic and therapeutic challenge among pediatric dermatological diseases due to its heterogeneous nature and impact on patient’s quality of life. In this context, the present study aimed to determine chronic urticaria’s clinical and epidemiological profile in children treated at the “Clínica Dei Bambini” Private Basic Hospital in Portoviejo. Methodology The present study adopted a qualitative-quantitative approach with an observational, descriptive, and cross-sec- tional design. The research was conducted in the outpatient and pediatric hospitalization areas of the “Clínica Dei Bam- bini” Private Basic Hospital in Portoviejo, Manabí, Ecua- dor. The population and sample consisted of an anonymized database collecting information from 32 medical records of pediatric patients aged 1 to 18 years diagnosed with chronic urticaria between February 2023 and February 2024. Due to their finite and manageable number, all cases that met the inclusion criteria were analyzed. Patients with in- complete medical records and those referred to other heal- thcare centers were excluded. The methodology included an analytical-synthetic approach, breaking data into its consti- tuent parts and integrating them for a comprehensive analy- sis. Manually collected data were processed and tabulated in Microsoft Excel, using descriptive statistics to calculate absolute frequencies and percentages. Data confidentiality was strictly safeguarded, ensuring patient anonymity and preventing any compromise to their integrity. The authors declared no conflicts of interest in con- ducting the study. The Human Research Ethics Committee (CEISH-UTM) approved the protocol under the code CEI- SH-UTM-INT_24-06-13_YCMM. Results and discussion The sociodemographic characteristics of the participants are shown in Table 1. The highest prevalence of cases was observed in the 1 to 5-year-old age group, accounting for 40.6%, followed by children aged 6 to 10 years, with 34.4%. Prevalence progressively decreased in the 11 to 15-year-old and 16 to 18-year-old groups, with percentages of 18.8 and

J. Adv. Educ. Sci. Humanit. (January - June 2025) 3(1): 1-7 3 6.3%, respectively. These results suggest that chronic urti- caria was more common in younger children, with a decline in frequency as age increased, which could reflect the pro- gressive development of the immune system associated with growth. Table 1. Sociodemographic factors of parents and children diagnosed with urticaria treated at “Clínica Dei Bambini” in Portoviejo Indicator Frequency Percentage Age of the children (years) 1a5 13 40.6 6 a 10 11 34.4 11 a 15 6 18.8 16 a 18 2 6.3 Gender of the children Female 10 31.3 Male 22 68.8 Place of origin Rural 3 9.4 Urban 29 90.6 Educational level of the parents Primary 13 40.6 Secondary 12 37.5 Third level 7 21.9 Economic level of the parents Low 0 0 Middle 32 100.0 High 0 0 The age distribution observed in this study coincided with that reported by Sánchez-Borges et al. (2014), who, in a group of 52 children with chronic urticaria, identified that the most frequent presentation was in children aged 1 to 7 and less common in adolescents. This behavior has been linked to the immaturity of the immune system and a higher susceptibility to environmental triggers during the early sta- ges of life. Regarding the distribution by sex, 68.8% of the cases were male, while 31.3% were female. Chronic urticaria is more common in boys than in girls, possibly due to biological, environmental, or behavioral factors that influence each sex differently. Zamitiz-Hernández (2021) reported a prevalence of chronic urticaria in children of 0.1 to 0.3%, being more frequent in males. As for the origin of the children studied, 90.6% came from urban areas, while only 9.4% resided in rural areas. This ur- ban predominance could be related to specific environmental and lifestyle factors in urban areas that influence the preva- lence of chronic urticaria in the pediatric population. Factors such as air pollution and urban lifestyles have been noted as contributors to the increase in cases. According to López et al. (2020), there is greater exposure to allergens and environ- mental pollutants in urban areas. It was found that 40.6% of the parents of the children had primary education, 37.5% had secondary education, and 21.9% had a higher education level. These data suggested that parents’ educational level could be linked to the manage- ment and prevention of the disease, as well as collaboration in the treatment outside the healthcare center, which could influence the quality of life and long-term treatment of the children. Although there are few studies on the educational level of parents of children with chronic urticaria, various authors have emphasized the importance of parents being well-informed and active collaborators in the management of chronic, allergic, or immunological skin diseases. This is because allergic diseases often have a multifactorial origin, involving genetic and environmental factors, posing a cha- llenge for families and physicians (Nevot & Gómez, 2018). Regarding the economic situation of the families, 100% of the cases corresponded to families with a middle econo- mic level, which could be related to specific risk factors for this group, lifestyle, or exposure to environmental triggers. It is important to note that the “Clínica Dei Bambini” Private Basic Hospital primarily serves a middle socioeconomic po- pulation, which could influence the representativeness of the cases studied. Studies such as those by Smith et al. (2017) have pointed out that socioeconomic disparities can affect access to specialized medical care and the ability to manage chronic conditions like urticaria. Table 2 revealed that 96.9% of the diagnoses were classi- fied as unspecified urticaria, while only 3.1% were classified explicitly as chronic spontaneous urticaria. Chronic spon- taneous urticaria (CSU), also known as chronic idiopathic urticaria or chronic urticaria, is a common disorder with an estimated prevalence between 0.5 and 1% of the general po- pulation (Marín et al., 2016). The high proportion of unspecified diagnoses (96.9%) in this study highlighted the need to improve diagnostic accu- racy in chronic urticaria cases. Kolkhir et al. (2022) empha- sized the importance of implementing advanced diagnostic techniques to differentiate the specific types of urticaria, allowing for more effective and personalized treatment. In Ecuador, Chérrez-Ojeda et al. (2017) reported that 57% of CSU cases were of idiopathic etiology, while 12% were associated with vasculitic urticaria. These findings suggested

J. Adv. Educ. Sci. Humanit. (January - June 2025) 3(1): 1-7 4 that the etiology of urticaria might vary depending on the geographic region where the disease is studied. 90.6% of the children had no family history of urticaria or allergies, while only 9.4% had such a history. The majority of children with chronic urticaria did not have a family history or any appa- rent predisposition to develop it. Table 2. Diagnosis of chronic urticaria in the studied patients Indicator Frequency Percentage Admission diagnosis Spontaneous urticaria 1 3.1 Unspecified urticaria 31 96.9 Family history of urticaria Yes 3 9.4 No 29 90.6 Possible causes of chronic urticaria Exposure to water 3 9.4 Air conditioning 2 6.3 Food 12 37.5 Medications 4 12.5 Chemicals 11 34.4 Duration of urticaria (weeks) 6 to 8 24 75.00 12 to 52 7 21.88 More than 52 1 3.13 Zamitiz-Hernández et al. (2021) found a low proportion of patients with a family history of urticaria or allergies, re- sults that were consistent with those of the present analysis (Zamitiz-Hernández et al., 2021). On the other hand, Brüske et al. (2014) suggested that, despite being one of the most common skin diseases, the available epidemiological data on family history of urticaria are limited and inconclusive. The primary triggers identified in the children of the study included food (37.5%), followed by chemicals (34.4%) and medications (12.5%). However, no specific details were recorded in the medical histories about the types of food, chemicals, or medications involved as possible triggers. Ad- ditionally, using air conditioning (cold air) and exposure to water were noted as possible triggers in 6.3 and 9.4% of the cases, respectively. Ferrá (2023) reported that, in his study with the pedia- tric population, the most common causes of acute urticaria were viral infections and upper respiratory tract infections. In chronic urticaria cases, hypersensitivity to medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and certain antibiotics, as well as foods, especially in pres- chool-aged children, predominated. These results were simi- lar to those found in this study. The results of this research differed from those reported by Mazur et al. (2020), who indicated that most patients (56%) had allergies to medications, with penicillin being the most commonly reported. The existing literature on chronic ur- ticaria has pointed out various triggering factors, including environmental, food-related, and medicinal. It has also been reported that patients with CSU tend to report higher rates of drug allergies compared to the general population. The duration of urticaria in the majority of cases (75.0%) was between 6 and 8 weeks. 21.88% of the patients expe- rienced symptoms that persisted between 3 and 12 months, while a small percentage (3.13%) had episodes of urticaria that lasted for more than 12 months. These results indica- ted that, although most patients had a relatively brief disease duration, a significant minority faced prolonged episodes, which might require more sustained and specialized inter- ventions. Table 3 presents the clinical characteristics of the children treated for chronic urticaria. The medical records did not do- cument a predominant symptom but rather a combination of signs and symptoms. The most frequent symptoms included the presence of hives and irritation in 18.8% of the patients, disseminated hives on the body in 15.6%, and hives accom- panied by itching and fever in 12.5%. Other observed symptoms included difficulty breathing (6.3%), rash (6.3%), sneezing (6.3%), fever (6.3%), swe- lling of the eyes and lips (6.3%), nasal discharge (3.1%), and digestive issues (3.1%). The diversity of clinical mani- festations of chronic urticaria in this age group was noted, highlighting the importance of proper diagnosis and clinical management for this chronic dermatological condition. The results of this study were in line with those reported by En- sina et al. (2022), who observed that hives accompanied by itching and, occasionally, a burning sensation were the most common symptoms. In their population, 40% of children presented only hives during the disease. The negative impact of symptoms on the children’s quality of life has been emphasized. Cruz-Hernández et al. (2019) documented that these manifestations affect pediatric pa- tients’ psychological and physical well-being, highlighting the need for a comprehensive approach to managing the di- sease. In children, chronic urticaria had a more significant

J. Adv. Educ. Sci. Humanit. (January - June 2025) 3(1): 1-7 5 impact on quality of life than adults. Between the ages of 0 and 4 years, children were three times more likely to be hos- pitalized, and between 20 and 30% of those who experienced an episode of aquagenic urticaria developed chronic urticaria for several years, as reported by Brüske et al. (2014). The results of this research highlighted the complexity of chronic urticaria in pediatric age and the need for multidisci- plinary approaches integrating clinical, epidemiological, and environmental research to improve the prevention, diagno- sis, and treatment of this condition in the pediatric popula Table 3. Clinical characteristics of children diagnosed with chronic urticaria Clinical manifestations Frequency Percentage Difficulty breathing, rash, itching 1 3.1 Respiratory issues, digestive problems, and itching 2 6.3 Difficulty breathing, itching, hives 2 6.3 Sneezing, hives, itching 1 3.1 Disseminated hives 5 15.6 Hives, itching, and fever 4 12.5 Hives and irritation 6 18.8 Sneezing, nasal discharge, rash 1 3.1 Digestive issues and itching 2 6.3 Rash, itching 2 6.3 Rash and rash 2 6.3 Swelling of eyes and lips, difficulty breathing, hives, itching 2 6.3 Digestive problems, hives, itching 1 3.1 Hives, fever, sneezing 1 3.1 Sánchez-Borges et al. (2024) studied 123 subjects under 18 years old, of which 71 had acute urticaria (57.7%), and 52 had chronic urticaria (42.2%). No statistically significant di- fferences between acute and chronic cases were found in the disease duration. Chronic urticaria had an average duration of 17.4 ± 24 months (1.5-108 months), reflecting a more pro- longed evolution of the disease than observed in this study. The management provided to patients diagnosed with chronic urticaria (Table 4) at the health center where the re- search was conducted mainly consisted of first-line therapies according to international guidelines for managing this di- sease. Table 4. Treatment used in chronic urticaria Treatment Frequency Percentage H1 Antihistamines (1st generation) Diphenhydramine 4 12.5 Corticosteroids 2 6.3 H1 Antihistamines (2nd generation) Loratadine 14 43.8 Cetirizine 8 25.0 Desloratadine 4 12.5 Second-generation H1 antihistamines were most frequent- ly used, with Loratadine being the most employed in 43.8% of cases, followed by Cetirizine in 25.0% and Desloratadine in 12.5% of patients. Second-line treatment, which includes increasing the dose of second-generation H1 antihistamines according to age, was not recorded, nor was Omalizumab prescribed, conside- red the third-line treatment for chronic urticaria. First-gene- ration antihistamines, such as Diphenhydramine, were used in four patients (12.5%), while systemic corticosteroids were only used in two cases (6.3%). In contrast, Coronado et al. (2021) reported that most patients in their study received immunotherapy, with only 5% using systemic corticosteroids or calcineurin inhibitors. Approximately half of the patients required the use of two or more different antihistamines, and in total, 81% did not achieve adequate symptom control with a single antihistami- ne. These results did not align with the findings of the pre- sent study. Sánchez-Borges et al. (2014) reported that all patients in their study were treated with approved doses of non-seda- ting antihistamines, and 7.6% (four patients) were prescribed combinations of two antihistamines. In their population,

J. Adv. Educ. Sci. Humanit. (January - June 2025) 3(1): 1-7 6 fexofenadine was the most frequently prescribed medication. Despite advances in available therapies, some patients continued to have unmet needs. Clinical trials are currently underway investigating the efficacy of new treatments, inclu- ding drugs targeting interleukins 4 and 13 (IL-4 and IL-13), such as dupilumab; IL-5 antagonists, such as benralizumab, mepolizumab, and reslizumab; inhibitors of thymic stromal lymphopoietin (TSLP), such as tezepelumab; anti-Siglec-8 agents; therapies with Bruton’s tyrosine kinase inhibitors (ri- lzabrutinib and remibrutinib); and inhibitors of spleen tyro- sine kinase (La Forgia et al., 2023). Conclusions The patients analyzed were mainly young male children (1-5 years old) from urban areas, with parents having a pri- mary education level and a middle economic status. Most presented unspecified chronic urticaria, with no family his- tory, and the main triggering factors were foods, followed by chemicals and medications. The most common clinical manifestations included hives, irritation, itching, and fever. The predominant treatment was second-generation H1 anti- histamines, especially Loratadine, while corticosteroids and first-generation antihistamines were used in a few cases. References Arias-Cruz, A., González-Díaz, S. N., Macías-Weinmann, A., Ibarra-Chávez, J. A., Sánchez-Guerra, D., Leal-Vi- llarreal, L., & Salinas-Díaz, M. R. (2018). Calidad de vida en urticaria crónica y su relación con el impacto económico y control de la enfermedad en pacientes atendidos en el Hospital Universitario de Monterrey, México. Revista Alergia México, 65(3), 250-258. ht- tps://doi.org/10.29262/ram.v65i3.398 Brüske, I., Standl, M.,Weidinger, S., Klümper, C., Hoffmann, B., Schaaf, B., Herbarth, O., Lehmann, I., von Berg, A., Berdel, D., Bauer, C. P., Koletzko, S., Heinrich, J., & Giniplus and Lisaplus Study Groups. Epidemiology of urticaria in infants and young children in Germany--re- sults from the German LISAplus and GINIplus Birth Cohort Studies. (2014). Pediatric Allergy and Immunol- ogy, 25(1), 36-42. https://doi.org/10.1111/pai.12146 Chérrez-Ojeda, I., Robles-Velasco, K., Bedoya-Riofrio, P., Schmid-Grendelmeier, P., Chérrez, S., Colbatzky, F., Cardona, R., Barberan-Torres, P., Calero, E., Calderón, J. C., Larco, J., & Chérrez, A. (2017). ¿Es posible simplificar el abordaje diagnóstico de urticaria cróni- ca? Una lista de verificación de información clínica. Revista Alergia México, 64(3), 309-326. https://doi. org/10.29262/ram.v64i3.276 Coronado, B., Ochoa-García, I. V., Torres-Lozano, C., Quin- tero-Ramos, A., & Ortega-Cisneros, M. (2021). Fre- cuencia y caracterización clínica de la urticaria crónica en un hospital de tercer nivel. Revista Alergia México, 68(2), 94-100. https://doi.org/10.29262/ram.v658i2.818 Cruz-Hernández, A., Caballero-López, C. G., López- García, A. I., Rivero-Yeverino, D., Arana-Muñoz, O., Papaqui-Tapia, J. S., Ortega-López, L., Rosales-Blan- co, A. G., Ruiz-Márquez, I. P., & Valle-Rodríguez, F. (2019). Prevalencia de la urticaria crónica y su perfil clínico epidemiológico. Alergia, Asma e Inmunología Pediátricas, 28(2), 47-50. https://www.medigraphic. com/cgi-bin/new/resumen.cgi?IDARTICULO=90060# Ensina, L. F., Silva, L., Chong, H., & Ben-Shoshanc, M. (2022). Urticaria and angioedema in children and ad- olescents: diagnostic challenge. Allergologia et immu- nopathologia (Madr), 50(S Pt 1), 17-29. https://doi. org/10.15586/aei.v50iSP1.538 Ferrá, T. M. (2023). Urticaria y angioedema. Folia Derma- tológica Cubana, 17(1), e351. https://revfdc.sld.cu/in- dex.php/fdc/article/download/351/362 Kanani, A., Betschel, S. D., & Warrington, R. (2018). Ur- ticaria and angioedema. Allergy, Asthma & Clinical Immunology, 14(Suppl 2), 59. https://doi.org/10.1186/ s13223-018-0288-z Kolkhir, P., Giménez-Arnau,A. M., Kulthanan, K., Peter, J., Metz, M., & Maurer, M. (2022). Urticaria. Nature Re- views Disease Primers, 8, 61. https://doi.org/10.1038/ s41572-022-00389-z La Forgia, M. P., Torre, A. C., Song, A., Ritchie, C. A., Medina, I., Cannavó, A., Luna, P. C., Gattolin, G., & Gomez, M. (2023). Actualización práctica de diagnósti- co y tratamiento de la urticaria crónica. Medicina (B Aires), 83(5), 772-792. https://pubmed.ncbi.nlm.nih. gov/37870335/ López, V. E., Pedroza, M. Á., & Huerta, L. J. G. (2020). Ur- ticaria crónica en niños. Revisión sistemática. Alergia, Asma e Inmunología Pediátrica, 29(1), 16-30. https:// doi.org/10.35366/93322.8 Marín, J. M., de León, F. J., Berbegal, L., & Silvestre, J. F. (2016). Guía clínica de urticaria en Atención Pri- maria. Atención Primaria, 48(10), 687-689. https://doi. org/10.1016/j.aprim.2016.01.011 Mazur, M., Czarnobilska, M., & Czarnobilska, E. (2020). Prevalence and potential risk factors of urticaria in the Polish population of children and adolescents. Advanc- es in Dermatology and Allergology, 37(5), 785-789.

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