Keywords:

Helicobacter pylori infection, chronic urticaria, allergens, permeability

Helicobacter pylori (H. pylori) is a bacteria that is identified in the stomach and cause peptic ulcer in most of cases.¹ The exact route of infection remains unknown but oral or fecal/oral exposure is the most likely cause of man-to-man transmission. Not only the gastrointestinal tract, other areas are also the target of H. pylori infection. The skin is an example and several studies have found a link between H. pylori infection and chronic urticaria.² It is postulated that infection with H. pylori increases the permeability of the mucosal lining of the stomach and thus increases the exposure to allergens in the gastrointestinal tract. Moreover, the immune response to H. pylori produces antibodies that encourage release of histamine in the skin.³

Case Report

A 47-year-old young man with history of suffering of functional bowel disorder persistently for the last 3 years, presented with the appearance of papulovesicular rash with marked itching and swelling of both the forearms and hands with some maculopapular rash in the other parts of the body with itching.

Examination revealed linear excoriations, erythematous papules in both the forearms and 1-2 vesicles in the palm and swelling of the forearms (Figs. 1 and 2).

Gastrointestinal, cardiovascular system and respiratory, neurological examinations revealed nothing significant. Findings from a complete blood cell count, assays for blood urea nitrogen level, thyroid function, liver function, stool routine parasites were normal and negative stool occult blood test except ultrasonography (USG) upper abdomen showed Grade 1 fatty liver and gastroscopy revealed H. pylori associated moderate chronic active gastritis and moderate chronic active duodenitis with moderate villous atrophy.

The patient was given oral clarithromycin 500 mg twice-daily, amoxicillin 1 g twice-daily, pantoprazole 40 mg twice-daily, amitriptyline 25 mg at bedtime daily along with levocetirizine 5 mg and calamine lotion was applied locally twice-daily for 2 weeks.

Following 2 weeks of treatment, the excoriated papules and vesicles improved significantly, but slight pruritus was present. Besides these, no adverse effects were noted. At 4 weeks follow-up, the lesions remained improved (Figs. 3 and 4).

Discussion

According to the definition of chronic urticaria, it is “A recalcitrant skin disease characterized by pruritic wheals lasting more than 6 weeks in the absence of physical cause.”¹ The symptoms of chronic urticaria are caused by the release of histamine and other skin mediator chemicals, where triggering factors are infections or infestations, food additives or nonsteroidal anti-inflammatory drugs (NSAIDs).

However in many cases, there is no known triggering factor to be identified and in that case it is designated as ‘idiopathic’ chronic urticaria. A number of studies have indicated that H. pylori infection can play a role in the development of urticaria/hives because of the damage caused to the stomach by the H. pylori infection, which leads to an increase in permeability of the delicate mucosal lining.² After that the immune system leads to inflammation on the skin layers. Besides these several other mechanisms are actively playing in the immune system for the development of chronic urticaria in H. pylori-infected persons.

Some studies have shown partial or complete remission in urticaria in patients who have successfully eradicated H. pylori, compared to patients who have not eradicated the infection.⁴ Moreover, several other studies have revealed that complete removal of H. pylori infection has a greater outcome on certain skin diseases like chronic urticaria, Behcet disease, lichen planus, atopic dermatitis, Sweet disease and systemic sclerosis, but diseases like psoriasis and rosacea associated with H. pylori infection even on complete eradication of H. pylori after full treatment showed unsatisfactory response.^5,6

Conclusion

Because chronic urticaria is a condition that can have a significant impact on quality-of-life, detection of H. pylori and its total removal from the body indeed leads to a positive outcome.⁶ In fact, a review paper on the role of H. pylori in skin disease makes the following recommendation:

“To cure at least some patients from quality-of-life reducing chronic urticaria, it seems worthwhile to eradicate H. pylori in all patients with chronic urticarial and H. pylori infection.”⁷

Limitations of this study include that only a single case is presented, so no definitive conclusion can be drawn about the complete removal of H. pylori in skin diseases at present.

References

1. Chey WD, Wong BC; Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori Am J Gastroenterol. 2007;102(8):1808-25.
2. Cover TL, Blaser MJ. Helicobacter pylori in health and disease. Gastroenterology. 2009;136(6):1863-73.
3. Yadav MK, Rishi JP, Nijawan S. Chronic urticaria and Helicobacter pylori. Indian J Med Sci. 2008;62(4):157-62.
4. Federman DG, Kirsner RS, Moriarty JP, Concato J. The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria. J Am Acad Dermatol. 2003;49(5):861-4.
5. Hernando-Harder AC, Booken N, Goerdt S, Singer MV, Harder H. Helicobacter pylori infection and dermatologic diseases. Eur J Dermatol. 2009;19(5):431-44.
6. Magen E, Mishal J, Schlesinger M, Scharf S. Eradication of Helicobacter pylori infection equally improves chronic urticaria with positive and negative autologous serum skin test. Helicobacter. 2007;12(5):567-71.
7. Wedi B, Kapp A. Helicobacter pylori infection in skin diseases: a critical appraisal. Am J Clin Dermatol. 2002;3(4):273-82.