ORIGINAL ARTICLE

Association of Chronic Urticaria with Psychological Distress: A Multicentre Cross-sectional Study

Samah TAWIL^1,2, Carla IRANI³, Riwa KFOURY⁴, Soula ABRAMIAN⁵, Pascale SALAMEH^1,4,6, Karsten WELLER⁷, Marcus MAURER⁷ and Khaled EZZEDINE^8,9

¹INSPECT-LB: Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Beirut, Lebanon, ²Lebanese American University, School of medicine, Byblos, Lebanon, Beirut, ³Internal Medicine and Clinical Immunology, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, ⁴Faculty of Pharmacy and of Medical Sciences, Lebanese University, Hadath, Lebanon, ⁵Drug Information Center, Lebanese Order of Pharmacists, Beirut, Lebanon, ⁶Faculty of Medical School, University of Nicosia, Nicosia, Cyprus, ⁷Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin, Berlin, Germany, ⁸Department of Dermatology, Henri-Mondor University Hospital, Creteil, France, ⁹EA7379 Epiderm E (Epidemiology in Dermatology and Therapeutics Evaluation), UPEC-University, Paris-Est, Creteil, Creteil, France

Chronic urticaria is a debilitating disease that affects health-related quality of life, but few studies have evaluated its impact on psychological wellbeing. The aim of this study was to evaluate the quality of life of patients with chronic urticaria and determine its impact on their emotional and psychological wellbeing. A cross-sectional multicentre study of a cluster of 264 Lebanese patients visiting dermatology/immunology clinics was conducted between July 2018 and June 2020. The impact of chronic urticaria on quality of life was assessed using the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and Dermatology Life Quality Index (DLQI), as well as its consequences on mood changes using the Patient Health Questionnaire-9 (PHQ-9) and Beirut Distress Score 22 (BDS-22) scores. A multivariable analysis of covariates was performed to determine the effect of the triggering factors of urticaria on both CU-Q2oL and PHQ-9. A moderate negative correlation was found between Urticaria Control Test and quality of life scores as well as PHQ-9 and BDS-22 (p < 0.001). Patients with the lowest Urticaria Control Test score had the highest impairment in quality of life and depression scores. In conclusion, chronic urticaria compromises patients’ quality of life and emotional wellbeing. This distress is more pronounced when the disease is more severe.

Key words: chronic urticaria; quality of life; depression; psychological; correlation.

 

 

INTRODUCTION

Chronic urticaria (CU) is characterized by the recurrent appearance of wheals and/or angioedema for more than 6 weeks. Most specialists concur that the discomfort associated with this disorder can pose a serious challenge that introduces a detrimental effect on patients’ quality of life (QoL) (1–5).

SIGNIFICANCE

Chronic urticaria is a dermatological disease that compromises the quality of life of patients, due to its debilitating symptoms. The recurrent pattern of this disease may have a detrimental effect on patients’ psychology, and many studies have demonstrated that patients may experience a prolonged psychological burden, such as depression. The evaluation of quality of life and psychological health is fundamental for a better assessment of disease progression and treatment efficacy. The results of this study demonstrate that urticaria is associated with an impairment in quality of life, which emphasizes the need for evaluation of the psychological health of patients visiting tertiary clinics.

Many studies have demonstrated that patients with CU experience a prolonged psychological burden, such as depression and anxiety (6–9). Others have shown that the symptoms of CU affect everyday life, limiting and impairing physical and emotional functioning, and act as an indirect burden on the life satisfaction of most of the patients (10–12). A recent survey showed that the majority of Canadian allergists reported that psychosocial parameters play a role in the pathogenesis of CU (13). In addition, a recent meta-analysis showed that the prevalence of any psychological condition among patients with CU was significantly higher than healthy subjects (14). Moreover, an online survey in Germany (ATTENTUS) reported the existence of a highly burdened population with CU outside specialized centres (15).

Thus, proper assessment of the health-related quality of life (HRQoL) using appropriate tools is important in estimating disease progression. Thus, many measures are used to assess QoL in patients with CU, such as the Dermatology Life Quality Index (DLQI) (16, 17), the Dermatology Quality of Life Scales (DQOLS) (18, 19) and the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) (20–23).

Although urticaria currently represents a public health concern in the Middle East, the disease is still under-represented in this region. Only a few studies, such as the one conducted by Alzahrani et al., have shown that 41% of Saudi patients with CU experienced a large effect on their QoL (24, 25). Therefore, a more in-depth investigation of the increasing burden of CU may help address challenges to medical care in this region. The aim of the current study was to expand the use of a previously cross-validated version of CU-Q2oL along with other scales to evaluate the impairment of different aspects of life in patients with CU, as well as its impact on psychological wellbeing, mental and emotional health.

MATERIALS AND METHODS

Study design and sample size

A multi-centred cross-sectional study was conducted between July 2018 and June 2020, using a cluster sample of Lebanese patients with CU visiting dermatology and/or immunology clinics from all districts of Lebanon. Using Epi-info™ 7 for calculation of the sample size in which the primary endpoint is the worldwide prevalence of urticaria, a total number of 264 participants were required to participate in the study (taking into account a prevalence of 0.5–1% and a precision measure of 1.2% (26)). A total sample size of 295 participants was adopted to account for any missing value.

Patients were included if they were > 18 years old with a diagnosis of CU, defined as the daily or almost daily occurrence of hives, with or without angioedema, for at least 6 weeks. Patients were excluded if they had acute urticaria (< 6 weeks of hives), urticaria vasculitis or angioedema as a sole symptom, dermatitis or other skin diseases. The study also excluded patients who had a diagnosed psychiatric disorder, cognitive impairment, or central nervous system disease.

Study conduct

Participants were given the self-administered questionnaire in Arabic (the local language) and answered it independently. Completion of the questionnaire took approximately 10–15 min. Illiterate patients, geriatric patients, and those who had reading difficulties were interviewed by scientific researchers who had received training in advance. Patients were asked to provide their contact information for further follow-up in case of any missing information. They provided information on their socio-demographic characteristics, such as sex, age, highest educational level, type of employment, income, marital status, and number of individuals per household, as well as their medical information, such as the main reason for the doctor’s visit, current and past medical history, any family history of dermatological diseases, symptoms of the disease and the main triggering factors, including food, medications, seasonal pollen, cold, heat, contact substances, insect bites, and animals. Each patient was asked to complete the questionnaire, which included several severity and QoL scales, and to recall appropriate information.

Description of the Urticaria Control Test

The Urticaria Control Test (UCT) is a 4-item questionnaire designed to assess the level of disease control among patients with CU within the past 4 weeks. Items assess the level of suffering due to the physical symptoms of urticaria, its impact on QoL, the effect of treatment on urticaria symptom control, and overall perceived urticaria control. Higher scores on the UCT are indicative of better disease control. The total score ranges from 0 (no disease control) to 16 (complete disease control). A score less than 12 indicates uncontrolled symptoms and a score less than 8 indicates very poor symptom control (27). The Arabic version of the UCT was previously linguistically validated to screen Arabic-speaking patients for poorly vs well-controlled disease (28).

Description of the Chronic Urticaria Quality of Life Questionnaire, and the Dermatology Life Quality Index

The CU-Q2oL comprises 23 items categorized into 6 domains: pruritus (n = 2), impact on life activities (n = 6), problems with sleep (n = 5), limits (n = 3), looks (n = 5), and swelling (n = 2). Each item is scored on a 5-point Likert scale, ranging from 1=”not at all” to 5=”very much”. The individual items are summed up to generate the overall CU-Q2oL score, which is then converted to a 0–100 scale. Higher scores indicate greater QoL impairment (29). It is noteworthy that a previously cross-validated Arabic version of CU-Q2oL was used in our study for data collection (30).

The DLQI is a HRQoL questionnaire for dermatological diseases that comprises 10 questions corresponding to 6 domains: symptoms and feeling, daily activities, leisure, work and school, personal relationships, and treatment (23). It is available in 55 languages, including Arabic (31–33). Like the CU-Q2oL, the Arabic DLQI was previously used for assessment of the QoL of a sample of Lebanese patients with CU (30). The total DLQI score ranges from 0 to 30. The answers are scored on a 4-point Likert scale (0 for not at all and 3 for very much). Higher scores indicate higher QoL impairment.

Description of Patient Health Questionnaire-9 (PHQ-9) and Beirut Distress Score 22 (BDS-22)

The PHQ-9 includes 9 items, which focus on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) for Major Depressive Disorder (34). Each item of PHQ-9 is scored on a scale of 0–3 (0 = not at all; 1 = several days; 2 = more than a week; 3 = nearly every day). The PHQ-9 total score ranges from 0 to 27 (scores of 0–9 are classified as mild depression; 10–14 as moderate depression; 15–19 as moderately severe depression; ≥ 20 as severe depression) (35). PHQ-9 validity was well established in a sample of Lebanese adults and it was shown to be a sensitive measure of depressive symptoms (36).

The BDS-22 is a 22-item questionnaire that differentiates among core symptoms of depression, anxiety, and perceived stress. It is a reliable and valid tool used for the assessment of psychological distress and mental health perception in the general population. It includes 6 factors, reflecting depressive symptoms, demotivation, psychosomatic symptoms, mood deterioration, intellectual inhibition and anxiety. The 22 items are answered on a Likert scale from 0 to 3 (0 never, 1 sometimes, 2 often, and 3 always) with a possible score from 0 to 66. The score is then summed up by adding up all the items and the higher the score, the greater the risk of psychological distress is (37, 38).

Data processing and statistical methods

All data analyses and statistical processes were performed using SPSS version 23 (IBM SPSS Software, Chicago, IL, USA). Continuous measures were summarized by means and standard deviation (SD) or by medians and interquartile range (IQR), where appropriate; categorical measures were summarized by percentage and 95% confidence intervals (95% CI).

Continuity correction χ² tests were used for the comparison of categorical variables between groups. The conformity of continuous variables to normal distribution was evaluated using visual histogram and probability graphs. Independent-samples t-test and analysis of variance (ANOVA) were used for the comparison of normally distributed variables. The variation of different scores among 3 different disease control levels (classified as very poorly controlled (UCT<8), poorly controlled (UCT 8–11), or well-controlled (UCT≥12) was investigated using the Kruskal–Wallis test.

The relationship between disease control and all remaining scores were evaluated using Pearson’s or Spearman’s correlation analysis. Correlation coefficients of < 0.3, 0.3–0.6, and > 0.6 were considered to indicate weak, moderate, and strong correlations, respectively (39). Multivariable analysis of variance (MANCOVA) was performed, where CU-Q2oL and PHQ-9 were the dependent variables, age and sex the covariates and socio-demographics and risk factors the independent variables in order to assess the effect of the different factors associated with urticaria on both QoL and depression. A p-value ≤ 0.05 was considered to be statistically significant.

Ethical considerations

The Lebanese University ethics committee waived the need for approval, as the study was observational and respected participants’ confidentiality. Patients provided their oral informed consent before participation.

RESULTS

Patients socio-demographic and disease characteristics

A total of 295 patients with CU participated in the study. The mean age was 35.7 ± 11.33 years (range 18–81). The female:male ratio was 161:134 (female: 54.6%). The majority of the patients did not have any positive family history of dermatological disease (75.8%). The final diagnosis was mainly confirmed an allergist/immunotherapist in most of the cases (87.1%), or dermatologist (8.1%), or physicians with other specialties, such as ear nose and throat (ENT), paediatrics, cardiovascular, pulmonologist, etc. (4.8%). Both spontaneous and induced types of urticaria were encountered, including physical (17.3% contact urticaria and 1.7% delayed pressure urticaria,) and non-physical (35.9% pollen allergy; 10.5% dust allergy; 2.4% solar urticaria; 2% heat-induced urticaria; and 1.4% cold-induced urticaria). More details about socio-demographic and disease characteristics are listed in Table I.

Table I. Sociodemographic characteristics

Characteristics	n (%)
Sex
Male	134 (45.4)
Female	161 (54.6)
Education level
Primary school degree	37 (12.6)
High school degree	78 (25.5)
University degree	150 (51)
Master’s degree	19 (6.5)
Doctorate degree	4 (1.4)
Technical education	6 (2)
Marital status
Single	80 (27.1)
Married	188 (67.1)
Widowed	1 (0.3)
Divorced	11 (3.7)
Financial status
Comfortable	44 (26.2)
Acceptable	114 (67.8)
Tough	10 (6)
Work status
Student	9 (3.1)
Unemployed	32 (12.8)
Employed	204 (69.2)
Retired	5 (1.7)
Co-morbidities
Allergic rhinitis	36 (12.2)
Asthma	30 (10.2)
Other allergies	80 (27.1)
Inflammatory bowel disease	4 (1.4)
Diabetes mellitus	4 (1.4)
Hypertension	22 (7.5)
Thyroid disease	14 (4.7)
Systemic lupus erythematosus	5 (1.7)
Symptoms
Red wheals and/or itching	136 (48.8)
Angioedema	3 (1.1)
Red wheals and angioedema	16 (5.7)
Red itchy wheals and angioedema	71 (25.4)
Red itchy wheals and respiratory distress	53 (19)
Treatment regimens
Antihistamines only	187 (63.3)
Corticosteroids only	4 (1.3)
Antihistamines and hydroxychloroquine	2 (0.6)
Antihistamines and corticosteroids	29 (9.8)
Antihistamines and montelukast	22 (7.4)
Antihistamines and corticosteroids and montelukast	1 (0.3)
Triggers
Unknown	68 (23.1)
Food allergy (including food additives)	45 (15.3)
Medications	18 (6.1)
Infection (viral, bacterial, fungal)	2 (0.7)
Contact	51 (17.3)
Animals	3 (1)
Pollen	103 (35.9)
Insect bites	2 (0.7)
Sunlight	7 (2.4)
Heat	6 (2)
Cold	4 (1.4)
Pressure	2 (0.7)
Emotional stress	7 (2.5)
Dust	31 (10.5)
Sweating	5 (1.7)
Exercise	5 (1.7)

Patients’ disease severity, quality of life and psychological distress assessment

The mean score of UCT in all patients with CU had a value of 9.3 ± 3.12, indicating a moderate disease control. The means of both DLQI and CU-Q2oL were 7.71 ± 5.82 and 40.06 ± 15.4 respectively. As for the scores measuring the psychological distress, the mean scores had values of 24.19 ± 14.5 and 12.5 ± 7.17 for BDS-22 and PHQ-9 scores, respectively, which indicate a mild depression level. More details about these scores are summarized in Table II.

Table II. Characteristics of severity and quality of life scores

Scores	Measurement	N	Min	Max	Median	Mean	SD	Percentiles
								25	50	75
Urticaria Control Test	Disease Severity	258	0	16	9.00	9.30	3.12	7.00	9.00	12.00
Dermatology Life Quality Index	HRQoL (dermatology)	275	0	26	6.00	7.71	5.82	4.00	6.00	11.00
Chronic Urticaria-Quality of Life Index	HRQoL (dermatology)	282	0	95	38.00	40.06	15.40	32.00	38.00	45.00
Beirut Distress Score	Psychological distress	287	0	59	24.00	24.19	14.49	13.00	24.00	35.00
Patient Health Questionnaire	Depression severity	131	0	27	13.00	12.53	7.17	6.00	13.00	18.00
HRQoL: health-related quality of life; SD: standard deviation.

Association between patient’s quality of life and urticaria control. Patients were classified into 3 UCT categories: 1: very poorly controlled (score < 8); 2: poorly controlled (score 8–11); and 3: well controlled (score ≥ 12). When comparing the DLQI scores among the 3 groups, no statistically significant difference in median scores was shown between the patients with a UCT score < 8 and UCT score 8–11. However, the well-controlled group had the lowest DLQI median score (4.00 ± 4.75; p < 0.001; Fig. 1a). The same trend was also seen in the variation of CU-Q2oL median scores, where no statistically significant differences were detected between the very poorly controlled and poorly controlled group, whereas patients in the well-controlled group showed the lowest CU-Q2oL median score (34.00 ± 14.00; p < 0.001; Fig. 1b).

Fig. 1. (a) Dermatology Life Quality Index (DLQI) median scores differences among Urticaria Control Test (UCT) categories; p < 0.001. (b) Chronic Urticaria-Quality of Life Index (CUQ2oL) median scores differences among UCT categories; p < 0.001* and °outlier values.

Association between patient’s psychological health and urticaria control. PHQ-9 and BDS-22 median scores differed significantly among the 3 UCT categories. Patients with UCT scores < 8 had the highest median scores of PHQ-9 and BDS-22 (17.5 ± 8.75 and 39.0 ± 18.5, respectively) when compared with poorly controlled (PHQ-9=16.0 ± 6.75 and BDS-22=27.5 ± 10.0; p < 0.001) and well-controlled groups (PHQ-9=4 ± 9.75 and BDS-22=13 ± 8.25; p < 0.001; Fig. 2a and 2b)

Fig. 2. (a) Patient Health Questionnaire (PHQ-9) median scores differences among Urticaria Control Test (UCT) categories; p < 0.001. (b) Beirut Distress Score (BDS-22) median scores differences among UCT categories; p < 0.001. °Outlier value.

Correlation between quality of life and psychological distress scores and urticaria control

The HRQoL scores were shown to have a moderate negative correlation with UCT; i.e. a moderate correlation was found between DLQI total score and UCT (rho = –0.51, p < 0.001) and CU-Q2oL total score and UCT (rho = –0.55, p < 0.001), respectively. The same was also noticed between the psychological distress scores and UCT (PHQ-9: rho = –0.55 and BDS-22: rho = –0.61, p < 0.001). More details about correlation measurements are shown in Fig. 3.

Fig. 3. (a) Correlation between Dermatology Life Quality Index (DLQI) total score and Urticaria Control Test (UCT); rho=–0.51; p<0.001. (b) Correlation between Chronic Urticaria-Quality of Life Index (CUQ2oL) total score and UCT; rho=–0.55; p < 0.001. (c) Correlation between Patient Health Questionnaire (PHQ-9) total score and UCT; rho=–0.55; p < 0.001. (d) Correlation between Beirut Distress Score (BDS-22) total score and UCT; rho=–0.61; p < 0.001.

Distribution of scores among different categories of clinical characteristics

MANCOVA analysis of both CU-Q2oL and PHQ-9 scores was performed among different categories of sociodemographic characteristics and risk factors, using sex and age as covariates. The model did not show any significant difference in covariance, and all assumptions of normality, linearity and correlation were taken into account. Variables such as spontaneous urticaria and emotional stress were associated with an increase in CU-Q2oL. Moreover, having a lower level of education than a university degree was associated with an increase in PHQ-9 score, indicating higher depression than other educational categories. More details about score differences are shown in Table III.

Table III. Multivariable analysis of variance (MANCOVA) multivariable analysis

Independent factor	CU-Q2oL		PHQ-9
	Corrected mean ± SD	p-value	Corrected mean ± SD	p-value
Marital status
Single	15.50 ± 17.30	0.543	5.58 ± 6.73	0.744
Married	19.33 ± 16.90		1.28 ± 8.53
Widowed	16.90 ± 27.90		6.86 ± 11.12
Divorced	36.28 ± 15.16		3.95 ± 6.90
Highest education
High school degree	20.50 ± 17.30	0.306	12.27 ± 6.90	0.027
University degree	11.11 ± 18.18		7.15 ± 7.25
Technical education	8.59 ± 26.10		6.19 ± 10.42
Financial status
Comfortable	9.34 ± 20.51	0.164	4.91 ± 8.18	0.667
Acceptable	5.61 ± 20.13		2.84 ± 8.03
Tough	25.24 ± 17.27		5.47 ± 6.88
Work status
Unemployed	17.74 ± 19.72	0.412	4.96 ± 7.86	0.543
Employed	16.37 ± 18.18		7.12 ± 7.25
Retired	18.53 ± 20.00		1.26 ± 7.97
Student	0.93 ± 21.60		4.27 ± 8.62
Type of urticaria
Spontaneous	20.34 ± 18.12	0.041	4.44 ± 7.79	0.981
Inducible	6.45 ± 19.55		4.37 ± 7.20
Family history of urticaria
No	21.78 ± 16.32	0.266	10.78 ± 6.51	0.036
Yes	5.01 ± 23.10		1.96 ± 9.21
Asthma
No	11.05 ± 18.66	0.526	1.76 ± 7.42	0.076
Yes	15.75 ± 19.17		7.05 ± 7.67
Allergy
No	13.27 ± 18.28	0.963	5.49 ± 7.29	0.335
Yes	13.53 ± 19.24		3.31 ± 7.67
Angioedema
No	14.86 ± 19.56	0.776	7.46 ± 7.8	0.139
Yes	11.93 ± 18.93		1.35 ± 7.54
Allergy triggers
Food
No	13.05 ± 18.04	0.919	2.84 ± 7.19	0.248
Yes	13.74 ± 19.47		5.97 ± 7.83
Medications
No	18.20 ± 17.94	0.473	4.85 ± 7.15	0.87
Yes	8.60 ± 21.34		3.97 ± 8.51
Infections
No	30.36 ± 13.92	0.163	1.83 ± 5.55	0.593
Yes	3.56 ± 28.00		6.98 ± 11.16
Pollen
No	13.94 ± 18.11	0.848	3.42 ± 7.22	0.386
Yes	12.85 ± 19.41		5.39 ± 7.74
Emotional stress
No	5.98 ± 19.35	0.01	3.14 ± 7.71	0.476
Yes	20.81 ± 18.80		5.67 ± 7.50
Bold values mean significant p-values (p < 0.05).

DISCUSSION

This study was conducted to evaluate the burden of CU on HRQoL and psychological wellbeing in real-life clinical practice. The demographic characteristics of the patients were comparable with the findings of previous publications (40, 41) and occurrence of CU was mostly detected in the category of 20-40 years old, which is consistent with the previous findings (15, 26).

This study evaluated disease control of urticaria using UCT score, and revealed that approximately 68.6% of patients with CU had uncontrolled symptoms. Also, a moderate negative correlation was shown between UCT scores and each of CU-Q2oL and DLQI. This is similar to the findings of the study by Weller et al. (27), in which it was reported that the screening accuracy of the UCT was high in screening disease severity. It is notable that similar findings were reported by other authors who highlighted a higher DLQI score among patients with high UCT score (42). Although a change in UCT may indicate a change in the patient’s HRQoL, as seen in the current study similar to the results of the study by Stull et al. (43), the moderate correlation can be explained by the fact that disease control and HRQoL are different concepts. HRQoL is influenced not only by the disease itself, but also by additional factors, such as sleep deprivation and other socio-demographic features.

The current findings have proven that CU affects the QoL of almost half of the affected patients (50.3%). Unsurprisingly, similar studies revealed that CU compromises the patients’ QoL underlining the need to provide the most appropriate treatment (44–46). In a study conducted by Alzahrani et al in Saudi Arabia, it was proven that disease severity had markedly affected self-perception and mental status (25). Moreover, another French study showed that CU impaired the QoL of the affected patients and underlined the fact that this impairment is often underestimated (47).

In addition, the current study has shown that patients with CU experienced depression and psychological distress, which was more serious when urticaria was less controlled. This was underlined by the study by Sperber et al., who performed a psychological assessment to 19 patients with chronic inducible urticaria and found that these patients had significantly higher depression and anxiety scores compared with the control group (48).

The goal of this study was to provide proof of concept for the potential utility of PHQ-9 and BDS-22 scales in allergy/immunology clinics in the management of patients with CU with regards to depression and psychological distress. Given the unpredictable nature of individual urticaria episodes, it is not surprising to find an association between CU and depression (9, 49).

The current study is similar to previous ones in which no impact on QoL was associated with urticaria in terms of sex differentiation, income, age, and marital status, etc. (47, 50). Only stress and the spontaneous type of urticaria were associated with an increase in CU-Q2oL score, while lower educational level was associated with more depression. This proves that stress may influence negatively the QoL of the patients affected with urticaria. In fact, CU is known to be a psycho-dermatological disorder. It was proven that factors such as stress can affect exacerbation of urticaria wheals, and psychological distress may be related to itch intensity (51, 52). Furthermore, it was shown that the patients who did not know the exact trigger behind their disease had worse impact on their QoL than those who did. This finding is logical, since it is usually easier to cope with the disease when the cause is well defined and avoidable. Regarding educational level, it is predictable to notice that patients with a lower educational level feel more depressed than those with more diplomas. Usually, people with a higher educational level have more employment chances and a better lifestyle, as seen in the study by Baumann et al. (53) on 355 students from Europe. It was concluded that the psychological dimension of QoL was positively associated with academic skills and more knowledge regarding employability and activities of daily living.

The current study provides the basis for further research projects regarding CU, which are of particular interest as this disease is often poorly controlled. Further research into poor disease control by the development of simple diagnostic tools to help patients become more integrated in the treatment process. Moreover, motivational interviewing technique and disease registries may help achieve better outcomes in disease management. It is essential for all healthcare professionals to examine further the psychological aspects of living with CU. Additional research on referral for counselling could be valuable, as this is something that is not covered in depth in the available guidelines.

To our knowledge, this is one of few studies to evaluate the impact of urticaria on QoL and psychological health. In addition, the use of the CU-Q2oL, which is a specific instrument to evaluate the HRQoL in CU, added power to this study, in contrast to most studies that used generic questionnaires for dermatological diseases, such as the DLQI alone. In addition, this study aimed to evaluate the impact of CU on daily activities in a multicentre setting, which enhances the generalizability of the results. Moreover, the fact that all patients with all types of CU were included improved the representability of the current sample. Despite this, some limitations should be considered. First, the retrospective collection of data may have increased the risk of recall bias. In addition, all outcome measures were self-reported, which may be open to bias such as social desirability. Furthermore, this study was uncontrolled in a small sample of patients with CU, which would have reduced power in detecting significant differences in QoL and depression scores. Moreover, researchers did not have access to medical records beyond initial screening for eligibility. As such, there is a lack of knowledge regarding changes in medical care and their possible effects on outcome measures or impact on QoL.

In conclusion, CU compromises the QoL of patients due to its debilitating symptoms, which can last for years. The evaluation of QoL is fundamental to better assess disease progression and treatment efficacy. The current findings call for psychological health evaluation of patients with CU in routine clinical practice.

ACKNOWLEDGEMENTS

Conflicts of interest: The authors declare that IC is a full–time physician practicing at the Internal Medicine and Clinical Immunology Department at Hôtel-Dieu de France hospital, Beirut. Otherwise, the authors have no other conflicts of interest or financial support from pharmaceutical companies to declare in relation to this work.

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