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Vitamin D treatment of idiopathic itch, rash, and urticaria/angioedema.

Clinical allergists/immunologists regularly address patient complaints of itching, hives, angioedema, and nonpathognomonic rashes that have defied identification and cure during multiple previous encounters with primary care practitioners, urgent care clinics, emergency rooms, and dermatologists. A combination of thorough history, physical examination, skin testing, patch testing, and laboratory studies may identify a drug, food, aeroallergen, contact allergen, or environmental exposure responsible for the cutaneous symptoms; however, if the diagnosis remains idiopathic, further investigation should include a 25-hydroxyvitamin D (25[OH]D) serum level. The major circulating form of vitamin D is 25(OH)D and reflects synthesis in sun-exposed skin as well as dietary intake. It is the standard measure of clinical vitamin D status. Serum 25(OH)D levels above 30–32 ng/mL are required for optimal health. Serum levels 10 ng/mL reflect severe vitamin D deficiency, levels 10–20 ng/mL are variously described as deficient or insufficient, and 25(OH)D levels of 20–30 ng/mL are defined as vitamin D insufficient. Although ascribing no cutaneous symptoms to low vitamin D, Holick and Chen highlight the prominence of vitamin D insufficiency in all age groups, with many studies reporting vitamin D insufficiency in 50% of individuals. Dietary sources of vitamin D include oily fish and egg yolks, as well as vitamin D–fortified milk (and a few other fortified foods), but many individual’s diets may be lacking in these sources. Sun exposure and skin production of vitamin D is unlikely to rectify dietary shortfalls of vitamin D in modern societies where individuals are spending more time indoors and actively avoiding the sun. Although vitamin D deficiency is epidemic, articles and textbooks rarely ascribe cutaneous consequences to low vitamin D. In contrast, low vitamin D is implicated in a majority of idiopathic cases of isolated pruritus, nonpathognomonic rashes, and urticaria/angioedema in this retrospective case series of 63 patients seen in a single allergist’s practice over 6 months between December 2008 and May 2009. Atopic dermatitis and defined dermatoses had been excluded. Patients had been drawn from a geographic area including the northern half of West Virginia and adjacent Pennsylvania and Maryland counties. A majority of patients had seen a dermatologist. Systemic steroids and multiple H1 and H2-antihistamines had been inconsistently therapeutic. Each patient had a thorough history, physical examination, routine laboratory studies, and appropriate skin testing or patch testing, all of which were unrevealing. All patients had symptomatic treatments continued, including antihistamines (H1 and H2) and topical preparations as needed. Each of the 63 patients with idiopathic cutaneous symptoms also had 25(OH)D measured. Of 63 patients, 90% (57/63) had low vitamin D (25[OH]D, 32 ng/ mL). These 57 patients were prescribed 8–12 weeks of vitamin D, 50,000 IU weekly, followed by daily supplementation with over-the-counter vitamin D, 1000 IU/day, and subsequent individual adjustments in dose based on serum levels of 25(OH)D. Response to treatment was recorded as either full resolution of cutaneous symptoms or failure to resolve. Patient information was anonymously archived into a database for analysis. Collected patient information included age, sex, referral status, cutaneous symptoms, symptom duration and corporal distribution, atopic status, relevant preexisting conditions, initial serum 25(OH)D, new diagnoses, treatments including vitamin D if prescribed, and response to treatments. The 57 patients with low 25(OH)D were then further analyzed for their response to treatment with oral vitamin D. The 57 patients with low 25(OH)D were a mean age of 47 years old, 70% were atopic, and 77% were female patients (Table 1). Median duration of idiopathic cutaneous symptoms was 18 months. Mean 25(OH)D was 18.0 ng/mL. With vitamin D treatment, 70% (40/57) had complete resolution of symptoms. Mean 25(OH)D for vitamin D–responsive patients (16.8 ng/mL) was significantly lower than for vitamin D–nonresponsive– treated patients (20.9 ng/mL; p 0.02 by unpaired From Exemplar Allergy & Asthma, Morgantown, West Virginia Address correspondence and reprint requests to David W. Goetz, M.D., Ph.D., Exemplar Allergy & Asthma, 1063 Maple Drive, Suite 1A, Morgantown, WV 26505 E-mail address: dwgoetz@pol.net Copyright © 2010, OceanSide Publications, Inc., U.S.A.