Dermographism in chronic spontaneous urticaria: associations with disease activity, autoimmunity, and disease duration

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Background and objective: Dermographism is a frequent clinical finding in patients with chronic spontaneous urticaria (CSU) and may reflect enhanced mast-cell reactivity, increased disease severity, and prolonged disease persistence. This study aimed to evaluate the clinical significance of dermographism in CSU, including its relationship with disease activity, disease duration, response to H1-antihistamines, autoimmune status, and autologous serum skin test (ASST) positivity. Methods: A prospective observational study was conducted at the Dermatology Department, General Hospital "8th September", Skopje, North Macedonia, between December 2021 and November 2022, including 230 patients with CSU. Disease activity was assessed using the Urticaria Activity Score over 7 days (UAS7). Dermographism was clinically evaluated during dermatological examination using standardized mechanical provocation testing. Autoimmune status was determined by the presence of autoimmune disease and/or positivity for autoantibodies including anti-thyroid peroxidase antibodies (anti-TPO), antinuclear antibodies (ANA), and rheumatoid factor (RF). ASST was performed to assess autoreactivity. Results: Among 230 patients with chronic spontaneous urticaria (CSU), dermographism was present in 161 (70.0%). Patients with dermographism had significantly higher disease activity, being more frequently classified as severe according to UAS7 compared with those without dermographism (82.0% vs. 18.0%, χ²=14.4, p=0.00015). Dermographism was not associated with therapeutic response to H1-antihistamines (69.3% vs. 30.7%, χ²=0.12, p=0.73), autoimmune status (72.4% vs. 27.6%, χ²=1.1, p=0.29), or ASST positivity (72.9% vs. 27.1%, χ²=1.4, p=0.24). Patients with dermographism had a significantly longer disease duration than those without dermographism (58.5 ± 47.1 months; median 54 [IQR 15-91] months, Z = 2.3, p=0.022). Conclusions: Dermographism is a common finding in patients with chronic spontaneous urticaria and is associated with greater disease activity and longer disease duration, suggesting a more severe and persistent disease phenotype. Despite the observed trends, no significant associations were identified between dermographism and H1-antihistamine response. In addition, the lack of significant associations with autoimmune status and ASST positivity does not support a definitive relationship between dermographism and immune dysregulation. Routine assessment of dermographism may help identify CSU patients at risk for increased disease burden and prolonged disease course.

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