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Introduction: Chronic urticaria is a disease manifested by a pruritic rash lasting longer than 6 weeks that may severely affect quality of life and daily function. Chronic urticaria can be further divided into chronic spontaneous urticaria which appears without a trigger and chronic inducible urticaria which evolves following distinct physical triggers. These two clinical manifestations could coexist in the same patient. The pathogenesis of chronic urticaria is not fully elucidated, although it is considered an autoimmune disease in at least 50% patients that produce auto- IgG antibodies targeted against the high affinity Fc receptor and to a lesser extent against IgE itself. Auto-antibodies associated with different autoimmune diseases can be detected such as those directed at thyroid proteins. Urticaria tends to spontaneously resolve in 50% of patients within the first year while others will suffer from it for a much longer period of time. The treatment of chronic urticaria has dramatically progressed in the last decade, enabling reduction of systemic corticosteroid use which has been the cornerstone of treatment in the past. The recommended treatment for chronic urticaria is currently based on a stepwise approach that enables achieving disease control with a reasonably good quality of life. The first step of the treatment ladder consists of selective, new generation, anti-H1 histamine blockers, which do not cross the blood brain barrier, starting from the recommended dose (first line) and increasing up to four-fold (second line). The third line of treatment is the addition of immune modulators such as leukotriene receptor blockers (Singulair), anti-IgE biological therapy (Xolair), or cyclosporine. In this review we present the updates and considerations arising during evaluation and treatment of chronic urticaria. The need for specific tests, immunologist/allergologist evaluation, as well as treatment modalities taking into consideration the large body of evidence that has accumulated in the last few years, the new international guidelines as well as their application in Israel have been addressed.

Allergy to seafood such as shrimps, crab, lobster and fish eggs is relatively infrequent in Israel compared to fish allergies and allergies to other foods. This is mainly due to the fact that most of the population and restaurants preserve and maintain Kosher food. Changes in the population eating habits, partly due to immigration, were followed by increased frequency of such sensitivities in recent years. We describe three typical cases that illustrate the characteristics of allergy to sea foods. Allergy to seafood can present as a single sensitivity or be part of an allergic tendency, atopy, with other allergic manifestations. Diagnosis by allergy skin test or laboratory evaluation by specific IgE is available for most sea foods but not for fish eggs. The current therapeutic approach is strict avoidance and all patients should be provided with and carry with them an epinephrine auto-injector.

Chronic rhinitis (CR) affects large populations worldwide, diagnosed in 40% of the population and is often associated with co-morbidities, such as asthma, sinusitis, rhinoconjunctivitis cognitive dysfunction, and leads to loss of work and school days. Recently, global clinical guidelines were proposed for allergic rhinitis (AR). Similarly, an Israeli expert panel, consisting of ENT and Allergy/Immunology specialists, was delegated to discuss the current approaches to CR (including allergic and non-allergic rhinitis) and to submit a consensus paper. The guidelines, briefly presented herein, describe the epidemiology, mechanisms, diagnostic procedures, treatment modalities and clinical-management algorithms. It is adapted to the Israeli health system and will be distributed to all physicians by the Israel Medical Association. The new clinical guidelines are expected to update current knowledge, improve communication between medical disciplines, provide medico-legal support and improve the management of CR.

Allergic rhinitis causes major illness and disability worldwide, but it is still underdiagnosed and undertreated. Allergic rhinitis is a risk factor for both the development and for exacerbations of asthma. Up to 30% of patients with rhinitis suffer from asthma, and the majority of patients with asthma suffer from rhinitis. Measurements of allergic status can help to identify risk factors that cause asthma. Hence, the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative recommends that the presence of asthma must be considered in all patients with rhinitis, and that in planning treatment, both should be considered together in terms of efficacy and safety. Treatment of rhinitis may improve asthma symptoms. Due to new studies and diagnostic techniques the ARIA guidelines, initially formed in 1999, were recently updated. They are intended for specialists, general physicians and health care providers in order to increase the knowledge on allergic rhinitis and its impact on asthma and to provide evidence-based revision on the diagnostic methods, treatments and a stepwise approach to management. There is a need for a collaborative effort of all specialists and primary physicians involved in the treatment of rhinitis and asthma for the proper implementation of the guidelines.

Background: Chronic idiopathic urticaria (CIU) is a common and frustrating disorder defined as a regular recurrence of hives for a period of more than 6 weeks, and has a major impact on patients' daily quality of life--H1 receptor antagonists are considered to be particularly effective in reducing pruritus, and are recommended as first-line treatment in patients with CIU. However, the efficacy of the treatment is insufficient., Objective: To evaluate the efficacy of desloratadine in CIU in Israeli patients., Methods: An open label multicenter study in 10 centers in Israel. Upon completion of 3-14 days screening for eligibility, eligible patients were given desloratadine 5 mg for 4 weeks. The DLQI questionnaire and the severity of CIU were assessed at baseline and each week for 28 days., Results: One hundred and four patients aged 19 to 85 years (mean +/- SD 45.6 +/- 15.6) who suffered from moderate CIU, despite previous treatment with anti-histamine agents, were selected and treated with desloratadine 5 mg daily for 28 days. There was significant improvement for dermatologic quality of life in each of 10 parameters and in work productivity, and significant decrease in CIU symptoms and signs including the number and size of hives. In the overall evaluation of treatment 51% of patients reported complete or marked relief and 20% had no relief. Adverse events were reported as mild in 10 patients and moderate to severe in 2 patients who discontinued the study due to headache., Conclusion: Desloratadine can be successfully used in the treatment of CIU.