Allergen Avoidance Measures Research Articles

Current Management of Allergic Rhinitis

Allergic rhinitis (AR) is the most common allergic disease worldwide and one of the most common chronic diseases in general. Allergic rhinitis is caused by inhalant allergens from outdoor and indoor environments with varying significance of different allergens in global regions. We provide options for the current management for AR including pharmacological treatments and nonpharmacological options and allergen immunotherapy (AIT). A literature review has been conducted in Medline, Pubmed, as well as the national and international study (ClinicalTrials.gov) and guideline registers and the Cochrane Library. Human studies published on the topic in the period up to and including November 2023 were taken into account. Allergen avoidance measures, pharmacotherapy, and AIT are the cornerstones of AR treatment. Nonpharmacological measures and behavioral recommendations should be adequately added. Tools of precision medicine are already playing a significant role and will be part of the diagnostic and therapeutic standard in the future. Patients benefit most in a network of different pharmacological and nonpharmacological treatment measures including AIT. Application of precision medicine tools for diagnosis and treatment will improve standards of care.

Allergic Rhinitis.

Allergic rhinitis (AR) affects more than 400 million people worldwide, making it 1 of the most prevalent chronic diseases. Childhood AR is increasing, and almost half of patients with AR develop symptoms before age 6 years. Although a diagnosis of AR is associated with higher socioeconomic status, underserved and urban populations have more indoor aeroallergen sensitizations and are likely underdiagnosed with AR, further exacerbating health-care disparities. AR negatively impacts quality of life, school performance, and overall health outcomes. Untreated AR in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. Many patients believe that they have seasonal allergies only but in reality have both perennial and seasonal AR, which may change the approach to allergen avoidance measures and treatment recommendations. Pharmacotherapy of AR has expanded, with many intranasal corticosteroids, intranasal antihistamines, and second-generation oral antihistamines approved for pediatric use. Allergen immunotherapy, including both subcutaneous and sublingual forms, are approved for children and are disease modifying, potentially reducing further allergen sensitization and progression to asthma. Many of the currently available biological therapies indicated for pediatric asthma and/or atopic diseases reduce AR symptoms as well. Children with moderate to severe or refractory AR or those with comorbidities should be referred to allergists for diagnostic testing and expanded management options, including immunotherapy and potential biological treatment.

A comparative study of intranasal steroids with intranasal antihistamines sprays v/s intranasal steroids sprays alone in management of allergic rhinitis

Allergic rhinitis is the most common form of rhinitis, worldwide, affecting close to 10% to 30% of the global population. Heredity and environmental exposures may contribute to a predisposition to allergies. Pharmacotherapy along with effective allergen avoidance measures forms the mainstay of management of Allergic Rhinitis. The evidence indicates that intranasal corticosteroids are more efficacious than are antihistamines in the control of Allergic Rhinitis symptoms. This "superiority" is principally related to their effect on nasal obstruction. The numbers of studies done to know the efficacy of combination sprays over steroidal sprays alone are very few and provide insufficient insight. The purpose of this study was to ascertain whether the combination nasal sprays should be prescribed as a standard medical management for allergic rhinitis or not, as to achieve better quality of life after treatment with maximum improvement in Total Nasal Symptom Score (TNSS). 100 subjects were taken up for this study, 50 in each group after fulfilling the inclusion and exclusion criteria. Subjects were allocated in two groups according to consultant’s preference. Subjects were evaluated for Total Nasal Symptom Score (TNSS) and score of Mini Rhino conjunctivitis Quality of Life Questionnaire (MiniRQLQ) before and after the treatment initiation The study was conducted in two groups based on drug given and both the groups were evaluated after 2 weeks and 4 weeks of medication on the basis of TNSS and MiniRQLQ score. Allergic Rhinitis was found to be more common in younger age group. Both the drugs were effective in reducing the Total nasal symptom scores (TNSS) and score of MiniRQLQ significantly (p<0.001). However, Combination Nasal Sprays (Intra-nasal corticosteroids with intranasal antihistamines) were found to be statistically superior when compared to only intranasal steroid sprays. Combination Nasal Sprays are highly efficacious and statistically better to steroid nasal sprays hence this study confirms the superiority of combination nasal sprays and recommends combination nasal sprays as first line of treatment for allergic rhinitis.

Parental Perspectives on the Implementation of House Dust Mite Avoidance Measures for Children with House Dust Mite Sensitization

ABSTRACTObjective: The avoidance of house dust mite (HDM) is crucial in the management of HDM allergies. We aimed to demonstrate the implementation and perspective of the parents whose children had HDM allergy/sensitization to HDM avoidance measures. Materials and Methods: Parents of the patients with HDM sensitization were interviewed via telephone questionnaires.Results: One hundred and three patients with asthma (73.8%), allergic rhinitis (AR) (77.7%) and/or atopic dermatitis (AD) (29.1%) aged four to 18 years were included in the study. Seventy-one patients had multiple allergic diseases (68.9%). Of the parents, 39.8% fully adhered to HDM avoidance measures, and their education status was as follows: 41.5% illiterate/elementary/middle school, 31.7% high school, and 26.8% associate’s degree/university. In addition, 32.2% of the mothers who were partially adherent (n=62) were illiterate or had graduated from elementary/middle school, 33.9% had graduated from high school, and 33.9% had an associate’s degree or had graduated from university. Forty-one (39.8%) mothers were working, and most of them (61%) had graduated from university or had an associate’s degree. Nearly half of the mothers who were partially adherent to HDM measures were working (n=32). In the multivariate analysis, the risk factors for partial adherence to measures was to be a working mother [OR:4.072, 95%CI: 1.350-12.882, p=0.013] and to have the belief that the measures were useless [OR:4.886, 95%CI: 1.499-15.923, p=0.008]. However, no relationship was shown between adherence to the measures and the severity of AR or AD, asthma control status and having multiple allergic diseases.Conclusion: Full adherence to HDM avoidance measures was considerably dependent on the mothers’ working status and belief in the ineffectiveness of the measures whereas there was no relationship to the severity of allergic diseases. This study also revealed how the education status of the mothers affected the adherence to allergen avoidance measures in real life.Keywords: Children, Dermatophagoides pteronyssinus,Dermatophagoides farinae, house dust mites, avoidance measures, parents, pediatrics, questionnaire

Patch testing: Uses, systems, risks/benefits, and its role in managing the patient with contact dermatitis

Patch testing is the gold standard diagnostic tool for cell-mediated type IV hypersensitivity reactions like allergic contact dermatitis. Sensitized individuals have primed antigen-specific T lymphocytes that cause a reaction when antigens are applied to the skin owing to prior sensitization. Patch testing can be used in the adult and pediatric populations, but it is contraindicated in patients with a known history of severe allergic reactions to suspected allergens, generalized active dermatitis, or extensive eczema. Patch test systems can be a comprehensive panel (70-80 allergens), but they can also be targeted and limited to a more common allergen series (35 allergens). The decision for allergen selection should be based on an accurate patient history, physical examination, and availability of allergens. Measurement and interpretation of the test results requires training and experience, as well as consideration of relevance and clinical history. Patch testing is generally considered safe with just a few known complications: excited skin syndrome, active sensitization, and rarely anaphylaxis or other cutaneous complications. Appropriately pretesting patient education can help to mitigate some of these complications. Based on patch testing results, patients should be educated regarding proper allergen avoidance measures to resolve symptoms of allergic contact dermatitis.

Protocolo de tratamiento del asma

Asthma treatment must be comprehensive and must consider the following four basic pillars: pharmacological treatment, allergen avoidance measures, allergen immunotherapy, and health education. Acute asthma attack is treated with rapid-acting bronchodilators together with inhaled corticosteroids and, only in some cases, systemic corticosteroids. Biological drugs will be used if improvement is not achieved or in severe eosinophilic asthma. Inhalation devices are essential to make the use of drugs profitable; in children, they must be adapted to the age and clinical situations. Maintenance treatment requires both proper diagnosis of type of asthma and periodic monitoring of therapeutic drug effect. Drugs to prevent are: antileukotrienes, inhaled corticosteroids, long-acting beta 2 stimulants and, in severe forms, monoclonal anti-IgE antibodies. Immunotherapy against allergens, very effective in pediatrics, has precise indications.

Prevention of Allergic Asthma with Allergen Avoidance Measures and the Role of Exposome.

It is well known that combination of sensitization and exposure to inhaled environmental allergens is related to both the development and elicitation of symptoms of asthma and that avoidance of allergens would exert beneficial effects in the prevention and control of the disease. Other important factors include the relevance of other allergens, exposure to sensitizing agents also outside patient's home, exposure to irritants (like chemical air pollutants), and the involvement of the patient with a correct education. It is also likely that clinical phase of allergic airway disease and the degree of airways remodeling represent relevant factors for the clinical outcome of allergen avoidance procedure. We reviewed existing evidence on prevention of asthma through allergen avoidance. The management of respiratory allergy is a complex strategy (including prevention, drugs, immunological, and educational interventions). In addition, it is difficult in real life to distinguish the efficacy of single interventions. However, a combined strategy is likely to produce clinical results. A combined strategy is likely to produce satisfactory management of asthma. Allergens are an important trigger factor for the development of symptoms of respiratory allergy, and avoidance measures are able to reduce allergen levels. It is likely that clinical phase of allergic airway disease and the degree of airways remodeling represents relevant factors for the clinical outcome of allergen avoidance procedures. Considering the management of respiratory allergy is a complex strategy; it is difficult in real life to distinguish the efficacy of single interventions. However, further studies better quantifying the effects of allergens are needed.

An Indian perspective on dust mites

Dust mites are the most important group of indoor allergens. The dust mites have been classified as house dust mites and storage mites, however, with recent knowledge the different dust mite species are now labelled as “domestic mites.” The dust mites have been isolated at numerous Indian locations and their sensitization in Indian population has also been documented. In view of high sensitization in India, it is important to recognize the role of dust mites and their allergens in the precipitation of allergic diseases including allergic rhinitis and asthma. Allergies to dust mites can be confirmed by a classical clinical history of perennial, early morning and indoor symptoms substantiated by a positive skin prick test to these allergens. Further management of allergies to mites is possible using appropriate allergen avoidance measures and allergen immunotherapy. Multifaceted avoidance measures can be used, but, allergen avoidance by the means of an allergen impermeable bed encasings has the best evidence and is recommended in different guidelines. Allergen immunotherapy, the disease-modifying modality, has been proven to efficacious for house dust mite allergies.

Does evidence support the use of cat allergen immunotherapy?

Cat allergy can manifest as allergic rhinitis, conjunctivitis and/or asthma. With widespread cat ownership and exposure, cat allergy has emerged as a major cause of morbidity. Cat allergen immunotherapy is a potential disease modifying treatment for patients with cat allergy. We examine evidence on the effectiveness, cost-effectiveness and safety of cat allergen immunotherapy and consider the clinical contexts in which it should be prescribed. The European Association of Allergy and Clinical Immunology systematic reviews on allergic rhinitis and asthma along with the accompanying guidelines on allergic rhinitis were used as primary sources of evidence. Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are most common routes of administration for allergen immunotherapy (AIT). A limited number of high-quality studies related to cat dander have shown mixed results in improvements in ocular and nasal symptoms, asthma symptoms, peak expiratory flow rate and medication use scores with subcutaneous immunotherapy. Two studies examining cat dander and cat-related allergy response with sublingual immunotherapy have shown mixed results in terms of symptomatic response. One randomized trial examining intralymphatic immunotherapy has shown a positive symptom response and a favourable safety profile. Although studies have reported mixed results regarding safety of SCIT, adverse events have been reported more commonly with SCIT than SLIT. There is a limited body of high-quality evidence on the effectiveness and safety of cat AIT and no high-quality data on its cost-effectiveness. The available evidence on effectiveness is mixed based on studying a limited array of immunological, physiological and patient-reported outcome measures. Based on this evidence and extrapolating on the wider evidence base in AIT, it is likely that some patients may benefit from this modality of treatment, particularly those with moderate-to-severe disease who are inadequately controlled on allergen avoidance measures and pharmacotherapy and those who are monosensitized to Felix Domesticus 1. Further evidence is, however, required from larger trials before more definitive advice can be offered.

Dog and Cat Allergies and Allergen Avoidance Measures in Korean Adult Pet Owners Who Participated in a Pet Exhibition.

PurposeThis study evaluated dog and cat allergies and their association with allergen avoidance measures in Korean adults.MethodsThe study population consisted of 537 adults who currently kept dogs or cats and participated in a pet exhibition in Korea. The subjects were asked to complete questionnaires regarding pet ownership, allergen avoidance, and allergy symptoms, and underwent skin prick tests. They were considered to have a dog or cat allergy if they suffered from one or more of allergy symptoms during contact with their pets.ResultsIn total, 103 of 407 dog owners (25.3%) and 45 of 130 cat owners (34.6%) had a dog or cat allergy, respectively. Dog owners kept 1.3±1.5 dogs; this number did not differ according to the presence of dog allergy. Dog owners with a dog allergy had owned their dogs longer than those without (88.0±72.0 vs 67.5±72.7 months, P<0.05). Cat owners kept 2.1±3.6 cats; this number did not differ according to the presence of cat allergy, nor did the duration of cat ownership. Cat owners with a cat allergy had facial contact and slept with their cats less frequently (8.6±11.9 vs 18.3±27.0 times/day, P<0.01; 71.1% vs 81.2%, P<0.05); however, they had their cats shaved and beds cleaned less frequently than those without (1.8±3.3 vs 3.2±4.4 times/year, P<0.05; 1.5±1.5 vs 3.9±6.0 times/month, P<0.01).ConclusionsCat owners with a cat allergy tried to minimize contact with their cats, but efforts to avoid indoor cat allergens were lower than those without. In comparison, dog owners with a dog allergy had kept their dogs for longer time than those without; however, current contact with their dogs and allergen avoidance measures did not differ between the 2 groups.

Corticosteroid phobia among parents of asthmatic children.

Özçeker D, Uçkun U, İslamova D, Tamay Z, Güler N. Corticosteroid phobia among parents of asthmatic children. Turk J Pediatr 2018; 60: 142-146. Asthma is one of the most prevalent chronic diseases among children. Its prevalence and morbidity have been rising in recent decades. Pediatric asthma causes a significant burden on families; allergen-avoidance measures, uncontrolled disease, and disease severity which are the major cost predictors of childhood asthma in Turkey. Inhaled corticosteroids (ICS) are considered as cornerstone medications in asthma management which reduce asthma morbidity and mortality. Our aim was to address corticosteroid phobia in caregivers of asthmatic children and its impact on asthma management. Five hundred caregivers of asthmatic children were interviewed using structured questionnaire in this study. Over fifty percent of the caregivers (56.8%), most of whom (82.6%) are already aware of using corticosteroids in their anti-asthma drug regimen, mentioned that they are afraid of using them. Almost one fourth of caregivers (24.8%) made either some changes in their treatment regimen or stopped using the drugs due to corticophobia. Of the caregivers 55.2% had no idea about the side effects of corticosteroids and only 12.6% of them mentioned that they were informed by their physicians about the effects of corticosteroids. Any change in asthma treatment regimen due to corticophobia was found to be related with poor asthma control level (p: 0.004). The impact of parental information about the effects and importance of steroids given by the physicians on better asthma control was found to be highly significant (p < 0.001). That`s why physicians and health care providers should spend enough time explaining the importance of adherence to treatment in asthma management, which may help in overcoming the fear of using ICS.

EAACI Guidelines on Allergen Immunotherapy: Allergic rhinoconjunctivitis.

Allergic rhinoconjunctivitis (AR) is an allergic disorder of the nose and eyes affecting about a fifth of the general population. Symptoms of AR can be controlled with allergen avoidance measures and pharmacotherapy. However, many patients continue to have ongoing symptoms and an impaired quality of life; pharmacotherapy may also induce some side-effects. Allergen immunotherapy (AIT) represents the only currently available treatment that targets the underlying pathophysiology, and it may have a disease-modifying effect. Either the subcutaneous (SCIT) or sublingual (SLIT) routes may be used. This Guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on AIT for AR and is part of the EAACI presidential project "EAACI Guidelines on Allergen Immunotherapy." It aims to provide evidence-based clinical recommendations and has been informed by a formal systematic review and meta-analysis. Its generation has followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included involvement of the full range of stakeholders. In general, broad evidence for the clinical efficacy of AIT for AR exists but a product-specific evaluation of evidence is recommended. In general, SCIT and SLIT are recommended for both seasonal and perennial AR for its short-term benefit. The strongest evidence for long-term benefit is documented for grass AIT (especially for the grass tablets) where long-term benefit is seen. To achieve long-term efficacy, it is recommended that a minimum of 3years of therapy is used. Many gaps in the evidence base exist, particularly around long-term benefit and use in children.

Acute Asthma in the Pediatric Emergency Department: Infections Are the Main Triggers of Exacerbations

Background Asthma exacerbations are a common reason for Emergency Department (ED) visits in children. Aim To analyze differences among age groups in terms of triggering factors and seasonality and to identify those with higher risk of severe exacerbations. Methods We retrospectively revised the files of children admitted for acute asthma in 2016 in our Pediatric ED. Results Visits for acute asthma were 603/23197 (2.6%). 76% of the patients were <6 years old and 24% ≥6. Infections were the main trigger of exacerbations in both groups; 33% of the school-aged children had a triggering allergic condition (versus 3% in <6 years; p < .01). 191 patients had a previous history of asthma; among them, 95 were ≥6 years, 67% of whom were not using any controller medication, showing a higher risk of a moderate-to-severe exacerbation than those under long-term therapy (p < .01). Exacerbations peaked in autumn and winter in preschoolers and in spring and early autumn in the school-aged children. Conclusions Infections are the main trigger of acute asthma in children of any age, followed by allergy in the school-aged children. Efforts for an improved management of patients affected by chronic asthma might go through individualized action plans and possibly vaccinations and allergen-avoidance measures.

Specific oral tolerance induction in childhood.

Food allergy continues to be a significant public health concern for which there are no approved treatments and management strategies primarily include allergen avoidance and pharmacological measures for accidental exposures. Food allergy is thought to result from either a failure to establish oral tolerance or the breakdown of existing oral tolerance, and therefore, experimental preventative and treatment strategies are now aimed at inducing specific oral tolerance. This may occur in infancy prior to the development of food allergy through the optimal timing of dietary exposure (primary oral tolerance induction) or as a treatment for established food allergy through oral immunotherapy (secondary oral tolerance induction). Trials examining the effectiveness of early dietary allergen exposure to prevent food allergy have yielded promising results for peanut allergy but not so for other allergens, although the results of several trials are yet to be published. Although infant feeding guidelines no longer advise to avoid allergenic foods and exposure to food allergens orally is an important step in inducing food tolerance by the immune system, evidence regarding the optimal timing, dose and form of these foods into the infant's diet is lacking. Likewise, oral immunotherapy trials appear promising for inducing desensitization; however, the long-term efficacy in achieving sustained desensitization and optimal protocols to achieve this is unknown. More research is needed in this emerging field.

Incidence of allergic contact sensitization in central Chinese subjects with chronic urticaria.

BACKGROUNDChronic urticaria (CU) can be provoked by a wide variety of causes. Some studies suggest contact sensitization may play a role in the disease.OBJECTIVETo investigate the incidence and distribution characteristics of allergic contact sensitization in central Chinese subjects with CU, and assess contact allergen avoidance measures in managing CU.METHODSPatch tests were performed, following the recommended standard procedure, with 20 selected allergens, in line with the European baseline series. All subjects with positive results were prescribed appropriate avoidance measures for the sensitizing substances, while subjects with negative results served as the control group. CU severity was assessed daily from week1 to week4 and for each subject, applying the Urticaria Activity Score.RESULTS42.9% (233/543) of subjects with CU showed positive reactions to one or more contact allergen(s). Potassium dichromate, benzene mix and carba mix were more common in male patients, while nickel sulfate was more frequent in females. The positive rates for different allergens varied with age and occupation. The median (interquartile range) severity scores at week 1 were 20 (14-21) and 15 (14-27) for the allergen avoidance group and control group, respectively (P>0.05); and 12 (7-15) and 14 (12-17) at week 4 (P<0.001).CONCLUSIONThe incidence of allergic contact sensitization in CU patients was high, and appropriate contact allergen avoidance measures benefitted CU management. Contact allergens may play a role in the pathogenic mechanism of CU and patch tests are an option for CU patients.

Individualized Household Allergen Intervention Lowers Allergen Level But Not Asthma Medication Use: A Randomized Controlled Trial

Environmental exposures to indoor allergens are major contributors to asthma symptoms, particularly in inner cities. The effectiveness of household allergen reduction as an adjunct to National Asthma Education Prevention Program guideline-based pharmacologic therapy in asthma has not been prospectively studied. To study the effect of individualized allergen reduction on ability to reduce asthma pharmacologic therapy over 40 weeks. We performed a randomized controlled trial to determine the effect of multifaceted indoor allergen avoidance measures on the ability to reduce asthma controller therapy in adults and children residing in New York City who were both sensitized and exposed to at least 1 indoor allergen. Asthma treatment and control were optimized in all subjects before randomization. A total of 125 subjects were randomized to receive individualized household allergen reduction and 122 received a sham intervention. Subjects in the intervention group significantly reduced all measured allergen levels (cat, dog, dust mite allergens in the bedroom, cockroach and mouse allergens in the kitchen and bedroom); those in the control group reduced only dust mite and mouse allergens in the bedroom and cockroach allergen in the kitchen. Participants in the intervention arm reduced National Asthma Education Prevention Program-based therapy from step 4.4 at randomization to 3.50 postintervention (range, 0-6); participants in the control arm reduced medication from step 4.4 to 3.4 (P= .76). There were no differences in other measured asthma outcomes. Targeted allergen avoidance measures do not allow for reduction in asthma pharmacologic therapy compared with usual care in patients already receiving optimal controller therapy.

Knowledge of Their Own Allergic Sensitizations in Asthmatic Patients and Its Impact on the Level of Asthma Control

BackgroundAsthma guidelines recommend the adoption of allergen avoidance measures (AAM). To do so, patients need to know their own allergies. However, this degree of knowledge has not yet been assessed. The aims of this study were to determine, in allergic asthma patients: (i) the degree of knowledge of their own allergic sensitizations; (ii) the percentage of those who knew all their allergies and, in addition, adopted AAM against all of them, and (iii) the possible impact of this degree of knowledge on the level of asthma control. Patients and methodsDescriptive, prospective and multicentre study, including 147 patients from 9 Respiratory Medicine outpatient clinics. After confirming the previous allergic asthma diagnosis, a questionnaire was completed. It included asthma control and severity levels, results of previous allergy tests, and the description and number of allergic sensitizations known by the patients and AAM followed. ResultsOnly 72 (49%) patients knew all their allergic sensitizations and only 48 (33%) were also following AAM against all the allergens to which they were allergic. No relationship was established between the degree of knowledge of their own allergies and the level of asthma control (P=.544). ConclusionsOverall knowledge about the allergic nature of their disease among asthmatic patients attending Spanish Respiratory Medicine Departments is inadequate. Furthermore, a higher degree of knowledge of their allergies does not seem to lead, by itself, to better asthma control. Both findings seem to question the effectiveness of current educational strategies in this field and consequently, and they should be revised.

Grado de conocimiento de las propias sensibilizaciones alérgicas en pacientes asmáticos y su repercusión en el nivel de control del asma

BackgroundAsthma guidelines recommend the adoption of allergen avoidance measures (AAM). To do so, patients need to know their own allergies. However, this degree of knowledge has not yet been assessed. The aims of this study were to determine, in allergic asthma patients: i)the degree of knowledge of their own allergic sensitizations; ii)the percentage of those who knew all their allergies and, in addition, adopted AAM against all of them, and iii)the possible impact of this degree of knowledge on the level of asthma control. Patients and methodsDescriptive, prospective and multicentre study, including 147patients from 9 Respiratory Medicine outpatient clinics. After confirming the previous allergic asthma diagnosis, a questionnaire was completed. It included asthma control and severity levels, results of previous allergy tests, and the description and number of allergic sensitizations known by the patients and AAM followed. ResultsOnly 72 (49%) patients knew all their allergic sensitizations and only 48 (33%) were also following AAM against all the allergens to which they were allergic. No relationship was established between the degree of knowledge of their own allergies and the level of asthma control (P=.544). ConclusionsOverall knowledge about the allergic nature of their disease among asthmatic patients attending Spanish Respiratory Medicine Departments is inadequate. Furthermore, a higher degree of knowledge of their allergies does not seem to lead, by itself, to better asthma control. Both findings seem to question the effectiveness of current educational strategies in this field and consequently, they should be revised.

Allergic Rhinitis: Changing Perspectives on Pathophysiology and Management

Allergic rhinitis has shown a dramatic increase in prevalence over the last two decades. Seasonal allergic rhinitis and perennial allergic rhinitis present as two clinically distinct entities. The pathophysiology of the nasal allergic reaction can be divided into the intermediate histaminic reaction and the late phase eosinophilic reaction. Nasal hypersensitivity blowing adjuvant and allergen priming may account for the ill-defined entity of chronic rhinitis. Management of allergic rhinitis should attempt to include allergen avoidance measures, as well as pharmacotherapeutic, immunotherapeutic and local nasal surgical considerations when indicated.

Chapter 5: Allergic rhinitis

Rhinitis is a symptomatic inflammatory disorder of the nose with different causes such as allergic, nonallergic, infectious, hormonal, drug induced, and occupational and from conditions such as sarcoidosis and necrotizing antineutrophil cytoplasmic antibodies positive (Wegener's) granulomatosis. Allergic rhinitis affects up to 40% of the population and results in nasal (ocular, soft palate, and inner ear) itching, congestion, sneezing, and clear rhinorrhea. Allergic rhinitis causes extranasal untoward effects including decreased quality of life, decreased sleep quality, obstructive sleep apnea, absenteeism from work and school, and impaired performance at work and school termed "presenteeism." The nasal mucosa is extremely vascular and changes in blood supply can lead to obstruction. Parasympathetic stimulation promotes an increase in nasal cavity resistance and nasal gland secretion. Sympathetic stimulation leads to vasoconstriction and consequent decrease in nasal cavity resistance. The nasal mucosa also contains noradrenergic noncholinergic system, but the contribution to clinical symptoms of neuropeptides such as substance P remains unclear. Management of allergic rhinitis combines allergen avoidance measures with pharmacotherapy, allergen immunotherapy, and education. Medications used for the treatment of allergic rhinitis can be administered intranasally or orally and include oral and intranasal H(1)-receptor antagonists (antihistamines), intranasal and systemic corticosteroids, intranasal anticholinergic agents, and leukotriene receptor antagonists. For intermittent mild allergic rhinitis, an oral or intranasal antihistamine is recommended. In individuals with persistent moderate/severe allergic rhinitis, an intranasal corticosteroid is preferred. When used in combination, an intranasal H(1)-receptor antagonist and a nasal steroid provide greater symptomatic relief than monotherapy. Allergen immunotherapy is the only disease-modifying intervention available.