How to Diagnose and Treat Local Allergic Rhinitis: A Challenge for Clinicians

Chronic rhinitis is a very common disease that can be divided in various phenotypes. Historically, the condition has been classified into the allergic rhinitis (AR) and non-allergic non-infectious rhinitis (NAR) forms, based on the results of the classical biomarkers of atopy: skin prick test and serum allergen-specific IgE However, this classification does not reflect the complexity of the rhinitis syndrome, as illustrated by the existence of non-atopic rhinitis patients who display a nasal reactivity to environmental allergens. This new phenotype has been termed local allergic rhinitis (LAR) and can be only recognized if an additional test such as the nasal allergen challenge (NAC) is integrated in the diagnostic algorithm for chronic rhinitis. Recent data shows that the NAC is a very safe and reliable technique ready for the clinical practice. LAR is a differentiated rhinitis phenotype which often commences during childhood and quickly progresses towards a clinical worsening and the association of comorbidities in other mucosal organs. Recent evidence supports the existence of a bronchial counterpart of LAR (local allergic asthma), which highlights the pathophysiological links between the upper and lower airways and reinforces the united airways concept. Importantly, several controlled studies have demonstrated the ability of allergen immunotherapy to control LAR symptoms while the therapy is being administered. This review emphasizes the need to implement the NAC in the clinical practice in order to facilitate the recognition of LAR patients, allowing for an early prescription of specific therapies with disease-modifying potential.

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Diagnostic Tools in Allergic Rhinitis

Frontiers in Allergy ◽

10.3389/falgy.2021.721851 ◽

2021 ◽

Vol 2 ◽

Author(s):

Almudena Testera-Montes ◽

Raquel Jurado ◽

Maria Salas ◽

Ibon Eguiluz-Gracia ◽

Cristobalina Mayorga

Keyword(s):

Allergic Rhinitis ◽

Allergen Challenge ◽

Indirect Costs ◽

Basophil Activation Test ◽

Diagnostic Tools ◽

Management Approach ◽

Prick Test ◽

Chronic Rhinitis ◽

Local Allergic Rhinitis

Allergic mechanisms account for most cases of chronic rhinitis. This condition is associated with significant impairment of quality of life and high indirect costs. The identification of the allergic triggers of rhinitis has been historically based on the performance of atopy test [skin prick test (SPT) and serum allergen-specific (s)IgE]. Nevertheless, these tests only denote sensitization, and atopy and allergy represent two different phenomena. It is now clear that allergic phenotypes of rhinitis can exist in both atopic (allergic rhinitis, AR) and non-atopic (local allergic rhinitis, LAR) individuals. Moreover, both allergic phenotypes can coexist in the same rhinitis patient (dual allergic rhinitis, DAR). Therefore, a diagnostic approach merely based on atopy tests is associated with a significant rate of misdiagnosis. The confirmation of the allergic etiology of rhinitis requires the performance of in vivo test like the nasal allergen challenge (NAC). NAC is mandatory for the diagnosis of LAR and DAR, and helps decide the best management approach in difficult cases of AR. Nevertheless, NAC is a laborious technique requiring human and technical resources. The basophil activation test (BAT) is a patient-friendly technique that has shown promising results for LAR and DAR diagnosis. In this review, the diagnostic usefulness for chronic rhinitis of SPT, NAC, olfactory tests, serum sIgE, BAT and the quantification of inflammatory mediators in nasal samples will be discussed. The accurate performance of an etiologic diagnosis of rhinitis patients will favor the prescription of specific therapies with disease-modifying potential like allergen immunotherapy.

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Diagnosis and Treatment of Local Allergic Rhinitis

Pathogens ◽

10.3390/pathogens11010080 ◽

2022 ◽

Vol 11 (1) ◽

pp. 80

Author(s):

Tetsuya Terada ◽

Ryo Kawata

Keyword(s):

Allergic Rhinitis ◽

Current Knowledge ◽

Provocation Test ◽

Basophil Activation Test ◽

Specific Ige ◽

Nasal Discharge ◽

Initial State ◽

Positive Type ◽

Chronic Rhinitis ◽

Local Allergic Rhinitis

Some patients with chronic rhinitis have a positive nasal allergen provocation test (NAPT) without systemic IgE sensitization by skin prick tests or serum allergen-specific IgE (sIgE). This novel concept is called local allergic rhinitis (LAR) and affects children and adults worldwide, but is underdiagnosed. LAR is not just the initial state of allergic rhinitis (AR), it is a unique form of chronic rhinitis that is neither classical AR nor non-AR. Many of the features of AR and LAR are similar, such as a positive NAPT, positive type 2 inflammatory markers, including the nasal discharge of sIgE, and a high incidence of asthma. A differential diagnosis of LAR needs to be considered in patients with symptoms suggestive of AR in the absence of systemic atopy, regardless of age. The diagnostic method for LAR relies on positive responses to single or multiple allergens in NAPT, the sensitivity, specificity, and reproducibility of which are high. The basophil activation test and measurement of IgE in nasal secretions also contribute to the diagnosis of LAR. Treatment for LAR is similar to that for AR and is supported by the efficacy and safety of allergen exposure avoidance, drug therapy, and allergen immunotherapy. This review discusses current knowledge on LAR.

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Prevalence of local allergic rhinitis to Dermatophagoides pteronyssinus in chronic rhinitis with negative skin prick test

Asian Pacific Journal of Allergy and Immunology ◽

10.12932/ap-170918-0408 ◽

2019 ◽

Cited By ~ 1

Keyword(s):

Allergic Rhinitis ◽

Skin Prick Test ◽

Dermatophagoides Pteronyssinus ◽

Prick Test ◽

Chronic Rhinitis ◽

Local Allergic Rhinitis ◽

Negative Skin Prick Test

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Recent advances in allergic rhinitis

F1000Research ◽

10.12688/f1000research.15367.1 ◽

2018 ◽

Vol 7 ◽

pp. 1333 ◽

Cited By ~ 16

Author(s):

Flavia C. L. Hoyte ◽

Harold S. Nelson

Keyword(s):

Allergic Rhinitis ◽

Work Productivity ◽

Allergen Challenge ◽

Economic Cost ◽

Symptomatic Treatment ◽

The United States ◽

Specific Ige ◽

Subcutaneous Immunotherapy ◽

Nasal Allergy

Allergic rhinitis affects 20 to 30% of adults in both the United States and Europe and perhaps a somewhat higher percentage of children. In addition to nasal and ocular symptoms directly related to the allergic process, interference of these symptoms with sleep leads to daytime sleepiness and impaired quality of life. Patients miss work because of symptoms but an even greater problem is interference with work productivity, or presenteeism, which has been reported to be the biggest contributor to the total economic cost of allergic rhinitis. There has been increasing awareness that many patients with either seasonal or perennial symptoms but negative skin and in vitro tests for allergen sensitivity have local nasal allergy, diagnosable by the presence of allergen-specific IgE in their nasal secretions or a positive nasal allergen challenge or both. The pharmaceutical management of allergic rhinitis rests on symptomatic treatment with antihistamines that perhaps are more effectively administered intranasally than orally and intranasal corticosteroids. Allergen immunotherapy is very effective, even for local allergic rhinitis, and the shortcomings of subcutaneous immunotherapy of inconvenience and safety are reduced by the introduction of sublingual immunotherapy (SLIT). Use of the latter is currently somewhat limited by the lack of appropriate dosing information for SLIT liquids and the limited number of allergens for which SLIT tablets are available.

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A Novel Method of Measuring Nasal Specific IgE in Systemic and Local Allergic Rhinitis Patients

Journal of Allergy and Clinical Immunology ◽

10.1016/j.jaci.2015.12.1177 ◽

2016 ◽

Vol 137 (2) ◽

pp. AB284 ◽

Cited By ~ 1

Author(s):

Paloma Campo ◽

Carmen Rondon ◽

Ana Prieto del Prado ◽

Maria Salas ◽

Luisa Galindo ◽

...

Keyword(s):

Allergic Rhinitis ◽

Specific Ige ◽

Local Allergic Rhinitis ◽

Novel Method

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Evolution of skin prick test and specific IgE values of venom immunotherapy in daily clinical practice

Journal of Allergy and Clinical Immunology ◽

10.1016/j.jaci.2019.12.850 ◽

2020 ◽

Vol 145 (2) ◽

pp. AB7

Author(s):

Cristiana Solorzano Zepeda ◽

Isabel Perez Allegue ◽

Alicia Barra Castro ◽

Jonnathan Acevedo Galvis ◽

Dario Antolin-Amerigo ◽

...

Keyword(s):

Clinical Practice ◽

Skin Prick Test ◽

Specific Ige ◽

Daily Clinical Practice ◽

Venom Immunotherapy ◽

Prick Test

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Hyeonggaeyeongyo-Tang for Treatment of Allergic and Nonallergic Rhinitis: A Prospective, Nonrandomized, Pre-Post Study

Evidence-based Complementary and Alternative Medicine ◽

10.1155/2016/9202675 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Min-Hee Kim ◽

Jaewoong Son ◽

Hae Jeong Nam ◽

Seong-Gyu Ko ◽

Inhwa Choi

Keyword(s):

Quality Of Life ◽

Allergic Rhinitis ◽

Life Questionnaire ◽

Nonallergic Rhinitis ◽

Prick Test ◽

Chronic Rhinitis ◽

Nasal Symptoms ◽

Significant Difference

Hyeonggaeyeongyo-tang (HYT) is an ancient formula of oriental medicine traditionally used to treat rhinitis; however, clinical evidence has not yet been established. The aim of this study was to investigate the short-term and long-term efficacy and safety of HYT for chronic rhinitis. Adult subjects with chronic rhinitis symptoms were recruited. The subjects received HYT for 4 weeks and had follow-up period of 8 weeks. Any medicines used to treat nasal symptoms were not permitted during the study. The skin prick test was performed to distinguish the subjects with allergic rhinitis from those with nonallergic rhinitis. After treatment, the total nasal symptoms score and the Rhinoconjunctivitis Quality of Life Questionnaire score significantly improved in the whole subject group, in the allergic rhinitis group, and in the nonallergic rhinitis group, with no adverse events. This improvement lasted during a follow-up period of 8 weeks. Total IgE and eosinophil levels showed no significant difference after treatment in the allergic rhinitis group. HYT improved nasal symptoms and quality of life in patients with allergic rhinitis and nonallergic rhinitis. This is the first clinical study to evaluate the use of HYT to treat patients with rhinitis. This trial has been registered with the ClinicalTrials.gov IdentifierNCT02477293.

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Local allergic rhinitis

Medicinski pregled ◽

10.2298/mpns14s1049b ◽

2014 ◽

Vol 67 (suppl. 1) ◽

pp. 49-56

Author(s):

Maja Buljcik-Cupic ◽

Dragana Lemez ◽

Slobodan Savovic ◽

Ljiljana Jovancevic ◽

Danijela Dragicevic

Keyword(s):

Allergic Rhinitis ◽

Nasal Mucosa ◽

Immunoglobulin E ◽

Provocation Test ◽

Allergic Response ◽

Prick Test ◽

Local Allergic Rhinitis ◽

Provocation Tests ◽

Number Of Patients ◽

The Impact

Local allergic rhinitis is a localized allergic response of the nasal mucosa to aeroallergens in the absence of atopy with characteristic production of specific local immunoglobulin E antibodies in the nasal mucosa, T helper type 2 cellular infiltration response during the exposure to aeroallergens and positive results via the nasal allergic provocation test with the release of inflammatory mediators (triptase and eosinophil cationic proteins). Even though the prevalence of local allergic rhinitis has been and is still being investigated, a large number of patients with diagnosed non-allergic rhinitis or idiopathic rhinitis are currently classified as having local allergic rhinitis. The causes of local allergic rhinitis are most commonly house dust, dust mites, pollens and many others. Diagnosis of local allergic rhinitis is made using nasal allergen provocation tests when the prick test for standard inhalation allergens and the serum specific immunoglobulin analysis for aeroallergens are negative. The increasing amount of data on localized allergic response in non-atopic patients asks for many answers regarding local allergic rhinitis. These answers can be obtained by a study on the prevalence and incidence in children and adults, the impact of positive family atopy in the development of disease, the impact of associated diseases of the lower respiratory tract and conjunctiva, the effectiveness of drug treatment and the issue of administration of specific immunotherapy.

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Different Development Forms of Local Allergic Rhinitis towards Birch

BioMed Research International ◽

10.1155/2020/3408561 ◽

2020 ◽

Vol 2020 ◽

pp. 1-9 ◽

Cited By ~ 2

Author(s):

Andrzej Bozek ◽

Janne Winterstein ◽

Beata Galuszka ◽

Jerzy Jarzab

Keyword(s):

Allergic Rhinitis ◽

Outcome Measurement ◽

Birch Pollen ◽

Specific Ige ◽

Active Group ◽

Placebo Control ◽

Double Blind ◽

Local Allergic Rhinitis ◽

The Mean ◽

The Impact

Background. Efficacy of allergen immunotherapy (AIT) in local allergic rhinitis (LAR) is a new subject of research. The presence of asthmatic symptoms in patients with LAR in the context of AIT is unexplored. Objective. The efficacy and safety of AIT in patients with LAR towards birch pollen were investigated. The possibility of concomitant local allergic asthma in studied patients and the impact of AIT on it were examined. Methods. 36 patients with LAR towards birch were included in three years of AIT in a double-blind, placebo-control study. Primary outcome measurement was the mean changes in the combined symptom and medication scores (CSMSs) after AIT, and the second is the changes in the quality of life (QoL). Skin prick tests, serum, nasal allergen-specific IgE to birch, nasal and bronchial provocation challenge tests with birch allergen, methacholine tests, and spirometry were carried out at baseline and after AIT. Results. Mean CSMSs of three years of AIT were significantly decreased in the active group from 5.88 (range: 4.11-9.01) to 1.98 (range: 1.22-4.51; p<0.05). After three years of AIT, there was a significant increase of toleration for birch allergen from the mean concentration of 6250±1200 SQ-U/ml up to 45000±2500 SQ-U/ml (p=0.02) during repeated nasal challenges. 16 patients with LAR had the positive results of methacholine tests, and 11 of them had a positive bronchial challenge to birch allergen. After AIT, the significant decrease of bronchial responsiveness to birch allergen in 5 from 7 patients was confirmed (p=0.03). QoL assessed by the use of the RQLQ score was improved after AIT from 1.84 (95% CI: 1.53-1.97) to 1.45 (95% CI: 1.32-1.62) score in the active group after three years of AIT therapy (p=0.03). Conclusion. AIT to birch can be useful and safe in a patient with local allergic rhinitis and also with concomitant asthmatic symptoms. Further studies are needed.

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Potential Differences between Local and Systemic Allergic Rhinitis Induced by Birch Pollen

International Archives of Allergy and Immunology ◽

10.1159/000509438 ◽

2020 ◽

Vol 181 (11) ◽

pp. 831-838

Author(s):

Andrzej Bozek ◽

Jolanta Zalejska Fiolka ◽

Anna Krajewska Wojtys ◽

Beata Galuszka ◽

Anna Cudak

Keyword(s):

Allergic Rhinitis ◽

Birch Pollen ◽

Provocation Test ◽

Basophil Activation Test ◽

Specific Ige ◽

Immunological Parameters ◽

Local Allergic Rhinitis ◽

Before And After ◽

Intermittent Allergic Rhinitis ◽

Bet V1

Introduction: Different endotypes of rhinitis are known, but its pathomechanism has not been conclusively established. For example, the precise difference between systemic allergic rhinitis (SAR) and local allergic rhinitis (LAR) is still being checked. Comparison of patients with LAR and with allergies to birch of those with intermittent allergic rhinitis, same allergy, or with non-allergic rhinitis (NAR) was the purpose of this study. Methods: Twenty-six patients with LAR, 18 with SAR and allergy to birch, and 21 with NAR were included. Patients who met the inclusion criteria were selected to undergo the following procedures at baseline: medical examinations, nasal provocation test (NPT), detection of nasal-specific IgE to birch as well as basophil activation test (BAT). All immunological parameters were detected before and after NPT. Results: Concentration of nasal IgE to Bet v1 increased comparably in the LAR and SAR groups after NPT to birch as follows: in 21 (81%) patients with LAR, 14 (78%) with SAR, and in everyone in the NAR group. Serum concentration of allergen-specific IgE to Bet v1 increased significantly from a median of 20.7 (25–75% interval: 11.2–35.6) IU/mL to 29.9 (13.6–44.1) (p = 0.028) after NPT in patients with SAR. Allergen-specific IgE to Bet v1 was absent in all patients with LAR and NAR before and after NPT. BAT with Bet v1 was positive in 22 (85%) patients with LAR, in 14 (78%) with SAR, and 2 (9.5%) with NAR. Conclusion: These obtained data suggest there are no potential mechanisms that could explain LAR compared to SAR.

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