Mechanisms and patient compliance of dust-mite avoidance regimens in dwellings of mite-allergic rhinitic patients

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Identification of allergens by IgE-specific testing improves outcomes in atopic dermatitis

INTRODUCTION

IgE quantitative assaying of allergens (IgEQAA) has long been implemented by allergists in determining patients' reactivities for allergic rhinitis and asthma, two of the three diagnoses in atopic syndrome. This test operates by measuring the patient's IgE response to different allergens and can identify potential triggers for a patient's symptoms. Despite this, IgEQAA has yet to see the same widespread use in the field of dermatology, specifically in the treatment of patients with atopic dermatitis (AD).

MATERIALS AND METHODS

The affected body surface area (BSA) at first presentation, IgEQAA classes, and total immunoglobulin E (IgE) concentration were taken retrospectively for 54 patients with AD.

RESULTS

Of the 54 patients observed, 41 had an abnormally high total IgE concentration (76%). Additionally, it was observed that nine (17%) of our patients significantly improved after making lifestyle changes.

CONCLUSION

Knowledge of the identified specific antigens can guide patients to make lifestyle modifications that may improve disease outcomes. IgEQAA and avoidance of allergens may help some patients with AD.

Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis

The term compliance simply indicates how much doses of the prescribed medication are taken, whereas the term adherence implies also an agreement between patient and physician about the therapeutic plan, and it is therefore preferred. Adherence is a main problem in all long-term treatments. Thus, it represents a problem also in the case of rhinitis, expecially concerning specific immunotherapy that must be assumed continuously for several years. Many factors can affect the adherence, depending on patient, on treatment itself and on the healthcare context, and all those factors usually interact. The adherence measured in controlled trials is usually good, but this does not reflect what happens in real life, where adherence should be preferably measured. There are few data on the adherence in real life for pharmacological treatments of allergic rhinitis (e.g. nasal steroids or antihistamines), whereas more data are available for specific immunotherapy. In this latter case, in real life, adherence seems to be far from optimal, for both sublingual and subcutaneous immunotherapy, although the recent studies agree on the fact that some interventions (i.e. patients' education, strict follow-up, regular contacts) could effectively improve the adherence. In this article, the literature concerning the adherence to pharmacological treatments and immunotherapy in allergic rhinitis was searched and reviewed.

House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review

BACKGROUND

To assess the benefits and harms of measures designed to reduce house dust mite (HDM) exposure in the management of house dust mite-sensitive allergic rhinitis.

METHODS

Systematic review of randomized controlled trials was made, in which HDM control measures have been evaluated in comparison with placebo or other HDM avoidance measures, in patients with clinically proven allergic rhinitis.

RESULTS

Nine trials involving 501 participants satisfied the inclusion criteria. These trials have investigated the effectiveness of bedroom environmental control programmes involving the use of HDM impermeable bedding covers (n = 4), acaricides (n = 2), high-efficiency particulate air filters (n = 2) and, using a factorial design, acaricide and HDM impermeable bedding covers in isolation and combination (n = 1). Seven of the nine trials reported that, when compared with control, the interventions studied resulted in significant reductions in HDM load. Of the interventions studied to date, acaricides appear to be the most promising, although the findings from these studies need to be interpreted with care because of their methodological limitations. House dust mite impermeable bedding as an isolated intervention is unlikely to offer benefit.

CONCLUSIONS

Trials have tended to be small and of poor methodological quality, making it difficult to offer any definitive recommendations. Interventions that achieve substantial reductions in HDM load may offer some benefit in reducing rhinitis symptoms. Isolated use of HDM impermeable bedding is unlikely to prove effective.

House dust mite avoidance measures for perennial allergic rhinitis

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2001 and previously updated in 2003 and 2007.It is estimated that in developed countries approximately 30% of the general population suffer from one or more allergic disorders, of which allergic rhinitis is particularly common. Perennial rhinitis is most often due to allergy to the house dust mite. In such patients house dust mite avoidance is logical, but there is considerable uncertainty regarding the efficacy and effectiveness of interventions designed to reduce dust mite exposure.

OBJECTIVES

To assess the benefit (and harm) of measures designed to reduce house dust mite exposure in the management of house dust mite sensitive allergic rhinitis.

SEARCH STRATEGY

Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials Register (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE and EMBASE. The date of the last search was 31 December 2009.

SELECTION CRITERIA

Randomised controlled trials, with or without blinding, in which house dust mite control measures have been evaluated in comparison with placebo or other dust mite avoidance measures, in patients with clinician-diagnosed allergic rhinitis and confirmed allergy to dust mite.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, graded methodological quality using the Cochrane approach and extracted data. Meta-analysis was neither possible nor appropriate due to heterogeneity of the patient groups studied.

MAIN RESULTS

Nine trials involving 501 participants satisfied the inclusion criteria. Only two studies investigating the effectiveness of mite impermeable bedding covers were of good quality; the remaining seven studies were small and of poor quality. Two trials investigated the efficacy of acaricides, another two trials investigated the role of high-efficiency particulate air (HEPA) filters. One trial, using a factorial design, investigated the efficacy of both acaricide and house dust mite impermeable bedding covers in isolation and combination; the remaining four trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers. Seven of the nine trials reported that, when compared with control, the interventions studied resulted in significant reductions in house dust mite load. Of the interventions studied to date, acaricides appear to be the most promising type of intervention, although the findings from these studies need to be interpreted with care because of their methodological limitations. House dust mite impermeable bedding as an isolated intervention is unlikely to offer clinical benefit. No serious adverse effects were reported from any of the interventions.

AUTHORS' CONCLUSIONS

Trials to date have on the whole been small and of poor methodological quality, making it difficult to offer any definitive recommendations on the role, if any, of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis. The results of these studies suggest that use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms and, if considered appropriate, these should be the interventions of choice. Isolated use of house dust mite impermeable bedding is unlikely to prove effective.

House dust mite avoidance measures for perennial allergic rhinitis

BACKGROUND

In developed countries, it is estimated that approximately 30% of the general population suffer from one or more allergic disorders, of which allergic rhinitis is the most common. Perennial rhinitis is most often due to allergy to the house dust mite. In such patients, house dust mite avoidance is logical, but there is considerable uncertainty regarding the efficacy and effectiveness of interventions designed to reduce dust mite exposure.

OBJECTIVES

To assess the benefit (and harm) of measures designed to reduce house dust mite exposure in the management of house dust mite sensitive allergic rhinitis.

SEARCH STRATEGY

Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials Register (CENTRAL) (The Cochrane Library, Issue 2, 2005), MEDLINE (1951 to 2005) and EMBASE (1974 to 2005). No restrictions on the language of publication were employed. The bibliography of each paper and other published reviews were checked for further references. The date of the last search was May 2005.

SELECTION CRITERIA

Randomised controlled trials (with or without blinding), in which house dust mite control measures have been evaluated in comparison with placebo or other dust mite avoidance measures, in patients with clinician diagnosed allergic rhinitis and confirmed allergy to dust mite.

DATA COLLECTION AND ANALYSIS

Two authors independently checked titles and abstracts identified by the searches and full text copies of all papers of potential relevance were considered. Trials were graded for methodological quality using the Cochrane approach. Data extraction was performed in a standardised manner. Meta-analysis was neither possible nor appropriate, because of the heterogeneity of the patient groups studied; a narrative overview of the results is therefore presented.

MAIN RESULTS

Seven trials satisfied the inclusion criteria. Of these, only two studies investigating the effectiveness of mite impermeable bedding covers were of good quality; the remaining five studies were small and of poor quality. Two trials investigated the efficacy of acaricides, another two trials investigated the role of high-efficiency particulate air filters; the remaining three trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers. Six of the seven trials showed that the interventions result in significant reductions in house dust mite load when compared with control. Of the house dust mite interventions studied to date, acaricides appear to be the most promising type of intervention, although the findings from the two studies which employed these interventions need to be interpreted with care because of their methodological limitations. Use of house dust mite impermeable bedding as an isolated intervention is unlikely to offer clinical benefit. No serious adverse effects were reported from any of the interventions.

AUTHORS' CONCLUSIONS

Trials to date have on the whole been small and of poor methodological quality, making it difficult to offer any definitive recommendations on the role, if any, of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis. The results of these studies suggest that use of acaricides and extensive bedroom based environmental control programmes may be of some benefit in reducing rhinitis symptoms and, if considered appropriate, these should be the interventions of choice. Isolated use of house dust mite impermeable bedding is unlikely to prove effective.

House dust mite avoidance measures for perennial allergic rhinitis

BACKGROUND

In developed countries, it is estimated that 15% of the general population suffer from one or more allergic disorders, of which allergic rhinitis is the most common. Perennial rhinitis is most often due to allergy to the house dust mite. In such patients, house dust mite avoidance is logical, but there is considerable uncertainty regarding the efficacy and effectiveness of interventions designed to reduce dust mite exposure.

OBJECTIVES

To assess the benefit (and harm) of measures designed to reduce house dust mite exposure in the management of house dust mite sensitive allergic rhinitis.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, Central, MEDLINE and EMBASE. No restrictions on the language of publication were employed. The bibliography of each paper and other published reviews were checked for further references. We wrote to first authors of all included trials in an attempt to identify further published and unpublished trials.

SELECTION CRITERIA

Randomised controlled trial (with or without blinding), in which house dust mite control measures have been evaluated in comparison with placebo or other dust mite avoidance measures, in patients with clinician diagnosed allergic rhinitis and confirmed allergy to dust mite.

DATA COLLECTION AND ANALYSIS

Two reviewers independently checked titles and abstracts identified by the searches and full text copies of all papers of potential relevance were considered. Trials were graded for methodological quality using the Cochrane approach. Data extraction was performed in a standardised manner. Meta-analysis was neither possible, nor considered appropriate, because of the heterogeneity of the patient groups studied; a narrative overview of the results is therefore presented.

MAIN RESULTS

Four trials satisfied the inclusion criteria, all of which were small and of poor quality. Two trials investigated the efficacy of acaricides, a third investigated the role of high-efficiency particulate air (HEPA) filters, whilst a fourth investigated the efficacy of a bedroom environmental control program that comprised use of a barrier mattress cover, fortnightly washing of bed covers, removal of soft furnishings and daily cleaning. Each of the four trials showed the interventions to result in significant reductions in house dust mite load when compared with control. Trial results suggest that the interventions may be effective in reducing some rhinitis symptoms, though it is not possible to provide a reliable summary estimate about the magnitude of such symptom reduction. No serious adverse effects were reported from the interventions.

REVIEWER'S CONCLUSIONS

Trials to date have been small and of poor methodological quality making it difficult to offer any definitive recommendations on the role, if any, of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis. The results of these studies suggest that interventions designed to reduce house dust mite exposure in patients with house dust mite allergic perennial rhinitis may be of some benefit in reducing rhinitis symptoms. Data at present is only available for acaricides, HEPA filters and a bedroom-based environmental control program; therefore, if considered appropriate, these should be the interventions of choice.

Does benzyl benzoate prevent colonization of new mattresses by mites? A prospective study

In 12 house-dust-mite-infested double beds, one of the mattresses was replaced by a new one, the other being regarded as a mite source. All new mattresses were treated in a double-blind fashion, with either benzyl benzoate or placebo before being placed on the bed as well as 1 year later. They were examined for mites and allergen concentrations over a period of 18 months. This period of time covered two mite seasons. Dust samples were taken bimonthly and analyzed by guanine test strip, microscopic mite counting, and determination of the mite allergens Der p 1 (Dermatophagoides pteronyssinus) and Der f 1 (D. farinae) by ELISA. Although, at the end of the observation period, the new mattresses still had significantly lower mite and allergen levels than the old mattresses, there were no significant differences between the placebo and the benzyl benzoate groups. In our setting, benzyl benzoate plus frequent cleansing was not significantly more effective in controlling mites than frequent cleansing alone.

Treatment of allergic rhinitis

An increased understanding of the pathophysiology of allergic rhinitis can provide a logical basis for improved therapeutic strategies tailored individually to each patient. The first recommendation is the avoidance of possible or verified allergens. If this does not provide significant relief or is impractical, then immunotherapy plays a preventative role in some patients and it has been shown to be effective in certain cases. Initially, most patients try new nonsedating antihistamines, sometimes combined with a short course of topical vasoconstrictors. When nasal obstruction is a problem, a steroid spray is preferred. It is often necessary to add topical treatment for eye symptoms, e.g. antihistamine or cromoglycate eyedrops. In severe cases simultaneous administration of nasal corticosteroids and nonsedating antihistamines may achieve optimal control of symptoms. Cromolyn derivates are also effective in mild or moderate rhinoconjunctivitis and are especially recommended in the treatment of children. Systemic corticosteroid therapy should be reserved for the rare patient with extreme symptoms, and limited to short courses. Recent studies have shown that if patients are provided with appropriate medication, education and instruction, symptoms of allergic rhinitis can be well controlled with minimum impairment of quality of life.

Benzyl-benzoate foam: effects on mite allergens in mattress, serum and nasal secretory IgE to Dermatophagoides pteronyssinus, and bronchial hyperreactivity in children with allergic asthma

Home mattresses of 24 asthmatic children with house dust mite allergy were sprayed with either benzyl-benzoate foam or placebo in a double blind fashion, 10 days before the children left the residential house for asthmatic children Istituto Pio XII (located in the Italian Alps in an environment free of mites) and went back to their own home for the Christmas and Easter holidays. A further group of 8 children, whose mattresses received no treatment, was kept as an absolute control. Two days after spraying, benzyl-benzoate or placebo were vacuumed from the mattresses. Acarex test was performed immediately before spraying and at the end of each holiday period of 20 and 10 days, respectively. Bronchial hyperreactivity as well as serum and nasal secretory specific IgE for Dermatophagoides pteronyssinus were assessed in all children immediately before leaving and within 48 hr after returning to the residential house. The results of the study show that sprayed benzyl-benzoate foam was no more effective than placebo in reducing the level of house dust mite recovered from patients' mattresses, or in reducing bronchial hyperreactivity and IgE concentration in serum and nasal secretions.

Clinical improvement after unusual avoidance measures in the home of an atopic dermatitis patient

A 27-year-old female office clerk with widespread atopic dermatitis (AD) since infancy appeared to be highly sensitized and exposed to molds, storage mites, and chicken feathers and moderately sensitized to house-dust mites and grass and birch pollens. Hardly any textiles were present in her home; that is, only 28 m2, which is less than 25% of the Dutch national average. The causal relationship between eczema and molds plus storage mites in this case of AD was strengthened by the positive effect of an unusual, multidisciplinary home-sanitation program involving cleaning of mineral surfaces and ventilation improvement. This home-sanitation program led to a gradual drop of total IgE and clinical symptom scores to 21% and 13%, respectively, of the original values.