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 Table of Contents  
CASE SERIES
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 231-235

Skin prick tests and subcutaneous immunotherapy with standardized allergens in children with moderate-to-severe allergic rhinitis


1 Department of Pediatrics, AIIMS, Kalyani, West Bengal, India
2 Department of Pulmonary Medicine, St. John's National Academy of Medical Sciences, Bengaluru, Karnataka, India
3 VN Allergy and Asthma Research Centre, Chennai, Tamil Nadu, India

Date of Submission25-Oct-2021
Date of Decision30-Oct-2021
Date of Acceptance06-Nov-2021
Date of Web Publication29-Nov-2021

Correspondence Address:
Dr. Nihar Ranjan Mishra
Department of Pediatrics, AIIMS, Kalyani, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_323_21

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  Abstract 

Background: Allergic rhinitis is common in Indian children, one of the common triggers being house dust mites. Skin prick tests (SPTs) and subcutaneous immunotherapy (SCIT) using standardized extracts of these aeroallergens are increasingly being used in the diagnosis and the management of allergic rhinitis in India. Clinical Description: We describe three children with moderate-to-severe allergic rhinitis who were considered ideal candidates for SCIT based on persistent typical clinical symptoms causing significant functional impairment, despite multiple medications for years, and positive family history. Each displayed characteristic local signs (crease over nasal bridge, pale nasal mucosa, and hypertrophy of the inferior nasal turbinates) and normal systemic examination. Management: Each of the children displayed significant sensitization with allergens containing standardized preparations of Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df) on the basis of which it was decided to start them on SCIT using the standard protocol. Large local reactions developed and were managed conservatively. All three responded well to bi-weekly shots of progressively increasing concentrations used in the induction phase of SCIT, and are currently asymptomatic on monthly maintenance doses that will continue for 2–3 years. Conclusion: Pediatricians should consider referring children with moderate-to-severe allergic rhinitis to Pediatric Allergists for SCIT if significant wheals are observed on SPT. SCIT not only stops the progression of disease, and improve the quality of life, but is also known to prevent the development of bronchial asthma.

Keywords: Aeroallergen, house dust mite, immunotherapy, skin prick tests, standardized allergen


How to cite this article:
Mishra NR, Nagaraju K, Voorakaranam K. Skin prick tests and subcutaneous immunotherapy with standardized allergens in children with moderate-to-severe allergic rhinitis. Indian Pediatr Case Rep 2021;1:231-5

How to cite this URL:
Mishra NR, Nagaraju K, Voorakaranam K. Skin prick tests and subcutaneous immunotherapy with standardized allergens in children with moderate-to-severe allergic rhinitis. Indian Pediatr Case Rep [serial online] 2021 [cited 2022 Jan 20];1:231-5. Available from: http://www.ipcares.org/text.asp?2021/1/4/231/331381

Allergic rhinitis is one of the most common allergic diseases worldwide, affecting 10%–25% of the population.[1] In India, allergic rhinitis is responsible for 55% of all allergies. Its incidence is 20%–30%, with prevalence apparently increasing over a few years.[2] The skin prick test (SPT) is the first line of investigation for evaluating immediate immunoglobulin E (IgE)-mediated allergies such as allergic rhinitis, rhinosinusitis, conjunctivitis, bronchial asthma, atopic dermatitis, and food allergies that manifest with acute hypersensitivity.[3] In STP, the allergen is administered intracutaneously and the size of the wheal measured; ≥3 mm considered significant.[3] The reliability of SPTs depends on the technique and materials of allergens,[4] the nature of which vary according to the allergy. For example, for allergic rhinitis, the extracts are made from common inhalant allergens such as house dust mite (Dermatophagoides species) and grass pollen. A stringent protocol of standardization, monitoring, and approval is followed for international extracts, which ensure inter- and intra-manufacturer consistency of mean allergen content.[5] Many indigenous extracts are now available in India. However, there is lack of a universal standardization in their preparation, though attempts are being made to use uniform immune-biochemical methods.[6] There is limited data comparing their potency and side effects with the international extracts.

Subcutaneous immunotherapy (SCIT) is being used widely for allergic rhinitis.[7] This is the practice of serial desensitization by supervised administration of progressively increasing doses of aeroallergens to which an individual exhibits specific IgE-mediated hypersensitivity. The schedule of the induction phase comprises administrating 5 sequential monthly vials of increasing concentration. The 1st vial is the most diluted (strength based on SPT wheal size); we generally start with 1:100,000 and end with 1:10. Multiple doses are administered from the same vial bi-weekly (at least 72 h apart) each month, with the volume increasing with each shot. When a high level of sensitization to a particular allergen is noted (wheal >10 mm in SPT), a less concentrated dose is used. Common adverse effects include large local reactions (LLR) at the injection site (swelling, pruritus, erythema, or pain).[3] These can be treated with supportive measures such as ice packs, topical or systemic corticosteroids, and second-generation antihistamines. Anaphylaxis occurs in <1%, mostly delayed-onset reactions, rather than life-threatening events.[8] In the maintenance phase, usually, the last dilution that was used in the induction phase is continued as a single-monthly-dose for 2–3 years. There are no published clinical trials from India, or local recommendations regarding allergen use in our population, i.e., content, dilution, etc. Most allergists use protocols based on the international guidelines and personal experience.

Besides having to deal with frequent health visits, multiple medications, and their adverse effects, children with moderate-to-severe allergic rhinitis suffer considerable impairment in their daily lives; irritability, fatigue, disturbed sleep, school absenteeism, poor scholastic performance, impairment in routine and recreational activities, and behavioral issues. SCIT not only alters the progression of disease but also reduces the likelihood of asthma, and financial implications. This case series aims at creating awareness among pediatricians about the use of SPT and SCIT in allergic rhinitis, and also highlight the importance of using standardized protocols.ng levels.td.

[TAG:2]Clinical Description [/TAG:2]


  Case 1 Top


A 12-year-old boy presented with frequent episodes of watery nasal discharge, sneezing, nasal irritation and blockade, headache, and mouth breathing for 7 years. Initially during the rainy seasons, the complaints now persisted throughout the year. His parents had consulted several physicians and he had received multiple medications (antihistamines, oral and intranasal steroids, and antibiotics and nasal decongestants), without improvement. There was a history of disturbed sleep (snoring, sleeping with mouth open, and daytime sleepiness), poor scholastic performance, and frequent school absenteeism. There was significant history of immediate nasal irritation, itching and redness of the eyes after eating prawns, and recurrent itchy, skin lesions on his thighs, since a few years. Additional details are given in [Table 1].
Table 1: Comparison of allergic rhinitis specific history and examination in all three cases

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The patient was thin built with normal vitals. Body mass index (BMI) was 16 kg/m2 (50th percentile). Local examination revealed thin and profuse nasal secretions, a crease over the nasal bridge, and pale nasal mucosa with hypertrophy of the inferior nasal turbinates. Dry cracked lips and bilateral hypertrophied tonsils were noted. The skin was dry and eczematous over his back and extensor surfaces of thighs. Remaining systemic examination was normal. The child was diagnosed as moderate-to-severe allergic rhinitis with atopic eczema.[9]

Management and outcome

Investigation results are detailed in [Table 1]. Since the child had refractory symptoms and SPT revealed sensitization to Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df), it was decided to administer SCIT with both allergens as per the international guidelines.[10] The child was asked to maintain a symptom diary. There was no significant wheal formation with the first 3 vials of standardized allergens (Dp and Df mix) used in the induction phase. However, he developed a swelling (10 cm × 8 cm) at the injection site after the first dose (0.05 ml) of the 4th vial (in the 4th month) as per the standard protocol.[10] There was no itching or redness. These events resolved within 6 h after treatment with only ice packs and oral levocetirizine. Pretreatment was given with levocetirizine, 30 min before each subsequent shot, and no further reactions were observed. The child became asymptomatic within 3 months [Figure 1] and is currently on monthly maintenance for a year[10] [Table 2].
Figure 1: Timeline showing improvement in symptoms of the three children during the induction phase of subcutaneous immunotherapy

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Table 2: Comparison of allergic rhinitis specific investigations and management in all three cases

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  Case 2 Top


An 11-year-old boy was brought with history of thick profuse nasal discharge, recurrent sneezing, and nasal blockade for 6 years. The symptoms were initially observed during winters, but later were present throughout the year. School attendance was intermittent. Details of history are given in [Table 1]. The child was obese (BMI >99th percentile) with stable vitals. Nasal examinations revealed thick and profuse nasal secretion, dark lines over the nasal bridge, and pale nasal mucosa with hypertrophy of the inferior nasal turbinates. The oral cavity examination and systemic examinations were normal. The child was diagnosed as modera te-to-severe allergic rhinitis.[9]

Management and outcome

Based on the clinical profile [Table 1] and [Table 2], SCIT with standardized Dp was planned. He became asymptomatic within 2 months [Figure 1] and is on monthly maintenance for 3 months.


  Case 3 Top


A 9-year-old girl presented with unresolved nasal discharge, sneezing, and nasal blockade for 4 years. An initial seasonal trend had become perennial since the previous year. There was history of recurrent episodes of dry and itchy skin lesions on her extremities and itching and redness of both eyes. Due to these complaints, the child unable to attend school regularly. Other details are given in [Table 1]. The girl was overweight (BMI >95th percentile) and stable. Salient examination findings were thick and profuse nasal secretions, dark lines underneath both eyes, and pale nasal mucosa with hypertrophy of the inferior nasal turbinates. The skin was dry and scaly over the extensor surfaces of the upper extremities, abdomen, and back. Both eyes were red and congested. The oral cavity was normal, as was the systemic examination. She was diagnosed with moderate-to-severe allergic rhinitis, allergic conjunctivitis, and atopic eczema.[9]

Management and outcome

Details of investigations and management are given in [Table 1] and [Table 2]. Refractory symptoms and sensitization to Df prompted us to start SCIT. [Figure 1] depicts the response; resolution of symptoms within 4 months of induction, and is presently on monthly maintenance for 6 months.


  Discussion Top


All three cases were diagnosed as moderate-to-severe allergic rhinitis,[10] displayed a high degree of sensitization to house dust mites on SPT, and showed significant improvement on SCIT, without requiring additional medication. We shall briefly discuss each of these aspects.

Allergic rhinitis is considered persistent if symptoms are present for more than 4 days a week for >4 consecutive weeks. Moderate-to-severe manifestations encompass symptoms that are severe enough to cause sleep disturbances, impairment of daily, scholastic, or recreational activities and persist despite pharmacologic therapy and avoidance of triggers. House dust mites (Dp and Df) are major allergens that are responsible for 80% of sensitization, globally.[5] That is why it is commonly used for SPT and SCIT in allergic rhinitis. The common first line of treatment includes antihistamines, intranasal steroids, saline irrigation, surgeries, avoidance of allergens, parenteral education, etc.[7] Indications for SCIT are: (i) moderate-to-severe allergic rhinitis (as in this case series); (ii) presence of definite allergy triggers; (iii) concurrent asthma or nasal polyposis; (iv) significant complications of allergic rhinitis such as recurrent otitis media or sinusitis; (v) intolerable adverse effects from medications or interference with scholastic performance or work productivity; and (vi) no improvement despite medications.

In SCIT, predefined doses of standardized allergens are given subcutaneously in the arm. The allergen preparation is individualized based on the allergen profile established from SPT response,[3],[10] the dose and dilution depending on the wheal size. For example, if child A develops a wheal of 12 mm to Dp, while child B develops a size of 6 mm to the same allergen, the 1st vial of Induction dose should be more diluted in A because of higher likelihood of a LLR. The biggest challenge in using indigenous Indian products is the lack of standardization, which makes following these principles of immunotherapy difficult. We hope this case series will trigger researchers to address the current unresolved areas particular to SPTs and SCIT in the Indian scenario.



Declaration of patient consent

The authors certify that they have obtained the appropriate consent from the parent. The legal guardian has given his consent for the images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published, and due efforts have been made to conceal the same, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Deb A, Mukherjee S, Saha BK, et al. Profile of patients with allergic rhinitis (AR): A clinic based cross-sectional study from Kolkata, India. J Clin Diagn Res 2014;8:67-70.  Back to cited text no. 1
    
2.
Prasad R, Kumar R. Allergy situation in India: What is being done? Indian J Chest Dis Allied Sci 2013;55:7-8.  Back to cited text no. 2
    
3.
Heinzerling L, Mari A, Bergmann KC, et al. The skin prick test – European standards. Clin Transl Allergy 2013;3:3.  Back to cited text no. 3
    
4.
Larenas-Linnemann D, Cruz AA, Gutierrez IR, et al. European and Mexican vs US diagnostic extracts of Bermuda grass and cat in skin testing. Ann Allergy Asthma Immunol 2011;106:421-8.  Back to cited text no. 4
    
5.
Christopher DJ, Ashok N, Ravivarma A, et al. Low potency of indian dust mite allergen skin prick test extracts compared to FDA-approved extracts: A double-blinded randomized control trial. Allergy Rhinol (Providence) 2018;9:2152656718796746.  Back to cited text no. 5
    
6.
Becker WM, Vogel L, Vieths S. Standardization of allergen extracts for immunotherapy: Where do we stand? Curr Opin Allergy Clin Immunol 2006;6:470-5.  Back to cited text no. 6
    
7.
Dayasiri K, Thadchanamoorthy V, Thisanayagam U. Diagnosis and management of allergic rhinitis in children. Int J Hum Health Sci 2021;05:159-62.  Back to cited text no. 7
    
8.
Australasian Society of Clinical Immunology and Allergy. Skin Prick Testing for the Diagnosis of Allergic Diseases. Manual for Practitioners; 2016. Available from: https://www.allergy.org.au/images/stories/pospapers/ASCIA_SPT_Manual_March_2016.pdf. [Last accessed on 2021 Sep 20].  Back to cited text no. 8
    
9.
Bousquet J, Khaltaev N, Cruz AA, et al. Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 2008;63 Suppl 86:8-160.  Back to cited text no. 9
    
10.
Sabin BR, Saltoun CA, Avila PC. Advances in upper airway diseases and allergen immunotherapy. J Allergy Clin Immunol 2011;127:342-50.  Back to cited text no. 10
    


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    Tables

  [Table 1], [Table 2]



 

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