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1 Continuing Education Column DOI: /jkma pissn: eissn: Diagnosis and treatment of allergic rhinitis Young Hoon Kim, MDKyung-Su Kim, MD Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea * Corresponding author: Kyung-Su Kim, ydrhinol@yuhs.ac Received July 7, 2010 Accepted July 21, 2010 Abstract Allergic rhinitis (AR) is a global health problem affecting at least 10 to 25% of the population, and is a chronic respiratory illness that affects quality of life, productivity, and other co-morbid conditions such as asthma and sinusitis. Classification of AR has been changed to intermittent/persistent (duration) and mild/moderate-severe (severity) based on the Allergic Rhinitis and Its Impact on Asthma (ARIA) workshop report published in A patient's history and skin prick test results are of utmost importance for its diagnosis regardless of classification system. Treatment should be based on the patient's age, severity, and duration of symptoms. The treatment algorithm has recently been revised by 2008 ARIA guidelines. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy, and surgery. Patients should be advised to avoid known allergens and educate themselves about their condition. Although allergen avoidance and immunotherapy are theoretically ideal, intranasal corticosteroids are the most effective treatment in persistent and moderate-severe AR. Sublingual immunotherapy has been introduced and has shown good results in its efficacy and safety. Physicians are advised to be alert to the state-of-the-art knowledge on AR and be willing to take advantage of recent progress on AR. Keywords: Allergic rhinitis; Skin test; Immunotherapy c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 780

2 Diagnosis and treatment of allergic rhinitis Intermittent symptoms <4 days per week or <4 consecutive weeks Persistent symptoms >4 days/week and >4 consecutive weeks Mild all of the following normal sleep no impairment of daily activities, sport, leisure no impairment of work and school symptoms present but not troublesome Figure 1. ARIA classification of severity of allergic rhinitis[4]. Moderate-severe one of more items sleep disturbance impairment of daily activities, sport, leissure impairment of school or work troublesome symptoms 781

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4 Diagnosis and treatment of allergic rhinitis Table 1. Differential diagnosis of rhinitis Allergic rhinitis Nonallergic rhinitis (continued) Conditions that may mimic symptoms of rhinitis Episodic rhinitis Gustatory rhinitis Cerebrospinal fluid rhinorrhea Occupational rhinitis Hormone-induced rhinitis Inflammatory or immunologic conditions (allergen) Hypothyroidism Midine granuloma Perennial rhinitis Menstrual cycle Nasal polyposis Seasonal rhinitis Oral contraceptives Sarcoidosis Nonallergic rhinitis Pregnancy Sjogrens syndrome Atrophic rhinitis Infectious rhinitis Systemic lupus erythematosus Chemical-or irritant-induced rhinitis Acute (usually viral) Wegeners granulomatosis Drug-induced rhinitis Chronic rhinosinusitis Relapsing polychondritis Antihypertensive medications Nonallergic rhinitis with eosinophilia Structural or mechanical conditions Nonsteroidal anti-inflammatory drugs syndrome Choanal atresia Oral contraceptives Occupational rhinitis (irritant) Deviated septum Rhinitis medicamentosa Perennial nonallergic rhinitis Enlarged adenoids Emotional rhinitis Vasomotor rhinitis Foreingn bodies Exercise-indued rhinitis Postural reflexes Hypertrophic turbinates Primary ciliary dyskinesia Nasal tumors Reflux-induced rhinitis or gastroesophageal reflux disease 783

5 Kim YHKim KS Table 2. Allergic vs. Non-allergic rhinitis Clinical characteristic Allergic rhinitis Non-allergic rhinitis Ancillary studies Positive skin tests Negative skin tests Exacerbating factors Allergen exposure Irritant exposure, weather changes Family history of allergies Usually present Usually absent Nasal eosinophilla Nature of symptoms Usually present Present in patients with nonallergic rhinitis with eosinophilia syndrome Congestion Common Common Postnasal drip Not prominent Prominent Pruritus Common Rare Rhinorrhea Sneezing Common Prominent Usually uncommon, but may be present in some patients Usually not prominent, but may predominate in some patients Other allergic symptoms Often present Absent Physical appearance of nasal mucosa Seasonality Variable, described as pale, boggy, and Swollen Seasonal variation Variable, erythematous Usually perennial, but symptoms may Worsen during weather changes. 784

6 Diagnosis and treatment of allergic rhinitis Diagnosis of allergic rhinitis Check for asthma especially in patients with severe and/or persistent rhinitis Intermittent symptoms Persistent symptoms Mild Moderate-severe Mild Moderate-severe Not in preferred order oral H1 blocker or intranasal H1-blocker and/or decongestantor LTRA Not in preferred order oral H1 blocker or intranasal H1-blocker and/or decongestant or Intranasal CS or LTRA (or cromone) In persistent rhinitis review the patient after 2-4 weeks If faliure: step-up If improved: continue for 1 month Improved Step-down and continue treatment for >1 month Add or increase intranasal CS dose In preferred order Intranasal CS H1 blocker or LTRA Review the patient after 2-4 weeks Rhinorrhea add ipratroplum Failure Review diagnosis Review compliance Query infections or other causes Blockage add decongestant or oral CS (short term) Failure referral to specialist Figure 2. ARIA algorithm for treatment of allergic rhinitis[20]. Allergen and irritant avoidance may be appropriate If conjunctivitis Add oral H1-blocker or intraocular H1-blocker or intraocular cromone (or saline) Consider specific immunotherapy 785

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9 Kim YHKim KS REFERENCES 11. Cockburn IM, Bailit HL, Berndt ER, Finkelstein SN. Loss of work productivity due to illness and medical treatment. J Occup Environ Med 1999; 41: Jee HM, Kim KW, Kim CS, Sohn MH, Shin DC, Kim KE. Prevalence of asthma, rhinitis, and eczema in Korean children using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires. Pediatr Allergy Respir Dis (Korea) 2009; 19: Bjorksten B, Clayton T, Stewart A, Strachan D. Worldwild time trends for symptoms of rhinitis and conjunctivitis: Phase III of the International Study of Asthma and Allergies in Childhood. Pediatr Allergy Immunol 2008; 19: Bousquet J, Van Cauwenberge P, Khaltaev N; Aria Workshop Group; World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001; 108(5 Suppl): S Salib RJ, Lau LC, Howarth PH. The novel use of the human nasal epithelial cell line RPMI 2650 as an in vitro model to study the influence of allergens and cytokines on transforming growth factor-beta gene expression and protein release. Clin Exp Allergy 2005; 35: Hamilton RG. Clinical laboratory assessment of immediatetype hypersensitivity. J Allergy Clin Immunol. 2010; 125: S Min YG. The pathophysiology, diagnosis and treatment of allergic rhinitis. Allergy Asthma Immunol Res 2010; 2: Jung YG, Cho HJ, Park GY, Min JY, Kim HY, Dhong HJ, Chung SK, Kim SW. Comparison of the skin-prick test and Phadia ImmunoCAP as tools to diagnose house-dust mite allergy. Am J Rhinol Allergy 2010; 24: Bang JH, Kim YJ, Shin HS, Lee BJ. Clinical analysis of allergic rhinitis in Seoul. J Rhinol 1996; 3: Heo Y, Kim HA. Correlation between skin prick test and enzyme-linked immunosorbent assay using serum for identification of subjects positive to major indoor respiratory allergen. J Env Health Sci 2008; 34: Larenas-Linnemann D, Matta JJ, Shah-Hosseini K, Michels A, Mösges R. Skin prick test evaluation of Dermatophagoides pteronyssinus diagnostic extracts from Europe, Mexico, and the United States. Ann Allergy Asthma Immunol 2010; 104: Nelson HS. Diagnostic procedures in allergy. I. allergy skin testing. Ann Allergy 1983; 51: Jang TY, Choi JC, Jung DH. Detection of Specific IgE Antibody from Nasal Secretion in Allergic Rhinitis. Korean J Otolaryngol 2000; 43: Han MY, Jee JM, Kim HY, Lee CA, Cho HJ, Hwang SG, Kim KE. Toll-like receptor 9 expression and interferon-secretion upon CpG-ODN stimulation in allergic subjects. Korean J Pediatr 2009; 52: Bousquet J, Vignola AM, Demoly P. Links between rhinitis and asthma. Allergy 2003; 58: Emanuel IA, Shah SB. Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Head Neck Surg 2000; 123: Nguyen LH, Manoukian JJ, Sobol SE, Tewfik TL, Mazer BD, Schloss MD, Taha R, Hamid QA. Similar allergic inflammation in the middle ear and upper airway: evidence linking otitis media with effusion to the united airway concept. J Allergy Clin Immunol 2004; 114: Ng TP, Tan WC. Epidemiology of allergic rhinitis and its associated risk factors in Singapore. Int J Epidemiol 1994; 23: Rha YH. Allergic rhinitis in children: diagnosis and treatment. Korean J Pediatr 2006; 49: Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, 788

10 Diagnosis and treatment of allergic rhinitis Togias A, Zuberbier T, Baena-Cagnani CE, Canoncia GW, van Weel C, Agache I, Ait-Khaled N, Bachert C, Blaiss MS, Bonini S, Boulet LP, Bousquet PJ, Camargos P, Carlsen KH, Chen Y, Custovic A, Dahl R, Demoly P, Douagui H, Durham SR, van Wijk RG, Kalayci O, Kaliner MA, Kim YY, Kowalski ML, Kuna P, Le LT, Lemiere C, Li J, Lockey RF, Mavale-Manuel S, Meltzer EO, Mohammad Y, Mullol J, Naclerio R, OHeir RE, Ohta K, Ouedraogo S, Palkonen S, Papadopoulos N, Passalacqua G, Pawankar R, Popov TA, Rabe KF, Rosado-pinto J, Scadding GK, Simons FE, Toskala E, Valovirta E, van Cauwenberge P, Wang DY, Wicjman M, Yawn BP, Yorgandipglu A, Yusuf OM, Zar H, Annesi-Maesano I, Bateman ED, Ben Kheder A, Boakye DA, Bouchard J, Burney P, Busse WW, Chang-Yeung M, Chavannes NH, Chuchalin A, Dolen WK, Emuzyte R, Grouse L, Humbert M, Jackson C, Johnston SL, Keith PK, Kemp JP, Klossek JM, Larenas- Linnemann D, Lipworth B, Malo JL, Marshall GD, Naspitz C, Nekam K, Niggemann B, Nizankowska-Mogilnicka E, Okamoto Y, Orru MP, Potter P, Price D, Stoloff SW, Vandenplas O, Viegi G, William D; World Health Organization; GA(2)LEN; AllerGen. 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: Moscato G, Vandenplas O, Van Wijk RG, Malo JL, Perfetti L, Quirce S, Walusiak J, Castano R, Pala G, Gautrin D, De Groot H, Folletti I, Yacoub MR, Siracusa A; European Academy of Allergology and Clinical Immunology. EAACI position paper on occupational rhinitis. Respir Res 2009; 10: Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician 2010; 81: Simons FER. H1-receptor antagonist: safety issues. Ann Allergy Asthma Immunol 1999; 83: Demoly P, Piette V, Daures JP. Treatment of allergic rhinitis during pregnancy. Drugs 2003; 63: Berger WE, White MV. Efficacy of azelastine nasal spray in patients with an unsatisfactory response to loratadine. Ann Allergy Asthma Immunol 2003; 91: Miadonna A, Tedeschi A, Leggieri E, Lorini M, Folco G, Sala A, Qualizza R, Froldi M, Zanussi C. Behavior and clinical relevance of histamine and leukotrienes C4 and B4 in grass pollen-induced rhinitis. Am Rev Respir Dis 1987; 136: Kurowski M, Kuna P, Gorski P. Montelukast plus cetrizine in the prophylactic treatment of seasonal allergic rhinitis: influence on clinical symptoms and nasal allergic inflammation. Allergy 2004; 59: Howarth PH. Leukotrienes in rhinitis. Am J Respir Crit Care Med 2000; 161: S133-S Pipkorn U, Proud D, Lichtenstein LM, Kagey-Sobotka A, Norman PS, Naclerio RM. Inhibition of mediator release in allergic rhinitis by pretreatment with topical glucocorticosteroids. N Engl J Med 1987; 316: Pipkorn U. Effect of topical glucocorticoid treatment on nasal mucosal mast cells in allergic rhinitis. Allergy 1983; 38: Schenkel EJ, Skoner DP, Bronsky EA, Miller SD, Pearlman DS, Rooklin A, Rosen JP, Ruff ME, Vanderwalker ML, Wanderer A, Damaraju CV, Nolop KB, Mesarina-Wicki B. Absence of growth retardation in children with pereneal allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. Pediatrics 2000; 105: E Allen DB, Meltzer EO, Lemanske RF Jr, Philpot EE, Faris MA, Kral KM, Prillaman BA, Rickard KA. No growth suppression in children treated with the maximum recommended dose of fluticasone propionate aqueous nasal spray for one year. Allergy Asthma Proc 2002; 23: Watson WT, Becker AB, Simons FE. Treatment of allergic rhinitis with intranasal corticosteroids in patients with mild asthma: effect on lower airway responsiveness. J Allergy Clin Immunol 1993; 91: Bousquet J, Demoly P, Michel FB. Specific immunotherapy in rhinitis and asthma. Ann Allergy Asthma Immunol 2001; 87: Scadding GK, Durham SR, Mirakian R, Jones NS, Leech SC, Farooque S, Ryan D, Walker SM, Clark AT, Dixon TA, Jolles SR, Siddique N, Cullinan P, Howarth PH, Nasser SM; British Society for Allergy and Clinical Immunology. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38: Frew AJ. Sublingual immunotherapy. N Engl J Med 2008; 358: Penagos M, Compalati E, Tarantini F, Baena-Cagnani R, Huerta J, Passalacqua G, Canoncia GW. Efficacy of sublingual immunotherapy in the treatment of allergic rhinitis in pediatric patient 3 to 18 years of age: meta-analysis of randomized, placebo-controlled, double-blind trials. Ann Allergy Asthma Immunol 2006; 97: Di Rienzo V, Marcucci F, Puccinelli P, Parmiani S, Frati F, Sensi L, Canonica GW, Passalacqua G. Long-lasting effect of sublingual immunotherapy in children with asthma due to house dust mite: a 10 year prospective study. Clin Exp Allergy 2003; 33: Cox LS, Linnemann DL, Nolte H, Weldon D, Finegold I, Nelson HS. Sublingual immunotherapy: a comprehensive review. J Allergy Clin Immunol 2006; 117: Plewako H, Arvidsson M, Petruson K, Oancea I, Holmberg K, Adelroth E, Gustafsson H, Sandstorm T, Rak S. 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11 Kim YHKim KS Peer Reviewers Commentary 790

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ÀÇÇÐ°�ÁÂc00Ì»óÀÏ˘ Common Allergic Diseases in Children Sang - Il Lee, M.D. Department of pediatrics Sungkyunkwan University School of Medicine, Samsung Medical Center E - mail : silee@smc.samsung.co.kr Abstract Allergy