Local Allergic Rhinitis: Is There a Role for Systemic Allergy Immunotherapy?

Abstract

Allergen immunotherapy (AIT), the etiologic treatment of allergic rhinoconjunctivitis and allergic asthma, has been shown to be an effective and safe treatment in patients with allergic respiratory disease. The efficacy of AIT in reducing symptoms and medication requirements has been demonstrated not only during treatment but also after it is discontinued. AIT is the only treatment that has the ability to modify the natural course of allergic rhinoconjunctivitis and asthma. In recent years, a new entity—local allergic rhinitis (LAR)—has been reported, which is characterized by the presence of a local allergic response to inhalant allergens, with negative skin tests and no detection of specific IgE antibodies in the peripheral blood. Patients had a nasal-specific response after nasal allergen challenge and a nasal Th2 inflammatory response with specific IgE antibodies, and showed clinical improvement with the classical treatment for allergic rhinitis (antihistamines and nasal corticosteroids). Ongoing evidence indicates that these patients benefit from subcutaneous AIT and supports this indication for LAR. Key points 1. LAR is a new phenotype of allergic rhinitis characterized by the presence of a localized allergic response in the nasal mucosa with negative skin test and no detection of serum-specific IgE antibodies in the peripheral blood. 2. It is an underdiagnosed/misdiagnosed respiratory disease that may affect patients from different countries and among different ethnic and age groups, showing a tendency toward worsening of the disease and a risk of developing asthma. 3. Patients with LAR commonly have persistent rhinitis, with moderate to severe nasal symptoms associated with conjunctivitis and/or asthma and impairment of their quality of life. 4. AIT is the etiological treatment of allergic respiratory disease and has the ability to modify its natural course. According to ARIA guidelines, it is indicated in moderate to severe persistent or intermittent allergic rhinitis and/or allergic asthma. 5. The efficacy and safety of subcutaneous allergen-specific immunotherapy for grass pollen and Dermatophagoides pteronyssinus has been demonstrated in adults with LAR.