Allergic rhinitis: From discernment of symptoms to implementation of new therapeutic modalities (2025)

Previous issues of the Proceedings, have addressed the great burden of disease and magnitude of unmet needs associated with allergic rhinitis.^1,2 Directly relating to these unachieved goals, six articles appear within the pages of this issue that focus on this disease.^3–8 Two original articles, describing the results of the Current Allergic Rhinitis Experiences Survey (CARES), investigate allergic rhinitis from the standpoint of patient and provider perception. Within the first of these survey articles, Fromer et al³ examine 1600 adult allergic rhinitis sufferers regarding their perceptions of their allergic rhinitis diagnosis, treatment preferences, and interactions with health care practitioners. In the second survey article, Blaiss et al⁴ assess 375 primary care physicians and 375 nurse practitioners/physician assistants from the standpoint of patient symptom recognition, diagnosis and management, particularly with regard to self-management. They report that the vast majority of health care workers consider intranasal corticosteroids to be the gold standard for allergic rhinitis treatment and have minimal safety concerns about intranasal steroid use. Confidence in the long term safety of intranasal corticosteroids is further supported by the report of Weinstein et al⁵ who performed a 52-week efficacy and safety trial of once-daily treatment with beclomethasone dipropionate nasal aerosol in an adolescent and adult population with perennial allergic rhinitis. Adding further to the topic of safety and efficacy of intranasal corticosteroids, Kuna et al⁶ describe a safety and efficacy trial comparing two formulations of mometasone nasal spray in adults with seasonal allergic rhinitis. Focusing on antihistamine therapy for allergic rhinitis, Skoner et al⁷ analyze the effects of cetirizine on symptom severity and quality of life in patients suffering from perennial allergic rhinitis. Finally, turning to novel forms of allergy immunotherapy for allergic rhinitis and asthma, Nelson⁸ discusses the limitations related to safety and inconvenience associated with subcutaneous immunotherapy which have led to the investigation and development of new forms of immunotherapy including sublingual administration.

In addition to the above described focus on allergic rhinitis, this issue features articles on a great diversity of topics including food allergy, asthma, urticaria, drug allergy, atopic dermatitis, sarcoidosis, and a Patient-Oriented Problem Solving “POPS” case, each of these articles being briefly described as follows.

In highly sensitized food allergic individuals, allergic reactions to foods have been reported to occur following inhalation of aerosolized, airborne food particles such as peanut, cow's milk and fish. Reportedly, the exposure can be trivial, as in mere smelling or being in the vicinity of the food. Because the clinical implications and lifestyle changes associated with allergic reactions to food by inhalation can be significant, a review of the published literature regarding the occurrence of food allergic reactions in children by the inhalation route by Leonardi et al⁹ is featured in this issue's “For the Patient” section. This segment, found in the back of this issue and also available online, consists of a one page synopsis of a selected article, that is written in a readily comprehensible fashion to help patients better understand the content of the full article and its diagnostic and therapeutic implications. It is printed in a format to allow reproduction on the practitioner's letterhead for distribution to patients.

Although the leukotriene receptor antagonist, montelukast, has had a proven track record of efficacy in reducing asthma exacerbations; the effect of optimal therapeutic dose size for asthma exacerbations varying in severity has not been rigorously examined. In this issue, Zhang et al¹⁰ systematically explore the evidence for montelukast, as a first-line or add-on therapy, in preventing and treating asthma exacerbations in adult populations of patients with asthma. Their meta-analysis suggests that montelukast significantly reduces mild, moderate and part of severe asthma exacerbations either in first-line or the add-on regimens, but did not reduce hospitalizations for acute asthma.

Based on previous publications showing a possible relationship between asthma and obesity, Ciprandi and colleagues¹¹ measured body mass index (BMI) and performed spirometry in 286 consecutive asthma patients evaluated in their clinic. In analyzing the relationship between lung function and BMI, they found that overweight and obese patients were more likely to have an abnormal FEV1, FVC and FEV1/FVC. From this information, the conclusion of this exclusively online article is that obesity is an important risk factor or airflow obstruction in patients with asthma. The authors recommend that BMI assessment should be routinely considered in patients with asthma.

Patients with chronic urticaria bear a significant burden of illness, and despite extensive investigation a cause is often not found.^12,13 In particular, a causal relationship between the long-suspected role of infection with urticaria, has been difficult to establish. Minciullo et al¹⁴ perform a systematic analysis of published cases of urticaria associated with bacterial infection and although they report finding only a weak association, recommend that clinicians should continue to consider bacterial infection in the diagnostic work-up of patients with urticaria.

Drug provocation tests are held as the gold standard in diagnosing nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. However, patient NSAID usage following a negative drug provocation test is not well established. In an original article, Bommarito et al¹⁵ assessed patients' compliance in NSAID usage after negative provocation testing. They report that patients who have undergone negative drug provocation tests to a suspected NSAID remain fearful of future reactions and avoid retaking the tested NSAID, even in the face of non-reactivity.

Patients with moderately severe atopic dermatitis suffer from significant morbidity including secondary infections and psychosocial disturbances. Currently, however, there are no established laboratory tests for identifying these patients to implement early treatment. Ong¹⁶ reports on the utility of food-specific IgE levels and superantigen-specific IgE levels as potential predictive markers of atopic dermatitis-associated morbidity.

It remains unclear whether atopy is associated with the development occurrence of sarcoidosis or affects its severity. In an exclusive online article, Hajdarbegovic et al¹⁷ describe their investigation of the life-time prevalence of atopic eczema, asthma and hay fever in sarcoidosis patients to assess whether atopy influences the severity and clinical course of sarcoidosis. Their investigation demonstrates that atopy is not associated with the occurrence of sarcoidosis, but that the presence of atopic eczema may decrease the likelihood of eye involvement.

Rounding out the issue is the most recent installment of the Patient-Oriented Problem Solving “POPS” series, which, as per tradition, is written by an allergy-immunology fellow-in-training from one of the 73 US allergy-immunology training programs. The purpose of the POPS series is to provide an innovative and practical learning experience for the allergist-immunologist using a format of clinical presentation, physical findings, appropriate laboratory studies, and differential diagnosis. Paul & Chang¹⁸ lead the reader through this process, describing the evaluation of a two year old girl referred for evaluation of recurrent rashes thought to be due to varicella zoster. This case illustrates the importance of a detailed immune assessment in the evaluation of unusually severe, recurrent, or atypical pediatric exanthemas.

In summary, the collection of articles found within the pages of this issue provides another insight into important allergic, cutaneous and respiratory disorders afflicting patients whom the allergist-immunologist serves. In keeping with the overall mission of the Proceedings, which is to distribute timely information regarding advancements in the knowledge and practice of allergy, asthma, and immunology to clinicians entrusted with the care of patients, it is our hope that the articles found within this issue achieve this goal and will help foster enhanced patient management through efficient workup and optimal therapy for a great diversity of clinical problems. On behalf of the editorial board, we hope you will enjoy the diversity of literature offered in this issue of the Proceedings.