Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

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Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

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Allergic Rhinitis and Its Impact on Asthma

Background In early life, the innate immune system can recognize both viable and nonviable parts of microorganisms. Immune activation may direct the immune response, thus conferring tolerance to allergens such as animal dander or tree and grass pollen. Methods Parents of children who were 6 to 13 years of age and were living in rural areas of Germany, Austria, or Switzerland where there were both farming and nonfarming households completed a standardized questionnaire on asthma and hay fever. Blood samples were obtained from the children and tested for atopic sensitization; peripheral-blood leukocytes were also harvested from the samples for testing. The levels of endotoxin in the bedding used by these children were examined in relation to clinical findings and to the cytokine-production profiles of peripheral-blood leukocytes that had been stimulated with lipopolysaccharide and staphylococcal enterotoxin B. Complete data were available for 812 children. Results Endotoxin levels in samples of dust from th...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa020057

Environmental exposure to endotoxin and its relation to asthma in school-age children.

Background: Allergic rhinitis represents a global health problem affecting 10% to 20% of the population. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines have been widely used to treat the approximately 500 million affected patients globally. Objective: To develop explicit, unambiguous, and transparent clinical recommendations systematically for treatment of allergic rhinitis on the basis of current best evidence. Methods: The authors updated ARIA clinical recommendations in collaboration with Global Allergy and Asthma European Network following the approach suggested by the Grading of Recommendations Assessment, Development and Evaluation working group. Results: This article presents recommendations about the prevention of allergic diseases, the use of oral and topical medications, allergen specific immunotherapy, and complementary treatments in patients with allergic rhinitis as well as patients with both allergic rhinitis and asthma. The guideline panel developed evidence profiles for each recommendation and considered health benefits and harms, burden, patient preferences, and resource use, when appropriate, to formulate recommendations for patients, clinicians, and other health care professionals. Conclusion: These are the most recent and currently the most systematically and transparently developed recommendations about the treatment of allergic rhinitis in adults and children. Patients, clinicians, and policy makers are encouraged to use these recommendations in their daily practice and to support their decisions.

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Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision

The allergenic content of the atmosphere varies according to climate, geography and vegetation. Data on the presence and prevalence of allergenic airborne pollens, obtained from both aerobiological studies and allergological investigations, make it possible to design pollen calendars with the approximate flowering period of the plants in the sampling area. In this way, even though pollen production and dispersal from year to year depend on the patterns of preseason weather and on the conditions prevailing at the time of anthesis, it is usually possible to forecast the chances of encountering high atmospheric allergenic pollen concentrations in different areas. Aerobiological and allergological studies show that the pollen map of Europe is changing also as a result of cultural factors (for example, importation of plants such as birch and cypress for urban parklands), greater international travel (e.g. colonization by ragweed in France, northern Italy, Austria, Hungary etc.) and climate change. In this regard, the higher frequency of weather extremes, like thunderstorms, and increasing episodes of long range transport of allergenic pollen represent new challenges for researchers. Furthermore, in the last few years, experimental data on pollen and subpollen-particles structure, the pathogenetic role of pollen and the interaction between pollen and air pollutants, gave new insights into the mechanisms of respiratory allergic diseases.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1398-9995.2007.01393.x

Allergenic pollen and pollen allergy in Europe

Can bronchial asthma with an highly prevalent airway (and systemic) vagal tone be considered an independent asthma phenotype? Possible role of anticholinergics

Respiratory allergic diseases appear to be increasingin both prevalence and severity in most countries, andsubjects living in urban and industrialized areas aremore likely to have respiratory allergic symptoms thanthose living in rural areas. This increase has beenlinked, among various factors, to air pollution and tothe westernized lifestyle. In the outdoor environment,the most important air pollutants are sulphur dioxide,nitrogen dioxide, ozone and particulate matter.Particulate diesel exhaust emissions, besides actingas irritant, are thought to modulate the immuneresponse, with an adjuvant activity on IgE synthesis,thereby facilitating allergic sensitization inpredisposed subjects. In other words, atopic statecan be upregulated by environmental influences, andsome subjects develop atopic disease in response tothese environmental factors when they are inhaled incombination with aeroallergens. Moreover, airpollutants produce greater responses in asthmaticsubjects. Since airborne pollen allergens and airpollutants are often increased contemporaneously, anenhanced IgE-mediated response to aeroallergens andenhanced airway inflammation could account for theincreasing frequency of allergic respiratory diseases,in particular those induced by pollen allergens, inurban areas.

On the interrelationship between outdoor air pollution and respiratory allergy

Washing the clothes of cat owners is a simple method to prevent cat allergen dispersal.

The symptoms of food allergy are rarely induced by skin contact. A 16-year-old boy was referred to our Allergology Centre after an episode of systemic symptoms triggered by accidental skin contact with a drop of cow milk (CM) dripped from a sandwich containing fresh cheese. The patient had been allergic to CM from the age of 24 months and had experienced several episodes of urticaria-angioedema after the ingestion of tiny or "hidden" amounts of CM proteins. In vivo and in vitro diagnostic procedures showed intense sensitisation to all CM proteins (1/100 dilutions of allergenic extracts produced large wheals, and class 4 specific IgE antibodies. Total IgE antibodies were elevate (770.0 UI/). A moderate degree of bronchial hyperresponsiveness was found (PC20 metacholine: 3.90 milligrams). This case report suggests that patients with a high degree of sensitisation to CM proteins should be alert to the danger of skin contact and should beware of "hidden" CM allergens.

Severe systemic allergic reaction induced by accidental skin contact with cow milk in a 16-year-old boy. A case report.

The aim of our study was the evaluation of clinical and epidemiological aspects of P pollen allergy, which is a very frequent cause of respiratory allergy in the Mediterranean area, in a homogeneous group of 442 monosensitive subjects (235 females and 207 males, mean age about 30 years) living in Naples. All patients underwent the following diagnostic procedures: anamnestic evaluation with an internal questionnaire, physical examination, SPT with commercially available allergenic extracts (DHS-Bayropharm Milan Italy); sNPT, NsBPT, and serum specific IgE determinations were also carried out in three groups of 50 different subjects. The results of our study show a highly relevant intensity of SPT positivity (4+ and 3+ in about 95% of patients). The age of onset of clinical symptoms ranged between 20-25 years, and the majority of P monosensitized patients were born in the spring months, with an early exposure to P allergens. Rhinoconjunctivitis and bronchial asthma, alone or association, represent the most common clinical manifestation of this allergy. The season in which patients experience clinical symptoms is prevalently spring (75, 12%). However, many people show a multiseasonal pattern (18, 55%). The frequency of SPT positivity to P allergens is increasing in the last 15 years, probably due to increased urban air pollution. In conclusion, the results of this study demonstrate the high frequency and severity of this pollinosis and seem to confirm some epidemiological aspects connected with other allergenic pollens (birth during the seasonal period of pollination and association with a high urban air pollution).

Gennaro Liccardi

Papers

Can bronchial asthma with an highly prevalent airway (and systemic) vagal tone be considered an independent asthma phenotype? Possible role of anticholinergics

On the interrelationship between outdoor air pollution and respiratory allergy

Washing the clothes of cat owners is a simple method to prevent cat allergen dispersal.

Severe systemic allergic reaction induced by accidental skin contact with cow milk in a 16-year-old boy. A case report.

Parietaria pollinosis: clinical and epidemiological aspects.