Abstract
Allergic rhinitis (AR) is a very common condition presenting to an Otorhinolaryngologist. Prevalence of AR is on the increase and it has significant impact on quality of life of the patient. Skin prick test (SPT) is a simple test to determine allergen sensitization status in patients with AR. There is wide variation in allergen panel used in SPT among various allergy clinics and many centres use a large panel of allergens which requires multiple skin pricks for the patient undergoing the test. Our aim was to identify a minimum panel of allergens among patients with symptoms of AR undergoing SPT which could be used as a screening panel for AR. The present study is a cross sectional study in patients with symptoms of AR undergoing SPT at Allergy clinic of Bangalore Baptist hospital over a period of 18 months from January 2018. 149 patients were included in the study and 26 patients who had negative SPT for all allergens tested were excluded. Prevalence of sensitization for individual allergens was calculated. House dust mite (Dermatophagoides pteronyssinus and Dermatophagoides farinae) was the most prevalent allergen to which 73.9% and 65.8% of our study population was sensitized respectively. We identified a minimum allergen panel of 3 allergens (Dermatophagoides pteronyssinus, Lambs quarter and Dermatophagoides farinae) which could identify > 90% of patients sensitized in the study group.
Keywords: Allergic rhinitis, Minimum allergen panel, Skin prick test, Allergen sensitization
Introduction
Allergic rhinitis (AR) is a global health problem and its prevalence is on the increase [1, 2]. AR and associated bronchial asthma contributes a huge financial burden to health care system. It also affects lifestyle and productivity of individual. It has substantial impact on quality of life. It is considered one of the most prevalent non communicable disease. An estimated 400 million people suffer from AR [3]. AR affect 20% of the Indian population [4]. Many patients presenting with nasal symptoms may have coexistent AR and failure to identify and control this could be one of the causes for poor outcome of treatment.
Skin prick test is a simple, cheap and safe test to determine the allergen sensitization status in AR patients.There is an unmet need for an ideal skin prick test (SPT) panel in India because of diverse geography and flora. It is crucial to combine the botany, airborne pollen and mould survey with allergen panel for skin tests to achieve the best diagnostic efficiency. Our aim was to assess the sensitization patterns and define a minimal battery of SPT allergens which can be used as a screening tool in allergy clinic.
Many patients especially in the pediatric age group are reluctant to undergo a large allergen panel SPT because of fear associated with multiple skin pricks. Screening test with limited number of allergens helps in alleviating the anxiety of those patients. In a financially constrained situation, a small panel of allergens saves money, time and human resources.
Aim
To determine a minimum allergen panel which can be used for screening patients with allergic rhinitis.
Materials and Methods
Study Design
Cross-sectional study done in Allergy Clinic of Department of ENT in Bangalore Baptist Hospital, Bangalore over a period of 18 months from January 2018 after the approval of hospital ethics committee.
Inclusion Criteria
Patients with symptoms of allergic rhinitis.
Exclusion Criteria
Patients who are on drugs interfering with SPT interpretation and who are unable to discontinue drugs like antihistamines, tricyclic antidepressants
Patients who took antihistamines within 72 h and patients on long term systemic steroids
Patients with severe allergy to any of the allergens in the allergen panel
Patients with severe dermatographism
Patients with severe unstable asthma
Patients with congenital or acquired immunodeficiency
Pregnant females
All subjects with symptoms of allergic rhinitis consenting for the study were enrolled. Inclusion and exclusion criteria was followed. Total of 149 subjects were included in our study. Detailed interview was conducted and Performa was filled. Allergen panel for skin prick test included 25 allergens which includes 2 dustmite, 10 pollen, 2 moulds, 1 animal dander (AllergoSPT, ALLERGOPHARMA), data of SPT was used for the study. SPT was performed on volar aspect of both forearm and size of the wheal measured after 20 min. Saline (0.9%) was used as negative control and Histamine was used as positive control (Figs. 1, 2).
Fig. 1.
Skin prick test materials, Bangalore Baptist Hospital
Fig. 2.
Skin prick test allergen panel, Bangalore Baptist Hospital
Ethics
A written informed consent was obtained from the participants before enrolling them into the study.
Data Analysis and Interpretation
Data was entered into Microsoft Excel (Windows 7; Version 2007) and analysis were done using the Statistical Package for Social Sciences (SPSS) for Windows software (version 22.0; SPSS Inc, Chicago). Descriptive statistics such as mean and standard deviation (SD) for continuous variables, frequencies and percentages for categorical variables were determined.
Sensitization to specific allergens was calculated as percentage of total sensitized patients. To identify minimum allergen panel step-by-step conditional approach which allowed to determine the selection of allergens from the one that gave the highest increase in prevalence of sensitization to the one that lowest was adopted as describe by Lou H et al. [5]. The minimum allergen panel was started with the most prevalent allergen and the next allergen was identified by a process of elimination, in which the subjects sensitized to the first allergen were excluded and the second allergen in the panel was determined as the most prevalent sensitizing allergen in the remaining group of patients. Increase in identifying sensitized patients by adding the second allergen in SPT panel did not include the subjects co-sensitized to both the first and second allergens, as they were previously detected by the first allergen in the panel. Likewise the third allergen in the panel was determined as the one that gave the highest probability of sensitization knowing the subjects were not sensitized to either the first or the second allergen. The procedure was repeated until none of the remaining allergens induced an increase in prevalence. The combination of allergens that identified at least 90% of all sensitized subjects was defined as the minimal allergen panel.
Observations and Results
Age Distribution
Among 149 subjects included in our study youngest was 4 years old and the oldest was 71 years old. The mean age was 29.46 years (SD = 12.19).
Sex Distribution
Overall sex distribution of the population shows almost equal distribution among males and females with 77 males (51.6%) and 72 females (48.3%). (M:F ratio = 1.069:1).
Results
Prevalence of Allergen Sensitization:
Out of 149 patients in our study group 123 patients were sensitive to one or more of allergens in the SPT. 26 patients who had a negative SPT for all allergens in our SPT panel were excluded. 91 patients (73.9%) were sensitive to Dermatophagoides pteronyssinus (Der p.) which was the most common allergen to which patients were sensitized. Second most common allergen was Dermatophagoides farinae (Der f.) with 81 patients (65.8%) being sensitized. House dust mites (Der p and Der f) were thus the most common allergen in our SPT tests. Prevalence of sensitization to individual allergens in our allergen panel is given in Table 1, Fig. 3.
Table 1.
Distribution according to Prevalence of allergen sensitization
| Allergen prevalence | Number | Percentage |
|---|---|---|
| Dermatophagoides pteronyssinus (Der p.) | 91 | 73.9 |
| Dermatophagoides farinae (Der f.) | 81 | 65.8 |
| Lambs quarter | 27 | 21.9 |
| Short ragweed | 25 | 20.3 |
| Bermuda grass | 22 | 17.8 |
| English plantain | 17 | 13.8 |
| Mug wort | 17 | 13.8 |
| Rye grass | 16 | 13.0 |
| Shrimp | 12 | 9.7 |
| Cat Epithelia | 11 | 8.9 |
| Corn | 11 | 8.9 |
| Timothy grass | 10 | 8.1 |
| Wheat | 9 | 7.3 |
| Locust black | 7 | 5.6 |
| Alternaria tenius | 3 | 2.4 |
| Penicillium notatum | 2 | 1.6 |
| Hens egg white | 2 | 1.6 |
| Chicken | 1 | 0.8 |
| Peanut | 0 | 0.0 |
| Banana | 0 | 0.0 |
| Cow’s Milk | 0 | 0.0 |
| Potato | 0 | 0.0 |
| Orange | 0 | 0.0 |
| Chocolate | 0 | 0.0 |
| Wheat Flour | 0 | 0.0 |
Fig. 3.
Distribution of Prevalence of Allergen sensitization. DP – Der p, DF – Der f, LQ – Lambs quarter, SR – Short ragweed, BG – Bermuda grass, EP – English plantain, MW – Mug wort, RG – Rye grass, TG – Timothy grass, LB – Locust black, AT – Alternaria tenius, PN – Penicillium notatum, HE – Hen’s egg white
Minimum Allergen Panel
Among 123 patients who had positive skin prick test result 17(13.8%) patients were monosensitized, 30(24.3%) patients were polysensitized (positive for more than 3 allergens). Out of 123 patients 91 patients (73.9%) were positive for Der p which is the most prevalent allergen in our study population. Even though the 2nd most prevalent allergen in our panel was Der f which was positive in 81 patients (65.8%), it had showed considerable overlap with patients positive for Der p and there by only 10 additional patients (8.1%) could be identified who were negative for Der p. Whereas Lambs quarter was positive for 27 patients, of which 15 patients were also positive for Der p or Der f or both thereby identifying 12 patients (9.7%) who were neither sensitive for Der p nor Der f. In other words Lambs quarter identified 12 patients (9.7%) who were not sensitive to Der p or Der f or both. Thus we added Lambs quarter as the second allergen in our minimum allergen panel followed by Der f. Addition of further allergens in the panel did not cause a significant increase in the number of patients sensitized. Thus a panel consisting of just 3 allergens, Dermatophagoides pteronyssinus, Lambs quarter and Dermatophagoides farinae accounted for more than 90% (91.7%) of all sensitized subjects in our study group. Thus we concluded a panel of these 3 allergens could be used as a minimum allergen panel for screening patients with allergic rhinitis (Table 2).
Table 2.
Prevalence of sensitization; allergens ordered from the most prevalent to the allergen with the least increase in identifying additional sensitized subjects
| Allergen | Prevalence | Increase in identifying sensitized patients by adding allergen in skin prick test | ||
|---|---|---|---|---|
| n | % | n | % | |
| Dermatophagoides pteronyssinus | 91 | 73.9 | – | – |
| Lambs quarter | 27 | 21.9 | 12 | 9.7 |
| Dermatophagoides Farinae | 81 | 65.8 | 10 | 8.1 |
| Bermuda grass | 22 | 17.8 | 3 | 2.4 |
| English plantain | 17 | 13.8 | 3 | 2.4 |
| Short ragweed | 25 | 20.3 | 2 | 1.6 |
| Mug wort | 17 | 13.8 | 1 | 0.8 |
| Rye grass | 16 | 13.0 | 1 | 0.8 |
| Shrimp | 12 | 9.7 | 1 | 0.8 |
| Cat Epithelia | 11 | 8.9 | 1 | 0.8 |
| Alternaria tenius | 3 | 2.4 | 1 | 0.8 |
| Penicillium notatum | 2 | 1.6 | 1 | 0.8 |
| Corn | 11 | 8.9 | 0 | 0 |
| Timothy grass | 10 | 8.1 | 0 | 0 |
| Wheat | 9 | 7.3 | 0 | 0 |
| Locust black | 7 | 5.6 | 0 | 0 |
| Hens egg white | 2 | 1.6 | 0 | 0 |
| Chicken | 1 | 0.8 | 0 | 0 |
Discussion
In our study the most prevalent allergen sensitization was to Dermatophagoides pteronyssinus, 91 patients (73.9%) followed by Dermatophagoides farinae for which 81 patients (65.8%) were sensitive. There was considerable co sensitization between Der p and Der f. Multi-allergen sensitization may be caused by parallel sensitization or cross-reactivity among closely related allergens. It is likely that immune system cannot distinguish Der p or Der f allergens due to their high degree of homology between these allergens.
Study by Mishra VD et al. also identified Dust mite as the most prevalent (60%) in their study group similar to our study [6]. Study by Wang J et al. concluded that the most common sensitization was to House dust mites namely Dermatophagoides farinae (71.1%) and D. pteronyssinus (67.5%) in their study group which is comparable to sensitization in our study group (65.8% and 73.9%) [7].
Study by Lou H et al. also identified Der p and Der f as the most prevalent allergen sensitization in their study. In their study they identified a minimum allergen panel of eight allergens (Dermatophagoides farinae, mugwort, Blatella, hazel, goosefoot, Penicillium notatum, animal dander and Dermatophagoides pteroynssinus) that could identify > 96% of sensitized subjects [5].
Study by Wang J et al. identified a panel of 3 allergens (D. farina, D. pteronyssinus, Platanus) which provided a positive sensitization rate > 95% of the sensitized patients [7].
Conclusion
A Minimum allergen panel consisting of 3 allergens, Dermatophagoides pteronyssinus, Lambs quarter and Dermatophagoides farinae can be used as a screening panel for SPT in AR.
Limitations
A selection bias may be present because it was a single centre study. We used standardized allergen extracts, which may not include the pollens in tropical climate. While the aim of our study was to identify a minimal allergen panel some clinically relevant allergens, might have been missed in the panel. The study population were not living in Bangalore throughout their life, immigration from other nearby states were not taken into consideration which could have affected the prevalence of sensitization to various allergens. Prevalence of sensitization to various allergens in our panel could not be compared in its entirety to another study because of wide variations in the allergen panel used in various studies.
Recommendations
We recommend use of a minimum allergen panel skin prick test as a screening tool for AR in Allergy clinic. Patients who are positive for any of the allergens in minimum allergen panel can be treated for AR without the need to undergo testing with full panel of SPT in a resource constrained situation. Patients with high index of suspicion for AR but negative for minimum allergen panel could be advised to undergo further evaluation with full panel allergens.
Acknowledgements
I wish to express my gratitude to Dr. Carolin George, Mr. Tata Rao for the help offered for statistical analysis and Mrs. Chaitra for translation and technical help.
Compliance with Ethical Standards
Conflict of Interest
None.
Ethical Approval
Study was approved by Institutional ethics committee.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Rafees Hassan Palliyalthodi, Email: rafeeshassan@gmail.com.
Badari Datta, Email: badari_datta@yahoo.co.in.
Anita Mariet Thomas, Email: anipious@gmail.com.
R. Kamala, Email: kamala0210@gmail.com
Brinda A. Poojari, Email: brindapoojari@yahoo.com
B. V. Manjula, Email: drmanjubv@gmail.com
Unmesh Warwantkar Rao, Email: unmesh284@rediffmail.com.
References
- 1.Aberg N, Hesselmar B, Aberg B, Eriksson B. Increase of asthma, allergic rhinitis and eczema in Swedish schoolchildren between 1979 and 1991. Clin Exp Allergy J Br Soc Allergy Clin Immunol. 1995;25(9):815–819. doi: 10.1111/j.1365-2222.1995.tb00023.x. [DOI] [PubMed] [Google Scholar]
- 2.Leynaert B, Neukirch F, Demoly P, Bousquet J. Epidemiologic evidence for asthma and rhinitis comorbidity. J Allergy Clin Immunol. 2000;106(5 Suppl):S201–205. doi: 10.1067/mai.2000.110151. [DOI] [PubMed] [Google Scholar]
- 3.Pawankar R, Bunnag C, Khaltaev N, Bousquet J. Allergic Rhinitis and Its Impact on Asthma in Asia Pacific and the ARIA Update 2008. World Allergy Organ J. 2012;5(Suppl 3):S212–217. doi: 10.1097/1939-4551-5-S3-S212. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Chogtu B, Magaji N, Magazine R, Acharya PR. Pattern of allergen sensitivity among patients with bronchial asthma and/or allergic rhinosinusitis in a tertiary care centre of Southern India. J Clin Diagn Res JCDR. 2017;11(8):1–4. doi: 10.7860/JCDR/2017/26973.10328. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lou H, Ma S, Zhao Y, Cao F, He F, Liu Z, et al. Sensitization patterns and minimum screening panels for aeroallergens in self-reported allergic rhinitis in China. Sci Rep. 2017;7(1):9286. doi: 10.1038/s41598-017-10111-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Identification of common allergens for united airway disease by skin prick test Mishra VD, Mahmood T, Mishra JK - Indian J Allergy Asthma Immunol [Internet]. [cited 2017 Nov 5]. Available from: http://www.ijaai.in/article.asp?issn=0972-6691;year=2016;volume=30;issue=2;spage=76;epage=79;aulast=Mishra
- 7.Wang J, Wu Y, Li J, Huang X, Zhu R. Eight aeroallergen skin extracts may be the optimal panel for allergic rhinitis patients in central China. Int Arch Allergy Immunol. 2017;173(4):193–198. doi: 10.1159/000479429. [DOI] [PubMed] [Google Scholar]