Defining pollen exposure times for clinical trials of allergen immunotherapy for pollen-induced rhinoconjunctivitis - an EAACI position paper.

BACKGROUND: Clinical efficacy of pollen allergen immunotherapy (AIT) has been broadly documented in randomized controlled trials. The underlying clinical endpoints are analysed in seasonal time periods predefined based on the background pollen concentration. However, any validated or generally accepted definition from academia or regulatory authorities for this relevant pollen exposure intensity or period of time (season) is currently not available. Therefore, this Task Force initiative of the European Academy of Allergy and Clinical Immunology (EAACI) aimed to propose definitions based on expert consensus. METHODS: A Task Force of the Immunotherapy and Aerobiology and Pollution Interest Groups of the EAACI reviewed the literature on pollen exposure in the context of defining relevant time intervals for evaluation of efficacy in AIT trials. Underlying principles in measuring pollen exposure and associated methodological problems and limitations were considered to achieve a consensus. RESULTS: The Task Force achieved a comprehensive position in defining pollen exposure times for different pollen types. Definitions are presented for 'pollen season', 'high pollen season' (or 'peak pollen period') and 'high pollen days'. CONCLUSION: This EAACI position paper provides definitions of pollen exposures for different pollen types for use in AIT trials. Their validity as standards remains to be tested in future studies.

Comparison of Molecular Multiplex and Singleplex Analysis of IgE to Grass Pollen Allergens in Untreated German Grass Pollen-Allergic Patients.

BACKGROUND: The ImmunoCAP ISAC 112 platform is the only commercially available molecular allergy IgE multiplex test. Data on the comparison of this rather novel test with the molecular singleplex ImmunoCAP IgE platform are lacking. OBJECTIVE: To compare the multiplex ISAC 112 platform and the singleplex ImmunoCAP platform in regard to IgE to grass pollen allergens in untreated grass pollen-allergic patients in Germany. METHODS: Serum samples from 101 adults with grass pollen allergy were analyzed for specific IgE (sIgE) to 8 allergenic molecules from timothy grass pollen and to the 112 allergenic molecules included in the ISAC panel. The results for the multiplex and singleplex tests were subsequently analyzed statistically. RESULTS: Comparison of sIgE to grass pollen allergens detected by ISAC 112 and the singleplex ImmunoCAP assay revealed the following correlation coefficients: 0.88 (rPhl p 1), 0.96 (rPhl p 2), 0.70 (nPhl p 4), 0.94 (rPhl p 5b), 0.92 (rPhl p 6), 0.85 (rPhl p 11), and 0.78 (rPhl p 12). CONCLUSION: Molecular testing with ISAC 112 correlates well with the ImmunoCAP platform for respective molecular timothy grass pollen allergens.

Comparison of molecular multiplex and singleplex analysis of IgE to grass pollen allergens in untreated german grass pollen–allergic patients

Antecedentes: El ImmunoCAP ISAC 112, es el único sistema comercial con determinación simultánea de múltiples alérgenos comercializado para el diagnóstico alergológico molecular. No existen estudios comparativos de este sistema con el ImmunoCAP para la determinación de IgE frente a un único alérgeno. Objetivos: Realizar un estudio comparativo para la determinación de IgE específica a alérgenos de polen de gramíneas en pacientes alemanes con alergia a estos pólenes, utilizando los sistemas ISAC IgE y el ImmunoCAP IgE. Métodos: Se estudiaron 101 sueros de adultos con alergia a pólenes de gramíneas, determinando la IgE específica a 8 alérgenos de hierba timotea mediante ImmunoCAP y a 112 alérgenos presentes en la plataforma ISAC. Posteriormente se realizó un análisis estadístico comparativo entre los resultados de ambos sistemas. Resultados: La comparación de los valores de IgE específica frente a los alérgenos de pólenes de gramíneas hallados en los sistemas ISAC e ImmunoCAP mostraron los siguientes coeficientes de correlación: 0.88 (rPhl p 1), 0.96 (rPhl p 2), 0.70 (nPhl p 4), 0.94 (rPhl p 5b), 0.92 (rPhl p 6), 0.85 (rPhl p 11) y 0.78 (rPhl p12). Conclusiones: El diagnóstico molecular con el Sistema ISAC guarda buena correlación con los resultados del ImmunoCAP para los alérgenos de hierba timotea presentes en ambas plataformas (AU)

Background: The ImmunoCAP ISAC 112 platform is the only commercially available molecular allergy IgE multiplex test. Data on the comparison of this rather novel test with the molecular singleplex ImmunoCAP IgE platform are lacking. Objective: To compare the multiplex ISAC 112 platform and the singleplex ImmunoCAP platform in regard to IgE to grass pollen allergens in untreated grass pollen–allergic patients in Germany. Methods: Serum samples from 101 adults with grass pollen allergy were analyzed for specific IgE (sIgE) to 8 allergenic molecules from timothy grass pollen and to the 112 allergenic molecules included in the ISAC panel. The results for the multiplex and singleplex tests were subsequently analyzed statistically. Results: Comparison of sIgE to grass pollen allergens detected by ISAC 112 and the singleplex ImmunoCAP assay revealed the following correlation coefficients: 0.88 (rPhl p 1), 0.96 (rPhl p 2), 0.70 (nPhl p 4), 0.94 (rPhl p 5b), 0.92 (rPhl p 6), 0.85 (rPhl p 11), and 0.78 (rPhl p12). Conclusion: Molecular testing with ISAC 112 correlates well with the ImmunoCAP platform for respective molecular timothy grass pollen allergens (AU)

Allergens. Heterogeneity of molecular sensitization profiles in grass pollen allergy--implications for immunotherapy?

BACKGROUND: Data on molecular allergy diagnostics in adults with grass pollen allergy with regard to conjunctival and nasal provocation test outcome and specific immunotherapy are lacking to date. OBJECTIVE: To assess whether molecular allergy diagnostics for grass pollen allergens could help with predicting provocation test outcomes and serve as a basis for future component-resolved specific immunotherapy. METHODS: Sera of 101 adults with grass pollen allergy was analysed for IgE against timothy grass pollen (Phleum pratense), rPhl p 1, rPhl p 2, nPhl p 4, rPhl p 5b, rPhl p 6, rPhl p 7, rPhl p 11 and rPhl p12 and correlated with the individuals' outcome in the nasal and conjunctival provocation tests and investigated in regard to a potential component-resolved specific immunotherapy. RESULTS: An increasing number of sensitizations to timothy grass allergens was correlated to a positive reaction in the conjunctival (4.9 vs. 3.6, P = 0.003) and nasal provocation tests (4.5 vs. 2.2, P = 0.0175). In molecular sensitization profiles, a substantial heterogeneity was detected, with none of the patients exactly matching the allergen composition of a previously published component-resolved specific immunotherapy containing Phl p 1, Phl p 2, Phl p 5a/b and Phl p 6. The results indicate that in 95% of the patients, a proportion of 50% of timothy-IgE would be targeted with such a specific immunotherapy, while in 50% and 10% of patients, 80% and 90% of timothy-IgE would be targeted, respectively. CONCLUSION AND CLINICAL RELEVANCE: Molecular allergy diagnostics is a prerequisite for future component-resolved specific immunotherapy due to the high heterogeneity of sensitization profiles. However, of current clinical relevance is the observed correlation between the number of sensitizations and provocation test outcome.

Acupuncture compared with oral antihistamine for type I hypersensitivity itch and skin response in adults with atopic dermatitis: a patient- and examiner-blinded, randomized, placebo-controlled, crossover trial.

BACKGROUND: Itch is the major symptom of atopic dermatitis (AD). Acupuncture has been shown to exhibit a significant effect on experimental itch in AD. Our study evaluated acupuncture and antihistamine itch therapy (cetirizine) on type I hypersensitivity itch and skin reaction in AD using a patient and examiner-blinded, randomized, placebo-controlled, crossover trial. METHODS: Allergen-induced itch was evaluated in 20 patients with AD after several interventions in separate sessions: preventive (preceding) and abortive (concurrent) verum acupuncture (VAp and VAa), cetirizine (10 mg, VC), corresponding placebo interventions (preventive, PAp, and abortive, PAa, placebo acupuncture; placebo cetirizine pill, PC) and a no-intervention control (NI). Itch was induced on the forearm and temperature modulated over 20 min, using our validated model. Outcome parameters included itch intensity, wheal and flare size and the D2 attention test. RESULTS: Mean itch intensity (SE: 0.31 each) was significantly lower following VAa (31.9) compared with all other groups (PAa: 36.5; VC: 36.8; VAp: 37.6; PC: 39.8; PAp: 39.9; NI: 45.7; P < 0.05). There was no significant difference between VAp and VC (P > 0.1), although both therapies were significantly superior to their respective placebo interventions (P < 0.05). Flare size following VAp was significantly smaller (P = 0.034) than that following PAp. D2 attention test score was significantly lower following VC compared with all other groups (P < 0.001). CONCLUSIONS: Both VA and cetirizine significantly reduced type I hypersensitivity itch in patients with AD, compared with both placebo and NI. Timing of acupuncture application was important, as VAa had the most significant effect on itch, potentially because of counter-irritation and/or distraction. Itch reduction following cetirizine coincided with reduced attention.

Api m 10, a genuine A. mellifera venom allergen, is clinically relevant but underrepresented in therapeutic extracts.

BACKGROUND: Generalized systemic reactions to stinging hymenoptera venom constitute a potentially fatal condition in venom-allergic individuals. Hence, the identification and characterization of all allergens is imperative for improvement of diagnosis and design of effective immunotherapeutic approaches. Our aim was the immunochemical characterization of the carbohydrate-rich protein Api m 10, an Apis mellifera venom component and putative allergen, with focus on the relevance of glycosylation. Furthermore, the presence of Api m 10 in honeybee venom (HBV) and licensed venom immunotherapy preparations was addressed. METHODS: Api m 10 was produced as soluble, aglycosylated protein in Escherichia coli and as differentially glycosylated protein providing a varying degree of fucosylation in insect cells. IgE reactivity and basophil activation of allergic patients were analyzed. For detection of Api m 10 in different venom preparations, a monoclonal human IgE antibody was generated. RESULTS: Both, the aglycosylated and the glycosylated variant of Api m 10 devoid of cross-reactive carbohydrate determinants (CCD), exhibited IgE reactivity with approximately 50% of HBV-sensitized patients. A corresponding reactivity could be documented for the activation of basophils. Although the detection of the native protein in crude HBV suggested content comparable to other relevant allergens, three therapeutical HBV extracts lacked detectable amounts of this component. CONCLUSION: Api m 10 is a genuine allergen of A. mellifera venom with IgE sensitizing potential in a significant fraction of allergic patients independent of CCD reactivity. Thus, Api m 10 could become a key element for component-resolved diagnostic tests and improved immunotherapeutic approaches in hymenoptera venom allergy.

Can immunoglobulin E-measurement replace challenge tests in allergic rhinoconjunctivits to grass pollen?

BACKGROUND: There is minimal data available concerning the dose-response relationship between allergen exposure and clinical reactivity for outdoor aeroallergens, such as timothy grass pollen. Timothy pollen-specific IgE (sIgE) determinations might assist in predicting the clinical reactivity in patients with allergic rhinoconjunctivitis (ARC). METHODS: Allergen-sIgE antibody levels of timothy grass pollen were correlated with individual threshold doses eliciting allergic reactions in skin prick test (SPT), conjunctival (CPT) and nasal (NPT) provocation tests in patients suffering from pollen-induced rhinoconjunctivitis and healthy controls. RESULTS: One hundred and four patients with ARC (median age: 27 years; range: 18-64; females: 58%) and 36 controls (25 years (22-77); females: 70%) were included in the study. Ninety-six percent of the patients showed a positive reaction in the nasal and 57% showed a positive reaction in the conjunctival provocation. With regarding to titrated SPT, 98% of the patients showed a positive skin test reaction; correlating with the level of sIgE for timothy (P < 0.001). For both provocation protocols, there was no correlation between the provocation concentration at the reaction and the level of sIgE for timothy. The ratio of sIgE/total IgE correlated with the dilution level of SPT (P < 0.002) and CPT (P < 0.01), respectively. CONCLUSION AND CLINICAL RELEVANCE: A dose-response relationship between the levels of sIgE and clinical outcome of timothy allergen exposure could not be established. Although IgE-determination remains an important key element in allergy diagnosis, provocation tests are procedures of choice if the clinical relevance of an allergen has to be confirmed.

Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema - a blinded, randomized, placebo-controlled, crossover trial.

BACKGROUND: Itch is a major symptom of allergic skin disease. Acupuncture has been shown to exhibit a significant effect on histamine-induced itch in healthy volunteers. We investigated the effect of acupuncture on type I hypersensitivity itch and skin reaction in a double-blind, randomized, placebo-controlled, crossover trial. METHODS: An allergen stimulus (house dust mite or grass pollen skin prick) was applied to 30 patients with atopic eczema before (direct effect) and after (preventive effect) two experimental approaches or control observation: acupuncture at points Quchi and Xuehai [verum acupuncture (VA), dominant side], 'placebo-point' acupuncture (PA, dominant side), no acupuncture (NA). Itch intensity was recorded on a visual analogue scale. After 10 min, wheal and flare size and skin perfusion (via LASER-Doppler) were measured at the stimulus site, and the validated Eppendorf Itch Questionnaire (EIQ) was answered. RESULTS: Mean itch intensity was significantly lower in VA (35.7 +/- 6.4) compared to NA (45.9 +/- 7.8) and PA (40.4 +/- 5.8) regarding the direct effect; and significantly lower in VA (34.3 +/- 7.1) and PA (37.8 +/- 5.6) compared to NA (44.6 +/- 6.2) regarding the preventive effect. In the preventive approach, mean wheal and flare size were significantly smaller in VA (0.38 +/- 0.12 cm(2)/8.1 +/- 2.0 cm(2)) compared to PA (0.54 +/- 0.13 cm(2)/13.5 +/- 2.8 cm(2)) and NA (0.73 +/- 0.28 cm(2)/15.1 +/- 4.1 cm(2)), and mean perfusion in VA (72.4 +/- 10.7) compared to NA (84.1 +/- 10.7). Mean EIQ ratings were significantly lower in VA compared to NA and PA in the treatment approach; and significantly lower in VA and PA compared to NA in the preventive approach. CONCLUSIONS: Acupuncture at the correct points showed a significant reduction in type I hypersensitivity itch in patients with atopic eczema. With time the preventive point-specific effect diminished with regard to subjective itch sensation, whereas it increased in suppressing skin-prick reactions.

ETFAD/EADV eczema task force 2009 position paper on diagnosis and treatment of atopic dermatitis.

BACKGROUND: The diagnosis of atopic dermatitis (AD) is made using evaluated clinical criteria. Management of AD must consider the symptomatic variability of the disease. METHODS: EADV eczema task force developed its guideline for atopic dermatitis diagnosis and treatment based on literature review and repeated consenting group discussions. RESULTS AND DISCUSSION: Basic therapy relies on hydrating topical treatment and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment based on topical glucocorticosteroids and topical calcineurin antagonists is used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, but the topical calcineurin inhibitors, tacrolimus and pimecrolimus are preferred in certain locations. Systemic anti-inflammatory treatment is an option for severe refractory cases. Microbial colonization and superinfection may induce disease exacerbation and can justify additional antimicrobial/antiseptic treatment. Systemic antihistamines (H1) can relieve pruritus, but do not have sufficient effect on eczema. Adjuvant therapy includes UV irradiation preferably of UVA1 wavelength or UVB 311 nm. Dietary recommendations should be specific and given only in diagnosed individual food allergy. Allergen-specific immunotherapy to aeroallergens may be useful in selected cases. Stress-induced exacerbations may make psychosomatic counselling recommendable. 'Eczema school' educational programmes have been proven to be helpful.

[Nickel levels in female dermatological patients]. / Innere Nickelbelastung von dermatologischen Patientinnen.

Nickel levels in urine were determined among 163 female dermatological patients aged 18 to 46 years. Data on life-style factors were collected in parallel via a questionnaire. Urinary nickel excretion was in the normal range of the German female population (0.2-46.1 microg Ni/g creatinine). The 95th percentile (3.9 microg Ni/l urine) exceeded the German reference value (3.0 microg Ni/l urine). In the multivariate regression analyses we found a statistically significant increase of ln-transformed nickel levels with increase in age and in women using dietary supplements. The following variables were not associated with Nickel urine levels: suffering from nickel eczema, smoking, drinking stagnated water, eating foods with high nickel contents and using nickel-containing kitchen utensils as, for example, an electric kettle with an open heater coil. We conclude that personal urinary levels should be assessed with simultaneous consideration of habits and life-style factors. A German national survery would be useful. Those patients who experience the exacerbation of their eczema in cases of oral provocation, for example, by a high nickel diet should be aware of potential sources of nickel, such as supplements.

[Atopic patch test. Atopic eczema and allergy]. / Atopie-Patch-Test. Atopisches Ekzem und Allergie.

The role of IgE-mediated allergic reactions in atopic eczema remains controversial. Using the atopy patch test, aeroallergens such as house dust mites, animal dander or pollen can be identified as relevant trigger factors in a subgroup of patients with atopic eczema. The atopy patch test is an epicutaneous patch test employing allergens known to elicit IgE-mediated reactions and used to evaluate eczematous skin reactions. In a series of single- and multicenter studies, a method was developed, standardized and compared to other diagnostic techniques (specific serum-IgE, skin prick test) in atopic eczema patients. With regard to clinical history, the most specific results were obtained with the atopy patch test (allergen-dependent 69-92%), while sensitivity was higher for skin prick test (69-82%) and specific IgE (65-94%). The characterization of a patient subgroup with relevant IgE-mediated allergy may lead to more efficient avoidance and perhaps even specific immunotherapy strategies in the management of atopic eczema.

Subcutaneous oleomas induced by self-injection of sesame seed oil for muscle augmentation.

This case presentation describes a 48-year-old man who experienced subcutaneous nodules 9 months after self-injection of sesame seed oil into the pectoral area for muscle augmentation. This procedure was reported by our patient to be frequently performed in the body-building and fitness scene. Ultrasound imaging showed multiple, low reflecting round nodular areas of up to 1 cm diameter in both breasts. Excision of a representative nodule revealed a cyst filled with oily material, surrounded by granulomatous tissue. This case report demonstrates an unusual side effect of augmentation measures in body-builders.

Gramineae pollen as trigger factors of atopic eczema: evaluation of diagnostic measures using the atopy patch test.

After contact with grass pollen, seasonal exacerbations of eczematous skin lesions have been described in a subgroup of patients with atopic eczema (AE). Epicutaneous patch testing with aeroallergens (atopy patch test. APT) has been used to investigate these patients. We performed comparative APT in 79 patients with AE and 20 control subjects (14 non-atopic volunteers and six patients with grass pollen allergic rhinoconjunctivitis). Subjects were tested with grass pollen allergen extract in petrolatum and with unprocessed native dry pollen of Dactylis glomerata. Results after 48 h were compared with the patient's history, corresponding skin prick test and specific IgE. Fifteen of the 79 AE patients showed clear-cut eczematous reactions to unprocessed D. glomerata pollen; 14 of these had an elevated serum IgE to D. glomerata and 13 had a positive skin prick test. Twenty patients had a positive APT reaction to grass pollen allergen extract, including 12 of the D. glomerata reactive subjects (P < 0.001). Positive patch test reactions to D. glomerata were seen in 66.7% of cases with and 10.5% of patients without a predictive history of exacerbations during the pollen season. For the standardized extract, these percentages were 75% vs. 16.4% (P < 0.001). No side-effects were observed. Control subjects showed no positive reactions. We conclude that grass pollen preparations may be used to investigate trigger factors for eczematous skin lesions in a subgroup of patients with AE.

The 'atopy patch test' in evaluating the role of aeroallergens in atopic eczema.

The atopy patch test (APT) is a procedure involving epicutaneous patch tests with allergens known to elicit IgE-mediated reactions and the evaluation of eczematous skin lesions. APT can be performed on normal uninvolved skin without artificial manipulations such as tape stripping or use of irritants. APT has been standardized regarding the use of vehicle and dose response relationships. In several studies, approximately two thirds of patients with atopic eczema (AE) showed positive APT reactions to aeroallergens, most frequently to house dust mite. Positive APT reactions were significantly more frequent in patients with a typical air-exposed eczematous distribution pattern. Using evaporimetry to study transepidermal water loss, allergen-induced disturbance of epidermal barrier functions was found to be significantly more pronounced on APT reactions compared to classical contact allergy patch test sites in the same individual. It has been shown that with APT eczematous skin lesions can be elicited by skin contact with aeroallergens, at least in a subgroup of patients with AE, and thereby, that IgE-mediated allergy does play a role in the etiopathophysiology of this disease. Future studies should help to bring this test into clinical routine in order to establish an equivalent for 'skin provocation' comparable to nasal and bronchial provocation tests in respiratory allergy.

The atopy patch test: an increased rate of reactivity in patients who have an air-exposed pattern of atopic eczema.

In a subgroup of patients with atopic eczema (AE), eczematous skin lesions can be induced by epicutaneous testing with aeroallergens (the atopy patch test: APT). An increased frequency of positive APT has been found in AE patients showing a predictive lesional pattern affecting air-exposed skin areas. This study investigates the dose-response of the APT in two different patient groups with AE. Petrolatum preparations of house dust mite, cat dander and grass pollen allergens in four concentrations (500-10,000 protein nitrogen units) were tested epicutaneously in 57 patients with AE, who were prospectively divided in two groups according to whether their AE pattern was with (group I) or without (group II) a predictive distribution. Sixty-nine per cent of patients in group I, and 39% in group II, had positive APT reactions (P = 0.02). The reactions in group I were elicitable with lower allergen concentrations (P = 0.03). A clinically recognizable subgroup of patients with AE showed increased cutaneous sensitivity to aeroallergens.

Atopy patch test with different vehicles and allergen concentrations: an approach to standardization.

BACKGROUND: In some patients with atopic eczema, eczematous skin lesions can be induced by patch testing with aeroallergens. METHODS: To establish a standardized system for the atopy patch test (APT), 36 patients with atopic eczema, four patients with rhinoconjunctivitis and 10 healthy control subjects were epicutaneously tested with allergen extracts from house dust mite, cat dander, and grass pollen. APTs were performed on nonabraded, uninvolved skin with 1000 and 10,000 protein nitrogen units (PNU)/gm allergen in petrolatum or hydrogel. Reactions were evaluated after 48 and 72 hours and compared with skin prick and specific serum IgE (CAP-RAST; Pharmacia, Uppsala, Sweden). RESULTS: After 48 hours, 57 clear-cut positive reactions with eczematous, often follicle-bound, appearance were diagnosed from a total of 432 test sites. Seventy-two percent of these positive reactions in patients with atopic eczema developed with 10,000 PNU/gm and 28% with 1000 PNU/gm. Sixty-seven percent of reactions were elicited with allergens in petrolatum versus 33% when hydrogel was used as vehicle. Allergen-specific concordances of APT (10,000 PNU/gm, petrolatum) ranged from 0.39 to 0.53 (prick test) and 0.42 to 0.69 (CAP-RAST). In healthy control subjects and patients with rhinoconjunctivitis without atopic eczema, no clear-cut positive APT reaction was seen. CONCLUSIONS: Petrolatum as vehicle and an allergen concentration higher than 1000 PNU/gm may lead to improved APT results on unchanged skin. In the future, the clinical relevance of an IgE-mediated sensitization for eczematous skin lesions may be evaluated by the APT.