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A 14-year-old boy presents to your clinic with year-round symptoms of sneezing, congestion, nasal discharge, and watery eyes. His symptoms seem to be worse after spending extended periods of time in his bedroom. He is healthy otherwise. On physical exam, he has pale nasal turbinates and moderate clear rhinorrhea. Skin prick shows a positive reaction to dust mite. What would you recommend to him initially?

A. Oral antihistamine

B. Oral leukotriene receptor antagonist

C. Intranasal steroids

D. Avoidance measures, frequent vacuuming, dust mite pillow and mattress encasement, washing beddings weekly, and an oral antihistamine

E. Immunotherapy to dust mite

Answer: D

The patient has perennial allergic rhinitis (AR) from dust mite allergy based on the history and skin test result. Optimal management of AR requires preventative measures to minimize exposure to allergens together with judicious use of pharmacologic agents to alleviate symptoms. Avoidance measures, such as dust mite mattress and pillow encasements, controlling humidity at home, frequent vacuuming, and washing bedding weekly, as well as use of a high-efficiency particulate arrestance (HEPA) filter, can be part of this first step.

Histamine is produced by mast cells and mediates many allergic symptoms, including AR. Antihistamines are generally safe and can be used in children. It is recommended to use preventative measures together with pharmacologic agents, such as antihistamines, as the optimal management to treat AR in children.

Leukotrienes are involved in allergic inflammation. They are comparable in terms of effectiveness as oral antihistamines. They are also generally safe to use in children.

Intranasal steroids are very effective anti-inflammatory drugs used to treat AR. They are more effective than anti-histamines and leukotriene receptor antagonist. However, their side effects make them less attractive for use in children.

Immunotherapy is a very effective therapy for AR. However, this is a time-consuming therapy that requires a lot of commitment. It is recommended for patients who have failed avoidance measures and medications to treat AR.

A 4-year-old boy with allergic rhinitis (AR) and sensitivities on skin-prick testing to tree, grass, ragweed, and dust mite presents to clinic for follow-up. His parents report that avoidance measures, antihistamines, and intranasal steroids have not been sufficient to control his symptoms. He has missed multiple days of school due to his symptoms. The family is interested in immunotherapy. What advice might you provide to the family?

A. He is not a good candidate for immunotherapy because patients need to demonstrate at ...

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