House dust mite
Summary
DermatophagoidesSummary pteronyssinus (Der p) is a house dust mite specie originally found in house dust. This domestic mite is highly allergenic, and exposure to its allergens in sensitized individuals is one of the most common cause of respiratory allergic diseases in the world. The main exposure route is inhalation and symptoms typically affects the upper and lower airways and eyes, causing allergic rhinitis, asthma, and sometimes anaphylaxis. Exposure via the skin can cause atopic dermatitis. Several Der p allergens have been characterized and are present on airborne fecal and body particles. Extensive IgE cross-reactivity exists between Der p and other house dust mite species. Partial cross-reactivity has been demonstrated to storage mite species. Cross-reactivity also exists among allergens in Der p and related arthropods including crustaceans (shrimp, crab, and lobster) and insects (cockroach, grasshopper), as well as members of the mollusk phylum (snails, clams, oysters, and squid. Management of house dust mite allergy includes avoidance, pharmacotherapy and specific allergen immunotherapy (AIT).
Epidemiology
Worldwide distribution
Dust mites are found worldwide, except in cold, dry high-altitude regions, polar areas, and extremely arid desert zones. House dust mites thrive in temperate climates, particularly in households and dwellings with damp and humid conditions. Allergens from the species D. pteronyssinus and D. farinae are commonly found in dust samples from homes, indicating the presence of both species in the same environment. Within any given geographical area, dust mites vary in their distribution among specific regions and with the seasons. D. farinae can tolerate dryer environmental conditions. D. pteronyssinus tends to be more abundant in Europe than in the United States. In northern areas of Europe where the climate is extremely dry, dust mites may not survive the winter.
High altitude is generally inhospitable to house dust mites, which may partly explain why, before the discovery of dust mites, sanitaria for asthma and other respiratory diseases were often built at high altitudes, such as the Alps in Europe and Colorado in the USA. Dust mite growth and sensitization are much lower in the Alps than at sea level, the apparent result of the lower indoor humidity at high altitude.
Living environment
Dust mites are most prevalent in households, where they thrive in dark environments and burrow deep into soft substrates like carpets, pillows, mattresses, and clothing. A higher mite allergen exposure has been correlated with higher education, higher household income, and lower population density in the home. Mite allergen levels are reported higher in older homes and non-air conditioned dwellings. A study from China found significant enrichment of house dust mite major allergens in air-conditioner filters located in dining rooms, shopping malls, hotels, and households. The concentration of Der p 1 in the air increased notably one hour after the air-conditioners were turned on.
Route Of Exposure
Main route
House dust mite allergens trigger allergic reactions primarily through inhalation of mite fecal particles and body fragments, which become airborne after disturbances like vacuuming or making the bed.
Other routes
Other routes include direct skin contact with contaminated bedding or furniture and accidental ingestion of mite particles by consumption of contaminated foods.
Clinical Relevance
Allergic rhinitis
Significant proportions of the allergic rhinitis patients and chronic rhinosinusitis patients with allergy are sensitized to house dust mites. The link between allergen sensitization and symptoms can be demonstrated using nasal challenge with mite allergen, which produces obstruction and rhinorrhea that correlate with mite skin test reactivity.
Information on the occurrence of ocular symptoms in association with allergic rhinitis is sparse, but one study of patients with allergic rhinitis to a variety of allergens including dust mites, found that most individuals also had ocular involvement with symptoms of pruritus, tearing, conjunctival injection, and eyelid edema.
Asthma
Dust mites including D pteronyssinus are one of the most frequent causes of respiratory allergies and mite exposure is a very important factor eliciting exacerbations of asthma.
Mite allergen exposure as a trigger to exacerbate existing asthma has been clearly and repeatedly demonstrated. The inhalation of dust mite allergen can have effects beyond bronchospasm, decreasing mucociliary clearance and thus increasing the deposition of other inhaled particles. The combination of mite sensitization and mite exposure together correlate with the severity of asthma symptoms, with increased exhaled nitric oxide and bronchial hyper-reactivity and with acute exacerbations resulting in admission to hospital.
Sensitization to Dermatophagoides mites also appears to exacerbate asthma attacks in children suffering from rhinovirus infections. The addition of viral infection to allergen exposure in mite-sensitized individuals results in more severe attacks with acute wheezing and hospitalization.
Mite allergy is a major risk factor for asthma and mite sensitization early in life has a significant impact on subsequent pulmonary function. One multicenter, birth cohort study followed 1314 children from birth to 13 years of age. Asthma symptoms and lung function, specific IgE, and perennial allergen exposure (mite, cat and dog dander) were assessed at regular intervals. The great majority (90%) of children with wheeze but no sensitization had lost their symptoms by school age and retained normal lung function at puberty. In contrast, sensitization to perennial allergens including mite, which developed in the first 3 years of life was correlated with compromised lung function at school age. Sensitization and exposure occurring later than 3 years of age resulted in much weaker effects on lung function, and sensitization to seasonal allergens such as pollens had no effect on subsequent lung function.
Atopic Dermatitis
The prevalence of sensitization to mites can be very high in patients with atopic dermatitis. The increase in the permeability of atopic skin and the ability of mite proteases to decrease skin barrier function may allow more effective sensitization with aeroallergens, initiating a cycle of inflammation and further allergen exposure.
Other diseases
Systemic allergic symptoms, sometimes severe, can occur after inadvertent ingestion of dust mites present in a food that has been colonized by mites, referred to as oral mite anaphylaxis. This was first reported in 1993, in a patient who ate a fried pastry made from flour that had been contaminated with D. farinae mites. Subsequently, multiple cases of systemic allergy have been reported in mite sensitized patients who ate a variety of foods made with mite-contaminated foods including pancakes, wheat and corn flour, grits and pizza. Storing any opened packages of baked goods mixes, grains, or flour in a refrigerator will prevent the growth of mite populations.
Diagnostics
In vitro diagnostics
Mite allergy diagnosis involves a physical examination and medical history review to identify associations between mite exposure and symptoms. Confirmation of Der p sensitization is achieved through in vitro specific IgE testing and skin prick testing. Specific IgE testing may be preferred over skin prick testing for individuals taking medications that could interfere with skin test results, such as certain antihistamines, or for those with skin conditions like dermatitis.
A systematic review and meta-analyses of eight studies involving 1,095 patients supported the use of Der p 1 and Der p 2 IgE as useful tools to aid in the diagnosis of Der p allergic rhinitis and/or allergic asthma, detecting sensitization in approximately 80-90% of patients who are allergic to house dust mites.
Prevention And Therapy
Prevention strategies
Avoidance
The effects of house dust mite reduction and avoidance measures on asthma, rhinitis, and eczema, have been assessed in systematic reviews following the Cochran Review methodology and criteria. In the Cochrane avoidance review on asthma, several trials were included involving in total 1,421 participants. The review on rhinitis included 9 randomized controlled trials involving 501 participants and for eczema, 7 randomized controlled studies were included in the final review.
Prevention of sensitization
Current Cochrane review evidence does not strongly support the effectiveness of avoidance measures in preventing sensitization to house dust mites. Zuiani (2020) reports that some studies have shown significant reductions in asthma exacerbations and symptoms with multi-faceted allergen avoidance approaches. However, these findings are more related to symptom reduction rather than the prevention of sensitization. Similarly, Sheikh (2010) concluded that while acaricides and extensive bedroom-based environmental control programs might reduce symptoms of allergic rhinitis, there is no strong evidence to support their effectiveness in preventing sensitization. Nankervis (2015) also reported that there is no clear evidence that house dust mite reduction and avoidance measures can prevent sensitization to house dust mites. However, the Nankervis 2015 review indicates that trials examining this question have been small and of low quality, making it difficult to draw definitive conclusions.
Reduction of allergic symptoms
In Zuiani (2020) several studies are reported to have shown significant reductions in asthma exacerbations, symptoms and acute health care visits after multi-faceted avoidance approaches targeting multiple allergens, including house dust mites. Effective strategies for allergen avoidance, particularly for house dust mites, include using mite-impermeable bedding covers, vacuum cleaners with HEPA filters, extensive bedroom-based environmental control programs, education on allergen avoidance and smoke exposure reduction, and combining physical barriers, acaricides, laundry services, and tailored education. Overall, a multi-faceted set of measures tailored to the patient's characteristics and home exposures was recommended to achieve the greatest reduction in allergen exposure and improving asthma symptoms.
The evidence supporting the effectiveness of house dust mite avoidance measures in managing perennial allergic rhinitis is limited. Some studies indicate that acaricides and comprehensive bedroom-based environmental control programs may alleviate rhinitis symptoms. However, the Cochrane review highlights the need for more high-quality research to confirm these findings and provide definitive recommendations for the use of house dust mite reduction and avoidance measures in managing perennial allergic rhinitis.
The Cochrane evidence regarding the effectiveness of house dust mite reduction and avoidance measures in managing eczema was found limited and inconclusive. Seven randomized controlled trials involving 324 adults and children with eczema were reviewed, including interventions like mattress and bedding covers, high-quality vacuuming, and mite-killing sprays. The trials did not provide sufficient evidence to recommend any specific measures, with no significant clinical benefit observed. The Cochrane review highlights the need for high-quality, long-term trials of simple interventions to assess the effectiveness of house dust allergen reduction and avoidance in managing eczema.
Allergen immunotherapy
Specific allergen immunotherapy (AIT) is a treatment option for house dust allergic patients with allergic rhinitis and allergic asthma. AIT is available in two main forms: subcutaneous immunotherapy (SCIT) administered via injections and sublingual immunotherapy (SLIT) taken under the tongue.
A recent real-world evidence study involving 7,260 patients with house dust mite AIT prescriptions and 21,780 control patients demonstrated that subcutaneous AIT reduces the need for medication to treat allergic rhinitis and allergic asthma. Additionally, it was found to delay the onset of asthma medication in patients with allergic rhinitis.
In the past decade, sublingual AIT tablets targeting house dust mite allergies have been developed and received regulatory approvals. These AIT tablets have demonstrated efficacy and safety in treating house dust mite induced allergic rhinitis in adults and children, as well as adult asthma.
A systematic review including 23 randomized controlled trials with 1, 957 patients across 13 countries evaluated the effectiveness of sublingual and subcutaneous AIT for atopic dermatitis (AD). The findings suggest that AIT likely improves AD severity, itch, and sleep disturbance, with moderate-to-high certainty evidence for several outcomes. SCIT was associated with a modest increase in adverse events, while SLIT had fewer side effects. The review highlights the potential benefits of AIT for long-term AD control and calls for further research to optimize treatment protocols and understand long-term impacts.
Component-resolved diagnosis (CRD) using major allergens Der p 1 and Der p 2 may allow the identification of those patients who are best suited for house dust mite AIT immunotherapy and a diagnostic algorithm integrating house dust mite allergenic molecules has been developed.
Specific IgG4 to induced by house dust mite AIT can be useful to confirm successful immunological stimulation against Der p molecules and delivery of AIT earlier in life may be associated with a greater increase in Der p specific IgG4. However, there is currently no firm clinical evidence that levels of specific IgG4 can predict or serve as biomarker for clinical efficacy in individual patients receiving AIT.
Cross-Reactivity
Studies have demonstrated almost complete IgE cross-reactivity between extracts of Der p and Der f and partial or low cross-reactivity between Der p and storage mites Lepidoglyphus destructor, Glycyphagus domesticus, Tyrophagus putrescentiae, Acarus siro and Blomia tropicalis. The group 1 and group 2 major allergens of Der p of Der f show high degree of IgE cross-reactivity.
Cross-reactivity also exists among allergens in dust mites and related arthropods including crustaceans (shrimp, crab, and lobster) and insects (cockroach, grasshopper), as well as members of the mollusk phylum (snails, clams, oysters, and squid). A pan-allergen responsible for these IgE cross-reactions to invertebrates is the muscle protein tropomyosin. In D. pteronyssinus mites, tropomyosin is represented by Der p 10 which shares sequence homology with shrimp tropomyosin Pen a 1, American cockroach tropomyosin Per a 7, and lobster tropomyosin Hom a 1. However, it is likely that tropomyosin is not the only relevant cross-reacting allergen, as there exist dust mite sensitive patients with shrimp allergy but not snail allergy, or with snail allergy but not shrimp allergy .
Explained Results
Allergen information
House dust mite Der p is an important indoor source of allergens, thriving in humid environments, beds and carpets. Allergens are present on mite fecal and body particles. Der p 1 and Der p 2 are the major allergens of Der p. Close to forty Der p allergens have been characterized.
Clinical relevance
Specific IgE to Der p is associated with allergic rhinitis, asthma, atopic dermatitis, and less frequently with symptoms following the intake of food contaminated by mites.
Cross reactivity
Extensive IgE cross-reactivity exists between extracts of Der p and Der f and partial or low cross-reactivity between Der p and storage mites. Cross-reactivity also exists among allergens in dust mites and related arthropods including crustaceans (shrimp, crab, and lobster) and insects (cockroach, grasshopper), as well as members of the mollusk phylum (snails, clams, oysters, and squid.
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