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\begin{document}

\title{Comment on Platts-Mills T, Caraballo L, Jacquet A, Zarzuk J. Dust mite
allergy. In: Dramburg S, Hilger C, Santos AF, de Las Vecillas L,
Aalberse RC, Acevedo N, et al. EAACI Molecular Allergology User's Guide
2.0. Pediatr Allergy Immunol. 2023 Mar;34 Suppl. 28:e13854.}



\author[1]{Ruperto González}%
\author[1]{Paloma Poza-Guedes}%
\author[2]{Fernando Pineda}%
\affil[1]{Hospital Universitario de Canarias}%
\affil[2]{Inmunotek SL}%


\vspace{-1em}



  
  \date{May 23, 2024}


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Comment on Platts-Mills T, Caraballo L, Jacquet A, Zarzuk J. Dust mite
allergy. In: Dramburg S, Hilger C, Santos AF, de Las Vecillas L,
Aalberse RC, Acevedo N, et al. EAACI Molecular Allergology User's Guide
2.0. Pediatr Allergy Immunol. 2023 Mar;34 Suppl. 28:e13854.

\emph{To the Editor,}

We read with great interest your chapter from the EAACI Molecular
Allergology User\selectlanguage{ngerman}´s Guide 2.0, entitled: Dust mite allergy {[}1{]}. The
development of Component Resolved Diagnosis (CRD) has efficiently
contributed to identify genuine sensitization to a panel of eliciting
allergens, thus allowing subsequent clinical decisions to an
individualized therapy. Given that two possible decision algorithms have
been proposed for mite allergy in both temperate and tropical countries
-including 4 and 7 individual molecules, respectively- several
complementary considerations could be addressed.

Firstly, since environmental variations, in climate warming and
industrialization are becoming a more globalized concern, changes in the
human allergen exposome are likely expected. Moreover, it has been
speculated that these changes may affect mite metabolism, leading to an
increased indoor allergen production worldwide and possibly a shift in
their species {[}2{]}. This is the case for \emph{Blomia tropicalis}
and\emph{Lepidoglyphus} \emph{destructor} (Glycyphagoidea family),
formerly considered as marginal storage mites with a limited allergenic
cross-reactivity with Pyroglyphidae mites, but currently showing as
relevant markers for atopic disease under specific weather conditions
{[}3{]}. As atopic pheno-endotypes are steadily evolving under a
changing allergen exposome, a decision approach -including an algorithm
with a larger number of commercially available individual molecules as
Der p 5, Der p 7 and/or Der p 21- is specially warranted in those
locations with a preponderant rate (up to 80\%) of polysensitized
subjects suffering from allergic rhinitis and/or asthma (Figure 1). In
addition, as polysensitization has a confirmed impact on the clinical
expression and severity of allergic disease {[}4{]}, the inclusion of
Lep d 2 from \emph{Lepidoglyphus} \emph{destructor} in our proposed
algorithm (Figure 2) may be of interest not only under tropical and
subtropical climate conditions but also the as a potential emerging
allergen source in temperate countries {[}5{]}.

Secondly, the description of locally serodominant allergens -Der p 7-
and the subsequent identification of clinically relevant allergens
-i.e., IgE binding molecules as Der p 5 with a defined allergenic
activity- is nowadays paving the road to a personalized management of
allergic diseases. Despite a perfect molecular matching between
patient´s IgE sensitization profile and allergen immunotherapy (AIT)
composition is ideally sought, a wide range of variations in the
representation of individual molecules in an extract is currently
allowed according to European guidelines {[}6{]}. In this regard, CRD
has greatly contributed to improve success of AIT only for those house
dust mite (HDM)-allergic patients who were exclusively sensitized to
specific molecules -i.e. Der p 1 and/or Der p 2- but not for patients
with a sensitization to other HDM allergens {[}7{]}. Therefore, the use
of standardized extracts of good quality with documented clinical
evidence -i.e. proven safety and efficacy- comprising those relevant
molecules present in the local allergen exposome, highlights the
importance of individualized care to AIT success. In fact, despite Der p
1, Der p 2 and/or Der p 23 account for more than 80\% of the specific
IgE to \emph{Dermatophagoides pteronyssinus} {[}1{]}, the absence of
evidence regarding a concurrent sensitization to the so-called mid-tier
allergens -i.e Der p 5, Der p 7 and/or Der p 21- may not be considered a
formal contraindication for AIT in selected cases.

Provided that AIT is still used in less than 10\% of subjects with
allergic respiratory diseases {[}6{]}, the progressive availability and
knowledge of allergenic molecules favors a better understanding of the
different sensitization profiles to benefit a broader number of patients
from the only potential disease-modifying therapy.

Ruperto González-Pérez\textsuperscript{1,2}, Paloma
Poza-Guedes\textsuperscript{1,2}, Fernando Pineda\textsuperscript{3}

\textsuperscript{1} Allergy Department, Hospital Universitario de
Canarias, Tenerife, Spain.

\textsuperscript{2} Severe Asthma Unit, Hospital Universitario de
Canarias, Tenerife, Spain.

\textsuperscript{3} Inmunotek SL Laboratories, Madrid, Spain.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Dramburg S, Hilger C, Santos AF, de Las Vecillas L, Aalberse RC,
  Acevedo N, et al. EAACI Molecular Allergology User's Guide 2.0.
  Pediatr Allergy Immunol. 2023 Mar;34 Suppl. 28:e13854.
\item
  Acevedo N, Zakzuk J, Caraballo L. House Dust Mite Allergy Under
  Changing Environments. Allergy Asthma Immunol Res. 2019
  Jul;11(4):450-469.
\item
  González-Pérez R, Poza-Guedes P, Pineda F, Castillo M, Sánchez-Machín
  I. Storage Mite Precision Allergy Molecular Diagnosis in the
  Moderate-to-Severe T2-High Asthma Phenotype. Int J Mol Sci. 2022 Apr
  13;23(8):4297.
\item
  Demoly P, Passalacqua G, Pfaar O, Sastre J, Wahn U. Management of the
  polyallergic patient with allergy immunotherapy: a practice-based
  approach. Allergy Asthma Clin Immunol. 2016 Jan 11;12:2.
\item
  Ojeda P, Sastre J, Olaguibel JM, Chivato T; investigators
  participating in the National Survey of the Spanish Society of
  Allergology and Clinical Immunology Alergológica 2015. Alergológica
  2015: A National Survey on Allergic Diseases in the Adult Spanish
  Population. J Investig Allergol Clin Immunol. 2018 Jun;28(3):151-164.
\item
  Alvaro-Lozano M, Akdis CA, Akdis M, Alviani C, Angier E, Arasi S, et
  al. EAACI Allergen Immunotherapy User's Guide. Pediatr Allergy
  Immunol. 2020 May;31 Suppl 25(Suppl 25):1-101.
\item
  Chen KW, Zieglmayer P, Zieglmayer R, Lemell P, Horak F, Bunu CP,
  Valenta R, Vrtala S. Selection of house dust mite-allergic patients by
  molecular diagnosis may enhance success of specific immunotherapy. J
  Allergy Clin Immunol. 2019 Mar;143(3):1248-1252.e12.
\end{enumerate}

\textbf{Figures and legends:}

\textbf{Figure 1:} Possible decision algorithm for mite allergic
rhinitis/asthma in temperate countries. SPT: Skin Prick Test. CRD:
Component Resolved Diagnosis. Dp: \emph{Dermatophagoides
pteronyssinus}extract. Df: \emph{Dermatophagoides farinae} extract. AIT:
Allergen Immunotherapy. CH: Clinical History. CRD Dp/Df*: Der p 1, Der p
2, Der p 5, Der p 7, Der p 10, Der p 21, and Der p 23. Molecular profile
A: Der p 1/Der p 2 and/or Der p 23, and/or Der p 5, and/or Der p 7
and/or Der p 21.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 2:} Possible decision algorithm for mite allergic
rhinitis/asthma in subtropical and tropical countries. SPT: Skin Prick
Test. CRD: Component Resolved Diagnosis. Dp: \emph{Dermatophagoides
pteronyssinus} extract. Df: \emph{Dermatophagoides farinae} extract.
Bt:\emph{Blomia tropicalis} extract. Ld: \emph{Lepidoglyphus
destructor}extract. AIT: Allergen Immunotherapy. CH: Clinical History.
CRD Dp/Df*: Der p 1, Der p 2, Der p 5, Der p 7, Der p 10, Der p 21, and
Der p 23. CRD Bl**: Blo t 5, Blo t 10, and Blo t 21. CRD
Lp\textsuperscript{\$}: Lep d 2. Molecular profile A: Der p 1/Der p 2
and/or Der p 23, and/or Der p 5, and/or Der p 7 and/or Der p 21.
Molecular profile B: Blo t 5 and/or Blo t 21.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

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