Environmental assessment and exposure control of dust mites: a practice parameter

1. Advise patients to minimize exposure of susceptible children to dust mite allergens to decrease their risk of developing mite-specific IgE. Because intermittent exposure to mite allergens can lead to sensitization, primary prevention might not be possible to achieve in regions where mite exposure is prevalent. (Strength of recommendation: strong, A evidence)

2. Advise patients to minimize exposure of dust mite sensitized children to dust mite allergens to decrease their risk of developing asthma and possibly rhinitis. (Strength of recommendation: strong, A evidence)

3. Advise dust mite sensitized patients with asthma or rhinitis to minimize exposure to dust mite allergens in addition to avoiding other relevant allergens to which they are sensitized and avoiding irritants, to decrease their risk of developing symptoms. (Strength of recommendation: strong, B evidence for asthma; strength of recommendation: strong, C evidence for rhinitis)

4. Advise patients to minimize exposure of dust mite sensitized children with atopic dermatitis to dust mite allergens, to decrease the symptoms of atopic dermatitis. (Strength of recommendation: moderate, C evidence)

5. Although 5% to 15% of patients who are highly sensitized to dust mite also are sensitized to crustaceans, the clinical significance of this is unknown. For that reason, no recommendations can be made regarding the need to advise crustacean-naive patients about their risk of ingestion. (Strength of recommendation: none, D evidence)

6. Evaluate patients who complain of oral symptoms or symptoms consistent with an IgE-mediated reaction after ingestion of grain flour for dust mite sensitization regardless of whether they have wheat-specific IgE. (Strength of recommendation: moderate, C evidence)

7. Test patients with suspected dust mite allergy for the presence of dust mite specific IgE using a skin prick test or in vitro test for specific IgE. (Strength of recommendation: strong, B evidence)

8. Currently there is no evidence supporting routine measurement of specific IgE to dust mite components, although such measurements may be considered when necessary, such as for patients with potential Der p 10 (tropomyosin as found in cockroach and crustaceans) sensitivity. (Strength of recom- mendation: weak, D evidence)

9. Encourage dust mite eallergic patients to obtain and use a hygrometer to measure humidity in their home. (Strength of recommendation: strong, D evidence)

10. Advise patients that relative humidity in the home should be kept at 35% to 50% to decrease the growth of dust mites. (Strength of recommendation: strong, B evidence)

11. Do not recommend the use of acaricides to eliminate mite populations because of their limited efficacy at lowering allergen levels and concerns about the use of chemical agents in the home. (Strength of recommendation: moderate, B evidence)

12. Tell patients that the use of physical measures to kill mites, such as heating, freezing, and desiccation, theoretically should be effective; however, controlled trials have not been performed to demonstrate clinical benefit when they are used. (Strength of recommendation: weak, D evidence)

13. Advise patients that bedding should be washed weekly to decrease dust mite numbers and mite allergen levels, and that high temperature is not necessary. Home hot water should be kept below the temperature (120 ) causes a scalding risk to occupants. (Strength of recommendation: strong, B evidence)

14. Suggest post intervention measurement of mite allergens in settled dust for homes in which mite-sensitive people live if symptoms persist despite reasonable efforts to decrease mite exposure. (Strength of recommendation: weak, D evidence)

15. Measurement of airborne mite allergens offers no benefit over their measurement in settled dust and therefore should not be recommended. (Strength of recommendation: moderate, C evidence)

16. Recommend regular vacuuming using cleaners that have high-efficiency particulate air (HEPA) filtration or with a central vacuum with adequate filtration or that vents to the outside to decrease exposure to dust mite allergen-containing particles. (Strength of recommendation: strong, B evidence)

17. Recommend that patients should use mite allergene proof mattress, box spring, and pillow encasings to decrease exposure to mite allergens. (Strength of recommendation: strong, B evidence)

18. Discourage members of families with an atopic background from sleeping in bunk beds. If bunk sleeping is necessary, the sensitized person ideally should sleep in the top bed and the top and bottom mattresses (and any fabric-covered “bunky

boards”) should be enclosed in allergen-impermeable encasings. (Strength of recommendation: moderate, B evidence)

19. Do not recommend tannic acid for decreasing mite allergens in carpet dust because it is only marginally effective. (Strength of recommendation: moderate, C evidence)

20. HEPA filtration alone is of uncertain benefit for patients with mite allergy, although it can decrease local exposure to airborne mite allergens and to some irritants. If used, recommend that HEPA cleaners should be placed in areas of mite contamination where air disturbance is likely to suspend particles so that they are available for removal. (Strength of recommendation: weak, C evidence)

21. Recommend a multifaceted approach for dust mite avoidance using a combination of techniques that includes repetitive and sequential interventions shown to decrease mite exposure, as described earlier, for patients with dust mite allergy who are at risk of mite exposure. (Strength of recommendation: moderate, A evidence)

22. Offer subcutaneous immunotherapy to dust mitee allergic patients with rhinitis or mild to moderate asthma if they meet the general criteria for receiving allergen immunotherapy (Strength of recommendation: strong, A evidence for asthma; strength of recommendation: moderate, B evidence for rhinitis)

23. Consider subcutaneous immunotherapy for dust mitee allergic patients with atopic dermatitis if they meet the general criteria for receiving allergen immunotherapy; however, possible exacerbation of the disease during the initial phase of immunotherapy should be discussed with the patient (Strength of recommendation: moderate, A evidence)

24. Patients receiving immunotherapy for dust mite ideally should receive a dose that delivers approximately 7 mg of Der p 1 per injection or 500 to 2,000 AU per injection to obtain an optimal balance between efficacy and safety. (Strength of recommendation: strong, A evidence)

25. US dust mite extracts can be mixed with pollen extracts, including grass and animal dander extracts. Also at mainte- nance immunotherapy concentration, US dust mite extracts can be mixed with fungal or cockroach extracts when glycerin content is kept at 10%. (Strength of recommendation: moderate, LB evidence)

26. Recommend 3 to 5 years of immunotherapy to obtain the maximum benefit from immunotherapy for dust mite induced asthma and rhinitis. (Strength of recommendation: moderate, A evidence)

27. Certain protocols and dosages of sublingual immunotherapy have been shown to be safe and effective for dust mite allergic patients with rhinitis, mild to moderate asthma, and/or atopic dermatitis; however, because there currently is no Food and Drug Administration approved product available in the United States, its use should not be recommended until such a product becomes available. (Strength of recommendation: moderate, A evidence)