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House dust mite sublingual immunotherapy seems more effective in children than adolescents and adults with allergic rhinitis

Published online by Cambridge University Press:  02 January 2026

Bingfeng Huang Open the ORCID record for Bingfeng Huang [Opens in a new window]  and
Wei Chen
Bingfeng Huang*
Affiliation:
Department of Otolaryngology, Head and Neck Surgery, Anji County Hospital of Chinese Medicine, Huzhou, Zhejiang, China
Wei Chen
Affiliation:
Department of Otolaryngology, Head and Neck Surgery, Anji County Hospital of Chinese Medicine, Huzhou, Zhejiang, China
*
Corresponding author: Bingfeng Huang; Email: 15205726162@sohu.com
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Abstract

Objective

To evaluate the efficacy differences of house dust mite sublingual immunotherapy in allergic rhinitis patients of different ages.

Methods

Ninety-two patients who underwent 1 year of house dust mite sublingual immunotherapy were retrospectively analysed and divided into groups of children (<14 years, n = 46) and adolescents and adults (≥14 years, n = 46). The total nasal symptoms, total medication, combined symptom and medication, and mini Rhinoconjunctivitis Quality of Life Questionnaire scores were assessed.

Results

Significant improvements were displayed after sublingual immunotherapy treatment compared with baseline (p < 0.001). In particular, children exhibited more pronounced improvements on each indicator than adolescents and adults at the end of 1 year of sublingual immunotherapy treatment (p < 0.05). Meanwhile, correlation analysis revealed that the mini Rhinoconjunctivitis Quality of Life Questionnaire score has positive correlations with the total nasal symptoms, total medication, and combined symptom and medication scores (all p < 0.001).

Conclusion

More notable improvements were seen in children than in adolescents and adults with allergic rhinitis after one year of house dust mite sublingual immunotherapy treatment.

Keywords

rhinitisDermatophagoides farinaesublingual immunotherapy

Information

Type
Main Article
Information
The Journal of Laryngology & Otology , Volume 140 , Issue 3 , March 2026 , pp. 258 - 263
Copyright
© The Author(s), 2026. Published by Cambridge University Press on behalf of J.L.O. (1984) LIMITED.

Introduction

Allergic rhinitis is a common chronic inflammatory disease of the upper respiratory tract that affects 10‒40 percent of the global population.Reference CF and Montejo1, Reference Wise, Damask, Roland, Ebert, Levy and Lin3 It is characterised by one or more symptoms including sneezing, itching, nasal congestion and rhinorrhoea. Moreover, house dust mites have been established to constitute the most common allergen in China and account for 83.7 percent of cases involving allergic airway diseases.Reference Zhang, Zhang, Liu, Zhang, Yang and Gao4, Reference Wang, Zheng, Lou, Wang, Zhang and Bo5 Allergic rhinitis itself evolves with age and this process can manifest as early as the second year of life.Reference Wise, Lin, Toskala, Orlandi, Akdis and Alt6 Once allergy develops, symptoms typically persist, often into adulthood.Reference Roditi and Shin7, Reference Savran, Bønnelykke and Ulrik8 Up to 80 percent of cases with allergic rhinitis develop symptoms before the age of 20 years.Reference Skoner9 In this way, because of the natural course of allergic disease, adults may showed more complicated situations, including poly-sensitisation pattern, longer duration of disease, more severe symptoms and greater use of medicine than children.Reference Ma, Wang, Zhuang, Shi, Ning and Lan10, Reference Sousa-Pinto, Valiulis, Melén, Koppelman, Papadopoulos and Makela12

Allergen immunotherapy, the aetiological treatment for allergic diseases, which can modify the immune system, has been used in China for over a decade.Reference Alvaro-Lozano, Akdis, Akdis, Alviani, Angier and Arasi13 For house dust mite sublingual immunotherapy in particular, multiple studies have confirmed its tolerability and significant efficacy in both adult and paediatric allergic rhinitis patients, with improving symptoms and quality of life, and reduced medication requirements.Reference Li, Xiao, Zeng, Tang, Zhou and Liu14, Reference Chen, Lin, Yan, Xu and Chai16 However, there is still limited research on the clinical efficacy and safety of sublingual immunotherapy in patients of different ages.Reference Ai, Zhang, Luo, Fan, Xia and Wang17

In human development, the immune system grows and matures with age. Initiation of sublingual immunotherapy in early childhood is associated with a clinically meaningful and permanent reduction in new cases of allergic asthma and lower healthcare costs among children with allergic rhinitis, indicating its long-term clinical benefits.Reference Hamelmann, Hammerby, Scharling, Pedersen, Okkels and Schmitt18 Meanwhile, adult allergic rhinitis patients tend to exhibit poorer treatment responses.Reference Chen, Chen, Lin, Huang, Liu and Zheng19 To further investigate the impact of age on the efficacy of house dust mite sublingual immunotherapy, this retrospective study was designed to directly compare the improvements in symptoms, medication usage and quality of life in paediatric and adolescent and adult allergic rhinitis patients after one year of treatment.

Methods

Study design

This retrospective and single-centre study was approved by the Medical Ethics Committee of Anji County Hospital of Chinese Medicine (Chairperson Hong Zhao) on 25 October 2021 (approval number: 010, 2021). All participants signed written informed consent. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

The patients were categorised as children (<14 years old, n = 46) or adolescents and adults (≥14 years old, n = 46) according to their age.

All patients underwent sublingual immunotherapy for one year with standardised Dermatophagoides farina drops (Huzhou, Zhejiang, China, Chanllergen, Zhejiang Wolwo Bio-Pharmaceutical Co., Ltd). The drops were administered according to the manufacturer’s instructions. The treatment process was conducted in two phases: an up-dosing phase and a maintenance phase. No. 1 (1 μg/ml), No. 2 (10 μg/ml) and No. 3 (100 μg/ml) were administered during the initial 3 weeks and 1, 2, 3, 4, 6, 8 and 10 drops were given each day for a week. Three drops per day of No. 4 (333 μg/ml) were administered during weeks 4 and 5, and 2 drops per day of No. 5 (1000 μg/ml) were administered from week 6 until the treatment was completed. Those in the children group were administered the drops under the supervision of their guardians. The first dose was taken under clinical supervision that lasted for at least 30 minutes. All patients were required to take a dose daily, keep the drops under the tongue for 1 to 3 minutes before swallowing and instructed not to drink within 15 minutes.

Study subjects

The complete data for 92 allergic rhinitis patients aged from 4 to 55 years who received 1 year of sublingual immunotherapy with standardised Dermatophagoides farina drops at the Anji County Hospital of Chinese Medicine from October 2021 to November 2022 were collected and collated. The treatment criteria of sublingual immunotherapy were as follows20: (1) patients diagnosed with moderated to severe persistent allergic rhinitis and aged 4–60 years; (2) patients only sensitised to Dermatophagoides farina, confirmed by the positive presence of skin prick test ≥ + + (patients with multiple sensitisations were excluded); (3) patients without severe systemic diseases such as poorly controlled cardiovascular diseases, immune diseases or malignant tumours, receiving β-blockers or angiotensin-converting enzyme inhibitors, serious psychological barriers or who failed to understand the risks and limitations of treatment, patients who were pregnant or lactating.

Clinical efficacy

The total nasal symptoms, total medication, combined symptom and medication, and mini Rhinoconjunctivitis Quality of Life Questionnaire scores of the two groups at baseline, 0.5 and 1 year of sublingual immunotherapy were assessed based on patient files and follow-up records.

A 4-point rating scale (0–3 points; 0 = asymptomatic, 1 = mild symptoms, 2 = moderated symptoms, 3 = severe symptoms) was used to assess four nasal symptoms (sneezing, rhinorrhoea, nasal itching and nasal obstruction). The total nasal symptoms score is the sum of the four symptom scores, ranging from 0 to 12 points.Reference Canonica, Baena-Cagnani, Bousquet, Bousquet, Lockey and Malling21

Patients were prescribed symptomatic medication to alleviate allergic rhinitis symptoms, including oral H1 antihistamines, oral leukotriene receptor antagonist, intranasal corticosteroids or oral corticosteroids. Medications were scored on the basis of the World Allergy Organization guidelines: 0 = none, 1 = oral antihistamines or leukotriene receptor antagonist, 2 = intranasal corticosteroids, 3 = oral corticosteroids. The total medication score was expressed as the highest scores for medication scores, ranging from 0 to 3 points.Reference Pfaar, Demoly, Gerth van Wijk, Bonini, Bousquet and Canonica22 The combined symptom and medication score is the sum of the average of the four nasal symptom and medication scores: combined symptom and medication score is equal to total nasal symptoms score/4 plus total medication score, which was used to reflect the severity of symptoms and medication intake simultaneously.

The mini Rhinoconjunctivitis Quality of Life Questionnaire score (0–6 points) reflects the impact of allergic rhinitis symptoms on the quality of life. The mini Rhinoconjunctivitis Quality of Life Questionnaire has 14 items in 5 dimensions: activities, practical problems, nose symptoms, eye symptoms and other symptoms. Patients were required to respond to each item based on a 7-point scale (0 = no impairment, 6 = severe impairment).Reference Juniper, Thompson, Ferrie and Roberts23 The overall mini Rhinoconjunctivitis Quality of Life Questionnaire score was obtained by averaging 14 items.

In addition, to directly compare the clinical efficacy of children and adolescent and adult patients, the change in the total nasal symptoms score 0.5 and the change in the total nasal symptoms score 1 were defined as the improvement percentage in total nasal symptoms scores from baseline to 0.5 and 1 year of sublingual immunotherapy treatment, with a similar definition for the change in the total medication score 0.5, the change in the total medication score 1, the change in the combined symptom and medication score 0.5, the change in the combined symptom and medication score 1, the change in the mini Rhinoconjunctivitis Quality of Life Questionnaire 0.5 and the change in the mini Rhinoconjunctivitis Quality of Life Questionnaire 1

Statistical analysis

Statistical analysis was performed using SPSS 26.0 software (IBM Corp, Armonk, NY, USA). The differences in baseline demographic characteristics, including family history of allergic rhinitis and grade of skin prick test, between the children and adolescents and adults group were analysed by the chi-square test. The intra- and inter-group comparisons of clinical characteristics were performed by the Friedman M test and the Mann–Whitney U test, respectively. The Pearson coefficient was calculated for the correlation between the different clinical outcomes. Graphs were generated using Graphpad Prism 8.0 software (La Jolla, USA). All tests were two-tailed and p less than 0.05 was considered statistically significant.

Results

Population characteristics

A total of 92 house dust mite-induced allergic rhinitis patients were included in this study, with 46 children and 46 adolescents and adults. The demographic characteristics of the population at baseline are shown in Table 1. There were no significant differences in family history of allergic diseases and grade of skin prick test (all p > 0.05; Table 1). Compared with paediatric patients in the children group, greater severity of symptoms, more medication usage and worse quality of life were observed in the adolescents and adults group, manifesting in the items of clinical characteristics including total nasal symptoms, total medication, combined symptom and medication, and mini Rhinoconjunctivitis Quality of Life Questionnaire scores (all p < 0.05).

Table 1.

Baseline characteristics

* Grade of skin prick test: the area of Dermatophagoides farina tested wheel divided by the area of standard positive control solution

Efficacy assessment

Clinical efficacy of sublingual immunotherapy in the children and adolescents and adults groups

The values of the total nasal symptoms, total medication, combined symptom and medication, and mini Rhinoconjunctivitis Quality of Life Questionnaire scores decreased significantly after 0.5 and 1 year of sublingual immunotherapy treatment compared with the baseline in both the children (all p < 0.001; Figure 1a) and adolescents and adults (all p < 0.001; Figure 1b) groups. In addition, continuous improvements were observed in the four efficacy indicators after 1 year of sublingual immunotherapy compared with 0.5 years of sublingual immunotherapy in the two groups (all p < 0.001; Figure 1).

Figure 1.

Comparison of TNSS, TMS, CSMS and the mini RQLQ in (a) the children group and (b) the adolescents and adults group at baseline, 0.5 and 1 year of sublingual immunotherapy. ***p less than 0.001 indicates a significant difference compared with baseline. TNSS = total nasal symptoms score; TMS = total medication score; CSMS = combined symptom and medication score; Mini-RQLQ = mini Rhinoconjunctivitis Quality of Life Questionnaire.

Comparison of clinical efficacy between the children and adolescents and adults groups

There were no statistically significant differences in the values of the change in the total nasal symptoms score 0.5, the change in the total medication score 0.5, the change in the combined symptom and medication score 0.5, and the change in the mini Rhinoconjunctivitis Quality of Life Questionnaire 0.5 between the children and adolescents and adults groups (p > 0.05; Figure 2a–d). However, with the continuation of sublingual immunotherapy treatment, the improvement percentages of all indicators at 1 year were significantly higher in children than in adolescents and adults (all p < 0.05; Figure 2a–d).

Figure 2.

Comparison the levels of the change in (a) total nasal symptoms score, (b) total medication score, (c) combined symptom and medication score and (d) mini Rhinoconjunctivitis Quality of Life Questionnaire score at 0.5 and 1 year of sublingual immunotherapy between the children group and the adolescents and adults group. △TNSS 0.5 = the improvement percentage in total nasal symptoms score from baseline to 0.5 year of sublingual immunotherapy; △TNSS 1 = the improvement percentage in total nasal symptoms score from baseline to 1 year of sublingual immunotherapy; △TMS 0.5 = the improvement percentage in total medication score from baseline to 0.5 year of sublingual immunotherapy; △TMS 1 = the improvement percentage in total medication score from baseline to 1 year of sublingual immunotherapy; △CSMS 0.5 = the improvement percentage in combined symptom and medication score from baseline to 0.5 year of sublingual immunotherapy; △CSMS 1 = the improvement percentage in combined symptom and medication score from baseline to 1 year of sublingual immunotherapy; △mini-RQLQ 0.5 = the improvement percentage in mini Rhinoconjunctivitis Quality of Life Questionnaire score from baseline to 0.5 year of sublingual immunotherapy; △ mini-RQLQ 1 = the improvement percentage in mini Rhinoconjunctivitis Quality of Life Questionnaire score from baseline to 1 year of sublingual immunotherapy. *p less than 0.05 indicates a significant difference between the children group and the adolescents and adults group.

Correlation analysis

The correlations between the mini Rhinoconjunctivitis Quality of Life Questionnaire and the other clinical outcomes were calculated from data including baseline, 0.5 and 1 year of treatment. As shown in Figure 3, positive correlations of the mini Rhinoconjunctivitis Quality of Life Questionnaire score were observed with the total nasal symptoms score (r = 0.84, 95 per cent confidence interval (CI) 0.81–0.87; Figure 3a), the total medication score (r = 0.86, 95 per cent CI 0.83–0.89; Figure 3b) and the combined symptom and medication score (r = 0.90, 95 per cent CI 0.87–0.92; Figure 3c) (all p < 0.001).

Figure 3.

Correlation analysis between different clinical outcomes: (a) mini RQLQ and TNSS; (b) mini RQLQ and TMS; (c) mini RQLQ and CSMS. Mini-RQLQ = mini Rhinoconjunctivitis Quality of Life Questionnaire score; TNSS = total nasal symptoms score; TMS = total medication score; CSMS = combined symptom and medication score.

Discussion

Allergies, which range from mild sensitivities to severe, life-threatening reactions, significantly impair quality of life and healthcare systems.Reference Goktas and Damadoglu24 Allergic rhinitis evolves with age and mild allergic rhinitis can gradually worsen and easily progress to more severe symptoms and other allergic diseases, such as asthma and atopic dermatitis.Reference Tsuge, Ikeda, Matsumoto, Yorifuji and Tsukahara25 Previous studies have shown that adults with allergic rhinitis reported more severe symptoms and greater medicine use than children with allergic rhinitis.Reference Izquierdo-Dominguez, Jauregui, Del Cuvillo, Montoro, Davila and Sastre11, Reference Sousa-Pinto, Valiulis, Melén, Koppelman, Papadopoulos and Makela12 Similar outcomes were observed in our study. At baseline, greater severity of symptoms, more medication usage and worse quality of life were observed in adolescent and adult patients compared with paediatric patients. This highlights the need for timely and standardised treatment for allergic diseases.Reference Blaiss26

House dust mite sublingual immunotherapy has proved to be extremely well tolerated and significantly effective in both adult and paediatric patients with allergic rhinitis.Reference Shao, Cui, Zheng, Peng, Zheng and Chen27, Reference Han, Chen and Wang28 In our study, both children and adolescent and adult allergic rhinitis patients experienced significant reductions in total nasal symptoms, total medication, combined symptom and medication, and mini Rhinoconjunctivitis Quality of Life Questionnaire scores after 0.5 and 1 year of sublingual immunotherapy. These findings further show that sublingual immunotherapy is an effective allergen-specific treatment.

Whether or not the age of treatment initiation affects the efficacy of sublingual immunotherapy has been a hot topic, but the findings from comparisons of the clinical efficacy of sublingual immunotherapy in patients of different ages have been inconsistent.

A retrospective study conducted by Han et al.Reference Han, Choi, Lee, Kim, Kim and Lee29 observed significantly comparable declines in total symptom score in children and adolescents and adults after one year of sublingual immunotherapy, with children and adolescents showing slightly better declines in allergic medication score than adults. Similarly, a study of 200 allergic rhinitis and allergic asthma patients found that sublingual immunotherapy was more effective in a pre-pubertal group than in a pubertal group, with better total nasal symptoms score, asthma control test and peak expiratory flow rate improvement in pre-pubertal children at the end of treatment.Reference Zhu, Yan, Cheng, Xiao, Fan and Cao30 This study showed similar results, with the improvement percentages of all clinical outcomes significantly superior in the children group compared with the adolescent and adult group after one year of sublingual immunotherapy, indicating that initiating sublingual immunotherapy early in childhood is more effective than initiating it in adolescents or adults.

However, a study conducted by Kim et al.Reference Kim, Rhee, Cho, Choe, Kim and Han31 revealed similar trends of improvement in total nasal symptoms and mini Rhinoconjunctivitis Quality of Life Questionnaire scores in both children and adults, with no significant differences. These findings are slightly different. This may be because, firstly, the sublingual immunotherapy drugs studied in these two studies were different. Secondly, the standard evaluation system recommended by the European Academy of Allergy and Clinical Immunology,Reference Pfaar, Demoly, Gerth van Wijk, Bonini, Bousquet and Canonica22 which includes total nasal symptoms, total medication, and combined symptom and medication scores was adopted in our study, while only nasal symptoms and the proportion of rescue medication decreased were assessed in the Kim et al. study, not the total medication and combined symptom and medication scores. Finally, the adult sample size in the Kim et al. study was slightly smaller than that in this study.

There are potential reasons for better clinical outcomes in children than in adolescents and adults. Firstly, allergic rhinitis is a chronic disease with a low chance of self-remission,Reference Bodtger and Linneberg32 therefore allergic rhinitis symptoms typically persist into adulthood. Intervening in the early stages of life can reduce the disease burden. Secondly, the immune system during childhood is immature and more easily corrected by sublingual immunotherapy treatment, manifesting great reduction of the risk on new allergic diseases and prevention of new sensitisations.Reference Alvaro-Lozano, Akdis, Akdis, Alviani, Angier and Arasi13, Reference Hamelmann, Hammerby, Scharling, Pedersen, Okkels and Schmitt18 Lastly, many studies have shown that children have better compliance with treatment than adults.Reference Kiotseridis, Arvidsson, Backer, Braendholt and Tunsäter33, Reference Wan, Xu, Lu, Lyu, Gu and Yuan34 This is primarily because children get more attention from their families, therefore they tend to complete sublingual immunotherapy treatment on time and will likely achieve complete efficacy. Adults are often under high life pressures and find it difficult to stick to a long-term treatment plan. Finally, the clinical effect was not satisfactory.Reference Wan, Xu, Lu, Lyu, Gu and Yuan34 More clinical studies about the long-term efficacy of house dust mite sublingual immunotherapy in different age groups are needed in the future.

The mini Rhinoconjunctivitis Quality of Life Questionnaire is a simplified version of the standard Rhinoconjunctivitis Quality of Life Questionnaire used to assess the improvement in patients’ quality of life.Reference Juniper, Thompson, Ferrie and Roberts23 Yang et al. found that all patients aged 4–60 years who completed treatment showed a significant decrease in their mini Rhinoconjunctivitis Quality of Life Questionnaire score.Reference Yang, Zheng, Zhou, Qiu, Zhan and Wei35 In this study, all patients finishing one year of sublingual immunotherapy also demonstrated a statistically significant improvement in their mini Rhinoconjunctivitis Quality of Life Questionnaire score. The correlation between the mini Rhinoconjunctivitis Quality of Life Questionnaire score and the total nasal symptoms, total medication, and combined symptom and medication scores was verified to be strongly positive. Above all, it showed that the mini Rhinoconjunctivitis Quality of Life Questionnaire is an effective tool that can evaluate the quality of life of patients with allergic diseases. It reflects the severity of symptoms, medication needs and their impact on patients’ daily lives.

In summary, one year of sublingual immunotherapy can significantly improve nasal symptoms, medication intake and quality of life in children and adolescents and adults with allergic rhinitis, with greater improvement observed in children. The mini Rhinoconjunctivitis Quality of Life Questionnaire can serve as a clinical tool for assessing the efficacy of sublingual immunotherapy.

  • • In human development, the immune system grows and matures with age

  • • Initiation of sublingual immunotherapy in early childhood is associated with clinically meaningful benefits

  • • There is limited research on clinical efficacy differences between children and adolescents and adults

  • • Our results indicated one year of house dust mite sublingual immunotherapy was effective in both children and adolescentsand adults with allergic rhinitis, but better improvement was observed in children compared with adolescents and adults

  • • The mini Rhinoconjunctivitis Quality of Life Questionnaire can serve as a clinical tool for assessing the efficacy of sublingual immunotherapy

Acknowledgements

Heartfelt thanks are extended to all the participants for their valuable time and contributions, and to the study co-ordinators for their diligent efforts in facilitating the smooth conduct of the experiments.

Competing interests

None declared

Footnotes

Bingfeng Huang takes responsibility for the integrity of the content of the paper

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Figure 0

Table 1. Baseline characteristics

Figure 1

Figure 1. Comparison of TNSS, TMS, CSMS and the mini RQLQ in (a) the children group and (b) the adolescents and adults group at baseline, 0.5 and 1 year of sublingual immunotherapy. ***p less than 0.001 indicates a significant difference compared with baseline. TNSS = total nasal symptoms score; TMS = total medication score; CSMS = combined symptom and medication score; Mini-RQLQ = mini Rhinoconjunctivitis Quality of Life Questionnaire.

Figure 2

Figure 2. Comparison the levels of the change in (a) total nasal symptoms score, (b) total medication score, (c) combined symptom and medication score and (d) mini Rhinoconjunctivitis Quality of Life Questionnaire score at 0.5 and 1 year of sublingual immunotherapy between the children group and the adolescents and adults group. △TNSS 0.5 = the improvement percentage in total nasal symptoms score from baseline to 0.5 year of sublingual immunotherapy; △TNSS 1 = the improvement percentage in total nasal symptoms score from baseline to 1 year of sublingual immunotherapy; △TMS 0.5 = the improvement percentage in total medication score from baseline to 0.5 year of sublingual immunotherapy; △TMS 1 = the improvement percentage in total medication score from baseline to 1 year of sublingual immunotherapy; △CSMS 0.5 = the improvement percentage in combined symptom and medication score from baseline to 0.5 year of sublingual immunotherapy; △CSMS 1 = the improvement percentage in combined symptom and medication score from baseline to 1 year of sublingual immunotherapy; △mini-RQLQ 0.5 = the improvement percentage in mini Rhinoconjunctivitis Quality of Life Questionnaire score from baseline to 0.5 year of sublingual immunotherapy; △ mini-RQLQ 1 = the improvement percentage in mini Rhinoconjunctivitis Quality of Life Questionnaire score from baseline to 1 year of sublingual immunotherapy. *p less than 0.05 indicates a significant difference between the children group and the adolescents and adults group.

Figure 3

Figure 3. Correlation analysis between different clinical outcomes: (a) mini RQLQ and TNSS; (b) mini RQLQ and TMS; (c) mini RQLQ and CSMS. Mini-RQLQ = mini Rhinoconjunctivitis Quality of Life Questionnaire score; TNSS = total nasal symptoms score; TMS = total medication score; CSMS = combined symptom and medication score.