Is there a link between atopic dermatitis with high Immunoglobulin E (IgE) and recurrent sinusitis?

Link Between Atopic Dermatitis with High IgE and Recurrent Sinusitis

There is a well-established association between atopic dermatitis with high IgE levels and recurrent sinusitis, as both conditions are part of the atopic disease spectrum and share common immunologic mechanisms.

The Atopic Connection

• Atopic dermatitis, allergic rhinitis, and sinusitis are part of the "atopic march," where patients with one atopic condition are at increased risk for developing others 1, 2
• High IgE levels are characteristic of atopic dermatitis and correlate with disease severity and the likelihood of developing other atopic conditions including rhinosinusitis 3, 4
• The prevalence of allergic rhinitis is 40% to 84% in adults with chronic rhinosinusitis, suggesting a strong association between these atopic conditions 1

Pathophysiologic Mechanisms

• Edema caused by allergic inflammation may obstruct the paranasal sinuses, as supported by a higher prevalence of mucoperiosteal disease on CT imaging in patients with allergies 1
• A hyperresponsive inflammatory state associated with allergic rhinitis may increase susceptibility to inflammation within the nose and paranasal sinuses, predisposing to rhinosinusitis 1
• In atopic dermatitis, T-helper type 2 cells produce interleukins (IL-4, IL-13, IL-31) that contribute to barrier dysfunction, which may extend to nasal and sinus mucosa 3

Clinical Implications

• Patients with recurrent sinusitis should be evaluated for underlying allergic factors, including atopic dermatitis and high IgE levels 1
• Extensive sinus disease on CT imaging is associated with allergy in 78% of patients and asthma in 71% 1
• Patients with both allergy and chronic rhinosinusitis are more symptomatic than non-allergic patients with similar CT findings 1

Diagnostic Considerations

• Allergy testing is recommended for patients with chronic or recurrent acute rhinosinusitis 1
• Skin tests are the preferred method for detecting IgE-mediated sensitivity, with in vitro allergen-specific immunoassays as an alternative 1
• Immunodeficiency evaluation should be considered in patients with recurrent sinusitis resistant to standard therapy, particularly when accompanied by other recurrent infections 1

Potential Immunodeficiency Overlap

• Extremely high IgE levels with recurrent infections may suggest hyper-IgE syndrome rather than simple atopic dermatitis 5
• Common variable immunodeficiency (10%) and IgA deficiency (6%) have been found in patients with radiographically diagnosed sinusitis refractory to medical and surgical therapy 1
• Laboratory studies for patients with recurrent sinusitis should include quantitative immunoglobulin measurements (IgG, IgA, IgM) and specific antibody responses to vaccines 1

Treatment Approach

1. Address the allergic component:

   • Environmental control measures for relevant allergens 1
   • Pharmacotherapy with intranasal corticosteroids, which can benefit both conditions 1
   • Consider allergen immunotherapy for selected patients 1

2. Manage sinusitis appropriately:

   • Antibiotics for bacterial infections, with extended courses for recurrent cases 1
   • For partial response, continue antibiotics for another 10-14 days 1
   • For poor response, consider broader-spectrum antibiotics that cover resistant bacteria 1

3. Consider specialty referrals:

   • Allergist-immunologist consultation for evaluation of underlying allergic factors, unusual pathogens, and possible immunodeficiency 1
   • Otolaryngology referral for evaluation of structural abnormalities if medical management fails 1

Pitfalls and Caveats

• Not all patients with atopic dermatitis and high IgE will develop sinusitis, but they are at increased risk 1
• Extremely high IgE levels (>10,000 IU/mL) with recurrent infections should raise suspicion for immunodeficiency syndromes rather than simple atopic dermatitis 5
• Gastroesophageal reflux disease (GERD) should also be considered in patients with refractory sinusitis, as pH probe monitoring shows a high incidence of both esophageal and nasopharyngeal reflux in these patients 1
• Cystic fibrosis should be considered in any patient with chronic sinusitis at an early age or in children with nasal polyps 1