Reply

To the Editor:

We have developed a novel computerized method to quantify allergic shiners1 and would like to acknowledge Dr Kelso's comment.2 The allergic shiner is believed to be caused by venous stasis resulting from nasal congestion.3, 4 Therefore, it is likely that any disorder with nasal obstruction as 1 of its symptoms can result in shiners—for example, chronic rhinosinusitis, nasal polyposis, ciliary dyskinesia syndromes, cystic fibrosis, and nonallergic rhinitis. Not including patients with these conditions as our controls may have overestimated the sensitivity and specificity of shiners for allergic diseases. However, the nature of allergic shiners is largely unknown. Even the causal inference between nasal obstruction and allergic shiners has not yet been clearly confirmed by any animal study or well designed clinical study. Most importantly, our study described a new tool to assess objectively the area and density of shiners, which will be useful for future studies investigating the pathogenesis and therapies for this important cosmetic facial manifestation of allergic rhinitis.1 We think the priorities should be first to verify the significance of shiners in children with allergic rhinitis and to document the previously unknown correlations of shiners with different severities of nasal and ophthalmic symptoms, instead of directly investigating in the very beginning of a series of studies the additional effect of allergies on shiners. In addition, shiners are referred to as “allergic” shiners only in patients with allergic rhinitis, but not in healthy children and not in children with nonallergic rhinitis. In other word, people do not call shiners “allergic shiners” until they know the person with shiners actually has allergic rhinitis. Hence people may use shiners, but definitely will not use “allergic” shiners, to predict allergic rhinitis. Moreover, we did not intend to use shiners to predict allergies in this study. That is why we did not include children with nonallergic rhinitis. Table II in this study1 has clearly shown that the sensitivities and specificities of “shiners with significant darkness” and “shiners with significant sizes” for a variety of allergic diseases were not good. Thus, we have not suggested them as signs to predict nasal allergies. Instead, we emphasized that the specificity of “dark shiners” for allergic rhinitis was as high as 100%. “Dark shiners” were defined in our article as shiners darker than two thirds of shiners in patients with allergic rhinitis during their first visit. Therefore it was fairly obvious that we did not use “dark shiners” to detect the presence of allergies. Furthermore, our study1 showed that there was no significant correlation between the darkness or size of shiners and current eosinophil count, serum total IgE level, and specific IgE level among children with allergic rhinitis. The possible additional effect of allergies on shiners in symptomatic children might be minimal.