BACKGROUND: Three allergic phenotypes of rhinitis have been described in adults: 
allergic rhinitis (AR), local allergic rhinitis (LAR), and dual allergic 
rhinitis (DAR, coexistence of AR and LAR). Nevertheless, most centers follow a 
diagnostic approach only based on skin prick test and serum allergen-specific 
IgE (collectively called atopy tests, AT). This approach prevents the 
recognition of LAR and DAR, the diagnosis of which requires a nasal allergen 
challenge (NAC). Here, we investigate the existence of LAR and DAR phenotypes in 
children and adolescents, and the misdiagnosis rate associated with a work-up 
exclusively based on AT.
METHODS: Clinical data were obtained during physician-conducted interviews, and 
AT and NAC were systematically performed in 5- to 18-year-old patients with 
chronic rhinitis. The misdiagnosis rate was defined as the proportion of cases 
where AT and NAC results were discordant.
RESULTS: A total of 173 patients (mean age 15.1 years, 39.9% male) completed the 
study. AR (positive AT and NAC), LAR (negative AT and positive NAC), DAR 
(positive AT and NAC for some allergens and negative AT and positive NAC for 
other allergens), and non-allergic rhinitis (negative NAC) were diagnosed in 
45.7%, 24.9%, 11.6%, and 17.9% of individuals, respectively. The clinical 
profile was comparable among allergic phenotypes, but allergic patients had a 
significantly earlier rhinitis onset, higher conjunctivitis prevalence, and more 
severe disease than NAR individuals. A diagnostic work-up exclusively based on 
AT misclassified 37.6% of patients.
CONCLUSIONS: LAR and DAR represent relevant differential diagnosis in pediatric 
rhinitis. NAC increases the diagnostic accuracy of clinical algorithms for 
rhinitis in children and adolescents.