CRD-guided step-up care for pediatric dust mite allergy: A systematic review of evidence gaps and global disparities (2014-2025).

Background: The management of house dust mite (HDM) allergies in children is evolving with new evidence for precision diagnosis and therapies. However, global disparities in resource availability and regional variations in sensitization profiles challenge the implementation of optimal care. Objective: To synthesize the latest evidence (2014-2025) and propose a component-resolved diagnosis (CRD)-guided stepped-care framework for pediatric HDM allergies, addressing evidence gaps and global health disparities. Methods: We conducted a systematic review following PRISMA guidelines and searched the PubMed, EMBASE, Cochrane Library, and Web of Science databases for randomized controlled trials, meta-analyses, cohort studies, and clinical guidelines. Two reviewers independently screened records, assessed eligibility, and extracted data. Of 3371 records identified, 92 studies met the inclusion criteria and were included in the qualitative synthesis. The outcomes included the efficacy and safety of environmental controls, immunotherapy (sublingual [SLIT] vs subcutaneous [SCIT]), biologics, and the role of CRD. A narrative synthesis was performed because of substantial clinical heterogeneity across studies, supplemented by recent meta-analyses in a quantitative context. Results: Individual studies reported short-term Der p 1 reductions of 45-60% with physical interventions; however, a meta-analysis of 17 Randomized Clinical Trials (RCTs) revealed that these reductions were insufficient to improve clinical outcomes, and long-term adherence remained poor (<42%). Compared with SCIT, SLIT demonstrated a superior safety profile (local reactions <10%) and lower systemic reaction risk (OR 2.6, 95% CI 1.8-3.8), whereas SCIT was more effective in polysensitized children (symptom remission: 40% vs. 25%; RR 1.60, 95% CI 1.12-2.28). Omalizumab improved lung function (FEV Conclusion: Based on the synthesized evidence, this review outlines a preliminary CRD-guided, stepped-care framework that integrates molecular sensitization profiles with clinical phenotype and resource availability. This conceptual model seeks to move beyond conventional one-size-fits-all approaches by proposing resource-stratified pathways that prioritize cost-effective strategies in resource-limited settings while reserving intensive therapies for high-risk subgroups. However, the framework remains conceptual and requires prospective validation in diverse clinical and socioeconomic settings before its utility for addressing global health disparities can be assessed. Future priorities include gathering long-term biologic safety data, conducting real-world cost-effectiveness analyses, and developing globally harmonized, resource-sensitive guidelines.