Allergic Rhinitis
Allergic rhinitis is an IgE-mediated inflammatory condition of the nose triggered by exposure to allergens such as pollen, house dust mites, mould, or animal dander. Hay fever is a specific form of allergic rhinitis, referring to seasonal allergic rhinitis triggered by seasonal allergens such as pollen.
This updated UKMLA guide to allergic rhinitis is based on NICE CKS, which covers causes, symptoms, diagnosis, and management.
Classification
Seasonal rhinitis (hay fever): symptoms occur at the same time each year in response to a seasonal allergen
- Most typically occurs in the summer but also depends on the pollen
Perennial rhinitis: symptoms occur throughout the year
Causes
Genetic predisposition is an important factor in allergic rhinitis development. Risk factors include:
- Family history of atopy (esp. allergic rhinitis)
- Food allergy in childhood
Asthma and allergic rhinitis often co-exist. Allergic rhinitis is a risk factor for the development of asthma.
Common environmental triggers:
- Pollens (grass, tree, weed)
- House dust mites
- Moulds
- Cat and dog hair
Clinical Features
Typical features:
- Classic bilateral symptoms that develop within minutes post-allergen exposure
- Sneezing
- Nasal itching
- Rhinorrhoea
- Nasal congestion
- Postnasal drip
- Cough, palate itching
- Features of chronic nasal congestion (e.g. snoring, mouth breathing, halitosis)
- Turbinate hypertrophy
Allergic rhinitis can co-exist with the following conditions:
- Asthma
- Allergic conjunctivitis
- Oral allergy syndrome
- Chronic sinusitis and nasal polyps (as a complication)
Allergic rhinitis can cause sleep disturbances and impact quality of life, especially during the peak pollen season.
Symptoms occur following exposure to a known causative allergen
- Tree pollens — intermittent or chronic symptoms occur from early to late spring.
- Grass pollens — intermittent or chronic symptoms occur from late spring to early summer.
- Weed pollens — intermittent or chronic symptoms may occur from early spring to early autumn.
- House dust mites — symptoms are worse on waking and are present all year-round, but may peak in autumn and spring.
- Animal dander — symptoms follow exposure to animal dander, and may be all year-round or occasional, depending on exposure.
- Occupational — intermittent or chronic symptoms tend to improve when the person is away from work, such as weekends and holidays.
Investigation and Diagnosis
Allergic rhinitis is primarily a clinical diagnosis based on a combination of:
- Typical history
- Clinical examination
- Response to 1st line treatment
Specialist may perform further testing if there is diagnostic doubt or failure to respond to treatment
- Allergen testing
- Skin prick testing
- RAST (measure level of serum-specific IgE to allergens)
- Nasal allergen challenge
- Nasal endoscopy
- CT
Management
General Advice / Conservative Management
- Consider nasal irrigation with saline solution
- Allergen avoidance (highly depends on the identified causative allergen, if any)
Specific Allergen Avoidance Techniques
| Causative allergen | Allergen avoidance techniques |
|---|---|
| Pollen allergy |
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| House dust mite allergy |
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| Animal allergy |
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| Occupational allergies |
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Pharmacological Management
1st Line Therapy
- Intranasal corticosteroids (e.g. mometasone, fluticasone), AND/OR
- Antihistamine (intranasal or oral)
- Intranasal: Azelastine hydrochloride is the only licensed intranasal spray
- Oral: offer 2nd-generation antihistamines like cetirizine, loratadine, fexofenadine
If there are also eye symptoms → add antihistamine eye drops or chromone eye drops (sodium cromoglycate, nedocromil)
Other information:
| Preference for treatment options |
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| What is the most effective regimen? |
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| Information on specific treatment options |
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2nd Line Therapy
Consider the following causes for treatment failure:
- Compliance
- Technique for using intranasal spray (the nozzle should be aiming for the lateral nasal wall, and the patient should just breathe in gently, instead of sniffing)
- Alternative diagnosis
Consider the following further therapies:
| Further therapy | Indication / description |
|---|---|
| Regular oral antihistamines (instead of PRN use) | Especially if there is persistent nasal itching and sneezing |
| Intranasal anticholinergic (e.g. ipratropium bromide) | Especially if there is persistent watery rhinorrhoea |
| Intranasal decongestant (e.g. xylometazoline) | Especially if congestion is a problem
Only for short-term use (up to 5-7 days), as long-term use is associated with:
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| LTRA (e.g. montelukast) | If there is a history of asthma and ongoing symptoms |
| Oral corticosteroids | “Last resort” due to side effects of systemic steroids
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