At a glance......
- 1 Pathophysiology
- 2 Types of Allergic Rhinitis
- 3 Causes of Allergic Rhinitis
- 4 Symptoms of Allergic Rhinitis
- 5 Treatment of Allergic Rhinitis
- 5.1 Avoidance
- 5.2 Oral antihistamines
- 5.3 Intranasal Antihistamines
- 5.4 Intranasal Corticosteroids
- 5.5 Leukotriene Receptor antagonists (LTRAs)
- 5.6 Anti-IgE antibody
- 5.7 Immunotherapy
- 5.8 Decongestants
- 5.9 Anticholinergics
- 5.10 Nasal saline
- 5.11 Steroids
- 5.12 Investigational therapies
- 5.13 Capsaicin
- 5.14 Silver nitrate
- 5.15 Acupuncture
- 6 Prevention
User Review( votes)
Allergic rhinitis (AR) is a symptomatic disorder of the nose induced after exposure to allergens via IgE-mediated hypersensitivity reactions, which are characterized by 4 cardinal symptoms of watery rhinorrhea, nasal obstruction, nasal itching and sneezing.[rx]
Allergic rhinitis a chronic inflammatory disease of the upper airways that has a major impact on the quality of life of patients and is a socio-economic burden. Understanding the underlying immune mechanisms is central to developing better and more targeted therapies. The inflammatory response in the nasal mucosa includes an immediate IgE-mediated mast cell response as well as a latephase response characterized by recruitment of eosinophils, basophils, and T cells expressing Th2 cytokines including interleukin (IL)-4, a switch factor for IgE synthesis, and IL-5, an eosinophil growth factor and on-going allergic inflammation.
In allergic rhinitis, numerous inflammatory cells, including mast cells, CD4-positive T cells, B cells, macrophages, and eosinophils, infiltrate the nasal lining upon exposure to an inciting allergen (most commonly airborne dust mite fecal particles, cockroach residues, animal dander, moulds, and pollens). The T cells infiltrating the nasal mucosa are predominantly T helper (Th)2 in nature and release cytokines (e.g., interleukin [IL]-3, IL-4, IL-5, and IL-13) that promote immunoglobulin E (IgE) production by plasma cells. IgE production, in turn, triggers the release of mediators, such as histamine and leukotrienes, that are responsible for arteriolar dilation, increased vascular permeability, itching, rhinorrhea (runny nose), mucous secretion, and smooth muscle contraction [rx,rx]. The mediators and cytokines released during the early phase of an immune response to an inciting allergen, trigger a further cellular inflammatory response over the next 4 to 8 hours (late-phase inflammatory response) which results in recurrent symptoms (usually nasal congestion) [rx,rx].
Types of Allergic Rhinitis
According the infection times
- Perennial Allergic Rhinitis – Four RCTs compared acupuncture with sham acupuncture and three of these reported improved symptoms or nasal symptoms with acupuncture; one RCT reported no difference in total nasal volume. Two of the positive RCTs were pooled in meta-analysis and suggested that acupuncture was associated with superior effects in nasal symptoms than sham acupuncture
- Seasonal allergic rhinitis – is sometimes called “hay fever.” But, people with seasonal allergic rhinitis do not have to have a fever and do not have to be exposed to hay to develop this condition. It is an allergic reaction to pollen from trees, grasses and weeds. This type of rhinitis occurs mainly in the spring and fall, when pollen from trees, grasses and weeds are in the air.
- Non-allergic rhinitis – is not caused by allergens. Smoke, chemicals or other irritating environmental conditions may provoke non-allergic rhinitis. Hormonal changes, physical defects of the nose (like a deviated septum) and the overuse of nose sprays may also cause it. Sometimes medications cause it. Often, the cause of this type of rhinitis is not well understood. But it is common in patients with non-allergic asthma. The symptoms are similar to allergy symptoms.
- Infectious rhinitis – is possibly the most common type of rhinitis. It is also known as the common cold or upper respiratory infection (URI). Colds occur when a cold virus settles into the mucous membranes of the nose and sinus cavities and causes an infection.
According to severity of allergic rhinitis may also be classified as
- Moderate-Severe intermittent,
- Mild-Persistent, and
- Moderate-Severe Persistent.
- Intermittent is when the symptoms occur <4 days per week or <4 consecutive weeks.
- Persistent is when symptoms occur >4 days/week and >4 consecutive weeks. [rx]
Causes of Allergic Rhinitis
There are various treatment options for allergies. Some things that trigger allergies (allergens) are easy to avoid, whereas others aren’t. Common allergens include the following:
House dust mites
Pets and farm animals
The venom (poison) in insect stings and bites
Contact allergens (e.g. metals or fragrance ingredients)
- Pollens of insect-pollinated plants are too large to remain airborne and pose no risk. Examples of plants commonly responsible for hay fever include:
- Allergic rhinitis may also be caused by allergy to Balsam of Peru, which is in various fragrances and other products.[rx][rx][rx]
- Trees – such as pine , birch, alder, cedar, hazel, horn beam, horse chestnut, willow, poplar, plane, linden/lime, and olive. In northern latitudes, birch is considered to be the most common allergenic tree pollen, with an estimated 15–20% of people with hay fever sensitive to birch pollen grains. A major antigen in these is a protein called Bet V I. Olive pollen is most predominant in Mediterranean regions.
- Grasses (Family Poaceae) – especially ryegras and timothy . An estimated 90% of people with hay fever are allergic to grass pollen.
- Allergy friendly” trees include – ash (female only), red maple, yellow poplar, dogwood, magnolia, double-flowered cherry, fir, spruce, and flowering plum.[rx]
Some of the causes of non-allergic rhinitis include
- Certain infections
- Certain medications (various over-the-counter and prescription preparations)
- Eating and drinking (sometimes specific foods, sometimes all food/drink consumption)
- Weather or temperature changes
- Hormonal changes or pregnancy
- Consumption of alcohol, especially red wine
- Inflammation or irritation in the nose unrelated to allergy
- Nasal symptoms of other medical conditions
Depending on the type of rhinitis, certain conditions may be associated, such as
- Acute sinusitis
- Inflammation of the eye (conjunctivitis)
- Atopic dermatitis or eczema
- Poor ventilation of the ears (or eustachian tube dysfunction)
- Laryngitis (inflammation causing hoarseness of voice)
- Eosinophilic esophagitis
- Sleep disturbance
Symptoms of Allergic Rhinitis
These are typical symptoms of allergies:
Runny or stuffy nose
Swollen mucous membranes
Gastrointestinal (stomach and bowel) problems
- rhinorrhea (excess nasal secretion), itching, sneezing fits, and nasal congestion and obstruction.
- Characteristic physical findings include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis (rings under the eyes known as “allergic shiners”),
- swollen nasal turbinates, and middle ear effusion.
- Stuffy nose due to blockage or congestion
- Itching, usually in the nose, mouth, eyes, or throat
- Puffy, swollen eyelids
Symptoms also may be triggered by common irritants such as:
- Cigarette smoke
- Strong odors, such as perfume, or hair spray and fumes
- Laundry detergents
- Cleaning solutions, pool chlorine, car exhaust and other air pollutants (i.e., ozone)
Allergic rhinitis can be associated with
- Decreased concentration and focus
- Limited activities
- Decreased decision-making capacity
- Impaired hand-eye coordination
- gic Rhinitis
The Diagnosis of Allergic Rhinitis
- Allergic symptoms – are those of “sneezers and runners” [rx]. All patients with persistent allergic rhinitis need a nasal examination (Anterior rhinoscopy, Nasal endoscopy). Functional tests (peak nasal inspiratory flow, rhinomanometry, or acoustic rhinometry) can be used to measure nasal obstruction.
- In vivo and in vitro tests- used to diagnose allergic diseases are directed towards the detection of free or cell-bound IgE. The diagnosis of allergy has been improved by allergen standardization providing satisfactory diagnostic vaccines for most inhalant allergens.
- Immediate hypersensitivity skin tests – are widely used to demonstrate an IgE-mediated allergic reaction. These represent a major diagnostic tool in the field of allergy. If properly performed, they yield useful confirmatory evidence for the diagnosis of a specific allergy. As there are many complexities for their performance and interpretation, they should be carried out by trained health professionals.
- The measurement of allergen-specific IgE – (radioallergosorbent testing, RAST) in serum is of importance and is of similar value to skin tests. They are more useful in patients having dermatitis, dermographism, and in cases where antihistamines have to be continued during testing [rx].
- Nasal challenge tests – with allergens are commonly used in research. They may be useful, especially in the diagnosis of occupational rhinitis.
- A computerized tomography (CT) – scan is used to exclude chronic rhinosinusitis, tumors, or when a complication is suspected
- Prick or scratch test – In this test, a tiny drop of a possible allergen is pricked or scratched into the skin. Also known as a percutaneous test, this is the most common type of skin test. The results are known within 10 to 20 minutes.
- Intradermal test – A small amount of a possible allergen is injected under the skin using a thin needle. The site is checked for a reaction after about 20 minutes. This test is typically more sensitive than the prick or scratch test.
The differential diagnosis for AR includes other forms of rhinitis that are not allergic. Children, particularly those under the age of 2 years, should also be assessed for congenital causes of nasal obstruction, such as choanal atresia and immunodeficiencies.[rx][rx][rx]
Vasomotor rhinitis – noninflammatory rhinitis that can be triggered by a change in temperature, odors or humidity
Infectious rhinitis – viral or bacterial infections, most commonly seen in the pediatric population
Cerebrospinal fluid leak – clear rhinitis refractory to treatment
Non-allergic rhinitis with eosinophilia syndrome (NARES) – infiltration of eosinophils in nasal tissue without allergic sensitization
Chemical rhinitis – exposure to chemicals through occupation, household chemicals, sport/leisure exposure
Rhinitis of pregnancy and hormonally-induced rhinitis
Drug-induced rhinitis – e.g., NSAIDs, ACE inhibitors, nasal decongestants, cocaine
Autoimmune, granulomatous, and vasculitic rhinitis – Granulomatosis with polyangiitis, sarcoidosis, etc.
Treatment of Allergic Rhinitis
The first approach in managing seasonal or perennial forms of hay fever should be to avoid the allergens that trigger symptoms.
- Stay indoors as much as possible when pollen counts are at their peak, usually during the midmorning and early evening (this may vary according to plant pollen), and when wind is blowing pollens around.
- Avoid using window fans that can draw pollens and molds into the house.
- Wear glasses or sunglasses when outdoors to minimize the amount of pollen getting into your eyes.
- Wear a pollen mask (such as a NIOSH-rated 95 filter mask) when mowing the lawn, raking leaves or gardening, and take appropriate medication beforehand.
- Don’t hang clothing outdoors to dry; pollen may cling to towels and sheets.
- Try not to rub your eyes; doing so will irritate them and could make your symptoms worse.
- Keep windows closed, and use air conditioning in your car and home. Make sure to keep your air conditioning unit clean.
- Reduce exposure to dust mites, especially in the bedroom. Use “mite-proof” covers for pillows, comforters and duvets, and mattresses and box springs. Wash your bedding frequently, using hot water (at least 130 degrees Fahrenheit).
- To limit exposure to mold, keep the humidity in your home low (between 30 and 50 percent) and clean your bathrooms, kitchen and basement regularly. Use a dehumidifier, especially in the basement and in other damp, humid places, and empty and clean it often. If mold is visible, clean it with mild detergent and a 5 percent bleach solution as directed by an allergist.
- Clean floors with a damp rag or mop, rather than dry-dusting or sweeping.
Exposure to pets
- Wash your hands immediately after petting any animals; wash your clothes after visiting friends with pets.
- If you are allergic to a household pet, keep the animal out of your home as much as possible. If the pet must be inside, keep it out of the bedroom so you are not exposed to animal allergens while you sleep.
- Close the air ducts to your bedroom if you have forced-air or central heating or cooling. Replace carpeting with hardwood, tile or linoleum, all of which are easier to keep dander-free.
- First-generation antihistamines – which have been used since the early 1940s, have some side effects such as sedation, memory impairment and psychomotor dysfunction, which cause many problems in clinical practice. In contrast, second-generation antihistamines penetrate the blood-brain barrier much less than first-generation antihistamines, and thus they have few side effects on the central nervous system.[rx] Oral antihistamines have been reported to be safe and effective in children.[rx] Terfenadine and astemizole were initially used second-generation antihistamines.
- Oral second generation antihistamines – are not as effective in the treatment of NAR, though first generation oral antihistamines may haves some benefit due to anticholinergic activity.[rx] Topical antihistamines on the other hand have been found to be very effective for the overall treatment of NAR. Of the two topical antihistamines on the market in the United States (azelastine and olopatadine), azelastine is the only one that has been shown to be efficacious for nonallergic rhinitis.[rx,rx] Banov and Lieberman[rx]evaluated the efficacy of the azelastine nasal spray in patients with nonallergic vasomotor rhinitis in a multicenter, randomized,
Some popular over-the-counter (OTC) antihistamines include
- Topical antihistamines have been reported to reduce itching, sneezing and rhiorrhea.[rx] However, they are less effective than intranasal corticosteroids and ineffective in eye symptoms.[rx] Intranasal azelastine twice a day can reduce the symptoms of seasonal AR patients who do not respond to oral antihistamines. They have some side effects such as mild sedation and metallic taste.[rx]
- Since intranasal corticosteroids – are not absorbed systemically, they induce few systemic side effects. Steroid particles penetrate the cellular membrane and bind to cytoplasmic steroid receptors. The steroid-receptor complex is transferred to the nucleus and binds to the specific DNA site. The anti-inflammatory effect is induced by alteration in protein synthesis after binding of the steroid-receptor complex to DNA or by affecting other transcription factors. Intranasal corticosteroids inhibit both early and late reactions and reduce IgE production and eosinophilia by inhibiting the secretion of cytokines including IL-4, IL-5 and IL-13. When intranasal corticosteroids are administered, eosinophils and basophils decrease in 1 week.[rx]
- Recently, budesonide, triamcinolone acetonide, fluticasone propionate, mometasone furoate and fluticasone furoate have been widely used. For a better choice of topical steroids, their pharmacological characteristics should be considered.
Leukotriene Receptor antagonists (LTRAs)
- The role of leukotrienes in allergic reactions is well known. The efficacy of LTRA has been demonstrated in asthma. Recently, some studies on the efficacy of LTRAs in AR patients have been reported. As previously mentioned, the 2008 ARIA guidelines re-evaluated the role of LTRAs.
- Interest in LTRAs has been increasing with the concept of “one airway, one disease”, and therefore many studies on LTRAs are being conducted. Pranlukast (Onon), montelukast (Singulair) are commercially available. Care should be taken in the clinical use of Pranlukast which is metabolized by hepatic CYP3A4 enzymes because its serum concentration can be elevated when administered with terfenadine, astemizole, ketoconazole or erythromycin.
- Omalizumab, an anti-IgE recombinant humanized monoclonal antibody, interferes with the interactions between mast cells/eosinophils and IgE by binding to free IgE and hence lowers serum free IgE.[rx] It also suppresses inflammatory reactions in blood or nasal mucosa[rx] and expression of FcεRI located on the surface of mast cells or eosinophils.[rx]
- Immunotherapy is the only therapeutic option that modifies the basic allergic mechanism by inducing desensitization and producing an anergy state for offending allergens. Immunotherapy was initially introduced for seasonal AR due to pollens. At present, its indications have been extended to other allergic diseases due to hymenoptera, house dust mite, animal dander or fungi.[rx]
Two types of immunotherapy are available: allergy shots and sublingual (under-the-tongue) tablets.
- Allergy shots – A treatment program, which can take three to five years, consists of injections of a diluted allergy extract, administered frequently in increasing doses until a maintenance dose is reached. Then the injection schedule is changed so that the same dose is given with longer intervals between injections. Immunotherapy helps the body build resistance to the effects of the allergen, reduces the intensity of symptoms caused by allergen exposure and sometimes can actually make skin test reactions disappear. As resistance develops over several months, symptoms should improve.
- Sublingual tablets – This type of immunotherapy was approved by the Food and Drug Administration in 2014. Starting several months before allergy season begins, patients dissolve a tablet under the tongue daily. Treatment can continue for as long as three years. Only a few allergens (certain grass and ragweed pollens and house dust mite) can be treated now with this method, but it is a promising therapy for the future.
- Currently there are no specific studies looking at the effectiveness of oral decongestants in the treatment of NAR. Thus, they should be considered adjunctive therapy, which is used on an as needed basis for nasal congestion that is not responsive to intranasal corticosteroids, topical antihistamines, or a combination of both.
Popular OTC decongestants include
- oxymetazoline (Afrin nasal spray)
- pseudoephedrine (Sudafed)
- phenylephrine (Sudafed PE)
- cetirizine with pseudoephedrine (Zyrtec-D)
If you have an abnormal heart rhythm, heart disease, history of stroke, anxiety, a sleep disorder, high blood pressure, or bladder issues, speak with your doctor before using a decongestant.
- The only topical anticholinergic medication approved in the United States for topical application is ipratropium bromide. Ipratropium bromide (0.03%) nasal spray is recommended when rhinorrhea is the predominant or only symptom, as in the case of gustatory rhinitis. From the updated rhinitis practice parameters, its use in combination with an intranasal corticosteroid is more effective than either drug alone for the treatment of rhinorrhea. This is not only effective, but safe as well since there is not an increased incidence of adverse events.[rx]
- Nasal lavage with saline solution has also been found to be a helpful alone or as an adjuvant therapy in patients with chronic rhinorrhea and rhinosinusitis.1 It is best performed immediately prior to intranasal corticosteroids or azelastine and may be especially helpful in reducing postnasal drip, sneezing, and congestion.[rx]
- Intranasal corticosteroids have been found to be effective in nonallergic rhinitis, especially in vasomotor rhinitis and NARES. Fluticasone propionate and beclomethasone are the only topical corticosteroids approved by the FDA in the US for the treatment of NAR. Clinically, there does not appear to be a difference between the intranasal steroids available at this time.[rx]
- Capsaicin is the chemical contained within the oil of Capsicum pepper and while it is initially irritating to the applied area, it eventually desensitizes the sensory neural fibers. It has been used intranasal to try and decrease nasal hyperreactivity responsible for rhinorrhea, sneezing, and congestion.[rx]
- A placebo-controlled studies using intranasal capsaicin in patient with nonallergic, noninfectious perennial rhinitis found a significant and long-term reduction in the visual analogue scale (VAS) scores in the treatment group but no difference objective measures of inflammation such as concentration of leukotriene C4/D4/E4, prostaglandin D2, and tryptase.[rx]
- Topically applied silver nitrate was found to be effective in a trial comparing silver nitrate, flunisolide, and placebo in patients with NAR. Improvement was found in patient reported rhinorrhea, sneezing and nasal congestion.[rx] Two prospective studies in patients with vasomotor rhinitis also found significant improvement in nasal symptoms.[rx,rx]
- From a systematic review of complementary and alternative medicine for rhinitis and asthma published in the Journal of Allergy and Clinical Immunology in 2006, the majority of studies on acupuncture were in allergic rhinitis and were not randomized, controlled, or descriptive. There was 1 nonrandomized study in NAR that showed no difference in nasal airflow and symptoms between acupuncture and electrostimulation.[rx]
The first and best option is to avoid contact with allergens. Other prevention tips are:
- Don’t touch or rub your nose.
- Wash your hands often with soap and water.
- Use a vacuum with a CERTIFIED asthma & allergy friendly® filter to reduce allergen exposure while vacuuming.
- Wash your bed linens and pillowcases in hot water and detergent to reduce allergens.
- Use dust-mite proof covers for pillows, comforters, duvets, mattresses and box springs.
- Keep pets out of the bedroom to reduce pet dander allergen in your bedding.
- Wear sunglasses and a wide-brimmed hat to reduce pollen getting into your eyes.
- Keep windows closed during high pollen and mold seasons. Use the air conditioner in your car and home
House Dust Mites
Dust mites are one of the biggest causes of allergies. They’re microscopic insects that breed in household dust.To help limit the number of mites in your house, you should:
- consider buying an air-permeable occlusive mattress and bedding covers – this type of bedding acts as a barrier to dust mites and their droppings
- choose wood or hard vinyl floor coverings instead of carpet
- fit roller blinds that can be easily wiped clean
- regularly clean cushions, soft toys, curtains and upholstered furniture, either by washing or vacuuming them
- use synthetic pillows and acrylic duvets instead of woollen blankets or feather bedding
- use a vacuum cleaner fitted with a high efficiency particulate air (HEPA) filter – it can remove more dust than ordinary vacuum cleaners
- use a clean damp cloth to wipe surfaces – dry dusting can spread allergens further
Concentrate your efforts on controlling dust mites in the areas of your home where you spend most time, such as the bedroom and living room.
It isn’t pet fur that causes an allergic reaction, but exposure to flakes of their dead skin, saliva and dried urine. If you can’t permanently remove a pet from the house, you may find the following tips useful
- keep pets outside as much as possible or limit them to one room, preferably one without carpet
- don’t allow pets in bedrooms
- wash pets at least once a fortnight
- groom dogs regularly outside
- regularly wash bedding and soft furnishings your pet has been on
Different plants and trees pollinate at different times of the year, so when you get allergic rhinitis will depend on what sort of pollen(s) you’re allergic to. Most people are affected during the spring and summer months because this is when most trees and plants pollinate. To avoid exposure to pollen, you may find the following tips useful:
- check weather reports for the pollen count and stay indoors when it’s high
- avoid line-drying clothes and bedding when the pollen count is high
- wear wraparound sunglasses to protect your eyes from pollen
- keep doors and windows shut during mid-morning and early evening, when there’s most pollen in the air
- shower, wash your hair and change your clothes after being outside
- avoid grassy areas, such as parks and fields, when possible
- if you have a lawn, consider asking someone else to cut the grass for you
Moulds can grow on any decaying matter, both in and outside the house. The moulds themselves aren’t allergens, but the spores they release are. Spores are released when there’s a sudden rise in temperature in a moist environment, such as when central heating is turned on in a damp house or wet clothes are dried next to a fireplace.
To help prevent mould spores, you should
- keep your home dry and well ventilated
- when showering or cooking, open windows but keep internal doors closed to prevent damp air spreading through the house, and use extractor fans
- avoid drying clothes indoors, storing clothes in damp cupboards and packing clothes too tightly in wardrobes
- deal with any damp and condensation in your home