Allergic rhinitis is a common condition that is relatively under-diagnosed and under-treated. It has gradually increased in prevalence, affecting up to 20% of the UK population1 and causing significant morbidity.2
It is caused by an allergic immune response to inhaled allergens. Atopy, high socioeconomic status, environmental pollution, birth during a pollen season, early weaning and maternal smoking are risk factors for allergic rhinitis.
Up to 80% of patients with allergic rhinitis develop symptoms before the age of 201. Symptoms include inflammation of the nasal mucosa which results in sneezing, rhinorrhoea, nasal congestion and itching. Allergic rhinitis may also be associated with inflammation of other mucous membranes and may be related to sinusitis, rhinosinusitis and allergicconjunctivitis.1 Eye symptoms are common in seasonal allergic rhinitis and may be present in up to 50% of cases of perennial rhinitis.1
Allergic rhinitis also is thought to be related to a similar hypersensitivity response in allergic asthma — allergic and non-allergic rhinitis are risk factors for developing asthma. There is an increased prevalence of asthma among patients with persistent or severe rhinitis.
Allergic rhinitis can have a significant impact on quality of life, for example it may cause poor sleep, affect schooling and affect work attendance.2 This is an important consideration in the Allergic Rhinitis and its Impact on Asthma (ARIA) guideline.
Allergic rhinitis can be seasonal (hayfever), perennial (persistent) or perennial with seasonal exacerbations. Seasonal allergic rhinitis is related to sensitivity to pollens and perennial allergic rhinitis is related to allergens such as dust mites and animal dander. The ARIA guideline classifies allergic rhinitis into intermittent or persistent cases that may be mild or moderate-severe.1
Allergic rhinitis may be diagnosed by the presence of nasal itching, sneezing, nasal congestion, rhinorrhoea, post-nasal drip and sometimes hyposmia.
Symptoms can arise within minutes of allergen exposure and may last for a couple of hours. Allergic conjunctivitis may also be present, occurring as a result of the nasal-ocular reflex as well as allergen contact with the conjunctival mucosa. In those with seasonal allergic rhinitis related to birch pollen, it is worth considering the possibility of an associated oral allergy syndrome.1
History and clinical examination
A careful history should include when symptoms start and whether there are factors that precede the onset of symptoms. This may identify triggers for allergic rhinitis in the home or the workplace. Pets and house dust mites may be factors at home, and at work there may be occupational allergens.3
If occupational rhinitis is suspected, it may be possible to prevent progression to occupational asthma. Resolution of symptoms while the patient is on holiday may suggest an environmental cause for allergic rhinitis. Rhinitis symptoms may also be attributable to Churg-Strauss syndrome, Wegener’s granulomatosis and sarcoidosis,1 so systemic review and clinical examination is important.
Clinical examination findings may include; mouth breathing, a horizontal nasal crease across the nose, surgical scars, polyps, crusting, mucosal congestion and nasal discharge.
The diagnosis may be confirmed by detecting specific IgE to airborne allergens, through skin-prick testing or on serum. This is particularly relevant if allergen-specific immunotherapy is being considered. Allergic rhinitis is often related to house dust mites as well as grass and tree pollens.
If there is unilateral rhinorrhoea a cerebrospinal fluid leak should be excluded. Unilateral rhinorrhoea may signify the presence of a malignancy, an antrochoanal polyp or a foreign body, or simply septal deviation. In the case of bilateral discharge, consideration should be given to the presence of a granulomatous disorder, nasal polyps or a bleeding diathesis.3
Bloody, purulent discharge, pain and nasal blockage may indicate an underlying malignancy.3 Wegener’s granulomatosis may present with nasal pain, nasal congestion, rhinitis, crusting and epistaxis.
If there is diagnostic doubt or red flags are present an ENT referral may be necessary. Furthermore, if patients are unresponsive to conventional treatment referral for consideration of immunotherapy may be indicated. Patients with suspected occupational rhinitis or asthma should be referred to secondary care. Children who have asthma with possible IgE-mediated food allergy should also be referred to secondary care.
Allergen avoidance is helpful and should be recommended, although it may not be practical or achievable. Avoiding walking in grassy open spaces in the early morning and evening as well as keeping windows shut in cars and buildings can help to reduce the risk of pollen exposure.4
There may be nasal hyperactivity to non-specific stimuli such as changes in temperature, exposure to cigarette smoke and pollution.1 Patient education is important in relation to these factors as well as the risk of disease progression and available treatments.
Intranasal corticosteroids are the mainstay of treatment.5 They may be used for moderate to severe allergic rhinitis and are the most effective agents (more effective than antihistamines used with an anti-leukotriene).1
Intranasal corticosteroids are helpful where the predominant symptom is nasal blockage and congestion,4 but they may improve conjunctival symptoms as well. Intranasal corticosteroids may exert their peak effect after several hours or days, however, maximum effectiveness is usually achieved after two to four weeks.6 There is some evidence supporting the use of nasal lavage.1
Oral antihistamines have a more rapid onset of action than nasal corticosteroids. Second-generation antihistamines including cetirizine and loratadine are associated with fewer adverse side effects. Oral antihistamines may be useful in patients with intermittent, mild symptoms of allergic rhinitis and in those who present with sneezing or rhinorrhoea.4 However, an intranasal corticosteroid is likely to be more effective.
Intranasal antihistamines may help with sneezing, itching and rhinorrhoea. Azelastine is the only intranasal antihistamine that is licensed in the UK for the treatment of allergic rhinitis.4 There is a rapid onset of action that may last up to 4 hours.
Adverse effects include epistaxis, nasal irritation and sedation. The use of intranasal antihistamines is limited by their cost and side-effect profile when compared with second generation oral antihistamines. Furthermore, intranasal antihistamines are less effective than intranasal corticosteroids. Combination therapy with intranasal corticosteroids and an antihistamine or leukotriene receptor antagonist is no more effective than monotherapy with intranasal corticosteroids.6
Sodium cromoglicate and nedocromil sodium may help with nasal symptoms but are considered less effective than intranasal corticosteroids.7 Anticholinergics such as ipratropium bromide may help with rhinorrhoea. Decongestants such as ephedrine and xylometazoline may help with nasal congestion but are associated with rhinitis medicamentosa if used inappropriately.7 The anti-leukotriene montelukast is approved in the UK for allergic rhinitis in association with asthma.1
Oral steroids may be considered if symptoms are severe. Moreover, oral corticosteroids can alleviate symptoms for important events such as examinations. Patients should be advised to re-attend within two to four weeks if their symptoms are not controlled.4
In selected cases, if symptomatic control is not achieved, sublingual or subcutaneous immunotherapy may be considered. This can reduce symptoms of allergic rhinitis and prevent asthma. Repeated injections with allergen extract are required for subcutaneous immunotherapy.1
Immunotherapy may result in remission of allergic rhinitis and reduce the risk of progression to asthma.8 Moreover the risk of developing new sensitisations to allergens is reduced.8 Allergen immunotherapy is the only disease-modifying intervention available.9
Pregnancy-induced rhinitis occurs in up to 20% of women and this is usually self-limiting.10 Decongestants should be avoided in pregnancy, but antihistamines may be considered.10
Medical management is guided by the frequency and severity of symptoms as well as the impact on quality of life.
- Dr Suneeta Kochhar, GP principal, St Leonards, East Sussex, UK
- Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic Rhinitis. Lancet 2011;378:2112-22
- Steinsvaag SK. Allergic rhinitis: an updated overview. Curr Allergy Asthma Rep. 2012;12:99-103.
- Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy 2008;38:19–42.
- NICE. Clinical Knowledge Summaries. Allergic rhinitis. 2015. Available from: cks.nice.org.uk/allergic-rhinitis#!scenariorecommendation. (accessed 6 May 2016).
- Carr WW. New therapeutic options for allergic rhinitis: back to the future with intranasal corticosteroid aerosols. Am J Rhinol Allergy. 2013; 27:309-13.
- Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician. 2010; 81:1440-6.
- Meltzer EO. Pharmacotherapeutic strategies for allergic rhinitis: matching treatment to symptoms, disease progression, and associated conditions. Allergy Asthma Proc 2013;34:301-11.
- Petalas K, Durham SR. Allergen immunotherapy for allergic rhinitis. Rhinology. 2013;51:99-110.
- Uzzaman A, Story R. Chapter 5: Allergic rhinitis. Allergy Asthma Proc. 2012; Suppl 1:S15-8.
- Angier E, Willington J, Scadding G, Holmes S, Walke S. Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Primary Care Respiratory Journal 2010;19:217-22.