This 14-year-old girl presented with a cough that was keeping her awake at night and causing drowsiness during the day.
Her nose was constantly running, causing embarrassment and a nasal blockage at night, exacerbating her sleep disturbance.
Her eyes were red, itchy and often discharging clear tears.There was a strong family history of atopy.
Her father had asthma and hayfever, and her mother had eczema and hayfever.
Her siblings had a variety of atopic conditions, including hayfever, asthma and eczema. The patient herself had no history of atopy. The symptoms indicated hayfever.
Hayfever symptoms present between March and September, triggered by tree pollens from March to mid-May, grass pollens from mid-May to July and weed pollen from the end of June to early September. Useful information on pollen counts can be obtained from the Met Office (www.metoffice.gov.uk).
Her mother and I first discussed some non-pharmacological measures that could be of benefit.
These include washing the hair before going to bed to remove pollens, drying laundry away from areas where pollen can build up, using petroleum jelly or balms to prevent pollens entering the nasal airways, wearing allergy masks, using air conditioning in the car and avoiding pets in the bedroom at night.
It was important to control the patient’s symptoms because her GCSE examinations were imminent and the symptoms were having a significant effect on her work.
OTC antihistamines, such as diphenhydramine and chlorphenamine, tend to be sedating so were not appropriate in this case.
Non-sedating antihistamines were considered, including loratadine, cetirizine and fexofenadine. These are theoretically non-sedating, but the effect varies from patient to patient.
Steroid nasal sprays, including beclometasone (twice daily) and fluticasone/budesonide (once daily), and topical antihistamines for the eyes (sodium cromoglycate, nedocromil sodium and olopatadine) were discussed. The patient opted to have all three treatment options.
The patient and her mother also asked about desensitisation. This procedure can only be undertaken
at a dedicated allergy clinic, requiring a secondary care referral.
Desensitisation can take the form of injection immunotherapy (SIT) or sublingual immunotherapy (SLIT).
The effectiveness of SIT is still not established. There is a very small risk of severe anaphylaxis (less so for SLIT, although SLIT is more expensive), so this should only be considered in severe cases, where conventional treatments have been ineffective.
- Dr Ramanathan is a GP in London