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Allergic rhinitis

Highlights

Allergic Rhinitis

Allergic rhinitis is the way some people respond to outdoor or indoor allergens:

Allergic rhinitis tends to run in families. If one or both parents have allergic rhinitis, there is a high likelihood that their children will also have allergic rhinitis. People with allergic rhinitis have an increased risk of developing asthma and other allergies. They are also at risk for developing sinusitis, sleep disorders (including snoring), nasal polyps, and ear infections.

Symptoms

Common symptoms of allergic rhinitis include:

Treatment

Home remedies for allergic rhinitis include nasal washes with a saline solution. Many different over-the-counter and prescription drugs are used to treat allergic rhinitis. These medications include oral and nasal antihistamines, corticosteroid nasal sprays, cromolyn, leukotriene antagonists such as montelukast (Singulair), and decongestants. Many of these drugs have side effects. Immunotherapy (“allergy shots”) may also be an option for some patients.

Prevention

In addition to avoiding exposure to allergy triggers, people with allergic rhinitis can take precautions to control their environment. These measures include bathing pets weekly, using vacuum cleaners and air conditioners with high efficiency particulate air (HEPA) filters, frequent washing of bedding and curtains, reducing humidity in the house, and removing sources of mold.

Drug Approval

In 2013, the FDA approved a liquid form of antihistamine for treatment of seasonal and perennial allergic rhinitis. Carboxamine (Karbinal ER) is approved for patients ages 2 years and older.

Introduction

Rhinitis is inflammation of the mucous membrane of the nasal passages. It results from severe nasal congestion or other changes that irritate the nose.

Allergic rhinitis is caused by a substance (allergan) that triggers an allergic response. As part of the allergic response, the body’s immune system launches a defensive attack by releasing histamine and other chemicals.

Allergic rhinitis is generally classified as either:

Allergens involved in allergic rhinitis come from either outdoor or indoor substances:

Rhinitis can also be due to non-allergic causes such as infections, temperature changes, hormonal changes, certain medications, cigarette smoke, stress, exercise, structural problems in the nose, or other factors. In non-allergic rhinitis, the immune system does not play a role in the body’s response to these factors.

Basic symptoms of both allergic and non-allergic rhinitis include:

Allergic rhinitis

Causes

The allergic process, called atopy, occurs when the body overreacts to a substance that it senses as a foreign “invader". The immune system works continuously to protect the body from potentially dangerous intruders such as bacteria, viruses, and toxins. However, for reasons not completely understood, some people are hypersensitive to substances that are typically harmless.

When the immune system inaccurately identifies these substances (allergens) as harmful, an allergic reaction and inflammatory response occurs.

There are many types of IgE antibodies, and each are associated with a specific allergen. This is why some people are allergic to cat dander, while others are not bothered by cats yet are allergic to pollen. In allergic rhinitis, the allergic reaction begins when an allergen comes into contact with the mucous membranes in the lining of the nose.

Seasonal allergic rhinitis occurs only during periods of intense airborne pollen or spores. It is commonly, although inaccurately, called hay fever. No fever accompanies this condition, and the allergic response is not dependent on hay. In general, triggers of seasonal allergy in the U.S. include:

Allergies

Allergens in the House. Allergens in the home are the most common triggers of perennial (year-round) allergic rhinitis. Household allergens include:

Risk Factors

Allergic rhinitis usually first appears in childhood or early adulthood but it can affect people of all ages.

Allergic rhinitis appears to have a genetic component. People with a parent who has allergic rhinitis have an increased risk of developing allergic rhinitis themselves. The risk increases significantly if both parents have allergic rhinitis.

Home or workplace environments can increase the risk for exposure to allergens (mold spores, dust mites, and animal dander) associated with allergic rhinitis.

Exclusively breastfeeding for the first 4 months of life appears to help prevent or delay allergies in high-risk infants. It is not clear if breastfeeding helps prevent the development of allergic rhinitis. There is some evidence that breastfeeding may help prevent wheezing and other symptoms of asthma, a condition that is sometimes associated with allergic rhinitis.

Prognosis

Seasonal allergic rhinitis tends to diminish as a person ages. The earlier the symptoms start, the greater the chances for improvement. People who develop seasonal allergic rhinitis in early childhood tend not to have the allergy in adulthood. In some cases, allergies go into remission for years and then return later in life. People who develop allergies after age 20, however, tend to continue to have allergic rhinitis at least into middle age.

Complications

Asthma and allergies often coexist. Patients with allergic rhinitis often have asthma or are at increased risk of developing it. Allergic rhinitis is also associated with eczema (atopic dermatitis), an allergic skin reaction characterized by itching, scaling, and red swollen skin. Chronic uncontrolled allergic rhinitis can worsen asthma attacks and eczema.

Although allergic rhinitis is not considered a serious condition, it can interfere with many important aspects of life. Nasal allergy sufferers often feel tired, miserable, or irritable. Allergic rhinitis can interfere with work or school performance.

People with allergic rhinitis, particularly those with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. Often they attribute this to allergy medication, but congestion may be the cause of these symptoms. Patients who have severe allergic rhinitis tend to have worse sleep problems, including snoring, than those with mild allergic rhinitis.

Any chronic rhinitis, whether allergic or nonallergic, can cause swelling in the turbinates, which may become persistent (turbinate hypertrophy). The turbinates are tiny shelf-like bony structures that project into the nasal passageways. They help warm, humidify, and clean the air that passes over them. If turbinate hypertrophy develops, it causes persistent nasal congestion and, sometimes, pressure and headache in the middle of the face and forehead. This condition may require surgery.

Other possible complications of allergic rhinitis include:

Symptoms

Symptoms of allergic rhinitis often occur in two phases, early and late.

Early Phase Symptoms. The early phase occurs within minutes of exposure to the allergens and includes:

Late-Phase Symptoms. Symptoms that may develop several hours or later include:

A newer classification system groups allergic rhinitis by how long symptoms last and how severe they are:

Diagnosis

In most cases, a doctor can diagnose allergic rhinitis based on the patient's symptoms. Your doctor will take your medical history and will ask about:

The doctor may examine the inside of the nose with an instrument called a speculum. This is a painless procedure that allows the doctor to check for redness and other signs of inflammation. The doctor will also usually check the eyes, ears, and chest.

Allergy testing may be used to confirm an allergic trigger identified by symptoms. A skin test is a simple method for detecting common allergens. Patients are usually tested for a panel of common allergens. Skin tests are rarely needed to diagnose milder seasonal allergic symptoms before a trial of treatment. Skin tests are not  completely accurate and are not appropriate for children younger than age 3.

The procedure is as follows:

In most situations, before testing occurs patients would have tried to avoid any of their known allergens, as well as tried medications, including nasal corticosteroid sprays. However, patients with more severe symptoms, particularly those with asthma, significant eczema, or nasal polyps, may benefit from earlier skin testing.

Nasal Smear. The doctor may take a nasal smear. The nasal secretion is examined microscopically for factors that might indicate a cause, such as increased numbers of white blood cells, indicating infection, or high counts of eosinophils. High eosinophil counts indicate an allergic condition, but low counts do not rule out allergic rhinitis.

Tests for IgE. Blood tests for IgE immunoglobulin production may also be performed. Newer enzyme-based assays using IgE antibodies have replaced an older test called RAST (radioallergosorbent test). The tests detect increased levels of allergen-specific IgE in response to particular allergens. Blood tests for IgE may be less accurate than skin tests. They should be performed only on patients who cannot undergo skin testing or when skin test results are uncertain.

In some cases of chronic or unresponsive seasonal rhinitis, a doctor may use endoscopy to examine for any irregularities in the nose structure. Endoscopy uses a tube inserted through the nose that contains a miniature camera to view the passageways.

Rhinitis always precedes and accompanies sinusitis, which is inflammation or infection of the mucosal lining of the sinuses. Acute sinusitis usually clears up on its own. Chronic sinusitis can be more difficult to treat.

Allergic rhinitis also needs to be distinguished from the cold or flu:

Treatment

Patients with allergic rhinitis have many treatment options available to them:

All drug treatments have side effects, some very unpleasant and, in rare cases, serious. Patients may need to try different drugs until they find one that relieves symptoms without producing excessively distressing side effects.

Treating mild allergy attacks usually involves little more than reducing exposure to allergens and using a nasal wash. Medications may also be used. Most medications for mild allergic rhinitis are available without a prescription.

Treatments for mild allergic rhinitis include:

For people who suffer from moderate-to-several seasonal allergies, doctors recommend:

Patients with perennial (year-round) allergic rhinitis or those who have bothersome symptoms that are active during most of the year may require daily medications. This is especially true if patients also have asthma.

Drug treatments for moderate-to-severe allergic rhinitis include

For mild allergic rhinitis, a nasal wash can help remove mucus from the nose. You can purchase a saline solution at a drug store or make one at home (2 cups of warm water, a teaspoon salt, pinch of baking soda). If you prepare your own saline solution, use bottled or boiled water, not plain tap water.

Here is a simple method for administering a nasal wash:

Neti pots have also become popular in recent years for prevention and treatment of allergic rhinitis. Nasal irrigation with a saline solution through a neti pot involves:

Antihistamine pills can sometimes help itching and redness in the eyes. Eye drops provide faster relief, and a combination of the two may be best. Eye drops for itchy eyes include.

General Side Effects and Warnings.

Some patients with allergies report symptom relief through modalities such as acupuncture and Chinese herbal medicine. While some studies have reported symptom improvement, it is not clear if this is due to a placebo effect.

Medications

Histamine is one of the chemicals released when antibodies overreact to allergens. It is the cause of many symptoms of allergic rhinitis. Antihistamine drugs can help relieve:

If possible, take an antihistamine before an anticipated allergy attack.

Many antihistamines are available. They include short-acting and long-acting forms, and come in oral pill and nasal spray forms.

Antihistamines are generally categorized as first- and second-generation. First-generation antihistamines, which include diphenhydramine (Benadryl, generic) and clemastine (Tavist, generic) cause more side effects (such as drowsiness) than most newer second-generation antihistamines. For this reason, second-generation antihistamines are generally preferred and recommended over first-generation antihistamines.

There are some notes of caution when taking any antihistamine:

Second-generation antihistamines are sometimes referred to collectively as nonsedating antihistamines. However, cetirizine (Zyrtec, generic) and the nasal spray antihistamines (Astelin, Patanase) may cause drowsiness when taken at recommended doses. Loratidine (Claritin, generic) and desloratadine (Clarinex) can cause drowsiness when taken at doses exceeding the recommended dose.

Brand Names. Second-generation antihistamines in pill form include:

Second-generation antihistamines in nasal form are as good as or better than the oral forms for treatment of seasonal allergic rhinitis. However, they can cause drowsiness, and are not as effective for allergic rhinitis as nasal corticosteroids. Nasal spray antihistamines are available by prescription and include:

In 2013, the FDA approved a liquid form of antihistamine for treatment of seasonal and perennial allergic rhinitis. Carboxamine (Karbinal ER) is approved for patients age 2 years and older.

Side Effects and Precautions.

Corticosteroids help reduce the inflammatory response associated with allergic reactions. Nasal-spray corticosteroids (commonly called steroids) are considered the most effective drugs for controlling the symptoms of moderate-to-severe allergic rhinitis. They are often used either alone or in combination with second-generation oral antihistamines.

The benefits of nasal spray steroids include:

Nasal-Spray Brands. Corticosteroids available in nasal spray form include:

Side Effects. Corticosteroids are powerful anti-inflammatory drugs. Although oral steroids can have many side effects, the nasal-spray form affects only local areas and has less risk for widespread side effects unless the drug is used excessively. Side effects of nasal steroids may include:

Possible Long-Term Complications. All corticosteroids suppress stress hormones. This effect can produce some serious long-term complications in people who take oral steroids. Researchers have found far fewer concerns with nasal administration or inhaled forms, but there may be certain problems:

Cromolyn serves as both an anti-inflammatory drug and a specific blocker for allergens. The standard cromolyn nasal spray (Nasalcrom, generic) is not as effective as steroid nasal sprays but does work well for many people with mild allergies. It is one of the preferred first-line therapies for pregnant women with mild allergic rhinitis. It may take up to 3 weeks to experience full benefit.

Side Effects. Cromolyn has no major side effects, but minor ones include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat. The spray can cause burning or irritation.

Leukotriene antagonists are oral drugs that block leukotrienes, powerful immune system factors that cause airway constriction and mucus production in allergy-related asthma. They appear to work as well as antihistamines for treatment of allergic rhinitis, but are not as effective as nasal corticosteroids.

Leukotriene antagonists include zafirlukast (Accolate) and montelukast (Singulair). These drugs are mainly used to treat asthma. Montelukast is also approved to treat seasonal allergies and indoor allergies.

The FDA warns that these drugs have been associated with behavior and mood changes, including agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, tremor, and suicidal thinking and behavior. Patients who take a leukotriene antagonist drug such as montelukast should be monitored for signs of behavioral and mood changes. Doctors should consider discontinuing the drug if patients exhibit any of these symptoms.

Decongestants work by shrinking blood vessels in the nose. Many over-the-counter decongestants are available, which can be either taken by mouth or applied to the nose.

Nasal Decongestants. Nasal-delivery decongestants are applied directly into the nasal passages with a spray, gel, drops, or vapors. Nasal decongestants come in long-acting or short-acting forms. The effects of short-acting decongestants last about 4 hours. Long-acting decongestants last 6 - 12 hours. The active ingredients in nasal decongestants include oxymetazoline, xylometazoline, and phenylephrine. Nasal forms work faster than oral decongestants and may not cause as much drowsiness. However, they can cause dependency and rebound.

The major problem with nasal-delivery decongestants, particularly long-acting forms, is a cycle of dependency and rebound effects. The 12-hour brands pose a particular risk for this effect.

The following precautions are important for people taking nasal decongestants:

Oral Decongestants. Oral decongestants also come in many brands, which have similar ingredients. The most common active ingredients are pseudoephedrine (Sudafed, other brands, generic) and phenylephrine, sometimes in combination with an antihistamine. Oral decongestants can cause side effects such as insomnia, irritability, nervousness, and heart palpitations. Taking pseudoephedrine in the morning, as opposed to later in the day or before bedtime, can help patients avoid these side effects.

Individuals at Risk for Complications from Decongestants. People who may be at higher risk for complications are those with certain medical conditions, including disorders that make blood vessels highly susceptible to contraction. Such conditions include:

No one with these conditions should use oral or nasal decongestants without a doctor's guidance. Other people who should not use decongestants without first consulting a doctor include:

Decongestants can cause dangerous interactions when combined with certain types of medications, such as the antidepressant MAO inhibitors. They can also serious problems when combined with methamphetamines or diet pills. Be sure to tell your doctor about any drug or herbal remedy you are taking. Caffeine can also increase the stimulant side effects of pseudoephedrine.

Ipratropium bromide (Atrovent, generic) is a prescription nasal spray that can help relieve runny nose. It works best when given in combination with a nasal corticosteroid. Side effects include nasal dryness, nosebleeds, and sore throat. It should not be used by people who have glaucoma or men who have an enlarged prostate gland.

Immunotherapy

Immunotherapy (commonly called "allergy shots") is a safe and effective treatment for patients with allergies. It is based on the premise that people who receive injections of a specific allergen will lose sensitivity to that allergen. The most common allergens for which shots are given are house dust, cat dander, grass pollen, and mold.

Immunotherapy benefits include:

Candidates for Immunotherapy. Immunotherapy may be given to anyone with allergies that do not get better with medication and who has had a positive allergy test to specific allergens. The latest guidelines indicate that immunotherapy is safe for young children. Immunotherapy is safe for pregnant women who are already receiving it, although half-strength doses are generally recommended, and it should not be started during pregnancy.

Individuals at Risk for Complications. People who should probably avoid immunotherapy include those who have:

The major downside to immunotherapy is that it requires a prolonged course of weekly injections. The process generally includes:

The use of an injection series is effective, but patients often have difficulty complying with the regimens. Some other schedules and delivery methods are being investigated that might make the program easier:

Recent reviews indicate that sublingual therapy may be helpful for asthma in particular, and may also be beneficial for allergic rhinitis and rhinoconjunctivitis. However, many questions remain including dosage and duration of treatment. At this time, sublingual immunotherapy is not considered standard practice in the United States. Other studies indicate that subcutaneous immunotherapy is more effective than sublingual immunotherapy.

Injections for ragweed and, sometimes, dust mites have higher risks for side effects than other allergy shots. If complications or allergic reactions develop, they usually occur within 20 minutes, although some can develop up to 2 hours after the shot is given.

Side effects of immunotherapy include:

Lifestyle Changes

People with existing allergies should avoid irritants or allergens. These triggers include:

Some studies suggest that early exposure to some of these allergens, including dust mites and pets, may actually prevent allergies from developing in children.

Controlling Pets. People who already have pets and are not allergic to them are probably at low risk for developing such allergies later on. When children are exposed to more than one dog or cat during their first year, they have a much lower risk for not only pet allergies but also seasonal allergies and asthma. (Pet exposure does not protect them from other allergens, notably dust mites and cockroaches).

For children who have an existing allergy to pets:

Preventing Exposure to Cigarette and Cooking Smoke. Although cigarette smoke is not a trigger for allergic rhinitis, parents who smoke should quit. Studies show that exposure to second-hand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children.

Controlling Dust. Spray furniture polish is very effective for reducing both dust and allergens. Air cleaners, filters for air conditioners, and vacuum cleaners with High Efficiency Particulate Air (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo is, however, effective in removing mites in house dust. Vacuuming actually stirs up both mites and cat allergens. People with these types of allergies should avoid having carpets or rugs in their homes. For children with allergies, vacuuming should be performed when the child is not around.

Bedding and Curtains:

Reducing Humidity in the House. Living in a damp environment is counterproductive:

Exterminating Pests (Cockroaches and Mice):

Avoiding Outdoor Allergens. The following are some recommendations for avoiding allergens outside:

Some evidence suggests that people with allergic rhinitis and asthma may benefit from a diet rich in omega-3 fatty acids (found in fish, almonds, walnuts, pumpkin, and flax seeds) and fruits and vegetables (at least five servings a day). Researchers are also studying probiotics -- so-called good bacteria, such as lactobacillus and bifidobacterium-- which can be obtained in supplements. Some studies have found that probiotics may help reduce allergic rhinitis symptom severity and medication use.

Resources

References

Al Sayyad JJ, Fedorowicz Z, Alhashimi D, Jamal A. Topical nasal steroids for intermittent and persistent allergic rhinitis in children. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD003163.

Bahls C. In the clinic. Allergic rhinitis. Ann Intern Med. 2007 Apr 3;146(7):ITC4-1-ITC4-16.

Blaiss MS. Safety considerations of intranasal corticosteroids for the treatment of allergic rhinitis. Allergy Asthma Proc. 2007 Mar-Apr;28(2):145-52.

Brinkhaus B, Ortiz M, Witt CM, Roll S, Linde K, Pfab F, et al. Acupuncture in patients with seasonal allergic rhinitis: a randomized trial. Ann Intern Med. 2013 Feb 19;158(4):225-34.

Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010 Sep;126(3):466-76.

Cox L, Nelson H, Lockey R, Calabria C, Chacko T, Finegold I, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011 Jan;127(1 Suppl):S1-55. Epub 2010 Dec 3.

Di Bona D, Plaia A, Leto-Barone MS, La Piana S, Di Lorenzo G. Efficacy of subcutaneous and sublingual immunotherapy with grass allergens for seasonal allergic rhinitis: a meta-analysis-based comparison. J Allergy Clin Immunol. 2012 Nov;130(5):1097-1107.e2. Epub 2012 Sep 27.

Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S103-15.

Frew AJ. Allergen immunotherapy. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S306-13.

Frew AJ. Sublingual immunotherapy. N Engl J Med. 2008 May 22;358(21):2259-64.

Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic rhinitis. Lancet. 2011 Dec 17;378(9809):2112-22. Epub 2011 Jul 23.

Lin SY, Erekosima N, Kim JM, Ramanathan M, Suarez-Cuervo C, Chelladurai Y, et al. Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. JAMA. 2013 Mar 27;309(12):1278-88.

Matricardi PM, Kuna P, Panetta V, Wahn U, Narkus A. Subcutaneous immunotherapy and pharmacotherapy in seasonal allergic rhinitis: a comparison based on meta-analyses. J Allergy Clin Immunol. 2011 Oct;128(4):791-799.e6. Epub 2011 May 26.

Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009 Nov 15;80(10):1117-9.

Saleh HA, Durham SR. Perennial rhinitis. BMJ. 2007 Sep 8;335(7618):502-7.

Scow DT, Luttermoser GK, Dickerson KS. Leukotriene inhibitors in the treatment of allergy and asthma. Am Fam Physician. 2007 Jan 1;75(1):65-70.

Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001563.

Sicherer SH, Wood RA; American Academy of Pediatrics Section On Allergy And Immunology. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2012 Jan;129(1):193-7. Epub 2011 Dec 26.

Smits WL, Giese JK, Letz KL, Inglefield JT, Schlie AR. Safety of rush immunotherapy using a modified schedule: a cumulative experience of 893 patients receiving multiple aeroallergens. Allergy Asthma Proc. 2007 May-Jun;28(3):305-12.

Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician. 2010 Jun 15;81(12):1440-6.

Vliagoftis H, Kouranos VD, Betsi GI, Falagas ME. Probiotics for the treatment of allergic rhinitis and asthma: systematic review of randomized controlled trials. Ann Allergy Asthma Immunol. 2008 Dec;101(6):570-9.

Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.



Review Date: 6/24/2013
Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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