Allergic Rhinitis

Aka: Allergic Rhinitis, Hayfever, Allergic Shiner, Dennie's Lines, Allergic Salute

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II. Epidemiology

  1. Onset under age 30
  2. Peak Incidence in childhood and adolescence
  3. Most common chronic disease in United States
    1. Affects 15 to 30% in U.S.
    2. Accounts for two million missed school days
    3. Accounts for three million missed work days
  4. Significantly affects quality of life

III. Pathophysiology

  1. IgE mediated, type I Antibody-Antigen reaction to allergens
  2. May take 4 years in a given region to be sensitized
  3. Sequence of events
    1. T Lymphocytes and B Lymphocytes release IgE Antibody
    2. Mast Cells in skin and mucosa are activated with second exposure mediated IgE-mediated cross-linking
    3. Mast Cells and intravascular Basophils degranulate
    4. Release of Histamine and chemotactic factors, Prostaglandins and Leukotrienes
      1. Results in mucosal vasodilation and edema, and nasal obstruction
      2. Late phase reactants release Histamine over 12 hour

IV. Associated Conditions

  1. Atopy
    1. Eczematous Dermatitis
    2. Allergic Rhinitis
    3. Asthma
  2. Allergic Triad (Samter's Triad)
    1. Aspirin Allergy
    2. Nasal Polyps
    3. Aspirin-Exacerbated Respiratory Disease (AERD) or Asthma

V. History

  1. Family History
    1. Allergy
    2. Asthma
    3. Atopy
  2. Other Risk Factors
    1. Atopy
    2. History of Nasal Trauma
    3. Medication use
      1. NSAIDs
      2. Antihypertensive Medications
      3. Oral Contraceptives

VI. Causes: Suspected Environmental Allergens

  1. Seasonal Allergens (U.S.)
    1. Tree pollen (early spring)
    2. Grass pollen (late spring)
    3. Outdoor Molds (summer and fall)
    4. Weed pollen (esp. ragweed, late summer to fall)
  2. Perennial
    1. Dust mites
    2. Animal dander

VII. Symptoms

  1. Specific
    1. Sneezing
    2. Rhinorrhea
    3. Nasal congestion
    4. Pruritus of the nose, eyes, and throat
    5. Eye Tearing and Conjunctival discharge
  2. Chronic Nasal Obstruction
    1. Mouth Breathing
    2. Snoring
    3. Anosmia
    4. Cough
    5. Headache
    6. Decreased Hearing
    7. Halitosis
  3. Generalized due to chronicity of Rhinitis
    1. Irritability
    2. Fatigue
    3. Depression
    4. Malaise
    5. Weakness

VIII. Signs

  1. Vitals
    1. Rule out Hypertension associated with Antihistamines
  2. Nose
    1. Use Nasal speculum with high power illumination
    2. Examine before and after topical nasal Decongestant
    3. Mucosa
      1. Pale blue
      2. Boggy
      3. Clear discharge
  3. Ocular
    1. Palpebral Conjunctiva pale and swollen
    2. Bulbar Conjunctiva injected with clear discharge
  4. Face
    1. Allergic Shiners
      1. Bluish purple rings around both eyes
      2. Results from chronic mid-face venous congestion
    2. Dennie's Lines
      1. Skin folds under eyes
    3. Allergic Salute
      1. Transverse nasal crease from chronic nose rubbing
  5. Mouth
    1. High arched narrow Palate OR
    2. Malocclusion from chronic mouth breathing
    3. "Cobblestoning" of adenoids and Tonsils
  6. Ear (Rule out associated Eustachian Tube Dysfunction)
    1. Dull, immobile Tympanic Membrane
    2. Conductive Hearing Loss
  7. Sinus (Rule out Sinusitis)
    1. Purulent discharge
    2. Tender
    3. Impaired transillumination

IX. Labs

  1. Background
    1. Allergic Rhinitis may be made on clinical grounds without specific testing
    2. Consider Allergy Testing when there is inadequate treatment response or diagnosis is unclear
    3. Allergy Testing is also indicated when instituting allergan specific treatment
  2. Skin Testing
    1. Gold standard
    2. Test Sensitivity 80 to 90%
  3. RadioAllergoSorbent Test (RAST Test)
    1. Use if unable to skin test contraindicated (e.g. Anaphylaxis, severe dermatologic conditions)
    2. Test Sensitivity 70 to 75%
    3. Test Specificity 80 to 100%
  4. Nasal Smears
    1. Eosinophils supportive of a diagnosis
  5. Complete Blood Count
    1. Normal White Blood Cell Count
    2. Increased Eosinophils
  6. IgE elevated (generally and allergan specific increases)
    1. IgE Levels are not correlated with clinical severity

X. Differential Diagnosis

  1. See Rhinitis Causes
  2. Irritants ( Cigarette Smoke, fumes and chemicals) are typically unrelated to Allergic Rhinitis

XI. Management: General Measures

  1. Decrease Environmental Allergens
  2. Nasal Saline
    1. Reduces symptoms and overall allergy medication use
    2. Hermelingmeier (2012) Am J Rhinol Allergy 26(5): e119-25 [PubMed]
  3. Non-Sedating Antihistamines
    1. May be reasonable to use as first-line if taken as needed only occasionally
    2. If regular use needed, then Intranasal Steroids are preferred
  4. Pregnancy and Lactation
    1. See Upper Respiratory Medications in Pregnancy
    2. See Medications in Lactation

XII. Management: First-Line - Intranasal Steroids

  1. See Intranasal Steroid
  2. Effects
    1. Effectively controls itching, sneezing and discharge
    2. Moderately controls blockage symptoms
    3. Small effect on impaired smell
    4. Onset of action within hours, but maximal effect requires 2-4 weeks of continuous use
    5. More effective than Antihistamines
      1. Yanez (2002) Ann Allergy Asthma Immunol 89(5): 479-84 [PubMed]
  3. Agents (Pregnancy category C unless otherwise noted)
    1. Age 2 years and older
      1. Fluticasone furoate (Veramyst, Flonase sensimist)
      2. Mometasone (Nosonex)
      3. Triamcinolone (Nasocort)
    2. Age 4 years and older
      1. Fluticasone propionate (Flonase)
    3. Age 6 years and older
      1. Beclomethasone (Beconase, Qnasl, Pregnancy category B)
      2. Budesonide (Rhinocort)
      3. Ciclesonide (Omnaris)
      4. Flunisolide

XIII. Management: First-Line - Antihistamines (non-sedating preferred)

  1. Effects
    1. Effectively controls itching and sneezing symptoms
    2. Moderately controls discharge
  2. Non-Sedating Antihistamines (first-line)
    1. Age 6 months and older
      1. Cetirizine (Zyrtec, Pregnancy category B)
      2. Desloratadine (Clarinex, Pregnancy category C, perennial allergies)
      3. Levocetirizine (Xyzal, Pregnancy category B, perennial allergies)
    2. Age 2 years and older
      1. Loratadine (Claritin, Pregnancy category B)
      2. Desloratadine (Clarinex, Pregnancy category C, seasonal allergies)
      3. Levocetirizine (Xyzal, Pregnancy category B, seasonal allergies)
    3. Age 6 years and older
      1. Fexofenadine (Allegra, Pregnancy category C)
  3. Sedating Antihistamines (for age 6 years and older; Non-Sedating Antihistamines are preferred instead)
    1. Diphenhydramine (Benadryl, Pregnancy Category B)
    2. Chlorpheniramine (ChlorTrimeton, Pregnancy Category B)

XIV. Management: Second-line Agents

  1. Overall symptoms persist
    1. Intranasal Antihistamines (pregnancy category C)
      1. Azelastine (Astelin)
        1. Approved for age >5 years (seasonal allergies) and >6 years (perennial allergies)
      2. Olopatadine (Patanase)
        1. Safe at 6 years and older
    2. Leukotriene Antagonists (risk of Major Depression and Suicide)
      1. Montelukast (Singulair)
        1. Pregnancy Category B
        2. Approved for age >6 months (perennial allergies) and >2 years (seasonal allergies)
    3. Intranasal Cromolyn (marginally effective, Mast Cell Stabilizer)
      1. Cromolyn (NasalCrom)
        1. Pregnancy category B
        2. Safe at 2 years and older (but not recommended for children)
  2. Rhinorrhea predominates
    1. See Rhinitis
    2. Nasal Saline
    3. Intranasal Ipratropium (Intranasal Atrovent)
      1. Effectively controls Nasal Discharge
  3. Ocular symptoms predominate
    1. Ocular Allergy Preparations (e.g. Patanol)

XV. Management: Refractory management

  1. Overall symptoms refractory to above measures
    1. Refer to allergy
    2. Allergy Testing
    3. Omalizumab (Xolair, approachs $1000 per dose)
      1. Anti-Immunoglobulin EAntibody
      2. Primarily indicated in Asthma, but also improves Allergic Rhinitis nasal symptoms
      3. Casale (2001) JAMA 286(23): 2956-67 [PubMed]
    4. Immunotherapy
      1. Subcutaneous Immunotherapy (standard, broad variety of allergens available)
      2. Sublingual Immunotherapy (expensive, limited allergens available)
  2. Severe acute exacerbation
    1. Generally avoid Systemic Corticosteroids in Allergic Rhinitis (use Inhaled Corticosteroids instead)
      1. However, some consultants will use short-course systemic steroids in severe cases (but poor evidence)
      2. Karaki (2013) Auris Nasus Larynx 40(3): 277-81 [PubMed]
  3. Other measures
    1. Petrolatum
      1. Applied 4 times daily to inside of nares
      2. Reduces nasal allergic symptoms
      3. Schwetz (2004) Arch Otolaryngol Head Neck Surg 130 [PubMed]

XVI. Complications

  1. Insomnia
  2. Inattention and Irritability
  3. Missed work and school
    1. Most common reason in U.S. for missed work
    2. Lamb (2006) Curr Med Res Opin 22(6): 1203-10 [PubMed]

XVII. References

  1. Plaut (2005) N Engl J Med 353(18): 1934-44 [PubMed]
  2. Price (2006) Prim Care Respir J 15(1): 58-70 [PubMed]
  3. Scadding (2008) Clin Exp Allergy 38(1): 19-42 [PubMed]
  4. Sur (2010) Am Fam Physician 81(12): 1440--6 [PubMed]
  5. Sur (2015) Am Fam Physician 92(11): 985-92 [PubMed]
  6. Wallace (2008) J Allergy Clin Immunol 122(2 suppl): S1-84 [PubMed]
  7. Weaver-Agostoni (2023) Am Fam Physician 107(5): 466-73 [PubMed]

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Ontology: Atopic rhinitis (C0002103)

Definition (NCI) Allergic rhinitis with a positive skin prick test (SPT equal or greater than 3 mm) to any allergen.(World Allergy Organization)
Concepts Disease or Syndrome (T047)
SnomedCT 38103000
English RHINITIS ALLERGIC ATOPIC, Atopic rhinitis, Rhinitis allergic atopic, Atopic rhinitis (disorder), Atopic Rhinitis
Dutch atopische allergische rhinitis, atopische rhinitis
French Rhinite allergique atopique, Rhinite atopique, RHINITE ALLERGIQUE ATOPIQUE
German Rhinitis allergisch atopisch, atopische Rhinitis, RHINITIS ALLERGISCH
Italian Rinite atopica, Rinite allergica atopica
Portuguese Rinite atópica, Rinite alérgica atópica, RINITE ALERGICA ATOPICA
Spanish Rinitis atópica, Rinitis alérgica atópica, RINITIS ALERGICA ATOPICA, rinitis atópica, rinitis atópica (trastorno)
Japanese アトピー性アレルギー性鼻炎, アトピー性鼻炎, ｱﾄﾋﾟｰｾｲｱﾚﾙｷﾞｰｾｲﾋﾞｴﾝ, ｱﾄﾋﾟｰｾｲﾋﾞｴﾝ
Czech Atopická rýma, Rýma alergická atopická
Hungarian Atopiás rhinitis, Allergiás rhinitis, atopiás
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hay fever (C0018621)

Definition (MEDLINEPLUS)

Each spring, summer, and fall, trees, weeds, and grasses release tiny pollen grains into the air. Some of the pollen ends up in your nose and throat. This can trigger a type of allergy called hay fever.

Symptoms can include

  • Sneezing, often with a runny or clogged nose
  • Coughing and postnasal drip
  • Itching eyes, nose and throat
  • Red and watery eyes
  • Dark circles under the eyes

Your health care provider may diagnose hay fever based on a physical exam and your symptoms. Sometimes skin or blood tests are used. Taking medicines and using nasal sprays can relieve symptoms. You can also rinse out your nose, but be sure to use distilled or sterilized water with saline. Allergy shots can help make you less sensitive to pollen and provide long-term relief.

NIH: National Institute of Allergy and Infectious Diseases
Definition (MSHCZE) Polinóza (pollinosis) – senná rýma. Onemocnění s přecitlivělostí na pyl, prach apod. (viz atopie). Krátce po vystavení se alergizující látce začíná postižený kýchat, má pocit ucpaného nosu, slzí a objevuje se řídký výtok z nosu. Současně může být zánět spojivek a bolesti hlavy. V nosní dutině mohou být polypy. Někdy bývají i jiné projevy atopie (astma, kopřivky apod). Srov. alergie, senzibilizace, desenzibilizace. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) Allergic rhinitis caused by outdoor allergens.
Definition (CSP) seasonal variety of allergic rhinitis, marked by acute conjunctivitis with lacrimation and itching; regarded as an allergic condition triggered by specific allergens.
Definition (MSH) Allergic rhinitis that occurs at the same time every year. It is characterized by acute CONJUNCTIVITIS with lacrimation and ITCHING, and regarded as an allergic condition triggered by specific ALLERGENS.
Concepts Disease or Syndrome (T047)
MSH D006255
ICD9 477.0
ICD10 J30.1 , J30
SnomedCT 444316004, 155536000, 195818002, 278515004, 70369002, 155537009, 266386004, 21719001, 367498001, 300910009
English Hayfever, Fever, Hay, HAY FEVER, Allergic rhinitis - pollens, pollenosis, allergic rhinitis due to pollen (diagnosis), allergic to pollens, spasmodic rhinorrhea, spasmodic rhinorrhea (diagnosis), seasonal allergic rhinitis, hay fever (diagnosis), allergic rhinitis due to pollen, hay fever, allergy to pollen, allergy to pollen (history), Pollen allergy, pollen allergy, allergy to pollens, Rhinitis due to pollen, Seasonal allergy (disorder), Seasonal allergy, Rhinitis, Allergic, Seasonal [Disease/Finding], seasonal allergy, allergies pollen, fever hay, allergy pollen, seasonal allergies, Seasonal Allergies, Hay fever - pollens, Pollinosis (& allergic rhinitis due to pollens), Allergic rhinitis due to pollen, Seasonal allergic rhinitis, Spasmodic rhinorrhea, Allergic rhinitis due to pollens, Allergy to pollen, Allergic rhinitis due to pollen (disorder), Allergy to pollen (disorder), Seasonal allergic rhinitis (disorder), Spasmodic rhinorrhoea, pollen; allergy, pollinosis, allergic; rhinitis, due to pollen, allergic; rhinitis, seasonal, due to pollen, allergy; pollen, rhinitis; allergic, due to pollen, rhinitis; allergic, seasonal, due to pollen, rhinitis; allergic, seasonal, rhinorrhea; spasmodic, spasmodic; rhinorrhea, Hay fever, Seasonal allergic rhinitis (disorder) [Ambiguous], Seasonal allergic rhinitis [Ambiguous], Hay Fever, Rhinitis, Allergic, Seasonal, Pollinosis, Pollen Allergy, Allergic Rhinitides, Seasonal, Allergic Rhinitis, Seasonal, Allergies, Pollen, Pollen Allergies, Pollinoses, Rhinitides, Seasonal Allergic, Rhinitis, Seasonal Allergic, Seasonal Allergic Rhinitis, Allergy, Pollen, Seasonal Allergic Rhinitides, hayfever
German HEUFIEBER, Pollenallergie, Allergische Rhinopathie durch Pollen, Rhinitis infolge von Pollen, jahreszeitbedingte allergische Rhinitis, Jahreszeitbedingte Allergie, Heufieber, Heuschnupfen, Pollinosis, Rhinitis, saisonale allergische, Pollinose
Italian Allergia stagionale, Allergia al polline, Pollinosi, Rinite allergica da pollini, Febbre da fieno, Allergia ai pollini, Rinite allergica stagionale
Dutch hooikoorts, pollinose, pollenallergie, seizoensgebonden allergische rhinitis, allergische rhinitis door pollen, allergie; pollen, allergisch; rinitis, door pollen, allergisch; rinitis, seizoengebonden, door pollen, pollen; allergie, rinitis; allergisch, door pollen, rinitis; allergisch, seizoengebonden, door pollen, rinitis; allergisch, seizoengebonden, rinorroe; spasmodisch, spasmodisch; rinorroe, Allergische rinitis door pollen, seizoensgebonden allergie, Allergische conjunctivitis, Allergische rhinitis, Conjunctivitis, allergische, Hooikoorts, Rhinitis, allergische, Rhinitis, allergische seizoensgebonden
Portuguese Alergia ao pólen, Febre dos fenos, FEBRE DOS FENOS, Alergia a Pólen, Rinite alérgica sazonal, Rinite alérgica por pólen, Alérgias próprias das estações do ano, Febre do Feno, Rinite Alérgica Sazonal, Polinose, Alergia ao Pólen
Spanish Fiebre del heno, Alergia al polen, FIEBRE DEL HENO, alergia estacional, alergia estacional (trastorno), alergia al polen (trastorno), alergia a polen (trastorno), alergia al polen, alergia a polen, rinitis alérgica secundaria a alérgeno, fiebre del heno, Alergia a Polen, Rinitis alérgica por polen, Rinitis alérgica estacional, polinosis, rinitis alérgica estacional (concepto no activo), rinitis alérgica estacional (trastorno), rinitis alérgica estacional, rinorrea espasmódica, Alergia estacional, rinitis alérgica por polen (trastorno), rinitis alérgica por polen, Polinosis, Rinitis Alérgica Estacional, Alergia al Polen, Fiebre del Heno
French Allergie aux pollens, RHUME DES FOINS, Rhinite allergique due au pollen, Allergie saisonnière, Coryza allergique périodique, Coryza spasmodique périodique, Rhinite allergique périodique, Rhinite spasmodique périodique, Rhume des foins, Allergie au pollen, Maladie de Bostock, Pollinose, Rhinite allergique saisonnière
Japanese 季節性アレルギー, ｷｾﾂｾｲｱﾚﾙｷﾞｰ, ｶﾌﾝｼｮｳ, ｶﾌﾝｱﾚﾙｷﾞｰ, ｺｿｳﾈﾂ, 花粉アレルギー, 枯草熱, アレルギー性季節性鼻炎, 花粉症, アレルギー性鼻炎-季節性, 鼻炎-アレルギー性季節性, 花粉によるアレルギー性鼻炎, ｷｾﾂｾｲｱﾚﾙｷﾞｰｾｲﾋﾞｴﾝ, ｶﾌﾝﾆﾖﾙｱﾚﾙｷﾞｰｾｲﾋﾞｴﾝ, 季節的アレルギー性鼻炎, 季節性アレルギー性鼻炎, 鼻炎-アレルギー性-季節的
Swedish Rinit, allergisk, årstidsbunden
Czech polinóza, senná rýma, Pylová alergie, Alergie na pyly, Polinóza, Sezónní alergie, sezonní alergická rýma, pylová alergie, sezónní alergická rinitida, rinitida alergická sezónní, sezónní alergická rýma, Sezónní alergická rýma, Alergická pylová rýma
Finnish Heinänuha
Russian RINIT ALLERGICHESKII SEZONNYI, SENNAIA LIKHORADKA, РИНИТ АЛЛЕРГИЧЕСКИЙ СЕЗОННЫЙ, СЕННАЯ ЛИХОРАДКА
Korean 화분에 의한 알레르기성 비염
Polish Nieżyt nosa alergiczny sezonowy, Gorączka sienna, Nieżyt nosa pyłkowy
Hungarian Pollenallergia, Pollinosis, Szezonális allergia, Szénanátha, Szezonális allergiás rhinitis, Pollen okozta allergiás rhinitis
Norwegian Pollenallergi, Sesongavhengig allergisk rhinitt, Høysnue, Høyfeber, Allergisk rhinitt, sesongavhengig
Croatian Sezonski alergijski rinitis, Rinitis, alergijski sezonski, Peludna groznica
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Allergic shiner (C1504524)

Concepts Pathologic Function (T046)
Dutch allergisch blauw oog
German Augenringe bei Allergie
Italian Occhiaie allergiche
Portuguese Olheiras alérgicas
Spanish Ojera alérgica
Japanese アレルギー性眼の隈, ｱﾚﾙｷﾞｰｾｲﾒﾉｸﾏ
French Décoloration bleutée infra-orbitaire d'origine allergique
Czech Alergické kruhy pod očima
Hungarian Allergiás kipirulás
English Allergic shiner
Derived from the NIH UMLS (Unified Medical Language System)

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