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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