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Allergic Rhinitis

Overview

Allergic rhinitis is a condition where an allergen (something that causes an allergic reaction) makes the inside of your nose swell or become inflamed. This can cause cold-like symptoms, such as sneezing, itchiness and a blocked or runny nose.

Hayfever is a type of allergic rhinitis that is caused by pollen. Other forms of allergic rhinitis may be caused by allergens, such as house dust mites or animal fur.

Some people only experience allergic rhinitis for a few months at a time. This is because they are sensitive to allergens, such as tree or grass pollen, which are only produced at certain times of the year. Others experience the condition all year round because they are sensitive to non-seasonal allergens, such as animal fur.

Allergic rhinitis is often accompanied by other allergic conditions, such as allergic conjunctivitis, a condition where allergens cause irritation to your eyes.

 

Identifying the allergen

 

Identifying the allergen that causes allergic rhinitis and, if possible, avoiding it is an important first step in managing the condition effectively.

Once diagnosed, mild cases of allergic rhinitis can usually be treated using over-the-counter (OTC) medicines. However, more serious cases may require treatment with a corticosteroid nasal spray or a combination of corticosteroid nasal spray and antihistamines.

 

Complications

Sinusitis

A common complication of allergic rhinitis is sinusitis. Sinusitis is an inflammation, or infection, of the small, air-filled cavities inside the cheekbones and forehead, which are known as the sinuses. Our sinuses can become filled with mucus, but the fluid is normally drained away from the sinuses. If the fluid cannot drain away, for example, due to a blockage, it can then become infected with bacteria.

Sinusitis is a common problem for people with allergic rhinitis because allergens can irritate the sinuses in the same way that they irritate the lining of the nose. There is also a risk of secondary infection because an excess of mucus, and nasal polyps, can stop the sinuses from draining properly.

Common symptoms of sinusitis are listed below.

  • Pain and tenderness of the infected sinus - you may experience a throbbing pain which is worse when you move your head, and toothache, or pain in your jaw, when you eat.
  • A blocked or runny nose - your nose may produce a greenish, or yellowish coloured mucus. If your nose becomes blocked with mucus, the pain and tenderness in the affected area may become worse.
  • High temperature.

 

The symptoms of sinusitis can be relieved by using over-the-counter (OTC) painkillers, such as paracetamol, ibuprofen or aspirin. These will relieve a headache, high temperature, and any pain, or tenderness that you may have around the infected area.

Children under 16 years of age should not take aspirin. Ibuprofen is not recommended for asthmatics, or those who have, or have had in the past, stomach conditions, such as ulcers. Speak to your GP if you are not sure about this.

Antibiotics may be recommended if you develop a secondary infection in your sinuses. If your sinusitis remains a long-term problem (chronic sinusitis) you may require surgery to improve the drainage of your sinuses.

Quality of life

The adverse effects of allergic rhinitis on the quality of life are often under-estimated. In a survey, 30% of people with allergic rhinitis said that the condition had an adverse effect on their home, work and social lives.

Children may also experience problems at school if their sleep is being disturbed by allergic rhinitis.

See your GP if you feel that your quality of life is suffering, or if you are worried about your child's performance at school. You, or your child, may need to have your (or their) treatment plan reassessed.

Causes

Allergic rhinitis is caused by the immune system (the body's natural defence system against infection) reacting to allergens as if they are harmful. The immune system does this by producing antibodies to fight off the allergen. Antibodies are special proteins contained in our blood that are made by the immune system to fight off viruses and infections that could harm us.

When small particles of an allergen come into contact with the inside of your nose and throat, an antibody called Immunoglobulin E (IgE) is released. This antibody causes other blood cells to release more chemicals (including histamine), which together, cause the symptoms of allergic rhinitis. Histamine causes most of the symptoms that occur in allergic rhinitis, such as:

  • swelling of the mucus membrane (the inside layer of your nose) which blocks the airway and causes congestion, and
  • the production of excess mucus, which occurs as a result of the swelling, and causes a runny nose and sneezing.

It is still unclear why people develop over-sensitivity to allergens. However, it seems to run in families. Exposure to cigarette smoke during childhood is also a risk factor.

Allergens

Allergic rhinitis is triggered by breathing in tiny particles of allergens. The most common types of airborne allergens are listed below.

  • House dust mites - are tiny insects that feed on the dead flakes of human skin. They can be found in mattresses, carpets, soft furniture, pillows and beds. It is not actually the dust mites themselves that cause rhinitis, but a chemical that is found in their excrement. They are present all year round, though their numbers tend to peak during spring and autumn. 
  • Tree and grass pollen - the tiny particles of pollen that are produced by trees and grasses can cause allergic rhinitis. Most trees usually pollinate between early to mid spring. Grasses pollinate at the end of spring and beginning of summer. 
  • Animals - it is not actually animal fur that causes allergic rhinitis; it is a reaction to flakes of dead animal skin, and their urine and saliva. Dogs and cats are the most common culprits, although some people can be affected by horses, cattle, rabbits and rodents, such as guinea pigs and hamsters. 
  • Work-related allergens - some people are affected by allergens that are present in their work environment, such as wood dust, flour dust, or latex.
Diagnosis

Your GP should be able to diagnose allergic rhinitis by asking you about your symptoms, and your personal and family medical history.

They will also ask about any triggers that seem to cause a reaction, and whether it happens at a particular place, or time.

Your GP may also examine the inside of your nose to check for the presence of nasal polyps. Nasal polyps are fleshy swellings that grow on the lining of the nose, or sinuses (small, air-filled cavities inside the cheekbones and forehead). They are caused by the inflammation associated with allergic rhinitis.

Your GP may ask you a couple of questions to rule out other possible causes of rhinitis, such as an infection, or exposure to chemicals.

Diagnosis is normally confirmed at the beginning of treatment. If you respond well to antihistamines, it is almost certain that your rhinitis is caused by an allergy.

If you do not respond well to treatment, or if the causes of your symptoms do not seem to be associated with allergens, your GP may refer you to a specialist for further testing.

Allergy testing

If the exact cause of your allergic rhinitis is uncertain, you may also be referred for allergy testing. Two tests that may be carried out include:

  • Skin prick test - this is usually the first test to be carried out when trying to determine which allergen is causing your allergic rhinitis. The allergens are placed onto your arm and introduced into the skin by pricking it with a short pin. If there is a positive reaction, your skin will become itchy, red and swollen.
  • Blood test - this is used to measure the amount of Immunoglobulin E (IgE) antibody in your blood which has been produced by your immune system in response to a suspected allergen.

 

The use of commercial allergy testing kits is not recommended. The testing is often of a lower standard than that provided by the NHS, or accredited private clinics. Also, it is important that the results of the test are interpreted by a qualified professional who has detailed knowledge of your symptoms and medical history.

Treatment
 

Self-care

If the symptoms of allergic rhinitis are mild, you should be able to treat the condition yourself, using over-the-counter (OTC) medications to relieve the symptoms. You should also take steps to avoid the particular allergen that triggers the condition. See the 'prevention' section for more information about this.

When to seek medical advice

If the symptoms of your allergic rhinitis are more severe, you may benefit from additional treatment. You should see your GP if your allergic rhinitis is:

  • causing disruption to your sleep,
  • impairing your ability to carry out everyday daily activities,
  • adversely affecting your performance at work (or, in the case of your child, their performance at school), and
  • not responding to over-the-counter (OTC) medications.

Treatment options

Your GP will decide what treatment is most suitable for you based on the type, severity, and frequency of your symptoms. They will also consider whether you have allergic conjunctivitis and nasal polyps, as well as allergic rhinitis. Also, you may have a preference regarding whether you want to take tablets, or use a nasal spray.

If your symptoms are intermittent, you will probably be given an antihistamine nasal spray, which you should use to relieve symptoms as required.

If you also have allergic conjunctivitis, or you do not like using nasal sprays, you will be given oral antihistamines instead.

If your symptoms are frequent, or persistent, and you have a nasal blockage, or nasal polyps, your GP may recommend that you use a nasal spray containing corticosteroids (topical intranasal corticosteroids).

If your symptoms are frequent, or persistent, but you do not have a nasal blockage, or nasal polyps, then either oral antihistamines, or a corticosteroid nasal spray can be used, depending on your preference.

Corticosteroids work by blocking many of the functions of the immune system and they also help to reduce inflammation. However, they take longer to take effect compared with antihistamines, but their effects last longer.

Side effects from inhaled corticosteroids are rare, but can include dryness and irritation of the nose, and nose bleeds.

If you require a rapid relief of symptoms, you may be given a short-term course of oral antihistamines to take in combination with your corticosteroid nasal spray.

If you are experiencing severe symptoms, and you are worried that they will impact on an important event, such as a driving test, or exam, let your GP know. They may recommend taking a seven-day course of oral corticosteroids, to help control your symptoms.

If your symptoms are caused by seasonal allergens, such as pollen, you should be able to stop taking your medication after the risk of being exposed to the allergen has passed. However, if your allergic rhinitis is caused by non-seasonal allergies, such as dust mites, you may require on-going treatment.

You should return to see your GP if your symptoms do not respond to treatment after two weeks.

Antihistamines

Antihistamines treat allergic rhinitis by blocking the action of the chemical, histamine, which the body releases when it thinks it is under attack from an allergen. Antihistamines can be taken as a tablet (oral), or as nasal sprays, or drops (topical intranasal). Oral antihistamines are available over-the-counter (OTC) without prescription from your pharmacist. However, antihistamine nasal sprays are only available with a prescription.

In the past, antihistamines were known to cause drowsiness, but now new types have been developed in order to avoid causing this side effect. However, a small number of people are still affected.

If you are taking antihistamines, you should see how you react to the medication before driving, or operating heavy machinery. You should also be aware that antihistamines can cause drowsiness if you take them and drink alcohol.

Oral antihistamines are not suitable for children who are under two years of age. Antihistamine nasal sprays are not suitable for children who are under five years of age.

If you are pregnant, you can take antihistamines, but it is recommended that you use a nasal spray, rather than taking tablets, to minimise any risk to your unborn child. Older antihistamines, including chlorphenamine (Piriton), loratidine, and /cetirizine, are preferred to newer medicines because there is more information available about their safety.

Nasal decongestants

Nasal decongestants should not be used to treat allergic rhinitis for more than five to seven days because using them for longer can actually make your congestion worse. If you are taking a type of antidepressant, known as a monoamine oxidase inhibitor (MAOI), you should not use nasal decongestants.

Add-ons to treatment

If your allergic rhinitis does not respond to treatment, there are several treatment options that your GP can 'add-on' to your original treatment. These include:

  • increasing the dose of your corticosteroid nasal spray,
  • using a short-term course of a decongestant nasal spray,
  • combining the use of oral antihistamines with corticosteroids nasal sprays, and possibly decongestants, and
  • using an inhaler containing a medicine called ipratropium, which will help to reduce excessive nasal discharge.

If you still do not respond to the add-on treatments, you will be referred to a specialist for further assessment and treatment.

Hyposensitisation (immunotherapy)

Hyposensitisation, or immunotherapy, is a type of treatment that is only suitable for people with certain types of allergy. For example, if you are only allergic to pollen, immunotherapy may be suitable for you.

Hyposensitisation is a method of treating allergies that involves gradually increasing a person's exposure to more and more of the allergen in order to make them less sensitive (desensitise) them to it. This will make them less likely to react adversely to the allergen when exposed to it in the future.

An immunotherapist (a specialist in the treatment of allergies) has the expertise necessary to decide which patients are suitable for hyposensitisation, and the treatment will usually be carried out under their supervision. This form of treatment carries a very small risk of causing a serious allergic reaction, known as anaphylactic shock, which can sometimes be fatal.

Surgery

Surgery is of limited use as a treatment for allergic rhinitis and is rarely used. However, if you have another condition that is making your rhinitis worse, such as nasal polyps, then surgery could be of benefit.

Prevention

The best way to prevent an allergic reaction is to avoid the allergen that causes it. However, this is not always easy. Allergens, such as dust mites, can be hard to spot and can breed in even the cleanest house. It can also sometimes be difficult to avoid pets, particularly if they belong to friends and family.

Below is some practical advice that should help you to avoid some of the most common allergens.

Dust mites

Unfortunately, keeping your house free from dust mites is difficult to achieve, requires a long-term commitment, and can be very expensive. There is also a lack of good quality evidence to show that this is an effective way of reducing, or preventing, the symptoms of allergic rhinitis. However, a number of experts have recommended it.

If you wish to try to reduce the number of dust mites in your house, some of the techniques listed below may be useful.

  • Choose wood, or hard vinyl floor coverings, instead of carpet.
  • Instead of curtains, fit roller blinds which can be easily wiped clean.
  • Remove cushions, soft toys, and other upholstered furniture.
  • Use synthetic pillows and acrylic duvets, instead of woollen blankets, or feather bedding.
  • Use a vacuum cleaner fitted with a high efficiency particulate air (HEPA) filter because it can remove more dust than ordinary vacuum cleaners.
  • Wipe surfaces using a damp, clean cloth because dry dusting can spread the allergens further.

Pets

It is not the pet fur that causes an allergic reaction, it is exposure to flakes of their dead skin, and their saliva and dried urine. If your personal circumstances prevent you from permanently removing the pet from the house, you may find the following tips useful.

  • Keep pets outside as much as possible, or limit them to one room, preferably one without carpet.
  • Do not allow pets in bedrooms because their skin flakes can remain in the air for a long time.
  • Wash pets at least one a fortnight.
  • Castration will reduce the production of allergens by male cats and dogs.

If you are visiting a friend or relative who has a pet, ask them not to dust, or vacuum, on the day you are visiting because this will 'disturb' the allergens and they will remain in the air. Taking an antihistamine medicine one hour before entering a pet-inhabited house can help to reduce symptoms.

Pollen

Different plants and trees pollinate at different times of the year, so when you get allergic rhinitis will depend on what sort of pollen(s) you are allergic to. Typically, people are affected during the spring and summer months because this is the time of year when most trees and plants pollinate. To avoid exposure to pollen, you may find that the tips outlined below are useful.

  • Check weather reports for the pollen count, and stay indoors when it is high.
  • Wear wrap-around sunglasses to protect you eyes from pollen.
  • Keep doors and windows shut during mid-morning and early evening because this is when there is most pollen in the air.
  • Avoid grassy areas, such as parks and fields.
  • Get someone else to cut the grass for you.
Symptoms

The common symptoms of allergic rhinitis include:

  • sneezing,
  • a runny nose,
  • an itchy nose, and
  • a blocked nose.

The symptoms of allergic rhinitis normally begin soon after exposure to an allergen. Many people experience mild symptoms, which can be easily and effectively treated. However, for others, the symptoms of allergic rhinitis can be more severe and cause problems with sleep, or they may interfere with everyday life.