ALLERGIC RHINITIS GUIDELINE

AIM
To provide guidance to all members of the primary health care team in the diagnosis
and treatment of allergic rhinitis in General Practice.
Goal
To control symptoms with the most acceptable treatment for the person with allergic
rhinitis
To refer people as appropriate
2
OBJECTIVES
To be able to:
Define the term allergic rhinitis
Discus the classification of the disease
Take a detailed history
Undertake a physical eamination of nose! ears! eyes and head and confirm
diagnosis
"ode the patient appropriately on the electronic computer system
Discuss allergy avoidance measures
Discuss treatment options available to the individual patient
#now when and how to refer on for more specialist care
Guidelines for the treatment of Allergic Rhinitis
Page 1 of 12
ALLERGIC RHINITIS
DEFINITION
$llergic rhinitis %$&' is an inflammation of the mucous membranes lining the nose
that is caused by a reaction to airborne allergens! such as pollen! mould! dust
mites! and animal dander. The early(phase response is prompted by histamine
released after allergen eposure and results in the acute symptoms of snee)ing*
nasal pruritus* rhinorrhea* nasal congestion* ocular itching+burning! redness! and
tearing+watering
2
CLASSIFICATION
The previous system of classifying a person with allergic rhinitis by the persistence
and severity of their symptoms to determine management has been modified.
,anagement is now divided into whether or not a person with symptoms of allergic
rhinitis is presently on treatment! and this is reflected in the scenarios offered.
2
Characteristic features of allergic rhinitis.
$n allergic cause for rhinitis is more likely when:
There is a personal or family history of atopy %asthma! ec)ema! or allergic
rhinitis'.
-ymptoms follow eposure to a known allergic cause of rhinitis:
.ouse dust mites / symptoms are worse on waking and are present year(
round but may peak in autumn and spring.
$nimal dander / symptoms follow eposure to animal dander. -ymptoms
may be year(round or occasional! depending on eposure.
Tree pollens / intermittent or chronic symptoms occur from early to late
spring.
Grass pollens / intermittent or chronic symptoms occur from late spring to
early summer.
0eed pollens / intermittent or chronic symptoms may occur from early spring
to early autumn.
$llergens encountered at work / intermittent or chronic symptoms tend to
improve when the person is away from work at weekends and holidays.
&hinitis is associated with nasal itching.
-ymptoms settle following treatment with antihistamines or topical
corticosteroids. "#-
2
MAKING A DIAGNOSIS
Guidelines for the treatment of Allergic Rhinitis
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$ etaile clinical history should be taken by the health care professional and the
following 1uestions asked:
.ow long has the condition been present2
Patients3 account of the symptoms
4amily history2
5mpact on lifestyle (its effect on home! work! leisure and sleep2
-easonal or perennial2
Trigger factors 6 allergic or non(allergic2
7posure to allergens at home or at work2
0hat is the main symptom2
Does the patient have a history of asthma! ec)ema or rhinitis2
!"#SICA$ E%AMINATION
The physical eamination should focus on the nose! but eamination of facial
features! eyes! ears! oropharyn! neck! lungs! and skin is also important. 8ook for
physical findings that may be consistent with a systemic disease that is associated
with rhinitis.
General facial features
9Allergic shiners9 are dark circles around the eyes and are related to vasodilation or
nasal congestion.
&Nasal crease& is a hori)ontal crease across the lower half of the bridge of the nose
that is caused by repeated upward rubbing of the tip of the nose by the palm of the
hand %ie! the 9allergic salute9'.
'Allergic Ga() :pen mouth breathing
E*a+ination of Nose
Guidelines for the treatment of Allergic Rhinitis
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The nasal eamination is best accomplished with a nasal speculum or an otoscope
with nasal adapter. 5n the specialist;s office! a rigid or fleible rhinolaryngoscope may
be used.
The mucosa of the nasal turbinates may be swollen %boggy' and have a pale! bluish(
gray color. -ome patients may have predominant erythema of the mucosa! which
can also be observed with rhinitis medicamentosa! infection! or vasomotor rhinitis.
0hile pale! boggy! blue(gray mucosa is typical for allergic rhinitis! mucosal
eamination findings cannot definitively distinguish between allergic and nonallergic
causes of rhinitis.
$ssess the character and 1uantity of nasal mucus. Thin and watery secretions are
fre1uently associated with allergic rhinitis! while thick and purulent secretions are
usually associated with sinusitis* however! thicker! purulent! colored mucus can also
occur with allergic rhinitis.
7amine the nasal septum to look for any deviation or septal perforation! which may
be present due to chronic rhinitis! granulomatous disease! cocaine abuse! prior
surgery! topical decongestant abuse! or! rarely! topical steroid overuse.
7amine the nasal cavity for other masses such as polyps or tumors. Polyps are firm
gray masses that are often attached by a stalk! which may not be visible. $fter
spraying a topical decongestant! polyps do not shrink! while the surrounding nasal
mucosa does shrink.
2
E*a+ination of Ears, e-es, an oro(har-n*
Perform otoscopy to look for tympanic membrane retraction! air(fluid levels! or
bubbles. Performing pneumatic otoscopy can be considered to look for abnormal
tympanic membrane mobility. These findings can be associated with allergic rhinitis!
particularly if eustachian tube dysfunction or secondary otitis media is present.
:cular eamination may reveal findings of in<ection and swelling of the palpebral
con<unctivae! with ecess tear production. Dennie(,organ
=>
lines %prominent creases
below the inferior eyelid' are associated with allergic rhinitis.
The term 9cobblestoning9
==
is used to describe streaks of lymphoid tissue on the
posterior pharyn! which is commonly observed with allergic rhinitis. Tonsillar
Guidelines for the treatment of Allergic Rhinitis
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hypertrophy can also be observed. ,alocclusion %overbite' and a high(arched palate
can be observed in patients who breathe from their mouths ecessively.
==
Nec.: 8ook for evidence of lymphadenopathy or thyroid disease.
$ungs: 8ook for the characteristic findings of asthma.
S.in: 7valuate for possible atopic dermatitis.
:ther: 8ook for any evidence of systemic diseases that may cause rhinitis %eg!
sarcoidosis! hypothyroidism! immunodeficiency! ciliary dyskinesia syndrome! other
connective tissue diseases'.
?
A$$E/GEN AVOIDANCE MEAS0/ES
$dvise allergen avoidance for people with:
Sus(ecte (ollen allerg-
$dvise people to avoid walking in grassy open spaces! particularly during the early
morning! evening! and night! when pollen counts are at their highest! and to keep
windows shut in cars and buildings. $dvise changing car pollen filters with each
service! if these are fitted.
4or people who want to try house dust mite avoidance measures! advise fitting
mattresses and pillows with house dust mite impermeable covers* use synthetic
pillows and acrylic duvets! and keep furry toys off the bed. 0ash all bedding and furry
toys at least once a week at high temperatures. 5f possible! choose wooden or hard
floor surfaces instead of carpets. @linds that can be wiped clean should be fitted
instead of curtains. -urfaces should be wiped regularly with a clean! damp cloth.
2
-uspected animal allergy after confirming the responsible allergen by allergen
testing.
Confir+e ani+al allerg-1 advise people with confirmed animal allergy that ideally
the animal should not be allowed in the house. 0hen this is not acceptable! advise
restricting their presence to the kitchen.
T/EATMENT O2 A$$E/GIC /"INITIS
Guidelines for the treatment of Allergic Rhinitis
Page 5 of 12
,anagement of patients with allergic rhinitis symptoms should always include
identification and where possible the avoidance of trigger factors.
4or eample:
!erennial rhinitis causative factors include the houseust +ite and
o+estic (ets especially cats.
Seasonal rhinitis 3allergens to (ollens.
Tree (ollens in the springtime and grass and 4ee in the summer.
Mouls and s(ores in the late summer and autumn months.
%$dvice about avoidance measures "linical topic ( $llergic rhinitis...-cenario: -tarting
treatment
2
2or (eo(le 4ho 4ant an 5as re6uire5 treat+ent for occasional s-+(to+s,
prescribe an antihistamine. 4or people with allergic con<unctivitis! children less than A
years of age! and people who prefer oral treatment! prescribe an oral antihistamine.
4or all other people! prescribe intranasal a)elastine.
2or (eo(le 4ho 4ant (re7enti7e treat+ent to control +ore fre6uent or (ersistent
s-+(to+s eplain the importance of regular treatment and good nasal spray+drop
techni1ue to control symptoms.
If the (reo+inant s-+(to+ is nasal 8loc.age or nasal (ol-(s are (resent,
prescribe an intranasal corticosteroid.
If the (reo+inant s-+(to+s are snee9ing or nasal ischarge, prescribe either an
oral antihistamine or an intranasal corticosteroid. 7plain the characteristics of
antihistamines and intranasal corticosteroids and prescribe:
$n antihistamine when oral treatment is preferred or allergic con<unctivitis is
present.
$n intranasal corticosteroid when more effective treatment is re1uired.
If (regnant or 8reastfeeing prescribe an intranasal corticosteroid first(line.
5f this is not tolerated or additional treatment is re1uired! "#- recommends prescribing
oral loratadine.
2
5ntranasal sodium cromoglicate and nasal douching can be used as alternative or add
on treatments.
Guidelines for the treatment of Allergic Rhinitis
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If ra(i relief of s-+(to+s is re6uire 4hile a4aiting (re7enti7e treat+ent to
ta.e effect1
5f nasal congestion is a problem prescribe an intranasal decongestant for up to B
days.
5f using a intranasal corticosteroid! prescribe an oral antihistamine.
If s-+(to+s are se7ere, i+(airing the 6ualit- of their life, (rescri8e a :3;< a-
course of (renisolone =<3>< +g a a- in aults, an ;< +g a a- in chilren.
$dvise people to reconsult after 26C weeks if symptoms remain inade1uately
controlled.
In depth
2

2O$$O? 0! ADVICE
Treat+ent of (atients 4ith 4ell controlle s-+(to+s of allergic rhinitis
$dvise people to continue treatment until they are no longer likely to be eposed to the
suspected allergen.
$dvise people who have recurrent episodes of allergic rhinitis controlled by intranasal
corticosteroids to restart treatment at least B days before re(eposure to allergen.
0hen the time of re6eposure to antigen is uncertain! such as the start of the
pollination season! start treatment several weeks before the most likely time of re6
eposure
If the (reo+inant s-+(to+s are snee9ing or nasal ischarge, prescribe either an
oral antihistamine or an intranasal corticosteroid. 7plain the characteristics of
antihistamines and intranasal corticosteroids and prescribe:
$n antihistamine when oral treatment is preferred or allergic con<unctivitis is present.
$n intranasal corticosteroid when more effective treatment is re1uired.
If ra(i relief of s-+(to+s is re6uire 4hile a4aiting (re7enti7e treat+ent to
ta.e effect1
5f nasal congestion is a problem prescribe an intranasal decongestant for up to B days.
5f using a intranasal corticosteroid! prescribe an oral antihistamine.
Guidelines for the treatment of Allergic Rhinitis
Page 7 of 12
If s-+(to+s are se7ere, i+(airing the 6ualit- of their life, (rescri8e a :3;< a-
course of (renisolone =<3>< +g a a- in aults, an ;< +g a a- in chilren.
$dvise people to reconsult after 26C weeks if symptoms remain inade1uately
controlled
The mainstay of treatment for allergic rhinitis over the last few years has been the
prescribing of nasal corticosteroid sprays and the newer non(sedating antihistamines.
These have been found to be etremely effective when either prescribed as
monotherapy or in combination.
D
0ith children who have allergic rhinitis topical Soiu+ Cro+ogl-cate represents an
alternative but weaker anti(inflammatory agent but suitable in younger children and
systemic side effects are less. 0hen using intra(nasal corticosteroid! 2luticasone
and Mo+etasone 2uronate are recommended for children and are licensed for E A
years of age.
4or maimum affect in seasonal rhinitis the drug should be commenced at least 2(C
weeks before symptoms begin.
Patient education is of great importance in the understanding of the disease! the
treatment options available and the importance of compliance.
The patients3 techni1ue when using the nasal spray is of the upmost importance and
a step by step instruction sheet should be given to the patient.
How to use your nasal sray
5
@oth the Doctor and the Practice Furse can help with this and the use of self(
management plans can be discussed and agreed by both parties. These plans can
either be verbal or written.
:nce the diagnosis has been made a stepwise approach can be introduced.
Treat+ent o(tions for "a- fe7er
Inter+ittent +il s-+(to+s 5ntermittent or regular oral antihistamines
are a good first choice.
Guidelines for the treatment of Allergic Rhinitis
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5ntranasal antihistamines have a faster
onset of action.
Inter+ittent +oerate to se7ere
s-+(to+s
5ntermittent or regular oral or intranasal
antihistamines.
5ntranasal corticosteroids or
decongestants ease nasal congestion.
5ntranasal decongestants can be used
short(term to relieve congestion and
allow penetration of an intranasal
corticosteroid.
!ersistent +oerate to se7ere
s-+(to+s
5ntranasal corticosteroids are the first(
choice treatment.
5ntranasal decongestants can be used
short(term to relieve congestion and
allow penetration of an intranasal
corticosteroid.
5f symptoms remain uncontrolled!
increase the corticosteroid dose or use a
different one.
5f itching and snee)ing are troublesome!
an antihistamine can be used.
5f watery rhinorrhoea is the predominant
symptom! try intranasal ipratropium.
5f symptoms continue to be poorly
controlled! consider a short course of oral
corticosteroids
If e-e s-+(to+s (reo+inate :ral antihistamines can be taken
intermittently or regularly.
5ntraocular antihistamines are an
alternative and act more rapidly*
they may be preferable for intermittent
use.
5ntraocular sodium cromoglicate can also
be used for prophylais of persistent eye
symptoms.
5f this is ineffective! try nedocromil or
lodoamide
C
.
.
Guidelines for the treatment of Allergic Rhinitis
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NB1 !/ODIG#@S classification of allergic rhinitis is1
5ntermittent symptoms occur less than four days a
week or for less than four weeks
Persistent symptoms occur more than four days per
week and for more than four weeks
,ild symptoms are not troublesome and
normal activities! such as sleep! sport!
leisure! work and school! are unaffected
,oderate symptoms are troublesome and one or
more of the
following occur: impairment of normal
activities! such as sport
C
De(ot corticosteroi inAections are not reco++ene 8- e*(erts 8ecause the
ris.38enefit (rofile for intra+uscular corticosterois is (oor co+(are 4ith
other treat+ents a7aila8le CKS
=

B
0ntil there is a clear e7ience of its a7antages o7er other ha- fe7er
treat+ents, incluing oral (renisolone, use of De(ot inAections of
T/IAMCINO$ONE is no longer acce(ta8le. C Drug an Thera(eutic Bulletin
;DDDE
F
Guidelines for the treatment of Allergic Rhinitis
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T/EATMENT 2AI$0/E
/e7ie4 iagnosis
G
/e7ie4 co+(liance
G
/e7ie4 techni6ue
G
Huer- infection or structural (ro8le+
G
Surgical referralIs(ecialist care

/eferences
Guidelines for the treatment of Allergic Rhinitis
Page 11 of 12
= 7rkka Galovirta! ,D! PhD* D ermot &yan! ,D
2>>Hhttp:++www.medscape.com+viewarticle+ABBIH?2
srcJmpKsponJD>KuacJHBBHBPF
2 "linical #nowledge -ummaries $llergic &hinitis
http:++cks.library.nhs.uk+allergicLrhinitisM(2?==HD
D "linical topic ( $llergic rhinitis...&eferences-heikh! $.! Panesar! -.-.! Dhami!
-. and -alvilla! -. %2>>B' Seasonal allergic rhinitis in adolescents and adults.
"linical 7vidence. @,N Publishing Group 8td. www.clinicalevidence.com
O$ccessed: >?+>=+2>>HP.
C ,e&ec 2>>C
http:++www.npc.co.uk+ebt+merec+therap+other+resources+merecLbulletinLvol=CL
noA.pdf
A .ow to use your nasal spray accessed 2>>? netdoctor.co.uk
I Drug and therapeutics @ulletin =???
B 0alker - %2>>?' ,anaging -evere -ummer .ay 4ever !ri+ar- "ealth Care
A(ril =<<D 7ol ;< issue J
H Depo(,edrone C>mg+ml ( -ummary of Product "haracteristics %-P"' (
electronic ,edicines "ompendium
%e,"'http:++emc.medicines.org.uk+medicine+DAC?
? Naven -heikh ,D ,ay 2>>H$llergic rhinitis
=> Dennie ,organ 8ines @@".co.uk health
http:++www.bbc.co.uk+health+conditions+allergies+aboutallergiesLspotting.shtml
== $llergic &hinitis the childrens hospital of Philadelphia 4eb 2>>? accessed =D
th

,ay 2>>?
http:++www.chop.edu+consumer+<sp+division+generic.<sp2idJBI??A
Guidelines for the treatment of Allergic Rhinitis
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