Allergic Rhinitis (Rhinitis alergi)

Author: Jack M Becker, MD, Clinical Associate Professor of Pediatrics, Drexel

University School of Medicine
Introduction
Background
Although allergic rhinitis (AR) is a common disease, the impact on daily life cannot
be underestimated. Some patients find allergic rhinitis to be just as debilitating and
intrusive as severe asthma. Employees with untreated allergies are reportedly 10%
less productive than coworkers without allergies, whereas those using allergy
medications to treat allergic rhinitis were only 3% less productive.1 This suggests
that effective medications may reduce the overall cost of decreased productivity.
Allergic rhinitis is caused by an immunoglobulin E (IgE)mediated reaction to various
allergens in the nasal mucosa. The most common allergens include dust mites, pet
danders, cockroaches, molds, and pollens. For example, tree pollen allergen binds
to IgE antibodies that are attached to a mast cell via Fce receptor. When 2 IgE
molecules bind to the same tree pollen allergen, they cause the mast cell to fire off
(degranurate), leading to release of various inflammatory mediators that cause the
symptoms we feel as allergic rhinitis, including sneezing; nasal congestion;
stuffiness; rhinorrhea (runny nose); cough; itching of the nose, eyes, and throat;
sinus pressure; headache; and epistaxis (bloody nose).
The allergens present in the outdoor environment vary with the time of year and
location. Knowing what allergens are in the environment at a specific time of year
helps in diagnosing and treating allergic rhinitis and helps in excluding allergy as a
cause of the patient's symptoms. For example, a patient who presents with nasal
congestion in November in Boston, Massachusetts cannot have allergic rhinitis
attributed to tree pollen allergy, which is prevalent in spring.
Allergen exposure likely causes both upper and lower airway inflammation, meaning
that both the nose and the lungs may be involved. Many experts believe that a
patient's airway needs to be evaluated as a total entity, not as individual parts.
Studies have shown that most patients with asthma also have allergic rhinitis.
Guidelines regarding the impact of allergic rhinitis on asthma have been
established.2 Allergic reactions of the upper airway can trigger lower airway
symptoms and vice versa. One study showed that patients with untreated allergic
rhinitis and asthma have an almost 2-fold greater risk of having an emergency
department visit and almost a 3-fold greater risk of being hospitalized for an asthma
exacerbation, respectively.3 Similarly there are studies that reveal treatment of one
disease entity improves the other.
The graphs below detail the significant impact of nasal allergies.
Impact of nasal allergies.
How patient feel when they have allergy symptoms.

Nasal symptoms and affect on work performance.

Pathophysiology
Understanding the function of the nose is important in order to understand allergic
rhinitis. The purpose of the nose is to filter, humidify, and regulate the temperature
of inspired air. This is accomplished on a large surface area spread over 3 turbinates
in each nostril. A triad of physical elements (ie, a thin layer of mucus, cilia, and
vibrissae [hairs] that trap particles in the air) accomplishes temperature regulation.
The amount of blood flow to each nostril regulates the size of the turbinates and
affects airflow resistance. The nature of the filtered particles can affect the nose.
Irritants (eg, cigarette smoke, cold air) cause short-term rhinitis; however, allergens
cause a cascade of events that can lead to more significant inflammatory reactions.
In short, rhinitis results from a local defense mechanism in the nasal airways that
attempts to prevent irritants and allergens from entering the lungs.
Allergic reactions require exposure and then sensitization to allergens. To be
sensitized, the patient must be exposed to allergens for a period of time.
Sensitization to highly allergenic indoor allergens can occur in children younger than
2 years. Sensitization to outdoor allergens usually occurs when a child is older than
3-5 years, and the average age at presentation is 9-10 years. The allergic reaction
begins with the cross-linking of the allergen to 2 adjacent IgE molecules that are
bound to high-affinity Fc receptors on the surface of a mast cell. This cross-linking
causes mast cells to degranulate, releasing various mediators. The best-known
mediators are histamine, prostaglandin D2, tryptase, heparin, and plateletactivating factor, as well as leukotrienes and other cytokines.
These substances produce 2 types of reactions: immediate and late-phase. The
immediate reactions in the nasal mucosa induce acute allergy symptoms (eg, nasal
itch, clear nasal discharge, sneezing, congestion). The late-phase reaction occurs
hours later, secondary to the recruitment of inflammatory cells into the tissue by
the action of mediators (termed chemokines) released by the mast cell. Recruited
cells are predominated by eosinophils and basophils, which, in turn, release their
inflammatory mediators, leading to continuation of the cascade. In very sensitive
individuals, this allergen-induced nasal inflammation causes priming of the nasal
mucosa. Primed nasal mucosa becomes hyperresponsive, at which point even
nonspecific triggers or small amounts of the antigen can cause significant
symptoms.
Frequency
United States
Prevalence in the United States is 10-20%.4 One survey demonstrated rates as high
as 38.2% when patients were asked if they experienced fewer than 7 days of
symptoms. When allergic rhinitis was defined as symptoms lasting more than 31
days, prevalence dropped to 17%.
International
In temperate areas of Europe and Asia, frequency is similar to that in the United
States.

Mortality/Morbidity
Mortality is not associated with allergic rhinitis, but significant morbidity occurs.
Morbidity is manifested in several ways. Annually, an estimated 824,000 school
days are missed, and an estimated 4,230,000 days of reduced quality-of-life
functions are reported.5 Comorbidity of other atopic diseases (asthma, atopic
dermatitis) or upper airway inflammation (sinusitis, otitis media) is significant in
allergic rhinitis. Individuals with allergic rhinitis have a higher frequency of these
conditions than individuals without allergic rhinitis.
Quality-of-life surveys have revealed that patients with significant allergic rhinitis
found symptoms to be just as debilitating as symptoms in patients with moderateto-severe asthma. Patients with allergic rhinitis felt they were equally impaired and
unable to participate in the activities of normal living similar to those with the
moderate-to-severe asthma. They felt that chronic congestion, sneezing, the need
to wipe the nose, and a decrease in restful sleep compromised levels of their daily
activity.
The financial cost of allergic rhinitis is difficult to estimate. Self-treating patients are
estimated to spend an average of 56 dollars per year. The direct cost of prescription
medication exceeds 6 billion dollars per year worldwide, and lost productivity is
estimated at 1.5 billion dollars per year.
Race
Allergic rhinitis has no race predilection; however, individuals from nonwhite
backgrounds seek out medical attention less often than whites.
Sex
Allergic rhinitis has no sex predilection.
Age
Allergic rhinitis usually presents in early childhood. Allergic rhinitis caused by
sensitization to outdoor allergens can occur in children older than 2 years; however,
sensitization in children aged 4-6 years is more common. Clinically significant
sensitization to indoor allergens may occur in children younger than 2 years. This is
typically associated with significant exposures to indoor allergens (eg, molds, furry
animals, cockroaches, dust mites). Some children may be sensitized to outdoor
allergens at this young age if they have significant exposure. Incidence continues to
increase until the fourth decade of life, when symptoms begin to fade; however,
individuals can develop symptoms at any age.
Clinical
History
The history of the patient with allergic rhinitis (AR) may be straightforward or may
include a complex set of symptoms. The diagnosis is easy to make in a patient with

a new pet or with symptoms that have distinct seasonal variation. Alternatively,
younger patients may present with varying signs or symptoms, the family may not
appreciate the nasal stuffiness but may note the chronic nasal congestion. In older
children, symptoms may have been present for years and, therefore, appear to be
less severe because the child has accommodated them.
Physicians should try to identify seasonal variations, provocative elements in the
environment, and the timing of events that lead to symptoms. Few patients present
soon after the onset of allergic rhinitis symptoms. Usually, allergic rhinitis symptoms
have been present for years and have been slowly worsening during each allergy
season.
This is especially true for patients with pet allergies. The symptoms appear slowly,
over years. They can worsen in the spring and fall and be confused with pollen
allergy. This occurs for pets usually shed more in the warmer weather and then in
the fall when more time is spent indoors with worsening symptoms. Also, many
families believe that the fact that the pet was present before the onset of the child's
symptoms exclude the possibility of allergy to the family pet, but this is not true.
The family often believe that the family pet is hypoallergenic. No cats or dogs are
truly hypoallergenic.
Unless a new exposure to large amounts of allergens is reported (eg, pet, feather
pillow), a patient who describes a sudden onset of nasal allergy symptoms is not
experiencing allergic symptoms. Sudden onset of nasal symptoms is often
associated with acute sinusitis or acute bacterial sinusitis superimposed on chronic
sinusitis. In children younger than 5 years, differentiating allergy symptoms from
recurrent upper respiratory viral infection is even more difficult, especially in those
who attend daycare and experience frequent rhinitis symptoms.
Nature of symptoms
Symptoms of rhinitis consist of rhinorrhea, nasal congestion, postnasal drainage,
repetitive sneezing, and itching of the palate, nose, or eyes. Snoring, frequent sore
throats, constant clearing of the throat, cough, itchy eyes, and headaches are
symptoms often associated with rhinitis.
When obtaining the history, ascertain the following:
Determine which symptoms are reported by the patient or parent.
Determine whether the patient has rhinorrhea, sniffling, nasal itching, sneezing,
cough, congestion, or nasal discharge. Determine the color of the nasal discharge.
Determine whether any associated ocular or respiratory symptoms are present.
Ask about snoring, which may worsen in pollen season.
Timing of symptoms
Identify whether symptoms are present or worsen during certain seasons, such as
the spring or fall. In addition, try to identify whether symptoms are worse in specific
places, such as home, work, or school, or when the patient is around animals.
Determine when symptoms occur and whether they occur primarily at night, in
school, outdoors, or at a relative's or friend's home.
Determine whether symptoms occur only at a certain time of the year or throughout
the year. Remember that symptoms in the fall and spring may still indicate a pet
allergy.
Determine whether symptoms ever improve and, if so, what actions help alleviate
symptoms. Most patients have tried over-the-counter antihistamine medication. If
these medications help, allergic rhinitis should be suspected; however, a negative

response does not eliminate the possibility of allergic rhinitis. Ask if the patient's
symptoms improve when they are away from certain locations. For example, a child
who has less symptoms at college or camp may have an allergy to the family pet,
feather pillows, or dust mites in their bedding.
Determine whether symptoms improve when the patient is taking antibiotics. Most
patients receive antibiotics for various reasons unrelated to nasal symptoms. If
symptoms respond to antibiotic therapy, the clinical diagnosis may be sinusitis,
which may have been either primary sinusitis or secondary sinusitis caused by
allergic rhinitis.
Duration of symptoms
Determine whether symptoms last for weeks, months, or hours.
Most pollen seasons are at least 6 weeks long in more moderate climates. In the
south and far north, the season can be longer or shorter, respectively. Symptoms
that last less than 2 weeks rarely indicate allergic rhinitis unless concomitant
exposure occurs.
In winter in the northern regions, virtually all pollens are absent; therefore, any
allergic rhinitislike symptoms are the result of indoor allergen exposure or are
associated with nonallergic causes. Although patients are usually exposed to the
same allergens throughout the year, allergic rhinitis symptoms triggered by indoor
allergens can worsen in winter secondary to longer hours spent indoors during the
cold months. This may also be associated with closed windows and doors in winter,
resulting in increased recirculation of indoor allergens. An example of winter-only
exposure is a person who is allergic to dust mites who uses a down comforter only
during the winter (dust mites are highly infested in a down comforter.)
Family history
Children with parents who have allergies or asthma are more likely to be affected.
If a child has one parent with allergies, chances are 30% that a child will have
allergic rhinitis. This increases to 50-70% if both parents have allergies or atopic
asthma.
Related medical history
Patients with a history of infantile eczema (atopic dermatitis) have a 70% chance of
having allergic rhinitis, asthma, or both.
Patients with a history of asthma also have higher incidence of allergic rhinitis.
Social and environmental history
The patient's environment is very important. Ask about the presence of a pet or
beddings (eg, pillow, bedspread, comforter [especially containing feathers]) and
other home items likely infested by dust mites (eg, carpeted floor, stuffed animals,
dusty closet, nonleather furniture) as well as the timing of initial exposure. Many
times, exposure to dust, feathers, or pets coincides with the onset of symptoms,
making diagnosis and treatment easier. However, patients could become sensitized
to indoor allergens by exposure in places other than the home where they spend a
fair numbers of hours (eg, schools, daycare center, baby sitters' and relatives'
homes).
Questions must be raised regarding any environment in which the patient spends
more than a few hours per week. This includes baby-sitters' and relatives' homes,
daycare facilities, and schools (classroom pets).
For children younger than 3 years, ask about the child's bed. Cribs or toddler beds
that use crib mattresses do not have dust mites because of the plastic covers, but
standard bedding (bed mattress) can harbor dust mites.

Physical
A full examination should always be performed to detect other diseases, such as
asthma, eczema, and cystic fibrosis, which occur in connection with allergic rhinitis.
Evaluation involves the head, eyes, ears, nose, and throat. Upon inspection, the
following signs can be noted:
Head
Allergic shiners (dark, puffy, lower eyelids) may be present (see image below).
Photo demonstrates allergic shiners. Note the periorbital edema and bluish
discoloration seen in allergic rhinitis and sinusitis.
Morgan-Dennie lines (lines under the lower eyelid) may be observed.
Transverse crease at the lower third of the nose secondary to the allergic salute,
which is the upward rubbing of the nose, is commonly seen in parents as well.
Eyes
Marked erythema of palpebral conjunctivae and papillary hypertrophy of tarsal
conjunctivae are observed. Chemosis of the conjunctivae may be present. Patients
usually have a watery discharge.
Cataracts have occurred from severe rubbing secondary to itching.
Ears
Tympanic membranes should be examined for the presence of chronic infection or
middle ear effusion.
The role of allergic rhinitis in chronic otitis media is not clear, but decreased
numbers of infections have been noted in children with allergic rhinitis once therapy
was instituted.
Nose
Nasal examination is often helpful in the diagnosis.
Turbinates are enlarged and have a pale-bluish mucosa due to edema.
Discharge is usually clear but can be white. The discharge is rarely yellow or green.
If colored discharge is observed, a diagnosis of viral infection or sinusitis should be
considered.
Dried blood is commonly observed secondary to trauma from rubbing the nose.
Polyps are rarely observed in children. If polyps are noted or suspected, perform
rhinoscopy. If polyps are detected, a workup for cystic fibrosis is mandatory in
children. Also consider the diagnosis of aspirin sensitivity in adults.
Throat
Inspection of the dentition can be informative. Discoloration of frontal incisors and a
high arched palate are associated with chronic mouth breathing. Malocclusion is
commonly associated with chronic mouth breathing.
Cobblestoning in the posterior pharynx is also a sign of follicular hypertrophy of
mucosal lymphoid tissue secondary to chronic nasal congestion and postnasal
drainage.
Note the size of tonsillar tissue, which may provide a clue to the size of the
adenoids; large adenoids can mimic the signs and symptoms of allergic rhinitis.
Chronic nasal congestion due to adenoid hypertrophy is frequently seen in young
children with recurrent otitis media and sinusitis.
Causes

Perennial symptoms are usually caused by indoor allergens, including the following:
Dust mites
Cat dander
Dog dander
Indoor molds
Cockroaches
Feathers: In most occasions, feather pillows and comforters are highly allergenic,
secondary to dust mite infestation. Nonfeathered bedding usually has less dust mite
infestation but does have progressively more dust mites over time; dust mites lay
eggs every 3 weeks and accumulate where human dander accumulates. Thus
nonwashable beddings (eg, pillows, bed mattress) should be encased by dust mite
proof encasings.
Other furry animals
Seasonal symptoms are usually caused by airborne pollen and outdoor molds,
including the following:
Tree pollen
Grass pollen
Outdoor mold spores
Weed pollen: Flowers do not cause allergic rhinitis because they do not use windborne pollination
Differential Diagnoses
Adenoidal hyperplasia
Nasal Polyps
Agammaglobulinemia
Sinusitis
Aspergillosis
Cystic Fibrosis
Gastroesophageal Reflux
Other Problems to Be Considered
Inflammatory causes
Bottle feeding (children >18 mo)
Vasomotor rhinitis
Viral infection
Obstructive causes
Adenoid hyperplasia
Choanal atresia
Foreign body
Deviated septum
Nasal polyps
Neoplasm
Oral allergy syndrome
Oral allergy syndrome (OAS) occurs when the body perceives certain foods,
primarily fruits and vegetables, as an allergen and causes a contact dermatitis
reaction in the mouth. This is often due to cross-reactivity between pollens and
fruit/vegetable allergens. These food allergens are heat labile and easily lose their
allergenicity with heating. Thus, patients with this condition report an itchy mouth
when eating certain fruits or vegetables in their natural form. For example, eating a
whole fresh apple causes a reaction, but eating apple pie or apple sauce or drinking
apple juice does not.

The most common pollens associated with OAS include birch and ragweed pollens.
Birch tree pollen cross-reacts with apple, pear, peach, celery, and carrots. Ragweed
cross-reacts with melon, watermelon, cantaloupe, honeydew, zucchini, and
cucumber.
Making the proper diagnosis is important because OAS can be confused with a
potentially life-threatening anaphylactic reaction to food allergens. Studies have
shown that use of allergen immunotherapy decreases or eliminates this reaction.
Workup
Laboratory Studies
No studies are needed in allergic rhinitis (AR) if the patient has a straightforward
history. When the history is confusing, various studies are helpful, including the
following:
Nasal smear: Eosinophils usually indicate allergy. Neutrophils are more indicative of
an infectious process, such as sinusitis.
CBC count with differential: A CBC count may reveal an increased number of
eosinophils. An eosinophil count within the reference range does not exclude
allergic rhinitis; however, an elevated eosinophil count is suggestive of the
diagnosis.
Immunoglobulin E (IgE): Serum IgE values are not routinely recommended to
evaluate atopy. An IgE value within the reference range does not exclude allergic
rhinitis; however, an elevated IgE value is suggestive of the diagnosis. Allergenspecific IgE testing, also known as radioallergosorbent test (RAST), can be helpful if
a specific allergen is suspected. Screening of a large number of allergens can cause
confusion because of the possibility of false positives. This is especially true for IgE
food allergy testing.
Skin prick testing: This test is highly sensitive and specific for aeroallergens.
Imaging Studies
Imaging studies are not needed unless sinusitis is suspected, in which case, a
limited CT scan of the sinuses (without contrast) is indicated.
Other Tests
RAST for common allergens can be used to identify the patient's triggers. These
might include dust mites, cat dander, dog dander, grass pollens, tree pollens, weed
pollens, and molds.
Foods rarely cause allergic rhinitis, and tests for food allergies are not indicated in
patients with allergic rhinitis.
RAST testing for allergens, such as dust mites, cat dander, and dog dander, is
almost as sensitive and specific as allergen skin testing.
Procedures
Skin testing to identify the triggering agent

Skin testing has high sensitivity and specificity and is the preferred method of quick
allergen identification for aeroallergens.
Skin testing is helpful if the allergens can be eliminated from the patient's
environment or if the patient can avoid them.
Skin testing is extremely helpful when patients are unresponsive to standard
therapy or are unwilling to acknowledge the trigger, which is especially true if the
family pet is a possible trigger.
Skin testing is required if the patient is interested in allergen immunotherapy.
Rhinoscopy: This is helpful in direct examination of the upper airway in identifying
whether the etiology of rhinitis is obstructive or infectious and for evaluation of
nasal polyposis.
Treatment
Medical Care
Treatment of allergic rhinitis (AR) can be divided into 3 categories: avoidance of
allergens or environmental controls, medications, and allergen-specific
immunotherapy (allergy shots).
Use of environmental controls is not adequately explored in most patients. For many
patients, the removal of the trigger can have a dramatic effect. Difficulty arises
when the trigger needs to be identified and eliminated. Eliminating the trigger may
be simple if removal of a feather pillow or blanket is involved; however, it can be
very difficult if a family pet needs to be removed. Although avoiding outdoor pollens
is impossible, the patient can reduce exposure to pollens to attenuate symptoms.
Identification and elimination is easiest for dust mite allergens.
Feathered bedding should be removed and replaced with a fiber-filled product
encased by dust miteproof encasings. Such encasings can be purchased at the
local stores or via mail orders. These encasings should be zip-locked and cover all
surface areas.
A bed pad that is placed on top is not helpful and may be another source of dust
mite infestation.
Less expensive plastic encasings may leak allergens through needle holes or
between zipper teeth; therefore, more expensive dust miteproof covers are
preferable.
The pillow must be covered; this is even more crucial than covering the bed
mattress itself because the pillow is where the patient's head usually spends most
of the night. Box springs usually do not need to be covered.
Care should be taken to be sure the encasings are dust miteproof. Some products
may claim to be an allergy cover but may not provide the proper protection for dust
mite. Also hypoallergenic bedding usually refers to the fact that the bedding is not
made of feathers and does not necessarily mean that it is dust miteproof.
Pollen is more difficult to avoid because daily activities must be altered to do so.
The patient is best advised to remain indoors with air-conditioning during the period
of the highest pollen counts of the day. Commonly, remaining indoors is not possible
because of activities, and many schools are not air-conditioned.
An easy intervention is to keep the windows closed, which is easily accomplished in
air-conditioned homes and must be done throughout the year. Windows tend to be
opened most frequently during fall and spring in moderate climates, but these

seasons are the worst possible times for open windows for patients with pollen
allergy. If windows must be open, open them during the day and close them at
night. Many pollen counts are highest during the night, especially for molds and
trees.
Another intervention is to obtain a window filter or filter fan, which allows air, but
not pollen, to enter the room.
Advise patients to wash head to toe and to change clothing upon coming in from the
outdoors during high pollen season. Avoid hanging cloths outdoors to dry.
The most difficult trigger to avoid is the family pet. Ideally, the pet should be
removed from the home, but removal is the option, not the rule. Some helpful
manipulations include removing the pet from the patient's bedroom and play area,
using air cleaners in these areas and, occasionally, frequently sponge-bathing the
pet (once per week). Even when these interventions are performed, many patients
continue to experience symptoms. Other therapies are necessary in these patients;
however, some patients choose to live with the source of offending allergens.
See Medication for a discussion of medications and allergen-specific immunotherapy
(ie, allergy shots). A recent study concluded that specific immunotherapy can be
recommended for treatment because it is effective in reducing symptoms.6
Surgical Care
No routine surgical care is needed.
Some patients may be seen by ear, nose, and throat (ENT) specialists, and
turbinectomies may be performed to provide some relief. This is an extreme
measure and is reserved for patients in whom all other therapies have failed.
Rarely, in adults, if nasal polyps do not respond to topical nasal steroids, surgical
removal may be necessary, although the polyps often grow back.
Consultations
Primary care physicians can attend to most patients.
Patients in whom diagnosis or treatment is more difficult may require consultation
with a specialist. This usually starts with an allergist, who performs a complete
allergy evaluation, including diagnostic tests. Therapy is instituted, which is a
combination of environmental manipulations, medications and, in some patients,
allergen-specific immunotherapy.
If medical therapies do not produce an adequate result, referral to an ENT specialist
should be indicated for possible surgical intervention.
Diet
Dietary restrictions do not help because allergic rhinitis is not triggered by foods.
Activity
No limitations are placed on activity.
For some pollens, patients with allergic rhinitis benefit from avoiding the outdoors
during peak pollen periods of the day. This time varies according to pollens and
location. Geographic location and distance from the source have an impact. Patients

who are miles away from the source have different peak pollen times than patients
near the source.
Medication
Many groups of medications are used for allergic rhinitis (AR), including
antihistamines, corticosteroids, decongestants, saline, sodium cromolyn, and
antileukotrienes. These can be further subdivided into intranasal and oral therapies.
Intranasal administration has the advantage of directly affecting the site of action,
and, in general, intranasal medications have fewer adverse effects and no systemic
effects. The main advantage of oral therapy is ease of use. Some patients resist
using intranasal medications.
Allergen-specific immunotherapy is an alternative form of therapy that has several
advantages. Most importantly, it is the only form of therapy that can cure allergy
symptoms. Allergen-specific immunotherapy must be customized to the patient's
individual allergies and involves weekly injections of increasing concentrations of an
allergen until the maintenance dose is reached and a monthly injection of the
maintenance dose for several years. The process usually does not produce clinical
results in the first 6 months but results are seen afterwards. The recommended
course is usually 4-5 years. Allergen-specific immunotherapy has been
demonstrated to be more cost effective and improves the patient's quality of life
more efficiently than standard allergy medications.
Sublingual immunotherapy is also available in some parts of the United States as
well as other countries of the world.7 In this form of therapy, small amounts of the
allergen are placed under the tongue on a daily basis. The 2 main advantages are
that no injections are necessary and that it can be administered at home. The
efficacy rate is about 20-30% in countries outside of the United States. Currently, it
is not approved by the US Food and Drug Administration (FDA), and the formulation
that is presently used has not been shown to be effective for this use. The
formulations that have been tested in other countries are not available in the United
States. This form of treatment is controversial.
The position from the National Allergy Organization is that the therapy may show
promise but is not ready for widespread use. A recent study concluded that 5-grasspollen sublingual immunotherapy tablets reduced symptom scores and medication
use in children and adolescents with grass pollenrelated allergic rhinitis.8
Saline nasal irrigation is effective in approximately 50% of patients with allergic
rhinitis. Irrigation assists the body's natural function of rinsing allergens out of nasal
passages. Tap water cannot be used because it is hypotonic and causes edema,
leading to greater congestion.
Oral antihistamines
Antihistamines are classified in several ways, including sedating and nonsedating,
newer and older, and first- and second-generation antihistamines (most widely
accepted classification). First-generation antihistamines are primarily over the
counter and are included in many combination products for cough, colds, and
allergies. These include brompheniramine (Dimetapp), chlorpheniramine (Atrohist),
and diphenhydramine (Benadryl). Loratadine (Claritin) and cetirizine (Zyrtec) are
now available over the counter without a prescription. Second-generation

antihistamines include desloratadine (Clarinex), fexofenadine (Allegra), and

levocetirizine dihydrochloride (XYZAL), which require a prescription.
EXAMPLE:
Cetirizine (Zyrtec)
Low-sedating second-generation medication with fewer adverse effects than firstgeneration medications. Selectively inhibits peripheral histamine H1 receptors.
Available as syr (5 mg/5 mL) and 5- or 10-mg tab.
Dosing:
Adult
5 mg PO qd in evening
CrCl 50-80 mL/min: 2.5 mg (half tab) PO qd in evening
CrCl 30-49 mL/min: 2.5 mg PO qod
CrCl 10-29 mL/min: 2.5 mg PO 2 times/wk
Pediatric
<6 years: Not established
6-11 years: 2.5 mg (half tab) PO qd in evening
12 years: Administer as in adults
Interaction: Coadministration with CNS depressants (eg, alcohol, sedativehypnotics) may increase somnolence; ritonavir increased plasma AUC of
measurable cetirizine by 42% and half-life by 53%
Contraindication: Documented hypersensitivity; CrCl <10 mL/min or hemodialysis;
children aged 6-11 y with renal impairment
Precaution:
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some
studies in animals
Precautions
Common adverse effects include somnolence, nasopharyngitis, fatigue, xerostomia,
and pharyngitis in adults and children >12 y; pyrexia, somnolence, cough, and
epistaxis commonly observed in children 6-12 y; caution with activities requiring
mental alertness
Intranasal corticosteroids
This class of medications is most effective. Intranasal corticosteroids are potent
anti-inflammatory agents shown to decrease allergic rhinitis symptoms in more than
90% of patients. Presently, 9 medications are available in this class, and all are
essentially equivalent in efficacy, although few head-to-head studies have been
performed. Mometasone (Nasonex) and fluticasone furoate (Veramyst) have been
demonstrated to have a somewhat faster onset of action; however, after one week,
no difference is found between medications. Most can be used on a oncedaily basis, and all have a similar safety profile. Nasonex is the only medication that
did not show an affect on growth at one year. Veramyst did not show a growth affect

in a 2-week study that is designed to evaluate for growth affects. A longer study
began in late 2007.
Intranasal decongestants
Decongestants are effective for short-term symptom control. They decrease nasal
discharge and congestion and are available without a prescription. The 2
medications in this group are oxymetazoline hydrochloride (Afrin) and ipratropium
bromide (Atrovent). Oxymetazoline hydrochloride is an addictive medication that is
effective in shrinking nasal membranes and is not recommended for long-term use.
Use of oxymetazoline hydrochloride for more than 7-10 d is habit forming. Patients
can be addicted for years at a time. Addiction is termed rhinitis medicamentosa.
Ipratropium bromide can be used for a prolonged period of time.
Intranasal mast cell stabilizers
These are effective therapy for AR in approximately 70-80% of patients. They
produce mast cell stabilization and antiallergic effects by inhibiting mast cell
degranulation. They have no direct anti-inflammatory or antihistaminic effects and
minimal bronchodilator effects. They are effective for prophylaxis. They also clean
out antigens mechanically, similar to saline. These products are now available over
the counter.
Antileukotrienes
Montelukast has been approved as monotherapy for allergic rhinitis. It has been
shown to be most effective in patients in whom significant congestion is a primary
complaint. It has also been shown to work as adjunctive therapy with present
second-generation antihistamines to provide greater relief of symptoms than
antihistamines alone. It is beneficial in patients with symptoms in whom present
antihistamines are not adequate. A study has shown a combination with cetirizine is
as effective as an intranasal corticosteroid. Antileukotriene can also be added to the
treatment plan in patients receiving antihistamines and intranasal therapy.
Follow-up
Further Outpatient Care
Patients with allergic rhinitis (AR) need continuous follow-up care because allergic
rhinitis is a chronic disease that waxes and wanes with seasons and age. The
fluctuation of symptoms requires adjustment of medications.
Patients rarely outgrow allergic rhinitis in childhood.
Refer patients in whom allergic rhinitis becomes hard to manage or diagnose to an
allergist for complete evaluation and advanced treatment, including institution of
allergen-specific immunotherapy.
Deterrence/Prevention
The best deterrent is to avoid allergens that trigger symptoms. This means diligent
environmental controls and patient compliance with medication use.
Complications

Primary complications of allergic rhinitis are associated diseases.

Sinusitis is a common complication occurring secondary to the inflamed nasal
turbinates that block the ostiomeatal complex of the sinuses and other sinus
passages.
Recurrent or chronic otitis media can also be a secondary complication. It is thought
to occur as a result of an inflamed nasal passages that adversely affect the
drainage of the auditory tube.
Allergic rhinitis can lead to rhinitis medicamentosa when topical nasal
decongestants are used in excess.
Allergic rhinitis can cause other conditions, such as insomnia, irritability, headache,
chronic fatigue, and pharyngitis. These occur secondary to chronic nasal congestion
and discharge, mouth breathing, and sleep disturbance.
Prognosis
Most patients are able to live normal lives with the symptoms.
Only patients who receive allergen-specific immunotherapy are cured of the
disease; however, many patients do very well with intermittent symptomatic
care. Allergic rhinitis symptoms may recur 2-3 years after discontinuation of
allergen immunotherapy.
A small percentage of patients improve during the teenage years, but in most,
symptoms recur in the early twenties or later. Symptoms begin to wane when
patients reach the fifth decade of life.
Patient Education
An abundance of educational material is available from many resources such as
medical associations, professional societies (eg, American Academy of Allergy,
Asthma, and Immunology, American College of Allergy, Asthma, and Immunology),
and pharmaceutical companies. All basically instruct the patient to avoid triggers,
use medications, and see a specialist if symptoms persist. Some educational
materials are very sophisticated, and several pharmaceutical companies provide
extensive web sites to assist patients.
For excellent patient education resources visit eMedicine's Allergy Center. Also, see
eMedicine's patient education articles Hay Fever, Indoor Allergies, and Allergy
Shots.
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Sourch:
1.http://emedicine.medscape.com/article/889259-overview
2.http://emedicine.medscape.com/article/889259-diagnosis
3.http://emedicine.medscape.com/article/889259-treatment
4.http://emedicine.medscape.com/article/889259-followup
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