The problem with allergies such as Hay Fever and Allergic Rhinitis is that it is considered to be a trivial and inconsequential disease. Symptoms such as runny nose, itchy eyes and nose with sneezing and blockage are obviously not life threatening, but affect up to 30% of the population and are the cause of significant disability and cost to society.
by Dr Adrian Morris.
Patients may also experience fatigue, irritability, as well as mood, cognitive and sleep disturbance in addition to the nasal, ocular and throat symptoms. Allergic rhinitis has important co-morbid associations such as chronic sinusitis, glue ear, asthma exacerbations, nasal polyps, sleep apnoea and dental malocclusion.
Chronic Allergic Rhinitis sufferers often have typical facial features called the “allergy face”. Nasal blockage and sinus congestion predispose to the bluish discolouration of the lower eyelids called “allergic shiners”, the characteristic linear creases under the eyelid are referred to as “Dennes lines”. Constant nasal rubbing typifies the “allergic salute” and results in a prominent “nasal crease” across the nose. Continuous nasal blockage causes “nasal” speech and mouth breathing with disturbed sleep. This results in a high arched palate and the “long face syndrome” with dental crowding and malocclusion (“Buck teeth”).
Allergic rhinitis may be either seasonal or perennial:
Seasonal allergic rhinitis is better known as “Hay fever”.
Tree and grass pollens and some fungi trigger seasonal allergic rhino-conjunctivitis (nose and eye allergy) during Springtime and early Summer (March to June). Allergy sufferers experience intense nasal and eye itching with explosive sneezing, watery eyes and nose and itchy palate and ears with profuse post-nasal drip. These people do not develop the typical “allergy face” but have seasonal puffiness of the eyes and eyelids with associated nasal membrane swelling. Southern England regularly experiences amongst the highest ambient grass pollen counts in the world during the summer and this can severely debilitate grass pollen allergic people during the season.
Perennial allergic rhinitis or a “permanent cold”.
Allergens such as house-dust mite droppings, cat and dog dandruff, horse hair, cockroach droppings and perhaps hamster or rabbit urine result in perennial allergic rhinitis with symptoms all year round. These patients are often misdiagnosed as having a “permanent” cold and receive inappropriate treatment with antibiotics. Their symptoms can be very subtle and include constant nasal blockage, snoring at night, watery post-nasal discharge, loss of taste and smell sensation and sneezing only on waking in the morning. Co-existent glue ear and chronic sinusitis with polyps (grape-like swellings inside the nose) are common.
In 1999, the World Health Organisation introduced a new classification for Allergic Rhinitis (ARIA Guidelines). The purpose was to try and create similar treatment guidelines for asthma and allergic rhinitis which often co-exist in the same patient (80% of asthma sufferers have concomitant allergic rhinitis). Instead of the traditional seasonal and perennial divisions, they introduced Intermittent Allergic Rhinitis and Persistent Allergic Rhinitis. Intermittent would replace the Seasonal (Hay fever) type disease and Persistent would replace Perennial Rhinitis (but some overlap does take place). These two groups are then further sub-divided into Mild and Moderate/Severe symptoms and treated according to the new guidelines.
Allergic rhinitis occurs in “atopic” youngsters usually with raised blood levels of IgE antibodies to the common inhalant allergens such as house dust mites, tree and grass pollen, animal dander, cockroaches and mould spores. Occasionally foods such as cow’s milk and food additives can cause worsening symptoms. Children are sensitised in early life but may only manifest their allergy symptoms later in life. Perennial allergic rhinitis usually manifests before the age of 10 years, while seasonal allergic rhinitis occurs more commonly in teenagers and young adult males. Primary sensitisation results in the production of specific IgE antibodies, which later cross-link with allergens on mast cells in the nasal membranes releasing histamine and the allergy cascade. If the condition becomes more entrenched as occurs in chronic perennial rhinitis, then other inflammatory mediators and immune cells become involved.
The allergy reaction in the nose involves a complex interaction between various inhalant allergens and immune cells. An allergen will link to specific IgE antibodies on mast cells near the nasal surface, resulting in histamine release. This is termed the Immediate Allergic Reaction. Other chemicals released by Mast cells include tryptase and prostaglandin. Histamine has a direct effect on nasal blood vessels causing swelling and nasal obstruction. It also has a reflex effect via sensory nerves causing sneezing, itching and further mucus production. This triggers a sequence of events with sneezing followed by watery nasal discharge and finally nasal blockage.
Subsequent nasal symptoms that develop between 3 and 12 hours after the initial allergen exposure are due to the Late Phase Reaction. Further immune mediator production occurs in the already inflamed nasal membranes and blood cells (eosinophils and basophils) infiltrate causing progressive nasal blockage and swelling.
Nasal hypersensitivity occurs when non-allergenic irritants such as dusts, perfume, tobacco smoke, ozone, sulphur dioxide, nitrogen dioxide, cold air and other environmental pollutants result in increased nasal membrane leakiness, increased nerve excitability, white blood cell infiltrates and more mast cells in the superficial nasal membranes. These factors lead to an increased nasal irritability to low doses of allergens. Some older blood pressure medications such as reserpine, methyldopa, ACE inhibitors and alpha blockers (used to treat prostate enlargement) as well as hormone replacement therapy (HRT) may in addition cause nasal obstruction. The last trimester of pregnancy is associated with worsening of nasal symptoms due to hormonal factors. While aspirin sensitive individuals will often develop rhinitis, sinusitis, asthma and nasal polyps after aspirin re-exposure (called Samter’s Triad).
A form of non-allergic rhinitis may develop in adulthood called Vasomotor Rhinitis with a profusely runny nose that seems to be triggered by non-specific environmental exposure such as changes in temperature, perfumes, cigarette smoke, air fresheners, air conditioners and does not respond to antihistamines or steroid nasal sprays.
Hay Fever Testing
We try initially to identify the allergen involved by taking a good allergy history and doing a thorough examination of the nose. We then try to confirm the cause of the allergy by Skin Scratch Testing or with blood tests such as specific IgE or Cap RAST testing.
Simple rhinoscopy or nasal examination using a good light-source will demonstrate pale bluish swollen nasal membranes, a moist discharge and occasionally evidence of polyps (grape-like swellings inside the nose).
Skin Scratch Tests for the common inhalant allergens are a very simple and cheap to perform and results are immediately available. Allergen test kits are available from ALK-Abello, Diagenics and Lofarma. These include extracts of House-dust mite, Cat, Dog, Mould spores, Grass and Tree Pollen. Skin tests help to confirm the causative allergen and the “wheal and flare” reaction on the skin will demonstrate the inflammatory nature of allergic rhinitis to the patient.
Blood specimens can be drawn and sent to a pathologist for RAST testing. The Phadiatop is an excellent screening test for the common inhalant allergens implicated in allergic rhinitis, if this test is positive, individual ImmunoCAP RAST tests are performed to determine the exact inhalant allergen. If food allergy is strongly suspected in children, the Paediatric Food Mix fx5 food screen (cow’s milk, wheat, egg, peanut, fish, and soya) is recommended. Total IgE may not be elevated in allergic rhinitis, unless there is associated asthma or eczema. A normal Total IgE can therefore not exclude allergic rhinitis. Parasite or worm infections and cigarette smoking may also confuse the issue by artificially raising the blood Total IgE. A new rapidly growing concept is that of “local” IgE production on respiratory and ocular membranes causing allergy. The allergic reaction in this case is very localised to the nasal membranes and conjunctiva and not picked up on routine allergy skin prick testing or RAST blood testing. However these patients respond to allergy treatment but test negative.
A useful laboratory test in “local” allergic rhinitis is to take a nasal mucus sample and test for white blood cells called eosinophils using Hansel’s Stain. If plenty of eosinophilic white blood cells are present, this helps to confirm the diagnosis of allergic rhinitis.
Radiology (sinus x-rays and CAT scanning) does not help in the diagnosis of allergic rhinitis, but will identify complications such as chronic sinusitis, infections, nasal polyps and sinus fluid levels.
Nitric oxide (NO) gas levels in air expired from the nasal passages tends to be higher in nasal allergic inflammation. This test is a useful measure of the degree of allergic inflammation, particularly in chronic persistent rhinitis.
Specialist nose surgeons make use of fibre-optic nasal endoscopes to visualise the nasal membranes, septum and osteo-meatal complex of the nasal sinuses. Rhino-manometry which is a measure of nasal air flow, nasal provocation tests with the chemical histamine and microscopy of nasal mucus specimens are of practical use for research purposes.
In a minority of patients with typical symptoms of nasal allergy, all allergy tests prove negative. We refer to these sufferers as having Chronic Non-allergic Rhinitis or Idiopathic Rhinitis. They are treated in a similar fashion to Allergic Rhinitis using the ARIA Guidelines. Some have profuse symptoms with eosinophil cells present in their nasal mucus and this condition is termed Non-allergic Rhinitis with Eosinophilia Syndrome (NARES).
There is a condition called Local Allergic Rhinitis (LAR) where the reaction is very localised to the nasal membrane or conjunctiva of the eye. This allergy has only local IgE production remaining on the surface, so allergy testing of the skin and blood will remain negative and they are falsely diagnosed as being “non-allergic”. They do however react adversely with a challenge test of allergen (pollen, dust mite or pet danders) and treatment is the same as for allergic rhinitis.
Once the offending allergen is identified, then Allergen Avoidance measures can be instituted. Grass pollens can be avoided, pets removed from the home and mattresses, pillows and carpets treated to eradicate house dust mites. If a particular food is implicated in allergic rhinitis, then that food should be excluded from the diet. Cigarette smoking should be strongly discouraged in all allergic individuals, as it will only exacerbate symptoms. Where allergen avoidance fails or is impractical, it may be necessary to commence medication to control symptoms and inflammation.
Allergic Rhinitis Treatment
In Perennial Allergic Rhinitis, treatment should to be taken continuously, whilst in Seasonal Allergic Rhinitis treatment only needs to be taken for symptom control during the peak pollen season.
Antihistamines are the mainstay of treatment in seasonal allergic rhinitis. They control the itch, sneeze runny nose and itchy eyes. Older antihistamines such as chlorpheniramine (Piriton), hydroxyzine (Atarax) and promethazine (Phenergan) control symptoms, are cheap but have significant sedating side effects because they cross the blood-brain barrier. The newer non-sedating antihistamines are more expensive, cause much less concentration disturbance, can be taken once a day and give good symptom control. Loratadine (Clarityn), desloratadine (Neoclarityn), fexofenadine (Telfast), Mizolastine (Mizollen) and cetirizine (Zirtek), or levocetirizine (Xyzal) are all recommended.
Antihistamine nasal sprays such as azelastine (Rhinolast) may be a useful additional treatment when symptom control of nasal and ocular itching is intractable. They have no effect on nasal blockage and tend to have an unpleasant taste.
Fears that older antihistamines may be a contributory factor in Alzheimers disease have not been borne out.
Nasal steroid sprays are the most effective method of controlling chronic persistent allergy rhinitis according to recent Meta-analyses. Steroid sprays applied directly to the nasal membranes have revolutionised the treatment of allergic rhinitis – particularly the chronic perennial type. They control the underlying chronic inflammatory process and therefore are the treatment of choice in most patients. These preparations are safe to use for prolonged periods of time at the recommended dosages. They act on various components of the nasal inflammatory process, causing blood vessel contraction, reducing blood vessel leakiness and reducing inflammatory cell numbers. Nasal steroids such as Flunisolide (Syntaris), Budesonide (Rhinocort Aqua) and Beclomethasone (Beconase) are particularly useful for their preventative effects and newer preparations such as Fluticasone (Flixonase, Avamys), Triamcinolone (Nasacort) and Mometasone (Nasonex) can be used effectively on a once daily basis
Betamethasone (Vista-Methasone) and Fluticasone (Flixonase Nasule) nose drops although very effective, because of their strength may be absorbed into the circulation and should not be used continuously for more than one month. Once symptom control is achieved, the daily dosage should be slowly reduced or a lower dose steroid nasal spray introduced. Dymista nasal spray contains both antihistamine Azelastine and steroid Fluticasone which helps both itching and reduces inflammation.
Nasal steroid sprays also control non-allergic rhinitis and reduce the size of polyps in the nose. Nasal steroid sprays have been shown to control allergic conjunctivitis as well as rhinitis symptoms. Occasionally they may cause local nasal irritation and nose bleeds if the central nasal septum is directly sprayed. They do not relieve palate and eye itch, so antihistamine tablets and drops may also need to be used. If significant nasal obstruction is present at commencement of treatment, then pre-treatment with a decongestant spray or a short course of oral steroids will be necessary for a few days.
Decongestant sprays can be used in the nose or orally in tablet-form for relief of nasal blockage and congestion. Decongestant sprays relieve nasal congestion very rapidly but over-use of these Ephedrine containing sprays is associated with rebound nasal congestion and so-called “rhinitis medicamentosa”. The safest preparation is Xylometazoline (Otrivine) but continuous use should be limited to 7 – 10 days at a time.
Oral decongestants such as pseudoephedrine (Sudafed and Galpseud) also combat nasal blockage by constricting blood vessels in the nasal membranes and throughout the body to some degree. They therefore may exacerbate blood pressure problems, dry mucus membranes, cause urine retention and trigger glaucoma. Some people are also sensitive to them and experience insomnia, restlessness, headache and palpitations.
Used in combination, the decongestant often compensates for the sedative effect of the anti-histamine although this may result in the side effect of jitteriness and insomnia
Cromolyn in the form of sodium cromoglicate has anti-inflammatory activity and relieves nasal itch, sneezing, mucus production and congestion particularly in seasonal allergic rhinitis. It is an extremely safe product but must be used 4 times a day, and is very effective in the eyes for treating allergic conjunctivitis. Cromolyn’s are a useful option for patients who prefer not to use nasal steroid sprays on an ongoing basis. Olopatadine (Opatanol) eyedrops are very effective for grass pollen-induced eye allergies when used twice daily. Combination cromoglycate and saline eye washes such as Optrex will flush away grass pollens as well control eye allergies.
Ipratropium bromide (Rinatec) is a spray derived from atropine. It provides good relief for the profuse watery nasal discharge including non-allergic or “vasomotor” rhinitis, sometimes likened to a “dripping tap”. It is a particular problem in older males with their so-called “old man’s drip”. Ipratropium is very safe to use, with rapid onset of activity and minimal side effects. It has no effect on nasal blockage, itch or sneezing. Sometimes it may excessively dry the nose and then a saline nasal spray will help if used in combination with the Rinatec
An oral steroid such as Prednisilone is particularly useful in controlling nasal symptoms in allergic rhinitis in cases of emergency (examinations, weddings etc.), and gives rapid relief especially when blockage is severe and intractable. They have significant generalised side-effects and should therefore only be used in severe disease for short periods of 5 to 14 days. Use of injection long-acting steroids (Depot Medrone, Kenalog and Adcortyl) should be discouraged as they can lead to osteoporosis, muscle damage, raised blood pressure, sugar diabetes, glaucoma, cataracts, stomach ulceration and chronic infections.
Immunotherapy and beyond
Sublingual and Injection Desensitisation Immunotherapy are effective options in severe grass pollen and Birch tree pollen allergic rhinitis, which are not controlled by regular medication. They should be restricted to those patients who are only allergic to Grass and Birch pollen or house dust mites. Potential adverse reactions such as urticaria and anaphylaxis during injection treatment, restrict its use to specialist allergy units with readily available resuscitation equipment. The course of injections should be commenced before the tree or grass pollen season starts and usually take 3 years to complete the course of treatment. For many years, ALK have marketed the highly regarded Alutard SQ range of desensitising products. Oral desensitisation is much safer and can be administered at home. This Sublingual Immunotherapy (SLIT) is now available from ALK Abello and Stallergenes and administered by oral tablets or drops dissolved under the tongue, commencing 2 months before and continuing for the duration of the grass pollen season. SLIT should also be used for 3 consecutive years to get best results and is licensed in the UK and available on prescription as Grazax (ALK Abello) and Staloral (Stallergenes). There have been a problem with the plant that produces Stallergenes vaccines in France and ongoing treatment provided has been unreliable. This treatment can be prescribed by GPs on NHS and private prescriptions and despite initial reports showing variable efficacy, this treatment is highly effective and successful in those severely afflicted with summer hay fever not responding to conventional treatment. Remember that Enzyme Potentiated Desensitisation EPD (which should not be confused with grass pollen desensitisation immunotherapy) is ineffective and not recommended for hayfever treatment.
Simple Hay Fever Remedies
Sodium chloride 0.9% (Sterimar) and sea salt water douching with or without a touch of bicarbonate of soda added is a useful non-drug treatment for clearing the nasal passages in allergic rhinitis. It is important to use “physiological” saline 0.9% for if the solution is too strong, nasal membrane damage may occur. The solution is sniffed up using a tea saucer and then expelled from the nose. Menthol nasal preparations also give some symptom relief while steam inhalations using a Eucalyptus extract will help decongest the nasal passages. Application of a small amount of Petroleum Jelly (Vaseline) to the lower nasal passages with a cotton bud also helps to relieve symptoms.
There is a growing demand by the general public for alternative therapies to conventional medication. These treatments are much less effective than conventional medication, but certain compounds may have some beneficial effects in allergic rhinitis. Most recently the herb Butterbur was shown to have some beneficial effects. It must be stressed that these preparations give minimal therapeutic benefit and should only be offered as second line treatment to conventional rhinitis medication.
Antioxidants are particularly popular in the lay press and are aggressively marketed by manufacturers as “cure all’s”. Vitamin C, Vitamin E, Beta-Carotene, Selenium and Zinc are included in this category. There is no evidence that these products have any beneficial effect in treating allergic rhinitis. Other medications such as carbocisteine, which is used in Cystic Fibrosis, is often co-prescribed in allergic rhinitis, but has little or no effect.
The leukotriene antagonists Zafirlukast (Accolate) and Montelukast (Singulair) seem to be useful additions in treating allergic rhinitis, especially in aspirin-sensitive people (Samter’s Triad). These products also seem to have beneficial effects in treating patients with asthma and co-existent allergic rhinitis as they block the activity of Leukotrienes in the nasal membranes. Olopatadine (Opatanol) is very effective for eye allergies associated with Hayfever. This eye drop has both antihistaminic and Mast Cell stabilising properties and has a simple twice daily dosage.
Role of dietary restriction
Some people will benefit from empirical dietary exclusion of common food allergens such as cow’s milk and food additives (benzoate, sulphites, colourings and nitrite) from their diet. This is often tried in patients who have intractable symptoms and don’t respond to other measures. The offending food should be excluded for a 4-week period to adequately evaluate any beneficial response. The advice of a qualified dietician may be sought if a prolonged dairy exclusion diet is instituted in children. Food additive such as sodium benzoate, sulphite, tartrazine and nitrites have been implicated as triggers for chronic non-allergic rhinitis and avoidance may benefit up to 8% of rhinitis sufferers.
Probably the greatest hurdle facing doctors treating perennial allergic rhinitis, is that of non-compliance or non-adherence to the treatment. Unfortunately most people will automatically stop treatment as soon as they experience some symptom relief, only for the symptoms to return. It is particularly difficult to persuade patients to continue to take medication as a preventative measure for controlling Hayfever and allergic rhinitis symptoms.
Finally our top 13 simple measures to combat hay fever!
- Remain indoors when pollen levels peak and when the grass in being cut
- Take antihistamines starting two weeks before the pollen season starts
- Apply a little Vaseline to the lower nostrils to protect and trap pollen grains from entering the upper nose
- Wash or douche the nasal passages with a dilute salt water solution or use commercial saline sprays available from all chemists as (Sterimar) and eye washes (Optrex)
- When travelling, make sure the car windows are closed and switch on the air con which will filter out pollen grains
- Wear protective “wrap around” sunglasses to prevent allergic eyes
- Keep the bedroom windows closed during the day to keep pollen grains out
- Rather tumble dry washing and do not hang washing outdoors during the day (it acts as a pollen trap)
- Shower and wash your hair in the evening as soon as you return home from work or college to remove all pollen
- Change into fresh clothes as soon as you return home from work (pollen will have become trapped in your clothes)
- Consider taking a tablespoonful of local honey everyday starting a few months before the pollen season starts – this may act as a form of oral desensitisation (the honey will have been contaminated with pollen)
- Consider using a nasal air filter on high pollen days
- Be wary of treatments that have not been validated such as infrared nasal torches, micro particulate sprays that coat the nasal mucosa and acupuncture elbow bands.
Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38: 19-42
Bousquet J, Van Cauwenhage P, Khaltaev N. ARIA Workshop Group. Allergic Rhinitis and its Impact on Asthma (ARIA) J Allergy Clin Immunol 2001;108 (suppl 5) : S147-333