Sneezing, congestion, and itching nose, eyes and throat are the hallmarks of allergic rhinitis, a condition that affects 40 million to 60 million Americans.
Allergic rhinitis, like skin rashes and other allergies, develops when the body’s immune system becomes sensitized and overreacts to something in the environment that typically causes no problem in most people.
Allergic rhinitis is commonly known as hay fever. But you don’t have to be exposed to hay to have symptoms. And contrary to what the name suggests, you don’t have a fever with hay fever although you might feel “feverish” and ill.
Allergic rhinitis takes two different forms:
- Seasonal: Symptoms of seasonal allergic rhinitis can occur during any pollen season (winter, spring, summer or fall). They are usually caused by allergic sensitivity to airborne mold spores or to pollens from trees, grasses and weeds.
- Perennial: People with perennial allergic rhinitis experience symptoms throughout the year without clear seasonal triggers. It is generally caused by dust mites, pet hair or dander, cockroaches or mold. Underlying or hidden food allergies rarely cause perennial nasal symptoms.
Some people may experience both types of rhinitis, with perennial symptoms getting worse during specific pollen seasons.
There are also non-allergic causes for rhinitis that can be caused by atrophy (aging), medications (Afrin and other nasal decongestants), vasomotor, and irritants.
Symptoms of allergic rhinitis have other causes as well, the most customary being the common cold — an example of infectious rhinitis. Most infections are relatively short-lived, with symptoms improving in three to seven days.
Allergic rhinitis can be associated with:
- Decreased concentration and focus
- Limited activities
- Decreased decision-making capacity
- Impaired hand-eye coordination
- Problems remembering things
- Sleep disorders
- Missed days of work or school
- More motor vehicle accidents
- More school or work injuries
Many parents of children with allergic rhinitis have said that their children are more moody and irritable during allergy season. Since children cannot always express their symptoms verbally, they may express their discomfort by acting up at school and at home. In addition, some children feel that having an allergy is a stigma that separates them from others.
It is important that the irritability or other symptoms caused by ear, nose or throat trouble are not mistaken for attention deficit disorder. With proper treatment symptoms can be kept under control and disruptions in learning and behavior can be avoided.
- Runny nose
- Itchy eyes, mouth or skin
- Stuffy nose due to blockage or congestion
- Fatigue (often reported due to poor quality sleep as a result of nasal obstruction)
- Outdoor allergens, such as pollens from grass, trees and weeds
- Indoor allergens, such as pet hair or dander, dust mites and mold
- Irritants, such as cigarette smoke, perfume and diesel exhaust
We start by taking a detailed history, looking for clues in your lifestyle that will help pinpoint the cause of your symptoms. You’ll be asked, among other things, about your work and home environments (including whether you have a pet), potential food triggers, your family’s medical history and the frequency and severity of your symptoms.
Sometimes allergic rhinitis can be complicated by several medical conditions, such as a deviated septum (curvature of the bone and cartilage that separate the nostrils) or nasal polyps (abnormal growths inside the nose and sinuses). Any of these conditions will be made worse by catching a cold. Nasal symptoms caused by more than one problem can be difficult to treat, often requiring the cooperation of an allergist and another specialist, such as an otolaryngologist (ear, nose and throat specialist) or a GI doctor for severe GERD.
You will likely be skin tested in which small amounts of suspected allergens are introduced into your skin. Skin testing is the easiest, most sensitive and generally least expensive way of identifying allergens.
Types of skin tests
- Prick or scratch test: This is the most common test we perform in our offices. Using a multitest plastic comb, a tiny drop of a possible allergen is pricked or scratched into the skin without using any needles. The skin is usually not broken and there should be no bleeding. Also known as a percutaneous test, this is the most common type of skin test. The results are known within 15 to 20 minutes. If you are very allergic, it can get very itchy!
- Intradermal test: We perform very few of these tests because they have a higher false positive rate. We reserve this type of test we we essentially want to rule out an allergic trigger because the negative predictive value of the test is very good. A small amount of a possible allergen is injected under the skin using a thin needle. The site is checked for a reaction after about 20 minutes. This test is typically more sensitive than the prick or scratch test.
Management and Treatment
The first approach in managing seasonal or perennial forms of hay fever should be avoidance of the allergens that trigger symptoms and good hygiene to remove allergens from your home and body.
- Stay indoors as much as possible when pollen counts are at their peak, usually during the midmorning and early evening (this may vary according to plant pollen), and when wind is blowing. The low pressure fronts that arrive ahead of storms can pull allergenic and inflammatory particles up from the soil and trigger symptoms.
- Avoid using window fans that can draw pollens and molds into the house.
- Wear glasses or sunglasses when outdoors to minimize the amount of pollen getting into your eyes.
- Wear a pollen mask (such as a NIOSH-rated 95 filter mask) when mowing the lawn, raking leaves or gardening, and take
- Premedicate to avoid symptoms.
- Don’t hang clothing outdoors to dry; pollen may cling to towels and sheets.
- Try not to rub your eyes; doing so will irritate them and could make your symptoms worse.
- When you are home for the day and before you plop down on the couch or into bed, put your clothes in the washing machine and take a shower with soap and shampoo. While in the shower perform a sinus rinse (distilled water or boiled water that has cooled to room temperature to which a preformulated pH and salt balanced mixture is added) to remove allergenic and inflammatory particles and mediators.
- Keep windows closed, and use air conditioning in your car and home. Make sure to keep your air conditioning unit clean.
- Reduce exposure to dust mites, especially in the bedroom. Use “mite-proof” covers for pillows, comforters and duvets, and mattresses and box springs. Wash your bedding frequently, using hot water (at least 130 degrees Fahrenheit).
- To limit exposure to mold, keep the humidity in your home low (between 30 and 50 percent) and clean your bathrooms, kitchen and basement regularly. Use a dehumidifier, especially in the basement and in other damp, humid places, and empty and clean it often. If mold is visible, clean it with mild detergent and a 5 percent bleach solution as directed by an allergist.
- Clean floors with a damp rag or mop, rather than dry-dusting or sweeping.
Exposure to pets
- Wash your hands immediately after petting any animals; wash your clothes after visiting friends with pets.
- If you are allergic to a household pet, keep the animal out of your home as much as possible. If the pet must be inside, keep it out of the bedroom (no co-sleeping) so you are not exposed to animal allergens while you sleep.
- Close the air ducts to your bedroom if you have forced-air or central heating or cooling. Replace carpeting with hardwood, tile or linoleum, all of which are easier to keep dander-free.
Many allergens that trigger allergic rhinitis are airborne, so you can’t always avoid them. If your symptoms can’t be well-controlled by simply avoiding triggers, we will recommend medications that reduce nasal congestion, runny nose, sneezing and itching. They are available in many forms — oral tablets, liquid medication, nasal sprays and eyedrops.
We have a more complete medication guide that you can view on our website.
Intranasal corticosteroids are the single most effective drug class for treating allergic rhinitis. They can significantly reduce nasal congestion as well as sneezing, itching and a runny nose.
These medications are very safe and are only rarely avoided, as in patients with uncontrolled glaucoma or cataracts. These sprays are designed to avoid the side effects that may occur from steroids that are taken by mouth or injection. Take care not to spray the medication against the center portion of the nose (the nasal septum). The most common side effects are local irritation and nasal bleeding. Some older preparations have been shown to have some effect on children’s growth; data about some newer steroids don’t indicate an effect on growth. The ones we prescribe are very safe for long term use.
Antihistamines are commonly used to treat allergic rhinitis. These medications counter the effects of histamine, the irritating chemical released within your body when an allergic reaction takes place. Although other chemicals are involved, histamine is primarily responsible for causing the symptoms. Antihistamines are found in eyedrops, nasal sprays and, most commonly, oral tablets and syrup.
Antihistamines help to relieve nasal allergy symptoms such as:
- Sneezing and an itchy, runny nose
- Eye itching, burning, tearing and redness
- Itchy skin, hives and eczema
They do NOT help congestion or to decrease inflammation in the nose and sinuses. In fact, overusing antihistamines might thicken paranasal sinus mucous viscosity and make secondary sinus infections more likely.
There are dozens of antihistamines; some are available over the counter, while others require a prescription. Patients respond to them in a wide variety of ways.
Generally, the newer (second-generation) products work well and produce only minor side effects. Some people find that an antihistamine becomes less effective as the allergy season worsens or as their allergies change over time. If you find that an antihistamine is becoming less effective, tell us and we may recommend a different type or strength of antihistamine. If you have excessive nasal dryness or thick nasal mucus, consult us before taking antihistamines. Ask us for advice if an antihistamine causes drowsiness or other side effects.
Proper use: Short-acting antihistamines can be taken every four to six hours, while timed-release antihistamines are taken every 12 to 24 hours. The short-acting antihistamines are often most helpful if taken 30 minutes before an anticipated exposure to an allergen (such as at a picnic during ragweed season). Timed-release antihistamines are better suited to long-term use for those who need daily medications. Proper use of these drugs is just as important as their selection. The most effective way to use them is before symptoms develop. A dose taken early can eliminate the need for many later doses to reduce established symptoms.
- Proper use of these drugs is just as important as their selection. The most effective way to use them is before symptoms develop. A dose taken early can eliminate the need for many later doses to reduce established symptoms. Many times a patient will say that he or she “took one, and it didn’t work.” If the patient had taken the antihistamine regularly for three to four days to build up blood levels of the medication, it might have been effective.
- Side effects: Older (first-generation) antihistamines may cause drowsiness or performance impairment, which can lead to accidents and personal injury. Even when these medications are taken only at bedtime, they can still cause considerable impairment the following day, even in people who do not feel drowsy. For this reason, it is important that you do not drive a car or work with dangerous machinery when you take a potentially sedating antihistamine. Some of the newer antihistamines do not cause drowsiness.
- A frequent side effect is excessive dryness of the mouth, nose and eyes. Less common side effects include restlessness, nervousness, overexcitability, insomnia, dizziness, headaches, euphoria, fainting, visual disturbances, decreased appetite, nausea, vomiting, abdominal distress, constipation, diarrhea, increased or decreased urination, urinary retention, high or low blood pressure, nightmares (especially in children), sore throat, unusual bleeding or bruising, chest tightness or palpitations. Men with prostate enlargement may encounter urinary problems while on antihistamines. Inform us if these reactions occur.
- Important precautions:
- Follow our instructions.
- Alcohol and tranquilizers increase the sedation side effects of antihistamines.
- Do not use more than one antihistamine at a time, unless instructed by us.
- Keep these medications out of the reach of children.
- Know how the medication affects you before working with heavy machinery, driving or doing other performance-intensive tasks; some products can slow your reaction time.
- Some antihistamines appear to be safe to take during pregnancy, but there have not been enough studies to determine the absolute safety of antihistamines in pregnancy. Again, consult your allergist or your obstetrician if you must take antihistamines.
- While antihistamines have been taken safely by millions of people in the last 50 years, don’t take antihistamines before telling your allergist if you are allergic to, or intolerant of, any medicine; are pregnant or intend to become pregnant while using this medication; are breast-feeding; have glaucoma or an enlarged prostate; or are ill.
- Never take anyone else’s medication.
Decongestants help relieve the stuffiness and pressure caused by swollen nasal tissue. They do not contain antihistamines, so they do not cause antihistaminic side effects. They do not relieve other symptoms of allergic rhinitis. Decongestants are available as prescription and nonprescription medications and are often found in combination with antihistamines or other medications. It is not uncommon for patients using decongestants to experience insomnia if they take the medication in the afternoon or evening. If this occurs, a dose reduction may be needed. At times, men with prostate enlargement may encounter urinary problems while on decongestants. Patients using medications to manage emotional or behavioral problems should discuss this with their allergist before using decongestants. Pregnant patients should also check with their allergist before starting decongestants.
Nonprescription decongestant nasal sprays work within minutes and last for hours, but you should not use them for more than a few days at a time unless instructed by us. Prolonged use can cause rhinitis medicamentosa, or rebound swelling of the nasal tissue. Stopping the use of the decongestant nasal spray will cure that swelling, provided that there is no underlying disorder.
Oral decongestants are found in many over-the-counter (OTC) and prescription medications, and may be the treatment of choice for nasal congestion. They don’t cause rhinitis medicamentosa but need to be avoided by some patients with high blood pressure, cardiac dysrhythmias and mitral valve prolapse.
Nonprescription saline nasal sprays will help counteract symptoms such as dry nasal passages or thick nasal mucus. Unlike decongestant nasal sprays, a saline nasal spray can be used as often as it is needed. Sometimes an allergist may recommend washing (douching) the nasal passage. There are many OTC delivery systems for saline rinses, including neti pots and saline rinse bottles.
Nasal cromolyn blocks the body’s release of allergy-causing substances. It does not work in all patients. The full dose is four times daily, and improvement of symptoms may take several weeks. Nasal cromolyn can help prevent allergic nasal reactions if taken prior to an allergen exposure.
Nasal ipratropium bromide spray can help reduce nasal drainage from allergic rhinitis or some forms of nonallergic rhinitis.
Leukotriene pathway inhibitors (montelukast and zafirlukast) block the action of leukotriene, a substance in the body that can cause symptoms of allergic rhinitis. These drugs are also used to treat asthma.
Immunotherapy may be recommended for people who don’t respond well to treatment with medications or who experience side effects from medications, who have allergen exposure that is unavoidable or who desire a more permanent solution to their allergies. Immunotherapy can be very effective in controlling allergic symptoms, but it doesn’t help the symptoms produced by nonallergic rhinitis.
Two types of immunotherapy are available: allergy shots and sublingual (under-the-tongue) drops/tablets.
- Allergy shots: A treatment program, which can take three to five years, consists of injections of a diluted allergy extract, administered frequently in increasing doses until a maintenance dose is reached. Then the injection schedule is changed so that the same dose is given with longer intervals between injections. Immunotherapy helps the body build resistance to the effects of the allergen, reduces the intensity of symptoms caused by allergen exposure and sometimes can actually make skin test reactions disappear. As resistance develops over several months, symptoms should improve.
- Sublingual: This type of immunotherapy was approved by the Food and Drug Administration in 2014. Starting several months before allergy season begins, patients dissolve a tablet under the tongue daily. Treatment can continue for as long as three years. Only a few allergens (certain grass and ragweed pollens) can be treated now with this method, but it is a promising therapy for the future. Allergy drops are prepared with the same extracts as allergy shots but are NOT FDA approved for that formulation and are considered off-labelled. They are also not covered by insurance. They might be appropriate for people who don’t have the time to come to the office for allergy shots, have had severe reactions to allergy shots, or are afraid of needles.
Eye allergy preparations may be helpful when the eyes are affected by the same allergens that trigger rhinitis, causing redness, watery eyes and itching. OTC eyedrops and oral medications are commonly used for short-term relief of some eye allergy symptoms. They may not relieve all symptoms, though, and prolonged use of some of these drops may actually cause your condition to worsen.
Prescription eyedrops and oral medications also are used to treat eye allergies. Prescription eyedrops provide both short- and long-term targeted relief of eye allergy symptoms, and can be used to manage them.