Allergic rhinitis

Last updated: April 21, 2022

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Allergic rhinitis is an acute or chronic inflammation of the nasal mucosa caused by a type 1 hypersensitivity reaction to an inhaled allergen (e.g., dust, animal dander, mold spores, plant pollen). It is the most common form of rhinitis and is associated with other allergic conditions such as atopic dermatitis and asthma. Clinical manifestations of allergic rhinitis include nasal congestion, rhinorrhea, sneezing, and postnasal drip. Exacerbation of allergic rhinitis symptoms may occur in certain seasons or with exposure to certain allergens. Allergic rhinitis is typically diagnosed based on clinical features. Allergen testing helps determine the causative allergen and may also be used to confirm the diagnosis if there is clinical uncertainty. Initial management involves allergen and irritant avoidance and pharmacotherapy with intranasal corticosteroids or oral or intranasal antihistamines. Allergen immunotherapy may be considered if initial treatment does not provide adequate symptom relief.

  • Most common form of rhinitis (affects 1 in 6 Americans) [1]
  • > in patients ≤ 21 years [2]
  • > in patients > 21 years

Epidemiological data refers to the US, unless otherwise specified.

Allergic rhinitis is defined as an acute or chronic rhinitis that is caused by exposure to an inhaled allergen (e.g., dust, animal dander, mold spores, plant pollen).

Hypertrophic turbinates are pink or violaceous, hard, sensitive to probing, immobile, and shrink with nasal decongestant therapy. Nasal polyps are pale, soft, mobile, insensitive, and do not decrease in size following therapy with nasal decongestants.

Classification on the basis of a temporal pattern of allergen exposure may help identify the causative antigen. Classification based on the frequency and duration of symptoms is useful for guiding treatment. [4][9]

Clinical classification of allergic rhinitis [4][5]
Classification criteria Definition
Temporal pattern of allergen exposure

Episodic allergic rhinitis

Symptoms occur on exposure to allergens that are not normally a part of the individual's environment.

Seasonal allergic rhinitis

Symptoms occur on exposure to allergens that occur during particular seasons.

Perennial allergic rhinitis

Symptoms occur on exposure to allergens that are normally a part of the patient's environment.
Frequency

Intermittent allergic rhinitis

Duration of symptoms: < 4 days/week or < 4 weeks/year

Persistent allergic rhinitis

Duration of symptoms: > 4 days/week for > 4 weeks/year
Severity

Mild allergic rhinitis

Symptoms do not interfere with the quality of life.
Moderate to severe allergic rhinitis Symptoms interfere with the quality of life.

Approach [1][5]

  • Obtain a detailed clinical history identifying:
  • Order allergen testing:
    • To identify the causative allergen in all patients with features consistent with allergic rhinitis [5]
    • To confirm the diagnosis in the following situations :
      • Poor response to empiric therapy [1]
      • Diagnostic uncertainty
  • Additional diagnostic modalities (e.g., imaging and nasal endoscopy)
    • Not routinely required
    • Consider in cases of diagnostic uncertainty (e.g., to rule out sinonasal disorders). [1]

Allergic rhinitis is primarily a clinical diagnosis in patients presenting with characteristic clinical features (i.e., nasal congestion, rhinorrhea, itchy nose, sneezing) that are triggered by seasonal, perennial, or episodic exposure to allergens. [5]

Epistaxis, unilateral rhinorrhea or nasal blockage, severe headache, or anosmia are atypical for allergic rhinitis and should prompt further workup for an alternative diagnosis. [1]

Allergen testing [1][5]

Testing for aeroallergens is recommended in all patients with features consistent with allergic rhinitis. Testing for food allergens is not routinely recommended. [5]

Skin tests

Skin tests to detect allergen sensitization can cause anaphylaxis! [1]

Blood tests

Blood tests for allergen sensitization are preferred if there is concern for anaphylaxis with skin testing, [1]

In asymptomatic individuals, a positive skin or blood test for a particular allergen is not diagnostic of an allergy to that allergen. [1]

The differential diagnoses listed here are not exhaustive.

Approach [1][5]

  • Recommend environmental modifications.
  • Initiate pharmacotherapy with antihistamines (intranasal or oral) or intranasal corticosteroids.
  • Assess response to therapy in 5–7 days.
    • If symptoms are under control:
      • Step down and stop pharmacotherapy if the trigger is no longer present.
      • Or administer treatment on an as-needed basis.
    • If symptoms are uncontrolled, consider any of the following :

Environmental modifications [1][5]

  • Advise patients to avoid exposure to putative allergens (e.g., dust, animal dander, mold spores, plant pollen, or latex).
  • Examples of environmental modifications include:
    • HEPA filters
    • Dust mite bedding covers
    • Pesticides against dust mites
    • Removal of pets

Pharmacotherapy [1][5]

Medications for allergic rhinitis can be initiated empirically. The choice of initial pharmacotherapy depends on the severity and type of allergic rhinitis and should be tailored to the clinical response (see “Approach” above).

Intranasal steroids are considered the most effective maintenance treatment for persistent allergic rhinitis. Potential adverse effects include nosebleeds and, rarely, septal perforation with long-term use. [5]

In patients with severe or refractory allergic rhinitis, consider a 5–7 day course of oral corticosteroids and refer to an allergist. [5]

Medications for allergic rhinitis [1][3][5]
Drug class

Examples

Clinical considerations
Intranasal corticosteroids
  • Can also improve ocular symptoms
  • Onset of maximal benefit: at least 2 weeks
Antihistamines
Decongestants (α1-sympathomimetics)
Mast cell stabilizers
Anticholinergics
Leukotriene receptor antagonists
  • Not a preferred treatment option
  • Risk of serious neuropsychiatric events, including suicidality
  • May be considered in patients with concomitant asthma after discussion of potential risks and benefits

Intranasal sympathomimetics should generally not be used for more than 3–5 days because of the risk of rebound nasal congestion (rhinitis medicamentosa). [1][5]

Montelukast is associated with a risk of serious psychiatric events including suicide and may only be used in patients with concomitant asthma using a shared decision-making strategy.

Allergen immunotherapy [1][5]

  • Controlled exposure to gradually increasing doses of the allergen (sublingually or subcutaneously) in order to reduce sensitivity to the allergen [11]
  • Consider in patients with allergen-specific IgE antibodies and any of the following: [5]
    • Inadequate symptom control with pharmacotherapy with/without environmental modifications
    • Preference for immunotherapy over other treatment methods after a shared decision-making conversation
    • Concomitant asthma
  • Generally requires ≥ 3 years of treatment

Surgery [1][5]

  1. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020; 146 (4): p.721-767. doi: 10.1016/j.jaci.2020.07.007 . | Open in Read by QxMD
  2. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg. 2015; 152 (1 Suppl): p.S1-S43. doi: 10.1177/0194599814561600 . | Open in Read by QxMD
  3. Sur DK, Plesa ML. Treatment of Allergic Rhinitis. Am Fam Physician. 2015; 92 (11): p.985-92.
  4. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: A practice parameter third update. J Allergy Clin Immunol. 2010; 127 (1): p.S1-S55. doi: 10.1016/j.jaci.2010.09.034 . | Open in Read by QxMD
  5. Matheson MC, Dharmage SC, Abramson MJ, et al. Early-life risk factors and incidence of rhinitis: Results from the European Community Respiratory Health Study—an international population-based cohort study. J Allergy Clin Immunol. 2011; 128 (4): p.816-823.e5. doi: 10.1016/j.jaci.2011.05.039 . | Open in Read by QxMD
  6. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015; 152 (2): p.197-206. doi: 10.1177/0194599814562166 . | Open in Read by QxMD
  7. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol. 2008; 122 (2 Suppl): p.S1-S84. doi: 10.1016/j.jaci.2008.06.003 . | Open in Read by QxMD
  8. Cullinan P. Early allergen exposure, skin prick responses, and atopic wheeze at age 5 in English children: a cohort study. Thorax. 2004; 59 (10): p.855-861. doi: 10.1136/thx.2003.019877 . | Open in Read by QxMD
  9. Duong QA, Pittet LF, Curtis N, Zimmermann P. Antibiotic exposure and adverse long-term health outcomes in children: a systematic review and meta-analysis. J Infect. 2022 . doi: 10.1016/j.jinf.2022.01.005 . | Open in Read by QxMD
  10. Stevens WW, Schleimer RP, Kern RC. Chronic Rhinosinusitis with Nasal Polyps. The Journal of Allergy and Clinical Immunology: In Practice. 2016; 4 (4): p.565-572. doi: 10.1016/j.jaip.2016.04.012 . | Open in Read by QxMD
  11. Berger A. Science commentary: Skin prick testing. BMJ. 2002; 325 (7361): p.414-414. doi: 10.1136/bmj.325.7361.414 . | Open in Read by QxMD

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