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Allergic rhinitis is a group of symptoms affecting the nose. These symptoms occur when you breathe insomething you are allergic to, such as dust, dander, insect venom, or pollen.

This article focuses on allergic rhinitis due to outdoor triggers, such as plant pollen. This type of allergicrhinitis is commonly called hay fever.

Causes, incidence, and risk factorsAn allergen is something that triggers an allergy. When a person with allergic rhinitis breathes inanallergensuch as pollen or dust, the body releases chemicals, including histamine. This causes allergysymptoms.Hay fever involves anallergic reactionto pollen. A similar reaction occurs with allergy to mold, animaldander, dust, and other allergens that you breathe in.

The pollens that cause hay fever vary from person to person and from area to area. Tiny, hard-to-seepollens often cause hay fever. Examples of plants that cause hay fever include:

Trees

Grasses Ragweed

The amount of pollen in the air can affect whether hay fever symptoms develop. Hot, dry, windy days aremore likely to have increased amounts of pollen in the air. On cool, damp, rainy days most pollen iswashed to the ground.

Some disorders may be linked to allergies. These includeeczemaandasthma.

Allergies are common. Your genes and environment may make you more likely to get allergies.

Allergies often run in families. If both your parents have allergies, you are likely to have allergies too. Thechance is greater if your mother has allergies.

Symptoms

Symptoms that occur shortly after you come into contact with the substance you are allergic to mayinclude:

Itchynose, mouth, eyes, throat, skin, or any area Problems with smell Runny nose Sneezing Tearing eyes

Symptoms that may develop later include:

Stuffy nose(nasal congestion) Coughing

Clogged ears and decreased sense of smell

Sore throat

Dark circles under the eyes

Puffiness under the eyes

Fatigue and irritability

Headache

People with allergic rhinitis often have allergy symptoms that also involve the eyes.
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Signs and tests

The health care provider will perform a physical exam and ask you questions about your symptoms. Yourhistory of symptoms is important in diagnosing allergic rhinitis. You will be asked whether your symptomsvary by time of day or season, and exposure to pets or other allergens.

Allergy testing may reveal the substances that trigger your symptoms. Skin testing is the most common

method of allergy testing. See the article onallergy testingfor detailed information.If your doctor determines you cannot have skin testing, special blood tests may help with the diagnosis.These tests can measure the levels of allergy-related substances, especially one called immunoglobulinE (IgE).

A complete blood count (CBC) test called the eosinophil white blood cell count may also help diagnoseallergies.

Treatment

LIFESTYLE AND AVOIDING ALLERGENS

The best treatment is to avoid what causes your allergic symptoms. It may be impossible to completelyavoid all your triggers. However, you can often take steps to reduce your exposure to triggers such as:

Dust

Mold

Pollen

There are many different medicines to treat allergic rhinitis. Which one your doctor prescribes depends onthe type and severity of your symptoms, your age, and whether you have other medical conditions (suchas asthma).

For mild allergic rhinitis, a nasal wash can help remove mucus from the nose. You can buy a salinesolution at a drug store or make one at home using one cup of warm water, half a teaspoon of salt, andpinch of baking soda.

Treatments for allergic rhinitis include:

ANTIHISTAMINES

Antihistamines work well for treating allergy symptoms. They are often used when symptoms do nothappen very often or do not last very long.

Many antihistamines taken by mouth can be bought over the counter, without a prescription.

Older antihistamines can cause sleepiness. They may affect a child's learning and make it unsafe

to drive or operate machines.

Newer antihistamines cause little or no sleepiness. They usually do not interfere with learning.

Antihistamine nasal sprays work well for treating allergic rhinitis. You may try these medicinesfirst.

CORTICOSTEROIDS

Nasal corticosteroid sprays are the most effective treatment for allergic rhinitis.

They work best when used nonstop, but they can also be helpful when used for shorter periods oftime.

Many brands are available. You will need a prescription from your doctor.

Corticosteroid sprays are safe for children and adults.
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DECONGESTANTS

Decongestants may also be helpful for reducing symptoms such as nasal stuffiness.

Do not use nasal spray decongestants for more than 3 days.

OTHER TREATMENTS

The leukotriene inhibitor Singulair is a prescription medicine approved to help control asthma andrelieve the symptoms of seasonal allergies.

Certain illnesses that are caused by allergies (such as asthma and eczema) may need other treatments.

ALLERGY SHOTS

Allergy shots (immunotherapy) are sometimes recommended if you cannot avoid the allergen and yoursymptoms are hard to control. This includes regular injections of the allergen. Each dose is slightly largerthan the dose before it. Allergy shots may help your body adjust to the substance that is causing thereaction (antigen).

Expectations (prognosis)

Most symptoms of allergic rhinitis can be treated. More severe cases need allergy shots.

Some people (especially children) may outgrow an allergy as the immune system becomes less sensitiveto the allergen. However, once a substance causes allergies, it usually continues to affect the person overthe long term.

Calling your health care provider

Call for an appointment with your health care provider if:

You have severe allergy or hay fever symptoms

Treatment that once worked for you no longer works

Your symptoms do not respond to treatment

Prevention

You can sometimes prevent symptoms by avoiding known allergens. During pollen season, people withhay fever should stay indoors where it is air conditioned, if possible.

Most trees produce pollen in the spring.

Grasses usually produce pollen during the late spring and summer.

Ragweed and other late-blooming plants produce pollen during late summer and early autumn.

Rhinitis is defined as inflammation of the nasal membranes[1] and is characterized by a symptomcomplex that consists of any combination of the following: sneezing, nasal congestion, nasalitching, and rhinorrhea.[2] The eyes, ears, sinuses, and throat can also be involved. Allergic rhinitisis the most common cause of rhinitis. It is an extremely common condition, affectingapproximately 20% of the population.
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Although allergic rhinitis is not a life-threatening condition, complications can occur and thecondition can significantly impair quality of life,[3, 4] which leads to a number of indirect costs. Thetotal direct and indirect cost of allergic rhinitis was recently estimated to be $5.3 billion peryear.[5]A 2011 analysis determined that patients with allergic rhinitis averaged 3 additional officevisits, 9 more prescriptions filled, and $1500 in incremental healthcare costs in 1 year than similarpatients without allergic rhinitis.[6]

Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes,middle ear, sinuses, and pharynx. The nose invariably is involved, and the other organs are affected incertain individuals. Inflammation of the mucous membranes is characterized by a complex interaction ofinflammatory mediators but ultimately is triggered by an immunoglobulin E (IgE)mediated response to anextrinsic protein.[7]

The tendency to develop allergic, or IgE-mediated, reactions to extrinsic allergens (proteins capable ofcausing an allergic reaction) has a genetic component. In susceptible individuals, exposure to certainforeign proteins leads to allergic sensitization, which is characterized by the production of specific IgEdirected against these proteins. This specific IgE coats the surface of mast cells, which are present in thenasal mucosa. When the specific protein (eg, a specific pollen grain) is inhaled into the nose, it can bindto the IgE on the mast cells, leading to immediate and delayed release of a number of mediators.[7, 8, 9]

The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin.[8,9] The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2.[10, 11,12] These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea (ie, nasalcongestion, sneezing, itching, redness, tearing, swelling, ear pressure, postnasal drip). Mucous glandsare stimulated, leading to increased secretions. Vascular permeability is increased, leading to plasmaexudation. Vasodilation occurs, leading to congestion and pressure. Sensory nerves are stimulated,leading to sneezing and itching. All of these events can occur in minutes; hence, this reaction is called theearly, or immediate, phase of the reaction.

Over 4-8 hours, these mediators, through a complex interplay of events, lead to the recruitment of otherinflammatory cells to the mucosa, such as neutrophils, eosinophils, lymphocytes, andmacrophages.[13] This results in continued inflammation, termed the late-phase response. The symptomsof the late-phase response are similar to those of the early phase, but less sneezing and itching and morecongestion and mucus production tend to occur.[13] The late phase may persist for hours or days.

Systemic effects, including fatigue, sleepiness, and malaise, can occur from the inflammatory response.These symptoms often contribute to impaired quality of life.

Allergic rhinitis affects approximately 40 million people in the United States.[14]Recent US figures suggesta 20% cumulative prevalence rate.[15, 16]

International

Scandinavian studies have demonstrated a cumulative prevalence rate of 15% in men and 14% inwomen.[17] The prevalence of allergic rhinitis may vary within and among countries.[18, 19, 20, 21] This may bedue to geographic differences in the types and potency of different allergens and the overall aeroallergenburden.

Mortality/Morbidity

While allergic rhinitis itself is not life-threatening (unless accompanied by severe asthma or anaphylaxis),morbidity from the condition can be significant. Allergic rhinitis often coexists with other disorders, suchasasthma,and may be associated with asthma exacerbations.[22, 23, 24]

Allergic rhinitis is also associated withotitis media,eustachian tube dysfunction,sinusitis,nasalpolyps,allergic conjunctivitis,andatopic dermatitis.[1, 2, 25] It may also contribute to learning diff iculties,sleep disorders, and fatigue.[26, 27, 28]

Numerous complications that can lead to increased morbidity or even mortality can occur secondary toallergic rhinitis. Possible complications include otitis media, eustachian tube dysfunction, acute sinusitis,and chronic sinusitis.
http://emedicine.medscape.com/article/296301-overviewhttp://emedicine.medscape.com/article/296301-overviewhttp://emedicine.medscape.com/article/296301-overviewhttp://emedicine.medscape.com/article/994656-overviewhttp://emedicine.medscape.com/article/994656-overviewhttp://emedicine.medscape.com/article/994656-overviewhttp://emedicine.medscape.com/article/858777-overviewhttp://emedicine.medscape.com/article/858777-overviewhttp://emedicine.medscape.com/article/232791-overviewhttp://emedicine.medscape.com/article/232791-overviewhttp://emedicine.medscape.com/article/232791-overviewhttp://emedicine.medscape.com/article/861353-overviewhttp://emedicine.medscape.com/article/861353-overviewhttp://emedicine.medscape.com/article/861353-overviewhttp://emedicine.medscape.com/article/861353-overviewhttp://emedicine.medscape.com/article/1191467-overviewhttp://emedicine.medscape.com/article/1191467-overviewhttp://emedicine.medscape.com/article/1191467-overviewhttp://emedicine.medscape.com/article/762045-overviewhttp://emedicine.medscape.com/article/762045-overviewhttp://emedicine.medscape.com/article/762045-overviewhttp://emedicine.medscape.com/article/1191467-overviewhttp://emedicine.medscape.com/article/861353-overviewhttp://emedicine.medscape.com/article/861353-overviewhttp://emedicine.medscape.com/article/232791-overviewhttp://emedicine.medscape.com/article/858777-overviewhttp://emedicine.medscape.com/article/994656-overviewhttp://emedicine.medscape.com/article/296301-overview


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Allergic rhinitis can be associated with a number of comorbid conditions, including asthma, atopicdermatitis, and nasal polyps. Evidence now suggests that uncontrolled allergic rhinitis can actuallyworsen the inflammation associated with asthma[22, 23, 24] or atopic dermatitis.[25] This could lead to furthermorbidity and even mortality.

Allergic rhinitis can frequently lead to significant impairment of quality of life. Symptoms such as fatigue,drowsiness (due to the disease or to medications), and malaise can lead to impaired work and schoolperformance, missed school or work days, and traffic accidents. The overall cost (direct and indirect) of

allergic rhinitis was recently estimated to be $5.3 billion per year.[5]

Race

Allergic rhinitis occurs in persons of all races. Prevalence of allergic rhinitis seems to vary among differentpopulations and cultures, which may be due to genetic differences, geographic factors or environmentaldifferences, or other population-based factors.

Sex

In childhood, allergic rhinitis is more common in boys than in girls, but in adulthood, the prevalence isapproximately equal between men and women.

Age

Onset of allergic rhinitis is common in childhood, adolescence, and early adult years, with a mean age ofonset 8-11 years, but allergic rhinitis may occur in persons of any age. In 80% of cases, allergic rhinitisdevelops by age 20 years.[29]The prevalence of allergic rhinitis has been reported to be as high as 40% inchildren, subsequently decreasing with age.[15, 16] In the geriatric population, rhinitis is less commonlyallergic in nature.

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istoryObtaining a detailed history is important in the evaluation of allergic rhinitis. Important elements includean evaluation of the nature, duration, and time course of symptoms; possible triggers for symptoms;

response to medications; comorbid conditions; family history of allergic diseases; environmentalexposures; occupational exposures; and effects on quality of life. A thorough history may help identifyspecific triggers, suggesting an allergic etiology for the rhinitis.

Symptoms that can be associated with allergic rhinitis include sneezing, itching (of nose, eyes, ears,palate), rhinorrhea, postnasal drip, congestion, anosmia, headache, earache, tearing, red eyes, eyeswelling, fatigue, drowsiness, and malaise.[2]

Symptoms and chronicity

Determine the age of onset of symptoms and whether symptoms have been present continuously sinceonset. While the onset of allergic rhinitis can occur well into adulthood, most patients develop symptomsby age 20 years.[29]

Determine the time pattern of symptoms and whether symptoms occur at a consistent level throughoutthe year (ie, perennial rhinitis), only occur in specific seasons (ie, seasonal rhinitis), or a combination ofthe two. During periods of exacerbation, determine whether symptoms occur on a daily basis or only onan episodic basis. Determine whether the symptoms are present all day or only at specific times duringthe day. This information can help suggest the diagnosis and determine possible triggers.

Determine which organ systems are affected and the specific symptoms. Some patients have exclusiveinvolvement of the nose, while others have involvement of multiple organs. Some patients primarily havesneezing, itching, tearing, and watery rhinorrhea (the classic hayfever presentation), while others mayonly complain of congestion. Significant complaints of congestion, particularly if unilateral, might suggestthe possibility of structural obstruction, such as a polyp, foreign body, or deviated septum.

Trigger factors

Determine whether symptoms are related temporally to specific trigger factors. This might includeexposure to pollens outdoors, mold spores while doing yard work, specific animals, or dust while cleaningthe house.
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Irritant triggers such as smoke, pollution, and strong smells can aggravate symptoms in a patient withallergic rhinitis. These are also common triggers of vasomotor rhinitis. Many patients have both allergicrhinitis and vasomotor rhinitis.

Other patients may describe year-round symptoms that do not appear to be associated with specifictriggers. This could be consistent with nonallergic rhinitis, but perennial allergens, such as dust mite oranimal exposure, should also be considered in this situation. With chronic exposure and chronicsymptoms, the patient may not be able to associate symptoms with a particular trigger.

Response to treatment

Response to treatment with antihistamines supports the diagnosis of allergic rhinitis, although sneezing,itching, and rhinorrhea associated with nonallergic rhinitis can also improve with antihistamines.[30]

Response to intranasal corticosteroids supports the diagnosis of allergic rhinitis, although some cases ofnonallergic rhinitis (particularly the nonallergic rhinitis with eosinophils syndrome [NARES]) also improvewith nasal steroids.

Comorbid conditions

Patients with allergic rhinitis may have other atopic conditions such as asthma[22, 23] or atopicdermatitis.[25] Of patients with allergic rhinitis, 20% also have symptoms of asthma. Uncontrolled allergic

rhinitis may cause worsening of asthma[24] or even atopic dermatitis.[25] Explore this possibility whenobtaining the patient history.

Look for conditions that can occur as complications of allergic rhinitis. Sinusitis occurs quite frequently.Other possible complications include otitis media, sleep disturbance or apnea, dental problems (overbite),and palatal abnormalities.[31] The treatment plan might be different if one of these complications is present.Nasal polyps occur in association with allergic rhinitis, although whether allergic rhinitis actually causespolyps remains unclear. Polyps may not respond to medical treatment and might predispose a patient tosinusitis or sleep disturbance (due to congestion).

Investigate past medical history, including other current medical conditions. Diseases such ashypothyroidism or sarcoidosis can cause nonallergic rhinitis. Concomitant medical conditions mightinfluence the choice of medication.

Family history

Because allergic rhinitis has a significant genetic component,[32] a positive family history for atopy makesthe diagnosis more likely.

In fact, a greater risk of allergic rhinitis exists if both parents are atopic than if one parent is atopic.However, the cause of allergic rhinitis appears to be multifactorial, and a person with no family history ofallergic rhinitis can develop allergic rhinitis.

Environmental and occupational exposure

A thorough history of environmental exposures helps to identify specific allergic triggers. This shouldinclude investigation of risk factors for exposure to perennial allergens (eg, dust mites, mold, pets).[33,34]

Risk factors for dust mite exposure include carpeting, heat, humidity, and bedding that does not havedust miteproof covers. Chronic dampness in the home is a risk factor for mold exposure. A history ofhobbies and recreational activities helps determine risk and a time pattern of pollen exposure.

Ask about the environment of the workplace or school. This might include exposure to ordinary perennialallergens (eg, mites, mold, pet dander) or unique occupational allergens (eg, laboratory animals, animalproducts, grains and organic materials, wood dust, latex, enzymes).

Effects on quality of life

An accurate assessment of the morbidity of allergic rhinitis cannot be obtained without asking about theeffects on the patient's quality of life. Specific validated questionnaires are available to help determineeffects on quality of life.[3, 4]

Determine the presence of symptoms such as fatigue, malaise, drowsiness (which may or may not berelated to medication), and headache.

Investigate sleep quality and ability to function at work.


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The physical examination should focus on the nose, but examination of facial features, eyes, ears,oropharynx, neck, lungs, and skin is also important. Look for physical findings that may be consistent witha systemic disease that is associated with rhinitis.

General facial features

"Allergic shiners" are dark circles around the eyes and are related to vasodilation or nasal congestion. [2, 35]

"Nasal crease" is a horizontal crease across the lower half of the bridge of the nose that is caused byrepeated upward rubbing of the tip of the nose by the palm of the hand (ie, the "allergic salute").[2, 35]

Nose

The nasal examination is best accomplished with a nasal speculum or an otoscope with nasal adapter. Inthe specialist's office, a rigid or flexible rhinolaryngoscope may be used.

The mucosa of the nasal turbinates may be swollen (boggy) and have a pale, bluish-gray color. Somepatients may have predominant erythema of the mucosa, which can also be observed with rhinitismedicamentosa, infection, or vasomotor rhinitis. While pale, boggy, blue-gray mucosa is typical forallergic rhinitis, mucosal examination findings cannot definitively distinguish between allergic andnonallergic causes of rhinitis.

Assess the character and quantity of nasal mucus. Thin and watery secretions are frequently associatedwith allergic rhinitis, while thick and purulent secretions are usually associated with sinusitis; however,thicker, purulent, colored mucus can also occur with allergic rhinitis.

Examine the nasal septum to look for any deviation or septal perforation, which may be present due tochronic rhinitis, granulomatous disease, cocaine abuse, prior surgery, topical decongestant abuse, or,rarely, topical steroid overuse.

Examine the nasal cavity for other masses such as polyps or tumors. Polyps are firm gray masses thatare often attached by a stalk, which may not be visible. After spraying a topical decongestant, polyps donot shrink, while the surrounding nasal mucosa does shrink.

Ears, eyes, and oropharynx

Perform otoscopy to look for tympanic membrane retraction, air-fluid levels, or bubbles. Performingpneumatic otoscopy can be considered to look for abnormal tympanic membrane mobility. These findingscan be associated with allergic rhinitis, particularly if eustachian tube dysfunction or secondary otitismedia is present.

Ocular examination may reveal findings of injection and swelling of the palpebral conjunctivae, withexcess tear production. Dennie-Morgan lines (prominent creases below the inferior eyelid) are associatedwith allergic rhinitis.[36]

The term "cobblestoning" is used to describe streaks of lymphoid tissue on the posterior pharynx, which iscommonly observed with allergic rhinitis. Tonsillar hypertrophy can also be observed. Malocclusion(overbite) and a high-arched palate can be observed in patients who breathe from their mouths

excessively.

[37]

Neck

Look for evidence of lymphadenopathy or thyroid disease.

Lungs

Look for the characteristic findings of asthma.

Skin

Evaluate for possible atopic dermatitis.

Other

Look for any evidence of systemic diseases that may cause rhinitis (eg, sarcoidosis, hypothyroidism,immunodeficiency, ciliary dyskinesia syndrome, other connective tissue diseases).


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The causes of allergic rhinitis may differ depending on whether the symptoms are seasonal, perennial, orsporadic/episodic. Some patients are sensitive to multiple allergens and can have perennial allergicrhinitis with seasonal exacerbations. While food allergy can cause rhinitis, particularly in children, it israrely a cause of allergic rhinitis in the absence of gastrointestinal or skin symptoms.

Seasonal allergic rhinitis is commonly caused by allergy to seasonal pollens and outdoor molds.

Pollens (tree, grass, and weed)

Tree pollens, which vary by geographic location, are typically present in high counts during the spring,although some species produce their pollens in the fall. Common tree families associated with allergicrhinitis include birch, oak, maple, cedar, olive, and elm.

Grass pollens also vary by geographic location. Most of the common grass species are associated withallergic rhinitis, including Kentucky bluegrass, orchard, redtop, timothy, vernal, meadow fescue, Bermuda,and perennial rye. A number of these grasses are cross-reactive, meaning that they have similarantigenic structures (ie, proteins recognized by specific IgE in allergic sensitization). Consequently, aperson who is allergic to one species is also likely to be sensitive to a number of other species. The grasspollens are most prominent from the late spring through the fall but can be present year-round in warmerclimates.

Weed pollens also vary geographically. Many of the weeds, such as short ragweed, which is a commoncause of allergic rhinitis in much of the United States, are most prominent in the late summer and fall.Other weed pollens are present year-round, particularly in warmer climates. Common weeds associatedwith allergic rhinitis include short ragweed, western ragweed, pigweed, sage, mugwort, yellow dock,sheep sorrel, English plantain, lamb's quarters, and Russian thistle.

Outdoor molds

Atmospheric conditions can affect the growth and dispersion of a number of molds; therefore, theirairborne prevalence may vary depending on climate and season.

For example,Alternariaand Cladosporiumare particularly prevalent in the dry and windy conditions of the

Great Plains states, where they grow on grasses and grains. Their dispersion often peaks on sunnyafternoons. They are virtually absent when snow is on the ground in winter, and they peak in the summermonths and early fall.

Aspergillusand Penicilliumcan be found both outdoors and indoors (particularly in humid households),with variable growth depending on the season or climate. Their spores can also be dispersed in dryconditions.

Perennial allergic rhinitis is typically caused by allergens within the home but can also be caused byoutdoor allergens that are present year-round.[38] In warmer climates, grass pollens can be presentthroughout the year. In some climates, individuals may be symptomatic due to trees and grasses in thewarmer months and molds and weeds in the winter.

House dust mites

In the United States, 2 major house dust mite species are associated with allergic rhinitis. Theseare Dermatophagoides farinaeand Dermatophagoides pteronyssinus.[33]

These mites feed on organic material in households, particularly the skin that is shed from humans andpets. They can be found in carpets, upholstered furniture, pillows, mattresses, comforters, and stuffedtoys.

While they thrive in warmer temperatures and high humidity, they can be found year-round in manyhouseholds. On the other hand, dust mites are rare in arid climates.

Pets

Allergy to indoor pets is a common cause of perennial allergic rhinitis.[33, 34]

Cat and dog allergies are encountered most commonly in allergy practice, although allergy has beenreported to occur with most of the furry animals and birds that are kept as indoor pets.


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Cockroaches

While cockroach allergy is most frequently considered a cause of asthma, particularly in the inner city, itcan also cause perennial allergic rhinitis in infested households.[39, 40]

Rodents

Rodent infestation may be associated with allergic sensitization.[41, 42, 43]

Sporadic allergic rhinitis causes

Sporadic allergic rhinitis, intermittent brief episodes of allergic rhinitis, is caused by intermittent exposureto an allergen. Often, this is due to pets or animals to which a person is not usually exposed. Sporadicallergic rhinitis can also be due to pollens, molds, or indoor allergens to which a person is not usuallyexposed. While allergy to specific foods can cause rhinitis, an individual affected by food allergy alsousually has some combination of gastrointestinal, skin, and lung involvement. In this situation, the historyfindings usually suggest an association with a particular food. Watery rhinorrhea occurring shortly aftereating may be vasomotor (and not allergic) in nature, mediated via the vagus nerve. This often is calledgustatory rhinitis.

Occupational allergic rhinitis

Occupational allergic rhinitis, which is caused by exposure to allergens in the workplace, can be sporadic,seasonal, or perennial. People who work near animals (eg, veterinarians, laboratory researchers, farmworkers) might have episodic symptoms when exposed to certain animals, daily symptoms while at theworkplace, or even continual symptoms (which can persist in the evenings and weekends with severesensitivity due to persistent late-phase inflammation). Some workers who may have seasonal symptomsinclude farmers, agricultural workers (exposure to pollens, animals, mold spores, and grains), and otheroutdoor workers. Other significant occupational allergens that may cause allergic rhinitis include wooddust, latex (due to inhalation of powder from gloves), acid anhydrides, glues, and psyllium (eg, nursinghome workers who administer it as medication).

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Testing for reaction to specific allergens can be helpful to confirm the diagnosis of allergic rhinitis and to

determine specific allergic triggers. If specific allergic triggers are known, then appropriate avoidancemeasures can be recommended. It is essential to know which allergens a patient is sensitive to in order toperform allergen immunotherapy (desensitization treatment). To an extent, allergy testing providesknowledge of the degree of sensitivity to a particular allergen. The most commonly used methods ofdetermining allergy to a particular substance are allergy skin testing (testing for immediatehypersensitivity reactions) and in vitro diagnostic tests, such as the radioallergosorbent test (RAST),which indirectly measures the quantity of specific IgE to a particular antigen.

Allergy skin tests (immediate hypersensitivity testing) are an in vivo method of determining immediate(IgE-mediated) hypersensitivity to specific allergens. Sensitivity to virtually all of the allergens that causeallergic rhinitis (see Causes) can be determined with skin testing.

By introducing an extract of a suspected allergen percutaneously, an immediate (early-phase) wheal-and-

flare reaction can be produced. Percutaneous introduction can be accomplished by placing a drop ofextract on the skin and scratching or pricking a needle through the epidermis under the drop. Dependingon the exact technique used, this testing is referred to as scratch, prick, or puncture testing.

The antigen in the extract binds to IgE on skin mast cells, leading to the early-phase (immediate-type)reaction, which results in the release of mediators such as histamine (see Pathophysiology). Thisgenerally occurs within 15-20 minutes. The released histamine causes the wheal-and-flare reaction (Acentral wheal is produced by infiltrating fluid, and surrounding erythema is produced due to vasodilation,with concomitant itching.). The size of the wheal-and-flare reaction roughly correlates with the degree ofsensitivity to the allergen.

The extract can also be introduced intradermally (ie, injected into the dermis with an intradermal [TB]needle). With this technique, the extract is allowed to contact the underlying dermal tissues, including skinmast cells. Intradermal testing is approximately 1000-fold more sensitive than percutaneous testing. This

should be performed with care by qualified specialists. The rate of false-positive results may be high.

In vitro allergy tests, ie, RAST, allow measurement of the amount of specific IgE to individual allergens ina sample of blood. The amount of specific IgE produced to a particular allergen approximately correlates
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with the allergic sensitivity to that substance. These tests allow determination of specific IgE to a numberof different allergens from one blood sample, but the sensitivity and specificity are not always as good asaccurate skin testing (depending on the laboratory and assay used for the RAST). As with skin testing,virtually all of the allergens that cause allergic rhinitis (see Causes) can be determined using the RAST,although testing for some allergens is less well established compared to others.

Testing every patient for sensitivity to every allergen known is not practical. Therefore, select a limitednumber of allergens for testing (this applies to both skin testing and RAST). When selecting allergens,select from among the allergens that are present locally and are known to cause clinically significantallergic disease. A clinician who is specifically trained in allergy testing should select allergens for testing.

Total serum IgE

This is a measurement of the total level of IgE in the blood (regardless of specificity). While patients withallergic rhinitis are more likely to have an elevated total IgE level than the normal population, this test isneither sensitive nor specific for allergic rhinitis. As many as 50% of patients with allergic rhinitis havenormal levels of total IgE, while 20% of nonaffected individuals can have elevated total IgE levels.Therefore, this test is generally not used alone to establish the diagnosis of allergic rhinitis, but the resultscan be helpful in some cases when combined with other factors.

Total blood eosinophil count

As with the total serum IgE, an elevated eosinophil count supports the diagnosis of allergic rhinitis, but itis neither sensitive nor specific for the diagnosis. The results can sometimes be helpful when combinedwith other factors.

While radiographic studies are not needed to establish the diagnosis of allergic rhinitis, they canbe helpful for evaluating possible structural abnormalities or to help detect complications orcomorbid conditions, such as sinusitis or adenoid hypertrophy.

A 3-view sinus series (Caldwell, Waters, and lateral views) can be helpful in evaluating forsinusitis of the maxillary, frontal, and sphenoid sinuses. The ethmoid sinuses are difficult to

visualize clearly on x-ray films. Plain x-ray films can be helpful for diagnosing acute sinusitis,but CT scanning of the sinuses is more sensitive and specific. For chronic sinusitis, plain x-rayfilms are often inconclusive, and CT scan is much preferred.

A lateral view of the neck can be helpful when evaluating for soft tissue abnormalities of thenasopharynx, such as adenoid hypertrophy.

CT scanning

Coronal CT scan images of the sinuses can be very helpful for evaluating acute or chronicsinusitis. In particular, obstruction of the ostiomeatal complex (a confluence of drainagechannels from the sinuses) can be seen quite clearly. CT scanning may also help delineate

polyps, turbinate swelling, septal abnormalities (eg, deviation), and bony abnormalities (eg,concha bullosa).

MRI

For evaluating sinusitis, MRI images are generally less helpful than CT scan images, largelybecause the bony structures are not seen as clearly on MRI images. However, soft tissues arevisualized quite well, making MRI images helpful for diagnosing malignancies of the upperairway.

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Nasal cytology: A nasal smear can sometimes be helpful for establishing the diagnosis of allergic rhinitis.A sample of secretions and cells is scraped from the surface of the nasal mucosa using a specialsampling probe. Secretions that are blown from the nose are not adequate. The presence of eosinophils
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is consistent with allergic rhinitis but also can be observed with NARES. Results are neither sensitive norspecific for allergic rhinitis and should not be used exclusively for establishing the diagnosis.

Rhinoscopy: While not routinely indicated, upper airway endoscopy (rhinolaryngoscopy) can beperformed if a complication or comorbid condition may be present. It can be helpful for evaluating

structural abnormalities (eg, polyps, adenoid hypertrophy, septal deviation, masses, foreign bodies) andchronic sinusitis (by visualizing the areas of sinus drainage). Nasal provocation (allergen challenge) testing: This procedure is essentially a research tool and is rarely

indicated in the routine evaluation of allergic rhinitis. The possible allergen is inhaled or otherwiseinoculated into the nose. The patient can then be monitored for development of symptoms or productionof secretions, or objective measurements of nasal congestion can be taken. Some consider this test thecriterion standard test for the diagnosis of allergic rhinitis.[44] However, it is not a practical test to performroutinely, and only an appropriately trained specialist should perform this test.

The management of allergic rhinitis consists of 3 major categories of treatment, (1) environmental control

measures and allergen avoidance, (2) pharmacological management, and (3) immunotherapy.

Environmental control measures and allergen avoidance involve both the avoidance of known allergens(substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, orirritant, triggers. Consider environmental control measures, when practical, in all cases of allergicrhinitis.[45]However, global environmental control without identification of specific triggers is inappropriate.

Pollens and outdoor molds

Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction ofoutdoor exposure during the season in which a particular type of pollen is present can be somewhathelpful. In general, tree pollens are present in the spring, grass pollens from the late spring throughsummer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist

(see Causes).Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during thistime, but this may not be reliable because pollen counts can also be influenced by a number of otherfactors. Keeping the windows and doors of the house and car closed as much as possible during thepollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a showerafter outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.

Despite all of these measures, patients who are allergic to pollens usually continue to be symptomaticduring the pollen season and usually require some other form of management. As with pollens, avoidanceof outdoor/seasonal molds may be difficult.

Indoor allergens

Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. Fordust mites, covering the mattress and pillows with impermeable covers helps reduce exposure.[46] Bedlinens should be washed every 2 weeks in hot (at least 130F) water to kill any mites present.[47,48]Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting shouldbe removed. The carpet can be treated with one of a number of chemical agents that kill the mites ordenature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrivewhen indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful.[49]

Indoor environmental control measures for mold allergy focus on reduction of excessive humidity andremoval of standing water. The environmental control measures for dust mites can also help reduce moldspores.

For animal allergy, complete avoidance is the best option. For patients who cannot, or who do not want

to, completely avoid an animal or pet, confinement of the animal to a noncarpeted room and keeping itentirely out of the bedroom can be of some benefit.[50] Cat allergen levels in the home can be reduced withhigh-efficiency particulate air (HEPA) filters and by bathing the cat every week (although this may beimpractical). Cockroach extermination may be helpful for cases of cockroach sensitivity.


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Occupational allergens

As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respiratormight be needed.

Nonspecific triggers

Exposure to smoke, strong perfumes and scents, fumes, rapid changes in temperature, and outdoorpollution can be nonspecific triggers in patients with allergic rhinitis. Consider avoidance of thesesituations or triggers if they seem to aggravate symptoms.

Pharmacotherapy

See Medication.

Immunotherapy (desensitization)

A considerable body of clinical research has established the effectiveness of high-dose allergy shots inreducing symptoms and medication requirements.[51]Success rates have been demonstrated to be as highas 80-90% for certain allergens. It is a long-term process; noticeable improvement is often not observedfor 6-12 months, and, if helpful, therapy should be continued for 3-5 years. Immunotherapy is not without

risk because severe systemic allergic reactions can sometimes occur. For these reasons, carefullyconsider the risks and benefits of immunotherapy in each patient and weigh the risks and benefits ofimmunotherapy against the risks and benefits of the other management options.

Sublingual immunotherapy (SLIT) is currently increasing in use, particularly in Europe. It is not yetapproved in the United States but clinical trials are underway, with plans for application for FDA approval.Differences between SLIT and subcutaneous immunotherapy (SCIT) need further study, includingresearch on differences in efficacy, durability, and safety. Thus far, the data on SLIT has focused largelyon pollen allergens. Whether SLIT will be effective for non-pollen allergens as well as pollens also needsadditional study. A 2012 meta-analysis of existing studies of SLIT for grass pollen reported that SCIT ismore effective than SLIT in controlling symptoms and in reducing the use of allergy medications inpatients with seasonal allergic rhinoconjuntivitis to grass pollen.[52]

Indications: Immunotherapy may be considered more strongly with severe disease, poor response toother management options, and the presence of comorbid conditions or complications. Immunotherapyis often combined with pharmacotherapy and environmental control.

Administration: Administer immunotherapy with allergens to which the patient is known to be sensitiveand that are present in the patient's environment (and cannot be easily avoided). The value ofimmunotherapy for pollens, dust mites, and cats is well established.[53, 54, 55, 56, 57] The value ofimmunotherapy for dogs and mold is less well established.[51, 53]

Contraindication: A number of potential contraindications to immunotherapy exist and need to beconsidered. Immunotherapy should only be performed by individuals who have been appropriatelytrained, who institute appropriate precautions, and who are equipped for potential adverse events.

ALLERGIC RHINITIS OVERVIEW

Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoyingsymptoms, including sneezing, itching, nasal congestion, runny nose, and post-nasal drip (the sensationthat mucus is draining from the sinuses down the back of the throat).

Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses (eg, the commoncold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs,some medical conditions, and other unidentifiable factors.


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For many people, rhinitis is a lifelong condition that waxes and wanes over time. Fortunately, thesymptoms of rhinitis can usually be controlled with a combination of environmental measures,medications, and immunotherapy (also called allergy shots).

Other forms of rhinitis are discussed separately. (See"Patient information: Nonallergic rhinitis (runny orstuffy nose) (Beyond the Basics)".)

WHO GETS ALLERGIC RHINITIS?

Allergic rhinitis, also known as hay fever, affects approximately 20 percent of people of all ages. The riskof developing allergic rhinitis is much higher in people with asthma or eczema and in people who have afamily history of asthma or rhinitis.

Allergic rhinitis can begin at any age, although most people first develop symptoms in childhood or youngadulthood. The symptoms are often at their worst in children and in people in their 30s and 40s. However,the severity of symptoms tends to vary throughout life; many people experience periods when they haveno symptoms at all.

ALLERGIC RHINITIS CAUSES

Allergic rhinitis is caused by a nasal reaction to small airborne particles called allergens (substances thatprovoke an allergic reaction). In some people, these particles also cause reactions in the lungs (asthma)and eyes (allergic conjunctivitis).

The allergic reaction is characterized by activation of two types of inflammatory cells, called mast cellsand basophils. These cells produce inflammatory substances, such as histamine, which cause fluid tobuild up in the nasal tissues (congestion), itching, sneezing, and runny nose. Over several hours, thesesubstances activate other inflammatory cells that can cause persistent symptoms.

Seasonal versus perennial allergic rhinitisAllergic rhinitis can be seasonal (occurring duringspecific seasons) or perennial (occurring year round). The allergens that most commonly cause seasonalallergic rhinitisinclude pollens from trees, grasses, and weeds, as well as spores from fungi and molds

(figure 1).

The allergens that most commonly cause perennial allergic rhinitisare dust mites, cockroaches, animaldander, and fungi or molds. Perennial allergic rhinitis tends to be more difficult to treat.

ALLERGIC RHINITIS SYMPTOMS

The symptoms of allergic rhinitis vary from person to person. Although the term "rhinitis" refers only to thenasal symptoms, many patients also experience problems with their eyes, throat, and ears. In addition,sleep can be disrupted, so it is helpful to consider the entire spectrum of symptoms.

Nose: watery nasal discharge, blocked nasal passages, sneezing, nasal itching, post-nasal drip,

loss of taste, facial pressure or pain. Eyes: itchy, red eyes, feeling of grittiness in the eyes, swelling and blueness of the skin below the

eyes (called allergic shiners) (see"Patient information: Allergic conjunctivitis (Beyond theBasics)").

Throat and ears: sore throat, hoarse voice, congestion or popping of the ears, itching of the throator ears.

Sleep: mouth breathing, frequent awakening, daytime fatigue, difficulty performing work.

When an allergen is present year round, the predominant symptoms include post-nasal drip, persistentnasal congestion, and poor-quality sleep.

ALLERGIC RHINITIS DIAGNOSIS

The diagnosis of allergic rhinitis is based upon a physical examination and the symptoms describedabove. Medical tests can confirm the diagnosis and identify the offending allergens.
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Identify allergens and other triggersIt is often possible to identify the allergens and other triggersthat provoke allergic rhinitis by:

Recalling the factors that precede symptoms Noting the time at which symptoms begin Identifying potential allergens in a person's home, work, and school environments

Skin tests may be useful for people whose symptoms are not well controlled with medications or in whomthe offending allergen is not obvious.

ALLERGIC RHINITIS TREATMENT

The treatment of allergic rhinitis includes reducing exposure to allergens and other triggers, incombination with medication therapy. In most people, these measures effectively control the symptoms.

Reduce exposure to triggersSome simple measures can reduce a person's exposure to allergensand triggers that provoke allergic rhinitis. These measures are discussed in detail in a separate topicreview. (See"Patient information: Trigger avoidance in allergic rhinitis (Beyond the Basics)".)

Several different classes of drugs counter the inflammation that causes symptoms of allergic rhinitis. Theseverity of symptoms and personal preferences usually guide the selection of specific drugs.

Nasal irrigation and saline spraysRinsing the nose with a salt-water (saline) solution is called nasalirrigation or nasal lavage. Saline is also available in a standard nasal spray, although this is not aseffective as using larger amounts of water in an irrigation.

Nasal irrigation is particularly useful for treating drainage down the back of the throat, sneezing, nasaldryness, and congestion. The treatment helps by rinsing out allergens and irritants from the nose. Salinerinses also clean the nasal lining and can be used before applying sprays containing medications, to get abetter effect from the medication.

Nasal lavage with warmed saline can be performed as needed, once per day, or twice daily for increasedsymptoms. Nasal lavage carries few risks when performed correctly and with sterilized water. Salinenasal sprays and irrigation kits can be purchased over-the-counter. Saline mixes can also be purchasedor patients can make their own solution.

A variety of devices, including bulb syringes, Neti pots, and bottle sprayers, may be used to perform nasallavage; instructions for nasal lavage are provided in the table (table 1). At least 200 mL (about 3/4 cup) offluid (salt solution made with distilled or boiled water or sterile saline, not tap water) is recommended foreach nostril.

Nasal glucocorticoidsNasal glucocorticoids (steroids delivered by a nasal spray) are the first-linetreatment for the symptoms of allergic rhinitis. These drugs have few side effects and dramatically relieve

symptoms in most people. Studies have shown that nasal glucocorticoids are more effective than oralantihistamines for symptom relief [1].

There are a number of nasal glucocorticoids available by prescription. Specific medications includefluticasone, mometasone, budesonide, flunisolide, triamcinolone, beclomethasone, fluticasone furoate,and ciclesonide. These drugs differ with regard to the frequency of doses, the spray device, and cost, butall are similarly effective for treating all the symptoms of allergic rhinitis.

People with severe rhinitis may need to use a nasal decongestant for a few days before starting a nasalglucocorticoid to reduce nasal swelling, which will allow the nasal spray to reach more areas of the nasalpassages (see'Decongestants'below).

Some symptom relief may occur on the first day of therapy with nasal glucocorticoids, although theirmaximal effectiveness may not be noticeable for days to weeks. For this reason, nasal glucocorticoids aremost effective when used regularly. Some people are able to use lower doses when symptoms are lesssevere.
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How to use a nasal sprayNasal sprays work best when they are used properly and the medicationremains in the nose rather than draining down the back of the throat. If the nose is crusted or containsmucus, it should be cleaned with a saline nasal spray before a nasal spray that contains medication.

The head should be positioned normally or with the chin slightly tucked. The spray should be directedaway from the nasal septum (the cartilage that divides the two sides of the nose). The spray is dispensedand then sniffed in slightly to pull it into the higher parts of the nose. Sniffing too hard will result in the

medicine draining down the throat, and should be avoided.

Some people find that holding one nostril closed with a finger improves their ability to draw the spray intothe upper nose. Medicine that drains into the throat should be spit out, since it is not effective unless itremains in the nose.

Side effectsThe side effects of nasal steroids are mild and may include a mildly unpleasant smell ortaste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding ofthe nasal septum, especially during the winter. These problems can be minimized by reducing the dose ofthe nasal steroid, applying a moisturizing nasal gel or spray to the septum before using the spray, orswitching to a water-based (rather than an alcohol-based) spray.

Studies suggest that nasal steroids are generally safe when used for many years. However, people whouse these drugs for years should have periodic nasal examinations to check for rare side effects, such asnasal infection.

Steroids taken as a pill or inhaled into the lungs can have side effects, especially when taken for longperiods of time. However, the doses used in nasal steroids are low and are NOT associated with theseside effects. However, clinicians usually recommend using the lowest effective dose.

AntihistaminesAntihistamines relieve the itching, sneezing, and runny nose of allergic rhinitis, butthey do not relieve nasal congestion. Combined treatment with nasal steroids or decongestants mayprovide greater symptom relief than use of either alone.

Oral medicationsSeveral antihistamines have been available for many years without a prescription,including brompheniramine (Dimetapp allergy, Nasahist B), chlorpheniramine (Chlor-Trimeton),diphenhydramine (Benadryl), and clemastine (Tavist). These drugs often cause sedation and shouldnot be used before driving or operating machinery. Even if the person does not feel excessively drowsy,these drugs can have a sedating effect. Thus, patients should use caution.

Less-sedating oral antihistamines include Loratadine (Claritin, Alavert), desloratadine (Clarinex),cetirizine (Zyrtec), levocetirizine (Xyzal), and fexofenadine (Allegra). Loratadine and cetirizine areavailable without a prescription. These drugs work as well as the sedating antihistamines for rhinitis, butthey are less sedating and are available in long-acting formulas. However, they may be more expensive.

Nasal spraysAzelastine (Astelin, Astepro) and olopatadine (Patanase) are prescription nasal

antihistamine sprays that can be used daily or when needed to relieve symptoms of post-nasal drip,congestion, and sneezing. These sprays start to work within minutes after use. The most common sideeffect with azelastine is a bad taste in the mouth immediately after use. This can be minimized by keepingthe head tilted forward while spraying, to prevent the medicine from draining down the throat (see'How touse a nasal spray'above).

DecongestantsDecongestants (like pseudoephedrine or phenylephrine [Sudafed, Actifed,Drixoral]) are often combined with antihistamines in oral, over-the-counter allergy drugs. In the UnitedStates, pseudoephedrine has been used to make illegal drugs, which caused many companies tosubstitute phenylephrine for pseudoephedrine. However, phenylephrine is not effective for treatingallergic rhinitis.

Oral decongestants elevate blood pressure and are not appropriate for people with high blood pressure orcertain cardiovascular conditions. Men with an enlarged prostate who have difficulty urinating may notice
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a worsening of this symptom when they take decongestants. (See"Patient information: Benign prostatichyperplasia (BPH) (Beyond the Basics)".)

Decongestants in the form of nasal sprays are also available, including oxymetazoline (Afrin) andphenylephrine (Neo-synephrine). Nasal decongestant sprays should not be used for more than two tothree days at a time because they may cause a type of rhinitis called rhinitis medicamentosa, whichcauses the nose to be congested constantly UNLESS the medication is used repeatedly. This condition

can be difficult to treat. To avoid it, do not use decongestant sprays for more than 3 days. (See"Patientinformation: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)".)

Cromolyn sodiumCromolyn sodium (Nasalcrom) prevents the symptoms of allergic rhinitis byinterfering with the ability of allergy cells to release natural chemicals that cause inflammation. This drugis available as an over-the-counter nasal spray that must be used three to four times per day, preferablybefore symptoms have begun, to effectively prevent the symptoms of allergic rhinitis.

Allergy shotsAllergy shots, also known as allergen immunotherapy, are injections given to reduce aperson's sensitivity to allergens. Allergy shots are only available for common allergens, such as pollens,cat and dog dander, dust mites, and molds. These shots contain solutions of the allergens to which aspecific person is allergic, and are made up individually for each person. The process of immunotherapychanges the person's immune response to the allergens over time. As a result, being exposed to theallergen causes fewer or even no symptoms.

Immunotherapy can help many people with allergic rhinitis. In children, immunotherapy can help preventdeveloping allergic asthma later in life. However, immunotherapy is relatively time-consuming and is oftenreserved for people who have a poor response to medication, or want to avoid taking medications long-term. Immunotherapy can be expensive, but many insurance plans cover the therapy because long-termuse of allergy medications is also costly.

Immunotherapy is usually started by an allergist. Treatment begins with several months of weeklyinjections of gradually increasing doses, followed by monthly maintenance injections.

Immunotherapy is usually administered for a minimum of three to five years. If immunotherapy isdiscontinued, the benefits gradually diminish over time, although some patients have several more yearsof symptom relief [2].

Immunotherapy injections carry a small risk of a severe allergic reaction. These reactions occur with afrequency of 6 of every 10,000 injections. The symptoms usually begin within 30 minutes of the injection.For this reason, patients are required to remain in the office after routine injections so that such a reactioncould be quickly treated. Because drugs called beta-blockers may interfere with the ability to treat thesereactions, people who take beta-blockers are often advised to avoid immunotherapy.

Other treatmentsOther drugs may be recommended for some people with allergic rhinitis.

Ipratropium Nasal atropine is effective for the treatment of severe runny nose. This drug,available as ipratropium bromide (Atrovent), is not generally recommended for people withglaucoma or men with an enlarged prostate.

Leukotriene modifiers Release of substances called leukotrienes may contribute to thesymptoms of allergic rhinitis. Drugs that block the actions of leukotrienes, called leukotrienemodifiers, can be very useful in patients with asthma and allergic rhinitis. However, nasal steroidsare more effective than leukotriene modifiers for treating allergic rhinitis; thus, leukotrienemodifiers are generally reserved for patients who cannot tolerate nasal sprays (due to nosebleeds) or azelastine (see'Antihistamines'above).

PREGNANCY AND ALLERGIC RHINITIS

Women who have allergic rhinitis before pregnancy may have worsening, improvement, or no change intheir symptoms during pregnancy. Most women notice some nasal congestion in the later stages of
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pregnancy, even if they did not have rhinitis before. This is called rhinitis of pregnancy, and is related tohormone levels. Rhinitis of pregnancy does not respond to medications and goes away after delivery. Thediscussion below applies only to allergic rhinitis.

As a general rule, medications should be avoided or used at the lowest dose that controls symptomsduring pregnancy. A woman should always review any medication (over-the-counter or prescription)before taking it during pregnancy. However, several of the drugs used to treat allergic rhinitis are thought

to be safe.

Saline sprays and nasal irrigation Women with mild rhinitis may be able to control symptomsusing only saline nasal sprays or irrigation, which do not contain any medications. (See'Nasalirrigation and saline sprays'above.)

If medication for rhinitis is needed during pregnancy, the following are considered to be safer choices:

Nasal sprays Certain nasal sprays are a sensible option for pregnant women, because muchless drug is required to control symptoms when it is sprayed directly into the nose, compared totaking that same medication by mouth.

Cromolyn nasal sprays are safe for use during pregnancy. Only a very small amount of drugis absorbed into the blood stream with this medication and no serious side effects are knownto occur. (See'Cromolyn sodium'above.)

Nasal glucocorticoids are considered safe for use in pregnancy, and women who are alreadytaking these can simply continue during pregnancy (table 1). Although no safety differences havebeen identified among the different nasal glucocorticoids, budesonide (Rhinocort Aqua) hasbeen approved for use in pregnancy for a longer time than the others. (See'Nasalglucocorticoids'above.)

Antihistamines Chlorpheniramine (Chlor-Trimeton and others), loratadine (Claritin), orcetirizine (Zyrtec) are the antihistamines of choice during pregnancy.

Decongestants Pseudoephedrine should be avoided during the first trimester of pregnancy ifpossible, because its safety has not been confirmed. After the first trimester, it should be usedonly when needed and only as directed. However, it should not be used at all by women with highblood pressure or pre-eclampsia. Phenylephrine should be avoided altogether during pregnancy.

Allergy shots Women already taking allergy shots who have not had allergic reactions to theshots in the past may safely continue treatment through pregnancy. However, the dose shouldnot be increased during pregnancy due to the risk of a serious allergic reaction (anaphylaxis),which could potentially reduce the blood supply to the fetus. For the same reason, allergy shotsare not started during pregnancy.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to yourmedical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics forpatients, as well as selected articles written for healthcare professionals, are also available. Some of themost relevant are listed below.

Patient level informationUpToDate offers two types of patient education materials.

The BasicsThe Basics patient education pieces answer the four or five key questions a patient might

have about a given condition. These articles are best for patients who want a general overview and whoprefer short, easy-to-read materials.
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Patient information: Seasonal allergies in adults (The Basics) Patient information: Giving your child over-the-counter medicines (The Basics)Patient information: Allergy shots (The Basics)Patient information: Allergy skin testing (The Basics)Patient information: Rinsing out your nose with salt water (The Basics)Patient information: Seasonal allergies in children (The Basics)

Beyond the BasicsBeyond the Basics patient education pieces are longer, more sophisticated, andmore detailed. These articles are best for patients who want in-depth information and are comfortablewith some medical jargon.

Patient information: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)Patient information: Allergic conjunctivitis (Beyond the Basics)Patient information: Trigger avoidance in allergic rhinitis (Beyond the Basics)Patient information: Benign prostatic hyperplasia (BPH) (Beyond the Basics)

Professional level informationProfessional level articles are designed to keep doctors and otherhealth professionals up-to-date on the latest medical findings. These articles are thorough, long, andcomplex, and they contain multiple references to the research on which they are based. Professionallevel articles are best for people who are comfortable with a lot of medical terminology and who want toread the same materials their doctors are reading.

Allergen avoidance in the treatment of asthma and allergic rhinitisAn overview of rhinitisChronic nonallergic rhinitisClinical manifestations, pathophysiology, and diagnosis of chronic rhinosinusitisAllergic rhinitis: Clinical manifestations, epidemiology, and diagnosisOccupational rhinitisPathogenesis of allergic rhinitis (rhinosinusitis)Pharmacotherapy of allergic rhinitis

The following organizations also provide reliable health information.

National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html) Allergy, Asthma, and Immunology Online

(www.acaai.org/public/advice/rhin.htm) American Academy of Allergy, Asthma, and Immunology

(www.aaaai.org/patients/publicedmat/tips/rhinitis.stm)

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NONALLERGIC RHINITIS CAUSES

The cause of nonallergic rhinitis is not usually known. However, many triggers of symptoms are known,and include tobacco smoke, traffic fumes, or strong odors and perfumes. People with nonallergic rhinitis
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are not bothered by pollen or furred animals (the common triggers in allergic rhinitis), although about one-half of people with this condition also have allergic rhinitis. (See"Patient information: Allergic rhinitis(seasonal allergies) (Beyond the Basics)".)

NONALLERGIC RHINITIS TREATMENT

Treatment of nonallergic rhinitis includes trigger avoidance, medications, and/or nasal rinsing or irrigation.

Trigger avoidanceExposure to tobacco smoke can be reduced if household members stop smokingor smoke only outside of the home. It is also important to avoid smoke exposure in the workplace.

Exposure to pollutants and irritants can be reduced by avoiding wood-burning stoves and fireplaces;properly venting other stoves and heaters; and avoiding cleaning agents and household sprays thattrigger symptoms.

Exposure to strong perfumes and scented products may be more difficult. People who are bothered bythese items should avoid using them and may need to request that coworkers, family, or friends do thesame. Some workplaces have policies regarding the use of strongly scented personal products.

Nasal rinsing and irrigationSimply rinsing the nose with a salt water (saline) solution one or moretimes a day is helpful for many patients with nonallergic rhinitis, as well as for other rhinitis conditions.Nasal rinsing is particularly useful for symptoms of postnasal drainage. Nasal rinsing can be done beforeuse of nasal medication so that the lining is freshly cleansed when the medication is applied.

The nose can be rinsed with small amounts of saline by using over-the-counter saline nasal sprays, orwith larger amounts of saline. The latter technique is called nasal irrigation or nasal lavage. Nasal spraysare easy to use but do not rinse the nasal passages as thoroughly as nasal irrigation. However, nasalirritation is less convenient and takes more time.

A variety of devices, including bulb syringes, irrigation pots (which look like small kettles), and bottlesprayers, may be used to perform nasal irrigation; instructions for the technique are provided in the table

(table 1). At least 200 mL (about 3/4 cup) of fluid is recommended for each nostril. Patients can maketheir own solution or buy commercially-prepared solutions. All are available without a prescription.

Nasal irrigation with warmed saline can be performed as needed, once per day, or twice daily forincreased symptoms. Nasal irrigation carries few risks when performed correctly. Very rare braininfections have been reported from the use of water that was not sterile.

Medications that worsen symptomsCertain medications can cause or worsen nasal symptoms(especially congestion). These include the following: birth control pills, some drugs for high bloodpressure (eg, alpha blockers and beta blockers), antidepressants, medications for erectile dysfunction,and some medications for prostatic enlargement. If rhinitis symptoms are bothersome and one of thesemedications is used, ask the prescriber if the medication could be aggravating the condition.

Nonallergic rhinitis medicationsDaily use of a nasal glucocorticoid and/or an antihistamine nasalspray can be helpful for people with nonallergic rhinitis. These medications may be used alone or incombination.

Nasal antihistaminesA prescription nasal antihistamine spray, such as azelastine (eg, Astelin,Astepro), can relieve symptoms of postnasal drip, congestion, and sneezing. These sprays start to workwithin minutes after use and can be used to treat symptoms after they develop. However, they are mosteffective when used on a regular basis.

The most common side effect of nasal antihistamines is a bad taste in the mouth immediately after use.This can be minimized by keeping the head tilted forward while spraying, to prevent the medicine fromdraining down the throat. The usual dose of azelastine is two sprays in each nostril twice per day.

Nasal glucocorticoidsA nasal glucocorticoid, fluticasone (eg, Flonase, generic equivalents), hasbeen shown to be effective for symptoms of nonallergic rhinitis. The dose is one squirt in each nostril
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twice per day. Other glucocorticoid nasal sprays may also be effective, although these have not beendirectly studied in people with nonallergic rhinitis.

Some symptom rel

allergic rhinitis is a

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