Hayfever and Rhinitis

What is it?

Rhinitis is inflammation of the nose, which is recognized by symptoms such as sneezing, runny nose, blocked / stuffy nose, itching and 'post-nasal drip' (mucus running down the back of the throat). It can occur in association with inflammation of the eyes or sinuses.

Rhinitis can have several causes, such as infection, a reaction to medication, irritation by dusts, or allergy. Allergic rhinitis is caused when the body mistakenly makes allergic antibody (IgE) to a substance such as pollen, housedust mites, cat, dog or moulds. These substances which trigger allergic reactrions are called allergens. The result of this reaction is the release of chemicals from cells in the nasal passages, eyes or airways which causes inflammation and irritation to the lining of the eyes, nose and throat.

Grass pollen is the most common allergen, which affects sufferers at the specific times of the year when grass pollen is released (May - July). However some people become allergic to tree or weed and shrub pollens, and will therefore be affected at different times of the year (February to June for trees; September and October for weeds). The patient who is allergic to tree, grass and weed pollens may suffer a very prolonged 'hayfever' season. Rhinitis which occurs for only part of the year in this way is called seasonal allergic rhinitis.

Symptoms that continue all year are called perennial allergic rhinitis and commonly relate to indoor allergens, such as house dust mites, pets and indoor moulds.

Symptoms

In an attempt to rid the body of allergens the immune system overreacts and releases chemicals (mediators) which cause inflammation. Some of these mediators (e.g. histamine) work quickly, causing sneezing, itching and runny nose. The eyes may also be affected, with itching, redness and watering (allergic conjunctivitis). Other mediators work more slowly, causing a blocked or stuffy nose, which may lead to headache and difficulty sleeping.

Rhinitis is often regarded as a trivial problem but studies have shown that it severely affects people's quality of life. It disturbs sleep, impairs daytime concentration and the ability to carry out tasks, causes people to miss work or school, and has been shown to affect pupil's school exam results.

People who suffer rhinitis are at increased risk of developing asthma. Inflammation at one end of the airway (the nose) often spreads to the other end (the lungs), as this has led to the 'one airway' approach to treatment. Asthmatics who also suffer rhinitis have less severe asthma and less A&E and hospital admissions if their rhinitis is treated effectively.

Pollen - food allergy

Some people with pollen allergy (especially allergy to tree pollens) may be affected by cross-reactions between their pollen allergy and certain foods. For example, they may find that when eating certain fruits and vegetables, especially raw, they get an itchy mouth or throat. Rarely, these symptoms can be more serious. See our factsheet Oral Allergy Syndrome for more details.

Management

Rhinitis can be managed by:

• avoidance of the allergic trigger (pollens, moulds, housedust mite etc);
• treatments that suppress the symptoms; and
• treatments that try to alter the immune system response to the allergen

Allergen avoidance is difficult for pollen allergy as the tiny pollen spores are windborne and travel for miles on air currents. However the following measures can be helpful:

• Monitor pollen forecasts daily and stay indoors wherever possible when the count is high (generally on warmer, dry days). Rain washes pollen from the air so counts should be lower on cooler, wet days
• Limit outdoor trips to rural areas. Sea breezes blow pollen inland, so escape to the sea instead.
• If you go out, shower and wash your hair on return, and change your clothing before coming back into the living room or bedroom.
• Keep windows closed when indoors and overnight whilst you are sleeping. This is most important in the early mornings, when pollen is being released, and in the evening when the air cools and pollens that have been carried up into the air begin to fall to ground level again.
• If you suffer symptoms indoors, a good air filter should help. Choose one that is proven to trap even small particles (see the Allergy UK website for lists of approved air filters).
• Avoid mowing lawns or raking leaves. If you must perform these tasks, use a face mask.
• Wear wraparound sunglasses when outdoors to keep allergens out of your eyes.
• Avoid line-drying clothes and bedding when pollen counts are high.
• Pollen counts tend to be high along roads with grass verges (dual-carriageways, motorways). Keep car windows closed and the air intake on 're-circulate' when driving. Choose a car that is fitted with an effective pollen filter, or get an in-car air filter.
• Apply Vaseline around the edge of each nostril. Gel nasal sprays are sometimes helpful; they act as a barrier to trap pollens.
• Choose hypo-allergenic eye make-up, especially mascara.
• Don't let pets get close to your face as they can carry pollen in their fur.
• Use goggles when swimming, whether in the sea or in a pool.

For allergen avoidance advice relating to indoor allergens such as housedust mite and pets, see our fact sheet Avoiding Indoor Allergens.

Treatments

The first main treatment is an antihistamine; usually in tablet form (liquids are available for children) although antihistamine nasal sprays are also available. There are a large range of antihistamines; the newer ones are mostly taken once daily and do not cause drowsiness in most people. This form of treatment can be all that is needed in some people and is most effective for an itching, sneezing and runny nose but less so for a blocked nose. Different antihistamines suit different people so if the first one you try is not helping, switch to another.

If your symptoms persist or are more severe, the regular use of a steroid nasal-spray is often effective in relieving symptoms, especially if a blocked nose is a problem. These are available from pharmacists or on prescription from your GP. As with antihistamines, there are different types of steroid nasal spray and you may need to try more than one to find the best solution.

Cromoglicate nasal sprays are a useful alternative to antihistamines in some people.

Additional drugs are available on prescription for people who suffer seasonal asthma as well as hayfever symptoms.

Nasal sprays that contain decongestants may be useful on the worst days but should not be used regularly.

Antihistamines and steroid nasal sprays often control eye symptoms as well, but eye drops are available over-the-counter or on prescription if needed. Cromoglicate drops are often effective.

All rhinitis treatments should be taken regularly, starting shortly before your symptoms normally begin. It is more difficult to control symptoms that are already well established. Only taking medications occasionally on the worst days is much less effective.

Desensitization (Immunotherapy)

Desensitization is available in two main forms, either as injections or as a tablet which dissolves under the tongue (sublingual therapy). To date, the most effective treatment is a course of injection immunotherapy, which can have long lasting benefits. Injection therapy is available for allergy to grass pollens, tree pollens, housedust mite allergy and allergy to pets. The tablet form of immunotherapy is currently only available for grass pollen allergy.

As immunotherapy is so intensive and time consuming, it is only those with extreme symptoms uncontrolled by normal medications, who receive this therapy. In order to be considered for desensitization you will need to be referred to a specialist allergy clinic by your GP.

Testing

Allergy testing is not usually required in simple hayfever because the trigger substances can be easily identified from the history of when and where symptoms occur. However in certain cases a skin prick test or blood test might be of some value.

If anything in these instructions is unclear, ask your physician for help or advice, or call the Allergy UK Helpline on 01322 619 898 (9am to 5pm Monday to Friday).

Updated 4/2009