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Hay Fever and Allergic Rhinitis

Rhinitis is inflammation of the nose, which is recognised by symptoms such as sneezing, runny nose, blocked / stuffy nose, itching and 'post-nasal drip' (the sensation of 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.


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Allergic rhinitis

is caused when the body makes allergic antibodies (IgE) to a substance such as pollen, house dust mites, cat, dog or moulds (these are known as allergens). In people sensitive to these allergens, exposure causes the release of chemicals from cells in the nasal passages, eyes or airways. This results in 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–June for trees; April to September for weeds; peak time September and October for moulds, although present most of the year). The patient who is allergic to tree, grass and weed pollens may suffer a very prolonged 'hay fever' 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 response to exposure of an allergen the body’s 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 children’s school exam results.

People who suffer rhinitis are at increased risk of developing asthma. Inflammation at the entrance to the airway (the nose) often affects the rest of the airway the bronchial tubes), and this has led to the 'one airway' approach to treatment.   Many asthmatics also suffer rhinitis and their asthma is better controlled and they have and less A&E and hospital admissions if their rhinitis is treated effectively.

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Pollen–food allergy or Oral allergy Syndrome

Some people with an allergy to pollens (especially 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, vegetables or tree nuts, especially raw, they get an itchy mouth or throat. See our factsheet Oral Allergy Syndrome for more details.

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Management

Rhinitis can be managed by:

1.      Avoidance of the allergic trigger (pollens, moulds, house dust mite etc.)

Allergen avoidance is difficult for people with allergy to substances in the air, such as pollen. For example, tiny pollen spores are windborne and travel for miles on air currents. However, many people do benefit from allergen avoidance to house dust mite and pets, while some simple measures, such as the use of a pollen barrier balm around the nostrils, can help to prevent allergens entering the nose. Nasal rinses with a normal saline solution are available to wash away allergens even for babies.  These can be used as frequently as required and in conjunction with prescribed or over-the-counter medications.

See Avoiding Respiratory Allergens for more information.

2. Treatments that suppress the symptoms of rhinitis

Antihistamines suppress the body’s release of histamine, triggering the initial symptoms of rhinitis. They are available as tablets (liquids are available for children) although antihistamine nasal sprays are also available. There are a large range of antihistamines; the recommended ones are mostly taken once daily and do not cause drowsiness in most people. This form of treatment can be all that is needed if symptoms are mild and is most effective for sneezing or an itching and runny nose, but not for a blocked nose. If the first antihistamine you try is not helping, switch to another after discussing with your GP.

If your symptoms persist, the regular use of a steroid nasal-spray to treat the inflammation is required, 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. Ideally nasal sprays should be started a week or two before your symptoms usually start to give the best effect. For moderate to severe symptoms, a spray that contains steroid plus antihistamine can now be prescribed by your GP.

Cromoglycate nasal sprays are useful alternatives to antihistamines in some people.  It is essential to use nasal sprays correctly.  Refer to the instructions with the spray.

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

Nasal sprays that contain decongestants may be useful on the worst days or for additional relief of congestion for an exam or special occasion but should not be used regularly because after a few days use, they can make symptoms worse. In addition to proper treatment, proprietary non-drug solutions that douche or wash-out mucus from blocked noses and sinuses give temporary relief.

Antihistamines and steroid nasal sprays often control eye symptoms as well, but eye drops are available over-the-counter or on prescription if needed. Cromoglycate drops are often effective but your GP can prescribe more effective drops for severe allergic eye symptoms.

All rhinitis treatments should be taken regularly as it is more difficult to control symptoms that are already well established. Only taking medications occasionally on the worst days is much less effective and you should aim to start using the preventative / treatment nasal sprays two weeks before your symptoms usually begin.

3. Treatments that alter the immune system response to the allergen

Specific immunotherapy (sometimes referred to as desensitisation) is a treatment for those with very severe allergic rhinitis despite correct use of all prescribed drugs.  The allergic person is given increasing doses of allergen frequently until a maintenance dose is reached. A maintence dose is then given regularly for a certain period.  It can be a very successful treatment for severe allergic rhinitis, as it causes the body to develop ‘regulatory’ immune cells which control the allergic reaction and results in tolerance to the allergen.  It has been used for many decades but must be prescribed and controlled by hospital allergy specialist. Immunotherapy is available in two main forms, either as injections, or as drops or 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 pollens, house dust mite and animal allergens and bee and wasp venom. Sublingual immunotherapy is currently restricted to dust mite, pollen and some pet allergens.

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 immunotherapy you will need to be referred to a specialist allergy clinic by your GP.

For more information, see our factsheet Immunotherapy.

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Allergy testing

Allergy testing is not usually required in simple hay fever 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 used by the doctor or nurse to help confirm the diagnosis.

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

 

Last updated: December 2013                    Next review date: December 2015
 
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