Allergic Rhinitis

Overview

This Guidelines summary of NICE's Clinical Knowledge Summary (CKS) on allergic rhinitis includes definition, diagnosis, assessment, differential diagnosis, and management of allergic rhinitis. Please refer to the full CKS for the complete set of recommendations.

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What Is It?

• Allergic rhinitis is an IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitized to allergens.
  • Rhinitis describes inflammation of the nasal mucosa, which causes typical clinical symptoms of sneezing, nasal discharge (rhinorrhoea), itching, and congestion. 
  • Rhinitis may be allergic, non-allergic, infective, or mixed. 
  • Where the sinuses are also involved, the condition is known as rhinosinusitis. 
  • When the eyes are also involved, the term rhinoconjunctivitis is used. 
  • Allergic rhinitis is mediated by the antibody IgE. Allergens; such as pollens, house dust mites, mould, or pet dander, trigger an abnormal IgE reaction in the nasal mucosa, triggering the release of histamine and other inflammatory mediators, which act on cells, nerve endings, and blood vessels to produce typical symptoms of rhinitis described above. 
• Allergic rhinitis may be classified according to duration and severity. 
  • Duration: 
    • Intermittent—Symptoms are present less than four days a week or for less than four weeks. 
    • Persistent—Symptoms are present at least four days a week and for at least four weeks. 
  • Severity—depending on the impact of the condition on sleep and daily activities. 
    • Mild—No disturbance of sleep or daily living activities. 
    • Moderate to severe—Sleep and/or daily living activities affected (sleep disturbance, impairment of school, work, leisure or sport, or otherwise troublesome symptoms.) 
• Allergic rhinitis can also be classified as seasonal or perennial. This may be inconsistent, however, and clinically it may be more useful to use the intermittent or persistent classification above. 
  • Seasonal rhinitis—Symptoms occur at the same time each year in response to a seasonal allergen. When triggered by grass or tree pollen, it is also known as 'hay fever' and most typically occurs in summer months, although, depending on the pollen, it may occur at other times of the year. It is usually accompanied by allergic conjunctivitis. 
  • Perennial rhinitis—Symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander. Symptoms will vary with the environment, however. 
• Occupational rhinitis describes rhinitis mediated by airborne substances in the work environment, and may be either allergic or non-allergic. 

When Should I Suspect Allergic Rhinitis?

• Suspect a diagnosis of allergic rhinitis if alternative causes for rhinitis have been excluded, and a person presents with typical clinical features:
  • Classic symptoms of sneezing, nasal itching, nasal discharge (rhinorrhoea), and nasal congestion—bilateral symptoms typically develop within minutes following allergen exposure.
  • Additional symptoms such as postnasal drip, itching of the palate, and cough, and features suggestive of chronic nasal congestion, such as snoring, mouth breathing, and halitosis.
  • Associated eye symptoms such as bilateral itching, redness, and tearing.
  • A personal or family history of atopy (asthma, eczema, or allergic rhinitis).
  • Symptoms that occur following exposure to a known causative allergen, such as:
    • Tree pollens—intermittent or chronic symptoms occur from early to late spring.
    • Grass pollens—intermittent or chronic symptoms occur from late spring to early summer.
    • Weed pollens—intermittent or chronic symptoms may occur from early spring to early autumn.
    • House dust mites—symptoms are worse on waking and are present all year-round, but may peak in autumn and spring.
    • Animal dander—symptoms follow exposure to animal dander, and may be all year-round or occasional, depending on exposure.
    • Occupational—intermittent or chronic symptoms tend to improve when the person is away from work, such as weekends and holidays.
  • Note: be aware that allergic and irritant rhinitis may co-exist, as chemical irritants may aggravate underlying allergic rhinitis.

How Should I Assess a Person with Suspected Allergic Rhinitis?

• Ask about:
  • The type, timing, frequency, persistence, and location of symptoms (indoors or outdoors). Ask whether symptoms are unilateral or bilateral. (Unilateral symptoms are more likely to be due to another cause of blockage, such as polyps, foreign body, carcinoma, or cerebrospinal fluid leak.)
  • The severity of symptoms and impact on the person's quality of life, including sleep, concentration, mood, behaviour, fatigue, and its impact on leisure activities, school, and work.
  • Housing conditions, pets, and occupation, to identify possible causative triggers and allergens.
    • Occupational history should include the nature of the job; duration of employment before symptoms developed; agents exposed to at work; and whether symptoms improve when the person is away from work such as weekends and holidays.
    • Note: people may be allergic to one or more allergens.
  • Symptoms that could suggest an alternative diagnosis. (These include unilateral symptoms, discoloured nasal discharge, recurrent nosebleeds, facial or nasal pain, or loss of sense of smell. Also, children under the age of 2 with continuous symptoms of rhinitis).
  • Symptoms suggesting associated conditions such as allergic conjunctivitis, asthma, eczema, sinusitis, and obstructive slee apnoea syndrome and manage accordingly.
    • Be aware that respiratory symptoms such as cough, wheeze, and breathlessness may be solely due to rhinitis rather than asthma, as bronchial hyper-reactivity may be induced by upper airway inflammation.
  • Medication history: Any drugs that may cause or aggravate symptoms; previous treatments and their effectiveness, including over-the-counter treatments such as antihistamines and intranasal corticosteroids.
  • Any family history of atopy.
• Examine for signs and underlying causes of rhinitis, and/or associated conditions:
  • Nasal intonation of the voice.
  • Mouth-breathing.
  • Darkened eye shadows under the lower eyelid due to chronic congestion (so-called 'allergic shiners').
  • Horizontal nasal crease across the dorsum of the nose (seen in severe rhinitis).
  • Deviated or perforated nasal septum and depressed or widened nasal bridge.
  • Nasal mucosa swelling and greyish discolouration with excessive clear secretions (typically seen in allergic rhinitis); nasal polyps (rare in children); hypertrophic nasal turbinates (suggests inflammation); and foreign bodies.
  • Purulent nasal discharge suggesting sinusitis.
  • Eye involvement suggesting allergic conjunctivitis.
  • Note: the nasal appearance may be normal in people with allergic rhinitis.
  • Growth should be assessed in children. (Severe airway disease may impact growth, as may the use of corticosteroids at multiple sites.) Measure height on presentation, in order to be able to monitor this, particularly children already on or starting corticosteroids in any form. 
• Allergic rhinitis can usually be diagnosed from the clinical history, supported by nasal examination and a response to first line treatment. Further investigations are usually only required if the allergen causing the symptoms can be avoided (as these measures can be problematic), if there are elements in the history or examination leading to diagnostic doubt, or if there is a lack of response to treatment. 

Investigations

• A therapeutic trial of first-line treatment may be considered as the first investigation or diagnostic tool when the history is typical. 
• Specialist allergy testing may involve skin prick testing or measuring the levels of serum-specific immunoglobulin E (IgE) to allergens such as house dust mites, pollen, and animal dander (radioallergosorbent test [RAST]). 
  • Skin prick testing may help to differentiate between allergic and non-allergic rhinitis, and has a high negative predictive value. It has a better positive predictive value than serum testing, and provides immediate results. However, results may be suppressed by recent antihistamine, tricyclic antidepressant (TCA), and topical corticosteroid use. Up to 15% of people with a positive skin prick test do not develop symptoms on exposure to the relevant allergen, and therefore positive tests alone do not confirm the causative allergen in the absence of a supportive history. 
  • Serum IgE testing may be used when skin prick testing is not possible or provides equivocal results. IgE levels do not necessarily relate to the degree of clinical reaction. 
• Other specialist investigations may be required where there is diagnostic doubt or failure to respond to treatment, such as: 
  • Nasal endoscopy. 
  • Nasal allergen challenge. 
  • Evaluation of nasal nitric oxide and ciliary beat frequency. 
  • Analysis of nasal fluid. 
  • CT scans. 

What Else Might It Be?

• Infective rhinitis
  • Symptoms have a typical onset of one week or less, with typical features of an associated viral upper respiratory tract infection, such as cough, fever, or lymphadenopathy. If nasal discharge is clear, infection is less likely.
• Non-allergic rhinitis
  • Autonomic or irritant rhinitis
    • Symptoms typically follow a known physical exposure (changes in temperature or humidity, or with exercise) or chemical irritant exposure (volatile chemicals such as perfumes, tobacco smoke, and odours). These triggers cause nasal airway hyper-reactivity through a non-IgE mediated pathway.
  • Drugs
    • A number of drugs may cause or aggravate rhinitis symptoms, such as alpha-blockers, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, chlorpromazine, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), phosphodiesterase inhibitors, and cocaine.
    • Rebound symptoms and a paradoxical increase in nasal congestion may occur when stopping prolonged treatment with intranasal decongestants due to rebound vasodilatation (so-called 'rhinitis medicamentosa').
  • Endocrine
    • Hormonal rhinitis should be considered when symptoms coincide with pregnancy, starting the oral contraceptive pill, hormone replacement therapy (HRT), or hypothyroidism.
  • Food and drink
    • Alcohol, sulphites, and spicy foods may cause rhinorrhoea and facial flushing.
  • Non-allergic rhinitis with eosinophilia syndrome (NARES)
    • This rare condition is a diagnosis of exclusion characterized by nasal eosinophils in people with perennial symptoms, and sometimes reduced sense of smell.
    • 50% of people develop aspirin-sensitive disease with asthma and nasal polyposis later in life.
    • NARES is a risk factor for developing or exacerbating obstructive sleep apnoea.
  • Occupational rhinitis 
    • Occupational rhinitis may be allergic or non-allergic, and is due to a cause in a particular work environment. 
    • Non-allergic causes include perfumes, smoke, formaldehyde, ammonia, and acids causing irritation or having corrosive effects. 
    • Examples of allergic causes are flour, animals, latex, animal-related allergens, fish, and biological enzymes. 
  • Systemic
    • May be caused by primary defects in mucus production (for example, cystic fibrosis), primary ciliary dyskinesia (Kartagener syndrome), and granulomatous disease (for example, granulomatotis with polyangitis [previously known as Wegener's granulomatosis] and sarcoidosis).
  • Structural
    • Typically caused by deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy, foreign body, or cerebrospinal fluid (CSF) leak (rare).
    • Sinonasal tumour (rare) should be excluded if there are unilateral symptoms, recurrent bloody nasal discharge or nosebleeds, nasal pain, anosmia, or visual disturbance.
    • Aging may cause morphological and functional changes in the nose, which may cause symptoms of rhinitis in older people.

What Self-management Strategies Should I Advise?

If a person has a diagnosis of allergic rhinitis:

• Provide advice on sources of information and support, such as:
  • The Allergy UK factsheets on Hay fever (Allergic Rhinitis) and Improving your indoor air quality. 
  • The NHS patient information leaflets Allergic rhinitis and Hay fever.
  • The patient information leaflet Hay Fever and Seasonal Allergies available on the www.patient.info website.
• Advise the person to consider the use of nasal irrigation with saline to rinse the nasal cavity using a spray, pump, or squirt bottle, which can be purchased over-the-counter.
• Provide advice on allergen avoidance techniques if there is a specific identified causative allergen:
  • For people with pollen allergy, advise to:
    • Avoid walking in grassy, open spaces, particularly during the early morning, early evening, and during mowing, when the pollen count is high.
    • Avoid drying washing outdoors when the pollen count is high.
    • Keep windows shut in cars and buildings when the pollen count is high.
    • Plan holidays to avoid the pollen season, where possible.
    • Shower or wash hair following high pollen exposures.
    • Consider the use of sunglasses (ideally wraparound) or nasal barriers (masks covering the nose and mouth or commercially available powders, balms or creams rubbed on the nose) when the pollen count is high. 
    • Consider monitoring the pollen count using a website such as the Met Office so that avoidance measures can be used when pollen counts are high. 
  • For people with confirmed house dust mite allergy following allergy testing, advise to:
    • Not fit mattresses, pillows, and duvets with house dust mite impermeable covers.
    • Use synthetic pillows and acrylic duvets, and keep furry toys off the bed.
    • Wash all bedding and furry toys at least once a week at high temperatures.
    • Choose wooden or hard floor surfaces instead of carpets, if possible.
    • Fit blinds that can be wiped clean instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.
  • For people with confirmed animal allergy following allergy testing, advise to:
    • Ideally not allow the animal in the house. If this is not acceptable or possible, advise restricting their presence to the kitchen.
    • Wash the animal and any surfaces they are in contact with, regularly.
  • For people with occupational allergy, advise to:
    • Avoid exposure to allergen completely where possible.
    • If elimination or complete avoidance of the allergens is not possible, reduce exposure to both known and potentially sensitizing allergens in the workplace, for example, by using latex-free gloves, wearing protective clothing, or a dust mask.
    • Ensure that their work environment is adequately ventilated and/or relocating to lower exposure areas in the workplace.
    • Use less hazardous chemicals, if possible and appropriate.

What Initial Drug Treatments Should I Recommend?

If a person has a diagnosis of allergic rhinitis, advise on self-management strategies and drug treatment options. Most local policies restrict prescribing for seasonal allergic rhinitis and patients are encouraged to buy treatment OTC. Generally, when the condition is long-term (such as perennial rhinitis), treatments available OTC may be prescribed in primary care. 

Advise on or prescribe first-line treatment, considering patient preference, age, severity of symptoms, persistence of symptoms and the following facts:

• First-line treatment options are intranasal corticosteroids and antihistamines (intranasal or non-sedating oral antihistamines), either alone or in combination. 
• Intranasal corticosteroids are the most effective treatment for allergic rhinitis, but patients may prefer oral medication. They may take several hours to several days to become effective. Options include intranasal mometasone furoate, fluticasone furoate, or fluticasone propionate, which have minimal systemic absorption. 
• Intranasal antihistamines (such as azelastine) have the fastest onset of action (within minutes) but are less effective than intranasal corticosteroids. 
• The combination of an intranasal corticosteroid and an oral antihistamine is no more effective than the intranasal corticosteroid on its own. However, the combination of an intranasal corticosteroid with an intranasal antihistamine is more effective than an intranasal corticosteroid on its own. 
• Consider regularly prescribed intranasal corticosteroids for people with moderate to severe, persistent allergic rhinitis. 

• In children, suggest an antihistamine (intranasal or oral non-sedating antihistamine).
• In adolescents and adults, any first-line treatment may be offered. (Intranasal or oral non-sedating antihistamine, or intranasal corticosteroid, or a combination of nasal corticosteroid with oral or intranasal antihistamine.)

• Suggest an intranasal corticosteroid or the combination of an intranasal corticosteroid with an intranasal antihistamine.
  • Advise the person that the onset of action for intranasal corticosteroids is 6–8 hours after the first dose, but the maximal effect may not be seen until after two weeks.
  • Nasal drops may be preferred if there is severe nasal obstruction.
  • Advise the person not to increase beyond the prescribed dose as there is no evidence of additional benefit, and do not switch to an alternative preparation as they all have comparable efficacy.
• If symptoms are intermittent and there is no ongoing allergen exposure, step down treatment and stop, but if symptoms are persistent or there is ongoing exposure then continue treatment or step up if not controlled.
  • If drug treatment provides adequate symptom control, advise the person to continue treatment until they are no longer likely to be exposed to the suspected allergen. For people allergic to:
    • House dust mite and/or pets in the home—symptoms are usually present throughout the year, requiring ongoing treatment.
    • Tree pollens—treatment is usually required from early to late spring.
    • Grass pollens—treatment is usually required from late spring to early summer.
    • Weed pollens—treatment is usually required from early spring to late autumn.
      • If there are recurrent episodes of symptoms controlled by intranasal corticosteroids, advise the person to restart treatment two weeks before re-exposure to causative allergens.
      • If the time of re-exposure is uncertain, such as the start of the pollination season, advise the person to start treatment several weeks before the most likely time of re-exposure.
  • Advise the person to be reviewed after 2–4 weeks if symptoms persist after initial treatment, as management may need to be stepped up.

• Advise or prescribe antihistamine eye drops or chromone eye drops (sodium cromoglycate, nedocromil).

How Should I Manage Treatment Failure?

Editor's note: as some treatments in this section are prescription-only medicines, referral to a prescriber may be required.

If a person has uncontrolled symptoms following initial self-management strategies and drug treatment:

• Consider causes for treatment failure.
  • Check compliance with self-management strategies, if appropriate.
  • Check compliance with initial drug treatments and/or the correct technique when using intranasal sprays or drops.
  • An alternative diagnosis or non-allergic cause for symptoms.
• Consider stepping up treatment if a person has refractory symptoms while using a regular intranasal corticosteroid preparation.
  • If sudden or severe nasal congestion is a problem, consider adding in a short-term intranasal decongestant such as xylometazoline for up to 5–7 days, depending on the person's age and preparation used.
  • If there is persistent watery rhinorrhoea despite a combined use of an intranasal corticosteroid and oral antihistamine, add in an intranasal anticholinergic such as ipratropium bromide in adults or young people aged 12 years or older.
  • If there is persistent nasal itching and sneezing, options are to add in an oral antihistamine to be used regularly rather than 'as needed', or to prescribe a combination preparation containing an intranasal antihistamine and an intranasal corticosteroid such as Dymista^® (azelastine and fluticasone propionate) or Ryaltris^® (olopatadine and mometasone)spray, if monotherapy with either an antihistamine or intranasal corticosteroid is ineffective.
    • Note: combined use of an intranasal and oral antihistamine is not recommended.
  • If the person has ongoing symptoms and a history of asthma, consider adding a leukotriene receptor antagonist such as montelukast to an oral or intranasal antihistamine.
  • If an adult has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief, such as: 
    • For adults—prednisolone 0.5 mg/kg in the morning for 5–10 days. 
    • For children—seek advice from a specialist if considering prescribing an oral corticosteroid in this situation. 
• If drug treatment provides adequate symptom control, advise the person to continue treatment until they are no longer likely to be exposed to the suspected allergen. For people allergic to: 
  • House dust mites and/or pets in the home—symptoms are usually present throughout the year, requiring ongoing treatment. 
  • Tree pollens—treatment is usually required from early to late spring. 
  • Grass pollens—treatment is usually required from late spring to early summer. 
  • Weed pollens—treatment is usually required from early spring to late autumn. 
    • If there are recurrent episodes of symptoms controlled by intranasal corticosteroids, advise the person to restart treatment two weeks before re-exposure to causative allergens. 
    • If the time of re-exposure is uncertain, such as the start of the pollination season, advise the person to start treatment several weeks before the most likely time of re-exposure. 
• Consider arranging referral for specialist assessment and management to an allergy or ear, nose, and throat (ENT) specialist if: 
  • There are red flag features such as unilateral symptoms, blood-stained nasal discharge, recurrent epistaxis, or nasal pain—arrange an urgent two-week wait referral to ENT. 
  • There is predominant nasal obstruction and/or a structural abnormality such as deviated nasal septum which makes intranasal drug treatment difficult—arrange referral to ENT. 
  • There are persistent symptoms despite optimal management in primary care—consider referral to an allergy specialist for allergy testing and possible immunotherapy treatment, depending on local referral pathways and availability. 
  • Allergen avoidance techniques such as house dust mite or animal dander avoidance are being considered—skin prick allergy testing to confirm the responsible allergen may be needed. 
  • The person would like to consider specialist immunotherapy treatment rather than take medication long term. 
  • The diagnosis is uncertain—consider referral to an allergy or ENT specialist, depending on clinical judgement. 

For recommendations on immunotherapy treatment, and for prescribing information relating to the drugs discussed in this summary, refer to the full CKS topic.