Allergic Rhinitis

Many seasonal and year round allergens can cause allergic rhinitis, and they can be found both indoors and outdoors. Perennial (year round) symptoms are frequently triggered by allergens that are in the home such as dust mites, cockroaches, mold spores and animal dander.

Seasonal symptoms may be triggered by tree, grass, weed pollen and airborne mold spores.

Some people may experience symptoms year round with worsening during certain pollen seasons. Spring is typically associated with tree pollen allergy. Summer symptoms may be due to grass and weed pollen, with fall symptoms caused by weed pollens. Mold spores may cause symptoms intermittently through the year.

When a sensitive person inhales an allergen (allergy causing substance) such as pollen, the immune system reacts abnormally to the allergen. The allergen can bind to the allergic antibody (IgE) that are attached to a number of cells and this binding of allergen to IgE causes release of chemicals such as histamine and leukotrienes. These cells line the nasal membranes and when they are “triggered” histamine, leukotrienes and other chemicals are released causing the typical symptoms of allergic rhinitis.

Known associations of allergic rhinitis include asthma, acute and chronic sinusitis, headaches, fatigue, cough and recurrent sore throats. Children may develop orthodontic problems and altered facial growth from mouth breathing. Allergy treatment can alleviate the majority of these symptoms.

An allergist-immunologist will begin with a detailed history including asking whether symptoms vary according to time of day, or the season, exposure to pets and dust or other allergens. You may be asked about your work and home environments, and your family medical history. After the medical history a physical exam is performed with special attention to the upper and lower airway. Often, the nasal lining is pale and purplish from engorged veins. Swelling of the eyelids, reddened conjunctivae (the whites of the eyes may be red), allergic shiners (dark areas under the lower eyelids) may be present. The back of the throat may have a cobblestone appearance. Allergy testing is frequently done to reveal specific allergens that one is reacting to. Allergists-immunologist may use skin testing, the easiest, most sensitive and least expensive way of making the diagnosis, and the results are available immediately. In rare cases, it may be necessary to do IgE allergy blood testing for specific allergens.

The goal of treatment is to reduce the allergy symptoms by using avoidance, medication and immunotherapy or allergy shots if the first two are not successful.
Avoidance may be difficult but there are several ways to lessen exposure. Seasonal allergens such as tree, grass and weed pollen are difficult to avoid outdoors but one can remain indoors with the windows closed and air conditioning on. A HEPA (High Efficiency Particulate Air) filter or other filtering unit and frequent a/c filter changes will help filter pollen and mold from indoor air. Automobile air conditioning filters and re-circulating air assist on the drive to and from work. Excessive exposure to outdoor mold spores can be prevented by avoiding lawn mowing, leaf raking and gardening. Outdoor air is most heavily saturated with pollen and mold spores between 5 and 10 am, so outdoor activity during that time should be avoided.

Reducing dust mites in the indoor environment is difficult but measures for dust mite-allergic individuals may include covering mattresses and pillows with dust mite proof plastic covers, washing bedding in hot temperatures and removing carpeting which may act as a reservoir for dust mites and animal dander. Using a mask when cleaning or vacuuming is also recommended.

Medication usage depends on the type and severity of symptoms. Antihistamines have been the main stay of treatment for allergic rhinitis. The first generation antihistamines such as chlorpheniramine and brompheniramine are effective, but their usefulness is limited by their sedation. The newer second generation antihistamines such as loratadine, fexofenadine and cetirizine have less sedation. Some are also available over the counter. Antihistamines may or may not be combined with decongestants, which reduce stuffiness.

Other medications which may be useful in treating allergic rhinitis include nasal sprays. Steroid nasal sprays are safe and effective and counter act the nasal inflammation. Corticosteroids are sometimes injected or taken orally, but usually on a short-term basis for extremely severe symptoms. Cromolyn is also available in a nasal spray over the counter, but is not as effective and must be used frequently for positive results. Topical antihistamine sprays are available by prescription for the acute relief of symptoms. Oral leukotriene receptor antagonists are available by prescription also to control allergic symptoms. Topical decongestant sprays should be avoided except for very short periods of time since their protracted use leads to rebound nasal congestion. Saline spray or nasal irrigation devices (e.g. Sinus Rinse, Netti pot) may alleviate nasal symptoms in some people.

Immunotherapy, known as “allergy shots,” may be recommended for those individuals who don’t respond well to avoidance and medications. Immunotherapy can be very effective in controlling allergic symptoms. It involves giving gradually increasing doses of the allergen to which the person is allergic, making the immune system less sensitive to that substance. With the building of resistance to the effects of the allergen, the intensity of symptoms caused by allergen exposure is reduced. As resistance develops, symptoms will improve. Allergy injections are usually given at variable intervals over a period of three to five years. More treatment options will be available in the near future as more research is taking place.

Another form of allergy immunotherapy has been approved in the United States called sublingual immunotherapy (SLIT) allergy tablets. Rather than shots, allergy tablets involve administering the allergens under the tongue on a daily basis either seasonally or year round. Like shots, tablets reduce symptoms by helping the body build resistance to the effects of an allergen. Unlike shots, tablets only treat one type of allergen and do not prevent the development of new allergies and asthma. FDA-approved SLIT tablets are available to treat allergies to ragweed, grass pollen and dust mites.

Allergy drops are another form of sublingual immunotherapy and work the same way as tablets. Drops are widely accepted and used in many countries around the world, but they have not been FDA approved in the U.S. and their usage is off-label.

There are many ways of treating allergies and each person’s treatment must be individualized based on the frequency, severity, and duration of symptoms. A board certified allergy, asthma and immunology specialist is the best person to consult for evaluation of allergic rhinitis symptoms and can assist in formulating the best plan to alleviate the symptoms which are occurring.