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.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

What Is It?

• Allergic rhinitis is an IgE-mediated inflammatory disorder of the nose which occurs when the nasal mucosa becomes exposed and sensitized to allergens.
  • This triggers the release of histamine and other inflammatory mediators, which act on cells, nerve endings, and blood vessels to produce typical symptoms of sneezing, nasal itching, discharge (rhinorrhoea), and congestion.
• Allergic rhinitis may be classified according to:
  • The timing, frequency, and persistence of symptoms. Note: the seasonal/perennial classification may be less applicable clinically, as symptoms may be triggered by many different allergens, and people may be exposed to different allergens throughout the year.
    • Seasonal—symptoms occur at the same time each year in response to a seasonal allergen. If caused by grass and tree pollen allergens, it is also known as 'hay fever'.
    • Perennial—symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander.
    • Intermittent—symptoms occur for less than four days a week, or less than four consecutive weeks, typically due to allergens such as animal dander.
    • Persistent—symptoms occur for more than four days a week and for more than four consecutive weeks, typically due to allergens such as house dust mites.
  • The severity of symptoms
    • Mild—if symptoms are not troublesome or impacting on quality of life.
    • Moderate or severe—if symptoms are troublesome and impacting on daily activities or sleep.
• Occupational allergic rhinitis describes symptoms in a previously unaffected person, due to exposure to allergens in the work environment, for example, flour allergy in a baker, or bleaching agents and hair dyes in a hairdresser.

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 which 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?

If a diagnosis of allergic rhinitis is suspected, assess the person to help guide appropriate management.

• Ask about:
  • The type, frequency, persistence, and location of symptoms (indoors or outdoors).
  • The severity of symptoms and impact on the person's quality of life, including sleep, concentration, mood, behaviour, and fatigue; 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 suggesting associated conditions such as allergic conjunctivitis, asthma, eczema, and sinusitis, 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.
  • 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.
  • 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; depressed or widened nasal bridge.
  • Nasal mucosa swelling and greyish discolouration (typically seen in allergic rhinitis); nasal polyps (rare in children); hypertrophic nasal turbinates (suggests inflammation); foreign bodies.
  • Purulent nasal discharge suggesting sinusitis.
  • Eye involvement suggesting allergic conjunctivitis.
  • Note: the nasal appearance may be normal in people with allergic rhinitis.

What Else Might it Be?

Alternative causes for rhinitis may include:

• Infective rhinitis
  • There is an acute onset of symptoms 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), 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 occasionally reduced sense of smell.
    • 50% of people develop aspirin-sensitive disease with asthma and nasal polyposis later in life.
  • 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), for example.
    • Sinonasal tumour (rare) should be excluded if there are unilateral symptoms, recurrent bloody nasal discharge or nosebleeds, nasal pain, anosmia, or visual disturbance.

What Self-management Strategies Should I Advise?

From age 24 months onwards.

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 bought over-the-counter.
• Provide advice on allergen avoidance techniques if there is a specific identified causative allergen.
  • For people with grass 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.
    • Plan holidays to avoid the pollen season, where possible.
    • Shower or wash hair following high pollen exposures.
  • 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:
    • Eliminate or reduce exposure to 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?

From age 24 months onwards.

If a person has a diagnosis of allergic rhinitis, advise on self-management strategies and drug treatment options:

• If the person has mild-to-moderate intermittent, or mild persistent symptoms:
  • Advise on the 'as-needed' use of an intranasal antihistamine first-line, or a second generation, non-sedating oral antihistamine, depending on the person's age and personal preference.
    • Advise that intranasal antihistamines (azelastine) have a faster onset of action and are more effective than oral preparations.
    • Oral antihistamine options include loratadine or cetirizine, which may be available over-the-counter.
  • Consider the use of an intranasal chromone such as sodium cromoglicate to be used 'as needed', if antihistamines are contraindicated or not tolerated.
    • Advise that these preparations need to be used up to four times a day.
• If the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective:
  • Prescribe a regular intranasal corticosteroid to be used during periods of allergen exposure.
    • Options include intranasal mometasone furoate, fluticasone furoate, or fluticasone propionate.
    • Advise the person that the onset of action 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 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.

For further information on management, including allergy testing, refer to the full Clinical Knowledge Summary.

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 nasal congestion is a problem, add in a short-term intranasal decongestant such as ephedrine or xylometazoline for up to 5–7 days, depending on the person's age and preparation used.
  • If there is persistent watery rhinorrhoea despite combined use of an intranasal corticosteroid and oral antihistamine, add in an intranasal anticholinergic such as ipratropium bromide.
  • 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 (azelastine) and intranasal corticosteroid (fluticasone propionate) such as Dymista^® 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 in a leukotriene receptor antagonist such as montelukast to an oral or intranasal antihistamine.
• If the person has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief.