Clinical Focus

Allergic rhinitis:
assessment and treatment
Steve Holmes and Jane Scullion
What is rhinitis and allergic rhinitis?

Abstract
Allergic rhinitis is a very common condition presenting in primary
care in the UK, especially in our population of patients with asthma.
The impact of allergic rhinitis is often underestimated, with evidence
that it can affect performance at work and school, including other
aspects of life. This article describes the important aspects of history,
examination, investigations and differential diagnoses, as well as
looking into the common causes of allergic rhinitis. The article also
looks at the common evidence-based treatments and the pitfalls in
therapy. The structure of the article should encourage a more active
approach to those presenting with rhinitis in primary care, and help
encourage a more accurate diagnosis.

n clinical practice we are often faced with people who

present with symptoms of allergic rhinitis. Sometimes
this is as a consequence of another presenting problem,
such as asthma, and sometimes in its own right.
Certainly, as the hay fever season begins in the UK, this
is certainly a time to be more aware of nasal symptoms.
Rhinitis significantly reduces quality of life
(Laforest et al, 2005), interferes with school attendance
and school performance (Walker et al, 2007; Van
Cauwenberge et al, 2009), as well as affecting attendance
at work (Cockburn et al, 1999). The overall cost to the
health service is substantial too (Van Cauwenberge
et al, 2009), and with current challenges to the health
service budget, it is even more important we manage
our patients effectively.
This article is based on the British Society for Allergy
and Clinical Immunology (BSACI) guidelines for
the management of allergic and non-allergic rhinitis
(Scadding et al, 2008) and primary care guidelines
(Angier et al, 2010).

Authors: Steve Holmes is a GP in Shepton Mallet,

Somerset; and Jane Scullion is nurse consultant at
Glenfield Hospitals, Leicester
Email: [Link]@[Link]

222

Rhinitis is an inflammation of the mucosa of the

nasal airways, clinically identified by symptoms of
nasal discharge, nasal blockage or congestion, and
at times itching/sneezing. Computed tomography
(CT) scan studies have shown most sufferers will
also have oedema of the sinus linings,which may
present with symptoms of facial pain and congestion
over the affected sinuses (Scadding et al, 2008). This
article classifies rhinitis into allergic, infective, and
non-allergic. For the purposes of this article we will
concentrate the discussion on allergic rhinitis.
The prevalence of allergic rhinitis has been
increasing over the last 30 years and is now thought to
affect at least 20% of the UK population (Maziak et al,
2003).
There are two types of allergic rhinitis: perennial
which occurs throughout the year; and seasonal
which occurs for a period of time every year.

Making a diagnosis

A good clinical history is important, detailing the onset,

duration, and severity of symptoms.
History
Generally, patients will present with sneezing, an itchy
nose, and possibly an itchy palate. These symptoms
may be seasonal (consider pollens or moulds); only
at home (consider pets or house dust mite); or only at
work (consider occupational allergens). Finding out if
symptoms persist during a holiday is useful in trying to
establish a cause. If there is remission during a holiday
then it should help clarify as to what local environment
causes the symptoms.
Nasal discharge
Rhinorrhoea can result in anterior discharge (dribble),
or produce a post-nasal drip. It is often used as a rule of
thumb that clear rhinorrhoea is unlikely to be infective,
and unilateral dribble suggests other causes other than
infective or allergic rhinitis.
Yellow nasal discharge indicates an allergy or
infection, green nasal discharge indicates primarily
infection, and blood tinged nasal discharge indicates
infection or potentially, other causes.
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Clinical Focus
Nasal obstruction
If the obstruction is persistent and unilateral then
a tumour or foreign bodies should be considered,
although usual septal deviation is the cause. Bilateral
obstruction may be septal, but is more often associated
with rhinitis or nasal polyps.
Eye symptoms, such as a gritty sensation, itchy,
irritation, and redness without discharge, are usually
linked with allergic rhinitis (especially seasonal causes).
Symptoms usually settle within 24 hours of removal
from the allergic trigger.
Nasal crusting/snoring are not usually associated
with allergic rhinitis, and if these are severe, other
causes should be considered.
Determining allergic triggers
It is often possible to be clear as to the allergic trigger
entirely from the history. Often no further investigation
or test is required. However, in some cases it can be useful
to confirm the allergen using skin prick testing or specific
IgE blood tests. The availability of these tests can vary
locally. Common allergic triggers are listed in Table1.

Table 1. Common allergic triggers

Many allergic triggers can be aggravated by other factors ([Link],
cold air, sulphur dioxide, glues, and solvents), which will often
aggravate work-placed allergens. The most common are listed below:
Mites: these are house dust mite or storage mites, and are the most
common cause of perennial rhinitis
Pollens: these are mainly seasonal. Although the condition is often
known as hay fever, it is not always hay that is the trigger but can be
caused by trees, other grasses, shrubs and some weeds. There can
be cross-reactivity in that some people are allergic to one pollen and
other similar protein-based allergens
Animals: the allergen in mice and rats is usually excreted in the urine,
hence avoidance of rodent urine can improve symptoms. The allergen
in cats, dogs and horses is in the sebaceous glands and saliva. It is
vital to be really clear about the trigger as advising the removal of
pets may be difficult for some family members (especially if symptoms
do not resolve if the animal is excluded)
Moulds: these include fungi, especially Alternaria, Aspergillus or
Cladosporium
Occupational: asking the patient their occupation is especially
important because with early diagnosis and avoidance the symptoms
can reverse. However, with persistent exposure, the rhinitis can
become irreversible (Patrick et al, 2003). Common allergens are
linked to flour, wood dust, and laboratory animals. Latex is a common
allergen (affecting many other groups, including health professionals).

224

Lower respiratory tract symptoms

People with asthma may also present with an element
of rhinitis, with an estimated 7580% of people with
asthma showing coexisting symptoms (Sibbald et al,
1991; Leynaert et al, 1999).
Family history
A family history of atopy (e.g. eczema, asthma, and
hay fever) makes the diagnosis of allergic rhinitis more
likely (Van Arsdel, 1959).
Differences between moderate or severe symptoms
Mild symptoms are usually accepted as symptoms
not affecting sleep, daily activities, work or school
(Scadding et al, 2008; Brozek et al, 2010). Moderate
to severe symptoms are when there is abnormal sleep,
impairment of daily activities (including sport and
leisure), or when the symptoms cause troublesome
problems at school or work.

Examination

People with allergic rhinitis often have a horizontal nasal

crease across the dorsum of the nose, caused by wiping
the nose or rubbing in an upward direction. The nose
should be examined for deviation or depressed nasal
bridge, previous evidence of trauma, and for nasal airflow
(a metal spatula or piece of mirror will mist when airflow
is present). Inserting an auroscope gently into the anterior
part of both nares can help rule out the following:
Septal perforations (from surgery or from the use of
cocaine or alpha agonists)
Nasal bleeding (usually in Littles area medially in the
lower part of the nares)
Presence or absence of nasal secretions and colour
Presence or absence of nasal polyps.

Investigations

Outside primary care, no further investigations are

carried out. In more specialized settings, further
objective measurements and endoscopy are undertaken.
Allergen specific IgE tests can be carried out by skin
prick testing or by a serum immunoassay.
Skin prick tests
Skin prick tests (SPTs) can be carried out routinely
to help to determine allergic or non-allergic causes,
and help to confirm a clinical diagnosis. It should be
remembered that 15% of positive tests do not relate to
symptoms on exposure (Droste et al, 1996). However, a
negative test has a high predictive value.
Antihistamines, tricyclic antidepressants and topical
steroids will suppress a SPT result. Those who have had
anaphylactic reactions in the past should be tested in a
specialist allergy clinic.
Specific serum IgE can be requested, although they
can have a similar falsely positive result to SPT and are
expensive. However, one of the problems is that there
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Clinical Focus

are more than 30000 specific serum IgE tests possible.

It is vitally important to follow local guidelines if
undertaking the serum testing and be clear about which
specific allergens you are looking for.
Other considerations
Infective rhinitis may be caused by viruses, is
occasionally caused by bacteria, and rarely by fungi
(for example, Aspergillus). If the patient presents with
atypical history or symptoms, consider non-allergic
rhinitis caused by the following:
Hormonal changes, e.g. pregnancy, puberty,
hormone replacement therapy, contraceptive pill
Food changes, e.g. alcohol, spicy food, pepper
Autonomic changes (triggered by physical or
chemical agents)
Drugs, e.g. alpha blockers, ACE inhibitors,
chlorpromazine, cocaine
Rhinitis medicamentosa with chronic nasal blockage
from prolonged use of nasal decongestants
Unknown causes.
Rarer causes
Eosinophilic or non-allergic rhinitis with
eosinophilia syndrome, where patients are aspirinsensitive and develop nasal polyps usually later in life
Primary mucus defect (cystic fibrosis) or ciliary
dyskinesia (Kartagener or Young syndromes)
Systemic inflammatory conditions (Churg-Strauss
syndrome, rheumatoid arthritis, Sjgren syndrome,
system lupus erythromatosis)
Sarcoidosis
Tumour or foreign body (usually unilateral).

Treatment

When the diagnosis has been established, the patient

should be given advice on how to improve his/her
quality of life and reduce the impact on work or school.
Asthma
It is always worthwhile checking and treating coexisting allergic rhinitis. This is recommended in
routine review of people with asthma (Pinnock et
al, 2010) and should be a standard part of clinical
assessment in a patient who is not controlled (Bousquet
et al, 2008; Brozek et al, 2010; Cazzola et al, 2011).
Education
Patient information leaflets are available from Patient
UK ([Link]). These can support a shared
informed decision-making process that the patient
can discuss with his/her clinician. A useful tip is to
recommend printing out the leaflet and the patient
can write down any questions he/she has for the next
appointment. A good relationship with the patient is
vital to improve his/her understanding and to enhance
his/her concordance with treatment recommendations.
226

Allergen avoidance
These decisions are often complicated and are
unfortunately not supported by a large amount of
literature, hence the various advice that is published.
Avoidance can be of benefit with domestic pets and
occupational allergens (e.g. latex, laboratory animals).
However, there is controversial evidence in reducing
allergen exposure.
Encasing mattresses and pillows in plastic or special
allergen-proof fabric has been shown to be beneficial in
trials (Scadding et al, 2008). This is also recommended
in the BSACI guidelines.
However a Cochrane review (Sheikh et al, 2010) has
suggested some limited benefits in the use of acaricides
and extensive bedroom-based environmental controls,
and failed to show a benefit in mattress encasement
(Recer et al, 2004; Sheikh et al, 2010).
Nasal douching and drops
Saline douching can reduce the symptoms in children
and adults with seasonal rhinitis, and it is well tolerated
by many (Tomooko and Davidson, 2000).

Pharmacotherapy

Oral H1 antihistamines
Oral H1 antihistamines reduce itch, sneeze and rhinorrhea. Regular treatment is more effective than as
needed use, and should be used in persistent rhinitis as
it can improve quality of life. Antihistamines reduce total nasal symptoms by around 7% (59%) compared to
placebo (Scadding et al, 2008), it does however, improve
allergic symptoms in other sites to the nose (conjunctiva, skin, and lower airways).
Desloratadine, fexofenadine, cetirizine and
levocetirizine have modest effects on nasal blockage.
First generation antihistamines (e.g. diphenhydramine,
chlorphenamine) can cause sedation, and may reduce
academic or work performance. Therefore, they should
be avoided (Sheikh et al, 2005).
Second generation antihistamines are less sedating
in most patients and do not cause prolongation of the
QT interval at normal doses, hence they have a reduced
risk of major drug interactions. Second generation
antihistamines commonly used in the UK are
acrivastine (three times daily), cetirizine, desloratadine,
fexofenadine, levocetirizine, loratidine and mizolastine.
Topical nasal antihistamines (e.g. azelastine) are
occasionally used for mild-to-moderate intermittent
and mild persistent rhinitis. They act quickly but can
cause local irritation and taste disturbances.
Topical intranasal corticosteroids
A systematic review demonstrated that topical
intranasal corticosteroids (INS) have a clean benefit
over antihistamines (Weinerm and Puy, 1998) in
reducing the symptoms of allergic rhinitis. They
reduce symptoms by around 17% more than placebo,
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Clinical Focus

and can also improve allergic conjunctivitis. Onset of

action is after 68 hours, but they can take up to a few
days to 2 weeks to provide maximum benefit. Some
with more severe seasonal allergic rhinitis should
start treatment 24 weeks before the allergic season is
expected to begin.
Sprays are much easier to use than nasal drops.
However, nasal drops are more likely to be used for
severe symptoms.
There is negligible systemic absorption for
fluticasone and mometasone, and modest absorption
for the others, except for betamethasone and
dexamethasone where the absorption is high. Therefore,
betamethasone and dexamethasone should only be used
in the short-term.
Around 10% of users develop local nasal irritation,
epistaxis or a sore throat (Scadding et al, 2008),
although the adverse effects are reduced with
appropriate use.
Systemic corticosteroids
Long-acting injectable steroids are no longer used
routinely for hay fever. This is because of the very high
steroid load and the cost. The steroid dose from the
injection is roughly equivalent to a 3-month oral course
of prednisolone, and is identified as increasing the
risk of osteoporosis and diabetes (Anonymous, 1999).
However, the Joint Formulary Committee suggests
that severe disabling symptoms occasionally justify the
use of systemic corticosteroids for short periods, for
example in students taking important examinations.
Leukotriene receptor antagonists
Some patients will benefit from the use of leukotriene
receptor antagonists (LTRAs) (such as montelukast),
although they are less effective than topical INS. In fact,
the combination of antihistamine and LTRAs are no more
effective than INS steroids alone (Scadding et al, 2008).

Box 1. Practice clinical audit tip

It is important to determine how well patients comply with medications
and how effectively they use their spray or nasal drops (Figures 1 and 2).
This survey can help clinicians check on how well you and your fellow
clinicians are working with patients to improve his/her symptoms.
When you look at the next 10 people with allergic rhinitis, consider the
following:
1. How many are complying with the recommended treatment?
2. How many are using their drops or intranasal spray appropriately?
From: British Society for Allergy and Clinical Immunology, 2008

LTRAs may have a place in patients with seasonal

allergic rhinitis and asthma (Brozek et al, 2010).
LTRAs are well-tolerated, although some patients
suffer from rashes, gastrointestinal symptoms or
headaches, and there are occasional reports of
Churg-Strauss syndrome linked to the use of a LTRA
(Scadding et al, 2008). Cause and effect have not been
proven here.

Other treatments

Topical anticholinergics (e.g. ipratropium) are rarely

used, but can be used as an add-on for allergic rhinitis
when watery rhinorrhea persists despite INS and oral
antihistamines.
Intranasal decongestants are rarely used and can
cause rhinitis medicamentosa, resulting in chronic nasal
obstruction symptoms if used for more than 2 weeks.
However, they can relieve symptoms in the early phase and
practitioners need to give patients clear advice on their use.
Oral decongestants (e.g. pseudoephedrine) are not
used in allergic rhinitis nor are they recommended in
national guidance.

1. Shake bottle well

2. Look down
3. Using the right hand for
the left nostril, put nozzle
just inside the nose aiming
towards outside wall
4. Squirt once or twice (in
two different directions)
5. Change hands and repeat
for other side
6. Do not sniff hard

Figure 1. Correct administration of nasal drops

(Scadding et al, 2008)
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Figure 2. Correct administration of nasal spray (Scadding

et al, 2008)
227

Clinical Focus

Allergen immunotherapy
In very severe perennial rhinitis or seasonal rhinitis the
patient should be referred to specialist allergy clinics
which can evaluate for the use of either subcutaneous
immunotherapy (SCIT) or sublingual immunotherapy
(SLIT). Both SCIT and SLIT are currently initiated
and delivered in allergy clinics and will often require
the patient to attend for several years on a regular
basis every 46 weeks, and remain in the clinic for at
least 1 hour after each injection. This is usually only
recommended if other regular treatments have failed. A
good example of a patient group in which this therapy
would be beneficial is when an equine veterinary
surgeon develops a severe allergic rhinitis when exposed
to horses. Attendance at the clinic wold help this patient
maintain their career, therefore the commitment of
attending the clinic would be acceptable to them.

Rhinitis and pregnancy

Around 20% of pregnant women have symptoms of

rhinitis linked to their pregnancy (Scadding et al, 2008).
Often, all that is required is reassurance or sometimes
nasal douching. INS are acceptable if symptoms are
significantly troublesome as they have a good safety
record.

Conclusions

Allergic rhinitis is common and affects patient quality of

life, school, and work attendance. A good diagnosis can
usually be made after taking a careful history supported by
clinical examination, and at times specific allergy testing.
If the patient has moderate to severe symptoms, then the
treatment of choice should be intranasal corticosteroids.
It is common that treatment failure is linked to poor
technique when using nasal sprays or drops. Treatment of
rhinitis is associated with improvement from asthma, and
since many people with asthma also present with allergic
rhinitis symptoms it should be considered routinely in
clinical practice when reviewing asthma patients.
Angier E, Willington J, Scadding G, Holmes S, Walker S (2010)
Management of allergic and non-allergic rhinitis: a primary care
summary of the BSACI guideline. Primary Care Resp J 19(3): 21722
Anonymous (1999) Any place for depot triamcinolone in hay fever?
Drug and Therapeutics Bulletin 37: 178
Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A

Key Points
Allergic rhinitis is a common problem
It can adversely impact on a patients work, school
performance, and quality of life
Most people with asthma have an element of allergic rhinitis
Diagnosis can often be made with careful history and
examination
Treatments are effective, but the use of nasal sprays or drops
can be variable.

228

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