Allergic Rhinitis (AR)
Definition:
Allergic rhinitis is an IgE-mediated inflammatory condition of the nasal mucosa induced by
exposure to allergens. It is characterized by sneezing, nasal congestion, rhinorrhea, nasal
itching, and often ocular symptoms.
Etiology:
Allergic rhinitis is caused by hypersensitivity to airborne allergens, including:
• Outdoor allergens:
o Pollen (trees, grasses, weeds)
o Mold spores
• Indoor allergens:
o Dust mites
o Animal dander (cat, dog)
o Cockroach antigen
o Indoor molds
• Occupational allergens:
o Latex
o Flour (baker’s asthma/rhinitis)
o Wood dust
Types of Allergic Rhinitis:
1. Seasonal Allergic Rhinitis (SAR):
o Triggered by seasonal allergens like pollen.
o Commonly known as "hay fever".
2. Perennial Allergic Rhinitis (PAR):
o Symptoms present year-round.
o Triggered by indoor allergens like dust mites, pet dander.
3. Episodic Allergic Rhinitis:
o Occurs sporadically upon exposure to allergens not normally present in
the patient’s environment (e.g., visiting a home with pets).
Risk Factors:
• Family history of atopy (asthma, eczema, allergic rhinitis)
• Personal history of other atopic diseases
• Early childhood exposure to allergens
• Elevated serum IgE levels
• Male sex (in childhood)
• Exposure to tobacco smoke or pollutants
• Firstborn status
• Cesarean delivery
Pathophysiology:
Allergic rhinitis is a Type I hypersensitivity reaction, involving:
1. Sensitization Phase:
o Allergen is inhaled and captured by antigen-presenting cells (APCs).
o APCs present the allergen to T-helper 2 (Th2) cells.
o Th2 cells produce IL-4, IL-5, and IL-13 → Stimulate B cells to produce
allergen-specific IgE.
2. Early Phase Reaction (minutes):
o Upon re-exposure, allergen binds to IgE on mast cells → Degranulation →
Release of histamine, leukotrienes, prostaglandins.
o Leads to sneezing, itching, rhinorrhea, nasal congestion.
3. Late Phase Reaction (hours later):
o Inflammatory cell recruitment (eosinophils, basophils, T cells).
o Prolonged nasal congestion and mucosal inflammation.
Signs and Symptoms:
Nasal:
• Sneezing
• Rhinorrhea (clear)
• Nasal congestion
• Nasal itching
• Postnasal drip
Ocular:
• Itchy, red, watery eyes
• Periorbital dark circles (“allergic shiners”)
Other findings:
• Mouth breathing
• Snoring
• Cough (especially at night)
• Fatigue
• “Allergic salute” (habitual upward rubbing of the nose)
Diagnosis:
History and Physical Examination:
• Pattern, duration, and triggers of symptoms
• Associated atopic conditions (asthma, eczema)
• Family history
Physical Findings:
• Pale, bluish, boggy nasal turbinates
• Clear nasal discharge
• Cobblestoning of posterior pharynx
• Dennie-Morgan lines (infraorbital folds)
Investigations:
• Skin Prick Testing (SPT): Gold standard for allergen identification.
• Serum specific IgE testing (RAST): Alternative to SPT if skin testing not feasible.
• Total IgE levels: May be elevated but not specific.
• Nasal smear: Eosinophilia supportive of allergic cause.
Differential Diagnosis:
Condition Key Differentiating Features
No IgE mediation, usually in adults, triggers include irritants like
Non-allergic rhinitis
smoke, perfume.
Vasomotor rhinitis Triggered by temperature changes, spicy food, not allergic.
Infectious rhinitis Purulent discharge, fever, shorter duration.
Obstruction, anosmia, often bilateral in allergic fungal sinusitis
Nasal polyps
or asthma.
Condition Key Differentiating Features
Deviated nasal
Chronic obstruction, no allergic signs, visible on exam.
septum
Stepwise Management:
General Principles:
• Identify and avoid triggers.
• Step up treatment based on severity and symptom control.
Step 1: Allergen Avoidance
• Dust mite control: mattress/pillow covers, wash bedding in hot water.
• Pet dander: keep pets out of bedroom, HEPA filters.
• Pollen: stay indoors during high pollen times, close windows.
• Mold: dehumidify, clean damp areas.
Step 2: Pharmacologic Therapy
Drug Class Examples Indications Notes
Fluticasone, First-line for Best efficacy for all
Intranasal
Mometasone, moderate-severe symptoms including
corticosteroids
Budesonide AR congestion. Use daily.
Oral
Loratadine, Cetirizine, Less sedating than 1st
antihistamines Mild symptoms
Fexofenadine gen; fast onset.
(2nd gen)
Intranasal Good for breakthrough
Azelastine Rapid relief
antihistamines symptoms.
Pseudoephedrine Nasal form for ≤3 days
Decongestants (oral), Oxymetazoline Short-term use to avoid rebound
(nasal) congestion.
Leukotriene Adjunct in allergic
Less effective than
receptor Montelukast asthma or
intranasal steroids.
antagonists persistent AR
Drug Class Examples Indications Notes
Reduces mucosal
Nasal saline
- Adjunctive irritation and helps
irrigation
drug delivery.
Step 3: Immunotherapy
• Indications:
o Inadequate control with medications
o Desire to reduce long-term medication use
o Known specific allergen
• Types:
o Subcutaneous Immunotherapy (SCIT)
o Sublingual Immunotherapy (SLIT)
Patient Education:
• Importance of adherence to treatment
• Correct use of intranasal sprays (pointing away from septum)
• Regular follow-up and monitoring symptom control
• Environmental control measures