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ALLERGIC RHINITIS OVERVIEW — The word "rhinitis" refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and postnasal drip (the sensation that mucus is draining from the sinuses down the back of the throat).
Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses, such as the common cold. Allergic rhinitis is caused by allergies to things in the air around you. Chronic (long-term) rhinitis is usually caused by allergies, but it can also result from overuse of certain drugs, some medical conditions, and other unknown factors.
For many people, allergic rhinitis is a lifelong condition that waxes and wanes over time. Fortunately, symptoms can usually be controlled with a combination of environmental measures, medications, and immunotherapy.
This article is about allergic rhinitis. Nonallergic rhinitis is discussed separately. (See "Patient education: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)".)
WHO GETS ALLERGIC RHINITIS? — Allergic rhinitis affects approximately 20 percent of people of all ages. The risk of developing allergic rhinitis is much higher in people with asthma or eczema and in people who have a family history of asthma or allergic rhinitis.
Allergic rhinitis can begin at any age, although most people first develop symptoms in childhood or young adulthood. The symptoms are often most severe in children and in people in their 30s and 40s. However, the severity of symptoms tends to vary throughout a person's life. Some people go through periods during which they have no symptoms at all.
ALLERGIC RHINITIS CAUSES — Allergic rhinitis is caused by a nasal reaction to small airborne particles called allergens (substances that provoke an allergic reaction). In some people, these particles also cause reactions in the lungs (asthma) and eyes (allergic conjunctivitis).
The allergic reaction results from activation of two types of inflammatory cells in the body called mast cells and basophils. These cells produce natural chemicals, such as histamine, which cause symptoms, such as nasal congestion, itching, sneezing, and a runny nose.
Seasonal versus perennial allergic rhinitis — Allergic rhinitis can be seasonal (occurring during specific seasons) or perennial (occurring year-round).
●The allergens that most commonly cause seasonal allergic rhinitis include pollens from trees, grasses, and weeds (figure 1).
●The allergens that most commonly cause perennial allergic rhinitis are dust mites, cockroaches, animal dander, and fungi or molds. Perennial allergic rhinitis tends to be more difficult to treat.
COMMON SIGNS AND SYMPTOMS — The symptoms of allergic rhinitis vary from person to person. Although the term "rhinitis" refers only to the nasal symptoms, many people also have symptoms that affect the eyes, throat, and ears. Sleep may be disrupted as well. Symptoms may include the following:
●Nose – Watery nasal discharge, blocked nasal passages, sneezing, nasal itching, postnasal drip, loss of taste, facial pressure or pain
●Eyes – Itchy red eyes, a feeling of grittiness in the eyes, swelling and dark discoloration of the skin below the eyes (called "allergic shiners") (see "Patient education: Allergic conjunctivitis (Beyond the Basics)")
●Throat and ears – Sore throat, hoarse voice, congestion or popping of the ears, itching of the throat or ears
●Sleep – Mouth breathing, frequent awakening, daytime fatigue, trouble doing normal activities (eg, work)
With perennial (year-round) allergic rhinitis, the predominant symptoms include postnasal drip, persistent nasal congestion, and trouble sleeping.
ALLERGIC RHINITIS DIAGNOSIS — Your doctor can diagnose allergic rhinitis by doing a physical examination reviewing your symptoms. Medical tests can confirm the diagnosis and identify the offending allergens.
Identifying allergens and other triggers — It is often possible to identify the allergens and other triggers that provoke allergic rhinitis by:
●Recalling where you were and what you were doing before your symptoms started (for example, spending time outside or around animals)
●Noting the time of year during which you have noticed symptoms
●Looking closely at the home, work, and school environments for potential allergens
Your doctor may suggest skin testing if your symptoms are not well-controlled with medications or if it is not clear what is causing your symptoms. This involves an allergist putting tiny amounts of different allergens on your skin and observing which cause a reaction. Blood tests are also available, although these are not needed in all situations.
ALLERGIC RHINITIS TREATMENT — The treatment of allergic rhinitis includes reducing exposure to allergens and other triggers in combination with medication therapy. In most people, this combined approach can effectively control symptoms.
Several different classes of drugs can treat the inflammation that causes symptoms of allergic rhinitis (table 1). These and other approaches, including nasal irrigation, allergy shots, or tablets that dissolve under the tongue, are discussed in the following section. The best treatment(s) will depend on your symptoms and personal preferences.
Avoiding the trigger(s) — Sometimes people can treat their allergic rhinitis simply by avoiding the things that trigger symptoms. For example, if a relative has cats that cause sneezing and itchy eyes, you can avoid being in the relative's house for extended periods of time or take an antihistamine several hours before visiting. However, most allergens are much harder to avoid. Trigger avoidance is discussed in more detail separately. (See "Patient education: Trigger avoidance in allergic rhinitis (Beyond the Basics)".)
Glucocorticoid nasal sprays — Nasal glucocorticoids (steroids) delivered by a nasal spray are the first-line treatment for the symptoms of allergic rhinitis. These drugs have few side effects and dramatically relieve symptoms in most people. Studies have shown that nasal steroids are more effective than oral antihistamines for symptom relief. (See 'Antihistamines' below.)
Some nasal steroids are available over-the-counter in the United States (sample brand names: Flonase Sensimist, Flonase Allergy Relief, Rhinocort Allergy), while others require a prescription (table 1). These drugs differ with regard to the frequency of doses, the spray device, and cost, but all are similarly effective for treating all of the symptoms of allergic rhinitis.
If you have severe symptoms, you may need to use a nasal decongestant for a few days before starting a nasal steroid to reduce nasal swelling. This allows the nasal spray to reach more areas within your nasal passages. (See 'Decongestants' below.)
Some people notice symptom relief on the first day of treatment with nasal steroids, although it may take days to weeks to notice the full effect. For this reason, nasal steroids are most effective when used regularly. Some people are able to use lower doses when symptoms are less severe.
How to use a nasal spray — Nasal sprays work best when they are used properly and the medication remains in the nose rather than draining down the back of the throat. If your nose is crusted or contains mucus, you can clean it with a saline (salt water) nasal spray before using a nasal spray that contains medication.
Hold your head straight or with your chin slightly tucked. Point the spray away from the nasal septum (the cartilage that divides the two sides of the nose). After spraying, sniff gently to pull it into the higher parts of your nose. Avoid sniffing too hard, as this can result in the medicine draining down your throat.
Some people find that holding one nostril closed with a finger improves their ability to draw the spray into the upper nose. Spit out any medicine that drains into your throat, since it is not effective unless it remains in the nose.
Side effects — The side effects of nasal steroids are mild and may include a slightly unpleasant smell or taste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding of the nasal septum, especially during the winter. You can minimize these problems by reducing the dose of your nasal steroid, applying a moisturizing nasal gel or spray to the septum before using the spray, or switching to a water-based (rather than an alcohol-based) spray.
Studies suggest that nasal steroids are generally safe when used for many years. However, if you use these drugs for years, let your health care provider know. You should have periodic nasal examinations to check for rare side effects, such as nasal infection.
Some people wonder about the side effects of steroids. It is true that steroids taken in other forms (ie, as a pill or inhaled into the lungs) can have side effects, especially when taken for long periods of time. However, the doses used in nasal steroids are low and are not associated with these side effects. Still, clinicians usually recommend using the lowest effective dose.
Use in children — In children, using steroid nasal sprays for an extended time may slightly slow growth rate. If your child requires a nasal steroid spray for more than two months of the year, talk to his or her doctor or nurse for advice.
Antihistamines — Antihistamines relieve the itching, sneezing, and runny nose of allergic rhinitis, but they do not relieve nasal congestion. Using them along with nasal steroids or decongestants may provide greater symptom relief than using one of these medications alone.
Nonsedating oral antihistamines — Commonly used oral antihistamines include loratadine (sample brand names: Claritin, Alavert), desloratadine (brand name: Clarinex), cetirizine (sample brand name: Zyrtec), levocetirizine (brand name: Xyzal), and fexofenadine (sample brand name: Allegra) (table 1). Loratadine, cetirizine, and fexofenadine are available without a prescription and in long-acting (eg, 24-hour) formulas.
Sedating oral antihistamines — Several other antihistamines have been available for many years without a prescription, including chlorpheniramine (sample brand name: Chlor-Trimeton), diphenhydramine (sample brand name: Benadryl), and clemastine (sample brand name: Tavist). However, these drugs often cause sedation and should not be used before driving or operating machinery or in children. Even if you do not feel excessively drowsy after taking an antihistamine, these drugs can have a sedating effect, so it is important to be careful. Because of the side effects associated with the older antihistamines, the newer, nonsedating versions are typically preferred if an antihistamine is used.
Nasal sprays — Azelastine (brand names: Astelin, Astepro) and olopatadine (brand name: Patanase) are nasal antihistamine sprays that can be used daily or when needed to relieve symptoms of postnasal drip, congestion, and sneezing. These sprays start to work within minutes after use. The most common side effect with azelastine is a bad taste in the mouth immediately after use. You can minimize this by keeping your head tilted forward while spraying to prevent the medicine from draining down your throat. (See 'How to use a nasal spray' above.)
Eye drops — If you have itching or irritation of the eyes with your other allergy symptoms, your doctor may suggest prescription or over-the-counter antihistamine eye drops. (See "Patient education: Allergic conjunctivitis (Beyond the Basics)".)
Combination glucocorticoid/antihistamine spray — A prescription combination of the nasal steroid fluticasone and the nasal antihistamine azelastine (brand name: Dymista) appears to improve symptoms of allergic rhinitis better than either drug alone in three clinical trials. The combination drug has the side effects of both when used at the recommended dose (one spray in each side of the nose twice per day) and is approved for use in people over 12 years old. The most common side effects are a bad taste, nose bleed, and headache.
Decongestants — The decongestant pseudoephedrine is available in combination with antihistamines in some oral, over-the-counter allergy medications. Examples include brompheniramine-pseudoephedrine (sample brand names: Brotapp, Rynex PSE), loratadine-pseudoephedrine (sample brand names: Alavert Allergy and Sinus, Claritin-D 12 Hour Allergy & Congestion), cetirizine-pseudoephedrine (brand name: Zyrtec-D Allergy & Congestion), and fexofenadine-pseudoephedrine (brand names: Allegra-D 12 Hour; Allegra-D 24 Hour) (table 1).
Oral decongestants elevate blood pressure and are not appropriate for people with high blood pressure or certain cardiovascular conditions.
Decongestants in the form of nasal sprays are also available, including oxymetazoline (sample brand name: Afrin) and phenylephrine (sample brand name: Neo-synephrine). However, these are not recommended for treating allergic rhinitis. It is better to use a medication that can safely be taken for weeks or even months, such as a nasal steroid spray (see 'Glucocorticoid nasal sprays' above). Nasal decongestant sprays should not be used for more than two to three days at a time, because they may cause a type of rhinitis called "rhinitis medicamentosa," which causes the nose to be congested constantly unless the medication is used repeatedly. This condition can be difficult to treat. (See "Patient education: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)".)
Cromolyn — Cromolyn (brand name: NasalCrom) prevents the symptoms of allergic rhinitis by interfering with the ability of allergy cells to release natural chemicals that cause inflammation. It is available as an over-the-counter nasal spray. Cromolyn must be used several times per day to effectively prevent the symptoms of seasonal allergic rhinitis. It works better if you use it before symptoms begin. It is generally not as effective as other treatments but may be a good option for temporary situations, for example, if you are visiting a friend or relative with pets that trigger your allergy symptoms.
Nasal irrigation and saline sprays — Rinsing the nose with a saline (salt water) solution is called "nasal irrigation" or "nasal lavage." Saline is also available in a standard nasal spray, although this is not as effective as using larger amounts of water in an irrigation.
Nasal irrigation is particularly useful for treating postnasal drip, sneezing, nasal dryness, and congestion. The treatment helps by rinsing out allergens and irritants from the nose. Saline rinses also clean the nasal lining. You can use it before applying a spray-containing medication to get a better effect from the medication.
Nasal irrigation with warmed saline can be performed once per day or twice if your symptoms are severe. Nasal irrigation carries few risks when done correctly and with saline made with sterilized water.
A variety of devices, including syringes, Neti pots, and bottle sprayers, may be used to perform nasal irrigation. Your doctor or pharmacist can recommend a nasal irrigation kit. These are available without a prescription.
Allergen immunotherapy — Immunotherapy involves trying to alter the way a person's immune system reacts to allergens. The most common form of immunotherapy is regular injections. Whether you are a candidate for immunotherapy depends on your history as well as what you are allergic to. This involves skin and/or blood tests to confirm your specific allergen(s).
Allergy shots — Allergy shots, also known as "allergen immunotherapy," are only available for common allergens, including pollens, cat and dog dander, dust mites, and molds. (They are not used to treat allergies to food, latex, or medicines). The shots contain solutions of the allergen(s) to which you are allergic. Each injection is prepared specifically for you. The process of immunotherapy changes your immune response to the allergens over time. As a result, being exposed to the allergen causes fewer symptoms and may even eliminate symptoms altogether.
Immunotherapy can help many people with allergic rhinitis. In children, immunotherapy can help prevent the development of allergic asthma later in life. However, immunotherapy is relatively time-consuming and is often reserved for people who have a poor response to medication or want to minimize the number of medications they need long-term. People initially stay on medications when they start immunotherapy and then gradually reduce the medications as their symptoms improve. Immunotherapy can be expensive, but many insurance plans cover it because long-term use of allergy medications is also costly.
Immunotherapy is usually started by an allergist. Treatment begins with several months of weekly injections of gradually increasing doses, followed by monthly maintenance injections.
Immunotherapy is usually continued for a minimum of three to five years. Studies have shown that getting shots for this long is more likely to provide a lasting benefit after stopping, compared with just one year or two. Once you stop getting the shots, the benefits gradually diminish over time. It is not possible to predict how long the effect of the shots will last in an individual.
Immunotherapy injections carry a small risk of a severe allergic reaction. These reactions occur with a frequency of 6 of every 10,000 injections. The symptoms usually begin within 30 minutes of the injection. For this reason, you will be required to remain in the office after routine injections, so you can get immediate treatment if you have this type of reaction. Because drugs called beta-blockers may interfere with the ability to treat these reactions, people who take beta-blockers are sometimes advised to avoid immunotherapy or to change to a different medication that is not a beta-blocker. If you are getting allergy shots and another clinician prescribes a beta-blocker medicine for high blood pressure or another reason, it is important to let your allergist know.
Immunotherapy pills placed under the tongue — "Sublingual immunotherapy" is a form of immunotherapy given as a daily pill that dissolves under the tongue. Sublingual immunotherapy is given every day for several months of the year. The first dose is given in the clinician's office, but after that, you can take it at home. This type of treatment does not involve getting shots, and it is very safe because it rarely causes severe allergic reactions. However, it is only available for a few types of allergies, and if you forget to take the pills daily, the treatment might not work.
Other treatments — Other drugs may be recommended for some people with allergic rhinitis.
●Ipratropium – This drug, available as ipratropium bromide (sample brand name: Atrovent), can help treat severe runny nose. It is not generally recommended for people with glaucoma or men with an enlarged prostate.
●Leukotriene modifiers – Natural chemicals called leukotrienes may contribute to the symptoms of allergic rhinitis in some people. Drugs that block the actions of leukotrienes, called leukotriene modifiers, can be very useful in people with both asthma and allergic rhinitis. The most commonly used medications are montelukast and zafirlukast. However, nasal steroids are more effective than leukotriene modifiers for treating allergic rhinitis. Thus, leukotriene modifiers are generally reserved for people who also have asthma or who cannot tolerate nasal sprays (due to nose bleeds, for example).
ALLERGIC RHINITIS IN PREGNANCY — Women who have allergic rhinitis before pregnancy may notice worsening, improvement, or no change in their symptoms during pregnancy. Most women notice some nasal congestion in the later stages of pregnancy, even if they did not have rhinitis before. This is called "rhinitis of pregnancy" and is related to hormone levels in the body, not allergies. Rhinitis of pregnancy does not respond to medications and goes away after delivery. The discussion below applies only to allergic rhinitis.
As a general rule, most medications should be avoided or used at the lowest dose that controls symptoms during pregnancy. If you are pregnant, it is important to review any medication (over-the-counter or prescription) before taking it, and talk to your health care provider if you have questions. However, several of the drugs used to treat allergic rhinitis are thought to be safe during pregnancy, so you should have options if your symptoms are bothersome.
If you are pregnant and have mild rhinitis, you may be able to control your symptoms using only saline nasal sprays or irrigation, which do not contain any medications (see 'Nasal irrigation and saline sprays' above). If you do need medication, the following are considered to be safer choices:
●Nasal sprays – Certain nasal sprays are a sensible option for pregnant women because much less medication is required to control symptoms when it is sprayed directly into the nose, compared with taking that same medication by mouth.
•Cromolyn nasal sprays are safe for use during pregnancy. Only a very small amount of drug is absorbed into the bloodstream with this medication, and no serious side effects are known to occur. (See 'Cromolyn' above.)
•Nasal steroids, as a group, are considered safe for use in pregnancy, although there is more information about some medications than others. We avoid triamcinolone (sample brand name: Nasacort Allergy 24HR) based on one study showing that there might be an increased risk of congenital respiratory defects if used in the first trimester. Overall, the study supports the use of nasal steroids when indicated during pregnancy. Pending further studies, we prefer to use other drugs, such as fluticasone (sample brand name: Flonase Allergy Relief), budesonide (brand names: Rhinocort Aqua, Rhinocort Allergy), or mometasone (brand name: Nasonex), during the first trimester. (See 'Glucocorticoid nasal sprays' above.)
●Antihistamines – Cetirizine (sample brand name: Zyrtec), loratadine (sample brand names: Claritin, Alavert), and chlorpheniramine (sample brand name: Chlor-Trimeton) are considered safe for use during pregnancy.
●Decongestants – Pseudoephedrine should be avoided during the first trimester of pregnancy if possible because its safety has not been confirmed. After the first trimester, it should be used only when needed and only as directed. However, you should not use it at all if you have high blood pressure or preeclampsia. Phenylephrine should be avoided altogether during pregnancy.
●Allergy shots – If you are already getting allergy shots and have not had allergic reactions to the shots in the past, you may continue treatment through pregnancy. However, the dose should not be increased during pregnancy due to the risk of a serious allergic reaction (anaphylaxis), which could potentially reduce the blood supply to the developing baby. For the same reason, allergy shots are not started during pregnancy.
ALLERGIC RHINITIS IN VERY YOUNG CHILDREN — Allergic rhinitis is not common in children younger than two, since they have not had much exposure to allergens in the environment. If your child has symptoms like a persistent runny nose, he or she should see a doctor to check for other possible causes.
If your child's doctor determines that he or she does have allergic rhinitis, treatment options include cromolyn (see 'Cromolyn' above) and nonsedating antihistamines, many of which are available in liquid form (see 'Nonsedating oral antihistamines' above). If these are not effective and your child's symptoms are severe, his or her doctor might suggest trying a glucocorticoid nasal spray for a limited time. (See 'Glucocorticoid nasal sprays' above.)
In children older than two years, treatment options for allergic rhinitis are generally the same as in adults. (See 'Allergic rhinitis treatment' above.)
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Environmental allergies in adults (The Basics)
Patient education: Giving your child over-the-counter medicines (The Basics)
Patient education: Allergy shots (The Basics)
Patient education: Allergy skin testing (The Basics)
Patient education: How to rinse out your nose with salt water (The Basics)
Patient education: Environmental allergies in children (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)
Patient education: Allergic conjunctivitis (Beyond the Basics)
Patient education: Trigger avoidance in allergic rhinitis (Beyond the Basics)
Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Allergen avoidance in the treatment of asthma and allergic rhinitis
An overview of rhinitis
Chronic nonallergic rhinitis
Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis
Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis
Pathogenesis of allergic rhinitis (rhinosinusitis)
Pharmacotherapy of allergic rhinitis
The following organizations also provide reliable health information.
●United States National Library of Medicine (medlineplus.gov/healthtopics.html)
●American College of Allergy, Asthma & Immunology (acaai.org/allergies/types/hay-fever-rhinitis)
●American Academy of Allergy, Asthma & Immunology (https://www.aaaai.org/Conditions-Treatments/Allergies/Hay-Fever-Rhinitis)
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