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Allergic Rhinitis

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Allergic rhinitis is an atopic condition characterized by sneezing, postnasal drip, nasal itching, and congestion.&nbsp;&nbsp; 
&nbsp;

Allergic rhinitis (also known as hay fever) is an atopic condition, which means that the person is genetically predisposed to develop allergic diseases<a href="#accordion">[1]</a>.

Hay fever is brought on by numerous indoor and outdoor allergens, including dust mites, mold, and pet dander along with plant and tree pollen. Even perfumes, hairspray, and simply being in the vicinity of wood smoke can cause it.

It&rsquo;s important to mention here that allergic rhinitis (AR) is not the same as infectious rhinitis or the common cold, even though both of these conditions present with similar symptoms, like sneezing, nasal congestion, and irritation of the eyes, nose, mouth, and throat<a href="#accordion">[2]</a>. 
&nbsp;

The prevalence of allergic rhinitis is about 15%<a href="#accordion">[1]</a>. The incident rate is highest for 20-40 years old after which it declines<a href="#accordion">[5]</a>.

While chronic rhinitis is more common in adults, seasonal allergic rhinitis appears to be more common in children such that it is considered one of the most prevalent chronic pediatric illnesses<a href="#accordion">[1]</a>. Data from the International Study for Asthma and Allergies in Childhood shows that 8.5% of children aged 6-7 years and 14.6% of children aged 13-14 years have rhinoconjunctivitis symptoms related to allergic rhinitis<a href="#accordion">[1]</a>.

Moreover, as demonstrated by numerous studies, the prevalence of AR has increased over time as a result of urbanization and environmental pollutants. Also, a study in Europe stressed that climate change over the past 30 years has further extended the pollen season<a href="#accordion">[5]</a>. 
&nbsp;

There are two variants of allergic rhinitis<a href="#accordion">[3]</a>:

<ul>
	<li>Seasonal (hay fever): The seasonal variant of the disease is caused by a reaction to airborne pollen and mold spores. Pollen from blossoming plants easily disperses through the air, which is why symptoms typically manifest in the spring, late summer, and fall. It is also the most common type of allergic rhinitis.</li>
	<li>Perennial: Perennial type of AR is caused by other allergens such as dust mites and pet hair or dander. Symptoms can occur anytime, all year long. 
	&nbsp;</li>
</ul>

The international Allergic Rhinitis and its Impact on Asthma (ARIA)&rsquo;s guidelines help when seasonal changes are unclear or not generally applicable. According to ARIA, patients with rhinitis are classified into one of four types<a href="#accordion">[6]</a>:

1. Intermittent: This means the symptoms are present for either less than 4 days a week or less than 4 weeks.

2. Persistent: This means the symptoms are present for either more than 4 days a week or more than 4 weeks.

3. Moderate-severe: This means that the condition does not exhibit any of the following symptoms &ndash; sleep disturbance, impairment of work or school, impairment of leisure or daily activities, and any troublesome symptoms.

4. Mild: This means that one or more of the following symptoms are present &ndash; sleep disturbance, impairment of work or school, impairment of leisure or daily activities, and any troublesome symptoms. 
&nbsp;

Signs and Symptoms

Most commonly reported signs and symptoms of allergic rhinitis include<a href="#accordion">[4]</a>:

<ul>
	<li>Sneezing</li>
	<li>Runny nose</li>
	<li>Stuffy nose</li>
	<li>Itchy nose</li>
	<li>Cough</li>
	<li>Pain or scratchiness in the throat</li>
	<li>Itchy and watery eyes</li>
	<li>Dark circles</li>
	<li>Persistent headaches</li>
	<li>Eczema-like symptoms, like extremely dry, itchy skin that can blister and weep</li>
	<li>Unusual fatigue</li>
</ul>

The individual usually experiences one or more of these symptoms immediately after being exposed to an allergen. Some symptoms, like chronic headaches and tiredness, only appear if the person&rsquo;s been exposed to allergens for a long period.

Some people only occasionally experience symptoms while others go through the symptoms year-round. If the symptoms continue for more than a few weeks and don&#39;t appear to be improving, it&rsquo;s important to consult a doctor about probable allergies.

NOTE: Hay fever doesn&#39;t have temperature as a symptom. 
&nbsp;

Causes

When an individual is exposed to an allergen, their body will release histamine, which causes the typical symptoms<a href="#accordion">[3]</a>.

The time of year has an impact on allergies:

<ul>
	<li>Allergies that begin in the spring (late April and May) are frequently due to tree pollen.</li>
	<li>Allergies that occur in the summer (late May to mid-July) are due to grass and weed pollen.</li>
	<li>Allergies that occur in the fall (late August to the first frost) are due to ragweed.</li>
</ul>

Allergens, which cause perennial allergic rhinitis, consist of: 
&nbsp;

<ul>
	<li>Mold</li>
</ul>

It frequently occurs in places where water tends to pool, like wet basements and shower curtains. Additionally, it is abundant in mulch, hay, and decomposing wood. Damp weather conditions make it worse.

<ul>
	<li>Animal Dander</li>
</ul>

Allergens can be found in the skin, saliva, and urine of animals with fur, such as cats and dogs. Dander exposure can occur when handling animal or household dust.

<ul>
	<li>Dust Mites</li>
</ul>

The microscopic living organisms known as dust mites can be found in carpeting, upholstered furniture, mattresses, and bedding. 
&nbsp;

There are no screening guidelines for AR. 
&nbsp;

Diagnosis

Consult a medical professional if the symptoms affect daily life. The doctor will perform a physical examination and inquire about the symptoms and medical history. Keeping a track of the symptoms over time can help the doctor identify the substances that trigger the allergic reaction.

However, the doctor might want to do an allergy skin test as well to find out exactly what the individual is allergic to. This involves exposing the skin to very small quantities of allergens while the doctor waits and observes how the body responds to each allergy.

There are essentially two approaches by which the allergen skin test can be done: 
&nbsp;

<ul>
	<li>Prick Or Scratch Test: A little drop of a potential allergy is scraped onto the skin during this test. This kind of skin test, also called a percutaneous test, is the most common test. If the person is allergic to the allergen, the area will be red and itchy in 15-30 minutes<a href="#accordion">[2]</a>. 
	&nbsp;</li>
	<li>Intradermal Test: A fine needle is used to inject a small quantity of a potential allergen beneath the skin. The site is examined after about 20 minutes. Compared to the prick or scratch test, the intradermal test is usually more sensitive. 
	&nbsp;</li>
</ul>

Additionally, the doctor can order a blood test, like the radioallergosorbent test, which allows the doctor to determine what the person is allergic to by looking for antibodies in the blood<a href="#accordion">[3]</a>. 
&nbsp;

Treatment

There are many techniques to manage allergic rhinitis. Always consult a physician before starting any new treatment for allergic rhinitis. 
&nbsp;

<h5>Antihistamines</h5>

Antihistamines can be used to treat allergies. They function by preventing the body from producing histamine. Some of these antihistamines include<a href="#accordion">[1]</a>:

<ul>
	<li>Fexofenadine</li>
	<li>Diphenhydramine</li>
	<li>Desloratadine</li>
	<li>Loratadine 
	&nbsp;</li>
</ul>

<h5>Decongestants</h5>

Decongestants can be used for a brief duration, often no more than 3 days, to reduce sinus pressure and stuffy nose symptoms. The only risk is if a person uses them for a long period, the meds can have a rebound effect. This means the symptoms worsen once the person stops taking decongestants. Typical over-the-counter decongestants consist of4:

<ul>
	<li>Oxymetazoline</li>
	<li>Pseudoephedrine</li>
	<li>Phenylephrine</li>
	<li>Cetirizine with pseudoephedrine 
	&nbsp;</li>
</ul>

<h5>Eye Drops And Nasal Sprays</h5>

Eye drops and nasal sprays can help reduce itching and other allergy-related symptoms for a brief period. Again, overusing some eye drops and nose drops can have a rebound effect similar to decongestants.

Immune responses and inflammation can both be alleviated by corticosteroids. Also, there is no rebound effect from corticosteroids. Therefore, steroid nasal sprays are commonly suggested as a long-term, practical method of managing allergy symptoms. 
&nbsp;

<h5>Immunotherapy</h5>

The doctor may advise immunotherapy or allergy injections if it&rsquo;s a case of severe allergies. It&rsquo;s part of a treatment strategy in addition to prescription drugs to reduce symptoms. Over time, these injections reduce the immunological reaction the person has to specific allergens.

Initially, during the building phase, the individual gets a shot 1-3 times a week for roughly 3-6 months to give the body time to adjust to the allergen.<a href="#accordion">[4]</a>

During the next phase, which is the maintenance phase, the person gets a shot every 2-4 weeks for 3-5 years. At this time, allergy symptoms may alleviate or go away entirely. However, an allergen can cause severe responses in certain people. Therefore, the allergist will always request their patient to stay in the office for 30-45 minutes after receiving the shot to ensure there&rsquo;s no severe or life-threatening reaction to the shot. 
&nbsp;

<h5>Sublingual Immunotherapy (SLIT)</h5>

SLIT involves sublingual (below the tongue) administration of a tablet containing a mixture of several allergens. Presently, SLIT medications, such as Oralair, work well for treating rhinitis and asthma allergies brought on by grass, tree, cat, dust mite, and ragweed pollen. The first dose is always given at the doctor&rsquo;s clinic after which the subsequent doses can be taken at home<a href="#accordion">[4]</a>. 
&nbsp;

<h5>Home Remedies</h5>

The type of allergen will determine the best home remedies.

<ul>
	<li>For seasonal or pollen allergies, use an air conditioner rather than opening the windows and, if possible, add an allergy-specific filter to the AC.</li>
	<li>Another option is to use a dehumidifier or a high-efficiency particulate air (HEPA) filter. </li>
	<li>Wash the blankets and linens in hot water, i.e., above 130&deg;F (54.4&deg;C) to deal with a dust mite allergy. </li>
	<li>Adding a HEPA filter to the vacuum can also help. </li>
	<li>Avoid installing carpet at the home. 
	&nbsp;</li>
</ul>

Some complications include<a href="#accordion">[4]</a>: 
&nbsp;

<ul>
	<li>Not being able to sleep all night</li>
	<li>An aggravation of previous asthma symptoms or onset of a new episode</li>
	<li>Recurrent ear infections</li>
	<li>Sinusitis</li>
	<li>Decreased productivity</li>
	<li>Recurrent headaches 
	&nbsp;</li>
</ul>

These include<a href="#accordion">[4]</a>: 
&nbsp;

<ul>
	<li>A family history of allergies</li>
	<li>Male sex&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/asthma">Asthma </a></li>
	<li>Atopic <a href="https://merisehat.pk/disease/eczema">eczema</a></li>
	<li>Smoking</li>
	<li>Exposure to cigarette smoking in the first year of life<a href="#accordion">[1]</a></li>
	<li>Using chemicals</li>
	<li>Cold temperatures</li>
	<li>Humid environment</li>
	<li>Air pollution 
	&nbsp;</li>
</ul>

The following measures can help prevent allergic rhinitis: 
&nbsp;

<ol>
	<li>Stay indoors when pollen counts are high.</li>
	<li>Refrain from exercising outdoors early in the morning.</li>
	<li>Shower and change clothes immediately after being outside.</li>
	<li>Close windows and doors as much as possible during typical allergy season.</li>
	<li>Cover the mouth and nose while working in the yard.</li>
	<li>Bathe dogs and cats at least twice a week to reduce dander.</li>
	<li>Remove carpets from the bedroom to avoid dust mites. 
	&nbsp;</li>
</ol>

According to a recent study, a single 300 mg omalizumab injection can be administered 2 weeks before the beginning of the pollen season to provide better overall symptom control and quality of life. This also relieves drug use in individuals with seasonal allergic rhinitis as compared to routine pharmacotherapy<a href="#accordion">[8]</a>. 
&nbsp;

Key Points

<ul>
	<li>Allergic rhinitis is an atopic condition characterized by sneezing, postnasal drip, nasal itching, and congestion.</li>
	<li>Allergic rhinitis (also known as hay fever) is brought on by numerous indoor and outdoor allergens, including dust mites, mold, and pet dander along with plant and tree pollen. Even perfumes, hairspray, and simply being in the vicinity of wood smoke can cause it.3.&nbsp; Patients with rhinitis are classified into one of four types: mild intermittent, mild persistent, moderate/severe intermittent, and moderate/severe persistent.</li>
	<li>Allergies that begin in the spring (late April and May) are frequently due to tree pollen.</li>
	<li>Allergies that occur in the summer (late May to mid-July) are due to grass and weed pollen.</li>
	<li>Allergies that occur in the fall (late August to the first frost) are due to ragweed.</li>
	<li>Antihistamines can be used to treat allergies. They function by preventing the body from producing histamine</li>
	<li>Decongestants can be used for a brief duration, often no more than 3 days, to reduce sinus pressure and stuffy nose symptoms.</li>
	<li>The doctor may advise immunotherapy or allergy injections if it&rsquo;s a case of severe allergies. 10.&nbsp; Staying indoors during the season of high pollen, refraining from exercising outdoors in the morning&nbsp;and showering and changing clothes right after being outside help. 
	&nbsp;</li>
</ul>

[1] Akhouri S, House SA. Allergic Rhinitis. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[2] Allergic rhinitis (hay fever): Symptoms, diagnosis & treatment (no date) Cleveland Clinic.

[3] Staff, F.E. (2022) Allergic rhinitis (allergies), familydoctor.org.

[4] Moore, K. (2019) Allergic rhinitis: Symptoms, treatment, and home remedies, Healthline. Healthline Media.

[5] Nur Husna, S.M. et al. (2022) Allergic rhinitis: A clinical and pathophysiological overview, Frontiers. Frontiers.

[6] Proceedings of the American Thoracic Society - ATS Journals.

[7] Hay fever (rhinitis): Symptoms & treatment (2022) ACAAI Public Website.

[8] Zhang Y, Xi L, Gao Y, et al. Omalizumab is effective in the preseasonal treatment of seasonal allergic rhinitis. Clin Transl Allergy. 2022;12(1):e12094. Published 2022 Jan 4. doi:10.1002/clt2.12094