Rhinitis, Allergic

Key Features

Essentials of Diagnosis

• Clear rhinorrhea, sneezing, tearing, eye irritation, and pruritus

• Associated symptoms include cough, bronchospasm, eczematous dermatitis

• Environmental allergen exposure in the presence of allergen specific IgE

General Considerations

• Seasonal allergic rhinitis is most commonly caused by pollens and spores

• Dust, household mites, air pollution, and pet dander may produce year-round symptoms, termed "perennial rhinitis"

• Climate change may have an impact on the occurrence of allergic rhinitis since increased temperature and carbon dioxide exposure cause increased pollen production in ragweed plants

Demographics

• Prevalence: 20–30% of adults and up to 40% of children

• Costs about $6 billion annually in the United States

Clinical Findings

Symptoms and Signs

• Nasal symptoms are often accompanied by eye irritation, pruritus, conjunctival erythema, and excessive tearing

• Symptoms of "hay fever" are similar to those of viral rhinitis but are usually persistent and may show seasonal variation

• Physical examination may reveal inflamed, edematous, or even pale boggy nasal mucosa

• The mucosa of the turbinates is usually pale or violaceous because of venous engorgement; this is in contrast to the erythema of viral rhinitis

• Nasal polyps, which are yellowish boggy masses of hypertrophic mucosa, may be seen

Differential Diagnosis

• Viral rhinitis (common cold)

• Viral conjunctivitis

• Vasomotor rhinitis (eg, cold air or irritant-induced)

• Acute or chronic sinusitis

• Rhinitis medicamentosa (drug-induced rhinitis)

• Nasal polyposis

• Foreign body

• Granulomatosis with polyangiitis

Diagnosis

Laboratory Tests

• Usually a clinical diagnosis

• Confirmation of IgE-mediated hypersensitivity to aeroallergens is occasionally indicated

• Allergy skin tests or radioallergosorbent testing (RAST) or enzyme-linked immunosorbent assay (ELISA) are available to detect specific IgE

Treatment

Medications

INTRANASAL CORTICOSTEROID SPRAYS

• More effective—and frequently less expensive—than nonsedating antihistamines

• Available preparations include

  • Beclomethasone (42 mcg/spray twice daily per nostril)

  • Flunisolide (25 mcg/spray twice daily per nostril)

  • Mometasone furoate (200 mcg once daily per nostril)

  • Budesonide (100 mcg twice daily per nostril)

  • Fluticasone propionate (200 mcg once daily per nostril)

• All intranasal corticosteroids sprays are considered equally effective

ANTIHISTAMINES

• Antihistamines

  • Loratadine (10 mg orally once daily), desloratadine (5 mg once daily), and fexofenadine (60 mg twice daily or 120 mg once daily) are nonsedating

  • Cetirizine (10 mg orally once daily) is minimally sedating

  • Brompheniramine or chlorpheniramine (4 mg orally every 6–8 hours, or 8–12 mg orally every 8–12 hours as a sustained-release tablet)

  • Clemastine (1.34–2.68 mg orally twice daily) may be less expensive though usually associated with some drowsiness

• Azelastine (two sprays per nostril, 1.1 mg/day), an H₁-receptor antagonist ...