What are Allergies?
Allergic rhinitis is a medical term for nasal allergies. It is an extremely common condition that affects millions of Americans and is one of the most common reasons patients see their primary care doctor. The condition can affect any age group including children, adolescents, and adults.
People usually have recurrent symptoms of a runny nose, nasal congestion, sneezing, and post-nasal drip. The condition can be very bothersome and may reduce the quality of life and productivity. Symptoms usually occur during certain seasons of the year such as spring (seasonal allergic rhinitis), but in some individuals, symptoms may occur throughout the entire year (perennial allergic rhinitis).
What Causes Allergies?
Allergic rhinitis is usually caused by allergens in the environment such as:
- Pet dander
- Dust mites
- Insects (cock roaches)
This may occur during a particular season (e.g., spring), in certain environments (e.g., home or work), or through exposure to pets. Allergens enter the nasal passage and promote the release of histamine. Histamine is a molecule that promotes inflammation and mucous secretion, resulting in swelling of the nasal passages and nasal congestion.
Inflammation in the nasal passage also results in a runny nose and the drainage of mucous behind the throat (post nasal drip). This leads to frequent clearing of the throat and cough. Symptoms can worsen if individuals are exposed to cigarette smoke.
How Common are Allergies?
Allergic rhinitis affects an estimated 20 to 40 million people in the United States. This may actually underestimate its true prevalence since the condition is not life threatening and many individuals do not seek medical evaluation for their symptoms. In fact, patients frequently treat themselves with over-the-counter medications.
Signs and Symptoms
Symptoms of allergic rhinitis can be similar to the common cold. The most common symptoms of allergic rhinitis include the following:
- Runny nose
- Nasal congestion
- Sneezing & nasal itching
- Post nasal drip
- Throat clearing & cough
Signs of allergic rhinitis include swollen nasal passages, clear mucous drainage from the nose, and a finding called “cobblestoning” on physical examination. Cobblestoning is a phenomenon that can be seen in the back of the throat and occurs because of long-term inflammation and activation of the lymphatic system. Enlarged lymphatic tissues have raised appearances that resemble cobblestones, hence the term cobblestoning.
People with allergies tend to have other symptoms associated with allergic rhinitis, such as eye allergies (allergic conjunctivitis), asthma, and hives (allergic rash).
Allergic rhinitis is a clinical diagnosis, meaning your doctor can diagnose it based on your symptoms and signs on physical examination. There are no specific tests to make the diagnosis.
Sometimes, if your symptoms are severe, your doctor will order skin or blood allergy tests to determine if you are a candidate for immunotherapy.
Allergy Medicine and Treatment
The treatment of allergic rhinitis includes avoiding allergens, medical therapy, and occasionally immunotherapy.
The first line treatment of allergic rhinitis is a class of medications called intranasal corticosteroids. Corticosteroids reduce inflammation, which is the main cause of a runny nose, nasal congestion, and post-nasal drip. There are various types of intranasal corticosteroids and now some of these agents are available over-the-counter. The most common intranasal corticosteroids include:
These medications can start working within hours, but their maximal effectiveness occurs after 1-2 weeks of daily or twice daily use.
These medications are also usually well tolerated and have no significant systemic side effects. Some side effects may include:
- Bloody nose
- Perforation of the nasal septum
- Oral candidiasis (yeast infection of the mouth)
There is some evidence that long-term use may be associated with osteoporosis and impaired bone growth in young patients.
An alternative to intranasal corticosteroids are intranasal antihistamines. The most common intranasal antihistamine is Astelin (azelastine). As we mentioned, histamine released in the nasal passages promotes inflammation. Therefore, intranasal antihistamines reduce the ability of histamine to start the inflammatory process, thereby decreasing nasal inflammation and symptoms of allergic rhinitis.
In addition to intranasal medications, individuals with allergic rhinitis may benefit from oral antihistamines. These include:
Oral antihistamines are frequently combined with intranasal corticosteroids if corticosteroids are not effective enough in reducing symptoms. Some antihistamines (e.g., Benadryl and sometimes Zyrtec) can cause sedation; therefore, these medications should be avoided during the day. These medications should also be avoided in elderly individuals as they can lead to confusion and increase the risk for falls.
Less commonly, medications such as Cromolyn or a class of drugs called leukotriene receptor antagonists may be recommended.
If your symptoms do not respond to the medications we have discussed so far, your doctor may prescribe a short course (1-2 weeks) of oral corticosteroids such as Prednisone or Solumedrol (e.g., Medrol dose pack). Long-term treatment with oral corticosteroids should be avoided as it can lead to weight gain, changes in mood or behavior, suppression of the immune system, diabetes, and osteoporosis.
Lastly, patients with severe allergies may benefit from seeing an allergist and receiving immunotherapy to decrease their allergic response to environmental allergens that trigger their symptoms.
- Sur DK, Plesa ML. Treatment of allergic rhinitis. Am Fam Physician. 2015 Dec 1;92(11):985-92. - https://www.aafp.org/afp/2015/1201/p985.html
- Klimek L, Mullol J, Hellings P, et al. Recent pharmacological developments in the treatment of perennial and persistent allergic rhinitis. Expert Opin Pharmacother. 2016;17(5):657-69. - https://www.ncbi.nlm.nih.gov/pubmed/26800187
- Stewart MG. Identification and management of undiagnosed and undertreated allergic rhinitis in adults and children. Clin Exp Allergy. 2008 May;38(5):751-60. - https://www.ncbi.nlm.nih.gov/pubmed/18419620
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.