Allergic Rhinitis
IgE-mediated nasal mucosal inflammation from inhaled allergens, producing congestion, rhinorrhea, sneezing, and itch.
Also known as: allergic rhinitis, hay fever, seasonal allergies, perennial rhinitis
Overview
IgE-mediated inflammation of the nasal mucosa triggered by inhalation of environmental allergens. Classified by pattern (seasonal vs perennial), frequency (intermittent vs persistent), and severity (mild vs moderate-severe).
Epidemiology
Affects 10-30% of US adults and up to 40% of children. Often coexists with asthma, atopic dermatitis, and food allergy ('atopic march'). Onset usually in childhood or adolescence; can persist or develop in adults.
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Risk factors
- Personal or family history of atopy (asthma, eczema, food allergy)
- Early-life exposure to allergens (dust mites, pets, pollen, cockroach, mold)
- Maternal smoking, urban environment
- Higher socioeconomic status (hygiene hypothesis association)
Pathophysiology
First exposure: APCs present allergen → Th2 differentiation → IL-4/IL-13 drive B-cell IgE production → IgE binds mast cells. Re-exposure: allergen crosslinks IgE on mast cells → degranulation with histamine, tryptase, leukotrienes → early-phase sneezing, itch, rhinorrhea (minutes). Late-phase 4-8 h later: eosinophil and Th2 infiltrate → congestion and hyperresponsiveness.
Clinical presentation
Symptoms
- Sneezing, especially in paroxysms
- Clear watery rhinorrhea
- Nasal congestion / obstruction (often the most bothersome)
- Itching of nose, eyes, palate, ears
- Postnasal drip with throat clearing or chronic cough
- Decreased smell/taste; sleep disturbance
Signs / physical exam
- Allergic shiners — dark infraorbital circles from venous stasis
- Dennie-Morgan lines — infraorbital folds
- Allergic salute (transverse nasal crease in children)
- Pale, bluish, boggy turbinates with clear discharge
- Cobblestoning of posterior oropharynx
- Conjunctival injection, tearing if concurrent allergic conjunctivitis
Classic findings
Pale boggy turbinates with clear watery rhinorrhea plus allergic shiners and a transverse nasal crease in an atopic child.
Differential diagnosis
- Viral rhinitis (common cold) — Acute onset, self-limited 7-10 days, sore throat/cough, no itching, no triggers; supportive care
- Nonallergic rhinitis (vasomotor) — Triggered by odors, temperature changes, foods; no itching, negative allergy testing; intranasal steroid or ipratropium
- Acute bacterial sinusitis — Symptoms >10 days or worsening after initial improvement, facial pain/pressure, purulent discharge, fever
- Rhinitis medicamentosa — Rebound congestion from prolonged topical decongestant (oxymetazoline) use >3-5 days; taper and replace with intranasal steroid
- Nasal polyps — Persistent obstruction, anosmia, asthma + aspirin sensitivity (Samter triad); pale gray grape-like masses on rhinoscopy
- Deviated septum / structural — Unilateral fixed obstruction, no allergic features
- Foreign body (children) — Unilateral foul purulent discharge in a young child; remove
- Pregnancy rhinitis — Congestion in 3rd trimester resolves postpartum; avoid systemic decongestants
- CSF rhinorrhea — Unilateral clear watery discharge after trauma or surgery; halo sign, beta-2 transferrin positive
Diagnostic workup
Diagnostic criteria
ARIA: based on temporal pattern (intermittent <4 days/week or <4 weeks; persistent ≥4 days/week AND ≥4 weeks) and severity (mild = normal sleep/activities; moderate-severe = impaired sleep, school/work, or troublesome symptoms).
Labs
- Clinical diagnosis in most cases — history of trigger-related symptoms with characteristic findings
- Skin prick testing (allergist) — most sensitive; identifies specific allergens; antihistamines must be held 5-7 days prior
- Serum specific IgE (ImmunoCAP) — when skin testing not feasible (severe eczema, antihistamine dependence, dermatographism)
- Total IgE and eosinophil count are nonspecific and not routinely needed
Imaging
- Not required for typical allergic rhinitis
- Nasal endoscopy if structural disease (polyps, deviated septum) or chronic sinusitis suspected
- CT sinus only if complicating rhinosinusitis
Diagnostic algorithm
| Severity / Pattern | Step Therapy |
|---|---|
| Mild intermittent | Oral 2nd-gen antihistamine PRN OR intranasal antihistamine |
| Moderate-severe intermittent | Intranasal corticosteroid ± 2nd-gen antihistamine |
| Mild persistent | Intranasal corticosteroid daily |
| Moderate-severe persistent | Intranasal corticosteroid + intranasal antihistamine; reassess in 2-4 weeks |
| Refractory or quality-of-life impact | Add leukotriene antagonist, consider allergen immunotherapy (SCIT/SLIT) |
Treatment
First-line
- Allergen avoidance: dust mite-impermeable bedding covers, HEPA filters, pet dander reduction, pollen avoidance and showering after exposure
- Intranasal corticosteroid — fluticasone propionate/furoate, mometasone, budesonide, or triamcinolone — most effective single agent for moderate-severe or persistent symptoms; takes days for full effect, weeks for peak
- Second-generation oral H1 antihistamine — loratadine, cetirizine, fexofenadine, or levocetirizine — first-line for mild/intermittent symptoms
- Intranasal antihistamine — azelastine or olopatadine — fast onset (minutes); can replace or add to oral agents
- Saline nasal irrigation (neti pot, sinus rinse) as adjunct
Second-line / adjunct
- Combination intranasal corticosteroid + intranasal antihistamine (fluticasone/azelastine) for moderate-severe symptoms
- Leukotriene receptor antagonist — montelukast — particularly if concurrent asthma; FDA boxed warning for neuropsychiatric effects
- Short course oral corticosteroids only for severe refractory exacerbations
- Topical decongestant — oxymetazoline — for short-term congestion (≤5 days) to avoid rhinitis medicamentosa
- Oral decongestant — pseudoephedrine — caution in HTN, glaucoma, BPH, hyperthyroidism
- Allergen immunotherapy — subcutaneous (SCIT) or sublingual (SLIT, e.g., grass, ragweed, dust mite tablets) — disease-modifying; consider for inadequate response, side effects to medications, or desire to reduce medication burden
Complications
- Sleep disturbance with daytime fatigue and impaired school/work performance
- Acute and chronic rhinosinusitis
- Otitis media with effusion in children
- Asthma exacerbations (unified airway)
- Nasal polyposis with chronic disease
PANCE pearls
- Intranasal corticosteroids outperform oral antihistamines for nasal congestion and overall symptom control.
- First-generation antihistamines (diphenhydramine, chlorpheniramine) cause sedation and cognitive impairment — avoid as first-line; especially avoid in elderly (Beers criteria).
- Oxymetazoline use >5 days causes rhinitis medicamentosa — treat by stopping the topical, replacing with intranasal steroid, and counseling.
- Allergic rhinitis plus asthma — treating the upper airway improves lower-airway control.
- Unilateral nasal obstruction, epistaxis, or anosmia is NOT classic allergic rhinitis — evaluate for polyp, tumor, or foreign body.
References
- AAAAI/ACAAI 2017 — Wallace DV et al. Joint Task Force Practice Parameter Update: Allergic Rhinitis. Ann Allergy Asthma Immunol 2017
- ARIA 2020 — Bousquet J et al. Next-generation ARIA care pathways for allergic rhinitis. Allergy 2019;74(11):2087-2102
- AAO-HNS 2015 — Seidman MD et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg 2015;152(1S):S1-S43
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