Allergic Rhinitis – Causes, Signs and symptoms

Allergic Rhinitis

Also called: Hay Fever, Seasonal Allergic Rhinitis, Sporadic Allergic Rhinitis, Perennial Allergic Rhinitis

Summary

Commonly called hay fever, allergic rhinitis is an inflammation of the inner lining of the nose that occurs when an allergic individual encounters an airborne allergen such as pollen, mold, dust mites or animal dander. Usually inhaled, these triggers generate allergy symptoms such as sneezing, coughing, runny nose, sore throat and itchy or watery eyes. Allergic rhinitis is very common, with an estimated 20 percent of Americans suffering from the condition, according to the American College of Allergy, Asthma and Immunology.

There are many types of related rhinitis, each with its own allergy trigger and symptoms. The two main types of allergic rhinitis are:

  • Perennial allergic rhinitis (PAR). Symptoms appear year-round.

  • Seasonal allergic rhinitis (SAR). Symptoms vary by the time of year.

SAR is the most common type of allergic rhinitis due to the heavy amounts of various pollens present at different times of the year. However, PAR is generally considered more uncomfortable since sufferers are often also sensitive to indoor allergens such as dust mites and pet dander.

There are other types of rhinitis that should not be confused with allergic rhinitis. All types of rhinitis affect nasal and sinus function. However, many other types of rhinitis respond to triggers that differ from those of allergic rhinitis (such as hormones, drugs or changes in weather). These fall into a general category of non-allergic rhinitis. Causes may include:

  • Infection, such as the flu or common cold

  • Nasal polyps

  • Hormonal imbalance, caused by pregnancy or other factors

  • Overuse of over-the-counter nasal sprays

  • Use of certain medications

  • Exposure to cold temperatures, high humidity, chemicals or other irritants

  • Structural problems within the nose or nasal passages

  • Eating spicy or hot temperature foods

It is important to note that allergic rhinitis is not a cold (infectious rhinitis). Cold symptoms and allergy symptoms are often similar, and diagnosing an allergy can be difficult as a result. Generally allergy symptoms persist for a longer period of time than cold symptoms (more than seven days).

To test for the condition, physicians will first need to rule out other potential causes of rhinitis. This begins with a review of the patient’s medical history.

Individuals with a family medical history of allergies are more likely to suffer from allergic rhinitis, particularly those with a history of asthma or eczema. In addition, uncontrolled allergic rhinitis may lead to a worsening of asthma.

Once allergic rhinitis is suspected, the next step is to identify the specific allergens to which the patient is sensitive. This is usually accomplished through skin testing, which involves exposing the patient’s skin to possible allergens to see if a reaction (rash) occurs, but may include blood tests as well.

The best way to treat allergic rhinitis is to avoid or limit exposure to the allergen as much as possible. Avoidance techniques will vary depending on the type of allergy. For instance, people with outdoor allergies may be advised to stay indoors on days with high pollen counts and keep windows and doors closed. People with either outdoor or indoor allergies may be advised to run their air conditioners frequently and use filters capable of removing allergens (such as mold spores) from the air.

Since it is often difficult to avoid airborne substances entirely, there are several different kinds of medication available for the treatment of allergy symptoms. Antihistamines, corticosteroids, leukotriene modifiers and decongestants are all effective at treating different types of allergic rhinitis symptoms.

When allergies cannot be controlled by avoidance or medications, allergy shots (immunotherapy) may be recommended. Taken over a period of months or years, these shots can help people build up a tolerance to their allergen triggers. This, in turn, can lead to the prevention or reduction of allergy symptoms. However, this form of treatment may not work at all, or may even cause a severe reaction in people who are especially sensitive to allergies.

About allergic rhinitis

Allergic rhinitis (hay fever) is a condition that affects an estimated 20 percent of Americans every year, according to the American College of Allergy, Asthma and Immunology. The condition is an allergy-induced inflammation of the nasal passages, throat and eyes. This is caused by certain trigger proteins found in airborne substances such as pollens and molds.

Non-allergic rhinitis produces symptoms similar to allergic rhinitis. However, it is actually caused by viruses or irritants (e.g., cigarette smoke, pollution, fragrances, paint fumes) and is not triggered by allergens. Because of the similarities, it may be difficult to distinguish between the two.

Because many types of pollen vary by season, allergic rhinitis is worse in the spring and mid to late summer for many people. However, those people who are allergic to indoor allergens such as dust mites, mold and animal dander often experience symptoms year-round.

Geography can also play a role in the timing and severity of rhinitis symptoms. Some plants pollinate later in the year if they are located farther to the north (or farther to the south in the Southern Hemisphere). For example, grasses in the north will often pollinate later in the spring or summer than grasses in the south because of the milder southern winters. Ragweed pollen is the main culprit in about 75 percent of allergic rhinitis cases. Ragweed appears in all parts of the United States in varying levels. It is less prevalent west of the Rockies.

Allergic rhinitis occurs when an airborne allergen gains access to the body, usually through the nose (though sometimes through ingestion or skin contact). To ward off the proteins in the allergen that the immune system has misidentified as a threat, IgE antibodies are produced. The IgE triggers the body’s mast cells, which in turn release powerful chemicals, such as histamines and leukotrienes. This sequence of events is known as an allergic cascade.

Histamines are directly responsible for most of the symptoms associated with an allergy. They cause itching, swelling and fluid leaking from cells, particularly in the tissues of the nose, skin, throat and lungs. In allergic rhinitis, the effects of histamines can be localized in specific areas, such as the:

  • Nose and nasal passages (rhinitis)
  • Sinuses (sinusitis)
  • Paranasal sinuses, adjacent to the nose (rhinosinusitis)
  • Tissues around the eye (conjunctivitis)

Histamine causes liquid to be produced in the membranes of the nose and sinuses (by dilating the small blood vessels located there). This causes mucus to form in the nose and sinuses, leading to congestion and sneezing. Histamine also causes tissues to swell in the nose and sinuses, which can further interfere with nasal and sinus function. Mucus dripping from the back of the nose and into the upper throat (known as postnasal drip) can cause coughing and sore throat.

The nasal tissues often go through a cycle of congestion and decongestion that lasts for several hours. People may experience nasal congestion switching back and forth along this cycle. If the congestion in the sinuses becomes severe enough, facial pressure and pain are often the result. Allergic rhinitis is often accompanied by allergic sinusitis, allergic rhinosinusitis and/or allergic conjunctivitis.

People with a family history of allergies are more likely to develop allergic rhinitis, particularly those people with other allergy-related conditions, such as eczema and asthma. Although allergic rhinitis can develop at any age, it usually appears in individuals before the age of 30.

Uncontrolled, allergic rhinitis can seriously impair quality of life. It can interfere with sleep, resulting in daytime sleepiness, and affect the ability to learn and perform tasks. In addition, untreated or improperly treated allergic rhinitis may eventually lead to other complications. These include chronic ear infections (otitis media) and ear dysfunction. Nasal polyps have also been associated with allergic rhinitis, though the connection is unclear.

The severity of allergic rhinitis symptoms usually improve as a patient ages. However, the condition can worsen over time in some people.

Types and differences of allergic rhinitis

All types of rhinitis are broken down into two classifications. Rhinitis that lasts for less than six weeks is called acute rhinitis. Rhinitis that continues to persist beyond six weeks is called chronic rhinitis.

Allergic rhinitis is broken up into three categories depending on the frequency and timing of symptoms. These are:

  • Seasonal allergic rhinitis (SAR). Individuals with this type of rhinitis have an immune system that reacts at different times of the year depending on the types of outdoor airborne allergens present. Seasonal allergens typically include tree, grass and weed pollens as well as outdoor molds. The severity of seasonal allergic rhinitis varies by seasons and geographies.

  • Perennial allergic rhinitis (PAR). Individuals with this condition have an immune system that reacts to indoor airborne allergens such as dust mites, indoor molds and animal allergens. Because these allergens are found indoors and do not vary by season, this type of rhinitis affects individuals year-round. In certain locations where pollen or mold is present all year, individuals may suffer from perennial rhinitis outdoors.

  • Sporadic allergic rhinitis. Individuals with this condition have occasional, sporadic episodes of allergic rhinitis caused by exposure to an allergen. Episodes are triggered when the person comes into contact with allergens to which they are not normally exposed. For instance, a person who is allergic to horse hair might have an episode of sporadic allergic rhinitis while visiting a ranch. In addition to airborne allergens like pollen and molds, sporadic allergic rhinitis can also be triggered by food allergies.

The various forms of allergic rhinitis often cause similar symptoms related to the sinuses (allergic sinusitis) and/or eyes (allergic conjunctivitis). In addition, more than one form of allergic rhinitis can occur in the same person.

Not all forms of rhinitis are allergy related. Those not associated with an allergic reaction belong to the general category of non-allergic rhinitis. Non-allergic rhinitis may result from a number of factors, including irritants (e.g., cigarette smoke, pollution, fragrances, paint fumes) or infections.

Occupational rhinitis is a classification sometimes used to describe episodes of allergic rhinitis that are triggered by allergens in the work place. However, occupational rhinitis can be caused by a range of both allergic and non-allergic factors.

Types of non-allergic rhinitis include:

  • Infectious rhinitis. Rhinitis caused by a virus or a bacterial infection, such as the flu or common cold. This condition is not sensitive to a specific allergen. Instead, it is caused by viruses or bacteria. If viral, symptoms usually resolve in three to seven days, but occasionally last longer. If bacterial, antibiotics may be used to treat the infection.

  • Neutrophilic rhinosinusitis. A type of infectious rhinitis commonly triggered by a sinus infection or related condition. It is often associated with viral infections (including colds and the flu). Symptoms usually include postnasal drip and sinus pain.

  • Structural rhinitis. Rhinitis caused by abnormalities in the structure of the nasal septum. These are often the result of an injury or birth condition (such as a crooked nasal passage). The condition is characterized by year-round congestion. Surgery can be effectively used to correct the problem.

  • Hormonal rhinitis. Rhinitis caused by hormone imbalances that occur with conditions such as pregnancy and hypothyroidism. Symptoms experienced during the pregnancy usually disappear after delivery.

  • Drug-induced rhinitis. Rhinitis that results from exposure to a number of medications, including ACE inhibitors, beta blockers, aspirin, some nonsteroidal anti-inflammatory drugs, and oral contraceptives and medications to treat high blood pressure (antihypertensives), erectile dysfunction and some psychiatric conditions. Cocaine use can also cause this condition.

  • Rhinitis medicamentosa. Rhinitis caused by frequent use of over-the-counter nasal sprays. It is characterized by severe nasal congestion. Discontinued use of nasal sprays (temporarily or permanently) will often improve the condition.

  • Eosinophilic rhinitis. Rhinitis caused by weather changes or air pressure variations. It may also be referred to as NARES (non-allergic rhinitis with eosinophilia syndrome). Symptoms are similar to perennial allergic rhinitis (PAR). Therefore, it is often eliminated as a cause of rhinitis before a diagnosis of PAR is made.

  • Gustatory rhinitis. Rhinitis that occurs after eating food, especially foods that are hot in temperature or very spicy. This is not the form of rhinitis associated with food allergies.

  • Vasomotor rhinitis. Rhinitis caused by all factors not covered in other categories. It is sometimes called irritant rhinitis, because symptoms are usually triggered by environmental factors, such as exposure to inhaled irritants, cold air, high humidity, strong odors or even stress. It is characterized by congestion, sneezing and runny nose.

Related conditions with allergic rhinitis

The histamine releases that occur as part of an allergic reaction can occur anywhere in the body. For this reason, allergic rhinitis is often accompanied by other conditions. These conditions are most likely to affect the functions of the nasal and sinus cavity where rhinitis symptoms persist. Conditions related to allergic rhinitis include:

  • Chronic sinusitis. An inflammation of the lining of the sinus cavities that can develop if allergic rhinitis symptoms persist for several years.

  • Allergic sinusitis.  Sinus cavity inflammation that is triggered by an allergic reaction.

  • Nasal polyps. Small growths in the lining of the nose that can develop and restrict normal breathing and sense of smell.

  • Rhinosinusitis. An inflammation of the paranasal sinuses (which are adjacent to the nose and lined with mucous membranes) that occurs with rhinitis. The condition frequently occurs in patients with non-seasonal allergies and in those with moderate to severe asthma.

  • Allergic conjunctivitis. Inflammation of the tissue lining the inside of the eyelid and caused by an allergic reaction. This condition can occur both seasonally and perennially.
  • Allergic bronchitis. Inflammation of the lung’s airways (bronchial tubes) that is brought on by an allergic reaction. The condition results in a persistent cough that produces large amounts of phlegm.

Asthma (a chronic inflammation of the body’s bronchial tissues) and eczema (an inflammatory skin disease) are also related to allergic rhinitis. People with these conditions are more likely to develop allergic rhinitis. In addition, uncontrolled allergic rhinitis may lead to a worsening of asthma.

Potential causes of allergic rhinitis

Allergic rhinitis is usually triggered when an allergic individual comes into contact with proteins found in certain airborne particles. These proteins can come from a variety of sources, but usually include:

  • Pollen. Small, powdery grains of flowering plants that can easily become airborne. These are most often produced by trees, grass and weeds.

  • Mold and mildew. Tiny fungus spores that can become airborne. These often thrive outdoors in soil, vegetation and rotting wood. They can be found indoors as well, especially in damp areas, basements and bathrooms.

  • Dust mites. Microscopic insects that inhabit household dust. They are often found indoors where there is less air circulation and on surfaces like carpets, bedding and stuffed animals.

  • Animal dander. Tiny scales or particles from an animal’s skin. These very often come from a dog or cat.

  • Cockroach debris. Droppings, eggs, saliva and small pieces of outer shell of cockroaches. These can be found indoors, even if an infestation of live pests is not currently a problem.

Most people are allergic to the proteins found in pollens and molds – which can easily become airborne and spread by the wind (like most allergic rhinitis allergens). When these allergens are inhaled (touching the lining of the inner nose), an allergic reaction is triggered. Although less common, reactions can also be triggered when the allergen is ingested (eaten) or comes in direct contact with the skin.

Because the airborne levels of pollen and mold change with the seasons, allergic individuals are more likely to experience symptoms during specific times of the year. Rhinitis allergies usually flare up in the spring when plants begin to bloom and release pollen. Some trees begin to pollinate as early as January in the southern United States and April in the northern states. By late spring, grasses are pollinating – followed by weeds in the summer and fall. Warmer climates will see outdoor mold spore growth peak by midsummer.

People susceptible to indoor molds, dust mites and pet dander often suffer allergy symptoms throughout the year.

Signs and symptoms of allergic rhinitis

Allergic rhinitis involves swelling in the sinuses and in the passage leading from the throat to the middle ear. Because of this, the most common symptom associated with allergic rhinitis is frequent and prolonged sneezing. Other common symptoms may include:

  • Itchy and runny nose
  • Congestion
  • Redness, swelling and itching of the eyes
  • Itchy and sore throat
  • Coughing
  • Ear infections and sinus infections
  • Postnasal drip
  • Fatigue
  • Facial pressure and pain

These symptoms often vary in severity depending on the individual and the environment. However, they will usually last throughout an entire season (with seasonal allergic rhinitis) or throughout the entire year (with perennial allergic rhinitis). The most severe cases are considered extremely uncomfortable and can make it difficult to carry out even everyday tasks.

It is important to note that symptoms occur less often in infants and young children. When they do occur, symptoms may cause the child to become irritable and interfere with feeding.

Diagnosis methods for allergic rhinitis

When allergic rhinitis is suspected, the first step is usually to perform a physical examination and obtain a complete medical history. Obtaining the patient’s medical history is important because the presence of other allergies, asthma or eczema raises the likelihood of a person having allergic rhinitis. A family history where allergies are common is another factor that predisposes a person towards allergic rhinitis. Typically the family history will show instances of allergic rhinitis, asthma or other airborne allergies.

The physician will ask the patient about the type of symptoms being experienced, as well as the duration of the symptoms. A physician will also take into account the time of year when evaluating a patient. The symptoms of allergic rhinitis are often seasonal, with symptoms appearing more often during the time of year when pollens and molds are most present. While the allergy season can differ by geography, most people experience allergic flare-ups in the spring or summer.

Allergic rhinitis symptoms often mimic those of a cold (non-allergic rhinitis). For this reason, diagnosing allergic rhinitis can be difficult. Generally, allergy symptoms persist for a longer period of time than cold symptoms (more than seven days), and the mucus produced in the nose during a cold is thicker than with rhinitis. Itching of the ears, nose and throat may be associated with allergic rhinitis, though usually not a cold.

The physician will also inquire about the patient’s home environment, work environment and hobbies. This will help the physician pinpoint the allergens that are triggering the symptoms.

Different types of rhinitis are triggered by different factors. Before a diagnosis of allergic rhinitis is made, physicians must be sure another type of rhinitis is not to blame. Changes in the weather, hormones in the individual or physical defects in the nasal septum (partition in the nasal cavity) can all cause rhinitis symptoms.

Once other potential causes of symptoms are ruled out, the next step in diagnosing allergic rhinitis is to identify the specific allergen triggering symptoms. The most common method of identifying allergens is skin testing. Trace amounts of a variety of different allergens are introduced to the patient’s skin. For each specific allergen, a different area of skin is used. When an area of skin reacts with a wheal or a raised red bump (skin rashes), the patient is likely allergic to that specific allergen.

Blood tests, such as a radioallergosorbent test (RAST Test), may be performed to measure the amount of IgE produced by a particular allergen. In addition, x-rays or other types of imaging tests may be performed to rule out other causes of rhinitis, such as possible structural abnormalities, or to detect complications caused by rhinitis.

Treatment options for allergic rhinitis

While there is no medication available that can cure allergic rhinitis, there are several types of medication available to address its symptoms.  Some medications are taken after the allergic reaction has occurred, to relieve symptoms. Others are taken regularly to accomplish one or more of the following:

  • Prevent the onset of symptoms entirely
  • Reduce the severity of symptoms when they occur
  • Reduce the frequency of allergic reactions

Depending on the severity of a patient’s symptoms and other factors, a physician can create a customized treatment program. This can often involve a combination of medications, including:

  • Antihistamines. Medications used to treat allergy symptoms such as sneezing, runny nose and itchy and watery eyes. Antihistamines work by neutralizing the effect of histamines that are released in the bloodstream during an allergic reaction.

  • Corticosteroids. Medications used to reduce the inflammation associated with symptoms such as nasal stuffiness, sneezing and runny nose. Corticosteroids work by enhancing the body’s ability to counteract the swelling, inflammation and mucus secretions caused by an allergic reaction.
  • Antihistamines can reduce symptoms when taken after the allergic reaction begins. However, they are most effective when taken 3 to 5 hours before coming into contact with an allergen – or on a regular basis. They can be taken as pills, liquids, nasal sprays, topical creams or eye drops. Short lasting, over-the-counter (OTC) antihistamines are commonly available, though stronger versions are available with a prescription.
  • Corticosteroids are most effective when taken on a daily basis, even when symptoms are not present. It often takes three to 10 days of treatment for this drug to reach full effect. Nasal corticosteroids (in the form of nasal spray) are the most effective method of delivery.
  • Leukotriene modifiers. Medications used to prevent both allergic rhinitis symptoms and asthma-related symptoms. This form of treatment effectively disrupts the leukotrienes that the immune system produces during an allergic reaction. Leukotrienes are often involved with the constriction of airways in the lungs.
  • Leukotriene modifiers are effective when used prior to an allergic reaction because they work to disrupt a specific chemical process in the allergic cascade, preventing some types of leukotriene from forming in the body. While these medications are primarily used in the prevention of asthma-related symptoms, some forms are finding increased use in the prevention of allergic rhinitis. They are taken daily or several times daily.
  • Decongestants. Medications used to reduce nasal congestion, swelling and redness. Often prescribed in combination with antihistamines for the treatment of allergic rhinitis, decongestants work by constricting swollen nasal tissues, which prevents fluid and mucus from forming.
  • They are available both OTC and by prescription and can be taken as pills, nasal sprays or eye drops. However, people should avoid overusing OTC nasal spray decongestants for longer than three days because this can actually cause a rebound in symptoms.
  • Allergy shots are one form of treatment that can prevent allergy symptoms from occurring for long periods of time. When using this type of immunotherapy, a person is gradually exposed to increasing amounts of a diluted allergen, administered through regular injections over a period of weeks, months or years. Eventually, a person builds up enough of a tolerance to the allergen that their symptoms are reduced (when encountering that particular allergen). The effectiveness of allergy shots varies from individual to individual. Allergy shots are usually reserved for patients who are unable to take or tolerate allergy medication, are unable to avoid allergen exposure or are unable to have their allergy symptoms adequately controlled by other methods.

Prevention methods for allergic rhinitis

The most effective way of controlling allergy symptoms is avoidance. By controlling the environment and minimizing exposure to known allergens, an individual can greatly limit the number and severity of allergic reactions. While this treatment method is not easy, there are several basic steps that can prevent contact with the pollens or molds that trigger allergic rhinitis. These steps include:

  • Stay indoors as much as possible during the pollen season (high pollen counts), and windy and humid days
  • During allergy season, try to keep windows and doors closed at home and in the car
  • Use air conditioning in the home and car, which cleans and dries out the air
  • Use an air filter that can remove allergens from the air, such as HEPA filters
  • Use a dehumidifier to prevent the growth of mold by reducing humidity
  • Avoid yard work that could stir up pollen and molds – such as mowing the lawn or raking leaves
  • Avoid early morning outdoor activities, when pollen counts are typically higher
  • Avoid hanging laundry outdoors to dry because pollens can collect on fabrics
  • Wash pets frequently to minimize the amount of allergens on their skin and coats
  • Shower frequently to wash airborne allergens from hair and skin

Other steps may be necessary for those individuals who are susceptible to specific types of allergen triggers. For instance, people allergic to dust mites should place dust-proof encasements on pillows, mattresses and box springs to take care of any moisture problems in the house. People allergic to their pets should remove the animals from the house, if possible, or at least keep the animals out of the bedroom.

Allergy shots (immunotherapy) may also be recommended as a prevention method. The treatment involves exposing an individual, through an injection, to a small dose of an allergen for allergic rhinitis. By repeating this process several times over a period of weeks, months or years, a physician can gradually reduce a person’s sensitivity to a particular allergen. The success of this treatment varies from individual to individual. Allergy shots are typically used when a person is not receptive to other forms of treatment, or the allergy is not adequately controlled by other methods.

Moving to another location to avoid seasonal allergies is usually not worth the trouble involved. While pollen levels can be particularly bad in some areas, ragweed pollen (which is a trigger for most people with allergic rhinitis) is found throughout the United States, including Alaska and Hawaii. Many times, a person will move to escape one type of airborne allergen (e.g., ragweed pollen), only to develop a sensitivity to a different type of allergen (e.g., grass pollen) in the new location.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about allergic rhinitis:

  1. Do my symptoms indicate allergic rhinitis?
  2. What tests will you use to determine the cause of my symptoms?
  3. What allergens are triggering my allergic rhinitis?
  4. What type of allergic rhinitis do I have?
  5. Does allergic rhinitis pose a danger to my overall health?
  6. What are my treatment options?
  7. Will I experience symptoms year-round or just at certain times of year?
  8. Will I need to take medication every day or just at certain times?
  9. How can I avoid the allergens that trigger my allergic rhinitis?
  10. Are my children more likely to develop allergic rhinitis because I have the condition?
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