Hay Fever (Allergic Rhinitis)
Rhinitis is inflammation of the nose; the symptoms of which can be sneezing, runny nose, blocked or stuffy nose, itching and dripping nose. It can be accompanied by inflammation of the eyes and/or sinuses. Rhinitis can have several causes, such as infection, a reaction to medication, irritation by dusts, or allergy - and at certain times of the year, pollen is a major culprit for the majority of hayfever sufferers.
Grass pollen is the most common allergen, which affects sufferers at the specific times of the year when grass pollen is released (May–July). However, some people become allergic to tree or weed and shrub pollens, and will therefore be affected at different times of the year (February–June for trees; June to September for weeds; peak time September and October for moulds, although present most of the year). The patient who is allergic to tree, grass and weed pollens may suffer a very prolonged 'hay fever' season. Rhinitis which occurs for only part of the year in this way is called seasonal allergic rhinitis.
In response to exposure of an allergen the body’s immune system overreacts and releases chemicals (mediators) which cause inflammation. Some of these mediators (e.g. histamine) work quickly, causing sneezing, itching and runny nose. The eyes may also be affected, with itching, redness and watering (allergic conjunctivitis). Other mediators, cause a blocked or stuffy nose and sinuses, which may lead to headache and difficulty sleeping.
Rhinitis is often regarded as a trivial problem but studies have shown that it severely affects people's quality of life. It disturbs sleep, impairs daytime concentration and the ability to carry out tasks, causes people to miss work or school, and has been shown to affect children’s school exam results.
People who suffer rhinitis are at increased risk of developing asthma. Inflammation at the beginning of the airway (the nose) frequently affects the lower airways leading to the lungs, and this has led to the 'one airway' approach to treatment. Many asthmatics also suffer rhinitis and their asthma is better controlled and they have and less A&E and hospital admissions if their rhinitis is treated effectively.
Rhinitis can be managed by:
1. Avoidance of the allergic trigger (pollens, moulds, house dust mite etc.)
Allergen avoidance is difficult for people with allergy to substances in the air, such as pollen. For example, tiny pollen spores are windborne and travel for miles on air currents. However, many people do benefit from allergen avoidance to house dust mite and pets, while some simple measures, such as the use of an allergen barrier balm applied around the nostrils, can help to prevent allergens entering the nose and triggering symptoms. Nasal rinses with a normal saline solution are available to wash away allergens even for babies. These can be used as frequently as required and in conjunction with prescribed or over-the-counter medications.
The following measures can be helpful:
- Monitor pollen forecasts daily and stay indoors wherever possible when the count is high (generally on warmer, dry days). Rain washes pollen from the air so counts should be lower on cooler, wet days
- Limit time spent in rural areas. Sea breezes blow pollen inland, so escape to the coast instead
- Use a saline nasal wash to remove pollens and allergens
- Apply an effective allergen barrier balm around the edge of each nostril to trap or block pollens and other allergens and help prevent a reaction. Allergen barriers are available as balms or gel nasal sprays and some people have found petroleum jelly can help
- On high pollen days, shower and wash your hair after arriving home and change your clothing
- Keep windows closed when indoors. This is most important in the early mornings, when pollen is being released, and in the evening when the air cools and pollens that have been carried up into the air begin to fall to ground level again
- If you suffer symptoms indoors, a good air filter should help. Choose one that is proven to trap even small particles (see the Allergy UK website for lists of approved air filters)
- Avoid mowing lawns or raking leaves yourself. If you must perform these tasks, use a filtration face mask (see Allergy UK’s products website)
- Wear wraparound sunglasses when outdoors to keep pollen allergens out of your eyes
- A hat with a peak or large brim can help keep pollens from your eyes and face
- Avoid drying washing on a clothes-line outside when pollen counts are high
- Pollen counts tend to be high along roads with grass verges (dual-carriageways, motorways). Keep car windows closed and the air intake on 're-circulate' when driving. Choose a car that is fitted with an effective pollen filter, or get an in-car air filter
- Choose hypo-allergenic eye make-up, especially mascara
- Don't let pets get close to your face as they can carry pollen in their fur. Wipe pets’ coats with a damp microfibre cloth to remove pollens when they have been out
- Use goggles when swimming, whether in the sea or in a pool.
2. Treatments that suppress the symptoms of rhinitis
Antihistamines reduce histamine production, the trigger in the initial symptoms of rhinitis. They are available as tablets (liquids are available for children) although antihistamine nasal sprays are also effective. There are a large range of antihistamines; the recommended ones are mostly taken once daily and do not cause drowsiness in most people. This form of treatment can be all that is needed if symptoms are mild and is most effective for sneezing or an itching and runny nose, but not for a blocked nose. If the first antihistamine you try is not helping, switch to another after discussing with your GP.
If your symptoms persist, the regular use of a steroid nasal-spray to treat the inflammation is required, especially if a blocked nose is a problem. These are available from pharmacists or on prescription from your GP. As with antihistamines, there are different types of steroid nasal spray and you may need to try more than one to find the best solution. Ideally nasal sprays should be started a week or two before your symptoms usually start to give the best effect. For moderate to severe symptoms, a spray that contains steroid plus antihistamine can now be prescribed by your GP.
Cromoglycate nasal sprays are useful alternatives to antihistamines in some people especially in children as they relieve mild inflammation it is essential to use nasal sprays correctly. Refer to the instructions with the spray.
Additional drugs are available on prescription for people who suffer seasonal asthma as well as hay fever symptoms.
Nasal sprays that contain decongestants may be useful on the worst days or for additional relief of congestion for an exam or special occasion but should not be used regularly because after a few days use, they can make symptoms worse. In addition to proper treatment, proprietary non-drug solutions that douche or wash-out mucus from blocked noses and sinuses give temporary relief.
Antihistamines and steroid nasal sprays often control eye symptoms as well but eye drops are available over-the-counter or on prescription if needed. Cromoglycate drops are often effective but your GP can prescribe more effective drops for severe allergic eye symptoms.
All rhinitis treatments should be taken regularly as it is more difficult to control symptoms that are already well established. Only taking medications occasionally on the worst days is much less effective and you should aim to start using the preventative / treatment nasal sprays two weeks before your symptoms usually begin.
3. Treatments that alter the immune system response to the allergen
Specific immunotherapy (sometimes referred to as desensitisation) is a treatment for those with very severe allergic rhinitis despite correct use of all prescribed drugs. The allergic person is given increasing doses of allergen frequently until a maintenance dose is reached. A maintenance dose is then given regularly for a certain period. It can be a very successful treatment for severe allergic rhinitis, as it causes the body to develop ‘regulatory’ immune cells which control the allergic reaction and results in tolerance to the allergen. It has been used for many decades but must be prescribed and controlled by hospital allergy specialist. Immunotherapy is available in two main forms, either as injections, or as drops or a tablet which dissolves under the tongue (sublingual therapy). To date, the most effective treatment is a course of injection immunotherapy, which can have long lasting benefits. Injection therapy is available for allergy to pollens, house dust mite and animal allergens and bee and wasp venom. Sublingual immunotherapy is currently restricted to dust mite, pollen and some pet allergens.
As immunotherapy is so intensive and time-consuming, it is only those with extreme symptoms uncontrolled by normal medications who receive this therapy. In order to be considered for immunotherapy you will need to be referred to a specialist allergy clinic by your GP.