Allergic Rhinitis & Hay Fever

Allergic rhinitis is the name given to a collection of symptoms that occur predominantly in the nose and eyes and are caused by airborne particles of dust, dander, or plant pollens in people who are allergic to these substances. When these symptoms are caused by pollen, the allergic rhinitis is commonly called hay fever.

What causes Allergic Rhinitis/Hay Fever and Who is at Risk?

Allergies are caused by an over-sensitive immune response. The immune system normally protects the body against harmful substances such as bacteria and viruses. Allergy symptoms occur when the immune system reacts to substances (allergens) that are generally harmless and in most people do not cause an immune response.

When a person with allergies breathes in an allergen such as pollen or dust, antibodies are produced. When the antibodies are stimulated by pollen and dust, histamine and other chemicals are released and cause itching, swelling, and mucus production. Symptoms vary from person to person. Very sensitive individuals can experience hives or other rashes.

Hay fever involves an allergic reaction to pollen. A similar reaction occurs with allergy to mold, animal dander, dust mites, and other common inhaled allergens.

The pollens that cause hay fever vary from person to person and from region to region. Large, visible pollens are seldom responsible for hay fever; tiny, hard to see pollens are more often the cause. Examples of plants commonly responsible for hay fever include:

  • Trees (deciduous and evergreen)
  • Grasses
  • Ragweed

The amount of pollen in the air can play a role in whether hay fever symptoms develop. Hot, dry, windy days are more likely to have increased amounts of pollen in the air than cool, damp, rainy days when most pollen is washed to the ground.

Symptoms

Diagnosis

Your doctor will perform a physical exam and ask you questions about your symptoms. Your history of symptoms is important when diagnosing allergic rhinitis. You need to note whether the symptoms vary according to time of day or season, on exposure to pets or other allergens, and in response to diet changes. While it should never replace a visit to your doctor, the Symptom Checker can help to identify symptoms that you or your children are having that may be related to allergic rhinitis.

Allergy testing may reveal the specific allergens you are reacting to. Skin testing is the most common method of allergy testing. This may include scratch, patch, or intradermal tests. During the scratch test, a drop of suspected allergen is placed on the skin and a series of scratches or pricks are made on the skin. If a raised, red area on the skin appears (called a wheal), this usually means the person has an allergy to that substance. Many different types of suspected allergy substances can be tested at once with skin testing. Patches involve placing a patch with the allergen on the skin for 24 to 72 hours to look for a reaction. Intradermal testing involves an injection of the allergen under the skin to look for a reaction; however, this method can have a high rate of false positives, meaning a reaction may occur even when the person is not truly allergic to the substance. You may need to stop taking certain medications 1 to 2 weeks before skin testing, particularly antihistamines. Be sure to discuss all of your medications with your doctor prior to allergy testing.

Another option to determine allergen sensitivities that can be used in place of skin testing is blood testing. These tests include the enzyme-linked immunosorbent assay (ELISA), radioallergosorbent testing (RAST) blood test, fluorescent enzyme immunoassays (FEIAs), and immunoassay capture test. These blood tests look for specific antibodies (for example, IgE) to allergens. Blood testing is usually more expensive than skin testing, and results may not be as quick, but it may be a better option for patients who cannot or should not have skin testing due to possible anaphylaxis or if they have extensive eczema.

Call your doctor if:

Call for an appointment with your health care provider if severe symptoms of allergies or hay fever occur, if previously successful treatment has become ineffective, or if your symptoms do not respond to treatment.

Treatment Options

The goal of treatment is to reduce allergy symptoms caused by the inflammation of affected tissues. The best "treatment" is to avoid what causes your allergic symptoms in the first place. It may be impossible to completely avoid all allergens to which you are sensitive, but you can often take steps to reduce exposure.

The American Academy of Allergy, Asthma and Immunology recommends the following steps to limit exposure to allergens:

  • Keep your windows closed at night; if possible, use air conditioning.
  • Stay indoors when the pollen or mold counts are high; use a mask when outside if symptoms are severe. When you return indoors, shower, shampoo, and change clothes.
  • Avoid lawn and garden work, if possible.
  • Do not hang clothes or sheets outside to dry.
  • Keep windows closed when traveling by car.
  • Medication options include the following:

    • First generation antihistamines such as diphenhydramine (Benadryl), brompheniramine, or chlorpheniramine (Chlor-Trimeton) can relieve mild-to-moderate symptoms but can also cause drowsiness. These are all available over-the-counter (OTC) without a prescription. A pediatrician should be consulted before using these medicines regularly in children as they may affect learning; in children first generation antihistamines may have an opposite effect to drowsiness, and lead to paradoxical excitability or hyperactivity.
    • Second generation antihistamines are also available OTC without a prescription. They cause little if any drowsiness and can work just as well as first generation antihistamines. They usually do not interfere with learning in children. These medications include fexofenadine (Allegra Allergy, Children's Allegra Allergy), cetirizine (Zyrtec Allergy, Children's Zyrtec Allergy), and loratadine (Alavert, Claritin, Claritin RediTabs). When OTC antihistamines are not effective, consult with your doctor who may be able to prescribe alternative antihistamines that may more effective.
    • Nasal corticosteroid sprays work very well for people with symptoms not relieved by antihistamines alone. This class of drug lessens nasal inflammation and blocks cytokines that may aggravate allergy symptoms. These prescription medications include fluticasone (Flonase), mometasone (Nasonex), ciclesonide (Zetonna) Nasal Aerosol and beclomethasone (QNASL). An over-the-counter option available without a prescription is triamcinolone (Nasacort Allergy 24HR).
    • Azelastine (Astelin, Astepro) is a nasal antihistamine spray that is used to treat allergic rhinitis. Dymista, a combination of azelastine with fluticasone (a nasal corticosteroid to decrease inflammation) is also available. Another prescription antihistamine nasal spray, olopatadine Patanase can be used twice a day. An additional nasal spray that is an anticholinergic and also approved for seasonal allergic rhinitis is ipratropium Atrovent Nasal.
    • Decongestants, such as phenylephrine, may also be helpful in reducing symptoms like nasal congestion, but they should not be used for long periods of time. Decongestants are often found in combination with antihistamines in OTC products. Check OTC labels to be sure you are only using an antihistamine, and not the combination product.
    • Cromolyn sodium is an over-the-counter (OTC) nasal spray (Nasalcrom) available at your pharmacy for treating hay fever. Cromolyn acts as a mast cell stabilizer, and must be used daily for its anti-allergy effect.
    • Eye drop versions of mast cell stabilizers and antihistamines are available for ocular allergies to relieve itchiness, redness, and tearing.
    • The leukotriene inhibitor Singulair is a prescription medicine approved to help prevent asthma symptoms, help relieve the symptoms of seasonal allergies, and to help prevent exercise-induced asthma. The generic form of the Singulair tablet, known as montelukast, is now available and may be more affordable. Zafirlukast (Accolate) is another prescription oral leukotriene inhibitor approved to help control and prevent asthma symptoms. Accolate is approved for use in adults and children 5 years and older. Singulair comes in a chewable tablet or dissolvable granules and is approved for allergies in children 2 years and older.

    The most appropriate medication depends on the type and severity of symptoms. Specific illnesses that are caused by allergies (such as asthma and eczema) may require other treatments.

    Allergy shots (immunotherapy) are occasionally recommended if the allergen cannot be avoided and if symptoms are hard to control. This includes regular injections of the allergen, given in increasing doses (each dose is slightly larger than the previous dose) that may help the body adjust to the antigen

    In April 2014, the FDA approved Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass Mixed Pollens Allergenic Extract) to treat allergic rhinitis (hay fever) with or without conjunctivitis (eye inflammation) that is caused by certain grass pollens in people ages 10 through 65 years. Oralair is the first sublingual (under the tongue) allergen extract approved in the United States. Oralair can be taken at home after the first dose, which is given in the clinic. People affected by hay fever may suffer from repetitive sneezing, nasal itching, runny nose, nasal congestion, and itchy and watery eyes and may need allergy shots; for those with certain grass allergies Oralair may be an alternative.

    See Also:

    References:

    • Bernstein IL et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol 2008; 100:S1-148.
    • Siles, R et al. Allergy blood testing: A practical guide for clinicians. Cleveland Clinic Journal of Medicine 2011; 78:585-92.
    • McArthur R. A practical approach to managing asthma and rhinitis. Prim Care Respir J 2012;21(2):230-232.
    • Mayo Clinic. Diseases and Conditions - Hay Fever. Posted July 17, 2012. Accessed April 5, 2014. http://www.mayoclinic.org/diseases-conditions/hay-fever/basics/definition/con-20020827
    • American Academy of Allergy Asthma and Immunology. Outdoor Allergens: Tips to Remember. 2013. Accessed April 5, 2014 at http://www.aaaai.org/conditions-and-treatments/library/at-a-glance/outdoor-allergens.aspx

Last updated: 2014-04-05 by L. Anderson, PharmD

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