Allergic Rhinitis & Hay Fever
What is Allergic Rhinitis (Hay Fever)?
Allergic rhinitis is the name given to a collection of symptoms that occur predominantly in the nose and eyes. These symptoms are caused by airborne particles of dust, dander, or plant pollen 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?
Allergies are caused by an overly 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 -- a type of protein -- are produced. When the antibodies are stimulated by pollen and dust, histamine and other chemicals are released in the body and can cause:
- Mucus production
Allergic rhinitis is predominantly an immunoglobulin E–mediated condition that impacts quality of life, including work and family life, and can worsen other conditions such as asthma. Symptom severity can 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 an 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)
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.
What Are the Symptoms of Hay Fever?
Symptoms of hay fever can be variable among different people; some people may have very severe, year-round (perennial) allergies, while others may have periodic (seasonal) symptoms, such as just in the spring or fall. Symptoms include:
- Itching nose, mouth, eyes, throat, skin, or any other area
- Runny or stuffy nose
- Postnasal drip
- Problems with smell
- Daytime fatigue
- Tearing, watery eyes
- Allergic shiners (swollen, blue-colored skin under the eyes)
- Sore or scratchy throat
Learn More: Seasonal Allergies - Top Prevention Tips
How Is Hay Fever Diagnosed?
To make a 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 the time of day or season
- Occur with exposure to pets or other allergens
- Appear 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.
How Do I Treat Hay Fever?
The goal of treatment is to reduce your allergy symptoms caused by the inflammation (swelling) of affected tissues. You should try to avoid what causes your allergic symptoms. 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.
What Medications Are Used to Treat Hay Fever?
Nasal corticosteroids, first and second generation antihistamines, mast cell stabilizers, and leukotriene modifiers are the most common agents used for allergies. The most appropriate medication depends on the type and severity of symptoms, patient preferences, and costs. Specific illnesses that are caused by allergies (such as asthma and eczema) may require additional or other treatments.
Nasal Corticosteroid Sprays
Nasal corticosteroid sprays are the first-line choice for symptoms of allergic rhinitis. This class of drug lessens nasal inflammation and blocks cytokines that may aggravate allergy symptoms. They have few side effects and can dramatically lower allergy symptoms in most people. Several options, such as fluticasone (Flonase Sensimist) and triamcinolone (Nasacort Allergy 24HR), are now available without a prescription.
Brand Name Examples
|Fluticasone Nasal||Flonase, Flonase Allergy Relief, Flonase Sensimist|
|Triamcinolone||Nasacort Allergy 24HR|
Learn More: Flonase - Avoid These Top 9 Mistakes
First Generation Antihistamines
First generation antihistamines can relieve mild-to-moderate symptoms but can also cause drowsiness. They can be used in combination with nasal corticosteroids when symptoms are not controlled but will still cause drowsiness. Do not use before driving or operating machinery. Many antihistamine products are available over-the-counter (OTC) without a prescription.
In children, first generation antihistamines may have an opposite effect to drowsiness, and lead to paradoxical excitability or hyperactivity. A pediatrician should be consulted before using these medicines regularly in children as they may affect learning.
Second Generation Antihistamines
Second generation antihistamines are also available OTC without a prescription. Most products cause little if any drowsiness and can work just as well as first generation antihistamines; cetirizine (Zyrtec) can cause drowsiness in some people. This class of antihistamine does not usually interfere with learning in children.
When OTC antihistamines are not effective, consult with your doctor who may be able to prescribe alternative antihistamines that may be more effective.
|Generic Name||Brand Name Examples|
|Fexofenadine||Allegra Allergy, Children's Allegra Allergy|
|Cetirizine||Zyrtec Allergy, Children’s Zyrtec|
|Loratadine||Alavert, Claritin, Claritin RediTabs|
|Desloratadine||Clarinex, Clarinex Reditabs|
|Levocetirizine||Xyzal, Xyzal Allergy 24HR|
Many combination antihistamine-decongestant products are available over-the-counter (OTC), but decongestants are not effective for allergic rhinitis and may not be needed. If you are only treating the symptoms of hayfever or allergic rhinitis, a single nasal corticosteroid with an antihistamine product, only if needed, is probably your best option and will help to avoid side effects due to a decongestant.
These products now typically contain the decongestant phenylephrine, although some products still contain pseudoephedrine, which is no longer available OTC in the U.S. due to use in making illegal drugs. In most states, pseudoephedrine is kept behind the pharmacy counter and requires a signature, with a limited timeframe to get a new supply.
Example brand names of commonly used combination antihistamine-decongestants include:
- Allegra-D 24 Hour
- Actifed Cold and Allergy
Other Treatment Options
|Generic Name||Brand Names||Comments|
|Azelastine / Fluticasone||Dymista||
A combination of azelastine with fluticasone (an antihistamine and nasal corticosteroid spray combination).
|Ipratropium bromide||Atrovent Nasal||A nasal spray that is an anticholinergic and also approved for seasonal or perennial allergic rhinitis.|
|Cromolyn nasal||Nasalcrom||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.|
|Montelukast||Singulair||An oral tablet prescription medicine approved to help prevent asthma symptoms, relieve the symptoms of allergic rhinitis, and prevent exercise-induced asthma.|
Learn More: Medications to Treat Allergic Rhinitis
Does Nasal Irrigation Work for Allergies?
Nasal irrigation is the process of cleansing the nose with a saline solution; nasal irrigation is also known as nasal lavage. Nasal irrigation can be helpful for:
- Drainage down the back of the throat
- Nasal dryness
This treatment helps rid any allergens or irritants from the nose. Nasal irrigation is a safe process if performed correctly and with saline made with sterilized water, distilled water, or previously boiled or filtered water. Nasal irrigation can be performed as needed, once or twice daily if symptoms become severe. However, if you are using a device, like a Neti pot, it’s important to follow directions.
What is A Neti Pot?
Neti pots, which look like a little tea pot, have become popular to treat symptoms of nasal allergies, sinus problems or colds. A Neti pot is a device that can be used with sterile water to manually irrigate and rinse the sinuses to remove clogged debris in the nasal passages. DO NOT use tap water.
Neti pots are often available in pharmacies and other retail shops. Saline (salt water) nasal spray or irrigation kits can be purchased over-the-counter, but patients can also make their own solutions for Neti pots. If you choose to make your own saltwater solution, it's important to use water that is safe.
The FDA has posted advice about using Neti pots as a method to rinse sinuses, and it’s important to follow directions closely to prevent an infection.
What Types of Water Can You Use in a Net Pot?
- Tap water is NOT safe to use in a Neti pot because bacteria, protozoa, amoeba, or other organisms can get into your nasal passages and lead to infections that can be serious, or even life-threatening.
- Distilled or sterilized water is safe. You can buy labeled water stating it is distilled or sterilized in U.S. grocery stores.
- Boiled and cooled tap water is safe. Boil tap water for 3 to 5 minutes, then cool it to lukewarm. Previously boiled water can be stored in a clean, closed container, but must be used within 24 hours.
- Water passed through a filter designed to trap potentially infectious organisms is another option. The US Centers for Disease Control and Prevention (CDC) has information on selecting these special filters.
How Do You Use a Neti Pot?
Check with your doctor before using nasal irrigation. To use a Neti pot, tilt your head sideways over the sink and place the spout of the Neti pot in the upper nostril. Breathing through your open mouth, gently pour the saltwater solution into your upper nostril so that the liquid drains through the lower nostril. Repeat on the other side.
Other devices besides Neti pots used to rinse sinuses include:
- Bulb syringes
- Squeeze bottles
- Battery-operated pulsed water devices
Be sure to clean any irrigation device after each use with distilled or sterile water and let air dry.
Saline nasal mist solutions (for example, Ayr Saline Nasal Mist) may be better to treat dry nasal membranes when rinsing with a Neti Pot is not needed or desired.
What Are Allergy Shots?
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). This may help the body adjust to the antigen. Immunotherapy is especially recommended for patients who don’t respond successfully to medication or would prefer to reduce the number of medications they need to take.
Most common allergens - pollen, cat and dog dander, dust mites, mold - can be controlled by allergy shots. As a result of regular injections of the allergen, immunotherapy modulates a patient’s immune response to the allergen. Immunotherapy is most successful when given in long periods of time - usually a minimum of 3 to 5 years.
Immunotherapy involves very little risk of causing a severe allergic reaction. An allergic reaction induced by immunotherapy occurs at a frequency of 6 to every 10,000 injections.
Oral Immunotherapy for Allergies
Is there an alternative to allergy shots? New sublingual (under the tongue) immunotherapies (allergenics) may offer an alternative to allergy shots.
|Generic Name||Brand Names|
|Mixed Grass Pollens Allergen||Oralair|
|Ragweed Pollen Allergen Extract||Ragwitek|
|Timothy Grass Pollen Allergen Extract||Grastek|
|House Dust Mite Allergen Extract||Odactra|
In April 2014, the FDA approved Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass Mixed Pollens Allergenic Extract), a sublingual (under the tongue) tablet 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.
Ragwitek, also approved in April 2014, is a once-daily sublingual (under-the-tongue) tablet that contains an allergen extract from short ragweed (Ambrosia artemisiifolia) pollen. Treatment should begin 12 weeks before the start of ragweed season and continued throughout the season. Ragweed season occurs in the U.S. in the late summer and early fall.
Grastek is a sublingual (under-the-tongue) tablet used for the treatment of grass pollen allergies with or without conjunctivitis for people allergic to Timothy grass or related grass pollens, as determined by a skin or blood test. Grastek can be used in persons age 5 through 65 years of age, and was FDA-approved in April 2014.
Odactra, approved in March 2017, is a sublingual allergen extract to treat house dust mite (HDM)-induced allergic rhinitis, with or without eye inflammation (conjunctivitis), in people 18 through 65 years of age. HDM allergies often occur due to allergies to mites found in bedding, furniture, and carpet leading to cough, itchy and runny nose, sneezing and watery eyes.
Can Hay Fever Get Worse During Pregnancy?
Women who have allergic rhinitis or hay fever may have worsening, improved, or unchanged allergy symptoms during pregnancy. Always speak with your doctor before taking any medication during pregnancy.
Generally, medications should be avoided or used at the lowest possible dose in pregnancy. But practically speaking this isn’t always possible. Some over-the-counter (OTC) medications related to allergic rhinitis are thought to be safe to use during pregnancy if medication must be used; these medications include:
- Cromolyn nasal spray, i.e., Nasalcrom
- Certain nasal corticosteroid sprays, i.e., fluticasone (Flonase, Flonase Sensimist), budesonide (Rhinocort) mometasone (Nasonex) - avoid Nasacort AQ (triamcinolone) nasal spray due to concerns in pregnancy
- Oral antihistamines, i.e., cetirizine (Zyrtec), loratadine (Claritin)
“Rhinitis of pregnancy” refers to an increase in nasal congestion that arises during the later stages of pregnancy due to hormones. The use of typical hay fever medications are not effective in rhinitis of pregnancy, but the condition will improve after pregnancy.
When Should I Call My Doctor About Hay Fever?
Call for an appointment with your healthcare 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. For mild, intermittent and infrequent symptoms, an oral over-the-counter antihistamine may be used on an as-needed basis. But if your symptoms continue to worsen or are ongoing, see your doctor to determine if regular use of a nasal corticosteroid would be a better option.
You may also consider join the Drugs.com Allergy Support Group to ask questions, share your experiences, and keep up with the news and drug approvals related to Allergies and Hay Fever.
- American Academy of Allergy Asthma and Immunology. Outdoor Allergens. Accessed June 27, 2017 at http://www.aaaai.org/conditions-and-treatments/library/at-a-glance/outdoor-allergens.aspx
- Is Rinsing Your Sinus With Neti Pots Safe? Consumer Update. U.S. Food and Drug Administration (FDA). Updated: January 24, 2017. Accessed June 27, 2017 at https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm316375.htm
- Sur D, Plesa M, Treatment of Allergic Rhinitis. Am Fam Physician. 2015 Dec 1;92(11):985-992. Accessed June 26, 2017 at http://www.aafp.org/afp/2015/1201/p985.html#afp20151201p985-f1
- DeShazo, Richard D., and Stephen F. Kemp. "Patient education: Allergic rhinitis (seasonal allergies) (Beyond the Basics)." UpToDate. Ed. Jonathan Corren and Anna M. Feldweg. UpToDate Inc., May 2017. Web. Accessed 19 June 2017 at https://www.uptodate.com/contents/allergic-rhinitis-seasonal-allergies-beyond-the-basics
- Hay Fever Disease Reference Guide - Mayo Clinic. Drugs.com. Accessed June 27, 2017 at https://www.drugs.com/mcd/hay-fever