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Allergic rhinitis (hay fever)

Hay_fever.jpgWhat is allergic rhinitis?

Hay fever is the common name to describe allergic rhinitis and involves a recurrent runny, stuffy, itchy nose, and frequent sneezing. It can also affect your eyes, sinuses, throat and ears. 


Like any other allergy, allergic rhinitis is an inappropriate immune system response to an allergen – most commonly house dust mite, pet, pollen and mould. The allergen comes into contact with the sensitive, moist lining in your nose and sinuses and sets off the allergic response.

Hay fever is often considered a nuisance rather than a major disease and most people will self-treat. However, recent studies have revealed that hay fever has a huge impact on quality of life.

What is the impact?

About 20 per cent of the general population suffers from rhinitis. Of these people, about one third develops problems before the age of 10.

The overall burden of allergic rhinitis is better understood when you consider that 50 per cent of patients experience symptoms for more than four months per year and that 20 per cent have symptoms for at least nine months per year.

Those affected by hay fever suffer more frequent and prolonged sinus infection, and for those who also have red, itchy eyes, there is the risk of developing infective conjunctivitis due to frequent rubbing. 

Persistent symptoms and poor quality sleep can result in lethargy, poor concentration and behavioural changes and impact on learning in young children.
Allergic rhinitis may predispose people to obstructive sleep apnoea, due to the upper airways collapsing during sleep. This results in reduced airflow, a drop in oxygen levels and disturbed sleep. 

Patients with allergic rhinitis also suffer from more frequent and prolonged respiratory infections, and asthma has been shown to be more difficult to control unless allergic rhinitis is also managed.
 

What is the link between allergic rhinitis and asthma?

Allergic rhinitis has been found to be an extremely common trigger for asthma in both children and adults. Allergic rhinitis can also exacerbate asthma, and it can make the diagnosis of asthma more difficult.

Around 80 per cent of people with asthma suffer from allergic rhinitis, and around one in four with allergic rhinitis has asthma. 

There is now very good evidence to support the idea that asthmatics who look after their upper airways well need less asthma medication and fewer hospital or GP visits. 

When treating both asthma and allergic rhinitis, the first step is to find out the cause of your problem. Once the causes have been identified, management regimes can be put into place to minimise the impact of the allergy, and this then reduces the need for medication. 
 

What causes allergic rhinitis?

The most common triggers for people with allergic rhinitis are pollen, dust mite, pet and mould allergens. 

Seasonal allergic rhinitis (hay fever) is usually triggered by wind-borne pollen from trees, grass and weeds. Early spring symptoms point to tree pollen, while nasal allergy in late spring and summer indicates that grass and weed pollens are the culprits. And overlapping the grass season is the weed pollen season, which usually starts in late spring and extends through to the end of summer. 

In New Zealand the seasons are not very distinct and they vary throughout the country because of the different climates. The season starts about one month earlier at the top of the North Island than the bottom of the South Island. Thus the hay fever season is not very well defined. 

Allergic rhinitis that persists year-round (perennial allergic rhinitis) is usually caused by house dust mites, pets, or mould. People with allergic rhinitis are often allergic to more than one allergen, such as dust mite and pollen, so may suffer from symptoms for months on end or all year round. 

Irritants such as strong perfumes and tobacco smoke can aggravate this condition.

Foods do not play as big a role as had been thought in the past.
 

What are the symptoms?

Symptoms of allergic rhinitis can be any combination of itching in the back of the throat, eyes or nose, sneezing, runny eyes or nose, and blocked nose.

A person may have any or all of the following:

  • watery discharge from the nose all the time, occasionally or during certain seasons of the year
  • stuffy nose all the time or during specific seasons
  • reddened, pebbly lining in the lower eyelids
  • frequent throat-clearing
  • breathing through the mouth
  • snoring
  • rabbit-like movements of the nose
  • a horizontal crease across the nose as a result of constant rubbing
  • bouts of sneezing, especially in the morning
  • repeated nosebleeds
  • headaches because of pressure from inside the nose
  • frequent earaches, fullness in the ear, ear infections or hearing loss
  • dizziness or nausea related to ear problems
  • chronic cold without much fever
  • nasal voice because of blocked nasal passages
  • dark circles under the eyes as a result of pressure from blocked nasal passages on the small blood vessels. Also known as "allergic shiners".

When does allergic rhinitis develop?

Allergic rhinitis typically develops in childhood. It is part of what we call the Allergic March, where children first develop eczema in infancy, sometimes followed by food allergy, and then go on to develop allergic rhinitis and then asthma.

The onset of dust mite allergy occurs often by the age of two, with grass pollen allergy beginning around three to four years of age. Tree pollen allergy develops from about seven years of age. 

It is not unusual to develop hay fever during adulthood. It can take as few as two to three seasons to become sensitised to pollen, but it depends on the individual.
 

How do you diagnose allergic rhinitis?

Your doctor will confirm the specific allergens causing your rhinitis by taking a complete symptom history, doing a physical examination, and performing skin prick tests.
 

How is allergic rhinitis treated?

It is useful to identify your triggers and try and avoid them. This can be difficult.
Pets: Make sure you keep it outside and never let it in the bedroom. It is never easy trying to decide on a new home for a pet, but in some cases this might be the best option. Even after you have removed your pet from your home, the allergens remain in furnishings for long periods afterwards and can cause symptoms. You will need to thoroughly clean your walls, floors and carpets to remove the allergen.
Dust mites: House dust mite reduction measures include mite-proof covers for the mattress, duvet and pillows. Removing items that collect dust from the bedroom will help. A good quality vacuum cleaner with HEPA filter for the exhaust air is essential to ensure that allergen is not disseminated in the atmosphere. Bedding should be washed frequently in water hotter than 55ºC. If you have soft toys, freeze them overnight and air in the sun.

Pollen: It is difficult to avoid pollen, however you can avoid going outside when pollen counts are high. The amount of pollen in the air is highest:
• In the morning
• Outside
• On windy days
• After a thunderstorm

See our pollen calendar for more information.
 

Medication

Non-sedating antihistamine tablets or liquid are useful in alleviating some of the symptoms of rhinitis. They are helpful in controlling sneezing, itching and a runny nose, but are ineffective in relieving nasal blockage. They can be used alone or in combination with other medications, such as nasal sprays.
Corticosteroid (anti-inflammatory) nasal sprays reduce the inflammation in the lining of the nose. They work best when used in a preventative manner, just like preventers for asthma. For example, they may be used for weeks or months at a time during an allergy season. Ask your doctor about the appropriate medication for your condition.
Decongestant nasal sprays can be used to unblock the nose, but should not be used for more than a few days at a time. Prolonged use may result in worsening of the nasal congestion.
Eye drops: The eye problems that sometimes occur with allergic rhinitis may not always respond to the above medications. Eye drops containing decongestants alone or in combination with antihistamine are available for mild to moderate eye problems. Eye irritation is one side effect. Prolonged use of decongestant eye drops can also cause rebound worsening when stopped. Some brands of eye drops can be used preventatively and are safe to use for prolonged periods - ask your doctor for more specific information.

Saline washes may help to clear your nose and soothe the lining of your nose. These are available from most pharmacies.

Desensitisation, or immunotherapy, is used to 'turn off' the abnormal response of the immune system to an allergen if medication does not work. It is mainly used to relieve the symptoms of hay fever and allergic asthma to pollen, mould, house dust mite and pet allergen, as well as to control severe reactions to insect stings.

To begin, a very dilute dose of the substance you are allergic to is administered by injection once or twice a week. This dose is gradually built up over three to four months on average, until a maintenance dose is achieved. Shots are then given monthly for at least three years.

This method of treatment is the only one that deals with the underlying cause of allergic rhinitis. Not everyone benefits from treatment, however the vast majority of patients show at least some degree of improvement. Ask your allergy specialist about whether you are a good candidate for immunotherapy.

Sublingual immunotherapy is another method, where drops of the allergen solution are taken under the tongue. It is not widely used outside of Europe.

This information is available as a fact sheet.


December 2008

This fact sheet is based on information available at the time of going to print but may be subject to change. It is important to remember that we are all different and individual cases require individual medical attention. Please be guided by your GP or specialist.

Acknowledgments: We would like to Associate Professor Rohan Ameratunga, Clinical Immunologist, Auckland Hospital, for assistance in writing this information. This fact sheet is also based on information provided by the Australasian Society of Clinical Immunology and Allergy and the National Asthma Council Australia.