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Allergic Rhinitis

NICE CKS Allergic rhinitis. Last revised Jan 2024.

Background

IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitised to allergens.

Classification:
  • Seasonal rhinitis (hay fever) - symptoms occur at the same time each year in response to a seasonal allergen
    • Most typically occurs in summer months but depends on the pollen
 
  • Perennial rhinitis - symptoms occur throughout the year

Common environmental triggers:
  • House dust mites 
  • Grass, tree, and weed pollens
  • Moulds
  • Cat and dog hair

Typical features:
  • Classic bilateral symptoms: sneezing, nasal itching, rhinorrhoea, nasal congestion
  • Postnasal drip
  • Associated eye symptoms (e.g. bilateral itching, redness, tearing)

Other suggestive features:
  • Personal / family history of atopy (asthma / eczema / allergic rhinitis)
  • Symptoms occur following exposure to a known causative allergen
    • Tree pollens — intermittent or chronic symptoms occur from early to late spring.
    • Grass pollens — intermittent or chronic symptoms occur from late spring to early summer.
    • Weed pollens — intermittent or chronic symptoms may occur from early spring to early autumn.
    • House dust mites — symptoms are worse on waking and are present all year-round, but may peak in autumn and spring.
    • Animal dander — symptoms follow exposure to animal dander, and may be all year-round or occasional, depending on exposure.
    • Occupational — intermittent or chronic symptoms tend to improve when the person is away from work, such as weekends and holidays.

Guidelines

Consider referral if:

  • Unilateral red-flag symptoms (blood stained nasal discharge / recurrent epistaxis / nasal pain) → 2 week wait referral to ENT
  • Structural abnormality / predominant nasal obstruction that makes intranasal drug treatment difficult
  • Persistent symptoms despite optimal management in primary care
  • Uncertain diagnosis

Clinical diagnosis based on a combination of:
  • History
  • Clinical exam 
  • Response to first line treatment

Specialist may perform allergy testing but not required for diagnosis:
  • Skin prick testing
  • RASTRadioallergosorbent test (measure level of serum-specific IgE to allergens)

  • Allergic avoidance technique    
  • Consider nasal irrigation with saline solution 

  • Intranasal corticosteroids (e.g. mometasone, fluticasone),
    • Most effective treatment
    • But may take several hours to days to become effective
AND/OR
  • Intranasal antihistamine / oral non-sedating antihistamines
    • Fastest onset of action (within minutes)
    • But less effective than intranasal corticosteroids


Additional treatment:
  • Presence of eye symptoms → antihistamine eye drops / chromone eye drops (sodium cromogylcate, nedocromil)
 
 

The most effective 1st line regimen is intranasal corticosteroid + intranasal antihistamine

Other information:

  • Intranasal corticosteroid + oral antihistamine is no more effective than intranasal corticosteroid on its own
  • Intranasal corticosteroid + intranasal antihistamine is more effective than intranasal corticosteroid on its own

If 1st line options are ineffective → consider adding:
  • Intranasal anticholinergic (e.g. ipratropium bromide)
  • Intranasal decongestant (e.g. xylometazoline) for up to 5-7 days - especially if congestion is a problem

Also consider
  • Changing 'as needed' oral antihistamine into regular oral antihistamine.
  • Short course of oral corticosteroid for 5-10 days if there is severe uncontrolled symptoms that are affecting quality of life.

References

Author: Stella Panou 
Reviewer:
Last edited: 05/05/2025