Patient journey:
Follow these steps to a better quality of life
Phase 1: Self-management
When should I see a general practitioner?When should I see a general practitioner?
- You still do not have a clear idea which allergen is causing your allergic symptoms
- You are still unable to control your symptoms despite avoiding the allergen that is causing your symptoms or despite any self-management measures
- You are looking for long-term sustained improvement of your symptoms
- You are looking for proper diagnosis and treatment by a physician
If your symptoms occur only one side of the nose or if you experience a sudden drop in weight or if you are generally feeling unwell, then you should not self-medicate but seek medical care.
Depending on your countries medical system you may also be able to see a specialist without prior consultation with a general practitioner (GP) if phase 1 is insufficient.
Phase 2: General Practitioner
When should I go to a specialist?When should I go to a specialist?
- You are still unable to control your symptoms despite first line treatment with anti-histamines and/or corticosteroids
- You are still looking for long-term sustained improvement of your allergic symptoms
What is Allergic rhinitis?
Allergic rhinitis refers to an inflammation of the nasal cavity caused by allergens, such as pollen, dust mites, mould, dander (skin flakes) from animals, etc. These allergens cause fits of sneezing, a runny nose, a blocked nose and/or itchiness in the nose, throat or eyes. Symptoms of allergic rhinitis can be present all year long, when it is a ‘perennial’ allergen like house dust mite, or a few months a year when it is a ‘seasonal’ allergen like grass pollen.
Allergic rhinitis is always a disease of both sides of the nose. If your symptoms are on one side, you have to see a physician. The most common respiratory allergies are hay fever and dust mite allergy. No less than 30% of the world’s population is affected.
What is the impact of allergic rhinitis?
The impact of allergic rhinitis on a patient’s daily activity is often underestimated. Persistent allergy can cause sleeping disorders, fatigue and reduced concentration and/or productivity. Patients with persistent nasal symptoms due to inflammation of the mucous membranes are also three times as likely to develop asthma. Be sure to consult your doctor if symptoms persist. The
doctor can confirm whether or not you have asthma.
COVID-19
I have allergic rhinitis. Am I at risk to get COVID-19?
Until today the available evidence suggests that allergic rhinitis patients are not at higher risk for Sars-CoV-2 infection (the virus causing COVID-19). Moreover, if allergic rhinitis patients develop COVID-19, there is no evidence for a more severe disease course compared to non-allergic patients.
I have loss of smell. Is this a symptom of my allergic rhinitis or do I have COVID-19?
In case of new-onset (sudden) loss of smell, the probability of COVID-19 is high and we recommend testing and/or self-quarantine. However, reduced sense of smell or loss-of-smell might also be a symptom of allergic rhinitis. In those cases there is often associated nasal obstruction/congestion and symptoms increase more over time.
symptoms and cause
Frequently Asked Questions
What is an allergen?
An allergen is a harmless substance (antigen) that produces an abnormal immune response in an allergic person. Allergen sources that give rise to nasal allergies are commonly found in the home environment, like house dust mites, furry pets (cat and dogs), mould and cockroaches, some plants, etc. The most common sources of outdoor allergens are pollen such as tree, grass and weed pollen.
How can I tell whether I have allergies or just a cold?
Common colds and allergies have many symptoms in common, including a runny nose, sneezing and a blocked nose. However, they have different causes. A common cold is caused by a virus, while allergies are a response of the immune system to triggers, known as allergens. Colds do generally last no longer than 2 weeks. Typical signs of viral infection in common cold are sudden unset of symptoms without seasonal or exposure-related onset, and with general malaise. Typical signs of allergies are itchy eyes, ears or palate. When symptoms last more than 2 weeks and symptoms of itch and watery rhinorrhoea remain, you may well have an allergy and should consult your doctor.
What is hay fever?
Hay fever is an old-fashioned name that we call now ‘allergic rhinitis caused by pollen (plant allergens)’. Plants that may cause hay fever are trees, grasses, and weeds. Pollen are carried by the wind, which is why they are called ‘airborne allergens’. Flower pollen are carried by insects and do not cause hay fever. The amount of pollen in the air are crucial for symptom induction. Hot, dry and windy days are more likely to have a lot of pollen in the air, while on cool, damp and rainy days, most pollen are washed out of the air.
Is allergic rhinitis inherited?
There is a clear hereditary component in allergic rhinitis, but you inherit the tendency to be allergic (called atopy) but not the specific allergy as such. Example: If both your parents have allergic rhinitis or other allergies, you are very likely to develop allergies too.
What is the difference between allergic rhinitis and non-allergic rhinitis?
Allergic rhinitis is caused by an immunological reaction to an allergen resulting in nasal inflammation. Non-allergic rhinitis can be caused by a wide variety of endogenous and exogenous stimuli resulting in nasal inflammation as well, but the underlying mechanism is different. Both patients with allergic and non-allergic rhinitis can become more sensitive to environmental triggers like smoke, strong odors and temperature changes, which is known as nasal hyper-reactivity. The symptoms of non-allergic and allergic rhinitis are similar; therefore, allergy testing is recommended to distinguish allergic from non-allergic rhinitis.
Can allergic rhinitis be cured?
Allergic rhinitis is a chronic disease. Most (medical) treatments induce symptom relief, with some treatments like immunotherapy or vaccine treatment aiming for a cure of allergic rhinitis. Immunotherapy alters the immune response to allergens that are inhaled, preventing inflammation to occur.
Is allergic rhinitis contagious?
Allergic rhinitis, like other allergic reactions, is caused by your immune system’s response to allergens and is therefore not contagious.
Is it important to treat allergic rhinitis?
You are advised to seek medical help when your symptoms are influencing/affecting your sleep, preventing you from carrying out daily activities, or adversely affecting your performance at work or school. Treating your allergic rhinitis might also prevent the development of asthma, a known co-morbidity (a co-morbidity is an additional condition co-occurring with a primary condition).
What can you do in your home environment?
The best way to prevent allergic rhinitis is to avoid exposure to the causative allergens. However, most environmental allergens are difficult to avoid. Luckily, symptoms of pollen-induced allergic rhinitis only occur upon exposure to pollen and will therefore disappear when the season is over. Although it may be impossible to avoid all allergens, you can often take steps to reduce your exposure in daily life.
If your symptoms are seasonal and most likely caused by pollen:
- Keep track of the start and the end of the pollen season via radio/television/website: www.polleninfo.org
- Avoid outside activities during the grass pollen season
- Keep your windows and doors closed during hot, dry and windy weather
- Choose a holiday destination closer to the seaside as pollen counts are usually lower there compared to the inland
- The best time to exercise outdoors is after a rainstorm or early in the morning
- Dry your washing indoors so that pollen cannot settle on your clothing
If your symptoms are perennial and most likely caused by house dust mites:
- House dust mites are common allergens and are not only present at home in beds, carpets and furniture but also in public spaces. Keep in mind that complete eradication is impossible.
- Preferably use a mattress made out of polyether foam or foam rubber
- Use special dust mite proof covers on your mattress, pillow and bedding
- Wash your bedding at least once every two weeks on at least 60°C/140°F
- Use curtains made out of thin cotton or plastic that are easy to clean or wash at 60°C/140°F
- Try to minimize the amount of fabric furniture, especially in the bedroom
- Choose smooth flooring such as parquet or cork while minimizing the amount of carpet as they are difficult to clean and disrupt ventilation
- Only buy washable stuffed animals and wash them at 60°C/140°F
- Ventilate the bedroom daily. Never close off the ventilation grills in exterior walls, not even during wintertime
- Dry your washing outdoors or in a tumble dryer
- Mop the floor regularly and use a vacuum cleaner with a HEPA filter
If your symptoms are perennial and most likely caused by pets:
Pet dander, the material that is shed from the body of animals, can also cause allergic responses. Do not take an animal in your house when you are allergic without discussing it with your health care provider first. Also take into account that hypo-allergic animals do not exist.
What can the pharmacist do?
Non-prescription sale of medicines such as tablets or sprays with antihistamines or corticosteroids is country dependent. Ask your pharmacist which medication without prescription can be used for treatment of allergic rhinitis in your country. Nasal rinsing is a cheap, easy and effective way to minimise your rhinitis symptoms. By nasal rinsing you mechanically “clean” the nasal mucosa from allergens and in this way may reduce the inflammatory reaction in the nose.
Watch here instructional videos on how to use nasal sprays correctly and perform nasal rinsing.
How is the diagnosis made?
In order to reach the correct diagnosis, your doctor will first discuss your symptoms extensively with you. He/she will carry out a physical examination and study the inside of your nose. Where necessary, the doctor will perform an allergy test to identify the allergen that is presumably causing your symptoms. Depending on the availability of these tests, this can be either a blood test or a skin prick test.
Allergy blood tests detect and measure the levels of allergen-specific antibodies in your blood and are preferred in patients with sensitive skin. In some countries, only a limited set of allergens are reimbursed per consultation. Skin prick tests are relatively cheap, not painful and provide a result after a couple of minutes.
If your allergy test is positive and this test is in line with your usual complaints, then the doctor will begin treatment with anti-allergic medication. If you react well to this, your symptoms can be assigned to an allergy. However, if you do not react well, then we recommend further investigation. In this case, it is highly likely that you are suffering from a different nose or sinus disease, such as non-allergic rhinitis or sinusitis.
Diagnosis
Frequently Asked Questions
What is the difference between allergic rhinitis and non-allergic rhinitis?
Allergic rhinitis is caused by an immunological reaction to an allergen resulting in nasal inflammation. Non-allergic rhinitis can be caused by a wide variety of endogenous and exogenous stimuli resulting in nasal inflammation as well, but the underlying mechanism is different. Both patients with allergic and non-allergic rhinitis can become more sensitive to environmental triggers like smoke, strong odours and temperature changes, which is known as nasal hyperreactivity. The symptoms of non-allergic and allergic rhinitis are similar; therefore, allergy testing is recommended to distinguish allergic from non-allergic rhinitis.
What is first-line treatment?
The type of treatment your doctor prescribes depends on various factors: the severity of your symptoms, the impact of the allergy on your daily life, the success or failure of previous treatment and the availability of medication. Allergic rhinitis can be prevented by avoiding allergens. However, if you do come into contact with them, then nasal rinsing is an easy way to keep your symptoms under control.
If this does not help, your doctor will prescribe a nasal spray or tablets with antihistamines and/or a nasal spray with corticosteroids. Nasal sprays with corticosteroids are preferably taken one month before the start of the allergy season because you will experience an improvement after 10 days with a maximal effect after 6 weeks. Anti-histamines work much faster and can therefore be taken when the first symptoms appear. Patients suffering from dust mite allergy usually take their treatment from August till April.
COVID-19
I have been diagnosed with COVID-19. Is it safe to continue my medication for Allergic Rhinitis?
Up until now, there is no scientific evidence that treatments for allergic rhinitis increase the risk of infection with Sars-CoV-2 (the virus causing COVID-19) or the severity of COVID-19. This means that allergen avoidance, nasal rinsing with salt water, nasal corticosteroids and anti-histamine treatment should be continued as prescribed, both in COVID-19 infected and non-infected patients.
I take allergen-immunotherapy for my allergic rhinitis. Should I continue my treatment during the COVID-19 pandemic?
Allergen-immunotherapy (AIT) or allergen vaccines (both injections and under the tongue) for the treatment of allergic rhinitis should be discontinued in COVID-19 diagnosed patients or suspected COVID-19 cases until complete clinical recovery (negative test result and/or adequate quarantine). Allergen-immunotherapy for allergic rhinitis should be continued in non-infected individuals and patients recovered from COVID-19.
Can I switch from SCIT to SLIT?
For patients who are receiving immunotherapy via injections (SCIT) and therefore need repeated visits to a physician or hospital, it can be considered an option to permanently or temporarily switch from SCIT to SLIT (therapy via drops or tablets), when there is a suitable alternative available.
Treatment
Frequently Asked Questions
How do antihistamines work?
Antihistamines are available in tablets and in spray/drops, with oral or nasal treatment being recommended depending on severity of disease. Antihistamines are drugs that block the action of a key mediator in allergic rhinitis: histamine. Histamine is released by mast cells upon binding of an allergen on an antibody on its surface. When an allergen enters the body, the immune system reacts by releasing large amounts of histamine locally (in the nose), causing symptoms of allergic rhinitis.
How do intranasal steroids work?
Intranasal (cortico)steroids are an effective drug in controlling the symptoms of allergic rhinitis, especially effective on nasal obstruction. The main mechanism by which intranasal steroids relieve symptoms is through their anti-inflammatory activity. They are effective in controlling the four major symptoms of allergic rhinitis: nasal congestion, rhinorrhoea, itching and sneezing. Nasal corticosteroid sprays also have a positive effect on the eye symptoms. The effect of the intranasal spray starts after 10 days, with maximal efficacy reached after several weeks of usage. Intranasal steroid sprays are safe for long-term use if patients follow the recommended doses and right application. The steroids are not taken up in the bloodstream and are therefore not associated with systemic side effects. Adverse reactions usually are limited to epistaxis (nosebleeds) due to improper application, nasal dryness/ crusting, abnormal taste and throat irritation.
Do I need antibiotics to treat allergic rhinitis?
Antibiotics are used for the treatment of bacterial infections. They are not used for the treatment of non-infectious rhinitis, like allergic rhinitis.
What to do after a doctor visit?
It is important to adhere to the therapy that your doctor has prescribed you and to monitor your symptoms in between consultations. Keep in mind that some treatments such as corticosteroids only show maximal effect after several weeks.
If your symptoms remain bothersome or if you develop new symptoms, it is important to take a new appointment with your doctor. If you have tried all first line treatments and remain uncontrolled or if you are looking for long-term effects, you might consider taking an appointment with an allergologist or ear-nose-throat specialist. In case you also experience symptoms of the lower airways such as shortness of breath, you should consider making an appointment with a pulmonologist.
How is the diagnosis made?
In order to reach the correct diagnosis, your doctor will first discuss your symptoms extensively with you. He/she will carry out a physical examination and study the inside of your nose. To examine any abnormalities inside your nose or sinuses, he/she will use a nasal endoscopy which is a thin, rigid instrument with a camera and a light. An ear, nose, and throat doctor (ENT; otolaryngologist) will do this procedure in his or her office. Typically, a nasal endoscopy only takes one to two minutes.
Where necessary, the doctor will perform an allergy test, using either a skin or blood test. During a skin prick test (or scratch test), drops of different allergens are placed on the skin. Then, after a needle prick, the allergen seeps into the skin. If you are allergic, a small itchy bump will appear within 15 minutes. Skin prick tests are not painful.
Patients who are diagnosed with allergic rhinitis are also three times as likely to develop asthma over time. Therefore, your doctor will also examine your lower airways and ask for the presence of typical symptoms of asthma such as a recurrent cough, shortness of breath and wheezing and recurrent cough, especially during night-time.
Nasal provocation testing
The nasal provocation test (or nasal challenge test) is essentially a research tool and is not fully implemented in the clinical routine evaluation of allergic rhinitis in every hospital. The allergen that is presumably causing your symptoms is inhaled into the nose. The patient will then be monitored for development of typical symptoms (such as itching, sneezing, nasal running) or production of secretions, or signs of nasal congestion.
Testing should be performed outside the pollen season, or in case of perennial allergens, only when mild symptoms that do not interfere with the test results are present. Your physician will inform you which treatment such as anti-histamines, corticosteroids, nasal decongestant,.. should be discontinued before testing. Smoking and alcohol intake should also be stopped 24-48 hours before the test.
What is second-line treatment?
The type of treatment your doctor prescribes depends on various factors: the severity of your symptoms, the impact of the allergy on your daily life, the success or failure of previous treatment and the availability of medication.
Allergic rhinitis can be prevented by avoiding allergens. However, if you do come into contact with them, then nasal rinsing is an easy way to keep your symptoms under control. If this does not help, your doctor will prescribe a nasal spray or tablets with antihistamines and/or a nasal spray with corticosteroids. If these first line treatments also fail to bring relief or if you are looking for long-term improvement, immunotherapy is another option.
If neither of the aforementioned treatments relieve the inflammation, an operation may be required in cases demonstrating a crooked nasal septum.
What is allergen immunotherapy?
Allergen immunotherapy is an immune-modulating treatment, aiming for a cure of the allergic disease. It involves the gradual exposure of your body with an increasing amount of allergen making your immune system tolerant. This can be carried out with tablets or drops containing the allergen under the tongue (this is called sublingual allergen immunotherapy, SLIT) or injections under the skin (subcutaneous allergen immunotherapy, SCIT).
This treatment improves nasal and ocular symptoms and reduces the need for symptomatic medication. Treatment response can be expected after several weeks/months. It is therefore very important to adhere to the therapy. When an effective dose is reached (the maintenance dose), you will need to continue treatment up to three years, both for sublingual and subcutaneous routes.
Allergen immunotherapy should only be carried out under the close supervision of a healthcare provider with experience in immunotherapy as there is a risk of adverse events.
COVID-19
I have been diagnosed with COVID-19. Is it safe to continue my medication for Allergic Rhinitis?
Up until now, there is no scientific evidence that treatments for allergic rhinitis increase the risk of infection with Sars-CoV-2 (the virus causing COVID-19) or the severity of COVID-19. This means that allergen avoidance, nasal rinsing with salt water, nasal corticosteroids and anti-histamine treatment should be continued as prescribed, both in COVID-19 infected and non-infected patients.
I take allergen-immunotherapy for my allergic rhinitis. Should I continue my treatment during the COVID-19 pandemic?
Allergen-immunotherapy (AIT) or allergen vaccines (both injections and under the tongue) for the treatment of allergic rhinitis should be discontinued in COVID-19 diagnosed patients or suspected COVID-19 cases until complete clinical recovery (negative test result and/or adequate quarantine). Allergen-immunotherapy for allergic rhinitis should be continued in non-infected individuals and patients recovered from COVID-19.
Can I switch from allergen-immunotherapy via injections to tablets or drops?
For patients who are receiving immunotherapy via injections (SCIT) and therefore need repeated visits to a physician or hospital, it can be considered an option to permanently or temporarily switch from SCIT to SLIT (therapy via drops or tablets), when there is a suitable alternative available.
Treatment
Frequently Asked Questions
Which allergic rhinitis patients would benefit from surgery
Patients who have uncontrolled allergic rhinitis with nasal obstruction as most bothersome symptom despite prolonged medical treatment could sometimes benefit from surgery. A thorough ENT examination is needed in uncontrolled allergic rhinitis patients in order to exclude structural nasal problems. For example: a severe septal deviation might make intranasal corticoid spray treatment less effective and be responsible for persistent nasal obstruction on one or both nasal sides.
What is the difference between SCIT and SLIT?
Subcutaneous allergen immunotherapy (SCIT) injections are administered right under the skin. In the beginning, injections are given weekly and this progresses to monthly administration after a number of weeks. Because SCIT treatment has a small but present risk of a severe allergic reaction, the treatment is performed by a trained health care provider/professional. After the injection you will have to stay at the health care professional for an observation period of minimum 30 minutes
Sublingual immunotherapy treatment (SLIT) tablets or drops containing the allergen are administered under the patient’s tongue and swallowed. The safety profile of SLIT is high; therefore, SLIT can be self-administrated by patients at home. It is recommended that the first dose is taken in the presence of a health care provider.
What are typical side effects related to SCIT?
Common local reactions to SCIT are a red and itchy swelling of the skin at the site of injection that will disappear within several hours to days. Sporadically some systemic reactions occur such as itchy eyes, sneezing and shortness of breath. In very rare cases, a severe reaction can occur resulting in a sudden drop in blood pressure. This is why it is recommended that patients wait in their doctor's office for at least 30 minutes after SCIT treatment.
What are typical side effects related to SLIT?
SLIT is usually a well-tolerated treatment with a good safety profile. For this reason, it can be administered at home by the patient itself in contrast to SCIT which has to be administered by a doctor. Like all treatments, SLIT can also cause a variety of side effects which are usually mild and transient. Some common side effects are an itchy nose, ears or eyes, swelling of the mouth and lips, coughing and sneezing. Some rare side effects are nausea and abdominal pain. Very uncommon side effects are intensive itching in palms of hand and soles of feet, urticaria and swelling of mouth and throat that create a feeling of fullness in the throat. Most of these side effects occur within the first week of treatment and then reduce over time.
What to do after a specialist visit?
If your symptoms remain bothersome or if you develop new symptoms, it is important to take a new appointment with your doctor. In case you also experience symptoms of the lower airways such as shortness of breath, you should consider making an appointment with a pulmonologist.
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