Allergic Rhinitis
Patient Education Handout associated with UMHS Clinical Care Guideline

This information is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your health-care provider or make an appointment to be seen if you have questions or concerns about this information or your medical condition.

What is allergic rhinitis?
Allergic rhinitis means allergies in the nose. Hay fever is allergies that occur during a certain season of the year.

What are the symptoms?

These symptoms may occur during a certain season or year-long. They can occur at any age. These symptoms may not always be caused by allergies. Symptoms can be caused as a side effect of drugs, chemical fumes, smoke, acute stress, being pregnant and overuse of nasal decongestant sprays.

How does it occur?
Allergic rhinitis occurs when the nose -- and most often the ears, sinuses, and throat -- come into contact with allergy-causing substances, called "allergens". The most common allergens are pollens, molds, dust, and animal dander. Some allergens are present only during certain seasons -- for example, ragweed in the fall. Other indoor allergens are present year-round -- for example, the mites in house dust.

When the lining of the nose and sinuses comes into contact with allergens, cells release chemicals, one of which is called histamine. Histamine causes the nose lining to swell, itch, and produce excess mucus.

How is it diagnosed?
The diagnosis of allergic rhinitis is most often made based on your medical history.  Allergic problems also run in families.  Some individualindividuals with allergic rhinitis also have asthma and/or eczema.  But it may take some work to figure out what you are allergic to.

Allergy tests are most often done if allergy shots are being considered. Your health care provider will probably suggest that you try treating your symptoms with medication first. If medications do not control your symptoms, allergy testing may be needed.

Treatment

Avoidance Therapy
We have all heard that "an ounce of prevention is worth a pound of cure," and first line treatment of nasal allergies is to avoid exposure to allergens that cause your symptoms. Be aware that allergens may be in your carpet and clothing for as long as six (6) months.

Dust mites are the cause of dust allergies. These mites thrive in moist areas and feed off tiny bits of human skin.
Allergies to animal dander are a concern for pet owners and those who work with animals. If animals cannot be taken away, they should be kept out of the bed, bedroom, and, common living areas.

Pollen is tough to avoid but pollen masks may help patients while mowing the grass and gardening. Good filters on the furnace and air conditioner can keep pollen out of the house. Change filters on furnaces and air conditioners often.

There is a large amount of mold outdoors from spring until the first hard frost. Molds are common in compost bins, leaf piles, and flower and vegetable gardens.

Indoor molds are found year-round, most often in damp, warm places. These include old shoes, books, luggage, old newspapers, and carpets (those that have been wet before have even more mold). Other indoor areas that have mold are refrigerator drip pans, shower curtains, and bathroom surfaces. Houseplants and dried flowers are a major source of molds and should be kept out of bedrooms and major living areas.

It is also important to decrease irritants to the nose. A saline spray should be used to clean and moisten the nasal passages. Avoid tobacco smoke and fumes that can bother the nose. Proper levels of moisture should be kept in your home, mainly in winter. Nasal dryness bothers the nose but indoor moisture levels over 50% allows molds and dust mites to grow.

Medications

Steroid nasal sprays are the most effective medications to reduce and prevent nasal allergy symptoms. Steroid nasal sprays are used frequently with a low chance of side effects: Sometimes they may cause nasal dryness or nosebleeds, but this can generally be avoided by correct spray technique and by using saline sprays. Because steroid sprays take several days to work, they must be used daily as directed. Relief from symptoms cannot be expected for five to ten days, even with correct use. These sprays should be used one to two weeks before a seasonal allergy period. For instance, use the spray one to two weeks before the pollen count begins to rise in the spring, or one to two weeks before the ragweed season starts in the fall. For patients with only seasonal allergy symptoms, these sprays can be stopped when the allergy season is over. Patients with year round allergy symptoms (perennial allergic rhinitis) will also benefit from steroid nasal sprays.  In all cases, correct use of the sprays is essential to ensure the maximal benefit:  Link here for Steps for Correct Use of Your Pump Nasal Spray

Decongestants cause "vasoconstriction” or shrinkage of swollen tissues in the nasal cavity and widen passages for breathing. Decongestant nasal sprays are NOT recommended for allergic rhinitis since they can cause an increase in congestion if used for longer than three days at a time. Oral decongestants (pills) are preferred; however, patients with high blood pressure, those taking tricyclic antidepressants and men with prostate enlargement should avoid oral decongestants.

Antihistamines block the effect of histamine on cells and can prevent the classic allergic reaction. Antihistamines are most effective when taken prior to allergen exposure. They relieve the "wet" symptoms such as sneezing, itching, and runny nose and eyes but have less effect on congestion, for which a decongestant may be added. Older antihistamines can cause significant drowsiness but newer antihistamines often have less side effects.

Antihistamine eye drops reduce the symptoms of itchy and watery eyes (allergic conjunctivitis) in patients that do not get adequate relief from oral antihistamines alone.

Antihistamine nose sprays block the nasal effects of histamine to relieve nasal drainage and may be useful for patients that cannot take oral antihistamines.

Montelukast (Singulair) works by blocking other chemicals (leukotrienes) that cause inflammation and symptoms of allergic rhinitis.  It is especially useful for patients who also have asthma or those who cannot use nasal steroid sprays.

Cromolyn sodium works by stabilizing cellular membranes and preventing the release of histamine. Because cromolyn sodium is expensive and needs to be used four times per day, it is not widely used in the treatment of allergic rhinitis. When used, it is best used prior to exposure to prevent symptoms. It is not that helpful in patients who are having significant allergy symptoms before they use it.

Immunotherapy

Immunotherapy, or "allergy shots," is the only measure that offers a "cure" for allergies. Shots would be a good fit for patients whose symptoms are hard to control with other medications, those who have a hard time avoiding certain allergens, and those with year-long symptoms or severe symptoms. Patients must be able to follow the program plan to receive allergy shots.

Other Information for Patients-Avoidance Measures for:
Pollen
DO: Use air conditioning
Close windows and doors
Wear loose, light clothing outdoors; shower, change, and wash clothes in hot water after each use
Vacation away during peak pollen season
AVOID:
Using fans
Flowers indoors, direct contact with plants (e.g., weeding)
Going outdoors on hot, dry days

Outdoor Molds
AVOID:
Compost piles, fallen leaves, cut grass (always if clippings are not bagged), barns, wooded areas
Sleeping/camping out, especially on wet ground
Greenhouses, antique shops, saunas, sleeping bags, summer cottages, some hotel rooms (especially if not air-conditioned)
Outdoor activities at sunset (when mold spores drop onto the ground)

Indoor Fungi
DO: Keep humidity at 25-45%
Clean surface with mold inhibitors/chlorine bleach: Impregnon, "X"-14, Mildew-Stop
Let window/car air conditioner run at full blast 3-5 minutes with window open when first turned on
Vent clothes dryers, stoves, and bathrooms to outdoors
Ventilate closets (use incandescent light bulbs)
Empty and clean garbage cans frequently
AVOID:
Leaks, old wallpaper
Basements
Old books, poorly ventilated- and poor air-conditioned libraries
Live Christmas trees
(Data from Pierece, W., Ed., Foundation for Allergy Care and Treatment (FACT). Facts from FACT, Vol 1l, Silver Spring, MD, American Academy of Otolaryngic Allergy, 1993: 1-2.)

Dust Mites
DO: Eliminate mite reservoirs:
Plastic encase pillows and mattresses
Wash bedding weekly (140° F or 60° C)
Remove carpets, feather/down bedding and pillows, stuffed animals
Reduce upholstered furniture to a minimum
Keep humidity 25-45%
Use air conditioner and dehumidifier
Use air filtration measures:
Portable HEPA filters
Vacuum cleaning
Exposure to heat or cold
AVOID:
Too-tight houses (use outdoor ventilation in spring and fall)

January 2007

Information maintained by the UMHS Clinical Care Guidelines Committee

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