Allergic Rhinitis Treatment & Management

  • Author: Javed Sheikh, MD; Chief Editor: Michael A Kaliner, MD   more...
 
Updated: May 7, 2012
 

Medical Care

The management of allergic rhinitis consists of 3 major categories of treatment, (1) environmental control measures and allergen avoidance, (2) pharmacological management, and (3) immunotherapy.

Environmental control measures and allergen avoidance involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allergic rhinitis.[45] However, global environmental control without identification of specific triggers is inappropriate.

Pollens and outdoor molds

Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction of outdoor exposure during the season in which a particular type of pollen is present can be somewhat helpful. In general, tree pollens are present in the spring, grass pollens from the late spring through summer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist (see Causes).

Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during this time, but this may not be reliable because pollen counts can also be influenced by a number of other factors. Keeping the windows and doors of the house and car closed as much as possible during the pollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a shower after outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.

Despite all of these measures, patients who are allergic to pollens usually continue to be symptomatic during the pollen season and usually require some other form of management. As with pollens, avoidance of outdoor/seasonal molds may be difficult.

Indoor allergens

Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. For dust mites, covering the mattress and pillows with impermeable covers helps reduce exposure.[46] Bed linens should be washed every 2 weeks in hot (at least 130°F) water to kill any mites present.[47, 48] Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting should be removed. The carpet can be treated with one of a number of chemical agents that kill the mites or denature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrive when indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful.[49]

Indoor environmental control measures for mold allergy focus on reduction of excessive humidity and removal of standing water. The environmental control measures for dust mites can also help reduce mold spores.

For animal allergy, complete avoidance is the best option. For patients who cannot, or who do not want to, completely avoid an animal or pet, confinement of the animal to a noncarpeted room and keeping it entirely out of the bedroom can be of some benefit.[50] Cat allergen levels in the home can be reduced with high-efficiency particulate air (HEPA) filters and by bathing the cat every week (although this may be impractical). Cockroach extermination may be helpful for cases of cockroach sensitivity.

Occupational allergens

As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respirator might be needed.

Nonspecific triggers

Exposure to smoke, strong perfumes and scents, fumes, rapid changes in temperature, and outdoor pollution can be nonspecific triggers in patients with allergic rhinitis. Consider avoidance of these situations or triggers if they seem to aggravate symptoms.

Pharmacotherapy

See Medication.

Immunotherapy (desensitization)

A considerable body of clinical research has established the effectiveness of high-dose allergy shots in reducing symptoms and medication requirements.[51] Success rates have been demonstrated to be as high as 80-90% for certain allergens. It is a long-term process; noticeable improvement is often not observed for 6-12 months, and, if helpful, therapy should be continued for 3-5 years. Immunotherapy is not without risk because severe systemic allergic reactions can sometimes occur. For these reasons, carefully consider the risks and benefits of immunotherapy in each patient and weigh the risks and benefits of immunotherapy against the risks and benefits of the other management options.

  • Indications: Immunotherapy may be considered more strongly with severe disease, poor response to other management options, and the presence of comorbid conditions or complications. Immunotherapy is often combined with pharmacotherapy and environmental control.
  • Administration: Administer immunotherapy with allergens to which the patient is known to be sensitive and that are present in the patient's environment (and cannot be easily avoided). The value of immunotherapy for pollens, dust mites, and cats is well established.[52, 53, 54, 55, 56] The value of immunotherapy for dogs and mold is less well established.[51, 52]
  • Contraindication: A number of potential contraindications to immunotherapy exist and need to be considered. Immunotherapy should only be performed by individuals who have been appropriately trained, who institute appropriate precautions, and who are equipped for potential adverse events.
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Surgical Care

Surgical care is not indicated for allergic rhinitis but may be indicated for comorbid or complicating conditions, such as chronic sinusitis, severe septal deviation (causing severe obstruction), nasal polyps, or other anatomical abnormalities. The value of turbinectomy is not established.

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Consultations

While the general practitioner can effectively treat most cases of straightforward allergic rhinitis, consider consultation with an allergist or immunologist for severe disease, poor response to pharmacotherapy, and the presence of comorbid conditions or complications. Consultation with other specialists also might be needed for comorbid conditions or complications. Consult with an allergy specialist when identification or clarification of specific allergic triggers is needed, when detailed counseling regarding environmental control measures is needed, when quality of life is significantly impaired, or when immunotherapy may be a consideration.

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Contributor Information and Disclosures
Author

Javed Sheikh, MD  Assistant Professor of Medicine, Harvard Medical School; Clinical Director, Division of Allergy and Inflammation, Clinical Director, Center for Eosinophilic Disorders, Beth Israel Deaconess Medical Center

Javed Sheikh, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American College of Allergy, Asthma and Immunology

Disclosure: Nothing to disclose.

Coauthor(s)

Umer Najib, MD  Clinical Research Fellow, Department of Medicine, Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

William F Schoenwetter, MD  Consultant in Allergic Diseases, Brainerd Medical Center, Brainerd, Minnesota

William F Schoenwetter, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Medical Association, Joint Council of Allergy, Asthma and Immunology, and Minnesota Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Stephen C Dreskin, MD, PhD  Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, University of Colorado Health Sciences Center

Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology

Disclosure: Genentech, Inc. Consulting fee Consulting; Clinical Immunization and Safety Assessment (CISA) Network (CDC) administered by America's Health Insurance Plans (AHIP) Consulting fee Consulting; Genentech, Inc. Grant/research funds Other; Medical Expert Panel, Department of Health and Human Services, Division of Vaccine Injury Compensation None Independent contractor; American Board of Allergy and Immunology Honoraria Board membership; Novartis, Inc Consulting fee Review panel membership

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD  Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy

Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians

Disclosure: Alcon Consulting fee Consulting; Teva Consulting fee Consulting; Meda Honoraria Speaking and teaching; Ista Consulting fee Consulting; sunovian Consulting fee Consulting; dey Honoraria Review panel membership

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