Patients with allergic rhinitis (AR) need continuous follow-up care because AR is a chronic disease that waxes and wanes with seasons and age. The fluctuation of symptoms requires adjustment of medications.
Patients rarely outgrow allergic rhinitis in childhood.
Treatment of allergic rhinitis (AR) can be divided into 3 categories: avoidance of allergens or environmental controls, medications, and allergen-specific immunotherapy (sublingual or allergy shots).
Use of environmental controls is not adequately explored in most patients. For many patients, the removal of the trigger can have a dramatic effect. Difficulty arises when the trigger needs to be identified and eliminated. Eliminating the trigger may be simple if removal of a feather pillow or blanket is involved; however, it can be very difficult if a family pet needs to be removed. Although avoiding outdoor pollens is impossible, the patient can reduce exposure to pollens to attenuate symptoms. This sometimes is as simple as closing a bedroom window, using an air conditioner, or installing a pollen filter.
Identification and elimination is easiest for dust mite allergens.
- Feathered bedding should be removed and replaced with a fiber-filled product encased by dust mite–proof encasings. Such encasings can be purchased at the local stores or via mail orders. These encasings should be zip-locked and cover all surface areas.
- A bed pad that is placed on top is not helpful and may be another source of dust mite infestation.
- Less expensive plastic encasings may leak allergens through needle holes or between zipper teeth; therefore, more expensive dust mite–proof covers are preferable.
- The pillow must be covered; this is even more crucial than covering the bed mattress itself because the pillow is where the patient's head usually spends most of the night. Box springs usually do not need to be covered.
- Care should be taken to be sure the encasings are dust mite–proof. Some products may claim to be an allergy cover but may not provide the proper protection for dust mite. Also hypoallergenic bedding usually refers to the fact that the bedding is not made of feathers and does not necessarily mean that it is dust mite–proof.
Pollen is more difficult to avoid because daily activities must be altered to do so.
- The patient is best advised to remain indoors with air-conditioning during the period of the highest pollen counts of the day. Commonly, remaining indoors is not possible because of activities, and many schools are not air-conditioned. If it is a room unit air-conditioner, then it must be set to indoor air as not to draw in the outdoor pollens and send them into the room.
- An easy intervention is to keep the windows closed, which is easily accomplished in air-conditioned homes and must be done throughout the year. Windows tend to be opened most frequently during fall and spring in moderate climates, but these seasons are the worst possible times for open windows for patients with pollen allergy. If windows must be open, open them during the day and close them at night. Many pollen counts are highest during the night, especially for molds and trees.
- Another intervention is to obtain a window filter or filter fan, which allows air, but not pollen, to enter the room.
- Advise patients to wash head to toe and to change clothing upon coming in from the outdoors during high pollen season. Avoid hanging cloths outdoors to dry.
The most difficult trigger to avoid is the family pet. Ideally, the pet should be removed from the home, but removal is the option, not the rule. Some helpful manipulations include removing the pet from the patient's bedroom and play area, using air cleaners in these areas and, occasionally, frequently sponge-bathing the pet (once per week). Even when these interventions are performed, many patients continue to experience symptoms. Other therapies are necessary in these patients; however, some patients choose to live with the source of offending allergens.
See Medication for a discussion of medications and allergen-specific immunotherapy (ie, allergy shots and sublingual  ). A 2009 study concluded that specific immunotherapy can be recommended for treatment because it is effective in reducing symptoms.  The US Food and Drug Administration (FDA) has approved several products for sublingual immunotherapy in patients with grass or ragweed allergy [13, 14, 15]
No routine surgical care is needed.
Some patients may be seen by ear, nose, and throat (ENT) specialists, and turbinectomies may be performed to provide some relief. This is an extreme measure and is reserved for patients in whom all other therapies have failed.
Rarely, in adults, if nasal polyps do not respond to topical nasal steroids, surgical removal may be necessary, although the polyps often grow back.
Primary care physicians can attend to most patients.
Patients in whom diagnosis or treatment is more difficult may require consultation with a specialist. This usually starts with an allergist, who performs a complete allergy evaluation, including diagnostic tests. Therapy is instituted, which is a combination of environmental manipulations, medications and, in some patients, allergen-specific immunotherapy.
Refer patients in whom allergic rhinitis becomes hard to manage or diagnose to an allergist for complete evaluation and advanced treatment, including institution of allergen-specific immunotherapy.
If medical therapies do not produce an adequate result, referral to an ENT specialist should be indicated for possible surgical intervention.
Dietary restrictions do not help because allergic rhinitis is not triggered by foods.
No limitations are placed on activity.
For some pollens, patients with allergic rhinitis benefit from avoiding the outdoors during peak pollen periods of the day. This time varies according to pollens and location. Geographic location and distance from the source have an impact. Patients who are miles away from the source have different peak pollen times than patients near the source.
The best deterrent is to avoid allergens that trigger symptoms. This means diligent environmental controls and patient compliance with medication use.
Exposure to allergens in first year may reduce subsequent wheezing and atopy.
In the Urban Environment and Childhood Asthma (URECA) study of 467 urban children who had at least 1 parent with an allergic disease or asthma, researchers found that exposure during the first year of life to specific allergens and bacteria reduced recurrent wheeze and atopy at age 3 years. [1, 2]
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