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Allergic Rhinitis (Hay Fever and Rose Fever)
and Chronic Nasal Congestion

* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

WHAT IS RHINITIS?

The Nasal Passages and Daily Congestion

The nose is separated into two passages by a wall of cartilage called the septum. The nasal passages are lined with a membrane that produces mucus. Mucus is one of the body's defense systems:

The mucus, a thin clear liquid, traps small particles and bacteria that are drawn into the nose as a person breathes.
The trapped bacteria usually remain harmless in healthy individuals.
Even under normal circumstances, this produces a cycle of congestion and decongestion that occurs continuously throughout the day.
When one side of the nose is congested, air passes through the open, or decongested, side. The sides alternate between being wide open and being narrowed.

Rhinitis

If the congestion becomes severe or other changes occur that irritate the nasal passage, rhinitis develops. Rhinitis describes a group of symptoms that include following:

Runny nose.
Itching.
Sneezing.

These symptoms may develop as a result of colds or environmental irritants, such as allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factors.

Infectious Rhinitis. If symptoms last less than six weeks, the condition is referred to as acute rhinitis and is usually caused by a cold or other infection or temporary overexposure to environmental chemicals or pollutants. [Infectious rhinitis is discussed in the Report #94, Colds, Flu, and Bronchitis. ]

Chronic Rhinitis . When rhinitis lasts for a longer period, the condition is called chronic rhinitis, and is most often caused by allergies but can also be caused by structural problems or chronic infections. [See Box Chronic Nonallergic Rhinitis.]

CAUSES OF CHRONIC NONALLERGIC RHINITIS

Immune Response

Some cases of chronic rhinitis are associated with increased numbers of white blood cells called eosinophils. These are components of the immune system that release powerful inflammatory factors, but are not related to the allergic response. This inflammatory response causes nasal congestion in susceptible people and can be triggered by cigarette smoke, dozens of other air pollutants, strong odors, alcoholic beverages, and exposure to cold. The elderly are at risk for chronic rhinitis as the mucous membranes become dry with age.

Vasomotor Rhinitis

Vasomotor rhinitis, also sometimes called idiopathic or irritant rhinitis, occurs when the nasal membrane swells in response to irritants, including smoke, environmental toxins, changes in temperature and humidity, and stress. Emotional stress and sexual arousal can also trigger congestion and stuffy nose. This over-reaction, however, is not associated with the immune response and the biologic causes are unknown. Symptoms of vasomotor rhinitis are similar to most of those caused by allergies. Usually, however, they are more severe and occur predominantly on one side of the nose.

Foreign Objects

Blockage in young children is very often caused by foreign objects that they have pushed up their nose. If they are left in place, they may eventually cause infection and nasal discharge, usually in one side of the nose, which may be yellow or green and foul smelling.

Blockage in the Nose from Polyps or Structural Abnormalities

A number of conditions may block the nasal passages.

Polyps. These are soft, gray, fluid-filled sacs that develop off stalk-like structures on the mucus membrane. They impede mucus drainage and restrict airflow. Polyps usually develop from sinus infections that cause overgrowth of the mucus membrane in the nose. They do not regress on their own and, in fact, may multiply and cause considerable obstruction.
Deviated Septum . A common structural abnormality that causes rhinitis is a deviated septum. The septum is the inner wall of cartilage and bone that separates the two sides of the nose. When it is deviated, it is not straight but shifted to one side, usually the left.
Other Causes of Blockage. Rarely, cleft palates, overgrowth of bones in the nose, or tumors cause rhinitis.

Surgery may be helpful for certain cases. A procedure called radioablation is also under investigation. It employs a surgical wand attached to a radiofrequency generator that applies energy to different areas of the nose. More research is needed, but the investigators involved in a recent study predict that this may be a new wave in treatment for chronic nasal congestion.

Nonallergic Rhinitis in Children

Chronic nasal congestion in children often accompanies a susceptibility to ear, sinus, or adenoid infections. Adenoids are spongy tissue masses located between ends of the nasal passages and the soft tissue in the back of the throat. Enlarged adenoids may also cause ear problems. The bacteria that cause these other infections, however, are not usually the cause of this chronic rhinitis.

Medications and Illegal Drugs

A number of drugs can cause rhinitis or worsen it in people with conditions such as deviated septum, allergies, or vasomotor rhinitis:

Overuse of decongestant sprays used to treat nasal congestion can, over time (three to five days), cause inflammation in the nasal passages and worsen rhinitis.
Many people with allergies and asthma are sensitive to some of the common painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs). They include the common drugs aspirin, ibuprofen (Motrin, Advil, Nuprin, Rufen), and naproxen (Aleve) among many others. Aspirin and products containing aspirin can even cause life-threatening asthma attacks in some highly susceptible individuals. NSAIDs vary, however, and some patients may not have a reaction to all of them. For minor pain, acetaminophen (eg, Tylenol), which is not an NSAID, is usually recommended for patients with intolerance to NSAIDs. A pharmacist should be consulted if the ingredients of any over-the-counter preparations are not known.
Other medications that may cause rhinitis include oral contraceptives, hormone replacement therapy, and some blood pressure medications, including beta-blockers and vasodilators.
Sniffing cocaine damages nasal passages and can cause chronic rhinitis.

Hormonal Changes in Women

Conditions that cause hormonal changes in women, such as pregnancy and hypothyroidism, can cause chronic rhinitis. In such cases the condition usually clears up after treatment of the disorder or, in the case of pregnancy, at delivery.

Medical Conditions

People with certain rare genetic or other medical conditions that affect the mucous membranes are at risk for chronic rhinitis, although rhinitis in such people is apt to be only one of many more serious conditions, including chronic sinusitis and respiratory problems. Wegener's granulomatosis, for example, is a serious but very rare illness that causes long-term swelling and tumor-like masses in air passages.

Rare genetic disorders that cause chronic rhinitis include the following:

Cystic fibrosis, in which the mucus is very thick.
Kartagener's syndrome. With this condition the body's major internal organs are located in the mirror-image position of their normal location. In addition, the body's cilia (hair-like-projections on many body tissues that help to move mucus and other fluids) are impaired or motionless.

In both disorders, mucus build-up also produces an environment favorable to infection-causing organisms.

WHAT ARE THE CAUSES AND TRIGGERS OF ALLERGIC RHINITIS?

Biologic Mechanisms Leading to Allergic Rhinitis

The body's immune system is designed to produce various factors to fight foreign substances, including bacteria, viruses, and other proteins that the immune system perceives as threatening. An allergic response occurs when the body's immune system over-responds or is hypersensitive to specific non-infectious particles. (Some experts believe that this hypersensitive response originally developed in humans as a way of fighting large invaders, such as parasites and worms.)

Among the important components of the immune system are antibodies. Antibodies are classified into five categories, called immunoglobulins (IgG, IgA, IgM, IgD, IgE). Overproduction of IgE antibodies is a key factor in the allergic reaction, which most likely occurs because of genetic factors.

During an allergic attack, IgE antibodies attach to cells known as mast cells , which are generally concentrated in the lungs, skin, and mucous membranes.
Once IgE binds to mast cells, these cells are programmed to release a number of chemicals, importantly histamine.
These chemicals open the blood vessels and cause skin redness and swollen membranes; when these effects occur in the nose, sneezing and congestion occurs.

Triggers of Seasonal Allergic Rhinitis (Hay Fever or Rose Fever)

Seasonal allergic rhinitis occurs only during periods of intense airborne pollen or spores. It is commonly, although inaccurately, called hay fever or rose fever, depending on whether it occurs in the late summer or spring. No fever accompanies this condition, and the allergic response is not dependent on either hay or roses. In general, triggers of seasonal allergy in the US are the following:

Ragweed. Ragweed is the most important cause of allergic rhinitis in the US, affecting about 75% of allergy sufferers. One plant can release one million pollen grains a day. Ragweed is everywhere in the US, although it is less prevalent along the West Coast, southern Florida, northern Maine, Alaska, and Hawaii. The effects of ragweed in the northern states are first felt in middle to late August and last until the first frost. Ragweed allergies tend to be most severe before midday.
Grasses. Grasses affect people in mid-May to late June. Grass allergies are experienced more in the late afternoon.
Tree Pollen. Small pollen grains from certain trees usually produce symptoms in late March and early April.
Mold Spoors. Mold spoors that grow on dead leaves and release spoors into the air are common allergens throughout the spring, summer and fall. Mold spores may peak on dry windy afternoons or on damp or rainy days in the early morning.

Triggers of Perennial (Year-Round) Allergic Rhinitis

Allergens in the house can cause year-long allergic rhinitis, called perennial rhinitis. Household allergens may include the following:

House dust mites.
Cockroaches.
Pet dander.
Molds growing on wall paper, house plants, carpeting, and upholstery.

Other possible triggers of perennial allergies are being investigated:

Air pollutants. Although difficult to prove, a number of investigations, including European studies in 1999 and 2000, reported an association between traffic-related air pollution and allergic rhinitis. Several studies have implicated diesel exhaust particles as having a role in allergic rhinitis.
Bacteria. Although bacteria do not cause allergic rhinitis, one study found higher numbers of colonies of the common bacteria Staphylococcus aureus in the nasal passages of patients with perennial rhinitis. The study suggested that the allergic condition may lead to higher bacterial levels, which in turn may aggravate the allergies.
A flame retardant called triphenyl phosphate, which is used to coat computer monitors is a known allergen. New computers contain more of this compound, but it is not known yet if this will cause rhinitis or other allergic symptoms in computer users.

WHAT ARE THE SYMPTOMS OF RHINITIS?

The general symptoms of rhinitis are congestion, runny nose, and post-nasal drip, in which mucous drips into the throat from the back of the nasal passage, especially when lying on the back. Symptoms may vary depending on the cause of rhinitis. Symptoms of influenza and sinusitis must also be differentiated from allergies and colds.

Symptoms of allergic rhinitis include a congested nose any of the following:

A runny or congested nose.
Frequent or repetitive sneezing.
Itching in the nose, eyes, throat, or roof of the mouth.
Plugged ears.
A decreased sense of smell.
Postnasal drip.
Sinus headaches.
Fatigue.
In some cases a slight decrease in attention span, worsened memory, and slower thinking.
In severe allergies, dark circles under the eye. The lower eyelid may be puffy and lined with creases.
Children may push their nose upward with the palm of their hand or twitch their nose rabbit-like to clear obstruction.

Interestingly, although people with allergic rhinitis may perceive that they are getting less air through the nose, one study reported that there was no difference between nonallergy and allergy seasons in total nasal airflow, and patients may be achieving complete airflow during allergy season through one nostril.

WHO GETS ALLERGIC RHINITIS?

Allergic rhinitis is the most common chronic condition in childhood. In general, about 26 million Americans have seasonal allergic rhinitis and up to 40 million may have mild symptoms. Estimating the number of people with allergic rhinitis is difficult, however. Studies in the US report prevelances as low as 4% to as high as 40%. One reason the studies vary so widely may be due to self-reporting. For example, in response to a Spanish survey, only 9.4% of adolescents said they have hay fever or allergic rhinitis although 30.3% of them describe having symptoms that are characteristic of allergic reactions. It is agreed, in any case, that in the US and around the world the numbers are increasing.

Family History

Genetic factors are the major determinants of allergies.

If both parents have an allergy, the risk to the child is 75%.
If one parent is allergic, the child's chances are 50%.

It should be noted that children with allergic family members are at highest risk for allergies themselves, but they can develop in anyone.

Age of Onset and Duration

Although allergies often appear first in childhood, they may develop at any age. In some cases, allergies go into remission for years and then return later in life. People who develop hay fever in early childhood are likely not to have the allergy in adulthood. Those who develop it after age 20, however, tend to continue to have hayfever at least into middle age.

Allergic Responses in Childhood

Having other allergies increases the risk for allergic rhinitis. Here are some examples:

Young children who have eczema (an allergic skin reaction) have a later risk for allergic rhinitis and asthma. In fact, a family history of eczema increases the risk.
Food allergies are associated with allergic rhinitis and asthma. (Early feeding patterns, time of weaning, and introduction of solid food have no effect on the risk of development of allergic symptoms. Although, there are some studies suggesting that breastfeeding may decrease or delay the risk of allergies.)

Westernization

Allergies and, even worse, asthma are on the rise. A number of international studies have reported an association between more Westernized lifestyles and a higher increase in asthma and allergies, although they have not been consistent. Ironically, theories to explain this increase point to healthier conditions in industrialized countries.

Protective Role of Early Respiratory Infections. An important theory blames the dramatic increase in allergies and asthma on the elimination of childhood infections since immunization has become widespread. The basic theory is as follows:

In the past, when children became infected with childhood diseases, the immune system released helper T-1 (TH1) white blood cells, which stimulate the body's infection-fighters.
At the same time, the immune system suppressed production of the helper T-2 (TH2) cells. These cells attack airborne allergens and parasites. They also release powerful inflammatory factors that are major contributors to the allergic response.
TH2 cells appear to be important in fetal development but in a normal environment, they are replaced as TH1 cells become more prevalent. With fewer TH2 cells, the child does not react to allergens.
When children are vaccinated, however, the TH2 cells remain active (instead of the TH1 cells). In genetically susceptible individuals, they continue to trigger the inflammatory events in response to allergens.

Of some support for this theory are studies reporting that being part of a large family or attending day care increases the risk for early infections but reduces the risk of allergies and childhood asthma. Another study reported that in regions where certain gastrointestinal infections were high because of poor food hygiene, allergies were lower.

It should be noted that exposure to childhood infections does not necessarily prevent allergies from developing, and this theory is no argument against immunization. Infections killed thousands of children every year before immunization became widespread. Allergic rhinitis is virtually never very serious and asthma, although it can be serious, is rarely fatal in children.

Overexposure to Indoor Allergens. One study in Germany that tracked East German children after the country became unified reported that children in the areas previously under communism experienced a significant increase in allergies, particularly hayfever, when they were exposed to a Western lifestyle. Included in lifestyle changes were the following:

Increases in wall-to-wall carpeting.
Increases in cat ownership.
Damper homes.
Consumption of margarine (which has been associated with hayfever).

Some scientists believe that children are overexposed to indoor allergens because they are now spending three hours or more indoors each day engaging in sedentary activities, including watching television, playing video games, or using a computer. This exposure is intensified by the recent trend of making homes more energy-efficient, which may result in more dust mites being trapped inside.

Within Western countries, however, children in lower income homes appear to have a higher sensitivity to common allergens such as those from cockroaches. The reason for this is unclear and requires more research.

Birth Month

One 1997 study reported that the month of one's birth might influence the risk for allergies:

Those born in September, October, or November had the highest levels of IgE (a key immune factor in allergies), so presumably a higher risk for seasonal allergies.
Those born in June, July, and August had the lowest levels of IgE.

Interestingly, a more recent Japanese study found a similar seasonal trend in risk factors for children with skin allergies but not for those with asthma or allergic rhinitis. If there is a seasonal trend, it is likely to be small.

HOW SERIOUS IS ALLERGIC RHINITIS?

Long-Term Outlook

Although perennial allergic rhinitis is certainly not considered a serious condition, it nonetheless can interfere with many important aspects of life. Seasonal allergic rhinitis tends to diminish as a person ages. The earlier the symptoms start the greater the chances for improvement. In one study over half of allergic subjects reported that by 40 years of age their symptoms had decreased, and 23% were symptom-free.

Fatigue and Sleepiness

People with allergic rhinitis, particularly those with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. Often they attribute this to medication, but studies suggest congestion may be the culprit in these symptoms.

Risk for Asthma

Children with allergic rhinitis alone appear to be at only slightly greater risk for asthma than the general population. Studies have reported that about 1% to 10% of children with allergic rhinitis developed asthma later on. Researchers are finding that cells called eosinophils, which are produced by the immune system and are an important component in asthma, are also found in allergic rhinitis patients. Although they are found in far lower numbers in allergic rhinitis patients than in those with asthma, eosinophils cause inflammation in the airways in the lung and may be a predisposing factor for developing asthma later on in some patients with allergic rhinitis. Additionally, allergic rhinitis has a negative impact on asthma in patients who suffer from both conditions; in fact, studies are showing that avoiding allergens may reduce the onset of asthma.

Increased Risk for Other Allergies

People with allergic rhinitis may be at higher risk for other allergies, including potentially serious food or latex allergies.

Complications of Chronic Rhinitis in Children

Children with severe allergies may have a higher risk for behavioral problems than those without allergies. Some research suggests that allergic rhinitis is responsible for two million missed school days each year.
Year-long allergic rhinitis is associated with ear infections (acute otitis media).
Chronic nasal obstruction from year-round allergies can affect a child's appearance. If a child can only breathe through the mouth, the continual force of air passing through the oral cavity can change the developing soft bones in the face, possibly causing an elongated face and an overbite from teeth coming in at an abnormal angle.
Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growth.

Associations with Other Disorders

Chronic Fatigue Syndrome (CFS). Some, although not all, studies have reported that a majority of CFS patients have allergies to food, pollen, metals (such as nickel or mercury), or other substances. (Most allergic people, in any case, do not have CFS.) Some research indicates that people with both allergies and emotional disorders, such as anxiety or depression, may be more vulnerable to the effects of the inflammatory response. This is a harmful overreaction of the immune response, which triggers the release of a number of immune factors, that can cause fatigue, joint aches, and fever and which can also affect the hypothalamus-pituitary-adrenal system in the brain.

One theory that may help tie in some of the various factors common to CFS suggests that allergies, stress, and infections may deplete a chemical in the body called adenosine triphosphate (ATP). This chemical stores energy in cells, and studies have reported a deficiency in many CFS patients. Supporting this theory was a study in which patients reported reduced CFS symptoms after they took a coenzyme called NADH, which increases ATP levels.

Rheumatoid Arthritis. Interestingly, research is finding that people with allergic rhinitis are less likely to have rheumatoid arthritis and vice versa. Patients who have both conditions tend to have less severe arthritic symptoms. Experts suggest that the immune response in one disorder may tend to neutralize the other.

WHAT TESTS MAY BE REQUIRED TO DIAGNOSE RHINITIS?

Medical and Personal History

To determine whether allergies are triggering rhinitis, the physician will ask a number of questions . They may include the following:

Whether a family history of allergies is present.
If there is a history of medical problems.
If the patient is taking any medications.
If the patient owns pets.

The time of day and year of allergy attacks. The timing of symptoms helps the physician make a diagnosis :

Rhinitis that appears seasonally is almost always due to pollens and outdoor allergens.
If symptoms occur throughout the year, the physician will suspect perennial allergic or non-allergic rhinitis.

Physical Examination

The physician will usually examine the inside of the nose with an instrument called a speculum. This is a painless examination and allows the doctor to check for redness and other signs of inflammation. The doctor will also usually check the eyes, ears, and chest.

Allergy Skin Tests

A skin test is a simple method for detecting common allergens in people. The test is not appropriate for children less than 3 years old. The procedure is as follows:

Small amounts of suspected allergens are applied to the skin with a needle prick or scratch (ie, epicutaneous test).
Or, small amounts of suspected allergens are injected a few cells deep into the skin (ie, intradermal test). This test may be more sensitive than the standard prick test.
If an allergy is present, a hive (a swollen reddened area) forms within about 20 minutes.

Patients should not take antihistamines for at least 12 to 72 hours before the test. Otherwise an allergic reaction may not show up. About 15% to 20% of people may have a skin reaction without actually having an allergy. Skin tests are rarely needed to diagnose mild seasonal allergic rhinitis, since the cause is usually obvious. Patients usually are tested for a panel of common allergens.

Laboratory Tests

Nasal Smear. The physician may take a nasal smear. The nasal secretion is examined microscopically for factors that might indicate a cause, such as increased numbers of white blood cells, indicating infection, or high counts of eosinophils. (High eosinophil counts indicate an allergic condition, but low counts do not rule out allergic rhinitis.)

Tests for IgE. Blood tests for IgE immunoglobulin production may also be performed. One called the radioallergosorbent Test (RAST) is used to detect increased levels of allergen-specific IgE in response to particular allergens. Blood tests for IgE may be less accurate than skin tests. They should only be performed on patients who cannot undergo skin testing or when skin test results are uncertain.

Imaging Tests

In people with chronic rhinitis, the physician may also check for sinusitis. Imaging tests may be useful if other tests are ambiguous.

A test called transillumination, in which a physician shines a bright light against the patient's cheek or forehead, is an inexpensive method for checking for abnormalities in the sinus cavities, although not highly accurate.
X-rays and CT scans may be useful for some cases of sinusitis.

Nasal Endoscopy

In certain cases of chronic or unresponsive seasonal rhinitis, a physician may use endoscopy to examine for any irregularities in the nose structure. Endoscopy employs a tube inserted through the nose that contains instruments and a miniature camera to view the passageways.

WHAT ARE THE GENERAL GUIDELINES FOR DRUGS USED IN TREATING ALLERGIC RHINITIS?

Home Remedies

Most cases of mild allergic rhinitis require little more than reducing exposure to allergens and using a nasal wash.

Drugs Used for Allergic Rhinitis Symptoms

Dozens of drugs are available for treating allergic rhinitis. Many are available over the counter but some require a prescription:

Drugs to Relieve Symptoms.

Nasal Washes.
Decongestants relieve nasal congestion and itchy eyes.
Decongestant/Antihistamine combinations.

Drugs to Prevent Allergy Attacks

Antihistamine tablets relieve sneezing and itching and can prevent nasal congestion before an allergy attack. At this time they are the first lines of prevention.
Nasal corticosteroids (commonly called steroids) reduce inflammation and are now considered to be the most effective measure for preventing allergy attacks.
Nasal cromolyn also reduces inflammation and may be sufficient in mild cases.

Newer agents are also under investigation. All drug treatments have side effects, some very unpleasant and, in rare cases, serious. Patients may need to try different drugs until they find one that relieves symptoms without producing excessively distressing side effects.

Immunotherapy (Allergy Shots)

Immunotherapy (allergy shots) is the only treatment that affects the cause of allergies and is highly effective. It also may prevent asthma and the development of new allergies in children. Many experts are now immediately recommending immunotherapy in people with both asthma and allergies.

Special Considerations for Drug Treatment in Children with Allergies

Because seasonal allergies generally last only a few weeks, most physicians do not recommend the more potent prescription treatments for children. One study noted, however, that in children with both asthma and allergies, intense treatments for allergic rhinitis may also improve asthmatic symptoms. It is important for parents to determine if the child is actually under severe distress and that the parent is not simply responding to their own anxiety when they hear the child snorting or snoring. Prescription drugs are required in only some severe cases.

AGENTS USED FOR ITCHY EYES

Agents Available

The following are eye drops for itchy eyes. Others are also available. Customers respond differently to these products, and report a wide range of effectiveness.

Antihistamine Eye Drops

Azelastine (Optivar).
Olopatadine (Patanol).
Ketotifen (Zaditor).
Levocabastine (Livostin) for relief of both nasal symptoms and itchy red eyes.

Decongestant Eye Drops

Phenylephrine (Allergan Relief).
Naphazoline (Naphcon, Opcon-A, Vasoclear).
Tetrahydrozoline (Murine Plus, Visine, A number of brands).

Combination Decongestant/Antihistamine

Visine A.

Corticosteroids

Loteprednol (Lotemax, Alrex).
Pemirolast (Alamast).

General Side Effects and Warning

All eye drops can cause stinging and some may cause headache and congestion.
No one should continue taking eye drops if they experience pain, changes in vision, worsened redness or irritation, or if the condition lasts more than three days.
Do not touch tip of the device or touch other surfaces with it. Replace the cap after using. Discard any solution that changes color or becomes cloudy.
People who have heart disease, high blood pressure, an enlarged prostate gland, and glaucoma should avoid eye drops.

HOW ARE DECONGESTANTS AND NASAL WASHES USED TO PREVENT ALLERGY SYMPTOMS?

For mild allergic rhinitis, a nasal wash can be helpful for removing mucus from the nose. Decongestants may help dry nasal congestion. They work by shrinking vessels in the nose. By reducing blockage, they decrease the risk of developing sinusitis caused by viruses or bacteria. Many over-the-counter decongestants are available, either in tablet form or as nasal or inhaled decongestants that are applied directly into the airways as sprays, drops, or vapors.

Nasal Wash

For mild allergic rhinitis, a nasal wash can be helpful for removing mucus from the nose. A saline solution can be purchased at a drug store or made at home. One study reported that neither a home-made solution (using one teaspoon of salt and one pinch of baking soda in a pint of warm water) nor a commercial hypertonic saline nasal wash had any effect on symptoms. Some physicians, however, argue for the effectiveness of a traditional nasal wash, used for centuries, that uses no baking soda and more fluid for each dose and less salt than the saline washes in the study. The process is something like this:

Lean over the sink head down.
Pour some solution into the palm of the hand and inhale it through the nose, one nostril at a time.
Spit the remaining solution out.
Gently blow the nose.

The solution may also be inserted into the nose using a large rubber ear syringe, available at a pharmacy. In this case the process is the following:

Lean over the sink head down.
Insert only the tip of the syringe into one nostril.
Gently squeeze the bulb several times to wash the nasal passage.
Then press the bulb firmly enough so that the solution passes into the mouth.
The process should be repeated in the other nostril.

A nasal wash should be performed several times a day.

Nasal-Delivery Decongestants

Nasal-delivery decongestants are applied directly into the nasal passages with a spray, gel, drops, or vapors. Nasal forms work faster than oral decongestants and have fewer side effects. They often require frequent administration, although long-acting forms are now available. Ingredients and brands of nasal decongestants include the following:

Long Acting Nasal-Delivery Decongestants. They are effective in a few minutes and remain so for six to 12 hours. Ingredients are the following:

Oxymetazoline: Brands include Vicks Sinex (12-hour brands), Afrin (12-hour brands), Dristan 12-Hour, Good Sense, Nostrilla, Neo-Synephrine 12-Hour.

Short-Acting Nasal-Delivery Decongestants. The effects usually last about four hours.

Phenylephrine: Neo-Synephrine (mild, regular, high-potency), 4-Way, Dristan Mist Spray, Vicks Sinex).
Naphazoline (Naphcon Forte, Privine).

Dependency and Rebound. The major hazard with nasal-delivery decongestants, particularly long-acting forms is a cycle of dependency and rebound effects. The 12-hour brands pose a particular risk for this effect. This effect works in the following way:

With prolonged use (more than three to five days), nasal decongestants lose effectiveness and even cause swelling in the nasal passages.
The patient then increases the frequency of their dose. The congestion worsens and the patient responds with even more frequent doses, in some cases to as often as every hour.
Individuals then become dependent on them.

Tips for Use. The following precautions are important for people taking nasal decongestants:

When using a nasal spray, spray each nostril once. Wait a minute to allow absorption into the mucosal tissues, and then spray again.
Keep the nasal passages moist. All forms of nasal decongestants can cause irritation and stinging. They also may dry out the affected areas and damage tissues.
Do not share droppers and inhalators with other people.
Use decongestants only for conditions requiring short-term use, such as before air travel or for a single-allergy attack. Do not take them more than three days in a row. With prolonged use, nasal decongestants become ineffective and result in the so-called rebound effect and dependence.
Discard sprayers, inhalators, or other decongestant delivery devices when the medication is no longer needed. Over time, these devices can become reservoirs for bacteria.
Discard the medicine if it becomes cloudy or unclear.

Oral Decongestants

Oral decongestants also come in many brands, which mainly differ in their ingredients. Common active ingredients include:

Pseudoephedrine: Sudafed, Actifed, Drixoral. Nearly every decongestant and combination remedy now contains pseudoephedrine, since the alternative decongestant, phenylpropanolamine (PPA) was taken off the market [see below]. Some oral decongestants, such as Nature's Way and others, contain naturally-derived pseudoephedrine from the Chinese herb ephedra. Side effects still apply to these products as well.
Phenylpropanolamine (PPA). PPA was a common ingredient in many decongestants, but has been withdrawn from the US market. [ See Warning Box, Decongestants and Phenylpropanolamine.]

Side Effects of Decongestants

Certain adverse effects are more apt to occur in oral than nasal decongestants and include the following:

Agitation and nervousness.
Drowsiness (particularly with oral decongestants and in combination with alcohol).
Changes in heart rate and blood pressure.
Avoid combinations of oral decongestants with alcohol or certain drugs, including monoamine oxidase inhibitors (MAOI) and sedatives.

Individuals at Risk for Complications from Decongestants. People who may be at higher risk for complications are those with certain medical conditions, including disorders that make blood vessels highly susceptible to contraction. Such condition include the following:

Heart disease.
High blood pressure. (Oral medications with pseudoephedrine have less of an effect on blood pressure than those containing phenylpropanolamine, but both should be avoided by anyone with high blood pressure.)
Thyroid disease.
Diabetes.
Prostate problems that cause urinary difficulties.
Migraines.
Raynaud's phenomenon.
High sensitivity to cold.
Emphysema or chronic bronchitis. (Such individuals should particularly avoid high-potency short-acting nasal decongestant.)

Anyone with these conditions should not use either oral or nasal decongestants without a doctor's guidance. Other groups who should also use these agents with caution are the following:

Anyone who is pregnant should not use these agents without consulting a physician.
Children appear to metabolize decongestants differently than adults. Decongestants should not be used at all in infants and small children, who are at particular risk for side effects that depress the central nervous system. Such symptoms cause changes in blood pressure, drowsiness, deep sleep, and, rarely, coma.

Warning Box: Decongestants and Phenylpropanolamine (PPA)

In response to reports of an increased risk of stroke in young women who took products, including oral decongestants, containing phenylpropanolamine (PPA), the Food and Drug Administration (FDA) began taking action to ban it from the US market in November of 2000.

Many agents contained this product. Nearly all, however, have now been withdrawn from the market or reformulated. A number of brands that previously contained PPA have now substituted other active ingredients (usually pseudoephedrine) and are safe to use. They include, but are not limited to the following:

Alka-Seltzer Plus Cold Medicine.
Coricidin D Cold, Flu and Sinus Tablets.
Dimetapp DM, Dimetapp Elixer.
Robitussin CF.
Contac Day/Night Allergy & Sinus.
All Triaminic products.

Anyone with old forms of these medications or any decongestant should check the labels and discard them if they contain phenylpropanolamine.

It should be noted that the incidence of stroke tended to occur in people who took diet suppressants containing PPA rather than decongestants with the ingredient. In any case, serious events were still very rare. Furthermore PPA has been used in dozens of medications for over 50 years. Extreme concern, therefore, is unwarranted.

Combination Antihistamines and Decongestants

Many prescription and non-prescription products that combine antihistamines and decongestants are available. A small sample of these combinations sold over the counter includes Allerest, Sudafed Severe Cold Formula, Vicks DayQuil, Claritin-D, Allegra D, Benadryl Allergy/Sinus, Contac Day/Night Allergy & Sinus. They may be effective for all symptoms within 60 minutes, with congestion clearing up first. As a rule, children should not be given combination remedies, which can cause headaches, agitation, and loss of appetite.

HOW ARE ANTIHISTAMINES USED IN ALLERGIC RHINITIS?

Histamine is one of the chemicals released when antibodies overreact to allergens and is the cause of many symptoms of allergic rhinitis. Antihistamines have the following benefits:

They relieve itching, sneezing, and nasal discharge.
They also relieve other allergy symptoms unrelated to rhinitis, including hives and some rashes.

Experts recommend that patients take them before an anticipated allergy attack if possible.

Many antihistamines are available and include short-acting and long-acting forms. They are available in tablet, nasal-inhaler, eye drop, and syrup form. Antihistamines are generally categorized as first- and second-generation, which generally are based on whether they have ingredients that cause greater or lesser sedation.

There are some notes of caution when taking any generation antihistamine:

Antihistamines may thicken mucus secretions and can actually worsen bacterial sinusitis. People with bacterial rhinitis or sinusitis should not use antihistamines, even during allergy season.
Antihistamines can lose their effectiveness over time and a different one may need to be tried.

First- Generation Antihistamines

First-Generation Antihistamines Ingredients and Brand Names. The older, so-called first generation antihistamines include:

Diphenhydramine (Benadryl).
Carbinoxamine (Clistin).
Clemastine (Tavist).
Chlorpheniramine (Chlor-Trimeton).
Brompheniramine (Dimetane).

First-generation antihistamines contain compounds called anticholinergics, which tend to produce the side effects that differentiate this group from second-generation antihistamines.

Side Effects. Side effects include the following.

Drowsiness and impaired thinking. These are serious side effects in adults. Some evidence indicates they pose a higher risk for work-related and automobile accidents than alcohol, narcotics, or prescription sedatives. Of interest, however, was a 2001 study suggesting that first-generation antihistamines do not have the same effect on children. In the study, children who took Benedryl had no greater impairment of alertness or learning than children not taking the antihistamine.
Dry mouth.
Dizziness.
Agitation.
Insomnia or nightmares.
Sore throat.
Rapid heart beat and chest tightness (uncommon and should be reported).
Men with enlarged prostate glands may experience difficulty urinating.

Tips for Using First-Generation Antihistamines. To offset the sedative effect, the following tips may be helpful:

Take at home a few hours before bedtime.
Avoid alcohol and tranquilizers, which increase drowsiness.
Avoid driving or operating heavy machinery.

It should be noted that sedation lessens over time.

Second Generation Antihistamines

Second-Generation Antihistamines Ingredients and Brand Names. The second-generation drugs include the following:

Fexofenadine (Allegra).
Loratidine (Claritin).
Cetirizine (Zyrtec).
Acrivastine (Semprex).
Norastemizole, levocabastine, and mizolastine are other promising and unique second-generation antihistamines under investigation in the US and Europe.

The newer second-generation antihistamines do not contain anticholinergics and so do not usually cause sedation at recommended doses. In fact, a 2000 study found fexofenadine (ie, Allegra) to result in less impairment in driving performance compared to first generation diphenhydramine (ie, Benadryl).

Side Effects and Precautions.

Common side effects may include headache, dry mouth, and dry nose. (These are often only temporary and go away during treatment.)
Rapid heart beat and chest tightness (uncommon and should be reported).
Some patients taking Claritin-D 24 Hour Extended Release tablets have reported obstruction in the upper gastrointestinal tract, including difficulty swallowing. It is not known if this is common or typical of all second-generation agents.

Women who are pregnant or nursing should avoid these medications unless recommended by a physician. The FDA has approved Claritin for children aged two to five and Allegra for children ages six through 11.

Nasal-Spray Antihistamines

Azelastine is the first antihistamine to be available in a nasal spray preparation (Astelin), and, according to one study is more cost effective than other remedies for seasonal allergies. It can reduce nasal congestion as well as allergy symptoms. In a 2000 study, it reduced nasal congestion and improved sleep in patients with perennial allergic rhinitis although it did not appear to improve daytime congestion or sleepiness. Its disadvantages are a bitter taste, drowsiness, and expense.

Problems with Earlier Second-Generation Antihistamines

Two earlier second generation drugs, terfenadine (Seldane) and astemizole (Hismanal), in rare cases, caused dangerous heart rhythm abnormalities, particularly in high doses or in people who have liver disease or are taking certain other medications. Both Seldane and Hismanal have been taken off the market. Allegra, Zyrtec, and Claritin do not appear to pose any of the dangers associated with Seldane. Anyone who takes a second-generation antihistamine, though, should probably avoid or use with caution combinations with the drugs that caused problems with Seldane and Hismanal. Such medications include the following:

The antibiotics clarithromycin (Biaxin) and troleandomycin.
Certain HIV protease inhibitors.
The antidepressants serotonin-reuptake inhibitors (eg, Prozac, Paxil, and Serzone).
The asthma drugs leukotriene-antagonists, such as zileuton (Zyflo).

WHEN ARE CORTICOSTEROIDS AND OTHER ANTI-INFLAMMATORY DRUGS USED FOR ALLERGIC RHINITIS?

A number of agents are available for reducing the inflammatory response in allergies and so preventing an attack in the first place.

Corticosteroid Nasal Sprays

Benefits of Corticosteroid Nasal Sprays. The most important anti-inflammatory agents are corticosteroids, also called glucocorticoids or, most commonly, steroids. Nasal spray steroids are proving to be safe and have the following benefits:

They reduce inflammation and mucus production and are proving to be the most effective agents for relieving symptoms of allergic rhinitis.
They may improve night sleep and daytime alertness in patients with perennial allergic rhinitis.
They also may be useful for treating polyps.

Some experts even recommend that patients now use a steroid nasal spray as primary treatment for allergic rhinitis and an antihistamine if the steroid spray is not effective. These drugs are not generally useful for nonallergic rhinitis. Corticosteroids do not relieve symptoms immediately but may take several hours before their effects are felt.

Nasal-Spray Brands. Corticosteroids available in nasal spray form include:

Beclomethasone (Beconase, Vancenase).
Fluticasone (Flonase).
Flunisolide (Nasalide).
Triamcinolone acetonide (Nasacort, Tri-Nasal).
Budesonide (Rhinocort). Rhinocort Aqua is approved for children over six and requires only one daily dose.
Mometasone furoate (Nasonex). Approved for use in patients as young as three.

Side Effects. Corticosteroids are powerful anti-inflammatory drugs. Although oral steroids can have many side effects, the nasal-spray form affects only local areas, and the risk for wide spread side effects is very low unless the drug is used excessively.

Headaches and nosebleed. These side effects are rare but should be reported to your doctor immediately.
Effect on growth. The major concern for children is whether they will adversely affect growth. Of some comfort are two major 2000 studies confirming previous ones reporting only a slight early effect on growth (about half an inch), which also appears to be temporary. It is not yet known, however, whether inhaled steroids effect lung growth in very young children.
Effect on eyes. Of some concern is the possible risk for adverse effects in the eyes, particularly glaucoma, which is a known side effect with oral steroids. Some ophthalmologists have observed higher pressure in the eye (a sign of glaucoma) in some patients taking nasal steroid sprays. (Studies have found no increased risk for cataracts in young people who have taken intranasal steroids.) All the conditions resolve after stopping the steroid, although periodic eye examinations are advised.
Use during pregnancy. These agents are most likely safe during pregnancy, but pregnant women should discuss all options carefully before taking them.
Nasal passage injury. Steroid sprays may injure the nasal septum (the bony area that separates the nasal passage) if the spray is directed onto it. This complication is very rare.
Lower resistance to infection. People with any infectious disease or injury in the nose should not take these drugs until the disease or wound has been treated and cured. People should avoid steroids who have not been vaccinated or had chicken pox or measles.

Cromolyn

Cromolyn serves as both an anti-inflammatory drug and a specific blocking agent for allergens. The standard cromolyn nasal spray (Nasalcrom) is not as effective as steroid nasal sprays but is effective for many people with mild allergies. It is one of the preferred first-line therapies for pregnant women with mild allergic rhinitis. It may take up to three weeks for a person to experience full benefit.

Side Effects. Cromolyn has no major side effects, but minor ones include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat. The spray can cause burning or irritation.

Leukotriene-Antagonists

Leukotriene-antagonists are oral drugs that block leukotrienes, powerful immune system factors that are important in causing airway constriction and mucus production in allergy-related asthma. These agents are currently being used for asthma. However, several studies have reported that montelukast (Singulaire) substantially reduces hay fever symptoms in children. A 2000 study has also found that zafirlukast (Accolate) helps relieve nasal symptoms from cat allergies. More research is needed.

WHAT IS IMMUNOTHERAPY (ALLERGY SHOTS)?

Advantages of Immunotherapy

Immunotherapy (allergy shots) is a highly effective treatment for patients with allergies. It is based on the premise that people who receive injections of a specific allergen will lose sensitivity to it. The most common allergens for which shots are given are house dust, cat dander, grass pollen, and mold.

Immunotherapy has many advantages:

It targets the specific allergen.
It may reduce sensitivity in airways in the lungs as well as in the upper airways.
It may help prevent the development of new allergies in children.
It may help prevent the development of asthma in children with allergies.

Candidates

Candidates for Immunotherapy. Immunotherapy (allergy shots) may be given to anyone over seven whose allergies are severe and do not respond to medication. At an international 2000 conference, many experts agreed that immunotherapy should be considered as soon as possible for children with asthma and allergies. Immunotherapy is safe for pregnant women with allergies, although dosing should not be increased during pregnancy.

Individuals at Risk for Complications. People who should probably avoid immunotherapy include the following:

People who have an extreme response to skin tests. This may predict an allergic reaction.
People who are actively wheezing.
Patients with uncontrolled severe asthma or lung disease.
Patients taking certain medications (such as beta-blockers).

The health status of anyone should be determined before starting treatment.

Administering Therapy

The major downside to immunotherapy is that it requires a prolonged course of weekly injections. The process is as follows:

Injections of diluted extracts of the allergen are given on a regular schedule, usually twice a week to weekly at first, then in increasing doses until a maintenance dose has been reached.
At that time, intervals between shots can be two to four weeks, and the treatment is continued for up to three to five years.
It usually takes several months and may take up to three years to reach a maintenance dose.
Patients can experience some relief within three to six months; if there is no benefit within 12 to 18 months, the shots should be discontinued.
After stopping immunotherapy, about one third of allergy sufferers no longer have any symptoms, one third have improved symptoms, and one third relapse completely.

Side Effects and Complications of Immunotherapy

Injections for ragweed and, possibly, excessive doses of dust mites, have higher risks for side effects than other allergy shots. If complications or allergic reactions develop, they usually occur within 20 minutes although some can develop up to two hours after the shot is given.

Side effects of immunotherapy include the following:

General itching, swelling, red eyes, hives, soreness at the injection site.
Rarely, low blood pressure, asthma exacerbation, or difficulty breathing. This is due to an extreme hypersensitivity response called anaphylaxis. It can also occur if excessive doses are given.
In rare cases, particularly because of excessive doses or if a patient has a serious lung problem, severe reactions can occur, which can be life threatening.

Premedicating patients with antihistamines and corticosteroids may help reduce the risk of reactions to immunotherapy, although this could mask early warning signs. This option should be used only after discussion with the doctor.

It should be noted that in one 10-year study, the incidence of any adverse effect was less than two-tenths of one percent, and the great majority of events were mild. The risk for a fatal response is estimated to be one per 63 million injections. (As a comparison, the risk for a fatal reaction to penicillin is much higher, one per 7.5 million injections.)

Investigative Methods to Improve Patient Compliance

The use of an injection series is effective but patients often fail to comply with the regimens. Some other schedules and delivery methods are being investigated that might make the program easier and less distressing.

Rush Immunotherapy. Investigators are studying so-called rush immunotherapy, in which patients achieve the full maintenance dose with several shots a day over a period of three to five days. Rush therapy uses modifications that reduce the risk of severe reactions to excessive doses. Studies are suggesting that it is effective and safe, with few side effects other than itching. Patients must be monitored closely during this period, however, for severe reactions.

Oral Forms. Trials are underway to test a method that uses an oral gelcap for delivering immunotherapy for hayfever. (Previously, taking a pill has not been feasible because digestive enzymes in the intestine rendered the therapy useless.) Small studies are promising, but larger ones are needed to determine the safety and effectiveness of this method.

Vaccines. Of particular interest is the development of vaccines that cause the immune system to become insensitive to allergens. One such vaccine uses a small protein from the allergen, which is injected into the patient. Other vaccines under investigation are those that use the allergen's genetic material (its DNA) to promote tolerance to the allergen.

HOW CAN ALLERGIC RHINITIS BE PREVENTED?

General Guidelines

Important irritants or allergens that should be avoid include the following:

Dust mites, specifically mite feces, which are coated with enzymes that contain a powerful allergen. These are the primary allergens in the home. (In one study, allergies to dust mites did not appear to have any affect on hospitalization, although they are capable of triggering asthma attacks.)
Animal dander (flakes of skin) and hair, including from cats, house mice, and dogs. Cats pose the greatest risk of all common pets. House mice are proving to be significant sources of allergens, particularly in urban children.
Pollen.
Molds.
Fungi.
Cockroaches are major asthma triggers and may reduce lung function even in people without a history of asthma.

Of some concern are studies reporting no change in asthmatic symptoms after controlling cat or dust mite allergens. More research is needed to identify the reasons for this.

Controlling Pets

If families of allergic children, particularly if they are asthmatic, choose to keep pets, the following precautions may be helpful in reducing risk:

Pets should be kept outside or, if this isn't possible, be confined to carpet-free areas outside the bedroom.
Cigarette smoke and damp houses increase the risk for reactions to cat allergies.
Washing cats and dogs once a week can reduce allergens. Dry s