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Diagnosing allergic rhinitis

Allergic rhinitis is the most common allergic condition en countered in general practice, affecting between 10-30% of adults and as many as 40% of children.1

It is defined as allergic inflammation of the nasal mucosa following exposure to an allergen or trigger to which the individual is sensitive. This can be divided into seasonal (as in hayfever or seasonal allergic rhinitis) or perennial (all year round). Common triggers include tree and grass pollens, mould spores, pet dander, and house dust mite.

What are the symptoms?
The symptoms are nasal itching, sneezing, watery rhinorrhoea, itchy eyes and palate, nasal blockage or congestion. Eye symptoms alongside nasal symptoms are very common, particularly in seasonal allergic rhinitis. Asthma frequently co-exists in patients with allergic rhinitis - 80% of asthmatics are likely to have some degree of rhinitis and this can exacerbate asthma if nasal symptoms are not adequately treated. Bousquet2 et al (2008) who developed the ARIA Guidelines for the management of rhinitis recommend that both asthma and rhinitis should be treated as 'one airway' and a similar approach applied to the management of both conditions.


Allergic rhinitis can cause considerable morbidity. This can lead to a marked reduction in quality of life, with reduced attendance and performance at both school and work. Snoring and sleep disturbance could also be factors leading to a drop in quality of life. Seasonal allergic rhinitis has been shown to decrease the exam performance of young people aged 15-16 years of age between mock and actual GCSE examinations in core subjects of English, Maths and Science,3 the effects of which can affect them for the rest of their working life.

The role of the primary care nurse
All patients with asthma should be seen in general practice once every 12-15 months under the Quality and Outcomes Framework (QOF), and primary care nurses should be actively looking for allergic rhinitis in their asthma patients as part of a strategy to help their patients manage their asthma well.
The most important step in diagnosing allergic rhinitis is to take a detailed history. This should include whether the symptoms recur at the same time each year (which might suggest pollens or moulds are the trigger), whether symptoms are worse at home (possible pet or dust mite allergy), at work (possible occupational allergy), or even on holiday (which might suggest an environmental cause). The likelihood of rhinitis symptoms having an allergic cause are much greater if the history reveals a family or personal history of allergy, and if the symptoms are obviously triggered by pollen or exposure to animals.


Both ARIA (Bousquet et al 2008)2 and British Society for Allergy and Clinical Immunology (BSACI) guidelines (Scadding et al 2008)4 recommend that allergic rhinitis should be classified based on symptom duration and/or severity, either persistent or intermittent symptoms which are mild or moderate to severe (see Figure 1).

Allergy testing
For the majority of patients there is little value in performing allergy tests for allergic rhinitis, as this will not affect the treatment choice. There are occasions when allergy testing can be useful, and skin prick testing or specific IgE blood tests can be performed to identify the allergen or to rule out allergy as a cause for the symptoms.


The history should always be used to guide choice of allergens as false positive results can occur. For example, if a patient was tested for cat and horse but only ever experienced symptoms when horse riding, and tests showed a positive response to cat as well as horse, the patient may believe they are allergic to cat.

The positive allergy test only shows that the patient is sensitised to cat, the allergy is only confirmed when there is a clinical expression of symptoms in response to exposure with cat.

Allergen avoidance
If the history suggests the allergen can be easily avoided (for example, avoiding going horse riding) then allergen avoidance may be an option.


Patients who have seasonal symptoms caused by tree and grass pollen should keep their home, car and work environments as closed as possible, particularly during the early morning and evening. Wind-pollinated plants, such as grasses, tend to release pollen particularly in the early morning, and then in the evening, when that same pollen, having risen into the upper atmosphere during the day, begins to descend again. Therefore outdoor activities should be avoided at these times.


Air conditioning can also help and some cars have pollen filters. Wearing wrap-around sunglasses may reduce eye symptoms by acting as a physical barrier. Some people find nasal air filters can help to reduce nose and eye symptoms, or simple barrier methods can be helpful, for example, applying a thin coat of Vaseline around the nostrils each morning can prevent pollen being breathed up the nose.


However for most people with allergic rhinitis their allergen cannot be easily avoided and pharmacotherapy becomes the main treatment option. The most effective treatments are a combination of long-acting antihistamines and nasal corticosteroids, and for eye symptoms sodium cromoglicate eye drops.

Managing allergic rhinitis
We know that rhinitis can cause asthma to exacerbate. Treatment with nasal corticosteroids often improves airway hyper-responsiveness and may reduce asthma symptoms if rhinitis is adequately controlled. However patients with asthma as well as allergic rhinitis should be treated with appropriate asthma medications and a self-management plan for both their asthma and rhinitis.


Antihistamines can be very effective at treating the symptoms of itch and runny nose associated with allergic rhinitis. First generation antihistamines should be avoided as they can have a significant sedative effect so should not be used when operating machinery; they also have a short duration of action. Side effects from the second generation antihistamines are rare; however some may still have a slightly sedative effect.

Patients are advised to shop around to find one which suits.
Nasal corticosteroids can be very effective at controlling the inflammation in the nose and some claim to help relieve eye symptoms as well. Side effects are rare, Beclomethasone (Beconase) has a higher bioavailability than newer nasal corticosteroids and monitoring of growth is recommended in children.5 Minor side effects include nasal crusting and nose bleeds, however these side effects are often linked to poor technique.6 Patients may also comment that they have tried a nasal spray previously and it did not work, although this is likely to be linked to poor technique. Therefore it is really important to ensure the patient has received specific training in using their nasal spray correctly (see Figure 2).


For itchy, watery eyes which have not been adequately controlled with antihistamines and nasal corticosteroids, topical sodium cromoglicate eye drops can be very effective. They do need to be used four times daily to get the best effect, and theyare contraindicated for contact lens wearers as they can discolour the lens.

Conclusion
Allergic rhinitis is common among adults and children. It causes considerable morbidity and can adversely affect asthma; 80% of asthmatics patients are likely to have allergic rhinitis. Primary care nurses should be actively looking for allergic rhinitis in their asthmatic patients and ensure this is being adequately managed.

References
1.     Turner P, Kemp A. Allergic rhinitis in children. J Paediatr Child Health 2012:48(4);302-10.
2.     Bousquet J, Khaltaer N, Cruz AA et al. Allergic rhinitis and its Impact on Asthma 2008 update. Allergy 2008:63;(Suppl. 86):8-160.
3.     Walker S, Khan-Wasti S, Fletcher M et al. Hayfever has a significant detrimental effect on national exam performance in UK teenagers. Eur Respir J 2005:26;903.
4.    BSACI guidelines Scadding GK, Durham SR, Marakian R, et al (2008). BSACI Guidelines for the management of allergic and non allergic rhinitis. Clinical and Experimental Allergy 38;19-32.
5.     Chaplin S, Scadding G. Nasal steroids: concise guide to properties and recommended use. Prescriber 2010;21(9):53-5.
6.     Gani F, Pozzi E, Crivellaro MA et al. The role of patient training in the management of seasonal rhinitis and asthma: clinical implications. Allergy 2001;56:65-8.