Allergic rhinitis (hay fever)

Overview

Definition

Allergic rhinitis (hay fever) is a reaction to airborne allergens. It affects between 1:6 and 1:10 Americans and is an IgE-mediated disorder of the immune system; 70% of cases occur before age 30. Symptoms resemble those of viral rhinitis but persist and show seasonal variation. This most common form of allergy involves the entire respiratory system—nasal cavity, mouth, throat, bronchi, lungs, and diaphragm. There is an inherited tendency, with a child having a 50% chance of developing such allergy if one parent is allergic and a 75% chance if both parents are allergic.

Etiology

The cause is an interaction of IgE on mast cells and basophils in the nasal mucosa with antigenic substances, especially pollens, grasses, or ragweed, which produce a seasonal variation; animal fur; dust, insect debris, household mites; inhaled irritants; changes in temperature or humidity.

Risk Factors

The following conditions can lead to allergic rhinitis.

Tendency to produce large quantities of IgE

Repeated exposure to allergen(s), which can be almost anything inhaled, eaten, touched, or injected into the body

Sufficient potency and duration of exposure

Other allergies

Familial predisposition

Smoking or prolonged exposure to second-hand smoke

Signs and Symptoms

Nasal obstruction, increased secretions, sneezing

Itching of mucous membranes of nose, eyes, posterior pharynx, conjunctivae

Sinus symptoms: headache, pressure behind the eyes, pain in the frontal area, tenderness over cheekbones, aching teeth

Ear infections

Stomach cramps

Skin rashes or hives

Urinary frequency or diarrhea

Differential Diagnosis

Viral, bacterial, or fungal infections

Sinusitis

Rhinitis medicamentosa

Vasomotor rhinitis

Obstruction of the septum

Bronchitis

Nasal polyps

Swollen adenoids

Systemic diseases—Wegener's granulomatosis, hypothyroidism (rare)

Chronic rhinitis

Diagnosis

Physical Examination

Turbinate mucosa is usually pale or blue and swollen, with nasal obstruction and copious secretions, sneezing, and itching of eyes, nose, and throat. Nasal polyps are uncommon, but serous otitis media occurs often, especially in young children. Cervical lymphadenopathy.

Laboratory Tests

Microscopic examination of nasal smear shows high numbers of eosinophils

Increased IgE level

Pathology/Pathophysiology

Submucosal edema

Congested mucous glands

Imaging

Sinus X rays for differential diagnosis

Other Diagnostic Procedures

On referral to an allergist, the following tests may be done.

Skin testing—Diluted extracts of allergens are injected under the skin or applied to scratches on the back or upper arm. Positive results are indicated by raised welts surrounded by redness and high serum levels of IgE antibodies.

Radioallergosorbent test (RAST)—Blood test to determine IgE levels

ELISA allergy testing for IgE and IgG

Treatment Options

Treatment Strategy

Eliminate rhinitis by maintaining an allergen-free environment.

Cover pillows and mattresses with plastic covers.

Use synthetic materials (foam mattresses, acrylics) instead of animal products (wool, horsehair).

Minimize dust-collecting household items (i.e., carpets, drapes).

Use of an air purifier/dust filter may help. When the allergen(s) is known, desensitization therapy can be done, which involves gradually increasing subdermal exposure to identified allergens; results vary.

Drug Therapies

Oral decongestants—such as pseudoephedrine (Sudafed, 60 to 120 mg orally tid to qid); have systemic effects.

Antihistamines—such as chlorpheniramine (Chlor-Trimeton; 4 mg orally every 6 to 8 hours, or 8 to 12 mg orally every 8 to 12 hours as sustained-release tablet), clemastine (Tavist; 1.34 to 2.67 mg orally bid; side effect of sedation often unacceptable.

Nonsedating antihistamines (histamine-receptor antagonists)—such as astemizole (Hismanal; 10 mg orally daily), loratadine (Claritin; 10 mg orally daily), cetirizine (Zyrtec; 10 mg orally daily), fexofenadine (Allegra; 60 mg orally bid), terfenadine (60 mg orally bid); although expensive and by prescription, are especially helpful in those patients who are intolerant of drowsiness; astemizole is associated with sudden death from presumed QT prolongation, especially in those receiving erythromycin or ketoconazole concomitantly; liver disease, hypokalemia are contraindications.

Nasal corticosteroid sprays—such as beclomethasone (Beconase AQ, Vancenase AQ, 42 mcg/spray), fluticasone (Flonase, two sprays in each nostril once daily, decreasing to one spray each day, based on response), budesonide (Rhinocort, two sprays in each nostril bid or four sprays in each nostril every morning), and flunisolide (Nasalide, 25 mcg/spray); effective if used appropriately—two activations in each nostril bid for one month; improvement takes one to two weeks.

Intranasal steroids—such as nasal cromolyn (Nasalcrom, one spray in each nostril tid to qid); used in seasonal allergies to shrink nasal polyps; must be started 24 to 36 hour before symptoms develop and must be used four to six times daily.

Alpha-adrenergic agents—applied to nasal mucosa; come in short-term and long-acting forms; continued use for more than a few days leads to rebound nasal congestion and rhinitis medicamentosa.

Systemic steroids—in severe cases and for short duration only.

Complementary and Alternative Therapies

Allergic rhinitis may be successfully treated with alternative therapies. Begin with nutrition guidelines. Use the tincture and homeopathic remedies for acute exacerbations.

Nutrition

Eliminate all known food allergens.

Minimize pro-inflammatory and highly allergenic foods such as saturated fats (meats and dairy products), refined foods, eggs, citrus, bananas, chocolate, peanuts, wheat, shellfish, food coloring, preservatives, caffeine, alcohol, tobacco, and sugar.

Increase intake of whole foods including fresh fruits and vegetables, whole grains, nuts, seeds.

Drink plenty of water and include fresh juices, especially carrot, celery, parsley, and pineapple.

Vitamin A (10,000 to 15,000 IU/day), zinc (20 to 30 mg/day), vitamin B6 (50 to 100 mg/day), and vitamin B5 (50 to 75 mg/day) for immune support

Vitamin C (1,000 mg tid to qid) to reduce inflammation, stabilize mast cells to decreasehistamine release

Vitamin E (400 IU/day) for proper immune function

N-acetylcysteine (200 mg tid) to reduce mucous formation

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20 minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Plants high in flavonoids (quercetin, curcuma, rose hips, bilberry) are especially useful as they reduce histamine release and stabilize connective tissue. Rose hips (Rosa canina) can be used as an infusion or solid extract. Nettles (Urtica urens) are traditionally used for hayfever and may be drunk as an infusion, 2 cups a day.

Quercetin 250 mg bid to tid to reduce inflammation.

A tincture of equal parts of coneflower (Echinacea angustifolia), goldenseal (Hydrastis canadensis), cleavers (Gallium aparine), eyebright (Euphrasia officinalis), ginger root (Zingiber officinalis), and elderberry (Sambucus nigra) will support immune function and lymphatic drainage, as well as increase circulation and tone the respiratory system. Take 30 drops bid to tid.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

Allium cepa—for copious, acrid nasal discharge with bland eye lacrimation that is better outdoors.

Euphrasia—for bland nasal discharge with acrid lacrimation that is relieved by lying down at night.

Sabadilla—for sneezing with watery discharge from nose and eyes.

Wyethia—for marked itching of the nose, throat, and soft palate.

Several OTC combination homeopathics are available for hayfever.

Physical Medicine

Contrast hydrotherapy. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. The overall effect is decreased inflammation, pain relief, and enhanced healing. Alternate three minutes hot with one minute cold. Repeat three times to complete one set. Do two to three sets/day.

Nasal lavage. Mix salt and water to taste like tears. Rinse nostrils by holding head over sink and letting water run from upper nostril to lower nostril. Keep nostrils lower than throat to prevent salt water draining into back of throat. Shrinks membranes and increases drainage.

Acupuncture

Treatment with acupuncture can help promote both immunity and lymphatic drainage while minimizing the effects of allergic rhinitis.

Massage

Therapeutic massage is an excellent way to assist local lymphatic drainage.

Patient Monitoring

Tolerance to substances changes over the lifetime, and emotional stress, viral illness, fatigue, exposure to chemical irritants, overexertion, or severe weather conditions can increase reactivity. Eliminating these things can raise the threshold, as can age (the immune system is less efficient, so IgE antibodies are less involved with challenging allergens).

Other Considerations

Prevention

If there is a family history of allergy, eliminate the usual allergens when possible before symptoms develop.

Breastfed children have healthier immune systems and fewer allergies.

Complications/Sequelae

Development of nonallergic rhinitis medicamentosa from use of nasal sprays more than twice daily for three consecutive days.

With use of cortisone—cataracts, glaucoma, increased blood pressure, ulcers, diabetes, edema, loss of bone density, avascular necrosis of bone and suppression of adrenal gland function.

Use of antihistamines or oral steroids may actually increase sensitivity.

Secondary infections

Compromised pulmonary function

Prognosis

Symptomatic relief is generally achieved.

Pregnancy

High levels of vitamins A and C are contraindicated in pregnancy.

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References

· The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Tiburon, Calif: Future Medicine Publishing, Inc; 1997.

· Ferri FF. Ferri's Clinical Advisor: Instant Diagnosis and Treatment. St Louis, Mo: Mosby-Year Book; 1999.

· Fisher C. Nettles: an aid to the treatment of allergic rhinitus. Eur J Herbal Med. 3(2): 34-35.

· Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993.

· Noble J, ed. Textbook of Primary Care Medicine. 2nd ed. St Louis, Mo: Mosby-Year Book; 1996.

· Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment 1994. Norwalk, Conn: Appleton & Lange; 1994.