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By Dr Dinkar Bakshi,
MBBS MD(Paed) MRCPCH FRCPCH MSc (Allergy)
Allergic rhinitis is the commonest chronic allergic disorder in children and is increasing in prevalence worldwide. About 1 in 4 adults in the UK suffer from some form of allergic rhinitis. The worldwide incidence of allergic rhinitis in adolescents is 14.6%.1 The pathogenesis is influenced by both genetic and environmental factors. It is caused by stimulation of specific IgE antibodies to airborne allergens, which in turn stimulate the mast cells to release histamine, leading to an inflammatory response. Most people associate allergic rhinitis with ‘seasonal’ hay fever symptoms triggered by pollen in spring/ summer. However, many patients have ‘perennial’ symptoms triggered by allergens in the home environment, i.e. house dust mite, moulds, cat and dog dander.2 A more recent classification of allergic rhinitis is ‘intermittent’ for symptoms lasting less than four days a week or less than four consecutive weeks, and ‘persistent’ for longer duration symptoms.2
Allergic rhinitis has a significant impact on quality of life and workforce productivity. The symptoms of rhinorrhea, nasal irritation, sneezing, nasal congestion, watery eyes and smell disturbance are more prominent in adolescents and young adults. It causes sleep deprivation, impairs concentration and alertness during the day, makes patients uncomfortable and causes a feeling of unease.3,4 The symptoms reach their peak during the spring and summer months, restricting outdoor activities in patients. There is robust evidence from clinical trials regarding detrimental effects especially during driving, and a negative effect on performance in the job.3,4 In extreme cases, this could lead to behavoural problems in children and/ or depression in teenagers and young adults. Depending on the symptoms and their effect on quality of life, allergic rhinitis is classified as ‘mild’, or ‘severe’ if sleep and daily activities are affected.5 In some cases, allergic rhinitis may be a trigger for asthma causing worsening of clinical symptoms and the need for more frequent use of inhalers.1,2 Therefore, allergic rhinitis may affect the earning potential of an individual, having a knock-on effect on the family, and by extrapolation on a larger scale have a negative impact on the health budget and national economy.3,4
School examinations in the UK are usually conducted in the months between May and June, which are the peak time period for allergic rhinitis (especially hay fever triggered by grass and tree pollen). In a significant study conducted by Education for Health in the UK in 2007, statistically significant results determined that children with allergic rhinitis symptoms, are likely to drop a grade between the ‘mock’ and ‘final’ GCSE
examinations to the tune of 40%.6 The incidence rises to 70% if the children are taking sedating anti-histamines. In addition, despite the wide availability of over the counter (OTC) non-sedating treatments, the study found that 28% of the children were on sedating anti-histamines like chlorpheniramine (piriton), diphenhydramine or hydroxyzine.6 This could have a potentially serious negative impact on their admission to university and career choices. In addition, it may compound the clinical situation in adolescents by causing undue anxiety and stress.6,7
The diagnosis of allergic rhinitis is made clinically based on the history and symptoms. A nasal examination revealing inflammation of the mucosa is easily done with an auroscope in clinic. Symptom reduction following treatment with anti-histamines confirms the diagnosis in most patients.8 Skin prick testing and blood tests for specific IgE antibodies to various airborne allergens like house dust mite, pollen, animal dander and moulds are used for persistent symptoms/ concomitant asthma to guide further management, based on local availability.8,9
Contemporary management of allergic rhinitis involves first of all avoidance of allergens and if needed nasal irrigation, anti-histamines, steroid nasal sprays, leukotriene receptor antagonists and specific immunotherapy (desensitization).
Allergen avoidance is centered around reducing exposure to house dust mite, animal dander and moulds in the home environment. This involves the use of anti-allergy bedding and preventing dampness in the home. Oral or nasal antihistamines are the mainstay of drug treatment. Nasal irrigation or douching with saline/ warm water is inexpensive and often used in medical management. 9
Immunotherapy (desensitization) is the administration of small graded increases of allergen to induce tolerance. It may be in the form of weekly/ monthly subcutaneous injections (SCIT) or a daily tablet via the sublingual route (SLIT). The administration is continued for 3 years with benefits lasting for another 5 years following completion of treatment.10 At present, specific immunotherapy is the only disease modifying therapy for persistent allergic rhinitis, but it may only be initiated in a specialized allergy unit.
Although nasal decongestants relieve nasal obstruction, they do not reduce itching and sneezing. Therefore, they are not recommended for use in the management of allergic rhinitis.9 Anti-histamines and nasal steroids have been found to be safe and relatively free of side-effects even with long term use.9 The most common reported side-effect is headache, but this has almost the same incidence with placebo use.
The British Society of Allergy and Clinical Immunology (BSACI) website www.bsaci.org has a complete list of accredited allergy clinics in the NHS with details regarding service provision, for eg. availability of a dietitian, skin prick testing and immunotherapy.11 The nearest accredited allergy clinic may be identified by using the search facility on the website based on the postcode or town.
In summary, allergic rhinitis is one of the commonest chronic illnesses in children and young adults. It affects not only the quality of life but also has serious implications on career choices, the health budget and the economy. Allergen avoidance, judicious use of medicines and appropriate referral to an allergist or ENT clinic are the cornerstones of management.
1. Alt-Khaled et al. ISAAC Phase Three Study Group, Global map of the prevalence of symptoms of rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood (ISAAC) phase three. Allergy 2009; 64:123-48.
2. Bousquet J et al. Allergic Rhinitis and its impact on Asthma (ARIA) 2008. Allergy 2008; 63 (suppl 86):8-160
3. Meltzer EO. Quality of life in chidren and adults with allergic rhinitis. J Allergy Clin Immunol 2001; 108(1 suppl):S45-53.
4. Roger A et al. AllergyAsthmaClinImmunol(2016)12:40.
5. O’Connor, Punekar. J Allergy Clin Immunol. 2006; S322. Abstract 1244.
6. Sheikh A, Panesar SS, Dhami S, Salvilla S. BMJ Clinical Evidence, April 2007.
7. Walker S et al. Seasonal allergic rhinitis is associated with a detrimental impact on exam performance in UK teenagers: case control study. J Allergy Clin Immunol 2007; 120(2):381-7.
8. Barr JG, Fox AT, Hopkins C. BMJ 2014; 349:g4153.
9. Scadding G et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy, Jan 2008; Vol 38, Issue 1:19-42.
10. EAACI position paper on Allergen Immunotherapy. J Allergy Clin Immunol. 2015 Sep; 136(3):556-68.
11. www.bsaci.org; website for the British Society of Allergy and Clinical Immunology.
For more information visit British Allergy Clinic website.
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