Allergic rhinitis may sound like a minor seasonal nuisance, but for many people it can mean weeks—or even months—of congestion, sneezing, runny nose, itchy eyes and poor sleep. Often called hay fever, allergic rhinitis happens when the immune system overreacts to allergens such as pollen, dust mites, mold or pet dander. Symptoms can come and go with the seasons or persist year-round, depending on a person’s triggers.
That makes allergic rhinitis more than an inconvenience. It can affect work, school, exercise and quality of life, and it can also overlap with conditions such as asthma or sinusitis. The good news: Patients do not have to simply “push through” allergy season. Understanding triggers, using medications correctly and knowing when to talk with a physician can help people better control symptoms and avoid common missteps.
The AMA’s What Doctors Want Patients to Know™ series gives physicians a platform to share what they want patients to understand about today’s healthcare headlines and how to take charge of their health through preventive care.
In this installment, Elvin Mendez, MD, an allergist and immunologist in Port Charlotte and Cape Coral, Florida with Lee Health, took time to discuss allergic rhinitis and what to know.
Lee Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Allergic rhinitis is an inflammation
“The term allergic rhinitis implies that there’s underlying inflammation taking place,” Dr. Mendez said. “Rhinitis also is inflammation of the nasal passages, but it’s a lot more than that. When you talk about allergic rhinitis, you’re talking about organ systems that are somewhat connected to that area.”
“You’re going to have symptoms that may affect the nose, but it may also affect the eyes, and we term that allergic conjunctivitis,” he explained. “Both of these terms can be used interchangeably in individuals experiencing symptoms because most of the time the symptoms overlap.
“So, you’ll have a person with allergic rhinitis symptoms such as congestion, runny nose, itchy nose and postnasal drainage, but they also experience itchy, watery eyes at the same time,” Dr. Mendez added.
There’s seasonal and perennial rhinitis
“The confusion is when you take the name of the disease and equate it to its presentation rather than the time of the year,” Dr. Mendez said. “When it presents itself, that’s where this seasonal rhinitis and perennial rhinitis come to play.”
“Seasonal rhinitis means that the symptoms are going to vary season after season. You’ll have some people with symptoms in the spring, summer or fall,” he said. “When we talk about perennial allergies, we're looking at allergens that are triggering symptoms year-round.”
Symptoms of allergic rhinitis last for weeks
Upper respiratory infections, such as the common cold, can have overlapping symptoms with allergic rhinitis.
“Early on you, may have someone with very similar overlapping symptoms—congestion, runny nose, sneezing—however, there may be fever, body aches and pains, or sinus pressure. Those are unlikely to be allergy-triggered,” Dr. Mendez said, noting “you’re not going to see fevers in a person with allergies, and you’re not going to see the sinus pressure and pain unless there’s a complication.
“And you’re certainly not going to see body aches and pains. Those are typically viral, which are the more common causes of infections in the spring and summer, and they’ll usually disappear by day three to five,” he added. “Now, allergy symptoms don’t work that way. They will linger on. If you have symptoms like this that are lingering on for a week’s time, you may want to start thinking of other things going on with you, provided you don’t have a fever or body aches and pains.”
“Typically, allergy symptoms will linger on longer. They don't have those severe symptoms, provided there are no complications, because allergies can present with complications,” Dr. Mendez said.
Genetics plays a significant role in allergic rhinitis risk
“I often start off with humor in the office when I see the kids with their parents … I tend to turn around and look at both parents and say, ‘OK, who’s responsible for this,’” Dr. Mendez said. That is because “genetics plays a significant role” in risk for allergic rhinitis.
“If you have one parent with allergic rhinitis, the odds are up to 50%. With both parents, there is anywhere from 60% to 80% risk that their children will have allergic rhinitis,” he explained. “So, genetics plays a significant role in terms of family history.”
Where you live can increase your risk for allergic rhinitis
Beyond family history, “the environment plays a role in risk for allergic rhinitis. We know there’s high risk if there’s chronic cigarette smoke exposure,” Dr. Mendez said. “We know that urban areas are at a much higher risk than rural areas. Socioeconomic factors also play a role.”
“If you look at people in rural areas, because of early exposure, they have less of a tendency than we do living in clean environments in our cities because of our enclosed environments,” he said. “Now, depending on how you live in those enclosed environments—such as urban areas where there’s a heavy set of cockroaches and animal dander, carpeting—those are going to increase the risk of developing specific indoor allergies versus someone who lives in a space that is climate-controlled, with humidity, no carpeting, no pets and a clean environment.”
Indoor allergies often develop earlier
“The way it works in population studies is that individuals will develop indoor allergies first,” Dr. Mendez said. “Children may be exposed to animal dander, house dust mites and cockroaches, which are present year-round, and may develop symptoms as early as one year of age.”
“Whether the perennial or indoor allergies are worse than outdoor, seasonal allergies, that is going to be based on the individual. The responses are very different,” he said. “Some are highly allergic to animal dander. Others are highly allergic to tree and grass pollen.”
“There are variances in concentration of exposure and underlying comorbidities because some individuals who have a higher tendency to allergies may have other comorbid allergy diseases like asthma or eczema,” Dr. Mendez explained. “Those obviously are going to be at higher risk than someone who is just experiencing some nasal symptoms.”
Cockroach allergy is similar to dust mite allergies
“Similar to house dust mites, the problem with cockroaches is not so much the cockroach itself, but the cockroach components that are left after they die,” Dr. Mendez said. “That becomes part of dust, so you’re going to have dust mite excrement and cockroach particles present in a dusty environment that you live in.”
“Unlike heavier house dust mite particles, which require close contact, for example on your pillow or on your mattress, cockroaches are very different because the allergen is light and airborne,” he said. “It’s a very light protein and you can be exposed to it similar to what you see with animal dander.”
Allergic rhinitis can be disruptive
“We as allergists are always striving to reduce the chance of missing work or school because people don’t realize allergies are a nuisance and a burden,” Dr. Mendez said, emphasizing that allergies are “a nuisance because they do interfere with sleep, and if you don’t sleep, you are grumpier or irritable and have less concentration.”
“Allergies cause over 2 million missed school days per year in the U.S., accounting for $10 billion in lost state funding nationwide due to school absenteeism. At-work productivity losses range from $2 billion to $4 billion a year,” he said. “If allergies are treated appropriately early on, we can offset some of those costs to the system. But also, those unproductive days at work and less performing days at school.”
Prevention depends on your trigger
“Depending on what seems to be the trigger, you may focus on some environmental control measures. Indoors is the easiest because we can control that,” said Dr. Mendez. Indoors, keep “pets out of the bedroom. An air purifier in the bedroom can also help reduce animal dander or even pollen that might get in.”
“Getting a pillow mattress cover is key to controlling dust mite allergy symptoms. We recommend them to everyone and you can buy them in most big box stores or online. They are extremely helpful in creating that barrier between you and the dust mite excrement,” he said. “In terms of cleanliness around cockroaches and dust and everything else, carpeting is a no. Sometimes we don’t have a choice because of renting or noise reduction, so more cleaning will be required.”
Additionally, “maintain humidity between 30% and 50%. Higher than that and you’re going to increase humidity, mold exposure and dust exposure,” Dr. Mendez said. “Don't open windows indoors during beautiful days in the midst of pollen season. Everybody loves to open their windows when it is nice out, but when pollination is highest, keep your windows closed.”
“If you do go out for a walk or run, try dusk or dawn, but just be cautious because early morning often has high pollen counts. After you come in, if you’re highly allergic to tree pollen or grass pollens, it is best to remove clothing, wash, shower. You want to get it off because it does attach to you,” he explained.
Change your mattress
“A mattress that is about five years old, has an average of 10 pounds of dust mites. You don’t think that might be a lot, but these things are microscopic—10 pounds is millions of dust mites,” Dr. Mendez said, adding that dust mites “come up to feed when they sense warmth on the surface area, so when there’s a body there.”
“Vacuuming a mattress helps but will not get rid of them. People also think that chemicals on the mattress or pillow will help. I discourage using chemicals on your surface areas,” he said. “Ideally, the best way of reducing exposure is with impermeable dust mite covers. Those are key.”
Treatment should come second
“The first thing to consider is whether you’re having seasonal or perennial allergies. The second thing is which organ systems are being affected because typically the symptoms affect nose and eyes. You want to focus on managing those symptoms,” Dr. Mendez said. “If you take an antihistamine orally, it’s going to block histamine receptors and at some point, you’re going to feel relief of symptoms as things move along, but you’re still experiencing symptoms. Anti-inflammatory therapy is the best approach early on, such as nasal sprays or eyedrops.”
“Patients often will start thinking about medications when they’re experiencing some interference in their daily activities,” he said. “By then there’s already inflammation taking place and typically in the nose there’s swelling of what we call the nasal turbinates, which is the reason why people get stuffy and congested. Antihistamines are not very effective for that. You have to use an anti-inflammatory drug and that’s where the topical intranasal corticosteroids come in play.”
For “eye drops, I use either lubricants—which will give you some temporary relief—or ophthalmic antihistamine eye drops,” Dr. Mendez said. “For long-term use, the most effective drugs are intranasal steroid sprays because if you were to reduce inflammation within a few weeks, you will probably have symptomatic relief for weeks thereafter. Unless, of course, you are a perennial allergy sufferer.”
“There's nothing wrong with using an antihistamine with an intranasal spray at the same time. But I tend to tell folks to stay clear of first-generation antihistamines. They're highly sedating. It's nonproductive,” Dr. Mendez said. “You're already having symptoms; you're going to compound those symptoms with sedation.”
It’s important to contact your doctor
“Overall, the key is to prevent symptoms from worsening so that you don’t have that quality of life affected because that’s a big thing for us,” Dr. Mendez said. “When patients come to see an allergist, it’s usually when they’ve tried everything and they don’t know what else to do.”
“Our role is to make sure we change that course,” he said. “We want to make an individual productive and healthy and be able to participate in society in a productive way and not sleep all day or on medications just because they’re having ongoing symptoms.”
“There are so many remedies out there. You walk through your local pharmacy and there are aisles of medications, and you wonder, ‘What am I going to take?’” Dr. Mendez said. “Everyone is trying to outpace the other with all these catchy terms. Most of them are what I call cocktails and mixtures of a variety of different products to give you symptomatic relief, but there are side effects associated with them and they’re not specific treatments for allergy.”
“We always recommend talking to your primary doctor or seeking specialty care for assistance, so that you can be placed on the right path,” he emphasized.
