Allergic Rhinitis in Adults

This guideline applies to adults.

Introduction

Allergic rhinitis is common: prevalence of 26% in adults in the UK (2004)¹.
It is typically lifelong; only 10% of children and young people outgrow the condition¹.
Symptoms can have a significant impact on quality of life, mood, sleep, concentration and behaviour.
Differential diagnosis includes acute rhinitis, non-allergic rhinitis (idiopathic, environmental, hormonal, drug-induced, vasomotor), chronic rhinosinusitis, nasal foreign body, nasal malignancy.

Not an exhaustive list.

A therapeutic trial of treatment is considered the first investigation when the history is typical.

In perennial allergic rhinitis, consider requesting specific serum IgE to common or suspected precipitants i.e. house dust mites, animal dander.

In seasonal allergic rhinitis, specific testing is not required in the first instance as the treatment is the same regardless of cause.

For detailed information about medical management of allergic rhinitis see:

Identify and eliminate allergens.
Encourage saline nasal irrigation.
Intranasal steroids are the most effective treatment if used correctly and regularly, see RMS guideline on the Nasal Steroid ladder:
- Intranasal steroid + oral antihistamine is no more effective than an intranasal steroid alone¹.
- Intranasal steroid + intranasal antihistamine is more effective than an intranasal steroid alone¹.
- If seasonal, start intranasal steroids 2 weeks before symptom onset¹.
- Regular therapy is more effective than “as required”.
- Avoid sedating antihistamines, depot corticosteroids, chronic use of nasal decongestants and systemically bioavailable intranasal steroids e.g. betamethasone.
Consider concomitant asthma and manage accordingly – treating allergic rhinitis will improve asthma.
Treatment failure should prompt a review of the diagnosis, compliance with treatment and intranasal steroid technique.
If an adult has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief¹.

Nasal foreign body:

Button/watch batteries – if not confident/experienced to remove, send straight to ED.
Other types of nasal foreign body – ENT first on-call.

Severe seasonal symptoms that are resistant to combination treatment at maximum doses throughout the season.
Severe perennial symptoms that are resistant to combination treatment at maximum doses for at least 3 months.

Referral to see if pets need re-housing
Requests for tests to prove that mould / old pet her is causing a problem in rental properties or another family member’s house

Very limited surgical options for allergic rhinitis.

Persistent nasal symptoms, likely secondary to rhinosinusitis overlay:
- not responding to an adequate trial of medication, and
- fail to meet the criteria for allergy referral.

Children and young people, aged under 16 years – refer to Paediatric ENT Services.

Review date	04 July 2025
Next review date	04 July 2027
GP speciality lead	Dr Laura Vines, GP, RMS Dr Melanie Schick, GP, RMS
Contributors	Ms Aileen Lambert, ENT Consultant Surgeon, RCHT Dr Andrew Whyte, Consultant Allergist and Immunologist, Derriford Dr Simon Bedwani, Consultant Paediatrician, RCHT