Allergic Rhinitis

This guideline applies to children and 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.

Red Flag Features

Not an exhaustive list.

Investigations

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.

Management Optimisation

For detailed information about medical management of allergic rhinitis in children and adults, see:

Key points:

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.

Onset of action of medication groups used in the treatment of allergic rhinitis:

Advice and Guidance

Seek ENT Advice and Guidance for:

Referral

Same-day Assessment

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.

Allergy Referral

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.
In children, severe uncontrolled symptoms affecting quality of life, where you are considering, and prior to, prescribing an oral corticosteroid.

Adults aged 16 years and over – refer to Immunology, Derriford.

Children and young people, aged under 16 years – refer to Paediatrics (RCHT – Dr Simon Bedwani, Derriford – Dr Mala Raman).

ENT Referral

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.

Adults aged 16 years and over – refer to Adult ENT Services.

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

Supporting Information

For professionals:

BSACI: Treatment of Rhinitis Flowchart

For patients:

NHS Allergic Rhinitis

References

Page Review Information

Review date	10/10/2024
Next review date	10/10/2026
GP speciality lead	Dr Laura Vines
Contributors	Ms Aileen Lambert, ENT Consultant Surgeon Dr Andrew Whyte, Consultant Allergist and Immunologist