Seasonal Allergic Rhinitis


When to consider referral

Referral criteria

1.    Seasonal symptoms that are severe and resistant to treatment (when combination treatment at maximum doses has been attempted throughout the season).  Treatment should be initiated at least 2 weeks before the anticipated start of the pollen season.

Primary care management prior to referral

1.    Exclude red flag features

a.    Unilateral symptoms, polyps, persistent blood stained discharge or persistent purulent discharge – consider referral to ENT.

2.    Mild symptoms should be treated with oral non-sedating antihistamines (cetirizine 10mg, loratadine 10mg, or fexofenadine 180mg) once daily. If required a higher dose of up to 3 times per day can be tried; this is above the licensed dose but there is good safety data and it may be effective in some people.

3.    Moderate-severe symptoms should be treated with intranasal antihistamine (eg azelastine/Rhinolast) if available, and/or an intranasal corticosteroid (eg Beconase, two sprays into each nostril twice daily. Consider trying alternatives, eg Nasonex, Avamys or Dymista) in addition to non-sedating antihistamines.  Consistent daily use of intranasal sprays is vital, given maximal effect may not be apparent for at least two weeks.

a.    Start antihistamines and intranasal corticosteroids two weeks before usual symptom onset and continue throughout season

b.    Training in appropriate nasal spray technique essential. Guidance is available at


4.    Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15-20mg for a maximum of 5 days as a one-off treatment can be used for severe symptoms uncontrolled on conventional therapy, to control symptoms during important periods (eg exams or other major events).

5.    Topical cromoglicate and nedocromil eyedrops are useful to manage allergic conjunctivitis.

6.    Consider a concomitant diagnosis of asthma and manage according to guidelines

-       Montelukast can be added to conventional therapy in patients with seasonal allergic rhinitis and concomitant asthma.

 Avoid sedating antihistamines, depot corticosteroids, and chronic use of decongestants.


No investigations are recommended prior to referral.


Differential diagnosis

-       Perennial rhinoconjunctivitis (non-seasonal)

-       Infective rhinosinusitis

-       Non-allergic (eg hormonal, drug-induced, vasomotor) rhinitis


For diagnostic algorithm see BSACI guidelines. Please note we will perform SPT and specific IgE as indicated



Information required with referral


Clinical history, background of treatment tried, any investigations performed.


Clinic options available


We have no Choose and Book slots available – we review and triage all referrals ourselves and allocate clinics appropriately.


Review Date                13/8/2019

New Review Date        13/8/2020

Author                          Dr Andrew Whyte, Consultant Allergist and Immunologist, Derriford Hospital

GP Sifter                              Dr Isabel Boyd


Version No.        3.1