Springtime: Allergic Rhinitis

By Dr Martie Conradie, MBChB, DCH (SA)

Spring at last! What a beautiful time. But, with pretty colours come flowers, with all the green comes grass and now there is pollen…then you sneeze.

Allergic rhinitis (a.k.a. hay fever) affects nearly 16 million people in South Africa. Although some suffer from seasonal allergic rhinitis, many people experience perennial rhinitis (symptoms experienced throughout the year) which makes allergic rhinitis one of the most common chronic illnesses in the country.

Springtime is known to cause allergies to flare up, and besides making you miserable, it may lead to other complications. But you do not have to tolerate the annoying symptoms if you understand what to avoid, which treatment to use and when to visit a doctor.

What is allergic rhinitis?

Allergic rhinitis is a condition where the lining of the nose is inflamed and swollen. It is commonly called “sinus”. It is characterised by a blocked nose, rhinorrhoea (runny nose), sneezing and an itchy nose.

Other symptoms include post-nasal drip, loss of smell, sore throat and allergic conjunctivitis (itchy, red and watery eyes).

Basically, what happens is that your immune system decides that a harmless substance is harmful, and it makes antibodies against this substance. When you are exposed to the substance again, the antibodies tell your immune system to release chemicals like histamine, which then lead to the symptoms. This is referred to as an allergic response to allergens.

People with allergic rhinitis may have intermittent (<4 days a week or <4 weeks) or persistent (>4 days per week and >4 weeks) symptoms which may be mild, moderate or severe.

A purely allergic rhinitis seldom exists, because there are other factors affecting the lining of the nose which do not involve your immune system.

Other types of rhinitis

Non-allergic rhinitis is a condition where the symptoms are not caused by an allergic response.

Triggers of non-allergic rhinitis may include:

Environmental or occupational irritants, such as dust, strong odours (even perfume) or chemicals used at your workplace
Changes in weather (temperature or humidity) – cause swelling of nasal membranes
Viral infections
Eating spicy food or drinking alcoholic beverages – it causes the membranes in your nose to swell leading to nasal congestion
Medications which include aspirin, ibuprofen and certain high blood pressure medications
Exercise or other strenuous activities
The overuse of decongestant nasal sprays – this type of rhinitis is called rhinitis medicamentosa and it is the reason nasal decongestants are often only prescribed for 3-5 days
Hormonal changes such as those due to pregnancy, menstruation or oral contraceptive use
Conditions such as obstructive sleep apnoea or acid reflux

Causes of allergic rhinitis

There are many triggers such as:

Tree pollen (early spring) – in South Africa, the common ones are plane, eucalyptus, acacia and oak tree pollen
Grass pollen (late spring and summer) – commonly buffalo and kikuyu grass
Dust mites, cockroaches and pet dander (perennial) – an allergy caused by cockroaches occur more often than one might think, while cats, dogs and horses cause most of the reactions related to pets
Indoor and outdoor fungi and mould spores (seasonal and perennial)

Some interesting things people can be allergic to in our country are mopane worms, marula fruit, impala, wildebeest and porcupine.

Allergic rhinitis symptoms are mostly brought on by inhalable allergens, but being exposed to any form of these allergens may result in allergic rhinitis, eczema or asthma.

The following factors may increase your risk of developing allergic rhinitis:

Having asthma, eczema or a family history of asthma or allergies
Working in a place where you are exposed to allergens, such as animal dander or pollen
Having had a mother who smoked (especially during the first year of your life)

Diagnosis

In one study 48% of people reported rhinitis symptoms, but only 14.9% had true allergic rhinitis after testing. Allergic rhinitis often requires specific treatment and it is therefore advised to rather get properly diagnosed, although the cause might not always be found.

To get to a diagnosis, your doctor will perform a physical examination, take a full medical history and might recommend the following tests:

Skin prick test – drops of different allergens are pricked into your skin and after a while the sizes of the hives (looking like mosquito bites) are measured. There might be no reaction, a small hive or a large hive and it can indicate whether you are allergic to the specific allergen or not. It is important that you have not taken an antihistamine for about 72 hours before the test.
Allergy blood tests – your immune system’s response to specific allergens can be measured by a lab. The test called “RAST” measures how much allergy-causing antibodies there are in your bloodstream (also called IgE antibodies).

It is best to have these tests done and analysed by an allergologist or a GP with an interest in allergies to ensure that the results are interpreted correctly.

There are more specialised tests, but these should only be requested by specialists when necessary for management.

Complications

Allergic rhinitis is not an insignificant disease. If uncontrolled, it can lead to:

A reduced quality of life – interfering with your work and enjoyment of activities
Poor sleep – resulting in fatigue and a general unwell feeling
Worsening of asthma or other medical conditions
Nasal polyps – non-cancerous growths of the membranes of the nose
Sinusitis – especially when your sinuses have been congested for a long time. Sinusitis is when there is inflammation or an infection (viral, bacterial or even fungal) of the lining of your sinuses.
Middle ear infections – the swollen membranes in your nose might obstruct the Eustachian tube (connecting your throat and middle ear) and this increases your susceptibility to middle ear infections. It is especially common in children.
Limiting your child’s ability to learn – when children feel unwell, cannot hear properly or are distracted by symptoms, they cannot learn effectively

Management

Many people have gotten so used to their symptoms that they do not visit their doctors. Over-the-counter therapies and alternative treatments are often used which might not adequately treat the problem. Poor control leads to complications.

Medications for allergic rhinitis include:

Antihistamines – pills, nasal sprays and eyedrops can be bought over the counter. These can reduce itching, sneezing and a runny nose, but it does not really relieve nasal congestion. It works by blocking the histamine that was released by your immune system during the allergic reaction. Some of these can cause sedation so specifically ask the pharmacist for a non-sedating antihistamine if you must be alert or at work, but generally they are safe.

Nasal corticosteroids – nasal sprays promote healing of the inflammation of the nasal lining and help to prevent nasal itching and a runny nose. These are often required for optimal control. There are a few available over the counter, but most of them need a prescription. They are safe for long-term use for most people, but it is good to discuss it with your doctor especially if you have other medical conditions or use chronic medication.

Decongestants – these are available as over-the-counter medication and come in tablets, nasal sprays and liquids. The active ingredients include pseudoephedrine, phenylephrine hydrochloride or oxymetazoline. They can however have a number of side effects such as raising your blood pressure, causing insomnia and headaches and increasing irritability. Nasal sprays can worsen nasal congestion if you use it for longer than 3-5 days.

Saline preparations – saline (basically a weak saltwater solution) is loved by the lining of your nose and sinuses. It is similar to the normal moisture normally present in your nose and it expedites healing of weakened membranes. There are saline sprays, drops for babies, and saline flushes. Rinsing your sinuses or nasal passages with sterile saline is an inexpensive and effective way to relieve nasal congestion.

Cromolyn sodium – this can be bought over the counter as a nasal spray and is available in an eyedrop form with a prescription. It also prevents the release of histamine and is most effective when you use it before you have symptoms and it does not have many side effects.

Montelukast – this is a tablet that can be prescribed by a doctor. It blocks the action of chemicals called leukotrienes which cause symptoms such as increased mucous production and is very effective for treatment of allergy-induced asthma. It can cause headaches and there have been rare instances of it causing psychological reactions such as agitation and depression.

Oral corticosteroids – pills such as prednisone are sometimes prescribed for severe symptoms. Corticosteroids can cause serious side effects such as cataracts and osteoporosis and therefore it is usually prescribed for only about 5 days. Corticosteroid syrup can be prescribed for kids, but please be aware that it can have serious side effects and regular use while they are young can result in problems when they are older. Do not be tempted to give it again without consulting a doctor when your child is unwell just because you have some left in the cupboard.

An interesting treatment for allergic rhinitis is immunotherapy where you regularly receive a small amount of an allergen to get your body to become used to it. This may decrease the need for medication. It is not readily available, but research shows good results especially for allergies to cat dander, dust mites and pollen.

See your doctor if you cannot find relief from your symptoms or if you have other conditions such as asthma or nasal polyps.

Prevention

It will be very difficult to avoid all allergens, but symptoms can be reduced by limiting your exposure. Consider the following advice:

If pollen is a trigger, don’t hang laundry outside since it can stick to sheets or clothes, avoid outdoor activity early in the morning when pollen counts are high, avoid mowing the lawn and wear a dust mask when cleaning the house or doing gardening.
If dust mites are the culprit, use allergy-proof covers on mattresses and pillows, wash your bedding in water heated to 40 degrees, vacuum carpets weekly with a vacuum cleaner (with a small-particle or HEPA filter if possible), spray insecticide which is specific to dust mites but which is safe to use on bedding and carpets, and really consider removing carpeting where you sleep if you experience severe symptoms.
To reduce allergens from cockroaches, block crevices where they can enter, keep the floors clear and store pet food in sealed containers.
Pet dander is a difficult one, especially if Woof and Fluffy are members of the family, but keep pets outside where possible, and bathe dogs twice a week (it has not been proven to be beneficial to bathe cats). If they must be inside, keep them out of your bedroom and off the furniture. Unfortunately, you will really have to consider sending a pet away to another loving home if you have a young child who is allergic.

Allergic rhinitis and COVID-19

Due to the current pandemic, you might get several judgemental looks from people if you start sneezing in public.

There are a few symptoms overlapping, but the typical sneezing and itching after exposure to allergens are very indicative of allergic rhinitis, whereas sudden onset of fever, coughing and shortness of breath are more characteristic of COVID-19.

If you test positive for SARS-CoV-2 and suffer from allergic rhinitis, it is however even more important for you to isolate since all the sneezing might spread the infection faster.

You might wonder whether you are at an increased risk of getting COVID-19 if you have allergic rhinitis. Currently people with well-controlled allergic rhinitis have not been shown to be at an increased risk. It is recommended that people with allergic rhinitis continue their usual treatment plan, ensure proper control of symptoms and follow good hygienic practices.

I hope that none of you will experience allergic rhinitis during this springtime, and that those of you who do, are able to manage it effectively to not develop complications.

If you want to read more about rhinitis, have a look at some of the references below.

Enjoy spring while picking flowers, being outside and seeing new life return.