What you need to know about allergic rhinitis (hay fever)

Allergic rhinitis, more commonly known as hay fever, affects around one in four UK adults and is becoming increasingly common. It refers to an acute (sudden) overreaction of your body to something in the environment that you inhale. This consequently triggers inflammation in your nose, which is responsible for the symptoms of allergic rhinitis. 

Here we’ll take a closer look at the symptoms, causes, diagnosis and treatments available.

Symptoms of allergic rhinitis

The symptoms of allergic rhinitis can be divided into two groups based on the phase or stage of the allergic reaction, which is medically known as a type 1 hypersensitivity reaction. This type of reaction occurs when cells in your blood called mast cells make a type of antibody called IgE. It is IgE that drives inflammation in your body. 

The initial acute phase of the reaction happens within minutes of exposure to the environmental agent (allergen) that triggers your allergic rhinitis. This causes itchy, irritated eyes, sneezing and a runny nose. 

The late phase of the reaction starts around 12 hours after exposure to the allergen and causes nasal congestion or blockage, sometimes alongside discharge running down the back of your nose into your throat (post-nasal drip). A post-nasal drip can mean you need to clear your throat more often and/or develop a more hoarse voice. 

When do symptoms occur?

In adults, symptoms usually first appear in those aged 20–40 years; however, symptoms can occur during the teenage years. During this time, symptoms are often at their worst and become less severe with age. 

Symptoms of allergic rhinitis can be seasonal or perennial. 

Symptoms of seasonal allergic rhinitis occur during specific times of year when the allergen is at particularly high levels in the environment eg tree pollen, grass pollen and weed pollen are high during their germination seasons.

Symptoms of perennial allergic rhinitis occur all year long as the allergen is present year-round eg animal dander and house dust mites. 

Individuals with seasonal allergic rhinitis tend to present more with acute phase symptoms ie itchy eyes, sneezing and a runny nose, while individuals with perennial allergic rhinitis tend to present more with late phase symptoms ie nasal congestion. 

Risk factors for allergic rhinitis

Your risk of developing allergic rhinitis is largely genetic ie you may be born with a predisposition to developing hypersensitivities. Consequently, your risk is higher if you have a family history of asthma, eczema, hay fever or eosinophilic oesophagitis. 

In the case of asthma, eight out of 10 people with asthma also have allergic rhinitis. Conversely, two out of 10 people with allergic rhinitis also have asthma. This means that if you have asthma, you’re highly likely to also have allergic rhinitis, and if you have allergic rhinitis, your risk of having asthma is higher than the general population but not extremely high. 

Individuals with allergic conjunctivitis are also more likely to develop allergic rhinitis, and vice versa.  

Getting a diagnosis

If you’re concerned that you may have allergic rhinitis, see your GP. They will ask you about your symptoms, including when they occur and how long they last, as well as your medical history. They may also physically examine your nose. 

They may then recommend that you take antihistamine medication or a nasal steroid spray. If your symptoms are significantly reduced with either of these treatments, then it is highly likely that you have allergic rhinitis. 

If it isn’t clear whether you have allergic rhinitis, or if other potential causes need to be investigated, your GP will refer you to see a specialist doctor, namely an ENT surgeon. 

Specialist testing

An ENT surgeon can use specific tools to identify what you are allergic to in the environment. 

This usually involves skin prick testing where small marks are made on your skin where a liquid containing a specific allergen has been applied. Results become apparent within 20 minutes — if you are allergic to the allergen, a red swelling (a weal) will develop on your skin. This indicates that when you breathe in this allergen, the inside of your nose becomes, similarly, inflamed. 

However, it is important to note that skin prick testing has a 15% false positive rate. This means for every 100 people tested, 15 will get a result that suggests they are allergic to a specific allergen, but it is not actually this allergen that is triggering their allergic rhinitis. This is because skin prick testing reveals your genetic predisposition to certain allergens, but in the real world, this may not necessarily be the allergen responsible for your symptoms. 

Another test that your doctor may recommend is a RAST (radioallergosorbent test) blood test. This test is more extensive than a skin prick test and involves testing multiple potential allergens using a single blood sample. It can measure how much IgE against a specific allergen is present in your blood and, therefore, indicates what level of inflammation is occurring in your body during an allergic reaction. 

Your doctor may also recommend that you have a nasal endoscopy, where a thin, telescope-like tube with a light and a camera on the end is passed into your nose to allow your doctor to look for any structural abnormalities or coincidental sinus inflammation, that could explain your symptoms. 

Treating allergic rhinitis

Allergy avoidance

The first step in alleviating your symptoms is to avoid the allergen triggering them whenever possible. 

If you have seasonal allergic rhinitis, try to avoid going out on high pollen days or during times of day when there is more pollen in the air — on warm days, pollen counts are usually lower in the morning. 

If you have perennial allergic rhinitis, you should also practise allergen avoidance. If you’re allergic to cat dander, avoid visiting homes that have cats. If you have a dog and are allergic to dog dander, do not allow your dog to come into your bedroom or sleep in your bed. If you are allergic to dust mites, regularly washing your linen at 60°C to kill the dust mites, using hypoallergenic bed linen and removing carpets and rugs from your bedroom, can be beneficial.

Other treatments

You can also use nasal flushing to clear out allergens trapped in your nose and take medication prescribed by your doctor ie antihistamines and/or nasal steroid sprays. In general, antihistamines provide effective relief from acute symptoms, such as itchy eyes, sneezing and a runny nose, while nasal steroid sprays help with nasal congestion. Some nasal sprays combine steroids and antihistamines, and these can be particularly effective. 

If you are using a nasal steroid spray, it is important to follow the directions for use carefully. You do not need to sniff or inhale forcefully, and you should avoid targeting it to the midline of your nose as this can lead to nosebleeds, dryness and crusting. Instead, when applying the spray into your left nostril, spray towards your left ear using your right hand and vice versa. 

If these treatments aren’t enough to manage your symptoms, your doctor may recommend immunotherapy. This involves either having an injection under your skin or taking a tablet or drop under your tongue containing a low dose of the allergen triggering your allergic rhinitis. 

This is administered regularly by a healthcare professional in a controlled environment. Over time, usually three to five years, your body develops a tolerance to the allergen, so that eventually your immune system no longer reacts to it. 

Can surgery help?

Surgery is only ever recommended for the most severe cases of allergic rhinitis where other measures are not effective. 

If your main symptom is severe nasal congestion, turbinate reduction surgery may help. 

Turbinates are small structures in your nose responsible for warming and humidifying (moistening) the air you breathe in. You have three pairs of turbinates and turbinate reduction surgery reduces the size of your inferior turbinates ie the pair closest to the nostril end of your nose. This aims to improve airflow through your nose; however, your congestion symptoms may return to previous levels two to three years after your operation. 

Complications of allergic rhinitis

The consequences of allergic rhinitis on quality of life are often underestimated due to the perceived mild nature of the symptoms. However, allergic rhinitis can have a significant impact on your ability to socialise and work.

Symptoms of allergic rhinitis can also disturb your sleep and lead to snoring. This can leave you feeling tired in the morning. 

Inflammation caused by allergic rhinitis can also affect other parts of your face beyond your nose, including your ears and sinuses. You may feel as if your ears are blocked or have a sensation of pressure in your ears — this can reduce your hearing. You may also develop inflammation of your sinuses (sinusitis). 

If you have both allergic rhinitis and asthma, poorly controlled allergic rhinitis can lead to more visits to the hospital due to asthma attacks.