Making the Diagnosis

To accurately assess and diagnose this patient’s condition, the clinician needs to eliminate other possible causes of symptoms. Lupus erythematosus usually presents with a butterfly-shaped rash that is typically centered on the upper cheeks and nose but does not involve the eyes. This rash is unlikely due to contact dermatitis because the patient’s history notes no new facial products or cosmetics were used prior to the rash. Dermatomyositis is very rare and usually associated with muscle weakness. Orbital cellulitis is associated with pain and fever and typically affects 1 eye.


Seasonal allergies classically present with symptoms of runny/itchy nose and or itchy eyes without fever or pain.  Less common signs and symptoms of seasonal allergies include mild sore throat or periorbital erythema, as seen in this case.  When symptoms of seasonal allergies occur they are bilateral and symmetrical in nature.  If there is drainage from the nose or eyes, the drainage should be clear.  Seasonal allergies can occur at any time but are most common in the spring or fall.

Physical examination may reveal pale, boggy mucosa, and clear drainage. There should be no fever despite the commonly used misnomer of hay fever.

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Differential diagnosis of seasonal allergies typically includes infections or inflammatory conditions, most commonly upper respiratory infections. The presence of pain, fever, or unilateral signs or symptoms should raise concern of an infectious cause or other conditions in the differential diagnosis. 

Once diagnosed, the patient may consider undergoing testing for specific allergic triggers. Treatment of allergic conditions typically includes antihistamines and topical steroids.  For more severe cases, cromolyn, a mast cell stabilizer, or oral steroids may be considered. The best way to prevent seasonal allergies is to avoid known triggers and use air purifiers. Complications of seasonal allergies can include the development of nasal polyps and secondary bacterial infection. 

Brady Pregerson, MD, is an emergency physician at Tri-City Medical Center and Scripps Coastal Urgent Care both in Oceanside, California.


Pregerson DB. Allergies. Emergency Medicine 1-Minute Consult. 5th ed. 2017;5.