Testing 

  • diagnostic testing
    • rarely needed for making initial treatment decisions for most adults
    • may be useful for 
      • patients with uncertain diagnosis
      • perceived need for objective confirmation
  • testing for specific triggers to confirm diagnosis of AR or aid management decisions
    • skin testing
    • specific IgE blood testing 
  • other diagnostic tests occasionally needed
    • nasal smears for eosinophils 
    • beta-2 transferrin (sensitive for confirming CSF rhinorrhea) 
    • sleep study 
    • pulmonary function test 
  • other testing in children may include
    • immune studies
    • sweat test
    • sinus CT
    • nasal endoscopy

Treatment 

  • allergen avoidance
    • dust mite avoidance
      • clinically effective avoidance includes combination of 
        • dust mite covers for bedding
        • humidity control
        • high efficiency particulate air (HEPA) vacuuming of carpeting
        • acaricides 
      • other common recommendations include
        • wash pillows and bed sheets regularly in hot water
        • remove carpeting, feather pillows, upholstered furniture; especially in bedroom
        • keep clothes off bedroom floor
        • dust frequently with damp cloth
        • ban furred pets from bedroom (or from home)
        • use double-bag vacuum bags
    • pollen allergen avoidance
      • keep windows closed
      • stay indoors on high-pollen days if highly allergic 
      • do not dry clothes outside
      • shower at bedtime
    • reduce indoor fungal exposure (may require removal of moisture sources and replacement of contaminating materials) 
    • cockroach elimination measures may include
      • careful sanitation of infested areas
      • not allowing food to stand open or remain on unwashed dishes or countertops
      • storage of garbage in tightly sealed containers
      • use of roach traps
      • insecticide application by professional exterminator if heavy infestation
    • animal avoidance (most effective, but may take 4 to 6 months for home to clear of allergens)

Medications

  • intranasal corticosteroids
    • most effective medication class  
    • more effective than combination of antihistamine and leukotriene antagonist in treatment of seasonal AR 
    • may be used as-needed (less effective than continuous use) 
  • other medications
    • intranasal antihistamines 
      • equal or superior to oral second-generation antihistamine
      • can be considered first-line treatment 
    • oral antihistamines (second-generation preferred)
    • oral and topical decongestants (use with caution in specific clinical situations) 
    • oral leukotriene receptor antagonists alone, or in combination with antihistamines
    • intranasal cromolyn 
    • anticholinergics (ipratropium or atropine sulfate nasal spray) may reduce rhinorrhea but not other nasal symptoms 
  • other therapies
    • nasal saline irrigation (alone or as adjunct)
    • butterbur 
    • acupuncture (limited evidence for prevention or treatment) 
    • homeopathic preparations (especially for ocular symptoms)
    • herbal medicines with some efficacy for allergic rhinitis include
      • combination of Cinnamomum zeylanicum, Malpighia glabra, and Bidens pilosa 
      • Astragalus membranaceus 
      • Bu-zhong-yi-qi-tang (a Chinese medicine) 
  • other nasal therapies 
    • petrolatum application to nares 4 times daily 
    • rhinophototherapy 
    • intranasal non-inhaled CO2 
  • immunotherapy
    • subcutaneous (“allergy shots”)
      • variable reduction of symptoms
      • consider if specific IgE antibodies to clinically relevant allergens present
      • fexofenadine pretreatment may prevent severe systemic reactions 
  • sublingual 
    • FDA-approved therapies include
      • Timothy grass pollen allergen extract
      • Sweet Vernal, Orchard Perennial Rye, Timothy and Kentucky bluegrass mixed pollens allergen extract
      • Short ragweed pollen allergen extract

Alan Drabkin, MD, is a senior clinical writer for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.