Hay Fever and Year-Round Nasal Allergy: Getting the Treatment Order Right
Allergic rhinitis is dismissed as a minor nuisance, yet it disrupts sleep, impairs concentration and work performance, and worsens asthma control. It is also commonly treated in the wrong order and with the wrong technique.
What is happening
An allergen is inhaled, IgE antibodies on mast cells in the nasal lining recognise it, and those cells release histamine and other mediators. The lining swells, mucus production increases, and nerve endings are irritated.
Symptoms: sneezing, clear runny nose, itching of nose, eyes, palate or ears, and blockage. Itch is the symptom that most reliably distinguishes allergy from a cold or sinus infection.
Classification is by duration rather than season: intermittent if less than four days a week or less than four weeks, and persistent if more.
Common triggers: pollens from trees, grasses and weeds, with seasonal patterns; dust mites, which are perennial and worse at night and on waking; pet dander; mould spores; and cockroach allergen.
The treatment ladder, in the right order
Intranasal corticosteroid spray is the most effective single treatment for moderate to severe or persistent allergic rhinitis. It outperforms oral antihistamines for congestion, which is the symptom antihistamines handle worst.
Two things people need to know and are rarely told:
- It takes days to weeks to reach full effect. Used once for a bad day and abandoned, it appears useless. Use it daily through the season
- Technique determines whether it works. See below
Oral antihistamines are good for sneezing, itch and runny nose, poor for blockage. Use a non-sedating second-generation one: cetirizine, loratadine, fexofenadine, bilastine. Avoid older sedating antihistamines such as chlorpheniramine for routine use; they impair next-day alertness and driving more than people realise.
Intranasal antihistamine sprays act within minutes, useful for rapid relief and in combination.
Combination nasal sprays containing both a steroid and an antihistamine are more effective than either alone for more severe disease.
Leukotriene receptor antagonists such as montelukast, more relevant where asthma coexists, with a caution about neuropsychiatric side effects.
Saline irrigation. Cheap, safe, genuinely effective as an adjunct, and useful before the steroid spray to clear the passage. Use sterile, distilled or previously boiled and cooled water, never untreated tap water.
Eye drops with antihistamine or mast cell stabiliser for prominent eye symptoms.
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Decongestant nasal sprays such as oxymetazoline work fast and must not be used for more than about three to five days. Longer use causes rebound congestion, rhinitis medicamentosa, which traps people in a cycle of using the spray to treat the problem the spray is causing.
Immunotherapy, given as subcutaneous injections or sublingual tablets or drops over three to five years. It is the only treatment that modifies the underlying allergy rather than suppressing symptoms, and benefits persist after completion. Worth considering for severe symptoms, poor response to medication, or when a specific allergen is confirmed.
Nasal spray technique, which almost everyone gets wrong
- Blow your nose gently first
- Shake the bottle
- Tilt your head slightly forward, not back
- Use the opposite hand to the nostril: right hand for left nostril
- Aim the nozzle outward, toward the ear on that side, not up at the bridge of the nose
- Spray while breathing in gently. Do not sniff hard, which pulls the medicine straight to the back of the throat where it does nothing
- Do not blow your nose immediately afterwards
Aiming at the septum is the commonest error and is also the cause of most nosebleeds from these sprays. Pointing outward both improves delivery and prevents the side effect.
Allergen reduction that is worth the effort
Dust mite, the most common perennial trigger:
- Allergen-proof covers on mattress and pillows, which have the best evidence of the measures available
- Wash bedding weekly at 60°C or above
- Reduce humidity below about 50 per cent
- Remove soft toys from the bed, or freeze them periodically
- Hard flooring in bedrooms where feasible
Single measures in isolation tend to disappoint; combinations work better.
Pollen:
- Check pollen counts and limit outdoor time at peak, usually morning and early evening
- Keep windows closed and use recirculation in the car
- Shower and change clothes after being outdoors
- Wraparound sunglasses
- Do not dry laundry outdoors in season
Pets: removal is most effective and least acceptable. Failing that, keep them out of the bedroom, wash them regularly, and use HEPA filtration.
Why it matters for asthma
The upper and lower airways behave as one system. Untreated allergic rhinitis is a well-documented cause of poor asthma control, and treating the nose improves the chest. If asthma is not controlled despite good inhaler technique and adherence, untreated nasal allergy is one of the first things to check.
When it is not allergy
Consider other diagnoses with: unilateral blockage, bloody or foul discharge, facial pain and pressure, loss of smell persisting, no itch or sneeze, symptoms starting after a medication, or no response to proper treatment. Nasal polyps, deviated septum, chronic sinusitis and non-allergic rhinitis all present similarly.
The short version
For persistent or moderate symptoms, a steroid nasal spray used daily and aimed outward is the most effective treatment, and both of those conditions matter. Antihistamines handle itch and sneeze but not blockage, decongestant sprays must not be used beyond a few days, and immunotherapy is the only option that changes the underlying allergy.