Drs Imran Rafi and Shuaib Nasser provide an overview of the updated BSACI allergic and non-allergic rhinitis guideline, and discuss what treatments are most effective

Imran

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Read this article to learn more about:

  • the distinction between allergic and non-allergic rhinitis
  • key symptoms that can aid diagnosis and what red flags to look out for
  • what therapies are most suitable to treat the varying symptoms of rhinitis.

Key points

Commissioning messages

In the UK, the prevalence of rhinitis ranges from 10.1% to 15.3% in children and is approximately 26% in adults. Rhinitis can have a significant impact on an affected individual’s quality of life, including their school and/or work attendance and performance.1

This article provides an overview, with permission from the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI), of the updated BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2008 and revised in 2017.1

What is rhinitis?

Rhinitis describes inflammation of the nasal mucosa with symptoms of nasal discharge, itching, sneezing, and nasal blockage or congestion. Rhinoconjunctivitis describes rhinitis with the conjunctivae also affected; rhinosinusitis describes rhinitis with the sinus linings also affected.1 Rhinitis is strongly associated with asthma; between 74% to 81% of people with asthma report symptoms of rhinitis.1

There is a hereditary component to the development of rhinitis, and gene-environment factors such as urban environment may increase incidence.1

Rhinitis can be divided into two main groups, allergic rhinitis and non-allergic rhinitis (NAR).

Allergic rhinitis

Allergic rhinitis occurs when the symptoms of rhinitis are caused by an IgE-mediated reaction to an allergen. Common patterns of allergen exposure include:1

  • seasonal: grass pollen, tree pollen, fungal spores such as alternaria
  • perennial: dust mites, pets
  • occupational: wood dust, flour dust, latex (see section on occupational rhinitis).

Seasonal allergic rhinitis is characterised by typical hay fever symptoms recurring at the same time each year, with rhinosinusitis and allergic conjunctivitis featuring prominently. Perennial allergic rhinitis has symptoms of rhinosinusitis, including sneezing, itch, rhinorrhoea, and nasal blockage. With occupational allergic rhinitis, there is often a lag period between exposure and onset of symptoms with some relief during weekends and holidays (see section below on occupational rhinitis).1

There may be a family history of allergic rhinitis or it may arise de novo.1

Figure 1 shows a simplified view of the immunological mechanisms of allergic rhinitis. People with allergic rhinitis have IgE antibodies for specific allergens. When exposed to the specific allergen, mast cell degranulation occurs alongside the release of pre-formed mediators (e.g. histamine, tryptase) resulting in itch, sneezing, nasal blockage, and rhinorrhoea. The release of rapidly-synthesised mediators (including leukotrienes and prostaglandins) contribute to nasal blockage, hyperactivity, and hyposmia.

Simplified immunological mechanisms of allergic rhinitis

Figure 1: Simplified view of the immunological mechanisms of allergic rhinitis1

Non-allergic rhinitis

People with NAR have chronic nasal symptoms (e.g. nasal blockage, rhinorrhoea) that are not caused by allergic or infectious triggers.3 There are two main subgroups:1

  • NAR with nasal inflammation
  • NAR without nasal inflammation or local IgE production.

On histology, NAR may demonstrate cellular infiltration characterised by increased numbers of eosinophils, lymphocytes, and mast cells.1

Occupational rhinitis

Occupational rhinitis describes abnormalities of the nasal mucosa mediated by airborne substances in the affected individual’s work environment, and can be either allergic or non-allergic. Over 300 agents are known to cause occupational rhinitis; these include:1

  • high molecular weight agents—protein allergens, such as latex and flour
  • low molecular weight agents—these include di-isocyanates and glutaraldehyde, and cause symptoms through irritant exposure or airway sensitisation.

Diagnosis

A diagnosis of rhinitis is primarily based on a detailed history and recognising key symptoms.1

Take a detailed history

Ask the patient about:1

  • triggers (seasonal, indoors/outdoors, work/school location, etc.)
  • improvement of symptoms on weekends and holidays
  • relationship to potential triggers and impact on quality of life
  • any family history of rhinitis
  • pets or other contact with animals
  • drug history, including use of:
    • alpha and beta-blockers (and other anti-hypertensives)
    • aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs)
    • oral contraceptives
    • topical sympathomimetics.

Look for key symptoms and signs

Key symptoms and signs of rhinitis include:1

  • rhinorrhoea with yellow or green discharge
  • nasal blockage (consider nasal polyps or septal deviation)
  • nasal crusting (consider systemic inflammatory or granulomatous polyangiitis disorder)
  • bleeding (often associated with rhinitis but may be secondary to topical corticosteroid, consider malignancy if bleeding is unilateral)
  • sneezing and itching
  • hyposmia caused by nasal polyps
  • eye symptoms including red eye, lid swelling, and periorbital oedema
  • cough, wheeze, and breathlessness—asthma or bronchiectasis may also be present
  • snoring and sleep problems
  • repeated sniffing and nasal intonation of speech.

See section on referral at the end of this article for red flag symptoms.1

Examination

In primary care, examination is usually limited to external appearance of the face and nose. An assessment of airway patency can be made quickly by looking for misting on a metal spatula, or using a peak nasal inspiratory flow meter. Anterior rhinoscopy using Thudichum’s speculum allows visualisation up to the middle meatus and sometimes beyond.

Investigations

If the patient’s symptoms and history do not suggest an obvious cause of rhinitis symptoms, it may be necessary to carry out further investigations. Allergy tests can help confirm if the rhinitis is due to a specific allergen. Investigations include:1

  • Skin prick tests
    • should be carried out routinely to determine if rhinitis is allergic or non-allergic
    • have a high negative predictive value; however, at least 15% of people with a positive skin prick test will not develop symptoms on exposure to the relevant allergen.
  • Serum total and specific IgE
    • can be requested if skin prick tests are not possible, or when a skin prick test together with the clinical history give equivocal or conflicting results
    • serum total IgE alone can give misleading results, but may aid interpretation of specific IgE results.
  • Laboratory investigations
    • usually unnecessary, unless indicated by the patient’s clinical history and results of skin prick tests—examples include:
      • full blood count, C-reactive protein, immunoglobulin profile, microbiological examination of sputum and sinus swabs when chronic infection is suspected
      • thyroid function tests if there is unexplained nasal blockage
      • urine toxicology when cocaine abuse is suspected
      • nasal secretions—asialo-transferrin for cerebrospinal fluid identification.
  • Exhaled nitric oxide
    • measurement of fractional exhaled nitric oxide can be used in the diagnosis and monitoring of asthma associated with rhinitis, which often goes unrecognised.
  • Radiology
    • a computed tomography scan can be helpful in the diagnosis of rhinosinusitis or nasal polyposis.

Classifying the rhinitis

Symptoms of sneezing, nasal itching, and itching of the palate are more likely to indicate allergic rhinitis; the investigations listed above can help confirm this.1

A diagnosis of non-allergic rhinitis is confirmed by exclusion of allergic rhinitis in patients who test negative on skin testing and serum specific IgE, when other causes of rhinitis have been ruled out (see Table 1).

TypeExamples of triggers/causeSigns and symptoms
Table 1: Common causes and triggers for non-allergic rhinitis1
Adapted from: Scadding G, Kariyawasam H, Scadding G et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised Edition 2017; first edition 2007). Clin Exp Allergy 2017; 47 (7): 856–889. Reproduced with permission.
Eosinophilic Up to 50% of people develop aspirin intolerance, with asthma and nasal polyposis occurring later in life Nasal congestion prominent often accompanied by asthma
Autonomic (formerly known as vasomotor) Physical or chemical triggers (e.g. changes in temperature) Watery/clear rhinorrhoea most prominent in the morning
Drugs    Many classes of anti-hypertensive drugs Nasal congestion
Cocaine Rhinorrhoea, crusting, pain, septal perforation
Nasal decongestants Rhinitis medicamentosa (blockage) with prolonged use 
Aspirin/NSAIDs Acute rhinitis symptoms with or without asthma 
Hormonal Pregnancy, contraceptives, HRT, menopause, puberty, thyroid disease, acromegaly Nasal blockage and/or rhinorrhoea
Food Alcohol, spicy foods, pepper, sulphites Rhinorrhoea, facial flushing, gustatory rhinorrhoea
Primary ciliary dyskinesias Kartagener’s syndrome Sinusitis, bronchiectasis, and reduced fertility
Primary mucus defect Cystic fibrosis and Young’s syndrome Children with nasal polyps must be screened for cystic fibrosis
Systemic/inflammatory Sjögren’s syndrome, SLE, eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) Nasal blockage, polyps, sinusitis, crusting
Immunodeficiency Antibody deficiency Chronic or recurrent infective sinusitis
Malignancy Squamous cell carcinoma, melanoma, lymphoma Bleeding, pain, nasal blockage, purulent discharge—these symptoms are often unilateral
Granulomatous disease Sarcoidosis, granulomatosis with polyangiitis (Wegener’s granulomatosis) External nasal swelling or collapsed bridge, sinusitis, blockage, crusting, bleeding, septal perforation
Structural Nasal septal deviation Usually only presents when rhinitis develops
BSACI=British Society for Allergy and Clinical Immunology; NSAIDs=non-steroidal anti-inflammatory drugs; HRT=hormone replacement therapy; SLE=systemic lupus erythematosus

A diagnosis of occupational rhinitis is made by:

  • taking a detailed history
  • a notable improvement of nasal symptoms over weekends and holidays
  • reviewing the patient’s symptom diary
  • skin-prick testing and measurement of specific IgE where appropriate.

Infective rhinitis (rhinitis caused by common cold or other infection) should always be considered.

Treatment

Allergen avoidance in allergic rhinitis

Common causes of perennial allergic rhinitis include house dust mite, indoor pets, and occupational allergens. Minimising exposure to these allergens will relieve symptoms; however, house dust mites in particular are difficult to completely avoid. Practical measures can reduce exposure to seasonal allergens like pollens, such as wearing sunglasses and nasal filters, and avoiding outdoor activity in the evening when pollen levels are highest. Table 2 highlights the evidence base for allergen avoidance.1

House dust mite—recommendations from trialsGrade of recommendation
Table 2: Evidence base for allergen avoidance1
Scadding G, Kariyawasam H, Scadding G et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised Edition 2017; first edition 2007). Clin Exp Allergy 2017; 47 (7): 856–889. Reproduced with permission.
Encase mattress, pillow and duvet in allergen-impermeable fabric A (against use as a single intervention)
Use of acaricides on carpets and soft furnishing
Pollen—other practical avoidance measures not tested in trials 
Minimising outdoor activity when pollen is highest (early morning, early evening, during mowing)
Avoiding going out during/after thunderstorms
Planning holidays to avoid the pollen season
Keeping windows closed (house and car)
Shower/wash hair following high exposures
Avoid drying washing outdoors when count is high

Pharmacotherapy

Minimising exposure to allergens and irritants may be difficult, and many people with rhinitis continue to experience symptoms despite taking avoidance measures. A large range of effective pharmacological treatments for rhinitis is available, and the nature of the patient’s symptoms should help determine selection of medication. Table 3 summarises available treatments and their effects upon individual symptoms. A rhinitis treatment algorithm to help guide treatment choice is also available, see Figure 2.

 SneezingRhinorrheaNasal obstructionNasal itchEye symptoms
Table 3: Pharmacotherapy effects on individual rhinitis symptoms1
Scadding G, Kariyawasam H, Scadding G et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised Edition 2017; first edition 2007). Clin Exp Allergy  2017; 47 (7): 856–889. Reproduced with permission.
H1‑antihistamines   
Oral ++ ++ + +++ ++ 
Intranasal  ++ ++ + ++ 0
Eye drops 0 0 0 0 +++
Corticosteroids     
Intranasal  +++ +++ ++ ++ ++
Chromones     
Intranasal + + + + 0
Eye drops 0 0 0 0 ++
Decongestants    
Intranasal 0 0 ++++ 0 0
Oral 0 0 + 0 0
Anti-cholinergenics 0 ++ 0 0 0
Anti-leukotrienes 0 + ++ 0 ++
Intranasal steroids and intranasal antihistamine 1 +++ +++ +++ +++ +++


Rhinitis treatment algorithm

Figure 2: Rhinitis treatment algorithm1

Source: Source: Scadding et al. Clin Exp Allergy 2017; 47 (7): 856–889. Reproduced with permission.

Additional therapies can be accomplished using two different medications, or a combination treatment in one device. There is, as yet, no comparative evidence on which to base this choice; however, concordance appears more likely when the regimen is simple.

AH=antihistamine; INS=intranasal corticosteroid; Rx=medication; INAH=intranasal antihistamine; LTRA=leukotriene receptor antagonist; OC=oral corticosteroids; Sx=symptoms.

H1‑antihistamines

Antihistamines should be used regularly and as a first-line therapy for mild-to-moderate intermittent rhinitis and mild persistent rhinitis. They are particularly effective at relieving rhinorrhoea and sneezing.1

There are three types of H1‑antihistamine:1

  • oral—alleviate sneezing, rhinorrhoea, nasal blockage, nasal itch, and eye symptoms
  • intranasal—superior to oral antihistamines in attenuating rhinitis symptoms and have no systemic adverse effects, but have limited effect on eye symptoms
  • eye drops—only effective at reducing eye symptoms, but do so better than oral antihistamines.

There have been no studies on the safety of H1‑antihistamine use during pregnancy. While antihistamines are generally not considered to be harmful, practical advice is to avoid their use in the first trimester and use only if the apparent benefit is greater than theoretical risk to the foetus. Cetirizine is the antihistamine most likely to be recommended by allergy clinics for pregnant women, and the lowest dose should be taken for the shortest possible duration. Antihistamines are excreted in breast milk; breastfeeding mothers are advised to avoid antihistamine use, particularly chlorphenamine, as it may cause drowsiness in the child.1

Corticosteroids

For the treatment of severe symptoms such as nasal blockage, intranasal corticosteroids (INS) are a first-line therapy and can either be used alone or in combination with antihistamines. Their maximum effect may not occur for around 2 weeks, so in the case of seasonal allergic rhinitis, starting treatment 2 weeks prior to a known allergen season is recommended. In around 10% of cases, INS cause nasal irritation, sore throat, or epistaxis. Systemic corticosteroids (0.5 mg per kg in adults for 5–10 days) are indicated only if symptoms of rhinitis fail to respond to a combination of antihistamines (both topical and oral) and INS taken on a regular basis (be sure to check compliance). Injectable corticosteroids are not recommended due to a poor risk–benefit profile compared with other treatments.1

Although the safety of INS in pregnancy has not been established, only minimal amounts pass into the blood stream and are therefore are commonly used during pregnancy.1

Combination therapy

A combination of topical antihistamine (azelastine) with topical corticosteroid (fluticasone propionate) is recommended when symptoms remain uncontrolled on antihistamine or INS monotherapy, or on a combination of oral antihistamine and INS.

Other treatment recommendations1

  • Intranasal decongestants should only be used for <10 days maximum to avoid rebound nasal blockage and rhinitis medicamentosa. They should always be co-prescribed with an intra-nasal corticosteroid
  • Oral decongestants are not recommended as they only have a weak effect on reducing nasal blockage and have many side-effects
  • Anti-leukotrienes have a similar therapeutic profile to antihistamines and have a role in treating patients with asthma and seasonal allergic rhinitis. They are less effective than intranasal steroids and demonstrate little additional benefit when added to antihistamines in most patients
  • Topical anti-cholinergics are effective for the treatment of watery rhinorrhoea that persists despite compliance with INS or INS in combination with antihistamine, but they have no effect on other nasal symptoms
  • Chromones have a weak effect on rhinitis symptoms, but have some effect on nasal blockage and are useful for individuals unable to take other medications (e.g. during pregnancy).

Immunotherapy

Immunotherapy (also know as desensitisation therapy) is highly effective at treating both perennial and seasonal allergic rhinitis. It can improve symptoms and quality of life, while reducing medication requirements. Treatment is available through NHS allergy clinics for patients who have demonstrated full compliance but failed to respond to combination treatment with INS and antihistamines taken regularly.2

In the UK, only grass and tree pollen desensitisation preparations are licensed for use in allergic rhinitis. Treatment is administered by multiple subcutaneous injections although some centres may be able to prescribe grass pollen tablets for sublingual therapy. Patients should be told to expect improvement in symptoms and most will continue to need other treatments as well.1

Treatment of non-allergic rhinitis

Non-allergic rhinitis is often more difficult to treat and often requires combination treatment with topical nasal antihistamines and topical corticosteroids. Intranasal ipratropium is effective in the treatment of NAR with predominant symptoms of watery rhinorrhoea.1

Rhinitis in children

Allergic rhinitis in early childhood is a risk factor for developing asthma in later childhood and adulthood. The presentation of allergic rhinitis in children can be influenced by co-morbidities including conjunctivitis, impaired hearing, rhinosinusitis, sleep problems, and pollen–food syndrome, therefore it is important to ask parents about these issues. A change in school performance may be an indicator of uncontrolled rhinitis symptoms, often associated with poor sleep.1

Diagnosis and treatment of rhinitis in children is similar as for adults. In primary care it is important to be aware of the effects of steroids on weight and height, especially in cases of multisystem allergic disease where children may be receiving corticosteroids for additional indications such as asthma and/or eczema.1

When to refer

Referral to ear, nose, and throat specialists

Patients presenting with the following red flag symptoms should be referred to an ear, nose, and throat (ENT) specialist:

  • unilateral rhinorrhoea—may indicate cerebrospinal fluid leak
  • unilateral nasal blockage—may indicate foreign body or tumour (urgent referral to ENT is required)
  • nasal crusting—may indicate granulomatosis or vasculitis
  • septal perforation—may indicate granulomatous disease.

Referral to an ENT specialist is also necessary when considering surgery (e.g. for nasal blockage, nasal polyps, anatomical variations of the septum). Note that there is poor evidence that surgery for inferior turbinate hypertrophy is beneficial.

Referral to an allergy clinic

Consider referring a patient with allergic rhinitis to an allergy clinic:4

  • when treatment with a combination of antihistamines and INS is ineffective
  • to consider immunotherapy in allergic rhinitis
  • when an allergic trigger is suspected and allergen avoidance could mitigate symptoms
  • if occupational rhinitis is suspected (also refer also to an occupational health service)
  • if symptoms persist despite surgery (e.g. recurrent sinusitis or nasal polyps)
  • if there is parental concern that a child’s persistent symptoms are affecting sleep or school performance
  • there is chronic infective sinusitis lasting >3 months—this may indicate immune deficiency.

Conclusion

This updated guideline reinforces the need for an accurate diagnosis of allergic and non-allergic rhinitis as this will determine management choices. All GPs must be aware of red flag symptoms and also know when to refer appropriately to either ENT or allergy clinics. There is a clear socio-economic impact of untreated or poorly controlled rhinitis. The treatment choices place the onus on the patient to adhere and comply with recommended treatment. There is still limited evidence about what to do with pregnant women and more research around this could be helpful to those women who experience symptoms during pregnancy. There remains a lack of allergy specialists in the UK, which could impact on those with severe symptoms who might benefit from immunotherapy treatments.

Key points

  • Rhinitis can have a significant impact on an affected individual’s quality of life
  • Prevalence of rhinitis ranges from 10.1% to 15.3% in children and approximately 26% in adults
  • Symptoms of allergic rhinitis are caused by an IgE-mediated reaction to an allergen
  • Skin prick tests allow identification of triggers for allergic rhinitis
  • Non-allergic rhinitis can cause chronic symptoms with blockage particularly prominent
  • Occupational rhinitis is a key consideration when diagnosing rhinitis
  • Diagnosis and treatment of rhinitis in children is similar to that for adults
  • Immunotherapy is effective in treating perennial and seasonal allergic rhinitis
  • Patients must understand the importance of adherence to regular therapy for rhinitis rather than as-required use
  • The BSACI rhinitis guideline highlights red flag symptoms and when to refer.
BSACI=British Society for Allergy and Clinical Immunology

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GP commissioning take home messages for England

written by Dr David Jenner, GP, Cullumpton, Devon

  • Rhinitis is a common condition that can usually be managed in primary care
  • Treatment pathways and relevant pharmacotherapies (based on the BSACI guideline recommendations) can be built into clinical algorithms in local formularies:
    • these formularies can identify drugs with low acquisition cost, as many of the products are now available generically
  • The algorithms should also identify triggers for referral to specialist services, including red flag symptoms
  • Commissioners should ensure specialist allergy clinics are available so that patients can be referred for skin prick testing and possible desensitisation regimes, as in practice these are often not readily accessible.

BSACI=British Society for Allergy and Clinical Immunology

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Read the Guidelines summary of the BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis for more information on identifying and managing rhinitis

References

  1. Scadding G, Kariyawasam H, Scadding G et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised Edition 2017; first edition 2007). Clin Exp Allergy 2017; 47 (7): 856–889.
  2. Walker S, Durham S, Till S et al. BSACI guidelines for immunotherapy for allergic rhinitis. Clin Exp Allergy 2011; 41: 1177–1200.
  3. Tran N, Vickery J, Blaiss M. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res 2011; 3 (3): 148–156.
  4. Scadding G, Durham S, Mirakian R, Jones N. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38 (1): 19–42.