Is treatment necessary for rhinitis?

Treatment of Rhinitis: A Clinical Decision Algorithm

Treatment is necessary for rhinitis when symptoms impact quality of life, interfere with daily functioning, or when complications are present. 1

Types of Rhinitis and Treatment Approach

Allergic Rhinitis

Allergic rhinitis affects 10-30% of adults and up to 40% of children 1, 2, presenting with:

• Nasal congestion
• Rhinorrhea (runny nose)
• Sneezing
• Itching of eyes, nose, and throat

Treatment Algorithm for Allergic Rhinitis:

1. Mild Intermittent or Mild Persistent Symptoms:

   • First-line: Second-generation H1 antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) OR intranasal antihistamines (azelastine, olopatadine) 2
   • Allergen avoidance measures should be implemented concurrently 1

2. Moderate to Severe Persistent Symptoms:

   • First-line: Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) 2
   • Can be used alone or in combination with intranasal antihistamines for enhanced efficacy 1
   • Intranasal corticosteroids are more effective for nasal congestion than antihistamines 3

Nonallergic Rhinitis

Presents primarily with nasal congestion and postnasal drainage, often with sinus pressure and ear symptoms 2.

Treatment Algorithm for Nonallergic Rhinitis:

1. Vasomotor Rhinitis:

   • First-line: Intranasal corticosteroids and intranasal antihistamines 1
   • Avoiding triggering irritants is crucial 1

2. Rhinitis with Predominant Rhinorrhea (e.g., gustatory rhinitis):

   • First-line: Intranasal anticholinergics (ipratropium bromide) 1, 4
   • Note: Oral nonsedating antihistamines are NOT effective for nonallergic rhinitis 1

3. Rhinitis Medicamentosa (rebound congestion from decongestant overuse):

   • Discontinuation of nasal decongestant sprays
   • Treatment with intranasal or systemic corticosteroids 1

4. Infectious Rhinitis:

   • Supportive measures to relieve ostiomeatal obstruction
   • Judicious use of antibiotics only for suspected bacterial sinusitis 1

When to Refer to a Specialist

Consultation with an allergist/immunologist is appropriate when:

1. Symptoms persist despite appropriate treatment
2. Complications develop (otitis media, sinusitis, nasal polyposis)
3. Comorbid conditions exist (asthma, chronic sinusitis)
4. Systemic corticosteroids have been required
5. Symptoms significantly decrease quality of life
6. Treatment produces adverse events
7. Allergic triggers need further identification 1

Important Considerations and Pitfalls

• Avoid overuse of decongestants: Topical decongestants should be limited to short-term use (<7 days) to prevent rhinitis medicamentosa 1, 3
• Antibiotic use caution: For suspected bacterial rhinosinusitis, antibiotics should be reserved for symptoms lasting 10-14 days or severe symptoms with fever, purulent discharge, and facial pain 1, 5
• Monitor for side effects: When using intranasal corticosteroids, monitor for local side effects. Systemic effects are rare at recommended doses 6
• Growth concerns in children: Monitor growth in pediatric patients receiving intranasal corticosteroids 6
• Medication selection: Choose medications based on predominant symptoms - antihistamines are better for sneezing and itching, while intranasal corticosteroids are superior for congestion 3

Assessing Treatment Response

Evaluate:

• Nasal symptoms (congestion, itching, rhinorrhea)
• Physical signs (edema of nasal turbinates)
• Quality of life indicators (sleep quality, ability to function at work/school)
• Impact on comorbid conditions (especially asthma) 1

Treatment should be adjusted based on response, with follow-up to ensure continued symptom control and absence of medication side effects.