What are the diagnostic criteria and treatment options for allergic rhinitis?

Diagnostic Criteria for Allergic Rhinitis

Allergic rhinitis is diagnosed clinically when patients present with one or more of the following symptoms—nasal congestion, runny nose, itchy nose, or sneezing—combined with a history of symptoms after allergen exposure, and confirmed by positive specific IgE testing (skin or blood) when the diagnosis is uncertain or empiric treatment fails. 1

Clinical Diagnosis

The diagnosis relies on three key components that must align:

• Symptom presentation: At least one of the cardinal symptoms must be present: nasal congestion, rhinorrhea, nasal itching, or sneezing 1, 2
• History of allergen exposure: Symptoms must correlate temporally with exposure to suspected allergens 1
• Physical examination findings: Look for clear rhinorrhea, pale/edematous nasal mucosa (especially in seasonal allergic rhinitis), red and watery eyes, nasal crease, dark circles under eyes (allergic shiners), or nasal/eye rubbing 1, 3

Key Historical Features to Elicit

When taking the history, document these specific elements 1:

• Temporal pattern: Seasonal (pollens), perennial (dust mites, pets), or episodic (intermittent exposures) 1
• Symptom characteristics: Pruritus and sneezing strongly suggest allergic rather than nonallergic rhinitis 1
• Age of onset: Allergic rhinitis typically begins before age 20 years 1
• Triggers: Specific allergen exposures, irritants, weather changes, geographic/environmental location 1
• Associated conditions: Asthma, atopic dermatitis, conjunctivitis, rhinosinusitis, otitis media 1

Important Diagnostic Pitfalls

• Isolated postnasal drainage is less likely to be allergic rhinitis 1
• Unilateral symptoms suggest structural problems (polyp, foreign body, septal deformity, tumor) rather than allergic rhinitis 1
• Positive skin tests without symptom correlation indicate the patient likely has nonallergic rhinitis, not allergic rhinitis 1
• Mucosal appearance alone cannot distinguish allergic from nonallergic rhinitis, as both can present with pale, edematous, or hyperemic mucosa 1

Confirmatory Testing

Specific IgE testing (preferably skin testing) should be performed when patients fail empiric treatment, when diagnosis is uncertain, or when knowledge of specific allergens is needed to guide avoidance or immunotherapy. 1

Skin Testing vs. In Vitro Testing

• Skin prick/puncture tests are the preferred diagnostic method due to simplicity, rapid results, low cost, and high sensitivity 1
• In vitro specific IgE tests (serum testing) have approximately 70-75% sensitivity compared to skin testing 1
• Indications for in vitro testing over skin testing: Widespread skin disease (severe eczema, dermatographism), inability to discontinue antihistamines, uncooperative patient, or unusually high anaphylaxis risk 1

Testing Interpretation

• Positive specific IgE must correlate with clinical symptoms to confirm allergic rhinitis 1
• Negative skin tests or negative in vitro IgE tests indicate nonallergic rhinitis, especially with poor allergen-symptom correlation 1
• Select allergens for testing based on patient age, geographic location, and environmental exposures 1

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Treatment Algorithm for Allergic Rhinitis

First-Line Pharmacotherapy

Intranasal corticosteroids are the most effective first-line treatment for persistent moderate-to-severe allergic rhinitis and should be used alone or combined with intranasal antihistamines. 2, 3

Treatment Selection Based on Severity

For mild intermittent or mild persistent allergic rhinitis:

• Second-generation oral H1 antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) 2
• OR intranasal antihistamines (azelastine, olopatadine) 1, 2

For persistent moderate-to-severe allergic rhinitis:

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) as monotherapy or combined with intranasal antihistamines 2, 3

Medication-Specific Considerations

Antihistamines:

• Second-generation antihistamines are strongly preferred over first-generation agents due to reduced sedation, performance impairment, and anticholinergic effects 1
• Effective for rhinorrhea, sneezing, and itching but have minimal effect on nasal congestion 1
• Continuous treatment is more effective than intermittent use for seasonal/perennial rhinitis 1
• Intranasal antihistamines may cause sedation or bitter taste in some patients 1

Intranasal corticosteroids:

• Maximum benefit may take several days to achieve; some patients note improvement within 12 hours 4
• Fluticasone propionate has <2% absolute bioavailability via intranasal route, minimizing systemic effects 4
• Common adverse effects (>3%): headache, pharyngitis, epistaxis, nasal burning/irritation 4

Leukotriene receptor antagonists:

• Should NOT be offered as primary monotherapy for allergic rhinitis 1
• May be used in combination with antihistamines (additive effect), but this combination is generally less efficacious than intranasal corticosteroids 1

Decongestants:

• Oral decongestants (pseudoephedrine, phenylephrine) reduce nasal congestion but can cause insomnia, appetite loss, irritability, palpitations 1
• Chronic use of topical decongestant sprays causes rhinitis medicamentosa and should be avoided 1

Combination Therapy

Offer combination pharmacologic therapy when monotherapy provides inadequate symptom control. 1

Allergen Avoidance

Allergen avoidance is fundamental to successful management but specific measures have variable evidence 1:

• Advise avoidance of identified allergens that correlate with clinical symptoms 1
• Environmental controls (pet removal, air filtration, bed covers, acaricides) may be offered but have limited proven efficacy 1
• HEPA filters are not effective at decreasing allergy symptoms 3
• Dust mite-proof mattress covers do not prevent allergic rhinitis in children ≤2 years 3

Immunotherapy

Allergen immunotherapy (subcutaneous or sublingual) should be offered to patients with inadequate response to pharmacotherapy with or without environmental controls. 1

• Effective for allergic rhinitis and allergic rhinoconjunctivitis with significant improvement in symptoms, medication scores, and quality of life 1
• Requires demonstrable specific IgE antibodies to clinically relevant allergens 1
• Decision depends on degree of symptom control with avoidance/medications, medication burden, adverse medication effects, symptom severity/duration, and quality of life impact 1

Surgical Intervention

Inferior turbinate reduction may be offered to patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. 1

Corticosteroid Use Cautions

• Short courses of oral corticosteroids may be appropriate for intractable symptoms or severe nasal polyposis 1
• Chronic oral or parenteral corticosteroids are inappropriate for allergic rhinitis 1
• If recommended intranasal doses are exceeded or patients are particularly sensitive, hypercorticism (Cushing syndrome) could occur 4

Alternative Therapies

Acupuncture may be offered to patients interested in nonpharmacologic therapy 1

Assessment of Comorbidities

Document presence of associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, as these require concurrent management 1