What is the diagnosis and treatment for frequent runny nose and sneezing, suspected to be allergic rhinitis?

Diagnosis and Treatment of Frequent Runny Nose and Sneezing

Clinical Diagnosis

Make the clinical diagnosis of allergic rhinitis when the patient presents with runny nose and sneezing, particularly if accompanied by nasal congestion, itchy nose, or red watery eyes, and findings consistent with an allergic cause on physical examination. 1

Key Diagnostic Features

History findings that strongly suggest allergic rhinitis include: 1

• Pruritus (itching) and sneezing are much more common in allergic than nonallergic rhinitis
• Seasonal exacerbations of symptoms
• Symptom onset typically before age 20 years
• Associated ocular symptoms (red, watery eyes)
• Family history of allergic rhinitis, asthma, or atopic dermatitis

Physical examination findings consistent with allergic rhinitis include: 1

• Clear rhinorrhea
• Pale discoloration of the nasal mucosa
• Nasal congestion
• Red and watery eyes

Important caveat: Mucosal appearance alone cannot definitively distinguish allergic from nonallergic rhinitis, as both may present with mucosal pallor, edema, or hyperemia. 1

When to Perform Allergy Testing

Perform or refer for specific IgE testing (skin or blood) when: 1

• The patient does not respond to empiric treatment
• The diagnosis is uncertain
• Knowledge of the specific causative allergen is needed to target therapy

Do not routinely perform sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1

Treatment Algorithm

For Patients with Primary Complaints of Sneezing and Runny Nose

Recommend oral second-generation/less sedating antihistamines as first-line therapy (such as cetirizine, fexofenadine, desloratadine, or loratadine). 1, 2

• Second-generation antihistamines are generally effective in reducing rhinorrhea, sneezing, and itching 1
• They are preferred over first-generation antihistamines because they have less risk of sedation, performance impairment, and anticholinergic effects 1
• Continuous treatment is more effective than intermittent use for ongoing allergen exposure 1

For Patients with Symptoms Affecting Quality of Life

Recommend intranasal corticosteroids (such as fluticasone, triamcinolone, budesonide, or mometasone) for patients whose symptoms affect their quality of life. 1, 3

• Intranasal corticosteroids are typically the most effective medication class for controlling all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1
• They are particularly useful for more severe allergic rhinitis 1
• When given in recommended doses, they are not generally associated with clinically significant systemic side effects 1
• Critical instruction: Direct patients to spray away from the nasal septum to minimize local side effects like nasal irritation and bleeding 1

For Moderate to Severe Persistent Allergic Rhinitis

Initiate treatment with an intranasal corticosteroid either alone or in combination with an intranasal antihistamine (such as azelastine or olopatadine). 4

• Intranasal corticosteroids may be considered for initial treatment without a previous trial of antihistamines 1
• Combination therapy with intranasal antihistamine and nasal steroid provides greater symptomatic relief than monotherapy 5

When First-Line Therapy Fails

Offer combination pharmacologic therapy in patients with inadequate response to monotherapy. 1

Offer or refer for immunotherapy (sublingual or subcutaneous) for patients who have inadequate response to pharmacologic therapy. 1

Important Caveats and Pitfalls

Medications to Avoid

Do not offer oral leukotriene receptor antagonists as primary therapy for allergic rhinitis. 1

• While LTRAs can be useful, they are generally less efficacious than intranasal corticosteroids 1

Avoid topical decongestants for more than 3 days to prevent rhinitis medicamentosa (rebound congestion). 1

• Some patients may develop rhinitis medicamentosa in as few as 3 days of regular use 1

Avoid chronic use of oral or parenteral corticosteroids for allergic rhinitis. 1

• Short courses (5-7 days) may be appropriate for intractable symptoms, but recurrent administration of parenteral corticosteroids is contraindicated 1

Assess for Comorbidities

Assess and document the presence of associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1

Environmental Controls

Advise avoidance of known allergens or environmental controls (removal of pets, air filtration systems, bed covers, acaricides) when specific allergens correlating with clinical symptoms have been identified. 1