How should allergic salute be managed in children and adolescents with allergic rhinitis?

Management of Allergic Salute in Children and Adolescents with Allergic Rhinitis

The allergic salute—the characteristic upward rubbing of the nose—is managed by treating the underlying allergic rhinitis with intranasal corticosteroids as first-line therapy, combined with allergen avoidance and environmental control measures. 1

Understanding the Allergic Salute

The allergic salute is a physical manifestation of chronic nasal itching and congestion in children with allergic rhinitis. This repetitive upward rubbing gesture develops as children attempt to relieve nasal itching and open obstructed nasal passages. 2 The gesture itself is not treated directly; rather, effective management of the underlying allergic rhinitis eliminates the need for this behavior.

First-Line Pharmacologic Management

Intranasal corticosteroids represent the most effective treatment for eliminating the allergic salute by controlling the underlying nasal inflammation and itching. 1

• Start with once-daily intranasal corticosteroids (mometasone furoate, fluticasone propionate, or budesonide) for children 4 years and older with moderate-to-severe symptoms 1
• These medications effectively reduce eosinophilic inflammation and cytokine release during the late-phase allergic response, which drives the chronic nasal congestion and itching that prompts the salute behavior 3
• Continuous daily dosing is more effective than intermittent use for perennial symptoms due to ongoing allergen exposure 1

Add a second-generation oral antihistamine for comprehensive symptom control, particularly targeting the nasal itching that drives the salute behavior:

• Cetirizine 5-10 mg daily, loratadine, or desloratadine are appropriate choices 1
• Second-generation antihistamines are especially effective for histamine-mediated symptoms including itching, sneezing, and rhinorrhea, while avoiding the sedation and cognitive impairment of first-generation agents 1
• Nasal itching is the distinguishing feature that drives the allergic salute, making antihistamines particularly valuable 2

Environmental Control Strategy

Identify and minimize exposure to specific allergens through targeted environmental interventions: 1

• Perform skin prick testing or serum-specific IgE testing to identify relevant allergens in children with recurrent symptoms 1
• For dust mite sensitivity: use allergen-impermeable mattress and pillow covers, wash bedding weekly in hot water, reduce bedroom humidity 1
• For pet allergens: remove pets from the home or at minimum keep them out of the bedroom, use HEPA air filters 1
• For mold sensitivity: control indoor humidity below 50%, repair water leaks promptly, improve ventilation in bathrooms and kitchens 1

Treatment Initiation Timing

Initiate anti-inflammatory therapy before pollen season or before repetitive aeroallergen exposure to modify the late-phase response and prevent the priming effect that amplifies symptoms. 3 When allergen challenges occur repeatedly, the amount of allergen required to induce symptoms decreases, making preemptive treatment particularly effective. 3

Monitoring and Escalation

Evaluate treatment response after 2-4 weeks of continuous therapy: 1

• For partial improvement: increase the intranasal corticosteroid dose or add an intranasal antihistamine (azelastine or olopatadine) 1
• For minimal improvement: reassess the diagnosis, verify medication adherence and proper administration technique, and consider alternative diagnoses 1
• For persistent symptoms despite optimal medical therapy after 3-6 months: consider allergen immunotherapy (subcutaneous or sublingual), which provides disease-modifying effects including prevention of new allergen sensitivities and reduced progression to asthma 1

Critical Comorbidity Assessment

Evaluate for underlying asthma in children presenting with allergic salute and rhinitis symptoms, particularly if cough is present. 1 Treating allergic rhinitis with intranasal corticosteroids may reduce asthma symptoms and prevent asthma development. 1 The allergic salute often coexists with other physical findings including:

• Allergic shiners (dark circles under the eyes from venous pooling due to chronic nasal obstruction) 4
• Pale, edematous nasal mucosa on examination 4, 2
• Associated symptoms of sniffing, snorting, throat clearing, chronic mouth breathing, and sleep disturbances 4

Common Pitfalls to Avoid

• Do not assume the allergic salute will resolve without treating the underlying allergic rhinitis—the behavior is driven by persistent nasal itching and congestion that requires pharmacologic intervention 2
• Do not use first-generation antihistamines, as they cause drowsiness and impair cognitive functioning, which can further affect school performance already compromised by allergic rhinitis 3
• Do not rely solely on oral antihistamines for moderate-to-severe symptoms—intranasal corticosteroids are more effective for comprehensive symptom control including the nasal congestion component 1
• Do not order imaging studies for uncomplicated nasal congestion, as abnormal findings are common in healthy children and do not guide management 4