What is the likely diagnosis and first‑line management for an adult with nocturnal cough, itching of the eyes, palate and nose, and periorbital hyperpigmentation (allergic shiners)?

Allergic Rhinitis with Upper Airway Cough Syndrome

This patient has allergic rhinitis with upper airway cough syndrome (UACS), and the first-line treatment is a first-generation antihistamine/decongestant combination (e.g., chlorpheniramine with sustained-release pseudoephedrine) plus intranasal corticosteroids (fluticasone 100-200 mcg daily). 1, 2

Clinical Diagnosis

The constellation of nocturnal cough, itching of eyes/palate/nose, and periorbital hyperpigmentation ("allergic shiners") is pathognomonic for allergic rhinitis. 1

Key diagnostic features include:

• Itching triad: nose, palate, and eyes—this distinguishes allergic from non-allergic rhinitis 1
• Allergic shiners: blue-grey periorbital hyperpigmentation from venous stasis, present in 60% of atopic patients 1
• Nocturnal cough: gravity-driven drainage of nasal secretions into the hypopharynx irritates cough receptors when supine 2
• Cobblestoning of posterior pharynx (if present on exam) supports UACS 2

The diagnosis is clinical and does not require allergy testing initially—testing is reserved for patients who fail empiric treatment or when specific allergen identification is needed for immunotherapy. 1

First-Line Treatment Algorithm

Immediate Initiation (Day 1)

Start both medications simultaneously:

1. First-generation antihistamine/decongestant combination 2, 3

   • Dexbrompheniramine maleate plus sustained-release pseudoephedrine, OR
   • Azatadine maleate plus sustained-release pseudoephedrine, OR
   • Chlorpheniramine with sustained-release pseudoephedrine
   • Dosing strategy: Start once-daily at bedtime for 2-3 days to minimize sedation, then advance to twice-daily 2
   • Why first-generation? Older antihistamines have anticholinergic properties that reduce secretions; newer non-sedating antihistamines (cetirizine, loratadine) are ineffective for UACS 2, 3

2. Intranasal corticosteroid 1, 4

   • Fluticasone propionate 100-200 mcg (1-2 sprays) per nostril daily
   • Alternative options: mometasone, triamcinolone, or budesonide
   • Duration: Full 1-month trial required to assess response 2, 3
   • Intranasal steroids are the most effective monotherapy for allergic rhinitis and work synergistically with antihistamines 4, 5

Adjunctive Therapy

Add high-volume nasal saline irrigation (150 mL per nostril, twice daily) to mechanically remove allergens, improve mucociliary clearance, and reduce edema—more effective than saline spray. 2, 3

Expected Timeline and Monitoring

• Initial response: Most patients improve within days to 2 weeks 2, 3
• Complete resolution: May require several weeks to a few months 2
• Reassessment point: If no improvement after 2 weeks of adequate treatment, proceed to sequential evaluation for asthma/non-asthmatic eosinophilic bronchitis and GERD 2, 3

Critical Side Effects to Monitor

First-generation antihistamines: 2

• Common: dry mouth, transient dizziness
• Serious: insomnia, urinary retention, jitteriness, tachycardia

Decongestants: 2, 3

• Monitor blood pressure—can worsen hypertension
• Avoid in uncontrolled hypertension, coronary artery disease, or glaucoma
• Can cause palpitations and insomnia

Intranasal corticosteroids: 4

• Minimal systemic absorption
• Local effects: epistaxis (rare), nasal dryness

Common Pitfalls to Avoid

1. Do not use second-generation antihistamines alone for UACS—cetirizine, fexofenadine, and loratadine lack the anticholinergic drying effects needed for postnasal drip 2, 3, 6

2. Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 days—causes rhinitis medicamentosa (rebound congestion) 2, 3

3. Do not overlook "silent" UACS—approximately 20% of patients have no obvious postnasal drip symptoms but still respond to treatment 2, 3

4. Do not stop partially effective treatments prematurely—UACS, asthma, and GERD account for 90% of chronic cough and often coexist; maintain all therapies that provide partial benefit 2

5. Do not confuse GERD with UACS—both cause throat irritation and cough that worsens when supine; if symptoms persist after 2 weeks of upper airway treatment, add empiric PPI therapy (omeprazole 20-40 mg twice daily before meals for 8 weeks) 2, 3

When to Escalate

If cough persists after 2 weeks of combined therapy: 2, 3

1. Add ipratropium bromide nasal spray (42 mcg per spray, 2 sprays per nostril 4 times daily) for additional anticholinergic drying 2, 3

2. Consider intranasal antihistamine (azelastine or olopatadine) added to the intranasal corticosteroid for rapid-onset relief 3

3. Obtain sinus imaging (CT) if purulent discharge, facial pain, or fever suggest bacterial sinusitis 2

4. Evaluate for asthma/cough-variant asthma—consider bronchoprovocation testing or empiric inhaled corticosteroid trial 2

5. Treat GERD empirically if clinical profile suggests reflux (cough after meals, throat clearing, hoarseness) 2, 3

Allergy Testing Indications

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

• Patient fails to respond to empiric treatment after 2-4 weeks
• Diagnosis remains uncertain
• Knowledge of specific allergen is needed to target avoidance strategies or immunotherapy
• Patient requests confirmatory testing before initiating long-term therapy