Allergic rhinitis, of which the seasonal type is called hay fever, is a type of
inflammation in the nose that occurs when the
immune system
The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splint ...
overreacts to
allergen
An allergen is a type of antigen that produces an abnormally vigorous immune response in which the immune system fights off a perceived threat that would otherwise be harmless to the body. Such reactions are called allergies.
In technical terms ...
s in the air.
Signs and symptoms include a runny or stuffy nose,
sneezing
A sneeze (also known as sternutation) is a semi-autonomous, convulsive expulsion of air from the lungs through the nose and mouth, usually caused by foreign particles irritating the nasal mucosa. A sneeze expels air forcibly from the mouth and ...
, red, itchy, and watery eyes, and swelling around the eyes.
The fluid from the nose is usually clear.
[ Symptom onset is often within minutes following allergen exposure, and can affect sleep and the ability to work or study.][ Some people may develop symptoms only during specific times of the year, often as a result of pollen exposure.][ Many people with allergic rhinitis also have ]asthma
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
, allergic conjunctivitis
Allergic conjunctivitis (AC) is inflammation of the conjunctiva (the membrane covering the white part of the eye) due to allergy. Although allergens differ among patients, the most common cause is hay fever. Symptoms consist of redness (mainly due ...
, or atopic dermatitis.
Allergic rhinitis is typically triggered by environmental allergens such as pollen, pet hair, dust, or mold
A mold () or mould () is one of the structures certain fungi can form. The dust-like, colored appearance of molds is due to the formation of spores containing fungal secondary metabolites. The spores are the dispersal units of the fungi. Not ...
.[ Inherited ]genetics
Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinian friar wor ...
and environmental exposures contribute to the development of allergies. Growing up on a farm and having multiple siblings decreases this risk.[ The underlying mechanism involves ]IgE antibodies
Immunoglobulin E (IgE) is a type of antibody (or immunoglobulin (Ig) " isotype") that has been found only in mammals. IgE is synthesised by plasma cells. Monomers of IgE consist of two heavy chains (ε chain) and two light chains, with the ...
that attach to an allergen, and subsequently result in the release of inflammatory chemicals such as histamine
Histamine is an organic nitrogenous compound involved in local immune responses, as well as regulating physiological functions in the gut and acting as a neurotransmitter for the brain, spinal cord, and uterus. Since histamine was discovered ...
from mast cells
A mast cell (also known as a mastocyte or a labrocyte) is a resident cell of connective tissue that contains many granules rich in histamine and heparin. Specifically, it is a type of granulocyte derived from the myeloid stem cell that is a ...
.[ It causes mucous membranes in the nose, eyes and throat to become inflamed and itchy as they work to eject the allergen. Diagnosis is typically based on a combination of symptoms and a ]skin prick test
Skin allergy testing comprises a range of methods for medical diagnosis of allergies that attempts to provoke a small, controlled, allergic response.
Methods
A microscopic amount of an allergen is introduced to a patient's skin by various mean ...
or blood tests for allergen-specific IgE antibodies. These tests, however, can be falsely positive. The symptoms of allergies resemble those of the common cold; however, they often last for more than two weeks and, despite the common name, typically do not include a fever
Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using val ...
.[
Exposure to animals early in life might reduce the risk of developing these specific allergies.][ Several different types of medications reduce allergic symptoms, including nasal steroids, ]antihistamine
Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provid ...
s, such as diphenhydramine
Diphenhydramine (DPH) is an antihistamine and sedative mainly used to treat allergies, insomnia, and symptoms of the common cold. It is also less commonly used for tremor in parkinsonism, and nausea. It is taken by mouth, injected into ...
, cromolyn sodium
Cromoglicic acid (INN)—also referred to as cromolyn (USAN), cromoglycate (former BAN), or cromoglicate—is traditionally described as a mast cell stabilizer, and is commonly marketed as the sodium salt sodium cromoglicate or cromolyn sodium. ...
, and leukotriene receptor antagonists
An antileukotriene, also known as leukotriene modifier and leukotriene receptor antagonist, is a medication which functions as a leukotriene-related enzyme inhibitor (arachidonate 5-lipoxygenase) or leukotriene receptor antagonist (cysteinyl leukot ...
such as montelukast
Montelukast, sold under the brand name Singulair among others, is a medication used in the maintenance treatment of asthma. It is generally less preferred for this use than inhaled corticosteroids. It is not useful for acute asthma attacks. Ot ...
. Oftentimes, medications do not completely control symptoms, and they may also have side effects.[ Exposing people to larger and larger amounts of allergen, known as ]allergen immunotherapy
Allergen immunotherapy, also known as desensitization or hypo-sensitization, is a medical treatment for environmental allergies, such as insect bites, and asthma. Immunotherapy involves exposing people to larger and larger amounts of allergen in ...
(AIT), is often effective. The allergen can be given as an injection under the skin or as a tablet under the tongue.[ Treatment typically lasts three to five years, after which benefits may be prolonged.][
Allergic rhinitis is the type of ]allergy
Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derm ...
that affects the greatest number of people.[ In Western countries, between 10 and 30% of people are affected in a given year.] It is most common between the ages of twenty and forty.[ The first accurate description is from the 10th-century physician ]Abu Bakr al-Razi
Abū Bakr al-Rāzī (full name: ar, أبو بکر محمد بن زکریاء الرازي, translit=Abū Bakr Muḥammad ibn Zakariyyāʾ al-Rāzī, label=none), () rather than ar, زکریاء, label=none (), as for example in , or in . In m ...
. In 1859, Charles Blackley
Charles Harrison Blackley (5 April 1820 – 4 September 1900) was the discoverer of the mechanism behind allergic rhinitis caused by pollen, commonly called hay fever. The isolation of hay fever as a condition had been known since 1819 through t ...
identified pollen as the cause. In 1906, the mechanism was determined by Clemens von Pirquet
Clemens Peter Freiherr von Pirquet (12 May 187428 February 1929) was an Austrian scientist and pediatrician best known for his contributions to the fields of bacteriology and immunology.
Career
Born in Vienna, he studied theology at the Universit ...
. The link with hay
Hay is grass, legumes, or other herbaceous plants that have been cut and dried to be stored for use as animal fodder, either for large grazing animals raised as livestock, such as cattle, horses, goats, and sheep, or for smaller domesticat ...
came about due to an early (and incorrect) theory that the symptoms were brought about by the smell of new hay. Although the scent per se is irrelevant, the correlation with hay remains more than random, as peak hay-harvesting season overlaps with peak pollen season, and hay-harvesting work puts people in close contact with seasonal allergens.
Signs and symptoms
The characteristic symptoms of allergic rhinitis are: rhinorrhea
Rhinorrhea, rhinorrhoea, or informally runny nose is the free discharge of a thin mucus fluid from the nose; it is a common condition. It is a common symptom of allergies ( hay fever) or certain viral infections, such as the common cold or CO ...
(excess nasal secretion), itching
Itch (also known as pruritus) is a Wikt:sensation, sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of Sensory system, sensory experience. Itch has many similarities to pain, ...
, sneezing fits, and nasal congestion and obstruction.[ Characteristic physical findings include ]conjunctiva
The conjunctiva is a thin mucous membrane that lines the inside of the eyelids and covers the sclera (the white of the eye). It is composed of non-keratinized, stratified squamous epithelium with goblet cells, stratified columnar epithelium ...
l swelling and erythema
Erythema (from the Greek , meaning red) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not asso ...
, eyelid swelling with Dennie–Morgan fold
A Dennie–Morgan fold, also known as a Dennie–Morgan line or an infraorbital fold, is a fold or line in the skin below the lower eyelid. It can simply be an ethnic/genetic trait, but was found in one study to occur in 25% of patients with atopic ...
s, lower eyelid venous stasis (rings under the eyes known as " allergic shiners"), swollen nasal turbinates
In anatomy, a nasal concha (), plural conchae (), also called a nasal turbinate or turbinal, is a long, narrow, curled shelf of bone tissue, bone that protrudes into the breathing passage of the nose in humans and various animals. The conchae ar ...
, and middle ear effusion.
There can also be behavioral signs; in order to relieve the irritation or flow of mucus, people may wipe or rub their nose with the palm of their hand in an upward motion: an action known as the "nasal salute" or the " allergic salute". This may result in a crease running across the nose (or above each nostril if only one side of the nose is wiped at a time), commonly referred to as the " transverse nasal crease", and can lead to permanent physical deformity if repeated enough.
People might also find that cross-reactivity
Cross-reactivity, in a general sense, is the reactivity of an observed agent which initiates reactions outside the main reaction expected. This has implications for any kind of test or assay, including diagnostic tests in medicine, and can be a c ...
occurs. For example, people allergic to birch pollen may also find that they have an allergic reaction to the skin of apples or potatoes. A clear sign of this is the occurrence of an itchy throat after eating an apple or sneezing when peeling potatoes or apples. This occurs because of similarities in the proteins of the pollen and the food. There are many cross-reacting substances. Hay fever is not a true fever, meaning it does not cause a core body temperature in the fever over 37.5–38.3 °C (99.5–100.9 °F).
Cause
Pollen is often considered as a cause of allergic rhinitis, hence called hay fever (See sub-section below).
Predisposing factors to allergic rhinitis include eczema (atopic dermatitis) and asthma. These three conditions can often occur together which is referred to as the atopic triad. Additionally, environmental exposures such as air pollution and maternal tobacco smoking can increase an individual's chances of developing allergies.
Pollen-related causes
Allergic rhinitis triggered by the pollens of specific seasonal plants is commonly known as "hay fever", because it is most prevalent during hay
Hay is grass, legumes, or other herbaceous plants that have been cut and dried to be stored for use as animal fodder, either for large grazing animals raised as livestock, such as cattle, horses, goats, and sheep, or for smaller domesticat ...
ing season. However, it is possible to have allergic rhinitis throughout the year. The pollen that causes hay fever varies between individuals and from region to region; in general, the tiny, hardly visible pollens of wind-pollinated
Anemophily or wind pollination is a form of pollination whereby pollen is distributed by wind. Almost all gymnosperms are anemophilous, as are many plants in the order Poales, including grasses, sedges, and rushes. Other common anemophilous pla ...
plant
Plants are predominantly photosynthetic eukaryotes of the kingdom Plantae. Historically, the plant kingdom encompassed all living things that were not animals, and included algae and fungi; however, all current definitions of Plantae exclu ...
s are the predominant cause. Pollens of insect-pollinated
Entomophily or insect pollination is a form of pollination whereby pollen of plants, especially but not only of flowering plants, is distributed by insects. Flowers pollinated by insects typically advertise themselves with bright colours, som ...
plants are too large to remain airborne and pose no risk. Examples of plants commonly responsible for hay fever include:
* Trees: such as pine (''Pinus
A pine is any conifer tree or shrub in the genus ''Pinus'' () of the family Pinaceae. ''Pinus'' is the sole genus in the subfamily Pinoideae. The World Flora Online created by the Royal Botanic Gardens, Kew and Missouri Botanical Garden ...
''), mulberry ('' Morus''), birch (''Betula
A birch is a thin-leaved deciduous hardwood tree of the genus ''Betula'' (), in the family Betulaceae, which also includes alders, hazels, and hornbeams. It is closely related to the beech- oak family Fagaceae. The genus ''Betula'' contains 30 t ...
''), alder (''Alnus
Alders are trees comprising the genus ''Alnus'' in the birch family Betulaceae. The genus comprises about 35 species of monoecious trees and shrubs, a few reaching a large size, distributed throughout the north temperate zone with a few sp ...
''), cedar (''Cedrus
''Cedrus'', common English name cedar, is a genus of coniferous trees in the plant family Pinaceae (subfamily Abietoideae). They are native to the mountains of the western Himalayas and the Mediterranean region, occurring at altitudes of 1,500 ...
''), hazel (''Corylus
The hazel (''Corylus'') is a genus of deciduous trees and large shrubs native to the temperate Northern Hemisphere. The genus is usually placed in the birch family Betulaceae,Germplasmgobills Information Network''Corylus''Rushforth, K. (1999). ...
''), hornbeam (''Carpinus
Hornbeams are hardwood trees in the flowering plant genus ''Carpinus'' in the birch family Betulaceae. The 30–40 species occur across much of the temperate regions of the Northern Hemisphere.
Origin of names
The common English name ''hornbea ...
''), horse chestnut (''Aesculus
The genus ''Aesculus'' ( or ), with species called buckeye and horse chestnut, comprises 13–19 species of flowering plants in the family Sapindaceae. They are trees and shrubs native to the temperate Northern Hemisphere, with six spe ...
''), willow (''Salix
Willows, also called sallows and osiers, from the genus ''Salix'', comprise around 400 speciesMabberley, D.J. 1997. The Plant Book, Cambridge University Press #2: Cambridge. of typically deciduous trees and shrubs, found primarily on moist s ...
''), poplar ('' Populus''), plane (''Platanus
''Platanus'' is a genus consisting of a small number of tree species native to the Northern Hemisphere. They are the sole living members of the family Platanaceae.
All mature members of ''Platanus'' are tall, reaching in height. All except ...
''), linden/lime ('' Tilia''), and olive (''Olea
''Olea'' ( ) is a genus of about 40 species in the family Oleaceae, native to warm temperate and tropical regions of the Middle East, southern Europe, Africa, southern Asia, and Australasia. They are evergreen trees and shrubs, with small ...
''). In northern latitudes, birch is considered to be the most common allergenic tree pollen, with an estimated 15–20% of people with hay fever sensitive to birch pollen grains. A major antigen in these is a protein called Bet V I. Olive pollen is most predominant in Mediterranean regions. Hay fever in Japan
is most commonly caused by pollen from ''Cryptomeria japonica'' (known as ''sugi'' in Japanese and often translated as "cedar" though it is not a member of the Cedrus genus) and Japanese cypress (known as ''hinoki''), two native Japanese tree sp ...
is caused primarily by sugi
''Cryptomeria'' (literally "hidden parts") is a monotypic genus of conifer in the cypress family Cupressaceae, formerly belonging to the family Taxodiaceae. It includes only one species, ''Cryptomeria japonica'' ( syn. ''Cupressus japonica'' ...
(''Cryptomeria japonica'') and hinoki
''Chamaecyparis obtusa'' (Japanese cypress, hinoki cypress or hinoki; ja, 檜 or , ) is a species of cypress native to central Japan in East Asia, and widely cultivated in the temperate northern hemisphere for its high-quality timber and orname ...
(''Chamaecyparis obtusa'') tree pollen.
** "Allergy friendly" trees include: female ash, red maple
''Acer'' () is a genus of trees and shrubs commonly known as maples. The genus is placed in the family Sapindaceae.Stevens, P. F. (2001 onwards). Angiosperm Phylogeny Website. Version 9, June 2008 nd more or less continuously updated since http ...
, yellow poplar
''Liriodendron tulipifera''—known as the tulip tree, American tulip tree, tulipwood, tuliptree, tulip poplar, whitewood, fiddletree, and yellow-poplar—is the North American representative of the two-species genus ''Liriodendron'' (the other ...
, dogwood
''Cornus'' is a genus of about 30–60 species of woody plants in the family Cornaceae, commonly known as dogwoods, which can generally be distinguished by their blossoms, berries, and distinctive bark. Most are deciduous trees or shru ...
, magnolia
''Magnolia'' is a large genus of about 210 to 340The number of species in the genus ''Magnolia'' depends on the taxonomic view that one takes up. Recent molecular and morphological research shows that former genera ''Talauma'', ''Dugandiodendro ...
, double-flowered
"Double-flowered" describes varieties of flowers with extra petals, often containing flowers within flowers. The double-flowered trait is often noted alongside the scientific name with the abbreviation ''fl. pl.'' (''flore pleno'', a Latin ablat ...
cherry, fir, spruce, and flowering plum.
* Grasses (Family Poaceae): especially ryegrass ('' Lolium'' sp.) and timothy (''Phleum pratense
Timothy (''Phleum pratense'') is an abundant perennial grass native to most of Europe except for the Mediterranean region. It is also known as timothy-grass, meadow cat's-tail or common cat's tail. It is a member of the genus ''Phleum'', consis ...
''). An estimated 90% of people with hay fever are allergic to grass pollen.
* Weeds: ragweed
Ragweeds are flowering plants in the genus ''Ambrosia'' in the aster family, Asteraceae. They are distributed in the tropical and subtropical regions of the Americas, especially North America,[Plantago
''Plantago'' is a genus of about 200 species of flowering plants in the family Plantaginaceae, commonly called plantains or fleaworts. The common name plantain is shared with the unrelated cooking plantain. Most are herbaceous plants, though ...]
''), nettle/parietaria (Urticaceae
The Urticaceae are a family, the nettle family, of flowering plants. The family name comes from the genus ''Urtica''. The Urticaceae include a number of well-known and useful plants, including nettles in the genus ''Urtica'', ramie (''Boehmeri ...
), mugwort
Mugwort is a common name for several species of aromatic flowering plants in the genus '' Artemisia.'' In Europe, mugwort most often refers to the species ''Artemisia vulgaris'', or common mugwort. In East Asia the species ''Artemisia argyi'' is ...
(''Artemisia Vulgaris''), Fat hen (''Chenopodium
''Chenopodium'' is a genus of numerous species of perennial or annual herbaceous flowering plants known as the goosefoots, which occur almost anywhere in the world. It is placed in the family Amaranthaceae in the APG II system; older classific ...
''), and sorrel/dock ('' Rumex'')
Allergic rhinitis may also be caused by allergy to Balsam of Peru
Balsam of Peru or Peru balsam, also known and marketed by many other names, is a balsam derived from a tree known as ''Myroxylon balsamum'' var. ''pereirae''; it is found in El Salvador, where it is an endemic species.
Balsam of Peru is used i ...
, which is in various fragrances and other products.
Genetic factors
The causes and pathogenesis of allergic rhinitis are hypothesized to be affected by both genetic and environmental factors, with many recent studies focusing on specific loci that could be potential therapeutic targets for the disease. Genome-wide association studies
In genomics, a genome-wide association study (GWA study, or GWAS), also known as whole genome association study (WGA study, or WGAS), is an observational study of a genome-wide set of genetic variants in different individuals to see if any varian ...
(GWAS) have identified a number of different loci and genetic pathways that seem to mediate the body's response to allergens and promote the development of allergic rhinitis, with some of the most promising results coming from studies involving single-nucleotide polymorphisms
In genetics, a single-nucleotide polymorphism (SNP ; plural SNPs ) is a germline substitution of a single nucleotide at a specific position in the genome. Although certain definitions require the substitution to be present in a sufficiently larg ...
(SNPs) in the interleukin-33
Interleukin 33 (IL-33) is a protein that in humans is encoded by the ''IL33'' gene.
Interleukin 33 is a member of the IL-1 family that potently drives production of T helper-2 (Th2)-associated cytokines (e.g., IL-4). IL33 is a ligand for ST2 ...
(IL-33) gene. The IL-33 protein that is encoded by the IL-33 gene is part of the interleukin family of cytokines that interact with T-helper 2 (Th2) cells, a specific type of T cell
A T cell is a type of lymphocyte. T cells are one of the important white blood cells of the immune system and play a central role in the adaptive immune response. T cells can be distinguished from other lymphocytes by the presence of a T-cell r ...
. Th2 cells contribute to the body's inflammatory response to allergens, and specific ST2 receptors, also known as IL1RL1
Interleukin 1 receptor-like 1, also known as IL1RL1 and ST2, is a protein that in humans is encoded by the ''IL1RL1'' gene.
Function
IL1RL1 is a member of the Toll-like receptor superfamily based on the function of its intracellular TIR domain ...
, on these cells bind to the ligand IL-33 protein. This IL-33/ST2 signaling pathway has been found to be one of the main genetic determinants in bronchial asthma
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
pathogenesis, and because of the pathological linkage between asthma and rhinitis, the experimental focus of IL-33 has now turned to its role in the development of allergic rhinitis in humans and mouse models
A model is an informative representation of an object, person or system. The term originally denoted the plans of a building in late 16th-century English, and derived via French and Italian ultimately from Latin ''modulus'', a measure.
Models c ...
. Recently, it was found that allergic rhinitis patients expressed higher levels of IL-33 in their nasal epithelium and had a higher concentration of ST2 serum in nasal passageways following their exposure to pollen and other allergens, indicating that this gene and its associated receptor are expressed at a higher rate in allergic rhinitis patients. In a 2020 study on polymorphisms of the IL-33 gene and their link to allergic rhinitis within the Han Chinese population, researchers found that five SNPs specifically contributed to the pathogenesis of allergic rhinitis, with three of those five SNPs previously identified as genetic determinants for asthma.
Another study focusing on Han Chinese children found that certain SNPs in the protein tyrosine phosphatase non-receptor 22 ( PTPN22) gene and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4
CTLA-4 or CTLA4 (cytotoxic T-lymphocyte-associated protein 4), also known as CD152 ( cluster of differentiation 152), is a protein receptor that functions as an immune checkpoint and downregulates immune responses. CTLA-4 is constitutively exp ...
) gene can be associated with childhood allergic rhinitis and allergic asthma. The encoded PTPN22 protein, which is found primarily in lymphoid
The lymphatic system, or lymphoid system, is an organ system in vertebrates that is part of the immune system, and complementary to the circulatory system. It consists of a large network of lymphatic vessels, lymph nodes, lymphatic or lymphoid o ...
tissue, acts as a post-translational
Post-translational modification (PTM) is the covalent and generally enzymatic modification of proteins following protein biosynthesis. This process occurs in the endoplasmic reticulum and the golgi apparatus. Proteins are synthesized by ribosom ...
regulator by removing phosphate groups from targeted proteins. Importantly, PTPN22 can affect the phosphorylation of T cell responses, and thus the subsequent proliferation of the T cells. As mentioned earlier, T cells contribute to the body's inflammatory response in a variety of ways, so any changes to the cells' structure and function can have potentially deleterious effects on the body's inflammatory response to allergens. To date, one SNP in the PTPN22 gene has been found to be significantly associated with allergic rhinitis onset in children. On the other hand, CTLA-4 is an immune-checkpoint protein that helps mediate and control the body's immune response to prevent overactivation. It is expressed only in T cells as a glycoprotein for the Immunoglobulin (Ig) protein family, also known as antibodies. There have been two SNPs in CTLA-4 that were found to be significantly associated with childhood allergic rhinitis. Both SNPs most likely affect the associated protein's shape and function, causing the body to exhibit an overactive immune response to the posed allergen. The polymorphisms in both genes are only beginning to be examined, therefore more research is needed to determine the severity of the impact of polymorphisms in the respective genes.
Finally, epigenetic alterations and associations are of particular interest to the study and ultimate treatment of allergic rhinitis. Specifically, microRNAs
MicroRNA (miRNA) are small, single-stranded, non-coding RNA molecules containing 21 to 23 nucleotides. Found in plants, animals and some viruses, miRNAs are involved in RNA silencing and post-transcriptional regulation of gene expression. miR ...
(miRNA) are hypothesized to be imperative to the pathogenesis of allergic rhinitis due to the post-transcriptional regulation
Post-transcriptional regulation is the control of gene expression at the RNA level. It occurs once the RNA polymerase has been attached to the gene's promoter and is synthesizing the nucleotide sequence. Therefore, as the name indicates, it occ ...
and repression of translation in their mRNA complement. Both miRNAs and their common carrier vessel exosomes have been found to play a role in the body's immune and inflammatory responses to allergens. miRNAs are housed and packaged inside of exosomes until they are ready to be released into the section of the cell that they are coded to reside and act. Repressing the translation of proteins can ultimately repress parts of the body's immune and inflammatory responses, thus contributing to the pathogenesis of allergic rhinitis and other autoimmune disorders. There are many miRNAs that have been deemed potential therapeutic targets for the treatment of allergic rhinitis by many different researchers, with the most widely studied being miR-133, miR-155, miR-205, miR-498, and let-7e.
Diagnosis
Allergy testing may reveal the specific allergens to which an individual is sensitive. Skin testing is the most common method of allergy testing. This may include a patch test to determine if a particular substance is causing the rhinitis, or an intradermal, scratch, or other test. Less commonly, the suspected allergen is dissolved and dropped onto the lower eyelid as a means of testing for allergies. This test should be done only by a physician, since it can be harmful if done improperly. In some individuals not able to undergo skin testing (as determined by the doctor), the RAST blood test may be helpful in determining specific allergen sensitivity. Peripheral eosinophilia can be seen in differential leukocyte count.
Allergy testing is not definitive. At times, these tests can reveal positive results for certain allergens that are not actually causing symptoms, and can also not pick up allergens that do cause an individual's symptoms. The intradermal allergy test is more sensitive than the skin prick test, but is also more often positive in people that do not have symptoms to that allergen.
Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. Specialized testing is necessary to diagnose local allergic rhinitis.
Classification
* Seasonal allergic rhinitis (hay fever): Caused by seasonal peaks in the airborne load of pollens.
* Perennial allergic rhinitis (nonseasonal allergic rhinitis; atopic rhinitis): Caused by allergens present throughout the year (e.g., dander).
Allergic rhinitis may be seasonal, perennial, or episodic. Seasonal allergic rhinitis occurs in particular during pollen seasons. It does not usually develop until after 6 years of age. Perennial allergic rhinitis occurs throughout the year. This type of allergic rhinitis is commonly seen in younger children.
Allergic rhinitis may also be classified as mild-intermittent, moderate-severe intermittent, mild-persistent, and moderate-severe persistent. Intermittent is when the symptoms occur <4 days per week or <4 consecutive weeks. Persistent is when symptoms occur >4 days/week and >4 consecutive weeks. The symptoms are considered mild with normal sleep, no impairment of daily activities, no impairment of work or school, and if symptoms are not troublesome. Severe symptoms result in sleep disturbance, impairment of daily activities, and impairment of school or work.
Local allergic rhinitis
Local allergic rhinitis is an allergic reaction in the nose to an allergen, without systemic allergies. So skin-prick and blood tests for allergy are negative, but there are IgE
Immunoglobulin E (IgE) is a type of antibody (or immunoglobulin (Ig) " isotype") that has been found only in mammals. IgE is synthesised by plasma cells. Monomers of IgE consist of two heavy chains (ε chain) and two light chains, with the ε c ...
antibodies produced in the nose that react to a specific allergen
An allergen is a type of antigen that produces an abnormally vigorous immune response in which the immune system fights off a perceived threat that would otherwise be harmless to the body. Such reactions are called allergies.
In technical terms ...
. Intradermal skin testing may also be negative.
The symptoms of local allergic rhinitis are the same as the symptoms of allergic rhinitis, including symptoms in the eyes. Just as with allergic rhinitis, people can have either seasonal or perennial local allergic rhinitis. The symptoms of local allergic rhinitis can be mild, moderate, or severe. Local allergic rhinitis is associated with conjunctivitis
Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The ...
and asthma
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
.
In one study, about 25% of people with rhinitis had local allergic rhinitis. In several studies, over 40% of people having been diagnosed with nonallergic rhinitis
Nonallergic rhinitis is rhinitis—inflammation of the inner part of the nose—not caused by an allergy. Nonallergic rhinitis displays symptoms including chronic sneezing or having a congested, drippy nose, without an identified allergic reaction ...
were found to actually have local allergic rhinitis. Steroid nasal sprays and oral antihistamines have been found to be effective for local allergic rhinitis.
As of 2014, local allergenic rhinitis had mostly been investigated in Europe; in the United States, the nasal provocation testing necessary to diagnose the condition was not widely available.
Prevention
Prevention often focuses on avoiding specific allergens that cause an individual's symptoms. These methods include not having pets, not having carpets or upholstered furniture in the home, and keeping the home dry. Specific anti-allergy zippered covers on household items like pillows and mattresses have also proven to be effective in preventing dust mite allergies.
Studies have shown that growing up on a farm and having many older siblings can decrease an individual's risk for developing allergic rhinitis.
Studies in young children have shown that there is higher risk of allergic rhinitis in those who have early exposure to foods or formula or heavy exposure to cigarette smoking within the first year of life.
Treatment
The goal of rhinitis treatment is to prevent or reduce the symptoms caused by the inflammation of affected tissues. Measures that are effective include avoiding the allergen. Intranasal corticosteroids are the preferred medical treatment for persistent symptoms, with other options if this is not effective.[ Second line therapies include ]antihistamines
Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provides re ...
, decongestants
A decongestant, or nasal decongestant, is a type of pharmaceutical drug that is used to relieve nasal congestion in the upper respiratory tract. The active ingredient in most decongestants is either pseudoephedrine or phenylephrine (the latter ...
, cromolyn
Cromoglicic acid ( INN)—also referred to as cromolyn (USAN), cromoglycate (former BAN), or cromoglicate—is traditionally described as a mast cell stabilizer, and is commonly marketed as the sodium salt sodium cromoglicate or cromolyn sodium. ...
, leukotriene receptor antagonists
An antileukotriene, also known as leukotriene modifier and leukotriene receptor antagonist, is a medication which functions as a leukotriene-related enzyme inhibitor (arachidonate 5-lipoxygenase) or leukotriene receptor antagonist (cysteinyl leukot ...
, and nasal irrigation
Nasal irrigation (also called nasal lavage, nasal toilet, or nasal douche) is a personal hygiene practice in which the nasal cavity is washed to flush out mucus and debris from the nose and sinuses, in order to enhance nasal breathing. Nasal i ...
.[ Antihistamines by mouth are suitable for occasional use with mild intermittent symptoms.][ ]Mite
Mites are small arachnids (eight-legged arthropods). Mites span two large orders of arachnids, the Acariformes and the Parasitiformes, which were historically grouped together in the subclass Acari, but genetic analysis does not show clear e ...
-proof covers, air filters, and withholding certain foods in childhood do not have evidence supporting their effectiveness.[
]
Antihistamines
Antihistamine
Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provid ...
drugs can be taken orally and nasally to control symptoms such as sneezing, rhinorrhea, itching, and conjunctivitis.
It is best to take oral antihistamine medication before exposure, especially for seasonal allergic rhinitis. In the case of nasal antihistamines like azelastine antihistamine nasal spray, relief from symptoms is experienced within 15 minutes allowing for a more immediate 'as-needed' approach to dosage. There is not enough evidence of antihistamine efficacy as an add-on therapy with nasal steroids in the management of intermittent or persistent allergic rhinitis in children, so its adverse effects and additional costs must be considered.
Ophthalmic antihistamines (such as azelastine in eye drop form and ketotifen
Ketotifen, sold under the brand name Zaditor among others, is a second-generation noncompetitive H1-antihistamine and mast cell stabilizer. It is most commonly sold as a salt with fumaric acid, ketotifen fumarate, and is available in two forms. I ...
) are used for conjunctivitis, while intranasal forms are used mainly for sneezing, rhinorrhea, and nasal pruritus.[
Antihistamine drugs can have undesirable side-effects, the most notable one being ]drowsiness
Somnolence (alternatively sleepiness or drowsiness) is a state of strong desire for sleep, or sleeping for unusually long periods (compare hypersomnia). It has distinct meanings and causes. It can refer to the usual state preceding falling asleep ...
in the case of oral antihistamine tablets. First-generation antihistamine drugs such as diphenhydramine
Diphenhydramine (DPH) is an antihistamine and sedative mainly used to treat allergies, insomnia, and symptoms of the common cold. It is also less commonly used for tremor in parkinsonism, and nausea. It is taken by mouth, injected into ...
cause drowsiness, while second- and third-generation antihistamines such as cetirizine
Cetirizine, sold under the brand name Zyrtec among others, is a second-generation antihistamine used to treat allergic rhinitis (hay fever), dermatitis, and urticaria (hives). It is taken by mouth. Effects generally begin within thirty minutes a ...
and loratadine
Loratadine, sold under the brand name Claritin among others, is a medication used to treat allergies. This includes allergic rhinitis (hay fever) and hives. It is also available in combination with pseudoephedrine, a decongestant, known as lora ...
are less likely to.[
Pseudoephedrine is also indicated for vasomotor rhinitis. It is used only when nasal congestion is present and can be used with antihistamines. In the United States, oral decongestants containing pseudoephedrine must be purchased behind the pharmacy counter in an effort to prevent the manufacturing of methamphetamine.] Desloratadine/pseudoephedrine can also be used for this condition
Steroids
Intranasal
Nasal administration, popularly known as snorting, is a route of administration in which drugs are insufflated through the nose. It can be a form of either topical administration or systemic administration, as the drugs thus locally delivere ...
corticosteroids are used to control symptoms associated with sneezing, rhinorrhea, itching, and nasal congestion. Steroid nasal spray
Nasal sprays are used to deliver medications locally in the nasal cavities or systemically. They are used locally for conditions such as nasal congestion and allergic rhinitis. In some situations, the nasal delivery route is preferred for syst ...
s are effective and safe, and may be effective without oral antihistamines. They take several days to act and so must be taken continually for several weeks, as their therapeutic effect builds up with time.
In 2013, a study compared the efficacy of mometasone furoate nasal spray to betamethasone
Betamethasone is a corticosteroid, steroid medication. It is used for a number of diseases including rheumatic disorders such as rheumatoid arthritis and systemic lupus erythematosus, skin diseases such as dermatitis and psoriasis, allergic con ...
oral tablets for the treatment of people with seasonal allergic rhinitis and found that the two have virtually equivalent effects on nasal symptoms in people.
Systemic steroids such as prednisone
Prednisone is a glucocorticoid medication mostly used to suppress the immune system and decrease inflammation in conditions such as asthma, COPD, and rheumatologic diseases. It is also used to treat high blood calcium due to cancer and ad ...
tablets and intramuscular triamcinolone acetonide
Triamcinolone acetonide, sold under the brand name Kenalog among others, is a synthetic corticosteroid medication used topically to treat various skin conditions, to relieve the discomfort of mouth sores, and by injection into joints to trea ...
or glucocorticoid
Glucocorticoids (or, less commonly, glucocorticosteroids) are a class of corticosteroids, which are a class of steroid hormones. Glucocorticoids are corticosteroids that bind to the glucocorticoid receptor that is present in almost every verteb ...
(such as betamethasone
Betamethasone is a corticosteroid, steroid medication. It is used for a number of diseases including rheumatic disorders such as rheumatoid arthritis and systemic lupus erythematosus, skin diseases such as dermatitis and psoriasis, allergic con ...
) injection are effective at reducing nasal inflammation, but their use is limited by their short duration of effect and the side-effects of prolonged steroid therapy.
Other
Other measures that may be used second line include: decongestant
A decongestant, or nasal decongestant, is a type of pharmaceutical drug that is used to relieve nasal congestion in the upper respiratory tract. The active ingredient in most decongestants is either pseudoephedrine or phenylephrine (the latter ...
s, cromolyn
Cromoglicic acid ( INN)—also referred to as cromolyn (USAN), cromoglycate (former BAN), or cromoglicate—is traditionally described as a mast cell stabilizer, and is commonly marketed as the sodium salt sodium cromoglicate or cromolyn sodium. ...
, leukotriene receptor antagonist
An antileukotriene, also known as leukotriene modifier and leukotriene receptor antagonist, is a medication which functions as a leukotriene-related enzyme inhibitor (arachidonate 5-lipoxygenase) or leukotriene receptor antagonist (cysteinyl leuko ...
s, and nonpharmacologic therapies such as nasal irrigation
Nasal irrigation (also called nasal lavage, nasal toilet, or nasal douche) is a personal hygiene practice in which the nasal cavity is washed to flush out mucus and debris from the nose and sinuses, in order to enhance nasal breathing. Nasal i ...
.[
]Topical decongestant Topical decongestants are decongestants applied directly to the nasal cavity. Their effectiveness by themselves in the common cold appears to have a small benefit in adults.
Topical decongestants should only be used by patients for a maximum of 5 ...
s may also be helpful in reducing symptoms such as nasal congestion, but should not be used for long periods, as stopping them after protracted use can lead to a rebound nasal congestion called rhinitis medicamentosa
Rhinitis medicamentosa (or RM) is a condition of rebound nasal congestion suspected to be brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) and certain oral med ...
.
For nocturnal symptoms, intranasal corticosteroids can be combined with nightly oxymetazoline
Oxymetazoline, sold under the brand name Afrin among others, is a topical decongestant and vasoconstrictor medication. It is available over-the-counter as a nasal spray to treat nasal congestion and nosebleeds, as eyedrops to treat eye rednes ...
, an adrenergic alpha-agonist, or an antihistamine nasal spray without risk of rhinitis medicamentosa.
Nasal saline irrigation (a practice where salt water is poured into the nostrils), may have benefits in both adults and children in relieving the symptoms of allergic rhinitis and it is unlikely to be associated with adverse effects.
Allergen immunotherapy
Allergen immunotherapy
Allergen immunotherapy, also known as desensitization or hypo-sensitization, is a medical treatment for environmental allergies, such as insect bites, and asthma. Immunotherapy involves exposing people to larger and larger amounts of allergen in ...
(AIT, also termed desensitization) treatment involves administering doses of allergens to accustom the body to substances that are generally harmless (pollen, house dust mites
House dust mites (HDM, or simply dust mites) are various species of acariform mites belonging to the family Pyroglyphidae that are found in association with dust in dwellings. They are known for causing allergies.
Biology
Species
The current ...
), thereby inducing specific long-term tolerance. Allergen immunotherapy is the only treatment that alters the disease mechanism. Immunotherapy can be administered orally (as sublingual tablets or sublingual drops), or by injections under the skin (subcutaneous). Subcutaneous immunotherapy is the most common form and has the largest body of evidence supporting its effectiveness.
Alternative medicine
There are no forms of complementary or alternative medicine that are evidence-based for allergic rhinitis. Therapeutic efficacy of alternative treatments such as acupuncture
Acupuncture is a form of alternative medicine and a component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body. Acupuncture is a pseudoscience; the theories and practices of TCM are not based on scientif ...
and homeopathy is not supported by available evidence. While some evidence shows that acupuncture is effective for rhinitis, specifically targeting the sphenopalatine ganglion acupoint, these trials are still limited. Overall, the quality of evidence for complementary-alternative medicine is not strong enough to be recommended by the American Academy of Allergy, Asthma and Immunology
Founded in 1943, the American Academy of Allergy, Asthma & Immunology (AAAAI) is a professional medical membership organization of nearly 6,800 allergist/ immunologists and related professionals around the world with advanced training and experie ...
.
Epidemiology
Allergic rhinitis is the type of allergy
Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derm ...
that affects the greatest number of people.[ In Western countries, between 10 and 30 percent of people are affected in a given year.][ It is most common between the ages of twenty and forty.][
]
History
The first accurate description is from the 10th century physician Rhazes
Abū Bakr al-Rāzī (full name: ar, أبو بکر محمد بن زکریاء الرازي, translit=Abū Bakr Muḥammad ibn Zakariyyāʾ al-Rāzī, label=none), () rather than ar, زکریاء, label=none (), as for example in , or in . In m ...
. Pollen was identified as the cause in 1859 by Charles Blackley
Charles Harrison Blackley (5 April 1820 – 4 September 1900) was the discoverer of the mechanism behind allergic rhinitis caused by pollen, commonly called hay fever. The isolation of hay fever as a condition had been known since 1819 through t ...
. In 1906 the mechanism was determined by Clemens von Pirquet
Clemens Peter Freiherr von Pirquet (12 May 187428 February 1929) was an Austrian scientist and pediatrician best known for his contributions to the fields of bacteriology and immunology.
Career
Born in Vienna, he studied theology at the Universit ...
.[ The link with ]hay
Hay is grass, legumes, or other herbaceous plants that have been cut and dried to be stored for use as animal fodder, either for large grazing animals raised as livestock, such as cattle, horses, goats, and sheep, or for smaller domesticat ...
came about due to an early (and incorrect) theory that the symptoms were brought about by the smell of new hay.
References
Further reading
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External links
*
Types of Pollen Allergies
{{DEFAULTSORT:Allergic Rhinitis
Allergology
Steroid-responsive inflammatory conditions
Type I hypersensitivity
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