Allergic Rhinitis

Definition And Disease Burden

Core Concepts

• Type 1 hypersensitive inflammation nasal mucosa.
• Induced exposure allergenic substances.
• Cardinal symptoms include sneezing, rhinorrhea, nasal itching, nasal block.
• Diagnosis requires minimum two cardinal symptoms present >1 hour/day most days annually.
• Affects 10-30% adults, nearly 40% children.
• Strong asthma association; 80% asthmatics possess allergic rhinitis.
• Conversely, 50% allergic rhinitis patients possess asthma.

Classification

Aria Guidelines

Category	Symptom Duration	Severity Features
Mild Intermittent	<4 days/week or <4 weeks	Normal sleep, normal daily activities, no troublesome symptoms.
Mild Persistent	>4 days/week and >4 weeks	Normal sleep, normal daily activities, no troublesome symptoms.
Moderate/Severe Intermittent	<4 days/week or <4 weeks	Sleep disorder, disturbed daily activities/school, troublesome symptoms.
Moderate/Severe Persistent	>4 days/week and >4 weeks	Sleep disorder, disturbed daily activities/school, troublesome symptoms.

Etiology And Triggers

Environmental And Chemical Factors

• Aeroallergens: Outdoor, indoor sources.
• Dust/Animals/Insects: House dust mites, cockroaches, pet dander.
• Occupational: Latex exposure.
• Pollutants: Biomass fuel, tobacco, gas, ozone, diesel exhaust.
• Drugs: Aspirin, nonsteroidal anti-inflammatory drugs.

Comorbidities

Disease Associations

Category	Associated Conditions
Primary	Asthma, sinusitis, otitis media with effusion, conjunctivitis, laryngitis, atopic dermatitis, recurrent upper respiratory tract infections, obstructive sleep apnea.
Secondary	Decreased quality life, adenoid hypertrophy, snoring, bruxism, dental malocclusion, learning impairment, attention impairment.

Evaluation And Diagnosis

Clinical And Laboratory Assessment

• Diagnosis requires detailed history, characteristic signs, confirmed allergen-specific Immunoglobulin E.
• Physical signs include transverse skin crease over nasal bridge, Dennie-Morgan folds below eyes, boggy turbinates.
• Allergen-specific Immunoglobulin E testing (skin prick, in vitro) supports diagnosis.
• Nasal smear reveals eosinophils >5/High Power Field.
• Total eosinophil count, total Immunoglobulin E lack specificity; routine recommendation denied.

Management Strategy

Allergen Avoidance

• Avoid high pollen, fungal, dusty environments.
• Implement rigorous pest control.
• House dust mite control involves avoiding wall-to-wall carpets, hot water washing bed sheets, sun drying mattresses.
• Dust mite encasing materials prevent mite intrusion.
• Maintain relative humidity <50% reducing mite concentration.

Pharmacotherapy Guidelines

• Second-generation antihistamines represent drugs choice mild intermittent disease.
• Intranasal antihistamines (>6 years) avoided due bitter taste, somnolence.
• Oral decongestants contraindicated children due systemic side effects (irritability, tachycardia, hypertension, insomnia).
• Inhaled nasal steroids provide optimal controller medication.
• Preferred inhaled nasal steroids include Mometasone furoate, Fluticasone propionate possessing low systemic bioavailability,.
• Allergen-specific immunotherapy (sublingual, subcutaneous) recommended difficult moderate-to-severe persistent cases,.

Stepwise Treatment Approach

Severity Grade	Recommended Pharmacotherapy
Mild Intermittent	Second-generation antihistamines, symptomatic relief medications.
Mild Persistent	Second-generation antihistamines, inhaled nasal steroids, leukotriene receptor antagonists.
Moderate/Severe Intermittent	Inhaled nasal steroids, intranasal antihistamines, leukotriene receptor antagonists, immunotherapy.
Moderate/Severe Persistent	Nasal saline irrigation, inhaled nasal steroids, leukotriene receptor antagonists, immunotherapy.
Severe Rhinorrhea Predominant	Ipratropium nasal spray addition.

Symptom-Based Drug Selection

Drug Class	Nasal Itching/Sneezing	Rhinorrhea	Nasal Obstruction	Impaired Smell
Oral Antihistamines	+++	++	+/-	-
Topical Corticosteroids	+++	+++	++	+
Topical Decongestants	-	-	+++	-
Ipratropium Bromide	-	+++	++	+

(Symptom relief efficacy).

Inhaled Nasal Steroid Dosage

Drug	Age Group	Recommended Dose
Mometasone Furoate	2-12 years	50 micrograms/nostril once daily.
Mometasone Furoate	>12 years	100 micrograms/nostril once daily.
Fluticasone Propionate	4-12 years	50 micrograms/nostril once daily.
Fluticasone Propionate	>12 years	100 micrograms/nostril once daily.