1. Allergic Rhinitis By Alex Pearce-Smith

2. Scenario • A 12 yr old boy comes into see you with his mum in June. He complains of a persistant runny nose and sore eyes for the last 3 wks. You suspect seasonal rhinitis. • What other points would you want to know from the history? • What examination would you perform? • How would you manage this?

3. What are these examples of?

4. Pathophysiology

5. Sub-types • Seasonal (hayfever) • Grass, Tree pollen allergens, same time each year. • Perennial • House dust mites, feathers, animal danders – throughout the year. • Occupational • Workplace – e.g. flour allergy in bakers.

6. Epidemiology • Approximately 25% of UK population • Age Matters • Seasonal more common in children • Perennial more common in adults • Increasing age a negative risk factor • Seasonal rhinitis more predisposition to itch, sneezing and diurnal symptoms. • Perennial – catarrh more prevelant and more likely to be diagnosed with asthma.

7. What to look for….. • Which of these are typical symptoms of Allergic Rhinitis? • Facial pain • Post nasal drip • Persistent runny nose • Unilateral Symptoms • Nasal obstruction • Nosebleeds • Nasal itch • Violent sneezing in bouts • Conjunctivitis

8. Classification

9. Treatment • Mild and Intermittent • Topical (rapid relief) – e.g. Azelastine. • Oral – e.g. Cetirizine, Loratadine, Fexofenadine. • Or LTRA (e.g. Montelukast – esp. in asthmatics). • Mild but persistent/ Moderate-Severe but Intermittent. • Trial of above +/- decongestant (max 2/52) • Nasal Corticosteroids – e.g.Fluticasone, Budesonide, Mometasone. • Review after a month • If improved continue for 1/12 • if not then step up treatment.

10. Treatment • Moderate/Severe and Persistent. • 1) Nasal corticosteroids, 2)Antihistamines, 3) LTRAs • Review after 2-4 wks • If improved continue for further month • If not rv diagnosis and compliance and consider: • Increase corticosteroid • Add antihistamine (if itch and sneeze) • Add Ipratropium (if rhinorrhoea) • Add decongestant/ oral steroids …….. refer

11. Consider Asthma • Strong link between allergic rhinitis and asthma. • If known asthmatic then review asthma control. • If no diagnosis of asthma try these 4 Qus. • Have you had an attack/recurrent wheeze? • Do you have a troublesome cough esp. at night? • Do you cough or wheeze after exercise? • Does your chest feel tight? • If yes to any of these then review asthma.

12. Allergen Avoidance….Can you think of 3? • Allergen impermeable covers fo matresses and pillows. • Wash bedding in hot water regularly. • Remove animals, teddys and carpets from bedrooms. • Air-conditioning. • Air Filters in bedroom • Dehumidifier • Vented drier to dry clothes • Minimize upholstered furniture.

13. Pollen Avoidance…. Can you think of 3 measures….. • Stay indoors and shut windows! • Wear sunglasses. • Wash hair and change clothes after returning from exposure to high pollen count. • Avoid drying clothes outdoors. • Pollen filters in cars. • Avoid grassy places. • Take a holiday by the sea when sx at worst! • Vasaline around nostrils • Pets carry pollen……

14. Testing? • Not usually necessary – but may be useful if struggling to isolate allergen or has suffered a severe reaction. • Skin Prick testing • Skin Prick Testing • RAST (specific IgE) • If skin prick inappropriate due to severe previous reaction/ on antihistamine.

15. Referral? • Referral should be considered if either: • refractory to treatment e.g. 6 weeks with nasal steroids • unilateral nasal symptoms • nasal perforation, ulceration or collapse • sero-sangionous discharge • high nasal cavity crusting • recurrent cellulitis • urgent referral required for periorbital cellulitis

16. Scenario • A 12 yr old boy comes into see you with his mum in June. He complains of a persistant runny nose and sore eyes for the last 3 wks. You suspect seasonal rhinitis. • What other points would you want to know from the history? • What examination would you perform? • How would you manage this?

17. Questions? • References • GP notebook • CKS • ARIA guidelines • Allergyuk.org • Patient.co.uk