Seasonal allergic rhinitis (hay fever): symptoms and treatment

NICE Clinical Knowledge Summaries (CKS) defines allergic rhinitis as an IgE-mediated inflammatory disorder of the nose, in which the lining of the nose becomes exposed and sensitised to allergens and produces sneezing, itching, a runny nose and congestion. It can be classified as seasonal, where symptoms occur at the same time each year, or perennial, where they happen throughout the year, typically because of dust mites or animal dander.

CKS says that when seasonal allergic rhinitis is caused by grass and tree pollen it is also known as hay fever. Intermittent means symptoms on fewer than four days a week or for fewer than four consecutive weeks, and persistent means more than four days a week for more than four weeks.

The NHS lists the symptoms of hay fever as:

• Sneezing and coughing.

• A runny or blocked nose.

• Itchy, red or watery eyes.

• An itchy throat, mouth, nose and ears.

• Loss of smell.

• Pain around the sides of the head and forehead, headache and tiredness.

Allergy UK points out that many people think of hay fever as a summer problem, but trees such as alder, birch and hazel release pollen at the start of spring and can cause symptoms early. The NHS says symptoms are usually worse between late March and September, particularly in warm, humid and windy weather when pollen counts are highest, and suggests checking the Met Office pollen forecast. Allergy UK adds that pollen counts tend to be higher in the early morning and evening.

Because the cause differs between people, it helps to note when your symptoms start and how they relate to the weather and the pollen forecast. That kind of pattern is useful information if you are ever referred for allergy testing, since CKS says a clinician will ask about the timing and persistence of symptoms.

CKS says allergic rhinitis should be suspected where classic symptoms follow exposure to a known allergen, with possible associated allergic conjunctivitis, asthma or eczema. A clinician will ask about the type, frequency, timing and persistence of symptoms, their severity and impact, housing, pets and occupation, medicines that may aggravate symptoms, and any family history of atopy. CKS lists uncertainty about the diagnosis, consideration of allergen avoidance and consideration of immunotherapy among the reasons allergy testing may be needed.

The NHS says there is currently no cure for hay fever and you cannot prevent it, but there are things you can do when the pollen count is high. It suggests the following:

• Put petroleum jelly around your nostrils to trap pollen.

• Wear wraparound sunglasses, a mask or a wide-brimmed hat.

• Shower and change clothes after being outside, and keep windows and doors shut as much as possible.

• Vacuum regularly, dust with a damp cloth, and use a pollen filter in the car and a HEPA filter in the vacuum cleaner.

• Avoid cutting grass, drying clothes outside, keeping fresh flowers in the house, and smoking or being around smoke.

The NHS says a pharmacist can suggest antihistamine drops, tablets or nasal sprays and steroid nasal sprays, and mentions that some antihistamines can make you very sleepy, so non-drowsy types may be preferable. A GP may prescribe a steroid treatment, and if steroids and other treatments do not work, may refer for immunotherapy, which gives small amounts of pollen as an injection or tablet to build up tolerance and usually starts a few months before the season.

CKS gives a stepped approach for clinicians. Initial management includes information, possible saline nasal irrigation, allergen avoidance, and an as-needed intranasal antihistamine or non-sedating oral antihistamine for mild or intermittent symptoms. Regular intranasal corticosteroids during allergen exposure are used for moderate to severe persistent symptoms or if initial treatment fails, with review after 2 to 4 weeks. For refractory disease it describes a combined intranasal antihistamine and corticosteroid spray, possible add-ons, and a short course of oral corticosteroid for severe, uncontrolled symptoms in adults.

The NHS says to see a GP if symptoms are getting worse or do not improve after pharmacy medicines. CKS says referral to an allergy or ear, nose and throat specialist is appropriate if there are red-flag features suggesting another diagnosis, persistent symptoms despite optimal primary care treatment, allergen avoidance such as dust mite or animal dander control is being considered because testing may be needed, the person would like immunotherapy instead of long-term medication, or the diagnosis is uncertain.

Allergy UK stresses that if you have asthma symptoms of a tight chest, wheeziness and difficulty breathing, urgent medical help should be sought. Call 999 for severe difficulty breathing.

CKS lists complications as reduced quality of life, impaired school and work performance, disturbed sleep, poor concentration, and possible development of asthma, sinusitis and nasal polyps. Allergy UK adds that hay fever symptoms can affect sleep quality, and sustained poor sleep can increase the risk of other illnesses. Treating symptoms early in the season, rather than waiting until they are severe, is therefore a sensible approach to discuss with a pharmacist or GP.

Most hay fever care is on the NHS through pharmacies and GPs. Private allergy clinics offer skin prick or blood testing and immunotherapy planning; ask whether the tests relate to your actual symptom pattern and how treatment will be reviewed.