What Is Allergic Rhinitis?
Allergic rhinitis (AR), commonly called hay fever, is chronic nasal inflammation caused by an IgE-mediated immune response to inhaled allergens. It is one of the most prevalent chronic diseases in India, affecting an estimated 20–30% of the population — yet it remains significantly undertreated because many patients consider it a minor nuisance rather than a medical condition.
Untreated allergic rhinitis impairs sleep, concentration, school performance, and work productivity. It is the most important risk factor for developing asthma.
Types of Allergic Rhinitis
- Intermittent AR — symptoms less than 4 days/week or less than 4 consecutive weeks. Example: pollen allergy with seasonal flares.
- Persistent AR — symptoms more than 4 days/week AND more than 4 consecutive weeks. Example: dust mite allergy with year-round symptoms.
- Mild — does not affect sleep, daily activities, or work
- Moderate-Severe — impairs sleep, daily activities, or work
Common Triggers in India
India’s allergen environment differs from Western countries. The major triggers in India are:
- House dust mites — Dermatophagoides pteronyssinus and farinae. The dominant allergen across India. Thrive in warm, humid conditions. Found in mattresses, pillows, carpets, and upholstered furniture.
- Cockroach allergen — a major trigger in urban Indian homes (Periplaneta americana and Blattella germanica)
- Fungi/Moulds — Aspergillus, Cladosporium, Alternaria. Common in humid climates and monsoon season.
- Pollen — Parthenium hysterophorus (congress grass) is particularly allergenic in India. Also prosopis, cynodon (bermuda grass), and various tree pollens.
- Pet dander — cats and dogs, increasingly relevant in urban India
- Occupational allergens — flour for bakers, latex, chemicals
Symptoms of Allergic Rhinitis
- Clear, watery nasal discharge (rhinorrhoea)
- Nasal congestion/blockage
- Sneezing — often in bursts of 5–10 sneezes
- Nasal and palatal itching
- Eye symptoms (allergic conjunctivitis) — red, itchy, watery eyes
- Post-nasal drip causing throat irritation and cough
- Reduced smell (hyposmia)
- Fatigue, poor concentration, sleep disturbance (“allergic brain fog”)
The Connection Between Allergic Rhinitis and Asthma
Allergic rhinitis and asthma are manifestations of the same allergic airway disease — the “unified airway” concept. Approximately 40% of AR patients have comorbid asthma, and 80% of asthma patients have AR. Treating rhinitis improves asthma control. Every AR patient should be screened for asthma symptoms, and every asthma patient should be asked about nasal symptoms.
Diagnosis
- Skin prick testing (SPT) — the gold standard. Small amounts of allergen extracts placed on skin; a positive wheal indicates sensitisation. Rapid, inexpensive, highly informative.
- Specific IgE blood tests (ImmunoCAP) — alternative to SPT, used when SPT is not possible (severe eczema, antihistamine use, dermographism)
- Nasal endoscopy — to assess turbinate hypertrophy, polyps, deviated septum
- Spirometry with bronchodilator reversibility — to screen for asthma
Treatment of Allergic Rhinitis
Step 1: Allergen Avoidance
Avoid or reduce exposure to identified triggers:
- Dust mites: Allergen-proof mattress and pillow covers, wash bedding in hot water weekly, reduce humidity to <50%, avoid carpets in bedroom, HEPA filter vacuum cleaners
- Cockroach: Seal cracks, proper food storage, pest control
- Moulds: Fix leaks, improve ventilation, use dehumidifier in monsoon
- Pollen: Keep windows closed during high pollen season, shower after outdoor activity
Step 2: Intranasal Corticosteroids (INCS) — First-Line Treatment
Intranasal corticosteroid sprays (fluticasone, mometasone, budesonide) are the most effective treatment for moderate-severe persistent AR — more effective than antihistamines for nasal blockage. They are safe for long-term use as negligible amounts are absorbed systemically at prescribed doses. Proper technique is essential for effect: spray towards the outer wall of each nostril, not the septum.
Step 3: Antihistamines
Second-generation antihistamines (cetirizine, loratadine, fexofenadine, levocetirizine, bilastine) reduce sneezing, itching, and runny nose. They are less effective for nasal congestion than INCS. Avoid sedating first-generation antihistamines (chlorpheniramine, promethazine) for daytime use — they impair driving and cognition.
Allergen Immunotherapy (AIT) — The Only Disease-Modifying Treatment
AIT (allergy shots or sublingual drops/tablets) is the only treatment that actually modifies the allergic disease — it induces immune tolerance to the allergen. It reduces symptoms, medication use, and the risk of developing new allergies or asthma. Recommended for patients with inadequate response to pharmacotherapy, those who want to reduce long-term medication dependence, or those developing asthma.
In India, subcutaneous immunotherapy (SCIT) with house dust mite, cockroach, and grass pollen extracts is available at specialist centres. Sublingual immunotherapy (SLIT) drops are also used. Course duration: 3–5 years.
Allergic Rhinitis in Pregnancy
AR is common in pregnant women and can worsen due to hormonal changes (pregnancy rhinitis). Safe treatments include: saline nasal irrigation, intranasal budesonide or fluticasone (Category B), and loratadine or cetirizine. Avoid decongestants (pseudoephedrine) especially in the first trimester.
FAQs About Allergic Rhinitis
Is allergic rhinitis curable?
Allergen immunotherapy can induce long-term tolerance that persists after completing the course — this is the closest to a “cure.” Pharmacotherapy controls but does not cure.
Will my child grow out of it?
Some children improve with age, but many do not. More importantly, untreated AR in children increases the risk of developing asthma. Treat early and consider immunotherapy in children with moderate-severe AR.
Written by Dr. Keerthivardhan, Clinical Immunologist, NIMS Hospital Hyderabad.