|
|
|
Overview |
|
|
Definition |
|
Allergic rhinitis (hay fever) is a reaction to airborne allergens. It affects
between 1:6 and 1:10 Americans and is an IgE-mediated disorder of the immune
system; 70% of cases occur before age 30. Symptoms resemble those of viral
rhinitis but persist and show seasonal variation. This most common form of
allergy involves the entire respiratory system—nasal
cavity, mouth, throat, bronchi, lungs, and diaphragm. There is an inherited
tendency, with a child having a 50% chance of developing such allergy if one
parent is allergic and a 75% chance if both parents are
allergic. |
|
|
Etiology |
|
The cause is an interaction of IgE on mast cells and basophils in the nasal
mucosa with antigenic substances, especially pollens, grasses, or ragweed, which
produce a seasonal variation; animal fur; dust, insect debris, household mites;
inhaled irritants; changes in temperature or humidity. |
|
|
Risk Factors |
|
The following conditions can lead to allergic rhinitis.
- Tendency to produce large quantities of IgE
- Repeated exposure to allergen(s), which can be almost anything
inhaled, eaten, touched, or injected into the body
- Sufficient potency and duration of exposure
- Other allergies
- Familial predisposition
- Smoking or prolonged exposure to second-hand
smoke
|
|
|
Signs and Symptoms |
|
- Nasal obstruction, increased secretions, sneezing
- Itching of mucous membranes of nose, eyes, posterior pharynx,
conjunctivae
- Sinus symptoms: headache, pressure behind the eyes, pain in the
frontal area, tenderness over cheekbones, aching teeth
- Ear infections
- Stomach cramps
- Skin rashes or hives
- Urinary frequency or
diarrhea
|
|
|
Differential
Diagnosis |
|
- Viral, bacterial, or fungal infections
- Sinusitis
- Rhinitis medicamentosa
- Vasomotor rhinitis
- Obstruction of the septum
- Bronchitis
- Nasal polyps
- Swollen adenoids
- Systemic diseases—Wegener's granulomatosis,
hypothyroidism (rare)
- Chronic rhinitis
|
|
|
Diagnosis |
|
|
Physical Examination |
|
Turbinate mucosa is usually pale or blue and swollen, with nasal obstruction
and copious secretions, sneezing, and itching of eyes, nose, and throat. Nasal
polyps are uncommon, but serous otitis media occurs often, especially in young
children. Cervical lymphadenopathy. |
|
|
Laboratory Tests |
|
- Microscopic examination of nasal smear shows high numbers of
eosinophils
- Increased IgE level
|
|
|
Pathology/Pathophysiology |
|
- Submucosal edema
- Congested mucous glands
|
|
|
Imaging |
|
Sinus X rays for differential diagnosis |
|
|
Other Diagnostic
Procedures |
|
On referral to an allergist, the following tests may be done.
- Skin testing—Diluted extracts of allergens
are injected under the skin or applied to scratches on the back or upper arm.
Positive results are indicated by raised welts surrounded by redness and high
serum levels of IgE antibodies.
- Radioallergosorbent test (RAST)—Blood test
to determine IgE levels
- ELISA allergy testing for IgE and
IgG
|
|
|
Treatment Options |
|
|
Treatment Strategy |
|
Eliminate rhinitis by maintaining an allergen-free
environment.
- Cover pillows and mattresses with plastic covers.
- Use synthetic materials (foam mattresses, acrylics) instead of animal
products (wool, horsehair).
- Minimize dust-collecting household items (i.e., carpets,
drapes).
Use of an air purifier/dust filter may help. When the allergen(s) is known,
desensitization therapy can be done, which involves gradually increasing
subdermal exposure to identified allergens; results vary. |
|
|
Drug Therapies |
|
- Oral decongestants—such as pseudoephedrine
(Sudafed, 60 to 120 mg orally tid to qid); have systemic effects.
- Antihistamines—such as chlorpheniramine
(Chlor-Trimeton; 4 mg orally every 6 to 8 hours, or 8 to 12 mg orally every 8 to
12 hours as sustained-release tablet), clemastine (Tavist; 1.34 to 2.67 mg
orally bid; side effect of sedation often unacceptable.
- Nonsedating antihistamines (histamine-receptor
antagonists)—such as astemizole (Hismanal; 10 mg orally
daily), loratadine (Claritin; 10 mg orally daily), cetirizine (Zyrtec; 10 mg
orally daily), fexofenadine (Allegra; 60 mg orally bid), terfenadine (60 mg
orally bid); although expensive and by prescription, are especially helpful in
those patients who are intolerant of drowsiness; astemizole is associated with
sudden death from presumed QT prolongation, especially in those receiving
erythromycin or ketoconazole concomitantly; liver disease, hypokalemia are
contraindications.
- Nasal corticosteroid sprays—such as
beclomethasone (Beconase AQ, Vancenase AQ, 42 mcg/spray), fluticasone (Flonase,
two sprays in each nostril once daily, decreasing to one spray each day, based
on response), budesonide (Rhinocort, two sprays in each nostril bid or four
sprays in each nostril every morning), and flunisolide (Nasalide, 25 mcg/spray);
effective if used appropriately—two activations in each
nostril bid for one month; improvement takes one to two weeks.
- Intranasal steroids—such as nasal cromolyn
(Nasalcrom, one spray in each nostril tid to qid); used in seasonal allergies to
shrink nasal polyps; must be started 24 to 36 hour before symptoms develop and
must be used four to six times daily.
- Alpha-adrenergic agents—applied to nasal
mucosa; come in short-term and long-acting forms; continued use for more than a
few days leads to rebound nasal congestion and rhinitis
medicamentosa.
- Systemic steroids—in severe cases and for
short duration only.
|
|
|
Complementary and Alternative
Therapies |
|
Allergic rhinitis may be successfully treated with alternative therapies.
Begin with nutrition guidelines. Use the tincture and homeopathic remedies for
acute exacerbations. |
|
|
Nutrition |
|
- Eliminate all known food allergens.
- Minimize pro-inflammatory and highly allergenic foods such as
saturated fats (meats and dairy products), refined foods, eggs, citrus, bananas,
chocolate, peanuts, wheat, shellfish, food coloring, preservatives, caffeine,
alcohol, tobacco, and sugar.
- Increase intake of whole foods including fresh fruits and vegetables,
whole grains, nuts, seeds.
- Drink plenty of water and include fresh juices, especially carrot,
celery, parsley, and pineapple.
- Vitamin A (10,000 to 15,000 IU/day), zinc (20 to 30 mg/day), vitamin
B6 (50 to 100 mg/day), and vitamin B5 (50 to 75 mg/day) for immune
support
- Vitamin C (1,000 mg tid to qid) to reduce inflammation, stabilize
mast cells to decreasehistamine release
- Vitamin E (400 IU/day) for proper immune function
- N-acetylcysteine (200 mg tid) to reduce mucous
formation
|
|
|
Herbs |
|
Herbs are generally a safe way to strengthen and tone the body's systems.
Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried
extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts).
Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot
water. Steep covered 10 to 20 minutes and drink 2 to 4 cups/day. Tinctures may
be used singly or in combination as noted.
- Plants high in flavonoids (quercetin, curcuma, rose hips, bilberry)
are especially useful as they reduce histamine release and stabilize connective
tissue. Rose hips (Rosa canina) can be used as an infusion or solid
extract. Nettles (Urtica urens) are traditionally used for hayfever and
may be drunk as an infusion, 2 cups a day.
- Quercetin 250 mg bid to tid to reduce inflammation.
- A tincture of equal parts of coneflower (Echinacea angustifolia),
goldenseal (Hydrastis canadensis), cleavers (Gallium aparine),
eyebright (Euphrasia officinalis), ginger root (Zingiber
officinalis), and elderberry (Sambucus nigra) will support immune
function and lymphatic drainage, as well as increase circulation and tone the
respiratory system. Take 30 drops bid to
tid.
|
|
|
Homeopathy |
|
An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Allium cepa—for copious, acrid nasal
discharge with bland eye lacrimation that is better outdoors.
- Euphrasia—for bland nasal discharge
with acrid lacrimation that is relieved by lying down at night.
- Sabadilla—for sneezing with watery
discharge from nose and eyes.
- Wyethia—for marked itching of the
nose, throat, and soft palate.
Several OTC combination homeopathics are available for
hayfever. |
|
|
Physical Medicine |
|
- Contrast hydrotherapy. Alternating hot and cold applications brings
nutrients to the site and diffuses metabolic waste from inflammation. The
overall effect is decreased inflammation, pain relief, and enhanced healing.
Alternate three minutes hot with one minute cold. Repeat three times to complete
one set. Do two to three sets/day.
- Nasal lavage. Mix salt and water to taste like tears. Rinse nostrils
by holding head over sink and letting water run from upper nostril to lower
nostril. Keep nostrils lower than throat to prevent salt water draining into
back of throat. Shrinks membranes and increases
drainage.
|
|
|
Acupuncture |
|
Treatment with acupuncture can help promote both immunity and lymphatic
drainage while minimizing the effects of allergic rhinitis. |
|
|
Massage |
|
Therapeutic massage is an excellent way to assist local lymphatic
drainage. |
|
|
Patient Monitoring |
|
Tolerance to substances changes over the lifetime, and emotional stress,
viral illness, fatigue, exposure to chemical irritants, overexertion, or severe
weather conditions can increase reactivity. Eliminating these things can raise
the threshold, as can age (the immune system is less efficient, so IgE
antibodies are less involved with challenging
allergens). |
|
|
Other
Considerations |
|
|
Prevention |
|
- If there is a family history of allergy, eliminate the usual
allergens when possible before symptoms develop.
- Breastfed children have healthier immune systems and fewer
allergies.
|
|
|
Complications/Sequelae |
|
- Development of nonallergic rhinitis medicamentosa from use of nasal
sprays more than twice daily for three consecutive days.
- With use of cortisone—cataracts, glaucoma,
increased blood pressure, ulcers, diabetes, edema, loss of bone density,
avascular necrosis of bone and suppression of adrenal gland function.
- Use of antihistamines or oral steroids may actually increase
sensitivity.
- Secondary infections
- Compromised pulmonary
function
|
|
|
Prognosis |
|
Symptomatic relief is generally achieved. |
|
|
Pregnancy |
|
High levels of vitamins A and C are contraindicated in
pregnancy. |
|
|
References |
|
The Burton Goldberg Group. Alternative Medicine: The Definitive Guide.
Tiburon, Calif: Future Medicine Publishing, Inc; 1997.
Ferri FF. Ferri's Clinical Advisor: Instant Diagnosis and Treatment.
St Louis, Mo: Mosby-Year Book; 1999.
Fisher C. Nettles: an aid to the treatment of allergic rhinitus. Eur J
Herbal Med. 3(2): 34-35.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993.
Noble J, ed. Textbook of Primary Care Medicine. 2nd ed. St Louis, Mo:
Mosby-Year Book; 1996.
Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and
Treatment 1994. Norwalk, Conn: Appleton & Lange;
1994. |
|
Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |