Allergic Rhinitis/Conjunctivitis (perennial / non-seasonal)

Scope

Diagnosis and management of perennial (non-seasonal) allergic rhinitis/conjunctivitis. For seasonal allergic rhinitis see separate guidelines

Assessment

Signs and Symptoms

  • Bilateral nasal itching
  • Congestion and rhinorrhoea
  • Sneezing
  • Bilateral conjunctivitis.

Ask about triggers (e.g. pets) if symptoms intermittent all year round (perennial).

Differential Diagnosis

  • Seasonal rhinitis (symptoms only in pollen season spring/summer)
  • Infective rhinosinusitis
  • Non-allergic (eg hormonal, drug-induced, vasomotor) rhinitis

For diagnostic algorithm see:

Red Flags

  • Unilateral symptoms
  • Polyps
  • Persistent blood stained discharge or persistent purulent discharge.

Consider referral to ENT. (see referral details)

Investigations

Send blood for specific IgE to suspect aero-allergen (most commonly house dust mite and pets if exposed).

Management

  1. Allergen avoidance where possible (e.g. house dust mite reduction measures or pet avoidance).
  2. Mild symptoms should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dosing (cetirizine 10mg, loratadine 10mg, or fexofenadine 180mg up to twice daily).
  3. Moderate-severe symptoms should be treated with intranasal corticosteroid (e.g. beclometasone, two sprays into each nostril twice daily; consider alternative (e.g. mometasone or fluticasone furoate) in addition to non-sedating antihistamines. Consistent daily use of intranasal use is vital, given maximal effect may not be apparent for at least two weeks.
    1. Training in appropriate nasal spray technique essential. Guidance is available at National asthma - intranasal-corticosteroid-spray-technique
  4. Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15 - 20mg for a maximum of 5 days as a one-off course can be used for severe symptoms uncontrolled on conventional therapy, to control symptoms during important periods (e.g. exams or other major events).
  5. Topical sodium cromoglicate eye drops are useful to manage allergic conjunctivitis, see section 11.4 Corticosteroid and other anti-inflammatory preparations

Consider a concomitant diagnosis of asthma and manage according to guidelines

Avoid sedating antihistamines, depot corticosteroids, and chronic use of decongestants.

Treatment failure should prompt a review of the diagnosis, compliance with therapy (regular therapy is more effective than "as required" treatment), and intranasal corticosteroid technique.

For more information see

North and East Devon Formulary: Allergic rhinitis

BSACI - Rhinitis management guidelines

Onlinelibrary.wiley - guidelines for the management of allergic and non-allergic rhinitis

Referral

Referral Criteria

  • Perennial symptoms that are severe and resistant to treatment (when combination treatment at maximum doses has been attempted for at least 3 months)

Referral Instructions

Red Flags – refer to ENT
  • Refer using e-Referral Service
    • Specialty: ENT
    • Clinic type: Not otherwise specified
    • Service: DRSS-South Devon & Torbay-Ear Nose and Throat- Devon CCG -15N
Refer to Peninsula Immunology and Allergy Service
  • Refer using e-Referral Service
    • Specialty: Allergy
    • Clinic type: Allergy
    • Service: DRSS-South Devon & Torbay-Allergy- Devon CCG - 15N

Referral Forms

DRSS Referral form

Torbay and South Devon seeking advice form

Supporting Information

GP Information

BSACI - Rhinitis management guidelines

Onlinelibrary.wiley - guidelines for the management of allergic and non-allergic rhinitis

Pathway Group

This guideline has been signed off by South Devon and Torbay CCG.

Publication date: March 2016

 

Home > Referral > SDevon & Torbay > Allergies > Allergic Rhinitis/Conjunctivitis (perennial / non-seasonal)

 

  • First line
  • Second line
  • Specialist
  • Hospital