Signs and Symptoms

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

Differential Diagnosis

• Perennial rhinoconjunctivitis (non-seasonal)
• Infective rhinosinusitis
• Non-allergic (e.g. hormonal, drug-induced, vasomotor) rhinitis

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

Consider referral to ENT (see referral details)

1. Mild symptoms should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dosing
2. Moderate-severe symptoms should be treated with intranasal corticosteroid 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. Start antihistamines and intranasal corticosteroids two weeks before usual symptom onset and continue throughout season
      
   2. Training in appropriate nasal spray technique essential. Guidance can be found by scrolling down to the nasal spray section at National asthma - intranasal-corticosteroid-spray-technique
3. Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15- 20mg for a maximum of 5 days as a one-off treatment can be used for severe symptoms uncontrolled on conventional therapy, to control symptoms during important periods (e.g. exams or other major events).
4. Topical anti-inflammatory eye drops are useful to manage allergic conjunctivitis.

Consider a concomitant diagnosis of asthma and manage according to guidelines

• Montelukast can be added to conventional therapy in patients with seasonal allergic rhinitis and concomitant asthma.

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.

Experience from Peninsula Immunology and Allergy Service suggests that 70% of patients referred with severe symptoms achieve satisfactory symptom control using non-sedating antihistamines and regular intranasal corticosteroids alone.

Referral Criteria

• Seasonal symptoms that are severe and resistant to treatment (when combination treatment at maximum doses has been attempted throughout the season). Treatment should be initiated at least 2 weeks before the anticipated start of the pollen season.

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 ICB -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 ICB - 15N

Referral Forms

DRSS Referral form

Torbay and South Devon seeking advice form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: March 2016

Updated: September 2023