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

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

Consider referral to ENT. (see referral details)

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

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.
3. 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. 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
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 anti-inflammatory eye drops are useful to manage allergic conjunctivitis.

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 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-Western-ENT- Devon ICB-15N

Refer to Peninsula Immunology and Allergy Service

• Refer using e-Referral Service
  • Specialty: Allergy
  • Clinic type: Allergy
  • Service: DRSS-Western-Allergy & Immunology-Devon ICB-15N

Referral Form

DRSS Referral form

Evidence

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

Pathway Group

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

Publication date: March 2016

Updated: September 2023