Allergic Rhinitis 12-Month Treatment Plan: Medication, Environment and Immunotherapy

Allergic rhinitis is an IgE-mediated hypersensitivity of the nasal mucosa. The classic tetrad: sneezing, rhinorrhoea, itching (nose, eyes, palate) and obstruction. Associated features: post-nasal drip, conjunctivitis, partial smell loss and impaired sleep.

Seasonal allergic rhinitis (hay fever) is driven by tree, grass and weed pollens. In Türkiye, tree pollens (olive, plane, birch) peak March-May, grasses May-July, weeds (composite, parietaria) August-October.

Perennial allergic rhinitis is linked to house-dust mite, animal dander (especially cat), moulds and cockroach allergens. Symptoms are continuous without a seasonal peak. The perennial form predominates in children; the seasonal form dominates in adults.

Comorbidities are common: allergic conjunctivitis, asthma (up to 40% with allergy), atopic dermatitis, sinusitis, otitis media. The "allergic march" — atopic dermatitis in infancy progressing to allergic rhinitis and asthma — is well described. Related service: our general ENT services.

Diagnosis is usually clinical — history and examination. Symptom seasonality, triggers, family history, and atopic comorbidities are assessed. Nasal endoscopy reveals mucosal pallor and bluish hue typical of allergy, polyp presence and the character of secretions.

Allergy testing confirms the diagnosis and is required for immunotherapy planning. Skin prick test (SPT) is the most common — a 15-20 allergen panel with results in 20 minutes, inexpensive. Antihistamines interfere (stop at least 5 days prior). For severe atopic dermatitis, pregnancy, or patients on beta-blockers, specific IgE assays (ImmunoCAP) are preferred.

Total IgE alone is not diagnostic; it is a screening parameter. Eosinophilia in blood or nasal smear can support the diagnosis. Nasal allergen provocation has limited clinical use and is mainly a research tool.

For house-dust mite: mite-proof covers on bedding and pillows, weekly washing at 60°C, replacing carpets with laminate, swapping fabric sofas for leather, keeping humidity below 50%, vacuuming with a HEPA filter. These steps alone can reduce symptom score by 20-30%.

For pollen: avoid outdoor exposure at peak times (early morning and late afternoon), keep windows closed, run AC on recirculation, change clothes and shower on return home, wear glasses outside. Tracking pollen forecasts optimises medication timing.

Animal allergy: ideally remove the animal — usually impractical. Restrict the pet from the bedroom, weekly bathing, frequent ventilation. Cat allergen stays airborne for months after the cat leaves the home, with elevated levels 4-6 months later.

Environmental control alone is rarely sufficient, but layered onto pharmacotherapy it meaningfully improves quality of life. The core message to patients: "You may still need medication, but there is also a lot you can do."

Intranasal corticosteroids (INCS) — mometasone furoate, fluticasone furoate / propionate, budesonide, beclomethasone — are the single most effective drug class for allergic rhinitis. Local anti-inflammatory action with minimal systemic absorption. Effective for all symptom categories, including obstruction.

Full effect develops after 1-2 weeks of regular use; expecting day-one effect is wrong. In seasonal disease start 1-2 weeks before pollen season. In perennial disease use year-round, titrating dose by season.

Technique determines efficacy: aim the spray toward the lateral nasal wall (not parallel to the floor of the nose). Head slightly forward. This avoids the septum and lowers epistaxis risk. Side effects: nasal bleeding (5-10%), dryness (2-5%), rare taste change. Systemic effects with modern molecules are negligible.

INCS safety in children is good; growth effect is under 0.5 cm/year, of low clinical significance. In pregnancy budesonide is preferred as a Category B agent. Step-by-step details: sinusitis page.

Second-generation oral H1 antihistamines (cetirizine 10 mg, loratadine 10 mg, desloratadine 5 mg, fexofenadine 120-180 mg, bilastine 20 mg) help sneezing, itching and rhinorrhoea. Obstruction relief is limited. Sedation is low (desloratadine, fexofenadine, bilastine are "non-sedating").

First-generation antihistamines (diphenhydramine, chlorpheniramine) are not recommended because of sedation — they impair concentration and reaction time and are unsuitable for drivers or school-age children.

Intranasal azelastine offers local action and rapid onset (15 minutes). The combined spray (azelastine + fluticasone) outperforms either monotherapy in moderate-severe cases.

Leukotriene receptor antagonist montelukast (10 mg/day) has value as add-on therapy when asthma coexists. It is not a first-line in isolated allergic rhinitis. FDA boxed-warning since 2020 for neuropsychiatric effects — informed counselling is required at prescribing.

Decongestant nasal sprays (oxymetazoline, xylometazoline) must be limited to under 3 days. Longer use causes rhinitis medicamentosa — rebound mucosal oedema.

Allergen-specific immunotherapy (AIT) is the only disease-modifying treatment — re-educating the immune system toward tolerance. Subcutaneous immunotherapy (SCIT) is classical: weekly build-up, then monthly maintenance for 3-5 years. Sublingual immunotherapy (SLIT) is daily tablets or drops at home.

Indications: moderate-to-severe allergic rhinitis with inadequate response to or intolerance of pharmacotherapy, mono- or oligo-sensitisation, and asthma-prevention in children (the evidence is strongest in paediatrics). Lower age limit is generally 5 years.

AIT is unique in changing disease trajectory: benefit persists 5-10 years beyond the 3-5-year course. In some patients durable remission is achieved. It also reduces the risk of progressing to asthma.

Risks: SCIT — local swelling, rare systemic reactions (anaphylaxis 1/1,000-1/10,000 injections). Administration in a clinic with 30-minute observation is required. SLIT has lower systemic risk; oral and lip swelling or itching can occur.

February-March: pre-season. Tree pollens approach. Start INCS 1-2 weeks before symptoms. Plan skin prick testing if not yet done. Review environmental controls.

April-June: peak tree and early grass season. INCS + daily antihistamine as standard. With inadequate control, add azelastine / fluticasone combined spray. Short oral steroid (prednisone 0.5 mg/kg, 5-7 days) is rarely considered for severe flares.

July-August: late grass and weed period. Maintain therapy. Summer holidays away from the allergen often bring relief.

September-October: parietaria, composite weeds. Obstruction may increase in this window. In refractory cases plan ENT consultation, sinus CT, evaluation of structural components (septum, turbinates).

November-January: low pollen, dust-mite dominant. Climate and bedding allergen control take priority. This window is a good time to start AIT — pre-season run-in. Annual review, medication reconciliation and planning for the next year happen here. We share patient experiences on our Istanbul ENT services.