By Dr. Vivek Sinha
The weather is getting warmer, the days are getting longer and in doctor’s offices across the country, calls are coming in from people asking for help with their seasonal allergies. The runny nose, the itchy eyes, the sneezing: Is there no relief for these symptoms? Luckily, there is a lot that we know about seasonal allergies and more importantly, there are many things that can be done to help. But like most things in medicine, we should start with the basics.
The medical term that physicians use most commonly when talking about seasonal allergies is allergic rhinosinusitis. It is a combination of symptoms that includes postnasal drip, cough, sneezing, runny nose, itching of the eyes, nose and palate and fatigue. This condition is extremely common in the United States and the economic burden it causes is significant. According to the National Library of Medicine, up to 30% of the U.S. population suffers from some level of allergic rhinosinusitis.
Seasonal allergic rhinosinusitis is actually caused by an allergy to indoor and outdoor allergens. Outdoor allergens include pollen from trees, grass and other plants. These allergy symptoms are usually predictable and reproducible year to year. The types of pollen can vary depending on geographic location. Indoor allergens usually include mold spores, cockroaches, animal dander and dust mites.
How do doctors diagnose allergic rhinosinusitis? While there are multiple factors to consider, obtaining an accurate and thorough history of symptoms is the first and most important step. After taking a thorough history, the next most important step is a thorough physical examination. There are certain specific findings that we see in patients. The skin of the nasal passages frequently will have a bluish tinge. Clear drainage may be visible in the front of the nasal passages or may even be seen dripping down the back of the throat. When this happens, the posterior pharynx may become inflamed and look like little cobblestones.
Allergy testing via blood testing or skin testing is an option. While both of these tests are very helpful in narrowing down specific allergens, the tests are not necessary to perform prior to making a formal diagnosis and formulating a treatment plan. As a primary care physician, I will often diagnose and treat patients based on clinical symptoms and history. However, in patients with symptoms who are not responding to treatment, those with unclear symptoms or very severe symptoms or those with concurrent severe asthma symptoms, we will often refer to an allergist for formal testing.
When it comes to treatment, luckily, we have several good options for patients suffering from this condition.
Often, the first line of treatment is utilizing nasal saline sprays/irrigation. These sprays can wash away allergens from the nasal passage and may resolve symptoms or they may be used immediately prior to using medicated nasal sprays. Saline nasal sprays are readily available over the counter and come in many different types of spray bottles, bulb syringes and neti pots. Due to the risk of bacteria, tap water is not recommended for nasal rinse.
The next line agent that we would go to is a glucocorticoid, or steroid, nasal spray. Typical examples are Nasacort and Flonase, although there are generic options available as well. These highly effective sprays are the single most effective treatment for maintenance therapy with the least amount of side effects. They target nasal congestion, sneezing, nasal itching and postnasal drip. While they can start working within an hour or two, in patients who have long-standing untreated symptoms, several days of treatment may be necessary prior to seeing the maximum benefit. Since these are steroids, they should be used only as directed and with caution. While the risk is small, long-term use of these medications can cause systemic side effects in both children and adults.
A third type of nasal spray is known as antihistamine nasal sprays. Examples include Astepro Allergy and Patanase. These medications have a rapid onset of action, but they often have a bitter taste that is bothersome to some people. These nasal sprays are a good option in people who need to avoid steroids, although they are typically not as effective.
The next line of medications that we often use are oral antihistamine pills. There are many over the counter options available, such as Benadryl, Claritin, Zyrtec or Allegra. These medicines target the histamine receptors and reduce the symptoms of sneezing, itching and runny nose. They are divided into first- and second-generation medications. The second-generation medications, such as Allegra, Zyrtec and Claritin, are usually preferred because they are less sedating.
Although they are less used and are generally not as effective as the over-the-counter options, prescription options are a useful add-on when symptoms are not able to be managed by over-the-counter medications alone. These medications have different mechanisms of action, which is why they may be useful as an add-on therapy. Examples of these medications include Singulair, a pill, Atrovent, an oral inhaler, and NaslCrom, a nasal spray.
There are also allergy shots for patients who have severe symptoms and whose condition is not improved by any of these medications.
Allergy treatment options are wide and varied, however, it is important to speak to your individual provider to ensure that these options are a safe and viable option given your individual medical history. So, speak to your doctor and get out and enjoy the weather!
The writer is chief medical officer of Belleview Medical Partners, an office and house call practice based in Old Town.