What Is Allergic Rhinitis?
Allergic rhinitis is a chronic inflammatory disease of the nasal mucosa mediated by immunoglobulin E (IgE), triggered by exposure to environmental allergens. It manifests with sneezing, watery rhinorrhea, nasal obstruction, and nasal pruritus, and is the most common allergic disease in the world.
Global prevalence is 10% to 30% of adults and up to 40% of children. In Brazil, epidemiologic studies show prevalence of 25-30% in schoolchildren. Allergic rhinitis is underdiagnosed and undertreated — up to 50% of patients don't seek medical care.
Beyond the direct impact on quality of life, allergic rhinitis is strongly associated with bronchial asthma. Up to 80% of asthmatics have concomitant allergic rhinitis, and uncontrolled rhinitis is a risk factor for poor asthma control. The "united airway" concept recognizes the relationship between upper and lower airways.
IgE Immune Response
Allergic rhinitis is mediated by specific IgE against environmental allergens. Sensitization involves genetic predisposition (atopy) and environmental exposure.
United Airway
Nasal and bronchial inflammation share mechanisms. Up to 80% of asthmatics have concomitant rhinitis, and treating rhinitis improves asthma control.
High Prevalence
Affects 10-30% of adults and up to 40% of children. It's the most common chronic childhood disease and the leading cause of school absenteeism.
Pathophysiology
Allergic rhinitis involves a type I hypersensitivity reaction. In the sensitization phase, the allergen is processed by dendritic cells that present peptides to type 2 helper T lymphocytes (Th2). These produce interleukins IL-4, IL-5, and IL-13, which stimulate B lymphocytes to produce specific IgE.
IgE binds to high-affinity receptors (FcεRI) on the surface of mast cells in the nasal mucosa. On re-exposure to the allergen, cross-linking of IgE molecules occurs, activating the mast cells, which release preformed mediators (histamine, tryptase) and synthesize new mediators (leukotrienes, prostaglandins).
Immediate and Late Phases
The immediate phase occurs within minutes and is mediated mainly by histamine: sneezing, pruritus, rhinorrhea, and vasodilation. The late phase, 4-8 hours later, involves recruitment of eosinophils, basophils, and T lymphocytes, causing persistent nasal obstruction and hyperreactivity.
Chronic inflammation leads to nasal priming — the mucosa becomes progressively more reactive, requiring increasingly smaller concentrations of allergen to trigger symptoms. This phenomenon explains the progressive worsening of symptoms over the course of allergen seasons.
Symptoms
The cardinal symptoms of allergic rhinitis are paroxysmal sneezing, watery rhinorrhea, nasal obstruction, and nasal pruritus. The ARIA (Allergic Rhinitis and its Impact on Asthma) classification divides rhinitis into intermittent or persistent, and mild or moderate/severe.
Symptoms of Allergic Rhinitis
- 01
Paroxysmal sneezing
Series of consecutive sneezes, especially in the morning or after allergen exposure. Typically 5-20 sneezes per episode.
- 02
Anterior watery rhinorrhea
Clear, fluid nasal discharge, different from the purulent rhinorrhea of sinusitis. May be abundant and bilateral.
- 03
Nasal obstruction
Bilateral alternating nasal congestion, worse at night. May cause mouth breathing, snoring, and sleep disturbances.
- 04
Nasal, ocular, and palatal pruritus
Itching of the nose (allergic salute in children), eyes, and palate. Ocular pruritus suggests concurrent allergic conjunctivitis.
- 05
Postnasal drip
Sensation of secretion running down the throat, possibly causing chronic cough and throat clearing.
- 06
Ocular symptoms
Tearing, conjunctival hyperemia, and eyelid edema. Present in up to 70% of patients (allergic rhinoconjunctivitis).
- 07
Fatigue and altered sleep
Chronic nasal obstruction causes fragmented sleep, daytime fatigue, and reduced concentration.
Diagnosis
The diagnosis of allergic rhinitis is clinical, based on a history of recurrent nasal symptoms associated with allergen exposure. Confirmation of allergic sensitization is done by skin prick tests or measurement of serum specific IgE.
Nasal endoscopy assesses the mucosa (pale and edematous appearance in allergic rhinitis) and rules out nasal polyps and septal deviations. Paranasal sinus CT is indicated when concurrent chronic sinusitis is suspected.
🏥ARIA Classification of Allergic Rhinitis
- 1.Intermittent: symptoms present less than 4 days per week or less than 4 consecutive weeks
- 2.Persistent: symptoms present more than 4 days per week and more than 4 consecutive weeks
- 3.Mild: preserved sleep, normal daily activities, work/school without impairment
- 4.Moderate/Severe: disturbed sleep, activity limitation, impairment of work/school, bothersome symptoms
DIFFERENTIAL DIAGNOSIS
Differential Diagnosis
Nonallergic Rhinitis
Negative allergen tests, late onset (adults), triggered by nonspecific irritants (smoke, perfumes, weather changes), no eosinophilia
Chronic Rhinosinusitis
Nasal obstruction, mucopurulent rhinorrhea, hyposmia, facial pressure; CT shows paranasal sinus mucosal thickening
Nasal Septal Deviation
Unilateral or asymmetric nasal obstruction, no paroxysmal sneezing, visible on anterior rhinoscopy; CT confirms
Nasal Polyps
Bilateral progressive nasal obstruction, anosmia, gray-pale mass appearance on nasal endoscopy; association with asthma and ASA
Rhinitis Medicamentosa
Chronic use of topical decongestants (oxymetazoline), rhinitis medicamentosa — rebound congestion after each dose
Nonallergic Rhinitis versus Allergic Rhinitis
Nonallergic rhinitis (NAR) accounts for up to 50% of chronic rhinitis and frequently coexists with allergic rhinitis (mixed rhinitis in up to 44% of cases). Differentiation matters because treatment differs: oral antihistamines are effective in allergic rhinitis but have little efficacy in NAR, while nasal ipratropium is more useful in NAR with predominant rhinorrhea.
Allergic rhinitis typically begins in childhood or adolescence, has specific allergic triggers, and presents nasal eosinophilia and positive allergen tests. NAR begins later (adults), is triggered by nonspecific irritants (weather changes, odors, occupational irritants), and has negative allergen tests. The specialist physician (otolaryngologist or allergist) is essential for the distinction and the correct therapeutic plan.
Nasal Polyps — An Important Complication
Nasal polyps are benign outgrowths of the nasal and sinus mucosa caused by chronic inflammation. When large, they cause progressive bilateral nasal obstruction, anosmia, and persistent sinus symptoms. The "Samter's triad" (nasal polyposis + asthma + ASA/NSAID intolerance) is a classic association that requires specific management — these patients have a risk of severe bronchospasm after ingestion of nonsteroidal anti-inflammatory drugs.
Diagnosis is confirmed by nasal endoscopy, which reveals gray-pale polypoid formations in the middle meatus. Paranasal sinus CT assesses extent. Treatment includes topical nasal corticosteroid (may reduce small polyps), oral corticosteroid courses for large polyps and, in refractory cases, endoscopic sinus surgery. Biologics such as dupilumab are approved for severe refractory nasal polyposis.
Rhinitis Medicamentosa
Rhinitis medicamentosa is caused by chronic use (more than 5-7 consecutive days) of topical nasal decongestants such as oxymetazoline and xylometazoline. Nasal adrenoreceptor dysregulation drives progressive rebound congestion — the patient needs increasingly frequent doses for relief, creating clinical dependence.
Treatment consists of gradual or abrupt decongestant withdrawal (with topical nasal corticosteroid support to ease withdrawal) and treatment of the underlying cause. The physician can guide an individualized weaning protocol. Never use topical nasal decongestants for more than 5-7 consecutive days — this is the safety limit for preventing dependence.
Treatment
Treatment of allergic rhinitis is based on three pillars: environmental control (reduction of allergen exposure), pharmacotherapy, and allergen-specific immunotherapy. The approach is stepwise according to the ARIA classification.
Environmental Control
Impermeable mattress and pillow covers, weekly bedding washes at 60°C / 140°F, humidity reduction (<50%), removal of carpets and curtains, HEPA filters. Modest standalone efficacy, but important as a complementary measure.
First-Line Pharmacotherapy
Topical nasal corticosteroid (mometasone, fluticasone, budesonide) — the most effective treatment for all symptoms. Second-generation antihistamines (cetirizine, loratadine, fexofenadine) for sneezing and pruritus. Saline nasal irrigation.
Second-Line Pharmacotherapy
Antileukotrienes (montelukast) as adjuncts. Nasal ipratropium for refractory rhinorrhea. Short-term topical nasal decongestants (maximum 5-7 days). Nasal corticosteroid combined with azelastine (Dymista).
Immunotherapy and Complementary Therapies
Allergen-specific immunotherapy (subcutaneous or sublingual) for 3-5 years in patients with moderate/severe rhinitis who don't respond to pharmacotherapy. Acupuncture as complementary therapy. Surgery (turbinectomy) for refractory obstruction.
Acupuncture as Treatment
Acupuncture is one of the complementary therapies with available clinical literature for allergic rhinitis. Mechanisms proposed in preclinical and clinical studies — not yet established as definitive — include possible modulation of the Th1/Th2 immune response, influence on specific IgE levels, regulation of histamine and neuropeptide release, and modulation of the nasal autonomic nervous system.
Large randomized clinical trials demonstrate that acupuncture significantly improves nasal symptom scores and quality of life compared with sham acupuncture. Clinical guidelines in several countries, including ARIA, recognize acupuncture as a complementary therapeutic option.
A typical protocol involves 12 sessions over 8 weeks, with benefits that may persist for months after treatment ends. Acupuncture is especially indicated for patients who prefer to reduce medication use or experience adverse effects with conventional pharmacotherapy.
Prognosis
Allergic rhinitis is a chronic condition that rarely resolves spontaneously, but it's controllable with appropriate treatment. Most patients achieve satisfactory symptom control with regular pharmacotherapy and environmental control.
Allergen-specific immunotherapy is the only treatment capable of modifying the natural history of the disease, reducing allergic sensitization and the risk of developing asthma in children with allergic rhinitis. Benefits persist for years after treatment ends.
Untreated complications include chronic sinusitis, otitis média with effusion, sleep disturbances, and impact on school and occupational performance. Early recognition and appropriate treatment prevent these consequences.
Myths and Facts
Myth vs. Fact
Allergic rhinitis is just a little cold — no need to treat
Allergic rhinitis is a chronic inflammatory disease that significantly impacts quality of life, sleep, and productivity. Without treatment, it can progress with complications such as chronic sinusitis and asthma.
Antihistamines are the best treatment
Topical nasal corticosteroid is superior to antihistamines for overall symptom control, especially nasal obstruction. Antihistamines are effective for sneezing and pruritus but insufficient for obstruction.
Food allergies cause allergic rhinitis
Allergic rhinitis is caused by aeroallergens (mites, pollens, fungi, animal epithelia), not by foods. Food allergies cause gastrointestinal, cutaneous, or anaphylactic symptoms, not persistent rhinitis.
Treatment with nasal decongestant is safe long term
Topical nasal decongestants used for more than 5-7 days cause rhinitis medicamentosa (rebound effect). Chronic use creates functional dependence and progressively worsens nasal obstruction.
Allergic rhinitis resolves with age
Although symptoms may fluctuate, allergic sensitization persists. Most patients will continue to have symptoms throughout life, although severity may vary.
When to Seek Help
Allergic rhinitis should be evaluated by a specialist when symptoms are persistent, impact quality of life, or don't respond to over-the-counter medications.
Frequently Asked Questions
Allergic rhinitis isn't curable, but it can be very well controlled. With appropriate treatment (environmental control, nasal corticosteroid, immunotherapy), most patients achieve complete symptom control. Allergen-specific immunotherapy is the only modality that modifies the natural history of the disease, potentially leading to prolonged remission.
Yes. Medical acupuncture has robust clinical evidence for allergic rhinitis — guidelines such as ARIA (Allergic Rhinitis and its Impact on Asthma, Bousquet 2020) and Cochrane studies confirm efficacy. Mechanisms include modulating the IgE response, reducing nasal eosinophilic inflammation, and regulating the autonomic nervous system. It can be used alone or combined with conventional treatment.
Topical nasal corticosteroid (mometasone, fluticasone, budesonide) is the most effective treatment for all allergic rhinitis symptoms, especially nasal obstruction. Oral or topical antihistamines control sneezing and rhinorrhea. Allergen-specific immunotherapy is the disease-modifying option indicated for moderate to severe persistent cases.
If you're sensitized to the animal's epithelia (confirmed by allergen testing), exposure should be minimized. In cases of confirmed pet allergy, the physician will assess whether separation is needed. Alternative measures include keeping the animal out of the bedroom, using HEPA filters, and cleaning frequently.
They're complementary options, not alternatives to each other. Allergen-specific immunotherapy is the only treatment that modifies long-term immunologic sensitization. Medical acupuncture can control symptoms, reduce medication needs, and improve quality of life, and can be combined with immunotherapy for optimized results.
Clinical diagnosis is based on history and physical examination. To identify specific allergens, the physician may request: skin prick tests, total and specific serum IgE measurement, and nasal endoscopy to assess the mucosa and rule out polyps or septal deviation. These tests guide treatment and immunotherapy.
Allergic rhinitis is a risk factor for the development of bronchial asthma — patients with uncontrolled rhinitis have a higher probability of developing asthma. The "united airway" concept explains that allergic inflammation of the upper and lower airways is continuous. Adequately treating rhinitis improves asthma control in patients with both conditions.
Yes. Nasal irrigation with isotonic or hypertonic saline solution (saline solution or rhinitis solution) removes allergens and secretions from the nasal mucosa, reduces inflammation, and improves nasal permeability. It's safe for daily use and potentiates nasal corticosteroid efficacy when used beforehand. Recommended as an adjunctive measure.
Most patients notice symptom improvement starting at the 3rd-4th session. An initial cycle of 8-10 sessions (twice a week) is standard for allergic rhinitis. Monthly maintenance sessions are recommended to prevent relapse, especially during periods of greater allergen exposure (spring/summer for pollens, year-round for mites).
No. Topical nasal decongestants (oxymetazoline, xylometazoline) shouldn't be used for more than 5-7 consecutive days. Prolonged use causes rhinitis medicamentosa — progressive rebound congestion that creates dependence. For chronic nasal obstruction, topical nasal corticosteroid is the safe, effective solution for continued use.
Related Reading
Deepen your knowledge with related articles