Allergic rhinitis is seasonal or perennial pruritus, sneezing, rhinorrhea, nasal congestion, and sometimes conjunctivitis, caused by exposure to pollens or other allergens. Diagnosis is by history and occasionally skin testing. First-line treatment is with a nasal glucocorticoid (with or without an oral or a nasal antihistamine) or with an oral antihistamine plus an oral decongestant.
Allergic rhinitis may occur seasonally or throughout the year (as a form of perennial rhinitis). Seasonal rhinitis is usually allergic. (See also Overview of Allergic and Atopic Disorders.)
At least 25% of perennial rhinitis is nonallergic. The numerous nonallergic forms of perennial rhinitis include infectious, vasomotor, medication-induced (eg, aspirin- or nonsteroidal anti-inflammatory drug [NSAID]–induced), atrophic rhinitis and nonallergic rhinitis with eosinophilia (NARES).
Seasonal allergic rhinitis (hay fever) is most often caused by plant allergens, which vary by season and geographic location. Common plant allergens include:
Spring: Tree pollens (eg, oak, elm, maple, alder, birch, juniper, olive)
Summer: Grass pollens (eg, Bermuda, timothy, sweet vernal, orchard, Johnson) and some weed pollens (eg, Russian thistle, English plantain)
Fall: Other weed pollens (eg, ragweed)
Causes also differ by region, and seasonal allergic rhinitis is occasionally caused by airborne fungal (mold) spores.
Perennial rhinitis is caused by year-round exposure to indoor inhaled allergens (eg, dust mite feces, cockroach components, animal dander) or by strong reactivity to plant pollens in consecutive seasons.
Allergic rhinitis and asthma frequently coexist.
Symptoms and Signs of Allergic Rhinitis
Patients have pruritus (in the nose, eyes, or mouth), sneezing, rhinorrhea, and nasal and sinus obstruction. Sinus obstruction may cause frontal headaches; viral or bacterial sinusitis is a frequent complication of allergic rhinitis. Coughing and wheezing may also occur, especially if asthma is also present.
The most prominent feature of perennial rhinitis is chronic nasal obstruction (manifesting as congestion), which, in children, can lead to chronic otitis media; symptoms vary in severity throughout the year. Itching is less prominent than in seasonal rhinitis. Chronic sinusitis and nasal polyps may develop.
This anterior rhinoscopy of a patient with allergic rhinitis shows boggy, bluish-red inferior turbinate hypertrophy.
CLINICA CLAROS/SCIENCE PHOTO LIBRARY
Signs include boggy or edematous, bluish-red nasal turbinates (ie, inferior turbinate hypertrophy).
This photo shows bilateral periorbital edema with mild blepharitis mostly of the lower eyelids and conjunctival erythema in a patient with allergic conjunctivitis. Pruritis and clear discharge may also be present.
DR P. MARAZZI/SCIENCE PHOTO LIBRARY
In some cases of allergic rhinitis, conjunctival symptoms may occur. Conjunctival symptoms include bilateral mild to severe ocular itching, conjunctival hyperemia, photosensitivity, chemosis, eyelid edema, and a watery or stringy discharge.
Diagnosis of Allergic Rhinitis
History and physical examination
Occasionally skin testing, allergen-specific serum IgE tests, or both
This diagnosis of allergic rhinitis is primarily clinical, with confirmatory allergen-specific testing performed when needed (1, 2). Typical nasal symptoms include sneezing, anterior rhinorrhea, congestion, and pruritus, sometimes accompanied by ocular symptoms such as pruritus, tearing, and redness.
Rhinitis is usually classified based on symptom duration and frequency as intermittent (< 4 days/week or < 4 consecutive weeks/year) or persistent (≥ 4 days/week and ≥ 4 consecutive weeks/year) (2).
Confirmatory testing is not routinely needed unless patients do not improve when treated empirically; for such patients, skin tests may be done to identify a reaction to pollens (seasonal) or to dust mite feces, cockroaches, animal dander, mold, or other antigens (perennial), which can be used to guide additional treatment.
Occasionally, skin test results are equivocal, or testing cannot be done (eg, because patients are taking medications that interfere with results and cannot safely be withheld); then, an allergen-specific serum IgE test may be done.
A nasal smear to detect eosinophils can be done to confirm allergic rhinitis. It can be a useful alternative to blood tests in children or used as an additional tool in the evaluation of rhinitis. Nasal smear testing has moderate sensitivity (> 50%) and high specificity (> 95%), however, the test is rarely done in practice (1, 3). Eosinophilia detected on nasal smear along with negative skin testing for allergens suggests either aspirin sensitivity or nonallergic rhinitis with eosinophilia (NARES).
Nonallergic perennial rhinitis can also be diagnosed based on history. Lack of a clinical response to treatment for assumed allergic rhinitis and negative results on skin tests and/or an allergen-specific serum IgE test also suggest a nonallergic cause; disorders to consider include nasal tumors, enlarged adenoids, hypertrophic nasal turbinates, granulomatosis with polyangiitis, and sarcoidosis.
Diagnosis references
1. Bernstein JA, Bernstein JS, Makol R, Ward S. Allergic Rhinitis: A Review. JAMA. 2024;331(10):866-877. doi:10.1001/jama.2024.0530
2. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767. doi:10.1016/j.jaci.2020.07.007
3. Usha G, Pal I, Kumar S, Mondal B, Basu G. Assessment of Nasal Smear Eosinophil Counts in Allergic Rhinitis: How Useful is it? Indian J Otolaryngol Head Neck Surg. 2022;74(4):540-546. doi:10.1007/s12070-022-03109-x
Treatment of Allergic Rhinitis
Removal or avoidance of environmental allergens
Antihistamines (oral, nasal, or both)
Nasal glucocorticoids
Sometimes desensitization (ie, immunotherapy)
The treatment approaches for seasonal and perennial allergic rhinitis are broadly similar, although allergen avoidance strategies differ depending on the suspected trigger (1). Removal or avoidance of environmental allergens (eg, eliminating dust mites and cockroaches) is recommended for perennial rhinitis. For moderate-to-severe, refractory, seasonal or perennial allergic rhinitis, desensitization (ie, allergen immunotherapy) may help alleviate symptoms. Treatment approaches vary depending on symptom pattern (ie, intermittent or persistent) and severity (mild, or moderate-to-severe) (2).
Medication classes used in the treatment of allergic rhinitis are:
Intranasal or oral antihistamines
Sometimes decongestants (intranasal or oral)
Sometimes combination therapy (eg, intranasal glucocorticoid plus intranasal antihistamine, intranasal antihistamine plus intranasal decongestant)
In general, treatment of intermittent rhinitis is with antihistamines (oral or intranasal). The treatment of persistent rhinitis is preferably with intranasal glucocorticoids, however, intranasal antihistamines or their combination (ie, intranasal glucocorticoids plus intranasal antihistamines) are alternatives.
Combinations of azelastine/fluticasone (137 mcg/50 mcg) and olopatadine/mometasone (665 mcg/25 mcg) may be used.
Intranasal saline, often forgotten, helps mobilize thick nasal secretions and hydrate nasal mucous membranes; various saline solution kits and irrigation devices (eg, squeeze bottles, bulb syringes) and kits are available over the counter, or patients can make their own solutions.
Montelukast, a leukotriene receptor antagonist, relieves allergic rhinitis symptoms bu should be used cautiously because of a boxed warning for neuropsychiatric adverse effects (eg, aggression, depression, sleep disturbances, suicidal thoughts and behavior). However, evidence from longitudinal data has been mixed, including two large cohort studies that did not identify an increased risk of neuropsychiatric adverse effects (3, 4).
Decongestants are not recommended as a first-line therapy but can provide short-term symptomatic relief of nasal congestion. Prolonged use of intranasal decongestant sprays (eg, oxymetazoline, phenylephrine) can lead to rebound congestion (rhinitis medicamentosa), and oral decongestants (eg, a sympathomimetic such as pseudoephedrine) may lead to tachycardia and hypertension. Therefore, the use of decongestants is not recommended beyond 3 to 5 days.
Less effective alternatives include nasal mast cell stabilizers (eg, cromolyn) and intranasal ipratropium, an anticholinergic, which relieves rhinorrhea.
Some medications may be particularly helpful when allergic rhinitis coexists with uncontrolled moderate to severe persistent asthma and chronic rhinosinusitis with nasal polyps. Omalizumab, a monoclonal antibody directed against IgE, and dupilumab, a monoclonal antibody directed against IL-4/IL-13, have demonstrated improvement in both upper airway symptoms and asthma (5, 6).
Treatment references
1. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767. doi:10.1016/j.jaci.2020.07.007
2. Bernstein JA, Bernstein JS, Makol R, Ward S. Allergic Rhinitis: A Review. JAMA. 2024;331(10):866-877. doi:10.1001/jama.2024.0530
3. Sansing-Foster V, Haug N, Mosholder A, et al. Risk of Psychiatric Adverse Events Among Montelukast Users. J Allergy Clin Immunol Pract. 2021;9(1):385-393.e12. doi:10.1016/j.jaip.2020.07.052
4. Wintzell V, Brenner P, Halldner L, Rhedin S, Gong T, Almqvist C. Montelukast Use and the Risk of Neuropsychiatric Adverse Events in Children. JAMA Pediatr. 2025;179(4):418-427. doi:10.1001/jamapediatrics.2024.5429
5. Rank MA, Chu DK, Bognanni A, et al. The Joint Task Force on Practice Parameters GRADE guidelines for the medical management of chronic rhinosinusitis with nasal polyposis. J Allergy Clin Immunol. 2023;151(2):386-398. doi:10.1016/j.jaci.2022.10.026
6. Sousa-Pinto B, Bousquet J, Vieira RJ, et al. Allergic Rhinitis and Its Impact on Asthma (ARIA)-EAACI Guidelines-2024-2025 Revision: Part I-Guidelines on Intranasal Treatments. Allergy. 2026;81(4):954-976. doi:10.1111/all.70131
Prevention of Allergic Rhinitis
Avoidance of triggers
Sometimes desensitization
Avoidance of triggers
For perennial allergies, triggers should be removed or avoided if possible. Strategies include the following:
Removing items that collect dust, such as knickknacks, magazines, books, and soft toys
Using synthetic fiber pillows and impermeable mattress covers
Frequently washing bed sheets, pillowcases, and blankets in hot water
Frequently cleaning the house, including dusting, vacuuming, and wet-mopping
Removing upholstered furniture and carpets or frequently vacuuming them
Replacing draperies and shades with blinds
Exterminating pests (eg, cockroaches, mice) to eliminate exposure
Using dehumidifiers in basements and other poorly aerated, damp rooms
Using high-efficiency particulate air (HEPA) vacuums and filters
Avoiding food or medication triggers
Limiting pets to certain rooms or keeping them out of the house
For people with severe seasonal allergies, possibly moving to an area that does not have the allergen
Adjunctive nonallergenic triggers (eg, cigarette smoke, strong odors, irritating fumes, air pollution, cold temperatures, high humidity) should also be avoided or controlled when possible.
Desensitization
Desensitization immunotherapy may be more effective for seasonal than for perennial allergic rhinitis; it is indicated when:
Symptoms are severe.
The allergen cannot be avoided.
Medication treatment is inadequate.
Desensitization can be achieved by the use of sublingual immunotherapy or subcutaneous immunotherapy.
First attempts at desensitization should begin soon after the pollen season ends to prepare for the next season; adverse reactions increase when desensitization is started during the pollen season because the person’s allergic immunity is already maximally stimulated.
See Immunotherapy for more information on administration of subcutaneous and sublingual immunotherapy.
Key Points
Seasonal rhinitis is usually an allergic reaction to pollens; perennial allergic rhinitis is caused by year-round exposure to indoor inhaled allergens or by strong reactivity to plant pollens in sequential seasons.
Patients with allergic rhinitis may have cough, wheezing, frontal headache, sinusitis, or, particularly in children with perennial rhinitis, otitis media.
Diagnosis of allergic rhinitis is usually based on the history; skin tests and sometimes an allergen-specific serum IgE test are needed only when patients do not respond to empiric treatment.
Try intranasal glucocorticoids for persistent rhinitis and oral or intranasal antihistamines for intermittent or seasonal rhinitis.
Other treatments include montelukast, decongestants, and intranasal mast cell stabilizers.
Desensitization immunotherapy (subcutaneous or sublingual) is indicated when symptoms are severe, allergens cannot be avoided, or medication treatment is inadequate.
Drug Information for the Topic
