SEASONAL ALLERGIC RHINITIS (HAY FEVER)

One of the most common diseases, especially in some parts of the US, is Seasonal Allergic Rhinitis. That the fancy term doctors give to plain old garden variety Hay Fever. As far as annoying symptoms, hay fever ranks right up there with some of the most symptomatic of diseases. Sufferers find it miserable and will seek any remedy they can find to ease symptoms. I have never had hay fever but after seeing hundreds of patients who had it, I think I have a good idea what they are dealing with.

Most hay fever is due to allergic reactions to grasses, ragweed, dust mites, and other airborne allergens. It is seasonal because in some areas of the country, airborne allergens are present only at certain times of the year, ie. “Hay fever season.” Perennial allergic rhinitis is a worse variety because patients have symptoms year round. The previously-mentioned dust mites are microscopic insect-like parasites that live in house dust, dead skin cells, or animal dander, and are more often associated with perennial rhinitis. 

When inhaled into the nasal passages, allergens cause a significant amount of local inflammatory reaction. Allergens of any variety stimulate Immunoglobulin-E to activate mast cells and basophils to release histamine and leukotrienes. (Basophils are a type of white blood cell. Mast cells are part of the immune system.) Histamine is very irritating to the cells lining the nose, sinuses, and throat and the membranes of the eyelids and eyeball. It’s presence causes swelling and vasodilation of the tissues. This reaction causes nasal obstruction, a runny nose and sneezing, and itchy, watery eyes and eyelids. My father-in-law was a particularly bad hay fever sufferer. His was seasonal, but during hay fever season he was so miserable, his physical activity was limited. He couldn’t breathe through his nose, sneezed all the time, and the whites of his eyes were visibly swollen. 

Seasonal allergic rhinitis is a clinical diagnosis—the diagnosis is made by history, physical exam findings, and symptoms. In more severe or challenging cases, skin testing is done to pinpoint what specific things the patient is allergic to. With that information, shots to desensitize the patient to that allergen could then be given.    

Does one “outgrow” allergies? The answer is yes. 

Can you develop new allergies late in life? Yes. You become sensitized to new allergens. 

Are allergies contagious? Of course not, but they are familial ie. they are inherited from your parents or grandparents.

Treatment of Allergic Rhinitis is designed to do two things. 

     1. Avoid the things you’re allergic to

     2. Suppress the allergy symptoms by attacking the immune response. 

Avoidance Therapy:

     Allergists have all sorts of recommendations for allergy sufferers to avoid allergens but relocating to another part of the country is no longer one of them. Allergens of some variety are present everywhere, and chances are, regardless of where you live, there will be something you are allergic to. Air purifiers, air filters, non-allergenic bedding, etc. are just a few avoidance measures. 

Suppress symptoms by attacking the immune response, ie. drug therapy:

     First-line treatment is intranasal steroids, or a cortisone nasal spray. Drugs like Flonase, Nasacort, Nasonex, etc. suppress the allergic response to the inhaled allergen. Drugs like Afrin, NeoSynephrine, or Vick’s Sinex ARE NOT recommended. They have a rebound effect that results in worse nasal congestion.

     Second-line treatment is non-sedating antihistamines such as Claritin, Allegra, Seldane, Zyrtec, or Xyzal, or leukotriene inhibitors such as Singulair and Accolate. Antihistamines block histamine receptors thus blunting the inflammatory and irritative effects of histamine. Leukotriene inhibitors decrease the allergic reaction by blocking receptors targeted by allergy mediators, leukotrienes. However, they are ineffective unless used with oral antihistamines or intranasal steroids. 

     Perennial allergic rhinitis patients are helped by immunotherapy (ie. allergy shots) that is prescribed after allergy skin testing identifies the allergens causing symptoms. I had dozens of patients who got allergy shots prescribed by one of the local allergists. Immunotherapy was given to most patients for a year and for some as long as three years. Did these shots help? I’m not certain I can say whether they did or not! Patients were given shots for so long and the effects were so gradual it was hard for patients to tell. Some perennial patients did get better, but might still have a seasonal breakthrough. Others noticed little change. Perhaps what they tested positive to wasn’t the only cause of their symptoms. There was a lot of subjectivity to responses. 

Dr. G’s Opinion: Hay fever sufferers are miserable during the peak of the season. If nasal steroids and/or antihistamines didn’t work, and the patient was very symptomatic, I was not above giving them a shot of Depo Medrol 80 mg, a cortisone product, that would give the patient 2-3 weeks of symptom relief. Methylprednisolone, the cortisone in Depo Medrol, was chemically bound to a substance that gradually released the steroid into the bloodstream over a 14-21 day period. Thus, a small dose of cortisone was released into the circulation for up the 3 weeks, and the allergy symptoms were suppressed as it flowed through the various tissues. It was important to continue other treatments as well. (I gave Depo Medrol only to patients who failed to respond to anything else).

Allergy shots I think helped more people than not. But improvement was slow and required a lot of patience to achieve. Avoidance therapy was always recommended but marginally effective. It’s impossible to create an allergen-free environment so something was always causing flare ups of rhinitis. Depo Medrol was always my back-up treatment. Allergists shudder at the idea of using cortisone indiscriminately in this manner, but I preferred to see a patient whose symptoms were gone, instead of being miserable. Those of you who suffer from seasonal allergic rhinitis know what I’m talking about. You’ll do anything to feel better. A single shot of cortisone once a year is virtually harmless. 

If you don’t have seasonal, or perennial, allergic rhinitis be thankful. Those folks dreaded allergy season because the symptoms were awful. Treatment has improved, but the perfect remedy is yet to be found.

Reference:  Weaver-Agostoni J, Kosak Z, Bartlett S. Allergic Rhinitis: Rapid Evidence Review Am Fam Phys 2023 May;107(5):466-472.