Allergic and non-allergic rhinitis

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Rhinitis describes inflammation or irritation producing obstruction, rhinorrhoea, sneezing or nasal itch. Allergic rhinitis is an allergen-specific immune response, often accompanied by conjunctival itching and watering. The practical classification also considers timing and impact: intermittent pollen-related symptoms may still be severe during examinations or outdoor work, while persistent indoor exposure can impair sleep throughout the year. A history connecting symptoms to exposure is more informative than an isolated allergy result.

Non-allergic rhinitis is a collection of mechanisms rather than one diagnosis. Vascular and neural responses to temperature, odours or food, hormonal changes and medicines can all contribute. Some patients have both allergic sensitisation and irritant sensitivity. Treatment should therefore target the dominant symptoms and relevant exposures, while checking for infection, polyps and fixed anatomical obstruction. Neither coloured mucus alone nor temporary improvement with a decongestant establishes a bacterial cause.

Key points

Itch, repeated sneezing, watery rhinorrhoea and itchy eyes linked to exposure favour allergic rhinitis.
Smoke, perfume, temperature change, spicy food and medicines can provoke non-allergic symptoms; mixed disease is common.
Ask about sleep, concentration, work exposure and asthma control rather than judging severity by nasal discharge alone.
Intranasal corticosteroids are the preferred medication for moderate or severe allergic rhinitis, particularly troublesome obstruction.
Use a combined intranasal antihistamine and corticosteroid when adequate single-agent treatment has not controlled allergic symptoms.
A positive allergen test shows sensitisation; it identifies the clinical trigger only when it fits the exposure history.
Current MHRA advice limits xylometazoline or oxymetazoline nasal decongestants to five consecutive days.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Relevant aeroallergens

Pollen, house dust mites, animal dander, moulds and certain occupational agents can trigger allergic rhinitis. Exposure timing and clinical symptoms distinguish a causal allergen from incidental laboratory sensitisation.

Irritant and vascular triggers

Changes in temperature, strong smells, smoke, alcohol or spicy food may activate non-allergic nasal responses. Hormonal changes and selected medicines can contribute, with overlapping mechanisms in the same person.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Immediate allergic response
Allergen recognition in a sensitised person activates mast cells and releases mediators such as histamine. This produces itching, sneezing and watery secretion soon after exposure.
2
Persistent mucosal inflammation
Later inflammatory cell recruitment sustains congestion and mucosal sensitivity. This helps explain why regular local corticosteroid treatment can improve obstruction more effectively than treating isolated histamine symptoms alone.
3
Non-allergic hyperreactivity
Altered sensory and autonomic responses can increase nasal secretion and vascular engorgement without a clinically relevant IgE mechanism. Mixed rhinitis combines these responses with allergic inflammation.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Allergic symptom pattern

Ask whether itch, bouts of sneezing and clear discharge begin after grass pollen, pets, dust or workplace exposure. Associated eye symptoms, eczema and asthma strengthen the pattern, but their absence does not rule it out.

Non-allergic triggers

Symptoms related to cold air, perfume, smoke, meals or pregnancy may occur without prominent itching. Review prescribed and over-the-counter medicines, including repeated nasal decongestant use, before labelling treatment failure.

Burden and lower airway disease

Ask about snoring, waking, fatigue, impaired concentration and avoidance of activities. Review wheeze, reliever use and nocturnal asthma symptoms: poorly controlled upper and lower airway disease often coexist and need coordinated treatment.

Examination and asymmetry

Inspect the external nose, septum, turbinates and visible secretions using appropriate illumination. Swollen turbinates may account for obstruction; a unilateral mass, crusting, contact bleeding or persistent marked asymmetry requires another diagnostic pathway.

Occupational relationship

Flour, wood dust, latex and animal exposures can be relevant. Improvement on holidays or days away from work should prompt an occupational history and specialist advice, especially when cough or wheeze accompanies nasal symptoms.

Red flags requiring action

Persistent unilateral bloody discharge or obstruction requires prompt examination and urgent ENT assessment for structural disease or malignancy.
Clear unilateral watery discharge after head injury raises possible cerebrospinal fluid leakage and needs emergency assessment.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Focused history and nasal examinationFirst step
Why
Establish the working diagnosis before requesting allergy investigations.
Interpretation and limitations
Typical bilateral exposure-linked symptoms often allow treatment without imaging. Examination must still look for a foreign body, polyps, septal disease or a suspicious unilateral lesion.
02
Targeted skin prick or specific IgE testing
Why
Clarify clinically plausible allergens when results will change management.
Interpretation and limitations
Select tests from the exposure history, especially before immunotherapy or substantial avoidance measures. Sensitisation without matching symptoms does not establish the cause; broad untargeted panels invite misleading findings.
03
Specialist nasal endoscopy
Why
Investigate persistent obstruction, bleeding or an uncertain visible abnormality.
Interpretation and limitations
Endoscopy can identify posterior polyps, structural narrowing or another lesion beyond anterior inspection. It is not a routine prerequisite for treating straightforward seasonal allergic rhinitis.
04
Asthma and occupational assessment
Why
Identify linked disease that changes overall airway management.
Interpretation and limitations
Use a structured respiratory assessment and objective asthma investigations when indicated. A nasal allergy diagnosis does not by itself confirm asthma or explain unexplained breathlessness.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Chronic rhinosinusitis

Persistent obstruction or discharge with smell reduction or facial symptoms lasting at least 12 weeks suggests a broader sinonasal disorder. Specialist examination may identify polyps or objective mucosal inflammation.

Structural obstruction

Septal deviation and turbinate enlargement can coexist with rhinitis. Persistent fixed asymmetry, a visible lesion or bleeding should prompt targeted examination rather than automatic escalation of allergy treatment.

Foreign body or tumour

Unilateral offensive discharge in a child suggests a retained object, while progressive unilateral bleeding or obstruction raises concern for a mass. These patterns require directed assessment rather than empirical allergy treatment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Initial careTreat a clear allergic patternFirst stepBilateral allergic symptoms cause persistent discomfort or impair daily activities.

1Agree practical trigger reduction and explain that perfect allergen avoidance is often unrealistic.
2EscalationUse a regularly administered intranasal corticosteroid for moderate or severe symptoms, demonstrating technique before prescribing escalation.
3An oral non-sedating antihistamine can help itch and sneezing; select treatment according to symptom burden and the patient's preferences.
4Review response, adherence and exposure after an adequate treatment period rather than assuming the medicine has failed after two doses.

02EscalationReassess uncontrolled nasal allergyEscalationSymptoms remain troublesome despite correctly used intranasal corticosteroid treatment.

1Check spray delivery, regularity, dose, duration and whether the working diagnosis still fits.
2Consider a combined intranasal antihistamine and corticosteroid when adequate monotherapy is insufficient, accounting for licensed age and safety restrictions.
3Refer severe persistent disease for specialist assessment, including whether allergen-specific immunotherapy is appropriate for proven clinically relevant sensitisation.
4Review asthma control at the same visit and investigate unilateral or bleeding symptoms instead of repeatedly increasing sprays.

03Alternative mechanismManage non-allergic or mixed rhinitisAlternativeIrritants, hormonal changes or medicines explain much of the symptom pattern.

1Reduce feasible irritant exposure and review potentially causative medicines with the relevant prescriber.
2Use saline and a symptom-directed nasal treatment trial, explaining that an oral antihistamine may offer little benefit when histamine is not the dominant mechanism.
3Identify prolonged topical decongestant use and agree a tailored, usually gradual withdrawal plan with treatment for the underlying obstruction.
4Arrange further assessment when symptoms persist despite appropriate treatment or the history and examination remain discordant.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Local anti-inflammatory treatment for troublesome allergic obstruction and associated nasal symptoms.

Mometasone furoate 50 micrograms per spray, Nasonex

For allergic rhinitis, administer two sprays into each nostril once daily, giving 200 micrograms daily. Once controlled, reduce to one spray per nostril daily. The prescription product permits up to four sprays per nostril once daily if necessary, with subsequent reduction; reassess response and use the lowest effective maintenance dose.

Do not use with untreated local nasal mucosal infection or before nasal surgery or trauma has healed. Check recurrent epistaxis, cumulative corticosteroid exposure, ocular symptoms and strong CYP3A inhibitors such as cobicistat. Pregnancy and breastfeeding require individual benefit-risk assessment; paediatric doses and growth monitoring differ. Nasonex is not recommended in patients with a nasal septal perforation.

Combined nasal antihistamine and corticosteroid for allergic rhinitis inadequately controlled by either component alone.

Azelastine and fluticasone propionate nasal spray, Dymista

For adults and adolescents aged 12 years or over, administer one spray into each nostril twice daily. Use regularly during the period of allergen exposure, then review ongoing need and control.

Avoid in hypersensitivity to the ingredients; it is not recommended below 12 years. Review severe hepatic disease and potent CYP3A inhibitors, including ritonavir and cobicistat. Account for possible fatigue or dizziness, local bleeding and corticosteroid ocular or systemic effects; review other sedating medicines and alcohol. Pregnancy or breastfeeding use requires a justified benefit-risk decision.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Sleep and functional impairment

Obstruction and nocturnal symptoms can disturb sleep, concentration and daytime functioning. Asking about practical consequences provides a more useful treatment target than the amount of visible nasal discharge.

Associated airway morbidity

Rhinitis frequently accompanies asthma. Worsening nasal symptoms should prompt review of lower airway control, although upper airway treatment does not replace the patient's asthma assessment or controller medication.

Treatment related nasal injury

Repeated vasoconstrictor exposure can perpetuate obstruction, while poorly directed corticosteroid sprays can cause local bleeding. Recognising these effects prevents inappropriate escalation and directs technique or withdrawal support.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

At follow-up, ask the patient to describe and demonstrate actual spray use; missed treatment and spraying towards the septum are common correctable problems.
Record improvement in sleep, nasal breathing, work or school performance and associated eye symptoms, not only an examination finding.
Inspect persistent bleeding, ulceration or crusting and reconsider the diagnosis if symptoms become unilateral or progressive.
Review all steroid routes together, especially when nasal treatment accompanies inhaled corticosteroids for asthma or potent interacting medicines.
For continuing treatment in children, use the licensed age-specific product and dose and monitor growth where indicated.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Saline preparation matters

Nasal irrigation can reduce secretions and improve comfort. Use a suitable commercial preparation or freshly prepared solution with previously boiled and cooled water, following device cleaning instructions; avoid introducing untreated water into a reusable irrigation system.

Sensitisation is not a prescription

The benefit of allergen immunotherapy depends on identifying an allergen that actually drives symptoms and selecting an appropriate specialist pathway. A large positive test alone should not lead to expensive avoidance measures or treatment.

Timing can improve prevention

For predictable seasonal disease, plan treatment before the usual difficult period and continue consistently during exposure. A corticosteroid spray controls inflammation over time and should not be judged by the immediate sensation expected from a vasoconstrictor.

Pregnancy changes the discussion

Hormonal congestion can coexist with pre-existing allergy. Start with practical avoidance and saline where suitable, then choose any medicine after pregnancy-specific assessment rather than assuming all nasal preparations are interchangeable or risk free.

11Common pitfallsFrequent interpretation and management errors.

01
Treating persistent one-sided bloody obstruction as hay fever because the patient also has a history of atopy.
02
Ordering broad allergy panels without deciding which results would alter avoidance advice or treatment.
03
Adding further medicines before checking technique, adherence and whether exposure continues at work or home.
04
Continuing topical decongestants beyond five days because they produce quick relief while the underlying rebound congestion worsens.