GP Guide to Hay fever Management
The following is intended as a guide to the non-specialist management of seasonal
and perennial rhinitis. If the following steps are ineffective in controlling symptoms or
there are other complications then referral to the Peninsula Specialist Immunology
and Allergy Service is appropriate and this will also be discussed.
Seasonal Rhinitis
Typical symptoms of nasal congestion, nasal discharge, sneezing and watery or
itchy eyes occur secondary to allergy to pollen. The timing of symptoms throughout
the year can indicate the likely pollen allergen however identifying the pollen
definitively does not change initial management and therefore testing is not
recommended at this stage. Below are the recommended actions.
1. Start regular treatments at least 2 weeks before symptoms normally begin, to
limit extent of mucosal inflammation
2. Regular long acting non-sedating antihistamine, (eg, cetirizine 10mg OD), if
ineffective change to a different agent (eg, fexofenadine 180mg OD). The
dose of antihistamine can be doubled to BD if required for severe symptoms
3. Regular topical nasal steroid spray; different preparations are available with
no clear advantage of any particular device. Correct spray technique is critical
to increase effectiveness and reduce side effects. Inform the patient to insert
the spray nozzle into their nostril aiming for the outside of the nostril, put chin
on chest, activate the device and breathe in gently. Repeat on other side.
This link shows a good technique video
https://www.youtube.com/watch?v=iaZdNhp8_40
If first line spray (eg beconase) is not tolerated, alternatives include Avamys
or Nasonex nasal sprays. It is important to try more than one nasal spray as
patients will have different preferences for different steroids/devices
4. Eye drops used liberally and regularly; there are numerous preparations
available with no clear advantage to a particular preparation.
5. Pollen avoidance is difficult to achieve but the following may help;
a. Wrap-around sunglasses
b. Changing clothes after being outside
c. Applying Vaseline to nostrils to try to trap the pollen
6. Reminders throughout the season – Hay fever management often fails
because patients do not maintain the regularity of their medications.
Reminders and motivation throughout the season can be helpful, for example
via a nurse-led telephone clinic.
If the above measures are used correctly and regularly but fail to achieve good
symptom control refer to the Peninsula Specialist Immunology and Allergy Service
for allergen identification and assessment for pollen desensitization.
Desensitization is available for certain pollens in injectable and sub-lingual forms. It
is not suitable for everyone and requires significant commitment from the patient.
Desensitization aims to reduce rhinitis symptoms from severe to moderate and
therefore traditional therapies as described above will still be necessary. If a patient
has multiple pollen allergies, desensitization may not provide complete benefit. If
desensitization is appropriate, it is important that any asthma and hypertension are
well controlled and that the patient is not taking any beta-blockers or ACE-I.
Perennial Rhinitis
Perrenial rhinitis can be caused by allergy to a large variety of aeroallergens which
are present all year round. Perennial and seasonal rhinitis can coexist and patients
can have multiple allergies to aeroallergens. Common perennial aeroallergens
include house dust mite, mould and pet dander and can be difficult to avoid or
control in the environment.
Treatment is with regularly long acting non-sedating antihistamines and topical nasal
steroids as described above. A referral to the Peninsula Specialist Immunology and
Allergy Service can help identify the allergens which in turn can help target
avoidance techniques. Alternatively a good screening test would include specific IgE
blood tests to house dust mite, mixed mould and any pets the patient has regular
contact with. Positive Specific IgE does not diagnose allergy (merely sensitization)
and the results can be difficult to interpret if the patient is atopic. Total IgE has no
place in routine allergy testing although can be useful in some cases if the patient is
atopic.
It is important to optimise any concomitant asthma and eczema care.
Desensitization to perennial aeroallergens is not routinely available in the southwest
however desensitisation to house dust mite is available in other parts of the country
and may be considered in exceptional cases..