Persistent Rhinitis

What is rhinitis and what is persistent rhinitis?

Rhinitis

Rhinitis means inflammation of the nose. Common symptoms include: sneezing, a blocked or congested nose, a watery discharge ('runny nose'), and an itchy nose. Less common symptoms include: itchy throat, loss of smell, face pain, headache, and itchy and watery, red eyes. The most common cause of rhinitis is a cold. Hay fever is another common cause. Rhinitis affects both nostrils at the same time.

Persistent rhinitis

This means that rhinitis symptoms continue long-term. One definition that doctors use for persistent rhinitis is rhinitis symptoms that last for an hour or more on most days of the year. However, in practice there is great variation. In many cases the symptoms are present for some part of the day on most days. In some cases the symptoms 'come and go'.

The severity can vary. Some people have mild nose irritation which comes and goes, and causes little trouble. On the other hand, some people become distressed by their regular, daily symptoms. Severe symptoms can affect your work, school, home and social life.

What causes persistent rhinitis?

The causes of persistent rhinitis can be divided into 'allergic' and 'non-allergic'. An allergic cause for persistent rhinitis is the most common.

Persistent allergic rhinitis

The most common cause of persistent rhinitis is an allergy to the house dust mite. However, allergy to pets or other animals is also common. Note: the thing that causes an allergy (e.g. house dust mite, dead animal skin etc.) is often known as the 'allergen'.

• The house dust mite is a tiny creature that is present in every home. It mainly lives in bedrooms, mattresses, pillows and carpets as part of the dust. It usually causes no harm, but some people are allergic to the tiny droppings (faeces) of the mite. House dust mites are present all year round but there is often a peak in their numbers in spring and autumn.
• Pets - Flakes of dead animal skin as well as urine and saliva from pets, such as a cat, dog, horse, hamster, guinea pig etc, are the cause of the allergy in some cases.
• Other allergies are less common. An allergy to something at work sometimes occurs. For example, to laboratory animals, or to latex, to flour or wood dust, or other chemicals. This may be suspected if symptoms ease at weekends or on holidays.

Hay fever (caused by an allergy to pollen) is another type of allergic rhinitis but it tends to be 'seasonal' and not 'persistent' because it occurs during a particular period each year (for example the grass pollen season during late spring and early summer). See separate leaflet called 'Hay Fever' for more detail.

Symptoms of allergy in the nose are due to the immune system reacting to the allergen (such as pollen or house dust mite droppings). Cells in the lining of the nose release histamine and other chemicals when they come into contact with the allergen. This causes inflammation in the nose (rhinitis) and the typical symptoms.

Persistent non-allergic rhinitis

There can be various other causes or 'triggers' for persistent rhinitis. These triggers can cause a rhinitis in their own right, but they can also make symptoms worse if you already have an allergic rhinitis. They include the following:

• Irritation of the nose by smoke, strong smells, fumes, chemicals, changes in temperature or humidity.
• Hormone changes during pregnancy and puberty can sometimes cause nose symptoms.
• If you have an over-active thyroid gland this can also sometimes lead to rhinitis.
• Food and drink - mainly hot, spicy food, or alcohol. Sensitivity to certain food colourings or preservatives may be a cause.
• Emotion such as stress or sexual arousal can sometimes affect the nose.
• Medication - a side effect from certain medicines is a rare cause. These include: beta-blocker medicines, aspirin and other anti-inflammatory medicines, ACE inhibitors (angiotensin converting enzyme inhibitors), the contraceptive pill and chlorpromazine.
• Rhinitis medicamentosa is the name given to rhinitis that can occur due to the overuse of nasal decongestant sprays. These sprays are used to help a blocked nose and they reduce swelling of blood vessels in your nose. However, if they are used for more than 5-7 days, the swelling can recur again. The temptation is to use yet more decongestant and a vicious circle can be set up. A similar problem can occur in people who abuse cocaine.

In some people, no specific trigger for their persistent rhinitis may be found. This is called 'idiopathic' rhinitis. Idiopathic means that there is no certain cause that has been found.

Who gets persistent rhinitis?

Persistent rhinitis is common. It can affect anyone of any age although it affects adults more commonly than children. Many people with persistent rhinitis say they have a 'persistent cold'. However, colds are due to virus infections, and normally only last a week or so. Persistent rhinitis is not due to an infection.

Allergic rhinitis (be it hay fever or persistent rhinitis) tends to run in families. You are also more likely to develop allergic rhinitis if you already have asthma or eczema. Equally, if you have allergic rhinitis, you are more likely to develop eczema or asthma. The conditions asthma, eczema and allergic rhinitis are known together as 'atopic' conditions or 'atopy'. A tendency to atopy can run in families.

Are any tests needed?

Usually not. Most cases are due to allergy, and the symptoms are usually typical. Your doctor can usually diagnose allergic persistent rhinitis by talking to you about your symptoms and your medical history. They may also examine your nose.

If allergic persistent rhinitis is suspected, your doctor or nurse will usually suggest treatment for your symptoms (see below). If the symptoms respond to treatment, this can help to confirm the diagnosis. Sometimes if the cause of persistent rhinitis is unclear, or when the diagnosis is in doubt, your doctor may suggest blood tests or skin prick allergy testing to look for the exact cause of your symptoms. See separate leaflet called 'Skin Prick Allergy Test' for more detail. Confirming the exact cause of any allergy may help if you want to try and avoid it (see below).

Other tests such as a detailed examination of your nose are sometimes needed to look for other possible causes of your symptoms, or if complications are suspected (for example, to check for a nose polyp).

What are the commonly used treatments?

The following treatment options are for allergic rhinitis - the most common cause of persistent rhinitis. Non-allergic rhinitis can be more difficult to treat and depends on the cause. Steroid nasal sprays may be helpful. Treatments for non-allergic rhinitis are not discussed further here.

The commonly used treatment options for allergic rhinitis are: avoiding the cause of the allergy, antihistamine nose sprays, antihistamine tablets, and steroid nose sprays.

Note: If your rhinitis symptoms are not controlled on the medication that you are taking after 2-4 weeks, you should discuss this with your doctor. You may need to try a different treatment or add in another treatment.

Avoiding the cause of the allergy

If you have persistent rhinitis caused by an allergy, if you can avoid the cause of an allergy, symptoms should reduce and stop. However, this is not as easy as it sounds.

• If you are allergic to house dust mite, you may find that symptoms are less severe if you reduce the number of mites in your home. This is hard work and involves using bedding covers, and regular cleaning and vacuuming with particular attention to your bedroom and bedclothes. The measures that need to be taken can be inconvenient and expensive. Also, there is a lack of good quality evidence in clinical trials and studies for the effectiveness of reducing the numbers of house dust mites in terms of reducing rhinitis symptoms. This may be because it is impossible to keep your home completely clear of house dust mites.
• If a pet is the cause, then for some people it is easy to give up the pet. However, for others it would be a great sadness to lose a pet. It may help if you keep pets out of the main living areas, and in particular, out of your bedroom. Washing pets regularly can also help.

If you want further advice on how to reduce house dust mite, see separate leaflet called 'House Dust Mite and Pet Allergy' for more detail. However, treatment with a nose spray or tablets (see below) often works so well that you may not have much motivation or need to avoid the cause of the allergy. Saying that, it is thought that if you have a pet or animal allergy and you do avoid any further contact, you may reduce your risk of developing asthma.

Antihistamine nose sprays

A dose from an antihistamine nose spray can rapidly ease itching, sneezing and watering (within 15 minutes or so). It may not be so good at easing congestion. Antihistamines work by blocking the action of histamine. This is one of the chemicals involved in allergy reactions. A spray can be used 'as-required' if you have mild symptoms. It can also be taken regularly to keep symptoms away.

Antihistamine tablets (or liquid medicines)

Antihistamines taken by mouth (tablets or liquids) are an alternative. They ease most of the symptoms but may not be so good at relieving nasal congestion (blocked nose). Antihistamines taken by mouth are good if you have eye symptoms as well as nose symptoms. They are also usually given to small children instead of a nasal spray. A dose usually works within an hour. Therefore, one can be taken 'as required' if symptoms are mild, or come and go. One can also be taken regularly if symptoms occur each day.

There are several brands of antihistamines that you can buy at pharmacies or get on prescription. Older brands such as chlorphenamine work well, but make some people drowsy, so they should not be taken if you are driving or operating machinery. There are several newer ones that cause less drowsiness. Ask your pharmacist for advice.

If you are pregnant or breastfeeding, it is advised to try to avoid antihistamines if possible. Treatment with a steroid nose spray is usually tried first (see below). An antihistamine may sometimes be used if your symptoms are not controlled. Discuss with your doctor or pharmacist if you are pregnant or breastfeeding and have rhinitis.

Steroid nose sprays and drops

A steroid nose spray usually works well to clear all the nose symptoms (itch, sneezing, watering and congestion). It works by reducing inflammation in the nose. A steroid nose spray also tends to ease eye symptoms. It is not clear how it helps the eye symptoms - but it does! Steroid nose drops are also sometimes used.

It takes several days for a steroid spray to build up to its full effect. Therefore, you will not have an immediate relief of symptoms when you first start it. In some people it can take up to three weeks or longer to be fully effective. So do persevere. A steroid nose spray tends to be the most effective treatment when symptoms are more severe. It can also be used in addition to antihistamines if symptoms are not fully controlled by either alone.

You need to use the spray each day to keep symptoms away. However, once symptoms have gone, the dose of a steroid spray can often be reduced to a low 'maintenance' dose each day to keep symptoms away. There are several brands that you can buy at pharmacies, or get on prescription. Side-effects or problems with steroid nose sprays are rare (read the packet leaflet for details).

Other treatment options

Other nose sprays

The following are sometimes used. They tend to be used if there are problems with any of the above treatments. Sometimes one is used as an 'add on' treatment in addition to one or more of the above treatments if symptoms are not fully controlled:

• Sodium cromoglicate nose spray. Like steroid sprays, it takes a while to build up its effect, and needs to be taken regularly. It is thought to work by stopping the release of histamine from certain cells. One disadvantage is that it needs to be taken 4-5 times a day (steroid sprays are taken 1-2 times a day).
• Ipratropium bromide nose spray may be worth a try if you have a lot of watery discharge. It has no effect on sneezing or congestion.
• Decongestant nose sprays that you can buy at pharmacies are not usually advised for more than a few days. They have an immediate effect to clear a blocked nose. However, if you use one for more than 5-7 days, a 'rebound', more severe congestion of the nose often develops. One may be useful for a few days to clear a blocked nose when you first use a steroid nose spray. The steroid can then get to the lining of the nose to work. Don't use decongestant nose sprays for more than seven days. You should also not use a decongestant nose spray if you are taking an antidepressant called a monoamine oxidase inhibitor (MAOI).

Eye drops

If you have eye symptoms and, if necessary, you can use eye drops in addition to other treatments.

• Antihistamine eye drops work quickly, so you can use them 'as required' to ease a flare up of eye symptoms. You can also use them regularly if needed. There are several brands.
• 'Mast cell stabilisers' are another type of eye drop. There are different brands. They are thought to work by stopping the release of histamine from certain cells (mast cells). You need to use them regularly to prevent symptoms.

Treatment for severe symptoms

Rarely, a short course of steroid tablets is prescribed. For example, for students sitting exams who have severe symptoms which are not eased by other treatments. Steroids usually work well to reduce inflammation. A short course is usually safe. However, you should not take steroid tablets for long periods to treat rhinitis as serious side-effects may develop. See separate leaflet called 'Steroid Tablets' for more detail.

Immunotherapy (desensitisation)

This treatment is sometimes used, mainly in cases where symptoms are severe and not helped by other treatments. It is done using a series of injections of the allergen causing the rhinitis, in increasing quantities. The idea is that your immune system will become 'desensitised' to the allergen. This means that the allergic response that your body mounts when it is exposed to the allergen in the future is reduced, so improving your symptoms.

Another technique is being developed which involves placing the allergen under the tongue. However, this may not yet be widely available.

Surgery

Surgery is not often used to treat allergic persistent rhinitis but if you develop complications such as nasal polyps (see below) it is sometimes needed.

How long is treatment needed for?

Persistent rhinitis is an ongoing (chronic) condition that usually needs regular treatment to prevent symptoms. However, over time the condition may ease, and even goes completely in some cases. It may be worth stopping treatment every six months or so to see if symptoms come back without the treatment. The treatment can be started again if symptoms return.

Of course, if you have persistent rhinitis caused by an allergy, if you remove the source of the allergy, your symptoms should reduce and stop. You may no longer need treatment.

Are there any complications of persistent rhinitis?

Sinusitis

Sinusitis can be a common complication of persistent rhinitis. The sinuses are small, air filled spaces inside the cheekbones and forehead. They make some mucus which drains into the nose through small channels. Allergens can irritate the lining of your sinuses in the same way that they irritate the lining of your nose.

If you have a blocked or congested nose or lots of nasal discharge, it can stop your sinuses from draining properly into your nose. This means that the mucus in the sinuses becomes 'blocked' and can be more easily infected. See separate leaflets called 'Acute Sinusitis' and 'Chronic Sinusitis' for more details.

Nasal polyps

Nasal polyps are sometimes a complication of rhinitis. A nasal polyp is a swelling that can grow from the lining of your nose. When it is fully grown it looks rather like a grape. One polyp can form or there may be a number of polyps together. Sometimes polyps can form in the sinuses as well. They are usually flesh-coloured, pale grey or pink.

If a polyp is big or if there are large numbers of polyps, a number of problems can develop. Your sense of smell may be affected or your nose may feel blocked causing difficulty breathing. Sometimes polyps can block the drainage of your sinuses and lead to sinusitis as described above. Large polyps may need to be surgically removed but smaller polyps can often be treated with steroid nose drops (see above) which help to shrink them.

Asthma

People with persistent rhinitis are also more likely to develop asthma.

Further help and advice

Allergy UK

3 White Oak Square, London Road, Swanley, Kent BR8 7AG
Allergy Helpline: 01322 619898
Web: www.allergyuk.org
A medical charity for people with allergy, food intolerance and chemical sensitivity that provides information and support.