Continuing Education Column DOI: 10.5124/jkma.2010.53.9.780 pissn: 1975-8456 eissn: 2093-5951 http://jkma.org Diagnosis and treatment of allergic rhinitis Young Hoon Kim, MDKyung-Su Kim, MD Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea * Corresponding author: Kyung-Su Kim, E-mail: ydrhinol@yuhs.ac Received July 7, 2010 Accepted July 21, 2010 Abstract Allergic rhinitis (AR) is a global health problem affecting at least 10 to 25% of the population, and is a chronic respiratory illness that affects quality of life, productivity, and other co-morbid conditions such as asthma and sinusitis. Classification of AR has been changed to intermittent/persistent (duration) and mild/moderate-severe (severity) based on the Allergic Rhinitis and Its Impact on Asthma (ARIA) workshop report published in 2001. A patient's history and skin prick test results are of utmost importance for its diagnosis regardless of classification system. Treatment should be based on the patient's age, severity, and duration of symptoms. The treatment algorithm has recently been revised by 2008 ARIA guidelines. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy, and surgery. Patients should be advised to avoid known allergens and educate themselves about their condition. Although allergen avoidance and immunotherapy are theoretically ideal, intranasal corticosteroids are the most effective treatment in persistent and moderate-severe AR. Sublingual immunotherapy has been introduced and has shown good results in its efficacy and safety. Physicians are advised to be alert to the state-of-the-art knowledge on AR and be willing to take advantage of recent progress on AR. Keywords: Allergic rhinitis; Skin test; Immunotherapy c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 780
Diagnosis and treatment of allergic rhinitis Intermittent symptoms <4 days per week or <4 consecutive weeks Persistent symptoms >4 days/week and >4 consecutive weeks Mild all of the following normal sleep no impairment of daily activities, sport, leisure no impairment of work and school symptoms present but not troublesome Figure 1. ARIA classification of severity of allergic rhinitis[4]. Moderate-severe one of more items sleep disturbance impairment of daily activities, sport, leissure impairment of school or work troublesome symptoms 781
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Diagnosis and treatment of allergic rhinitis Table 1. Differential diagnosis of rhinitis Allergic rhinitis Nonallergic rhinitis (continued) Conditions that may mimic symptoms of rhinitis Episodic rhinitis Gustatory rhinitis Cerebrospinal fluid rhinorrhea Occupational rhinitis Hormone-induced rhinitis Inflammatory or immunologic conditions (allergen) Hypothyroidism Midine granuloma Perennial rhinitis Menstrual cycle Nasal polyposis Seasonal rhinitis Oral contraceptives Sarcoidosis Nonallergic rhinitis Pregnancy Sjogrens syndrome Atrophic rhinitis Infectious rhinitis Systemic lupus erythematosus Chemical-or irritant-induced rhinitis Acute (usually viral) Wegeners granulomatosis Drug-induced rhinitis Chronic rhinosinusitis Relapsing polychondritis Antihypertensive medications Nonallergic rhinitis with eosinophilia Structural or mechanical conditions Nonsteroidal anti-inflammatory drugs syndrome Choanal atresia Oral contraceptives Occupational rhinitis (irritant) Deviated septum Rhinitis medicamentosa Perennial nonallergic rhinitis Enlarged adenoids Emotional rhinitis Vasomotor rhinitis Foreingn bodies Exercise-indued rhinitis Postural reflexes Hypertrophic turbinates Primary ciliary dyskinesia Nasal tumors Reflux-induced rhinitis or gastroesophageal reflux disease 783
Kim YHKim KS Table 2. Allergic vs. Non-allergic rhinitis Clinical characteristic Allergic rhinitis Non-allergic rhinitis Ancillary studies Positive skin tests Negative skin tests Exacerbating factors Allergen exposure Irritant exposure, weather changes Family history of allergies Usually present Usually absent Nasal eosinophilla Nature of symptoms Usually present Present in patients with nonallergic rhinitis with eosinophilia syndrome Congestion Common Common Postnasal drip Not prominent Prominent Pruritus Common Rare Rhinorrhea Sneezing Common Prominent Usually uncommon, but may be present in some patients Usually not prominent, but may predominate in some patients Other allergic symptoms Often present Absent Physical appearance of nasal mucosa Seasonality Variable, described as pale, boggy, and Swollen Seasonal variation Variable, erythematous Usually perennial, but symptoms may Worsen during weather changes. 784
Diagnosis and treatment of allergic rhinitis Diagnosis of allergic rhinitis Check for asthma especially in patients with severe and/or persistent rhinitis Intermittent symptoms Persistent symptoms Mild Moderate-severe Mild Moderate-severe Not in preferred order oral H1 blocker or intranasal H1-blocker and/or decongestantor LTRA Not in preferred order oral H1 blocker or intranasal H1-blocker and/or decongestant or Intranasal CS or LTRA (or cromone) In persistent rhinitis review the patient after 2-4 weeks If faliure: step-up If improved: continue for 1 month Improved Step-down and continue treatment for >1 month Add or increase intranasal CS dose In preferred order Intranasal CS H1 blocker or LTRA Review the patient after 2-4 weeks Rhinorrhea add ipratroplum Failure Review diagnosis Review compliance Query infections or other causes Blockage add decongestant or oral CS (short term) Failure referral to specialist Figure 2. ARIA algorithm for treatment of allergic rhinitis[20]. Allergen and irritant avoidance may be appropriate If conjunctivitis Add oral H1-blocker or intraocular H1-blocker or intraocular cromone (or saline) Consider specific immunotherapy 785
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Diagnosis and treatment of allergic rhinitis 787
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