How is allergic rhinitis treated?

Treatment goals for allergic rhinitis

The main goal is to alleviate the symptoms of the disease. The complex of therapeutic measures includes the elimination of allergens, drug treatment, specific immunotherapy and patient education.

Indications for hospitalization

Treatment of allergic rhinitis is carried out on an outpatient basis.

Elimination of allergens

Treatment of allergic rhinitis begins with identifying possible causative allergens, after the elimination of which, in most cases, rhinitis symptoms decrease.

The main groups of allergens that cause allergic rhinitis

• Pollen allergens (pollen of trees, cereals and weeds). During the flowering season, to eliminate allergens, it is recommended to keep windows and doors indoors and in the car closed, use air conditioning systems indoors, and limit the time spent outdoors. After a walk, it is advisable to take a shower or bath to remove pollen from the body and prevent contamination of linen.
• Mold spores. In case of allergy to mold spores, it is recommended to frequently clean rooms where mold growth is possible, thoroughly clean humidifiers, hoods to remove steam, use fungicides, and maintain relative humidity in the room below 40%.
• House dust mites, insects (cockroaches, moths and fleas). House dust mite allergens are found in the highest concentration in carpets, mattresses, pillows, upholstered furniture, clothing (mainly in children's clothing), and soft toys. Mite excrement is the main allergen in house dust. Elimination measures:
  • carpets are replaced with easy-to-clean ones, preference is given to wooden and leather furniture;
  • bedding is washed in hot water (at least 60 °C) at least once a week;
  • use special anti-mite bedding and mattress covers that do not allow the allergen to pass through (this helps reduce the concentration of house dust mites, but does not lead to a significant reduction in the symptoms of allergic rhinitis);
  • the relative humidity in the apartment is maintained at a level no higher than 40%;
  • use a vacuum cleaner with a built-in HEPA filter and thick-walled dust collectors (using air purifiers is ineffective in removing mite allergens);
  • To destroy ticks, special chemical preparations are used - acaricides (for example, for carpets - a solution containing benzyl benzoate, for upholstered furniture - a 3% solution of tannic acid; acaricides are effective when used regularly);
  • To remove cockroaches, insecticide treatment by specially trained personnel is recommended.
• Animal allergens. Elimination measures:
  • getting rid of pets;
  • preventing the animal from being in the child’s bedroom (if it is impossible to remove it);
  • weekly bathing of the animal (helps to reduce the amount of allergens, but the benefits of this procedure are questionable);
  • use of HEPA filters (reduces the amount of allergens in the room, but is less effective than removing the animal).

Of course, specific desensitization is great, but at least 30 injections are needed, and what to do if there is polyallergy. The course lasts 4 months. Unlike bronchial asthma, with allergic rhinitis in children, even accelerated specific immunotherapy according to Ziselson (36 days) is also hardly justified. Recently, local immunotherapy has become popular, which is carried out with standardized allergens of house dust, cereals, grasses and begins before the peak of the season with a frequency of 3 times a week for three months by intranasal insufflations.

Clinical improvement should be expected after a long period of time (weeks) after elimination of allergens.

Food allergens can cause rhinorrhea in young children.

Drug treatment of allergic rhinitis

If elimination of allergens does not lead to a reduction in the severity of symptoms, drug treatment is started.

Anti-inflammatory drugs

Local (intranasal) glucocorticosteroids are the drugs of choice in the treatment of allergic rhinitis; they effectively reduce the severity of symptoms such as itching, sneezing, rhinorrhea and nasal congestion. Due to the anti-inflammatory effect, these drugs are more effective than intranasal cromones and systemic antihistamines. The clinical onset of action of intranasal glucocorticosteroids occurs on the 2nd-3rd day of treatment, the maximum effect occurs by the 2nd-3rd week and lasts throughout the course of treatment. To achieve disease control, their regular and long-term use is recommended. Modern intranasal glucocorticosteroids, such as mometasone and fluticasone, are preferred for use in pediatric practice. They adequately control the symptoms of allergic rhinitis and are well tolerated. The advantages of these drugs include the possibility of their use once a day and minimal systemic absorption (<0.1 and 2%, respectively). Side effects occur in 5-10% of cases, among local effects the most common are sneezing, burning, irritation of the nasal mucosa, which are usually minimal and do not require discontinuation of the drug. In rare cases, with improper use of intranasal glucocorticosteroids (spraying on the nasal septum), perforation of the nasal septum is possible. Numerous studies in children have shown that the use of modern intranasal glucocorticosteroids (mometasone, fluticasone) in therapeutic doses does not affect growth and the hypothalamic-pituitary-adrenal system. It has been proven that mometasone does not have side systemic effects even with long-term (1 year) use. Given the results of individual clinical studies indicating growth retardation in children aged 3-9 years with the use of beclomethasone and growth retardation of the lower extremities in children with the use of budesonide, these glucocorticosteroids are undesirable for use in pediatric practice.

The preventive effect of mometasone on the course of seasonal allergic rhinitis has been proven. When using the drug in a therapeutic dosage 1 month before the expected flowering, the number of days free from allergic manifestations increases significantly.

To increase the effectiveness of intranasal glucocorticosteroids, it is recommended to clear the nasal cavity of mucus before administering the drugs, as well as to use moisturizers.

• Mometasone is used in children from 2 years of age, prescribed 1 insufflation (50 mcg) in each half of the nose 1 time per day.
• Fluticasone is approved for use in children aged 4 years and over, and is prescribed 1 dose (50 mcg) in each half of the nose.
• Beclomethasone is used from 6 years of age, prescribed 1-2 inhalations (50-100 mcg) 2-4 times a day, depending on age.
• Budesonide is used in children from 6 years of age, prescribed 1 dose (50 mcg) in each half of the nose 1 time per day, the maximum daily dose is 200 mcg.

Mometasone (nasonex) has an optimal efficacy/safety profile in the class of intranasal glucocorticoids. Due to its pharmacological properties, the highest lipophilicity and final viscosity, mometasone furoate quickly penetrates the mucous membrane of the nasal cavity, practically does not flow down the back wall of the pharynx and has a maximum effect at the site of inflammation. This determines the high local anti-inflammatory activity and systemic safety of the drug.

Systemic glucocorticosteroids (orally or parenterally) reduce the severity of symptoms of allergic rhinitis, but given the possibility of developing systemic side effects, their use in the treatment of allergic rhinitis in children is very limited.

Second-generation antihistamines are the basis for treating allergic rhinitis regardless of its severity. This is due to the fact that allergic rhinitis is a systemic disease that is often associated with other manifestations of allergy (bronchial asthma/bronchial hyperreactivity, urticaria, atopic dermatitis). In addition, clinical studies have shown that in moderate and severe forms of the disease, monotherapy with intranasal glucocorticosteroids is not always effective enough (more than 50% of patients require additional antihistamines).

Antihistamines

Systemic antihistamines prevent and reduce symptoms of allergic rhinitis such as itching, sneezing, rhinorrhea, but are less effective against nasal obstruction. There is no risk of tachyphylaxis when taking second-generation antihistamines.

First-generation antihistamines (chloropyramine, mebhydrolin, clemastine) are rarely used in the treatment of allergic rhinitis due to their pronounced sedative and anticholinergic side effects. These drugs impair cognitive functions: concentration, memory, and learning ability.

Second-generation antihistamines, such as desloratadine, loratadine and fexofenadine, do not penetrate the blood-brain barrier and, in therapeutic doses, do not have a sedative effect and do not affect concentration, memory or learning ability.

Cetirizine and levocetirizine pass through the blood-brain barrier to a lesser extent than first-generation antihistamines; in therapeutic doses, they can cause sedation (in 15% and 5-6% of cases, respectively).

• Desloratadine is used in children aged 1-5 years at 1.25 mg (2.5 ml), from 6 to 11 years - 2.5 mg (5 ml) once a day in the form of syrup, over 12 years - 5 mg (1 tablet or 10 ml of syrup) once a day.
• Loratadine is used in children over 2 years of age. Children weighing less than 30 kg are prescribed 5 mg once a day, children weighing more than 30 kg - 10 mg once a day.
• Cetirizine for children from 1 year to 6 years old is prescribed at 2.5 mg 2 times a day or 5 mg 1 time per day in the form of drops, for children over 6 years old - 10 mg once or 5 mg 2 times a day.
• Fexofenadine is used in children aged 6-12 years at 30 mg once a day, over 12 years - 120-180 mg once a day.

Desloratadine is the most studied antihistamine in patients with allergic rhinitis. In numerous clinical studies, desloratadine has demonstrated high efficacy against all symptoms of allergic rhinitis, including nasal congestion, as well as concomitant ocular and bronchial symptoms (in patients with concomitant allergic conjunctivitis and asthma).

In terms of reducing the severity of allergic rhinitis symptoms, antihistamines are less effective than intranasal glucocorticosteroids and are comparable to or even superior to cromones. In mild allergic rhinitis, second-generation antihistamines can be used as monotherapy. In moderate to severe allergic rhinitis, the addition of second-generation antihistamines to intranasal glucocorticosteroid treatment is justified.

Intranasal antihistamines (azelastine) are effective in the treatment of seasonal and year-round allergic rhinitis. When using them, burning in the nose, bitter and metallic taste in the mouth are possible. Azelastine is used in children over 5 years old in the form of a nasal spray, 1 insufflation 2 times a day.

Cremona

Cromoglycic acid is less effective than intranasal glucocorticosteroids, but more effective than placebo, in the treatment of allergic rhinitis. The drug is used in children with mild allergic rhinitis in the form of nasal sprays, 1-2 insufflations in each nasal passage 4 times a day. Cromoglycic acid is the drug of first choice in children under 3 years of age, and the second choice in children over 3 years of age. The most effective is prophylactic use of the drug (before contact with allergens). Side effects are minimal.

Combination treatment of allergic rhinitis

For patients with moderate to severe disease or if initial treatment is ineffective, combination therapy may be prescribed, which includes intranasal glucocorticosteroids and second-generation antihistamines or cromoglicic acid. Combination therapy with second-generation antihistamines and intranasal glucocorticoids helps to achieve the effect using lower doses of the latter.

Medicines to relieve symptoms

Decongestants. Intranasal vasoconstrictors (naphazoline, oxymetazoline, xylometazoline) for the treatment of allergic rhinitis in children are not recommended for more than 3-7 days due to the risk of developing systemic side effects and tachyphylaxis, which is manifested by rebound edema of the nasal mucosa. With prolonged use of drugs in this group, drug-induced rhinitis occurs. It is permissible to use vasoconstrictors in patients with severe nasal congestion before prescribing intranasal glucocorticosteroids for no more than 1 week.

Moisturizers. This group of drugs helps moisturize and cleanse the nasal mucosa.

Effect of different groups of drugs on individual symptoms of allergic rhinitis

Medicines	Sneezing	Nasal discharge	Itchy nose	Nasal congestion
Antihistamines	+++	++	+++	?
Intranasal GCS	+++	+++	+++	++
Cremona	+	+	+	+/-
Decongestants				+++

Allergen-specific immunotherapy

This method of treatment involves the introduction of increasing doses of an allergen to which the patient has been found to be hypersensitive. It is used to treat allergic rhinitis associated with hypersensitivity to plant pollen and house dust mites, as well as (with a lesser effect) in case of sensitization to animal allergens and mold. Allergen-specific immunotherapy is carried out when elimination measures and drug treatment are ineffective or when there are undesirable side effects from the drugs used. It is used in children over 5 years old. The duration of treatment is 3-5 years. Allergen-specific immunotherapy is carried out according to an individually developed regimen under the supervision of an allergist. Patients receiving the allergen parenterally should be under the supervision of a doctor for 30-60 minutes after the injection (the possible time for the development of side effects).

Other Treatments for Allergic Rhinitis

Surgical treatment

Indications:

• irreversible forms of hypertrophy of the nasal turbinates that arise against the background of allergic rhinitis;
• true hyperplasia of the pharyngeal tonsil, significantly impairing nasal breathing and/or accompanied by hearing impairment;
• anomalies of the intranasal anatomy;
• pathology of the paranasal sinuses that cannot be eliminated in any other way.

Patient education

• Providing detailed information on elimination activities.
• Familiarization with modern treatment methods and possible side effects.
• Introduction to various measures for preventing exacerbations of allergic rhinitis (pre-seasonal prevention before expected contact with an allergen).
• Conducting allergy schools, providing teaching materials and manuals.

Surgical methods of treatment of allergic rhinitis

Chronic tonsillitis: Tonsillectomy has not been shown to improve the clinical picture of allergic rhinitis.

Deviation of the nasal septum: removal of the spines is definitely indicated. Resection is treated with caution, it is indicated only in combination with bronchopulmonary syndrome and at an older age.

Hypertrophic rhinitis: surgical treatment is indicated, however, it is advisable to use submucous methods of conchotomy with a laser.

Anomalies in the area of the middle nasal passage: it is highly desirable to eliminate them endoscopically or with a laser.

Hypertrophy in the vomer area: mandatory laser or cryotherapy.

Nasal polyposis: up to 3 years - conservative treatment, immunotherapy is effective. After 3 years - careful removal of polyps without opening the ethmoid labyrinth with subsequent conservative anti-relapse therapy.

Chronic sinusitis: endonasal opening, restoration of aeration. Removal of individual small polyps and cysts. Radical surgery - only for infectious-allergic forms in older age.

Adenoids: in allergic rhinitis, the pharyngeal tonsil also becomes a shock organ, where inhaled allergens are retained. This fact is confirmed by immunological and histological methods. Hypertrophy of II and III degrees is a clear indication for adenotomy, but the attitude to this operation in allergic rhinitis should be careful. Preoperative preparation is indicated, the operation should be performed outside of an exacerbation of rhinitis, in case of hay fever - outside the flowering season. Postoperative therapy is mandatory, since it is in this group that a large percentage of relapses is observed.

The difference in the approach to surgical correction in the nasal cavity and paranasal sinuses

We believe that in the latter case a separate classification is appropriate. This is due to several factors. Allergic rhinitis has significant features in different age groups, so the main criterion here should be the age approach. The course of allergic rhinitis and its etiology (allergens) differ from those in adults. Heredity, immunological status, anatomical and physiological conditions (for example, the absence of frontal sinuses), age-related variations in the structure that create conditions for an excessive concentration of allergens and the formation of focal zones of allergic inflammation are of great importance. There are other concomitant diseases of the ENT organs (for example, adenoids), a different approach to surgery (for example, submucous resection of the nasal septum), other combinations with infections (for example, with childhood infections), functional disorders prevail, organic ones are less characteristic (for example, severe nasal polyposis). The possibilities of treatment due to side effects of drugs, the danger of systemic diseases and methodological difficulties in local treatment are reflected. All this indicates the advisability of a separate classification of allergic rhinitis in childhood.

Age classification of allergic rhinitis in childhood

Age, years	0-3	3-7	7-14
Etiology of allergy	Food Medicines	Inhalation	Inhalation
Flow	Constant forms	Seasonal Permanent	Seasonal Permanent
Associated ENT diseases	Developmental anomalies of the nose Ethmoiditis Sinusitis	Adenoids Exudative otitis; Maxillary ethmoiditis	Nasal polyposis Polypous sinusitis Hypertrophy of the nasal turbinates Frontal sinusitis Sphentiditis Deviated septum
Related Allergic Diseases	Exudative diathesis Atopic dermatitis Conjunctivitis	Asthmatic bronchitis	Bronchial asthma Atopic dermatitis
Surgical treatment	Elimination of developmental anomalies of the nose Puncture of the maxillary sinuses	Adenotomy Ethmoidectomy Puncture of the maxillary sinuses Christotomy Endonasal maxillary antrotomy	Resection of the nasal septum Laser surgery on the nasal turbinates (submucosa) Trepanopuncture of the frontal sinuses Radical surgery on the maxillary sinuses

Tactics for further management

Frequency of observation of a patient with allergic rhinitis:

• pediatrician - during exacerbation according to clinical indications, usually once every 5-7 days; outside of exacerbation - once every 6 months;
• allergist - outside of exacerbation, once every 3-6 months.

Indications for consultation with other specialists

The patient should be referred to a specialist (allergist, otolaryngologist) in the following cases:

• ineffectiveness of oral/intranasal drug treatment;
• moderate to severe persistent symptoms;
• the need for skin testing/radioallergosorbent testing to identify causative allergens in order to carry out elimination measures and decide on allergen-specific immunotherapy.
• concomitant diseases (atopic dermatitis, bronchial asthma, chronic/recurrent rhinosinusitis);
• any severe allergic reactions that cause concern for the child and parents.

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