1. Simple allergic rhinitis is traditionally managed with antihistamines. Non specific antihistamines are available over the counter and are most often combined with a nasal decongestant such as pseudoephedrine, in part to enhance their efficacy and in part to counteract the side effect of drowsiness. Newer H1 specific antihistamines require prescription and are less likely to cause drowsiness. Different individuals respond differently to the different antihistamines. There does not seem to be a single "best" antihistamine for all.
   
   
2. Environmental control is complex. There are excellent free patient handouts provided by companies which benefit from the sale of the equipment. The following are our general recommendations.

   Environmental Control
   House Dust:
   House dust is partially composed of the breakdown products of natural plant and animal fibers. If the fibers or materials that makeup a large part of the home furnishings (rugs, curtains, stuffed furniture, bedding, etc.) are replaced with synthetic materials (nylon, acetate, polyester, etc.), which are nonbio-degradable, many of the sources of house dust will be eliminated.

   Bedroom:
   Since a large part of each 24 hours is spent in the bedroom, dust control in this area should be more vigorous.

   1. Remove stuffed or upholstered furniture.
   2. Furniture should have smooth plastic, metal, or wood finishes.
   3. Remove from the room and the adjoining closet, all stored books, toys, clothing, bedding, etc. which collect and produce dust. Such articles that must be stored in the bedroom should be placed in plastic bags and sealed.
   4. Bare wood or tile floors are best; if a rug seems necessary, washable throw rugs are best. Any rug should be 100 percent synthetic and the pad should be foam or rubber.
   5. Curtains or drapes should be easily launderable and of synthetic material, although cotton is permissible.
   6. Forced-air heater ducts leading to the bedroom should be closed off or a polyester filter should be replaced often during the winter months.
   7. Bedding must be of synthetic material and laundered frequently. Avoid feather or kapok filled pillows. Mattresses and box springs should be covered by zippered, vinyl mattress covers. (These may be purchased at most large department stores (Sears, etc.) or Allergen Proof Encasings, P.O. Box 5236, 1450 E. 363rd Street, Eastlake, Ohio 44094.
   8. Windows and doors leading to the bedroom should remain closed as much as possible.
   9. Walls, ceilings, and floors should be washed. Daily cleaning with a damp mop and a damp cloth is important.
   10. Vacuums disperse large amounts of dust particles into the air; therefore, it's best to have the allergic person outside the home during and for at least two hours after running the vacuum. If the allergic individual does the vacuuming, a mask should be worn.

   

   
   Special Items

   1. Pets, furry or feathered, should NOT be allowed in the home at any time.
   2. House plants should not be placed in the bedroom; the soil contains mold and biodegradable material which can be extremely allergenic.
   3. Mold (mildew, fungi) are associated with damp places and can be eliminated or retarded by lowering the humidity via vents, fans, heaters, etc. and by using mold retardants such as Captan (Orthofungicide), (can be purchased at a local nursery). Zephiran (Benzalkonium Chloride) 1:750, found in pharmacies. Other commercially available mold retardants such as Lysol can also be used. Captan, is nonpoisonous to humans, and may be sprayed through a garden spray; use eight tablespoons of 25% solution or four tablespoons of 50% powder per gallon of water. Zephiran (full strength) may be sprayed on walls, etc.
   4. Air cleaners or air purifiers are very helpful. Portable units should be placed in the bedroom at a location where the clean air flow is across the head of the bed. Larger units are also available which are incorporated with your existing forced air heating system. There are two basic types of air cleaners in the market, a HEPA filter or an electronic air cleaner (electronic precipitator). Both appear to work well, but the HEPA filter is thought to be the most efficient. Air cleaners may be rented to assess usefulness. Rental fees are usually applicable to sale price.
   5. Tobacco smoke is an irritant to the respiratory system and smoking should not be allowed in the home.
   6. Numerous commercial products are available; Environmental Control Products or to Allergy Control Products.
      
      
3. Nasal steroids provide impressive treatment for allergic rhinitis. They should be used daily, as their benefit derives from suppressing both the short and the long term inflammatory allergic response. All the nasal steroids have similar efficacy. The newer nasal steroids have seemingly fewer side effects, i.e. nasal irritation and bleeding and require only once a day administration.
   
   
4. Nasal Irrigation with a Waterpik:
   Purchase or otherwise obtain an adjustable Waterpik, the same Waterpik that is traditionally used for oral hygiene. Nasal attachments to the Waterpik for nasal irrigation are available. The three commercially available nasal adapters are:
   • The Ethicare Nasal Adapter made by Ethicare Products, P.O. Box 5027, Fort Lauderdale, FL 33310. (954) 742-3599.
   • The Grossan Nasal Adapter made by HydroMed Inc., P.O. Box 591273, Los Angeles, CA 90009. (800) 560-9007.
   • The Anthony Products nasal irrigator from Anthony Products (API), 7711 Records Street, Indianapolis, IN 46226. (800) 428-1610.

   Fill the Waterpik bowl to a volume of 500 cc with warm tap water. Many prefer body temperature water at 97 degrees, others prefer slightly cooler temperature. Plain water burns as does hypertonic saline. Normally, one, two or at the most three teaspoons of salt are added to the 500 cc of tap water. Most patients do well with a single teaspoon. The pressure adjustor should be turned to the lowest pressure and the patient leans over the sink holding the Waterpik nasal adaptor first to one nostril then the other. Each nasal cavity is irrigated. Sometimes the water runs through the pharynx and out the mouth and sometimes it will run out the contralateral nostril. Each nasal chamber is irrigated until clean. Some patients irrigate with 250 cc on one side and then 250 cc on the other. Others alternate back and forth using 50-100 cc at a time on each side.

   Most people benefit from twice daily irrigations. Many irrigate once a day and a few will irrigate three, four or even more times a day. Our recommendation is to begin with twice daily irrigations and then adjust and modify to comfort and benefit.

For additional information you are referred to the Handbook of Nasal Disease.

Overview of Allergic Rhinitis

Allergic Rhinitis affects 30–40 percent of Americans. It is a very common illness. Inhalant allergens typically include dust mites, molds, animal danders, (cats more than dogs) and botanical pollens typically: trees and grasses.

The symptoms of allergic rhinitis are: itchy nose, itchy eyes and sneezing. Symptoms of obstruction and rhinorrhea are caused by allergic rhinitis, but are also caused by bacterial sinusitis and are not normally helpful in the differential. The occasional "attack" of allergy is well treated with an antihistamine. The newer H1 specific antihistamines are less sedating and for those who take them on a regular basis, seem superior to the over-the-counter antihistamines or antihistamine/decongestant combinations.

For the patient with allergic rhinitis who does not obtain adequate relief with antihistamines, a trial of nasal steroids is recommended. The standard is beclomethasone, 320 micrograms daily. Newer nasal steroid preparations are available. The pharmaceutical industry claims advantages of once daily application and fewer side-effects. The newer nasal steroids are best prescribed when their cost is equal or less than the beclomethasone preparations or when an individual has side-effects with the old delivery system and tolerates the new preparations more easily.

When the above fails to provide relief, a 10 or 20 inhalant panel skin test or RAST test is indicated. The efficacy of skin testing and RAST testing is equal. The choice is cost and convenience.

Once the specific allergens are identified, the key to the treatment of allergic rhinitis is environmental control.

Most allergy product companies have educational materials with appropriate product information. These can be easily obtained by the primary care physician. In fact, many of the companies who provide the products for environmental control have very nice brochures with excellent information available at no charge. They are more than willing to send 50 or 100 at a time.

Environmental control combined with nasal steroids will successfully manage a large percentage of individuals with allergic rhinitis. Those with other underlying illness such as anatomic nasal obstruction or chronic sinusitis may benefit from ENT consultation and surgery. The individual with unrelenting allergic rhinitis may benefit from desensitization.

While I am a proponent of desensitization, it is a tremendous undertaking. The underlying allergies are identified and then a special desensitization serum is custom made and administered to the patient 3 times a week for the first six-twelve months and once a week for a long time thereafter. This is expensive and a major time commitment.

Nasal irrigation with a Waterpik is an ancillary procedure, which we, at the UCSD Nasal Dysfunction Clinic have found to provide substantial benefit to those with allergic rhinitis. Irrigating the nasal cavity once or twice a day either washes away enough of the allergen laden mucus or by some other mechanism provides sufficient benefit that many patients report tremendous relief.