Allergic rhinitis is a common allergic disease affecting 10-40% of the global population. It is characterized by nasal symptoms such as sneezing, itching, and congestion that are triggered by an IgE-mediated immune reaction to allergens. Common allergens include pollen, dust mites, molds and animal dander. Diagnosis involves assessing symptoms and performing tests like skin prick tests and allergen blood tests. Management includes allergen avoidance, oral antihistamines, intranasal corticosteroids, immunotherapy, and leukotriene receptor antagonists. Allergen immunotherapy offers potential for long-term tolerance and disease modification.

1. ALLERGIC RHINITIS
- Dr. Tejaswi Chandra

2. • Background and Epidemiology
• Pathogenesis
• Clinical manifestations
• Diagnosis
• Management
• Complications
• Prognosis

3. EPIDEMIOLOGY
• Allergic rhinitis (AR) is an allergic inflammation of the nasal
membranes, affecting 10-40% of the global population and 20-30% of
Indian population and that 15% develop Asthma.
• It is characterized as seasonal (SAR) or perennial (PAR).
• AR is the most frequent allergic, chronic disease in the pediatric
population and is often associated with other allergic diseases.

4. DEFINITION
• AR is defined as a symptomatic disorder of the nose characterized by:
- Itching
- Nasal discharge (rhinorrhea)
- Sneezing
- Nasal airway obstruction
• It is induced by an IgE-mediated immune reaction after allergen
exposure.

6. PATHOPHYSIOLOGY
• Occurs in four phases:
- Sensitization
- Subsequent reaction to allergen – Early phase
- Late phase reaction
- Systemic activation

10. CAUSES
• SAR
- Pollen from grass, weed and trees
• PAR
- House dust mites
- Molds and fungus spores
- Cockroaches
- Animal danders, smoking exposure
- Chemicals and certain foods
• Medications / drug use

11. • The best established risk factor for AR is a family history of allergy.
• Genes that are involved in the atopy are 4q, 5q, 11q, 12q and
chromosome 13
- Allergic rhinitis--a total genome-scan for susceptibility genes
suggests a locus on chromosome 4q24-q27 – ( European journal of
human genetics )

12. CLINICAL SYMPTOMS AND SIGNS
 Nasal
Rhinorrhea, nasal obstruction, nasal itching, sneezing, post nasal drip,
deviated nasal septum
 Eyes
Lacrimation, redness, burning, conjunctival itching, swelling, allergic
shiners
 Ears
Itching, fullness
Anosmia, headache, malaise

16. • Are the symptoms better or worse during certain times of the year?
• Does the discharge have any color ? Consistency?
• Does anything make the symptoms better?
• Is there a family h/o allergy or asthma
• Are there any other symptoms?
• Home environment? (carpeting, age of house, pets, locale, etc.)
• Occupational environment?

17. ARIA GUIDELINES

18. CLINICAL TESTING
• The diagnosis is based on association between a typical history of
allergic symptoms and results of diagnostic tests.
- History & Examination
- Skin prick test (SPT)
- RAST / Allergen ELISA
- Cytological examination of nasal mucosa
- Nasal allergen provocation test

19. SKIN PRICK TEST
• Simplest in-vivo test to assess the presence of IgE sensitization.
• Simple, safe and cost-effective tool.
• Low risk of systemic reactions.
• Positive results >3mm wheal
• Highly sensitive test.
• Technique.

22. BLOOD TESTS FOR ALLERGY
• RAST
- Allergen is bound to a solid phase
- Incubated with the patient’s serum
- IgE molecules bind to the allergen
- After washing, radio labelled anti - IgE is added
- Radioactivity is measured
• Immuno CAP RAST
- Allergen is coupled to a cellulose carrier
- anti-IgE is enzyme-labelled with a fluorescent substrate acting as the
developing agent
• ELISA

23. • Cytological studies – Non invasive study of cellular changes within the
nasal mucosa.
- Useful tool in the diagnosis of NARNE, NARES, NARMA, NARESMA
• Nasal allergen provocation test
- To identify local allergic rhinitis (LAR)
- Localised nasal allergic response in the absence of markers of
systemic atopy.

24. MANAGEMENT
 Allergen avoidance
Pharmacotherapy
Allergen immunotherapy

26. HOUSE DUST MITE ALLERGEN
AVOIDANCE
• Adequate ventilation to decrease
humidity.
• Wash bedding regularly at 600 c.
• Encase pillows, mattress and quilt in
allergen impermeable covers.
• Use vacuum cleaners with HEPA filters.
• Remove carpets, curtains, stuffed toys
from bedroom.

28. ORAL ANTIHISTAMINES

29. NEWER GENERATION OF ANTIHISTAMINES
• First line treatment for mild allergic rhinitis
• Effective for
- Rhinorrhea
- Nasal pruritus
- Sneezing
• Minimal or no side effects
• Rapid onset and 24-hour duration of action

30. DECONGESTANTS
• Oral
- Pseudoephedrine
• Nasal
- Phenylephrine
- Oxymetazoline
- Xylometazoline

31. ANTI-LEUKOTRIENE AGENTS
• CysLT1 Receptor Antagonists
- Montelukast
- Pranlukast
- Zafirlukast
• 5-Lipoxygenase Inhibitors
- Zileuton

32. • Equipotent to H1 receptor antagonists but with onset of action after 2
days.
• Reduce nasal and systemic eosinophilia
• Safe
• Causes dyspepsia

33. INTRANASAL CORTICOSTEROIDS
• Beclomethasone dipropionate
• Budesonide
• Ciclesonide
• Flunisolide
• Fluticasone propionate
• Mometasone furoate
• Triamcinolone acetonide

34. • Most potent anti-inflammatory agents
• Effective in treatment of all nasal symptoms
• Superior to anti-histamines and anti-leukotrienes
• First line pharmacotherapy

37. IMMUNOTHERAPY
• Current treatment modalities – allergen avoidance and symptomatic
therapy – have shortcomings.
• Many patients experience residual symptoms despite multiple
pharmacotherapy.
• Immunotherapy is a treatment that alters the course of the disease and
improves symptom control.
• Indicated for patients who have poor symptom control with standard
treatment.

38. • Repeated administration of an allergen extract in order to induce
immunological tolerance , with a reduction in clinical symptoms and
requirements for medication during subsequent natural allergen
exposure.
• Offers potential for
- Sustained prevention of all allergic symptoms
- Disease modification to avoid progression
- Disease remission

39. HOW DOES IT WORK ?
• Modifies B cell responses (increased production of blocking IgG4
antibodies which prevent allergen/IgE complexes) to give long term
tolerance.
• AIT also suppresses naïve T cells transformation to induce tolerance

41. • SCIT - Multiple injections with increasing dose
• SLIT – Can be taken by patient at home
 Check IgE and Tryptase levels.
Treatment for 3years
Anti-IgE - Omalizumab

43. • Differentials
- Vasomotor rhinitis
- Non allergic rhinitis with eosinophilia
- Infectious rhinitis
- Rhinitis medicamentosa

45. • To conclude ….
- AR is very common and causes considerable morbidity.
- Adequate and appropriate treatment leads to significant
improvement in quality of life.
- Co-morbid conditions are common and warrants special attention
and treatment for optimal results.
- Environmental manipulation is also important in the control of
disease.

46. THANK YOU