# Allergic Rhinitis & Seasonal/Perennial Allergies **Prepared by:** Pedro Cheung MD **Last Updated:** May 2026 ## What Is Allergic Rhinitis? Allergic rhinitis is an inflammation of the nasal passages triggered when your immune system overreacts to something you've breathed in — called an **allergen**. Your immune system mistakenly identifies the allergen as a threat and releases a chemical called **histamine**, which causes the itching, swelling, and congestion you feel. There are two main types: |Type|Triggers|When It Occurs| |---|---|---| |**Seasonal (Hay Fever)**|Tree, grass, and weed pollen; outdoor mold spores|Spring, summer, and early fall — varies by region| |**Perennial (Year-Round)**|Dust mites, pet dander, cockroach particles, indoor mold|Year-round; often worse in winter when windows are closed| You can have one or both types at the same time. About **1 in 5 Americans** has allergic rhinitis, making it one of the most common chronic conditions. --- ## Common Symptoms Symptoms typically appear within minutes of exposure to your trigger. You may experience some or all of the following: **Nose & Throat** - Frequent sneezing - Runny nose (clear, watery discharge) - Stuffy or congested nose - Postnasal drip (mucus dripping down the back of your throat) - Itchy nose, roof of the mouth, or throat - Persistent cough or sore throat **Eyes** - Itchy, red, or watery eyes - Puffy or swollen eyelids - Dark circles under the eyes ("allergic shiners") **General** - Fatigue and difficulty concentrating - Headaches or sinus pressure - Clogged or "full" sensation in the ears - Disrupted sleep > **Important:** Allergic rhinitis is _not_ a cold. Colds are caused by viruses and usually include fever, body aches, and thick yellow/green discharge. If you're unsure, see your doctor. --- ## How Is It Diagnosed? Your doctor will usually diagnose allergic rhinitis based on: 1. **Your symptom history** — when they occur, what makes them worse, and how long they've lasted 2. **Physical examination** — your doctor looks for a pale or bluish swollen nasal lining, a horizontal crease across the nose (from repeated nose-wiping), and allergic shiners under the eyes 3. **Allergy testing** (if needed) — a **skin prick test** (most accurate) or **blood test** (IgE levels) can identify your specific triggers Knowing your exact triggers helps you avoid them and choose the right treatment. --- ## Part 1: Lifestyle Changes & Environmental Controls Reducing your exposure to allergens is one of the most important — and often underused — strategies for controlling symptoms. These changes work _alongside_ medications, not instead of them. --- ### For Pollen (Seasonal Allergies) - **Check the pollen forecast daily.** Weather apps and websites like [pollen.com](https://www.pollen.com/) or the National Allergy Bureau (AAAAI) post daily pollen counts. On high-count days, plan ahead. - **Stay indoors during peak pollen hours.** Pollen counts are typically highest before 10 a.m. and after sunset. Schedule outdoor activities for midday or early afternoon. - **Keep windows closed.** Use air conditioning in your home and car, especially during pollen season. Set your car to recirculate indoor air. - **Shower after being outdoors.** Pollen clings to your hair, skin, and clothing. Change clothes and shower as soon as you come inside on high-pollen days. - **Don't hang laundry outside.** Sheets and towels act like pollen traps. Use a dryer instead. - **Wear wraparound sunglasses outdoors** to reduce the amount of pollen that reaches your eyes. - **Avoid lawn mowing, raking, and gardening** during pollen season. If unavoidable, wear a well-fitting N95 or pollen mask. - **Stay indoors before and during thunderstorms in pollen season.** When pollen grains hit water, they can burst into tiny particles that penetrate deeper into the airways — a phenomenon called thunderstorm asthma. --- ### For Dust Mites (Perennial Allergies) Dust mites are microscopic creatures that live in bedding, upholstery, and carpets. They are one of the most common triggers of year-round allergies. - **Use allergen-proof mattress and pillow covers.** Zippered, tightly woven covers (not just standard mattress pads) prevent mites from reaching the sleeping surface. - **Wash bedding weekly in hot water (≥ 60°C / 140°F).** This temperature kills dust mites. If washing in cold water, use a eucalyptus oil or tea tree oil laundry product. - **Hot tumble dry washed items for at least 10 minutes** to ensure mites are killed. - **Remove carpet if possible.** Hardwood, tile, or laminate flooring dramatically reduces dust mite populations. If you must keep carpet, vacuum weekly with a HEPA-filtered vacuum. - **Reduce upholstered furniture and soft furnishings** such as heavy curtains and stuffed animals. If you keep stuffed animals, wash them regularly or place them in a sealed plastic bag in the freezer overnight. - **Damp-dust or use electrostatic cloths** on hard surfaces to trap dust rather than scatter it. - **Keep indoor humidity below 50%.** Dust mites thrive in humidity above 50–60%. A dehumidifier or air conditioner can help, especially in damp climates. A hygrometer (inexpensive at hardware stores) measures indoor humidity. --- ### For Pet Dander (Perennial Allergies) Pet allergens — found in the skin flakes, saliva, and urine of animals — are extremely sticky and can remain in a home for months after a pet is removed. - **The most effective measure is removing the pet from the home.** This is difficult for many families, but note that it can take **up to 20 weeks** for allergen levels to drop significantly after a pet leaves. - **If keeping the pet:** ban it from the bedroom entirely and keep bedroom doors closed at all times. Your bedroom should be an allergen-free refuge. - **Consider keeping pets primarily outdoors** if symptoms are manageable. - **Wash pets regularly** (though evidence on symptom reduction is uncertain, it may reduce allergen load). - **Wash your hands after handling animals** and avoid touching your face. --- ### Indoor Air Quality - **Use air conditioning** in your home and car — it filters and dries the air, reducing both pollen and mold. - **Replace HVAC filters regularly** with high-efficiency filters (MERV 11 or higher). Change every 1–3 months. - **Portable HEPA air purifiers** in the bedroom can reduce small particle concentrations (pet dander, dust mite particles) by 65–90%. Place the unit close to where you sleep and ensure it's sized for the room. Change filters on schedule — dirty filters can become allergen sources themselves. - **Control moisture and mold.** Fix any water leaks promptly. Use a dehumidifier in damp spaces. Clean visible mold with appropriate cleaners. Ensure good ventilation in bathrooms and kitchens. - **Avoid smoking and secondhand smoke** indoors — smoke severely worsens allergic inflammation. - **Limit strong odors and aerosols** such as perfumes, cleaning sprays, and air fresheners, which can irritate already-inflamed nasal passages. > **A note on HEPA filters:** While HEPA air purifiers reduce allergen particle concentrations, clinical studies show mixed results for symptom improvement when used as a _single_ measure. They work best as _part of a comprehensive strategy_ that includes the other controls above. --- ### Nasal Saline Rinse (Nasal Irrigation) This simple, inexpensive technique is one of the best-supported non-drug treatments for allergic rhinitis. It works by physically flushing allergens, irritants, and excess mucus from your nasal passages. **Evidence:** Clinical studies show nasal saline irrigation reduces nasal symptom scores and improves quality of life. Large-volume, positive-pressure devices (e.g., neti pots, squeeze bottles) are significantly more effective than small-volume saline sprays. **How to do it safely:** 1. Use **sterile, distilled, or previously boiled water** — never tap water directly (rare but serious infections have been reported). 2. **Prepared saline packets** (e.g., NeilMed, Simply Saline, Arm & Hammer) are convenient and premixed. 3. **To make at home:** Mix 1 cup (240 mL) of distilled or boiled (then cooled) water + ½ teaspoon (3 g) non-iodized salt + a pinch of baking soda. 4. Rinse over a sink, tilting your head sideways, so the solution flows in one nostril and out the other. 5. **Clean and air-dry your device after every use** to prevent contamination. 6. Rinse **once or twice daily** during allergy season or more frequently as needed. --- ## Part 2: Over-the-Counter (OTC) Medications There are several effective OTC options for allergic rhinitis. Understanding what each type does will help you use them correctly — and combine them wisely when needed. --- ### 1. Intranasal Corticosteroid Sprays 🏆 _First-Line Treatment_ **Examples (all now OTC):** - Fluticasone propionate (Flonase Allergy Relief) - Triamcinolone acetonide (Nasacort Allergy 24HR) - Budesonide (Rhinocort Allergy) **How they work:** These sprays deliver a low-dose anti-inflammatory steroid directly to the nasal lining. They reduce swelling, mucus production, itching, and congestion. They also help with eye symptoms. **What the evidence says:** Multiple guidelines — including the American Academy of Allergy, Asthma & Immunology (AAAAI), the American Academy of Family Physicians (AAFP, 2023), and the ARIA 2020 guidelines — consistently rank intranasal corticosteroids (INCS) as the **single most effective treatment** for allergic rhinitis, superior to antihistamines and all other OTC options. **Important tips:** - **Start early.** Begin your nasal spray **1–2 weeks before your allergy season typically starts.** Prevention is far more effective than treating a flare that's already begun. - **They take time to work.** Full effect may take 1–2 weeks of consistent daily use. Don't give up after a few days. - **Use every day** for best results. They can also be used intermittently on high-pollen days if preferred — they still help. - **Use them correctly** (see technique box below). - **Safe for long-term use.** These sprays have very little absorption into the bloodstream. Side effects are typically mild: occasional nosebleeds or a mildly sore nose. If nosebleeds occur, aim the spray away from the septum (the center dividing wall). - **Do not use oral steroids** (prednisone pills) for allergic rhinitis — the risks outweigh the benefits. > **Proper nasal spray technique:** Gently blow your nose first. Tilt your head slightly forward. Insert the nozzle just inside the nostril, aimed toward the outer wall of the nose (away from the septum). Breathe in gently through the nose while pressing the pump. Avoid sniffing hard after spraying. --- ### 2. Oral Antihistamines **Examples:** - Cetirizine (Zyrtec) — once daily; may cause mild drowsiness in some people - Loratadine (Claritin) — once daily; least sedating - Fexofenadine (Allegra) — once daily; least sedating, no food interactions unlike older studies suggested - Levocetirizine (Xyzal) — once daily **How they work:** Antihistamines block histamine receptors, reducing sneezing, runny nose, and itching. They work quickly (within 1–2 hours) but are generally **less effective than nasal corticosteroid sprays**, particularly for nasal congestion. **What the evidence says:** Second-generation antihistamines (cetirizine, loratadine, fexofenadine) are preferred over first-generation antihistamines. The AAAAI/AAFP guidelines **strongly recommend against** first-generation antihistamines (Benadryl/diphenhydramine) for regular use due to sedation, impaired performance, poor sleep quality, and a potential association with dementia with long-term use. **Important tips:** - Use **second-generation antihistamines only** (Zyrtec, Claritin, Allegra, Xyzal) for regular treatment. - **Never use Benadryl (diphenhydramine) regularly** for allergies — it significantly impairs driving, concentration, and daytime functioning, even if you don't feel drowsy. - Antihistamines are great for **quick-onset sneezing and itching** and can be added to a nasal steroid spray when symptoms remain bothersome. - Some people respond better to one antihistamine over another — it's reasonable to try a different one if the first isn't working well. - Evidence does **not** support combining a nasal steroid spray with an oral antihistamine as _initial_ therapy — the combination adds little benefit over the nasal spray alone for most people. --- ### 3. Decongestants **Oral examples:** Pseudoephedrine (Sudafed — behind the pharmacy counter), phenylephrine (various combination products — less effective) **Nasal spray examples:** Oxymetazoline (Afrin), xylometazoline **How they work:** Decongestants shrink swollen blood vessels in the nasal passages, rapidly relieving stuffiness. They do _not_ address the underlying allergic reaction. **Important cautions:** - **Nasal decongestant sprays: MAXIMUM 3 days.** Using Afrin or similar sprays for more than 3 days causes **rebound congestion (rhinitis medicamentosa)** — your nose becomes _more_ congested when the spray wears off, trapping you in a cycle of dependence. These sprays are for short-term use only (e.g., a sudden severe flare or travel). - **Oral pseudoephedrine (Sudafed):** More effective than phenylephrine. Use with caution if you have high blood pressure, heart disease, hyperthyroidism, glaucoma, or are taking antidepressants. May cause insomnia or jitteriness. Available behind the pharmacy counter due to legal regulations — you'll need to show ID. - Decongestants are best used occasionally for breakthrough congestion, not as daily allergy management. --- ### 4. Antihistamine Eye Drops (OTC) **Examples:** Ketotifen (Zaditor, Alaway), olopatadine (Pataday — previously Rx, now OTC) **How they work:** These drops block histamine directly at the eye surface, rapidly relieving itchy, red, watery eyes. They work faster and more reliably on eye symptoms than oral antihistamines. **Tips:** - Use **1–2 drops per eye, up to twice daily** during allergy season. - Use **artificial tears first** to flush allergens from the eye, then wait a few minutes before applying antihistamine drops. - **Remove contact lenses** before applying and wait at least 10 minutes before reinserting. - **Cool compresses** (a cold damp cloth over closed eyes for a few minutes) can provide soothing relief as needed. --- ### 5. Cromolyn Sodium Nasal Spray (NasalCrom) **How it works:** This spray prevents mast cells from releasing histamine and other inflammatory chemicals. It is **preventive, not rescue** — it must be used _before_ allergen exposure to be effective. **Tips:** - Must be used **3–4 times daily**, every day, beginning before pollen season starts. - Much less effective than nasal corticosteroid sprays but very safe, with virtually no side effects. - A reasonable option for those who prefer to avoid steroids (e.g., during pregnancy — consult your doctor first). --- ### 6. Saline Nasal Sprays **Examples:** Simply Saline, Ayr, Ocean, Arm & Hammer Simply Saline **How they work:** Moisturize and gently clear the nasal passages. They do not treat the allergy itself but soothe irritated mucosa and can be used as often as needed. Excellent complement to other treatments. **Note:** These small-volume sprays are less effective than large-volume nasal irrigation (see above) for flushing allergens. --- ## OTC Treatment Summary at a Glance |Symptom|Best First Choice|Add-On Options| |---|---|---| |**Congestion**|Nasal corticosteroid spray (Flonase, Nasacort, Rhinocort)|Oral pseudoephedrine (short-term)| |**Sneezing & runny nose**|Nasal corticosteroid spray|Second-generation oral antihistamine| |**Itchy, watery eyes**|OTC antihistamine eye drops (Zaditor, Pataday)|Cool compresses, artificial tears| |**Itchy nose/throat**|Second-generation oral antihistamine|Nasal corticosteroid spray| |**Postnasal drip**|Nasal corticosteroid spray|Saline nasal rinse| |**All-around symptom control**|Nasal corticosteroid spray daily|Second-generation antihistamine as needed| --- ## When to See Your Doctor OTC treatments control symptoms for most people. However, see your doctor if: - Your symptoms are **not controlled** after 2–4 weeks of consistent OTC treatment - Symptoms are **severely disrupting your sleep or daily life** - You also have **asthma**, and your asthma is getting worse (allergic rhinitis and asthma frequently coexist) - You develop signs of a **sinus infection**: thick green/yellow discharge, facial pain, or fever - You're **pregnant or breastfeeding** and unsure about medication safety - You want to explore **allergy testing** to identify your specific triggers - You're interested in **allergen immunotherapy** (allergy shots or sublingual tablets), which can provide long-term desensitization and is the only treatment that modifies the underlying disease --- ## Things That Do NOT Work (and One Myth to Dispel) - **Dietary restrictions are not recommended for allergic rhinitis.** There is no evidence that dairy products, gluten, or other foods worsen nasal allergy symptoms. Eliminating foods without a confirmed food allergy is unnecessary and can cause nutritional harm, especially in children. - **Benadryl (diphenhydramine) as regular therapy:** Avoid. The sedating effects impair driving and cognition even when you don't feel sleepy, and long-term use raises concerns about dementia risk. - **Oral corticosteroids (prednisone pills):** Not recommended for allergic rhinitis due to significant side effects with repeated use. - **Herbal remedies:** Some (e.g., butterbur, spirulina) show preliminary promise, but current evidence is insufficient to recommend them. Discuss with your doctor before using. --- ## A Note on Allergy Immunotherapy (Allergy Shots & Sublingual Tablets) If environmental controls and medications aren't giving you adequate relief, or if you'd like a more permanent solution, ask your doctor about **allergen immunotherapy**: - **Allergy shots (subcutaneous immunotherapy):** A series of injections containing gradually increasing doses of your specific allergen(s). Given over 3–5 years, they can reduce sensitivity long-term — even after treatment ends. Effective for pollen, dust mites, pet dander, mold, and insect stings. - **Sublingual (under-the-tongue) tablets:** FDA-approved for grass pollen (Grastek), ragweed pollen (Ragwitek), and dust mites (Odactra). Taken daily at home; first dose given in the doctor's office. Convenient alternative for some patients. Immunotherapy is the **only treatment that addresses the root cause** of your allergies, not just the symptoms. --- ## Quick Reference: Daily Allergy Action Plan **Every day during season:** - [ ] Check local pollen count (weather app, pollen.com, AAAAI) - [ ] Take nasal corticosteroid spray (Flonase, Nasacort, or Rhinocort) — **before symptoms if possible** - [ ] Rinse nasal passages with saline (morning and/or evening) - [ ] Keep windows closed; use air conditioning **As needed:** - [ ] Second-generation antihistamine for sneezing/itching flares - [ ] OTC antihistamine eye drops for eye symptoms - [ ] Cool compress for eye relief - [ ] Afrin nasal spray — **only if severely congested, maximum 2–3 days** **After outdoor exposure:** - [ ] Change clothes - [ ] Shower and wash hair - [ ] Rinse eyes with artificial tears --- ## Key Takeaways 1. **Nasal corticosteroid sprays are the most effective OTC treatment.** Start them 1–2 weeks before your season begins and use them consistently. 2. **Use second-generation antihistamines** (Zyrtec, Claritin, Allegra) — not Benadryl — for itch and sneezing. 3. **Limit nasal decongestant sprays to 3 days** to avoid rebound congestion. 4. **Nasal saline rinse** is safe, inexpensive, and effective — do it daily. 5. **Reduce allergen exposure at home** — especially in the bedroom — for perennial allergies. 6. **See your doctor** if symptoms aren't controlled, or to discuss allergy testing or immunotherapy. --- _This handout is for educational purposes and does not replace personalized medical advice. If you have questions about your specific symptoms or medications, please speak with your healthcare provider._ **Trusted sources for more information:** - American Academy of Allergy, Asthma & Immunology: [aaaai.org](https://www.aaaai.org/) - American College of Allergy, Asthma & Immunology: [acaai.org](https://acaai.org/) - Mayo Clinic: [mayoclinic.org](https://www.mayoclinic.org/) - National Allergy Bureau (pollen counts): [nab.aafa.org](https://nab.aafa.org/)