Seasonal Allergic Rhinitis

  • Roua Azmeh
  • Mark S. Dykewicz


Allergic rhinitis is a significant chronic health problem worldwide. It can be divided into seasonal and perennial classifications based on the timing of symptoms and the causative agents. Empiric treatment can be initiated without allergy testing, but testing is required for definitive diagnosis and consideration of certain trigger-specific therapies such as allergen avoidance and allergen immunotherapy. There are many options for pharmacotherapy and non-pharmacologic therapy, and the selection must be made based on symptoms, patient age/comorbidities, and patient/family preferences. Intranasal corticosteroids are the most effective medication class for monotherapy management of SAR and when combined with intranasal antihistamines can be even more effective. For patients with multiple allergies or who desire to reduce their reliance on medication, allergen immunotherapy can be a good option and is the only therapy that can permanently alter the course of the disease. Both step-down and step-up approaches are appropriate based on individual patient needs and preferences. This chapter discusses seasonal allergic rhinitis in particular and reviews oral and intranasal pharmacotherapy options as well as allergen immunotherapy.


Seasonal allergic rhinitis Pollen Hay fever Antihistamine Pruritus Allergen Immunotherapy 


  1. 1.
    Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al., Global Allergy and Asthma European Network, Grading of Recommendations Assessment, Development and Evaluation Working Group. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126(3):466–76.CrossRefGoogle Scholar
  2. 2.
    Seidman MD, Gurgel RK, Lin SY, Schwartz SR, Baroody FM, Bonner JR, et al., Guideline Otolaryngology Development Group. AAO-HNSF. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015:152(1 Suppl):S1–43.CrossRefGoogle Scholar
  3. 3.
    Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al., Joint Task Force on Practice, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma, and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1–84.Google Scholar
  4. 4.
    Settipane RA, Schwindt C. Chapter 15: allergic rhinitis. Am J Rhinol Allergy. 2013;27(Suppl1):S52–5.CrossRefGoogle Scholar
  5. 5.
    American College of Allergy, Asthma & Immunology. Allergy facts. Accessed 1 Jan 2017.
  6. 6.
    Soni A. Allergic rhinitis: trends in use and expenditures, 2000 and 2005. Statistical brief no. 204. Bethesda, MD: Agency for Healthcare Research and Quality; 2008.Google Scholar
  7. 7.
    Lang K, Allen-Ramey F, Huang H, Rock M, Kaufman E, Dykewicz MS. Health care resource use and associated costs among patients with seasonal versus perennial allergic rhinitis. Allergy Asthma Proc. 2016;37(5):103–11.CrossRefGoogle Scholar
  8. 8.
    Meltzer EO, Gross GN, Katial R, Storms WW. Allergic rhinitis substantially impacts patient quality of life: findings from the nasal allergy survey assessing limitations. J Fam Pract. 2012;61(2 Suppl):S5–S10.PubMedGoogle Scholar
  9. 9.
    Canonica GW, Bousquet J, Mullol J, Scadding GK, VIrchow JC. A survey of the burden of allergic rhinitis in Europe. Allergy. 2007;62(Suppl 85):17–25.CrossRefGoogle Scholar
  10. 10.
    Leger D, Annesi-Maesano I, Carat F, Rugina M, Chanal I, Pribil C, et al. Allergic rhinitis and its consequences on quality of sleep: an unexplored area. Arch Intern Med. 2006;166(16):1744–8.CrossRefGoogle Scholar
  11. 11.
    Meltzer EO, Farrar JR, Sennet C. Findings from an online survey assessing the burden and management of seasonal allergic rhinoconjunctivitis in US patients. J Allergy Clin Immunol Pract. 2017;5(3):779–789.e6. Scholar
  12. 12.
    Bielory L, Skoner DP, Blaiss MS, Leatherman B, Dykewicz MS, Smith N, et al. Ocular and nasal allergy symptom burden in America: the allergies, immunotherapy, and RhinoconjunctivitiS (AIRS) surveys. Allergy Asthma Proc. 2014;35:211–8.CrossRefGoogle Scholar
  13. 13.
    Carr TF, Saltoun CA. Chapter 2: skin testing in allergy. Allergy Asthma Proc. 2012;33(Suppl 1):S6–8.CrossRefGoogle Scholar
  14. 14.
    Meltzer EO, Rickard KA, Westlund RE, Cook CK. Onset of therapeutic effect of fluticasone propionate aqueous nasal spray. Ann Allergy Asthma Immunol. 2001;86:286–91.CrossRefGoogle Scholar
  15. 15.
    Day JH, Briscoe MP, Rafeiro E, Ellis AK, Pettersson E, Akerlund A. Onset of action of intranasal budesonide (Rhinocort aqua) in seasonal allergic rhinitis studied in a controlled exposure model. J Allergy Clin Immunol. 2000;105:489–94.CrossRefGoogle Scholar
  16. 16.
    Berkowitz RB, Bernstein DI, LaForce C, Pedinoff AJ, Rooklin AR, Damaraju CR, et al. Onset of action of mometasone furoate nasal spray (NASONEX) in seasonal allergic rhinitis. Allergy. 1999;54:64–9.CrossRefGoogle Scholar
  17. 17.
    Horak F, Zieglmayer UP, Zieglmayer R, Kavina A, Marschall K, Munzel U, et al. Azelastine nasal spray and desloratadine tablets in pollen-induced seasonal allergic rhinitis: a pharmacodynamic study of onset of action and efficacy. Curr Med Res Opin. 2006;22:151–7.CrossRefGoogle Scholar
  18. 18.
    Patel P, Roland PS, Marple BF, Benninger PJ, Margalias H, Brubaker M, et al. An assessment of the onset and duration of action of olopatadine nasal spray. Otolaryngol Head Neck Surg. 2007;137:918–24.CrossRefGoogle Scholar
  19. 19.
    Patel D, Garadi R, Brubaker M, Conroy JP, Kaji Y, Crenshaw K, et al. Onset and duration of action of nasal sprays in seasonal allergic rhinitis patients: olopatadine hydrochloride versus mometasone furoate monohydrate. Allergy Asthma Proc. 2007;28:592–9.CrossRefGoogle Scholar
  20. 20.
    Patel P, D’Andrea C, Sacks HJ. Onset of action of azelastine nasal spray compared with mometasone nasal spray and placebo in subjects with seasonal allergic rhinitis evaluated in an environmental exposure chamber. Am J Rhinol. 2007;21:499–503.CrossRefGoogle Scholar
  21. 21.
    Morris S, Eccles R, Martez SJ, Riker DK, Witek TJ. An evaluation of nasal response following different treatment regimes of oxymetazoline with reference to rebound congestion. Am J Rhinol. 1997;11:109–15.CrossRefGoogle Scholar
  22. 22.
    Yoo JK, Seikaly H, Calhoun KH. Extended use of topical nasal decongestants. Laryngoscope. 1997;107:40–3.CrossRefGoogle Scholar
  23. 23.
    Petruson B. Treatment with xylometazoline (Otrivin) nosedrops over a six-week period. Rhinology. 1981;19:167–72.PubMedGoogle Scholar
  24. 24.
    Watanabe H, Foo TH, Djazaeri B, Duncombe P, Mackay IS, Durham SR. Oxymetazoline nasal spray three times daily for four weeks in normal subjects is not associated with rebound congestion or tachyphylaxis. Rhinology. 2003;41:167–74.PubMedGoogle Scholar
  25. 25.
    Thongngarm T, Assanasen P, Pradubpongsa P, Tantilipikorn P. The effectiveness of oxymetazoline plus intranasal steroid in the treatment of chronic rhinitis: a randomised controlled trial. Asian Pac J Allergy Immunol. 2016;34:30–7.PubMedGoogle Scholar
  26. 26.
    Meltzer EO, Bernstein DI, Prenner BM, Berger WE, Shekar T, Teper AA. Mometasone furoate nasal spray plus oxymetazoline nasal spray: short-term efficacy and safety in seasonal allergic rhinitis. Am J Rhinol Allergy. 2013;27:102–8.CrossRefGoogle Scholar
  27. 27.
    Baroody FM, Brown D, Gavanescu L, DeTineo M, Naclerio RM. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol. 2011;127:927–34.CrossRefGoogle Scholar
  28. 28.
    Ferguson BJ, Paramaesvaran S, Rubinstein E. A study of the effect of nasal steroid sprays in perennial allergic rhinitis patients with rhinitis medicamentosa. Otolaryngol Head Neck Surg. 2001;125:253–60.CrossRefGoogle Scholar
  29. 29.
    Vaidyanathan S, Williamson P, Clearie K, Khan F, Lipworth B. Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion. Am J Respir Crit Care Med. 2010;182:19–24.CrossRefGoogle Scholar
  30. 30.
    Spector SL, Toshener D, Gay I, Rosenman E. Beneficial effects of propylene and polyethylene glycol and saline in the treatment of perennial rhinitis. Clin Allergy. 1982;12:187–96.CrossRefGoogle Scholar
  31. 31.
    Cox L, Nelson H, Lockey R, Calabria C, Chacko T, Finegold I, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011;127(1 Suppl):S1–55.CrossRefGoogle Scholar
  32. 32.
    Skoner DP, Blaiss MS, Dykewicz MS, Smith N, Leatherman B, Bielory L, Walstein N, Craig TJ, Allen-Ramey F. The allergies, immunotherapy, and RhinoconjunctivitiS (AIRS) survey: patients’ experience with allergen immunotherapy. Allergy Asthma Proc. 2014;35:219–26.CrossRefGoogle Scholar
  33. 33.
    Greenhawt M, Oppenheimer J, Nelson M, Nelson H, Lockey R, Lieberman P, et al. Sublingual immunotherapy: a focused allergen immunotherapy practice parameter update. Ann Allergy Asthma Immunol. 2017 Mar;118(3):276–282.e2.CrossRefGoogle Scholar
  34. 34.
    Durham SR, Creticos PS, Nelson HS, Li Z, Kaur A, Meltzer EO, et al. Treatment effect of sublingual immunotherapy tablets and pharmacotherapies for seasonal and perennial allergic rhinits: pooled analyses. J Allergy Clin Immunol. 2016;138:1081–1088.e4.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal MedicineSaint Louis University HospitalSt LouisUSA

Personalised recommendations