When Should I See a Doctor For Hay Fever/Hay fever is a type of inflammation in the nose which occurs when the immune system overreacts to allergens in the air.[rx] Signs and symptoms include a runny or stuffy nose, sneezing, red, itchy, and watery eyes, and swelling around the eyes.[rx] The fluid from the nose is usually clear.[rx] Symptom onset is often within minutes following exposure and they can affect sleep, the ability to work, and the ability to concentrate at school.[rx] Those whose symptoms are due to pollen typically develop symptoms during specific times of the year.[rx] Many people with allergic rhinitis also have asthma, allergic conjunctivitis, or atopic dermatitis.[rx]
Pathophysiology
In predisposed persons exposed to certain allergens, IgE antibodies specific for food are formed that bind to basophils, macrophages, mast cells, and dendritic cells on Fc epsilon receptors. Once food allergens enter the mucosal barriers and reach cell-bound IgE antibodies, these mediators are released and cause smooth muscle to contract, vasodilation, and mucus secretion, which result in symptoms of immediate hypersensitivity (allergy). Activated mast cells and macrophages that attract and activate eosinophils and lymphocytes release cytokines. This leads to prolonged inflammation, affecting the skin (flushing, angioedema, or urticaria), respiratory tract (rhinorrhea, nasal pruritus with nasal congestion, sneezing, dyspnea, laryngeal edema, wheezing), gastrointestinal tract (nausea, oral pruritus, vomiting, angioedema, abdominal pain, diarrhea), and cardiovascular system (hypotension, loss of consciousness, dysrhythmias) as per the Nelson Textbook of Pediatrics.[rx][rx]
Causes of Hay Fever
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Immune system disorders, for example hay fever or other allergies
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Deviated nasal septum (where the wall between the two nostrils is bent to one side) or other abnormalities in or near the nose
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Intolerance of acetylsalicylic acid (ASA – the drug in Aspirin)
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Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
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Asthma is a chronic inflammatory disorder of the airways. This feature of asthma has implications for the diagnosis, management, and potential prevention of the disease.
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The immuno histopathologic features of asthma include inflammatory cell infiltration:
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Neutrophils (especially in sudden-onset, fatal asthma exacerbations; occupational asthma, and patients who smoke)
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Eosinophils
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Lymphocytes
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Mast cell activation
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Epithelial cell injury
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Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity.
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In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis.
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Gene-by-environment interactions are important to the expression of asthma.
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Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.
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Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma.
Symptoms of Hay Fever
Often has the following typical symptoms
- Coughing – Coughing from asthma often is worse at night or early in the morning, making it hard to sleep.
- Wheezing – Wheezing is a whistling or squeaky sound that occurs when you breathe.
- Chest tightness – This may feel like something is squeezing or sitting on your chest.
- Shortness of breath – Some people who have asthma say they can’t catch their breath or they feel out of breath. You may feel like you can’t get air out of your lungs.
- Increasing difficulty breathing – (measurable with a peak flow meter, a device used to check how well your lungs are working)
- Shortness of breath
- Trouble sleeping caused by shortness of breath, coughing or wheezing
- A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in children)
- Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu
- Stuffy nose
- Coughing
- Fever
- Pain
- Swelling
- A build-up of pus
Diagnosis of Hay Fever
History and Physical
Pertinent History
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Onset of symptoms
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Environmental triggers (inside and outside the home) and risk factors (such as tobacco use or exposures)
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Current therapy and previous history specific to their attacks
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History of prior hospitalization or intubation for asthma
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Occupation (sensitizers and 10% by irritants cause 90% of occupational asthma)*
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Ask about food allergies
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Gastroesophageal reflux disease (GERD) symptoms
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Use of medications such as NSAIDs and aspirin
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If exercise triggers shortness of breath
Asthma Symptoms
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Coughing
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Shortness of breath
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Wheezing
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Chest tightness or pressure
Physical Examination Findings during an Acute Exacerbation
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Tachypnea
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Wheezing
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Accessory muscle use
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Retractions
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Prolonged expiratory phase
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Sometimes there is limited air movement which can occur in severe cases
Sensitizers include animals, bioaerosols, drugs, enzymes, latex, plants, seafood, acid anhydrides, metals, wood dust, persulfate, rosin, and isocyanates. Irritants include chlorine and high-level dust and smoke. [rx],[rx]
Gastrointestinal
Food allergies that cause gastrointestinal manifestations are often the initial form of allergy to affect infants and young children, causing irritability, vomiting or “spitting-up,” diarrhea, and poor weight gain. There are three main entities related to food allergies associated with gastrointestinal symptoms
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Food protein-induced enterocolitis syndrome (FPIES) – these patients can present with emesis one to three hours after feeding, and constant exposure might result in abdominal distention, bloody diarrhea, anemia, and faltering weight and are provoked by cow’s milk or soy protein-based formulas.
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Food protein-induced proctocolitis – is known to cause blood-streaked stools in otherwise healthy infants in the first few months of life and is associated with breastfed infants.
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Food protein-induced enteropathy – is associated with steatorrhea and poor weight gain in the first several months of life.
Skin
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Atopic dermatitis – also known as eczema, is linked to asthma and allergic rhinitis, and about 30% of children with moderate to severe atopic dermatitis have food allergies.
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Acute urticaria and angioedema – are one of the most common symptoms of food allergic reactions and tend to have very rapid onset after the responsible allergen is ingested. Most likely foods include egg, milk, peanuts, and nuts, but sesame and poppy seeds and fruits such as kiwi have been linked.
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Perioral dermatitis – is benign and is regularly a contact dermatitis caused by substances in toothpaste, gum, lipstick, or medications. These tend to resolve spontaneously.
Respiratory
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Respiratory food allergies – are uncommon as isolated symptoms. Wheezing occurs in approximately 25% of IgE-mediated food allergic reactions, but only approximately 10% of asthmatic patients have food-induced respiratory symptoms.
Hay Fever Treatment
Various medications are available to treat the symptoms:
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Antihistamines
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Steroids (corticosteroids)
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Chromones (mast cell stabilizers)
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Leukotriene receptor antagonists
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Decongestant nasal drops and sprays
There are also non-drug alternatives such as saline (salt water) nasal sprays and nasal washes (nasal irrigation). Allergen-specific immunotherapy (also known as desensitization) can reduce your sensitivity to allergens over the long term. Like with vaccines, this treatment approach involves being exposed to small amounts of the substance by having it injected or placing it under your tongue. In allergen-specific immunotherapy, you are exposed to the allergen at regular intervals. The treatment takes about three years to complete.
Antihistamines
Oral antihistamines are effective in patients with mild to moderate disease, particularly in those whose main symptoms are palatal itch, sneezing, rhinorrhoea, or eye symptoms. Antihistamines have little effect, however, on nasal blockage.
Terfenadine and astemizole are the most commonly prescribed drugs, are effective, and rarely cause drowsiness or anticholinergic side effects. With these drugs it is important to emphasise the manufacturers’ instructions in view of the extremely rare complication of cardiac arrhythmias in overdose and, in the case of terfenadine, interactions with erythromycin or ketoconazole (which should not be given concurrently).
Newer alternatives include loratadine and fexofenadine. Acrivastine is short acting and may be useful when symptoms are mild and episodic. Cetirizine has also been shown to be highly effective in placebo controlled trials. The place of topical nasal antihistamines in hay fever is currently being evaluated.
Corticosteroids
Topical corticosteroids are extremely potent, with a low potential for systemic side effects. They are the best treatment for patients with moderate to severe nasal symptoms. Aqueous corticosteroids are better tolerated than those in fluorocarbon propellants and have a better local distribution in the nose. The side effects are minor—local irritation and occasional (in 5% of cases) bleeding. Treatment should be started before the beginning of the hay fever season for maximal effect. Patients should be given instruction on the importance of regular treatment and how to use the nasal spray.
Topical corticosteroids are effective against all nasal symptoms, including nasal blockage. Although systemic absorption is negligible in adults, care should be taken when nasal steroids are given to children who are also taking inhaled steroids for asthma or topical steroids for eczema. Sodium cromoglycate two to four times daily is an alternative, particularly in children. Eye drops containing sodium cromoglycate, such as Opticrom, are effective in most patients (often within minutes) for allergic symptoms affecting the eyes.
First line treatment in children.
Second line treatment
In patients who fail to respond to antihistamines or topical corticosteroids, a short course of an oral corticosteroid (say, prednisolone 20 mg for five days) may produce rapid relief of symptoms. This is particularly effective when the nose is completely obstructed as topical treatment will not gain access to the nose.
An alternative is to use a topical decongestant short term to allow penetration of topical corticosteroids. Ipratroprium bromide may have a role when watery rhinorrhoea is pronounced.
In general it is important to establish which are the patient’s dominant symptoms and, particularly for severe symptoms, to match the treatment to the symptoms.
Leukotriene receptor antagonists
These medications block the action of leukotrienes – chemical messengers that play an important role in the inflammatory response that happens in the airways. In Germany they have been approved for the treatment of asthma when used in the form of tablets. As well as relieving asthma symptoms, they can also relieve the symptoms of hay fever. So doctors can prescribe leukotriene receptor antagonists for people above the age of 15 who have both asthma and hay fever. Possible side effects include respiratory tract infections (infections of the airways) and headaches.
Chromones (mast cell stabilizers)
Mast cell stabilizers prevent histamine from being released by certain cells in the body known as mast cells. This reduces allergic and inflammatory responses in the body. They are used in the form of nasal sprays, and are usually used to prevent symptoms, but they can also relieve symptoms. Possible side effects include irritation of the membranes lining the nose, and an unpleasant taste in your mouth.
Decongestant (anti-swelling) nose drops and nasal sprays
Decongestant nose drops and nasal sprays reduce swelling in the membranes lining the nose and the sinuses, making it easier to breathe through your nose. They are not suitable for the long-term treatment of allergic rhinitis, though. Although they open your nasal passages and make it easier to breathe, your nose might “get used to“ them after a short while, and then they have the opposite effect: The membranes become swollen again and it’s difficult to breathe through your nose. These medications can also cause side effects like nosebleeds. So it is recommended that these medications not be used for longer than 5 to 7 days.
Avoiding allergens
Patients with allergies are usually advised to avoid the provoking allergen. It is, however, controversial whether this should be routinely recommended for pollen allergy. As hay fever is usually not severe or life threatening, drugs can allow patients to lead a normal life without unnecessary restrictions. But patients with debilitating symptoms may benefit from simple advice. Pollen counts at ground level are highest during the evening and at night, when open grassy spaces should be avoided.
Immunotherapy
Most patients with hay fever will have their symptoms controlled by the above measures. Patients whose symptoms remain uncontrolled may benefit from “allergen injection immunotherapy.” This form of treatment is performed only in specialised centres. Careful selection of patients for this treatment is essential, and immunotherapy is contraindicated in those with chronic asthma. Indications and guidelines for immunotherapy in Britain were the subject of a recent report by the British Society for Allergy and Clinical Immunology.
Home Treatment
An individual cannot prevent the development of an allergy, but people who experience hay fever may find some strategies useful for minimizing the impact.
Here are some tips
- Be aware of the pollen count during susceptible months. Information is available through the internet and other media. Pollen count tends to be higher on humid and windy non-rainy days and during the early evening.
- Keep windows and doors shut when the pollen count is high.
- Avoid mowing the lawn during susceptible months, choose low-pollen days for gardening, and keep away from grassy areas when pollen counts are high.
- Regularly splash the eyes with cool water, to sooth them and clear them of pollen.
- Shower and change your clothes after coming indoors, when pollen counts are high.
- Use wrap-around glasses to protect the eyes from pollen.
- Wear a hat to prevent pollen from collecting in the hair and then sprinkling down onto the eyes and face.
- Have your car fitted with a pollen filter, and drive with the windows closed at high-count times.
- Do not have flowers inside your home.
- Keep all surfaces, floors, and carpets as dust free as possible.
- Choose a vacuum cleaner with a good filter.
- Use “mite-proof” bedding.
- Use a dehumidifier to prevent mold.
- Keep away from cigarette smoke, and quit, if you are a smoker.
- Wash pets when they come indoors on a high pollen count day, or smooth their fur down with a damp cloth.
- Smear Vaseline around the inside edges of your nostrils, as it helps stop pollen from getting through.
- Ask a physician for a plan, if you know your susceptible time is just around the corner.
References
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