Seasonal Allergic Rhinitis: Diagnosis and Management
- Mayta
- Aug 15
- 3 min read
Definition
Seasonal allergic rhinitis (SAR) is an IgE-mediated inflammation of the nasal mucosa triggered by airborne allergens present during specific seasons — commonly pollen from trees, grasses, and weeds.
Pathophysiology
Sensitization: Initial exposure to allergen → IgE production → binds to mast cells.
Re-exposure: Allergen cross-links IgE → mast cell degranulation → release of histamine, leukotrienes, prostaglandins.
Early-phase response (minutes): Sneezing, itching, rhinorrhea.
Late-phase response (hours): Nasal congestion from inflammatory cell infiltration.
Epidemiology
Common in children and young adults.
Prevalence up to 20–30% worldwide.
Family history of atopy increases risk.
Clinical Presentation
Symptoms (worsen during specific seasons):
Sneezing
Nasal congestion
Clear watery rhinorrhea
Nasal itching
Ocular symptoms (itchy, watery, red eyes)
Triggers:
Tree pollens (spring)
Grass pollens (summer)
Weed pollens (fall)
Diagnosis
1. History — seasonal pattern, symptom triggers, family history of allergy.2. Physical examination:
Allergic shiners (dark infraorbital circles)
Pale, bluish, edematous nasal mucosa
Clear nasal discharge
Dennie–Morgan folds under lower eyelids
Mouth breathing in severe cases
3. Investigations (if needed):
Skin prick test or serum-specific IgE to identify allergens.
Nasal cytology (eosinophils).
Rule out sinusitis, vasomotor rhinitis, or nasal polyps.
Management
A. Allergen Avoidance
Environmental control: Monitor pollen counts, stay indoors during peak hours (early morning, windy days), use air conditioning with HEPA filters.
Personal protection: Sunglasses outdoors, mask if mowing lawn, shower + change clothes after outdoor exposure.
B. Pharmacotherapy
First-line: Intranasal Corticosteroids (most effective)
Used daily, correct spray technique (slightly outward from nasal septum).Start 1–2 weeks before allergen season for prevention.
Drug | Usual Adult Dose | Max Dose | Notes |
Fluticasone propionate (Flixonase®) 50 mcg/spray | 1–2 sprays/nostril OD | 200 mcg/day | Onset 6–12 h, peak effect ~3 days |
Mometasone furoate (Nasonex®) 50 mcg/spray | 2 sprays/nostril OD or 1 spray/nostril BID | 200 mcg/day | Very low systemic absorption |
Budesonide (Rhinocort®) 64 mcg/spray | 1 spray/nostril BID or 2 sprays/nostril OD | 256 mcg/day | Pregnancy category B — safe option |
💡 Pediatric dosing: usually half adult dose; always check product-specific recommendations.
Adjunctive: Oral Second-Generation Antihistamines
Rapid onset (1–3 h), best for sneezing, itching, rhinorrhea.Minimal effect on congestion compared to nasal steroids.
Drug | Adult Dose | Pediatric Dose | Notes |
Cetirizine | 10 mg PO OD | 5–10 mg PO OD (≥2 yrs) | Mild sedation possible |
Loratadine | 10 mg PO OD | 5–10 mg PO OD (≥2 yrs) | Non-sedating |
Fexofenadine | 120 mg PO OD or 60 mg PO BID | 30–60 mg PO BID (≥2 yrs) | Non-sedating, fast onset |
Adjunctive: Intranasal Antihistamines
Faster onset than steroids (~15–30 min).Good for as-needed relief or in combo with steroids for severe SAR.
Drug | Adult Dose | Pediatric Dose | Notes |
Azelastine 137 mcg/spray | 1–2 sprays/nostril BID | 1 spray/nostril BID (≥5 yrs) | May cause bitter taste, drowsiness |
Olopatadine 665 mcg/spray | 2 sprays/nostril BID | Not for <6 yrs | Good ocular + nasal symptom control |
Adjunctive: Ocular Antihistamine/Mast Cell Stabilizer Drops
For allergic conjunctivitis symptoms.
Drug | Dose | Notes |
Olopatadine 0.1% | 1 drop/eye BID | Fast relief, long duration |
Ketotifen 0.025% | 1 drop/eye BID | OTC in many countries |
Combination Therapy
Fluticasone + Azelastine (Dymista®) 50 mcg/137 mcg per spray:
Dose: 1 spray/nostril BID
Combines anti-inflammatory + rapid antihistamine effect.
Useful in severe or uncontrolled SAR despite monotherapy.
C. Saline Nasal Irrigation
Isotonic (0.9%) or hypertonic (1.5–3%) saline rinse.
Dose: 50–250 mL per nostril OD–BID via squeeze bottle or neti pot.
Use before steroid spray to improve drug penetration.
D. Allergen Immunotherapy (AIT)
Subcutaneous (SCIT):
Weekly build-up injections → monthly maintenance.
Duration: 3–5 years.
Sublingual (SLIT):
Daily allergen tablet/drop under tongue.
Start 3–4 months before season, continue through exposure period.
Indicated for:
Moderate–severe SAR not controlled with optimal pharmacotherapy
Patient preference to reduce long-term drug use
Specific IgE-proven allergen sensitization
Stepwise Summary Table (Adult)
Step | Therapy | Example Dose |
1 | Intranasal corticosteroid | Fluticasone 1–2 sprays/nostril OD |
2 | + Oral antihistamine | Cetirizine 10 mg PO OD |
3 | + Intranasal antihistamine | Azelastine 1 spray/nostril BID |
4 | + Ocular drops if needed | Olopatadine 1 drop/eye BID |
5 | Consider AIT | SCIT monthly or SLIT daily |
Prognosis
SAR is not life-threatening but can impair quality of life, school/work performance, and predispose to asthma exacerbations.
Good control is achievable with consistent treatment and avoidance strategies.
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