Clinical Conversations: Allergic and Non-Allergic Rhinitis – A Practical Approach for GPs | Part two
Allergic and non-allergic rhinitis are extremely common and distressing conditions. Dr Jessica Tattersall discusses the importance of history in order to differentiate between the two and to maximise improvement. She also discusses the co-morbidities and updated management options. This is part two, the final part of this article.
This is part two of this series. Listen to Part 1 >>
• Inflammatory types of rhinitis can be a Type 2 hypersensitivity response without being IgE-mediated. These types will respond well to steroids, especially combined with topical antihistamines. The triggers are similar to non-allergic rhinitis, plus smoke and occupational aspects.
• It is important to find out if there is a preventable cause in chronic non-inflammatory rhinitis, but it is still most likely idiopathic. Common triggers include things like perfume, hairspray, cosmetics, antiperspirants, deodorants, any kind of aerosols, cleaning products, soaps, powders, candles, incense, scented flowers, paints and solvents.
• In occupational triggers, the inflammatory as well as non-inflammatory causes often occur together “mixed rhinitis”. There often with this condition a history of allergic rhinitis that has been worsened by the onset of non-allergic rhinitis, roughly about the age of thirty to thirty-five years.
• Senile rhinitis (patients over seventy years of age) is a non-inflammatory rhinitis. Patients have no other symptoms apart from a profuse runny nose and ipratropium bromide, works brilliantly.
• Gustatory rhinitis is non-inflammatory and occurs only when eating spicy or other precipitating foods, is not associated with blockage, sneeze or itch and ipratropium bromide works well.
• Far too much importance is put on the positive blood test or skin prick test in rhinitis, because the positive test does not equate to having the allergy; there must be a cause and effect and so the history is most important.
• It doesn’t matter if the rhinitis is more allergic or more non-allergic, because the corticosteroid, especially combined with an antihistamine, works well for both.
• For non-allergic rhinitis refractory to corticosteroids, our clinic uses capsaicin spray four to five times a day, at least twenty minutes apart, until the burning sensation ceases. That can take five days up to two weeks, then it is used periodically as maintenance. Warn the patient that is stings.
I am not going to go into the very complex neuropathic pathways that are thought to be at play in non-allergic rhinitis. Just be aware that there are inflammatory types and there are non-inflammatory types of pathways. It is a very complex, with several different systems potentially interacting with one another. I am going to try to keep it simple ...