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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- IgE-mediated type 1 hypersensitivity to aeroallergens — seasonal (pollen: grass, tree) or perennial (house dust mite, animal dander)
- Part of the "atopic triad" with asthma and eczema — 80% of asthmatic children have allergic rhinitis
- First-line treatment: intranasal corticosteroid spray (e.g. fluticasone, mometasone, beclometasone)
- Add oral non-sedating antihistamine (cetirizine, loratadine, fexofenadine) for additional symptom control
- Allergen avoidance, nasal saline irrigation, and antihistamine eye drops for conjunctivitis symptoms
Overview
Allergic rhinitis is an IgE-mediated type 1 hypersensitivity reaction of the nasal mucosa to aeroallergens. It is classified as seasonal (hay fever — triggered by tree pollen in spring, grass pollen in summer, weed pollen in autumn) or perennial (year-round — triggered by house dust mite, animal dander, mould). The ARIA classification divides it into intermittent (<4 days/week or <4 weeks) or persistent (≥4 days/week and ≥4 weeks), and mild or moderate-severe based on impact on quality of life. Allergic rhinitis is a risk factor for asthma development and worsens asthma control.
Epidemiology
Allergic rhinitis affects approximately 20–30% of the UK population, making it one of the most common chronic conditions. Prevalence is increasing, particularly in developed countries. Peak onset is in childhood and adolescence. It is strongly associated with atopy — approximately 80% of asthmatic children have coexisting allergic rhinitis. Hay fever peaks in the UK from May to July (grass pollen season). The condition significantly impacts quality of life, sleep, work productivity, and school performance.
Clinical Features
Symptoms
Sneezing — often in paroxysms
Rhinorrhoea — clear, watery nasal discharge
Nasal obstruction/congestion
Nasal and palatal itching
Eye symptoms: itching, watering, redness (allergic conjunctivitis) — common with seasonal rhinitis
Post-nasal drip causing throat clearing and cough
Impaired sense of smell (hyposmia)
Unilateral symptoms, bloody discharge, or facial pain = NOT typical — consider alternative diagnosis
Signs
Pale, swollen (boggy) inferior turbinates on anterior rhinoscopy
Allergic shiners (periorbital darkening from venous congestion)
Transverse nasal crease (from habitual upward wiping — "allergic salute")
Mouth breathing (nasal obstruction)
Conjunctival injection and chemosis
Nasal polyps may coexist — particularly in adults with perennial rhinitis
Investigations
First-line
Clinical diagnosisBased on typical history of allergen-related symptoms — investigations are not always needed
Second-line
Skin prick testingIdentifies specific allergen sensitisation — rapid, inexpensive, performed in allergy clinics
Specific IgE (RAST)Blood test for specific allergen IgE — alternative to skin prick testing; useful if skin testing contraindicated or antihistamines cannot be stopped
Specialist
Nasal endoscopyIf symptoms are atypical, unilateral, or if nasal polyps or structural abnormality suspected
CT sinusesIf chronic sinusitis or nasal polyps suspected
1
Allergen avoidance
- Pollen: check pollen forecasts, keep windows closed, shower after outdoor activity, wear wraparound sunglasses
- House dust mite: allergen-proof mattress/pillow covers, hot-wash bedding, reduce soft furnishings (evidence is limited)
- Pet dander: reduce exposure, keep pets out of bedrooms
2
Pharmacotherapy — first-line
- Intranasal corticosteroid spray: fluticasone propionate, mometasone, or beclometasone — MOST EFFECTIVE single treatment
- Correct technique: aim spray laterally (away from septum), use regularly (not just PRN)
- Takes 1–2 weeks for full effect — start before pollen season if possible
- Oral non-sedating antihistamine: cetirizine 10 mg OD, loratadine 10 mg OD, or fexofenadine 120–180 mg OD
3
Add-on therapies
- Antihistamine eye drops (azelastine, olopatadine) for allergic conjunctivitis
- Nasal saline irrigation (douching) — adjunctive relief
- Short course of oral prednisolone (5–7 days) for severe symptoms not responding to topical treatment (e.g. during exams or important events)
- Ipratropium bromide nasal spray for profuse watery rhinorrhoea
- Leukotriene receptor antagonist (montelukast) if coexisting asthma
4
Specialist referral
- Immunotherapy (subcutaneous or sublingual) for moderate-severe allergic rhinitis not controlled with pharmacotherapy
- Effective for grass and tree pollen, house dust mite — treatment duration typically 3 years
- Refer if nasal polyps, unilateral symptoms, or diagnostic uncertainty
Complications
- Asthma exacerbation: Untreated allergic rhinitis worsens asthma control — "one airway, one disease"
- Sinusitis: From mucosal oedema obstructing sinus drainage
- Nasal polyps: Particularly with perennial rhinitis and aspirin sensitivity (Samter triad: asthma + nasal polyps + aspirin sensitivity)
- Sleep disturbance: Nasal obstruction impairs sleep quality
- Reduced quality of life: Impacts school and work performance, social functioning
UKMLA Exam Tips
- 1Intranasal corticosteroid is the MOST EFFECTIVE single treatment for allergic rhinitis — more effective than oral antihistamines alone
- 2Allergic rhinitis + asthma + eczema = atopic triad — treat rhinitis to improve asthma control
- 3Hay fever = seasonal allergic rhinitis — grass pollen is the commonest UK trigger (May–July)
- 4Sedating antihistamines (chlorphenamine) should be avoided in daytime — use non-sedating (cetirizine, loratadine, fexofenadine)
- 5Intranasal steroid spray technique: aim LATERALLY (away from septum) to avoid epistaxis and septal perforation
- 6Unilateral nasal symptoms are NOT typical of allergic rhinitis — think nasal polyp, foreign body, or malignancy
- 7Immunotherapy (desensitisation) is available for severe cases unresponsive to standard treatment — typically 3-year course
practicetest your knowledge on Allergic Rhinitis and Hay FeverApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — Respiratory and beyond.
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Allergic Rhinitis and Hay Fever: guidance by region
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