Executive summary (stepwise, GP-ready)
- First-line options: intranasal corticosteroid and/or non-sedating antihistamine (oral or intranasal). Choice depends on severity and predominant symptoms.
- Most common failure: poor spray technique or under-dosing (patients stop after 2 days).
- Refractory symptoms: consider combination intranasal steroid + antihistamine spray where appropriate.
- Eyes: add topical antihistamine/mast-cell stabiliser drops if conjunctivitis prominent.
Intranasal steroid technique (snippet-friendly)
- Use daily for at least 2–4 weeks before declaring failure (many improve sooner, but persistence matters).
- Aim nozzle outwards (towards the ear) to reduce septal irritation/epistaxis.
- Use after saline irrigation if heavy congestion; treat rhinitis drivers (smoke, allergens).
Stepwise treatment
- Mild intermittent: oral non-sedating antihistamine (e.g., cetirizine/loratadine) ± intranasal antihistamine.
- Moderate–severe or persistent: intranasal corticosteroid as core therapy ± oral/intranasal antihistamine.
- If uncontrolled: consider a combined intranasal corticosteroid + antihistamine spray where suitable.
- Conjunctivitis: add eye drops (topical antihistamine/mast-cell stabiliser) and consider allergen avoidance measures.
Red flags (think beyond allergic rhinitis)
Unilateral nasal obstruction, recurrent epistaxis, facial pain/swelling, anosmia not explained by rhinitis, systemic symptoms, or suspected nasal polyps/refractory symptoms may need ENT assessment.
Frequently asked questions
What’s the best “single intervention” for moderate–severe symptoms?
A correctly used intranasal corticosteroid, daily and long enough. It targets nasal inflammation more effectively than oral antihistamines alone in many moderate–severe cases.
Why do patients say “sprays don’t work”?
Most commonly due to technique, stopping too early, or not using daily. Show technique and set expectations (often 1–2 weeks for strong effect).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.