Allergic Rhinitis - Clinical Manifestations, Epidemiology, and Diagnosis PDF

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Allergicrhinitis:Clinicalmanifestations,epidemiology,anddiagnosis
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Authors
RichardDdeShazo,MD
StephenFKemp,MD
SectionEditor
JonathanCorren,MD
DeputyEditor
AnnaMFeldweg,MD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jan2015.|Thistopiclastupdated:Oct22,2014.
INTRODUCTIONANDTERMINOLOGYAllergicrhinitis,orallergicrhinosinusitis,ischaracterizedby
paroxysmsofsneezing,rhinorrhea,andnasalobstruction,oftenaccompaniedbyitchingoftheeyes,nose,and
palate.Postnasaldrip,cough,irritability,andfatigueareothercommonsymptoms[13].
Someinvestigatorsprefertheterm"rhinosinusitis"totheseparateterms"rhinitis"and"sinusitis."Thisis
becausethenoseandsinusmucosaarecontiguous,rhinitisandsinusitisfrequentlyoccurtogether,rhinitis
commonlyleadstosinusitis,andnasalsymptomsarecommonwithsinusitis.However,withinthistopicreview,
rhinitisandsinusitisarereferredtoseparately,giventhatmanagementissuesmaydifferforeachcondition,and
detailedreviewsofacuteandchronicsinusitisarepresentedelsewhere.(See"Acutesinusitisandrhinosinusitis
inadults:Clinicalmanifestationsanddiagnosis"and"Chronicrhinosinusitis:Clinicalmanifestations,
pathophysiology,anddiagnosis"and"Acutesinusitisandrhinosinusitisinadults:Treatment".)
Theclinicalmanifestations,epidemiology,anddiagnosisofallergicrhinitisarepresentedinthistopicreview.
Thepathogenesisandtreatmentofthisconditionarediscussedseparately.(See"Pathogenesisofallergic
rhinitis(rhinosinusitis)"and"Pharmacotherapyofallergicrhinitis".)
EPIDEMIOLOGYAllergicrhinitisiscommon,affecting10to30percentofchildrenandadultsintheUnited
Statesandotherindustrializedcountries[49].Itmaybelesscommoninsomepartsoftheworld,althougheven
developingcountriesreportsignificantrates[1016].Theprevalenceofasthma,rhinoconjunctivitis,andeczema
weresystematicallyevaluatedinapproximately1.2millionchildrenin98countriesintheInternationalStudyof
AsthmaandAllergiesinChildhood(ISAAC)[17].Theoverallprevalenceofrhinoconjunctivitisinchildrenaged6
to7yearsand13to14yearswas8.5and14.6percent,respectively.
Theprevalenceintheindustrializedworldisincreasing,particularlyinurbanareas[1820].Theoriesaboutthe
reasonsforincreasingprevalencearereviewedseparately.(See"Increasingprevalenceofasthmaandallergic
rhinitis".)
EconomicburdenAllergicrhinitisisassociatedwithsignificantmorbidityandexpense[2124]:
Itaccountsforatleast2.5percentofallclinicianvisits,2millionlostschooldaysperyear,6millionlost
workdays,and28millionrestrictedworkdaysperyear.
Theaveragenumberofannualprescriptionsforpatientswithallergicrhinitisisnearlydoublethatfor
patientswithoutallergicrhinitis(19versus10)[24].
Studiesperformedintheyearsaround2000reported2.4billionAmericandollarsspentonprescription
andoverthecountermedicationsandUSD$1.1billioninclinicianbillings,causingatotalindirectand
directcostofseveralbilliondollarsperyear[2527].
Thereisevidencethattheeconomicburdenisincreasing,atleastintheUnitedStates.Medicalspendingto
treatallergicrhinitisalmostdoubledfrom2000to2005(USD$6.1to$11.2billiondollars)[28].Inadditionto
costsdirectlyattributabletoallergicrhinitis,thedisorderishighlyassociatedwithasthmaandsinusitis,further
expandingitseconomicimpact.
RISKFACTORSThefollowingareproposedoridentifiedriskfactorsforallergicrhinitis[2932]:
http://www.bidi.uam.mx:5667/contents/allergicrhinitisclinicalmanifestationsepidemiologyanddiagnosis?topicKey=ALLRG%2F7525&elapsedTime
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Familyhistoryofatopy(ie,thegeneticpredispositiontodevelopallergicdiseases)
Malesex
Birthduringthepollenseason
Firstbornstatus
Earlyuseofantibiotics
Maternalsmokingexposureinthefirstyearoflife
Exposuretoindoorallergens,suchasdustmiteallergen
SerumIgE>100int.units/mLbeforeagesix
PresenceofallergenspecificimmunoglobulinE(IgE)
Areviewofmultiplestudiesreportedthatthepresenceofeachofthesefactorswasassociatedwithapositive
likelihoodratioforthediagnosisthatrangedfromthreetofive[33].(See"Pathogenesisofallergicrhinitis
(rhinosinusitis)".)
CLINICALMANIFESTATIONS
SignsandsymptomsAllergicrhinitispresentswithparoxysmsofsneezing,rhinorrhea,nasalobstruction,
andnasalitching.Postnasaldrip,cough,irritability,andfatigueareothercommonsymptoms[13].Some
patientsexperienceitchingofthepalateandinnerear.Thosewithconcomitantallergicconjunctivitisreport
bilateralitching,tearing,and/orburningoftheeyes.(See"Allergicconjunctivitis:Clinicalmanifestationsand
diagnosis",sectionon'Clinicalmanifestations'.)
Youngchildrentypicallydonotblowtheirnoses,andinstead,mayrepeatedlysnort,sniff,cough,andcleartheir
throats.Somescratchtheiritchypalateswiththeirtongues,producingaclickingsound(palatalclick).
QualityoflifeandcognitivefunctionSleepdisturbedbreathingisoneofthemostimportantsequelae
ofuntreatedallergicrhinitis[34,35].Fatigueandgeneralizedmalaisearecommon,althoughpatientsrarely
reportthesesymptomsdirectly[36,37].Allergicrhinitisisassociatedwithahostofcognitiveandpsychiatric
issuesinchildrenandadolescents,includingattentiondeficithyperactivitydisorder,lowerexamscoresduring
peakpollenseasons,poorconcentration,impairedathleticperformance,andlowselfesteem[8,3841].In
adults,allergicrhinitisisassociatedwithanxiety,depression,reducedacademicperformanceandwork
productivity(andlowerthanthatofpatientswithasthma),impairedsexualperformance,andlowerqualityoflife
scores[10,36,4245].
PatternsofsymptomsAllergicrhinitismaybeclassifiedbytemporalpattern(intermittentorpersistent)
andbyseverity(mildormoderatesevere)(table1)[46]:
IntermittentSymptomsarepresentlessthanfourdaysperweekorforlessthanfourweeks
PersistentSymptomsarepresentmorethanfourdaysperweekandformorethanfourweeks
MildNoneoftheitemslistedbelowfor"moderatesevere"arepresent
ModeratesevereOneormoreofthefollowingitemsispresent:
Sleepdisturbance
Impairmentofschoolorworkperformance
Impairmentofdailyactivities,leisure,and/orsportactivities
Troublesomesymptoms
Thisclassificationsystemwasproposedbyaninternationalworkshopof34specialistsinrespiratoryallergy,in
collaborationwiththeWorldHealthOrganization(WHO)[46].TheWHOhadtargetedallergicrhinitisbecauseof
itsimpactonasthmaandmirrorstheconsensusasthmaguidelines.
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Othercommonlyusedtermsare"seasonal,"whichisallergicrhinitisthatoccursataparticulartimeoftheyear
(figure1),and"perennial,"whichdescribessymptomstoallergensthatarepresentyearround[47].Thissystem
ofclassificationispreferredbytheUSFoodandDrugAdministration(FDA).
Patientswhosesymptomsoccurepisodicallyareoftenmoreawareofthedisabilitycausedbyallergicrhinitis,
whereaspatientswithchronicsymptomsoftenadapttosignificantimpairmentovertime,andmaynotseek
medicalcareuntilsymptomsbecomesevere[40,41,48,49].Children,inparticular,willenduresignificant
disability.
Persistent/perennialsymptomsaremorecommonthanpurelyintermittentorseasonalsymptoms,although
manypatientshaveperennialsymptomswithseasonalexacerbations[50,51].
Seasonalallergyrhinitisisusuallycausedbypollenfromtrees,grasses,andweeds.Dependinguponthe
geographicarea,pollinationperiodsforcertaintypesofplantsarewellknown(figure1).Colloquialnames
sometimescorrectlyidentifythetriggeringpollen(eg,cedarfever),althoughinothercases,aplantthatisnot
causingsymptomsbutisveryvisibleatthesametimeisimplicatedbythename(eg,rosefever,whichrefersto
allergicrhinitiscausedbygrassesthatpollinateatthesametimethatrosesbloom,orhayfever,whichoccursin
thefallwhenhayisbeinggathered,butiscausedbyweedpollensorfrommoldgrowinginthehay).Symptoms
ofseasonalallergicrhinitisarepredictableandreproduciblefromyeartoyear.
Perennialallergicrhinitisusuallyreflectsallergytoindoorallergenslikedustmites,cockroaches,moldspores,
oranimaldander,althoughaeroallergensmaycauseperennialrhinitisintropicalorsubtropicalclimates.
Perennialrhinitisduetooutdoorallergensiscommoninsubtropicalregionswithlongpollinatingseasonsand
ubiquitousmoldanddustmiteallergens,andwithoccupationalallergenexposure[52].(See"Occupational
rhinitis".)
Itisimportanttounderstandthatallergicrhinitis,whetherseasonalorperennial,maybedifficulttodistinguish
clinicallyfromthenonallergicformsofrhinitis,sincenotallseasonalandperennialsymptomsareuniqueto
allergicformsofrhinitis[50,51].Asanexample,chronicnonallergicrhinitiscanbetriggeredbychangesin
weatherandtemperature,andmayappeartohaveaseasonalpatterninsomepatients.Thus,foranaccurate
diagnosisofallergicrhinitis,diagnostictestingmayberequired.(See'Allergenspecifictesting'belowand
"Chronicnonallergicrhinitis".)
IncreasingsensitivityovertimeWhenapatientiscontinuallyexposedtoanallergen,persistentnasal
mucosalinflammationdevelops.Insuchpatients,symptomsofrhinitisoccuronexposuretolowerdosesof
allergen(priming)andtononspecificirritants(hyperreactivity).Clinically,thisresultsincontinuedandfrequently
moresevererhinitissymptomswithexposuretolowallergenconcentrations.Thisphenomenonofincreasing
sensitivityovertimeprobablyresultsfromaloweringofthethresholdforaclinicalresponse.Sequentialallergen
challengesinpatientswithallergicrhinitisresultinmoresymptomsandhigherlevelsofhistamineand
inflammatorycellsinnasalwashes[53].Presumably,theinducedinflammationrecruitsadditionalinflammatory
cellsandtheirproductsintotheprocess,producingincreasingsymptoms.
Concomitantwithallergenpriming,thenosebecomesprogressivelymoresensitivetocholinomimeticstimuli,
suchasmethacholineandhistamine,aswellasirritantstimulilikecoldair[54].Overtime,manypatientswith
allergicrhinitisreportheightenedsensitivitytoirritants(eg,tobaccosmoke,particulatepollution),volatile
substances,andstrongscentsandperfumes[55].
PhysicalfindingsThefollowingphysicalfindingsmaybepresentinpatientswithactiveallergicrhinitis[56]:
Infraorbitaledemaanddarkeningduetosubcutaneousvenodilation,findingsthataresometimesreferred
toas"allergicshiners"
Accentuatedlinesorfoldsbelowthelowerlids(DennieMorganlines),whichsuggestsconcomitantallergic
conjunctivitis(see"Allergicconjunctivitis:Clinicalmanifestationsanddiagnosis")
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Atransversenasalcreasecausedbyrepeatedrubbingandpushingthetipofthenoseupwiththehand
(the"allergicsalute")
"Allergicfacies,"whicharetypicallyseeninchildrenwithearlyonsetallergicrhinitis,consistofahighly
archedpalate,openmouthduetomouthbreathing,anddentalmalocclusion(picture1)
Theinternalstructuresofthenose,oropharynx,andearsshouldbeexamined:
Thenasalmucosaofpatientswithactiveallergicrhinitisfrequentlyhasapalebluishhueorpalloralong
withturbinateedema
Clearrhinorrheamaybevisibleanteriorly,orifthenasalpassagesareobstructed,rhinorrheamaybe
visibledrippingdowntheposteriorpharynx
Hyperplasticlymphoidtissueliningtheposteriorpharynx,whichresemblescobblestones(afindingcalled
"cobblestoning")
Serousfluidmayaccumulatebehindtympanicmembranesinpatientswithsignificantnasalmucosal
swellingandeustachiantubedysfunction[57]
RoutinelaboratoryfindingsRoutinelaboratoriesareusuallynormal.Neitherperipheralbloodeosinophil
countsnortotalserumimmunoglobulinE(IgE)levels(elevatedinonly30to40percentofpatients)are
sensitiveenoughtohelpdiagnoseallergicrhinitis.(See"TherelationshipbetweenIgEandallergicdisease",
sectionon'Allergicrhinitis'.)
NaturalhistoryAllergicrhinitistypicallyrequiresafewyearsofallergenexposuretodevelop.Accordingly,it
isuncommoninchildrenundertwoyearsofage.Ifaveryyoungchildappearstohavepersistentnasal
symptoms,otherdisordersshouldbeconsidered.(See'Differentialdiagnosis'below.)
Sensitizationtoaeroallergensgenerallyprecedestheappearanceofrhinitissymptoms[58].Sensitization
describesthepresenceofallergenspecificIgE,asmeasuredbyskintestingorinvitrotests.However,
sensitizationisnotsynonymouswithallergy,andapersoncanbesensitizedtoanallergenwithoutdeveloping
symptomswhenexposedtothatallergen.Onlyasubsetofsensitizedindividualsdemonstrateclinicalallergy
[59].Thedistinctionbetweensensitizationandclinicalallergyisdiscussedinmoredetailelsewhere.(See"The
relationshipbetweenIgEandallergicdisease",sectionon'Sensitization'.)
Inchildren,sensitizationandthenclinicalallergydevelopfirsttoallergensthatarecontinuallypresentinthe
environment(eg,dustmitesoranimaldanders)andthentopollensandotherseasonalallergens.Inastudyof
approximately600children,atleasttwoseasonsofpollenexposurewererequiredbeforemostchildren
developedallergicsymptoms[60].
Aftertheageoftwo,theprevalenceofallergicrhinitissteadilyincreases,demonstratingabimodalpeakinthe
earlyschoolandearlyadultyears.Inaprospectivestudyof2024children,theprevalenceofallergicrhinitis
increasedfrom5percentattheageoffouryears,to14percentatageeight[58].Theprevalencethengradually
increases,peakinginearlyadulthood.Theconditionisusuallypersistentthroughoutadulthood,withsome
improvementinolderage[18,21,6167].
Allergicrhinitisuncommonlypresentsforthefirsttimeinolderadults,unlessthereisasignificantchangein
exposures(eg,anewpetoramovetoadifferentclimate).Thus,inanolderadultwithnewnasalsymptoms,
othercausesofrhinitisshouldbeconsidered.Achangeinresponsetotreatmentinolderadultsmayindicate
thedevelopmentofvasomotororatrophicrhinitis.(See"Atrophicrhinosinusitis".)
ASSOCIATEDCONDITIONSAllergicrhinitisoccursinassociationwithanumberofotherdisorders,
includingallergicconjunctivitis,acuteorchronicsinusitis,asthma,andatopicdermatitis(eczema).
AllergicconjunctivitisUpto60percentofpatientswithallergicrhinitishaveconcomitantallergic
conjunctivitis[68].Allergicconjunctivitispresentswithitching,tearing,conjunctivaledema,hyperemia,
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waterydischarge,burning,andphotophobia(picture2).Eyelidedemaisalsocommon.Symptomsare
usuallybilateral.(See"Allergicconjunctivitis:Clinicalmanifestationsanddiagnosis".)
SinusitisNasalinflammationassociatedwithallergicrhinitiscanalsocauseobstructionofthesinus
ostiomeatalcomplex,therebypredisposingtobacterialinfectionofthesinuses.Thisprocessaccountsfor
asmuchas30to80percentofcasesofacuteandchronicbacterialsinusitis,respectively.However,
purulentsinusitiswithoutconcurrentrhinitisisrare,giventhatthesetissuesareanatomicallycontiguous
[69].
Symptomsofbacterialsinusitisincludenasalcongestion,purulentrhinorrheaorpostnasaldrip,facialor
dentalpain,andcough.Purulentrhinorrhea,purulentpostnasaldrip,paininamaxillarytoothor,in
children,persistentcough,arethemostusefulpredictorsofbacterialsinusitis.However,nosingle
symptomhasahighdegreeofsensitivityorspecificityindiscriminatingbacterialsinusitisfromallergicor
viralrhinitis[70,71].(See"Acutesinusitisandrhinosinusitisinadults:Clinicalmanifestationsand
diagnosis"and"Acutebacterialrhinosinusitisinchildren:Clinicalfeaturesanddiagnosis",sectionon
'Anatomy'.)
AsthmaUpto50percentofpatientswithasthmahaveallergicrhinitis.Inchildren,coughandwheeze
arethemostcommonsymptomsandareoftenmoreprominentwithexertion(table2).Adultsmayreport
anycombinationofcough,wheeze,orchesttightness.Therelationshipsbetweenasthmaandallergic
rhinitisarediscussedindetailseparately.(See"Relationshipsbetweenrhinosinusitisandasthma"and
"Epidemiologyofasthma"and"Asthmainchildrenyoungerthan12years:Initialevaluationanddiagnosis"
and"Diagnosisofasthmainadolescentsandadults".)
Atopicdermatitis(eczema)Inchildren,atopicdermatitispresentswithintenselypruriticerythematous
patcheswithpapulesandsomecrusting,usuallyaffectingtheface,scalp,extremities,ortrunk,with
sparingofthediaperareas.
Inolderindividualswithmorechronicdisease,atopicdermatitispresentswiththickenedskin,increased
skinmarkings(lichenification),andexcoriatedandfibroticpapules.Theflexuralareas(neck,antecubital
fossae,andpoplitealfossae)aremostcommonlyinvolvedinadults.Thisdisorderisdiscussedseparately.
(See"Epidemiology,clinicalmanifestations,anddiagnosisofatopicdermatitis(eczema)".)
OralallergysyndromeOralallergysyndromeisaformoffoodallergythatdevelopsinindividualswho
aresensitizedtopollens.Patientsreportitchingand/ormildswellingofthemouthandthroatimmediately
followingingestionofcertainuncookedfruits(suchasapples,peaches,plums,cherries,andsomenuts)
orrawvegetables.Thesymptomsresultfromcontacturticariaintheoropharynxcausedbypollenrelated
proteinsinthesefoods.(See"Clinicalmanifestationsanddiagnosisoforalallergysyndrome(pollenfood
allergysyndrome)"and"Managementandprognosisoforalallergysyndrome(pollenfoodallergy
syndrome)".)
OtherconditionsAllergicrhinitisisstronglyassociatedandprobablycausallyrelatedtoeustachiantube
dysfunction,causingconcomitantserousandacuteotitismedia[57].Nasalobstructionduetosevere
allergicrhinitiscanalsocausesleepdisorderedbreathingandanosmia[7275].Theremaybean
increasedprevalenceofmigraineheadacheinpatientswithallergicrhinitis[76].
DIAGNOSISThediagnosisofallergicrhinitiscanbemadeonclinicalgroundsbaseduponthepresenceof
characteristicsymptoms(ie,paroxysmsofsneezing,rhinorrhea,nasalobstruction,nasalitching,postnasaldrip,
cough,irritability,andfatigue),asuggestiveclinicalhistory(includingthepresenceofriskfactors),and
supportivefindingsonphysicalexamination.Allergyskintestingconfirmsthatthepatientissensitizedto
aeroallergens,althoughitisnotnecessaryfortheinitialdiagnosis.
Imagingisnotusuallyperformedinthediagnosisofallergicrhinitisunlessaconcomitantconditionsuchas
chronicrhinosinusitis(CRS)issuspectedorthereisahistoryoffacialtraumaorfeaturestosuggestanatomic
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abnormalities(unilateralcongestionorobstruction).
Ifthepatient'ssymptomsprovedifficulttomanageorthetrigger(s)forthesymptomsarenotapparent,then
furtherevaluationisindicatedtodemonstratethatthepatientissensitizedtoaeroallergensandthatsymptoms
occurwhenexpectedfortheallergensinquestion.Sensitizationcanbedemonstratedwitheitherallergyskin
testingorinvitrotestsforallergenspecificimmunoglobulinE(IgE).(See'Whentorefer'below.)
Apositiveresponsetoatherapeutictrialofeithertopicalnasalglucocorticoidsortopicalantihistaminesdoesnot
conclusivelyestablishadiagnosisofallergicrhinitis,becausethesetherapiesarealsoeffectiveinthetreatment
ofnonallergicrhinitis[77,78].(See"Chronicnonallergicrhinitis",sectionon'Management'.)
HistorySomeformsofallergicrhinitiscanbereadilydiagnosedbyhistoryalone,whileothersmayrequire
additionalevaluationforaccuratediagnosis:
Seasonalallergicrhinitisisoftendiagnosedbythehistoryalone,becauseitisreproduciblefromyearto
year.Seasonalallergicrhinitiscausedbytreeandgrasspollentypicallyoccursinthespring,and
symptomscausedbyragweedpollenexposureoccurinthefall,althoughthereareregionalvariations
(figure1).
Somecasesofepisodicallergicrhinitiscanbediagnosedbyhistoryaloneifthereisanobvious
connectionbetweenexposureandtheonsetofsymptoms.Asanexample,ahistoryofepisodicexposure
toanimalsorhighlevelsofhousedustresultinginacuteallergicsymptomsmaybereadilydiagnosedas
episodicallergicrhinitis.
Bycomparison,theculpritallergensinperennial/persistentallergicrhinitismaynotbereadilyapparent
fromtheclinicalhistory.Perennialallergicrhinitisusuallyreflectsallergytoindoorallergenslikedustmites,
cockroaches,oranimaldander,althoughpollensmaycauseperennialrhinitisintropicalorsubtropical
climates.
PhysicalexaminationThenose,oropharynx,tympanicmembranes,andeyesshouldbeexamined,aseach
ofthesestructuresmayshowfindingsofallergicrhinitisorassociateddisorders.(See'Physicalfindings'above.)
Theinternalstructuresofthenoseandthenasalmucosacanbevisualizedusingastandardofficeotoscope
withadisposabletip.Stabilizingthetipagainstthepatient'suppernarespreventspainfulproddingofthe
mucosa,whichisnormallyexquisitelysensitivetotouch.
Inpatientsolderthanfiveyearsofage,flexiblefiberopticrhinoscopyishelpfulbutnotessentialfordiagnosis.If
pursued,itshouldbeperformedbycliniciansspecificallytrainedinthetechnique.Thistechniqueisdescribed
elsewhere.(See"Chronicrhinosinusitis:Clinicalmanifestations,pathophysiology,anddiagnosis",sectionon
'Rhinoscopyandendoscopy'.)
AllergenspecifictestingItisnotnecessarytoperformtestingforallergenspecificIgE,eitherwithblood
testsorskintesting,beforemakingthepresumptivediagnosisofallergicrhinitisandinitiatingtreatment.Primary
careclinicianstreatthemajorityofpatientswithallergicrhinitisandofteninitiatetherapyempirically,identifying
possibletriggersonlythroughtheclinicalhistory.Thisapproachisadequateformanypatients.
Despitetheabove,theuseofdiagnostictestingtoidentifyculpritallergenshasbeenassociatedwithimproved
patientoutcomes[79].Identifyingtheallergensthatareimportanttoanindividualfacilitatesavoidanceofthe
allergenandidentifiescandidatesforallergenimmunotherapy,whichcaneventuallyreducerelianceonchronic
medications.
Properlyperformedskintestingisthemostconvenient,sensitive,andleastexpensivescreeningmethodto
detectallergicsensitization[80].Skintestingisusuallyperformedbyallergyexpertsbecause,although
generallyconsideredasafetechnique,raresystemicallergicreactionsarepossibleinresponsetothetesting
itself.
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SkintestingImmediatehypersensitivityskintesting(prickskintests)isaquick,costeffective,andsafe
waytoidentifythepresenceofallergenspecificIgE[80,81].Thesetestsareusuallyperformedbyallergy
specialists.Insensitivepatients,testingwithselecteddiagnosticsolutionsoftree,grass,orweedpollen,mold,
housedustmite,and/oranimalallergensresultsinawhealandflarereactionattheskintestsitewithin20
minutes.Positiveprickskintestscorrelatemorecloselywithsymptomsthanintradermaltests.(See"Overview
ofskintestingforallergicdisease".)
Skintestingisparticularlyusefulamongpatientswith:
Anuncleardiagnosisbaseduponthehistoryandphysicalexamination
Poorlycontrolledsymptoms,suchaspersistentnasalsymptomsand/oraninadequateclinicalresponseto
nasalglucocorticoids
Coexistingpersistentasthmaand/orrecurrentsinusitis/otitis
Ahighpretestprobabilityofallergicrhinitisandnegativeinvitrotestresultstosuspectedculpritallergens
(becausethesensitivityofskintestingisusuallysuperiortothatofinvitrotesting)
Apatient'sexpresseddesiretotrytoavoidtheallergenratherthantakemedicationstocontrolsymptoms
Skintestingaverysymptomaticpollenallergicpatientduringpeakpollenseasonshouldbeavoided,asitcan
aggravatesymptomsfurtherandmaybeassociatedwithhigherratesofsystemicreactionsduringtesting.In
thissetting,thepatient'ssymptomsshouldbetreatedempiricallyandtestingshouldbedeferreduntilthepatient
islesssymptomatic.
SerumtestsforallergyImmunoassaystodetectallergenspecificIgEantibodiesintheserumhave
limitedutilityinthediagnosisofallergicrhinitis[80].Thesetestsaresometimesreferredtoas
radioallergosorbenttests,orRASTs,becauseearliermethodsutilizedradioactivereagents.Modernmethods
aremorecorrectlyreferredtoasimmunoassaysforallergenspecificIgE.
IgEimmunoassaysprovidesimilarinformationasthatobtainedwithallergenskintests,althoughtheyaremore
expensiveandlesssensitiveforthediagnosisofallergytoinhalantallergenscomparedwithskintests.The
precisesensitivityofIgEimmunoassayscomparedwithskinpricktestinghasbeenreportedtorangefromless
than50percenttomorethan90percent,withtheaveragebeing70to75percentinmoststudies.Similar
sensitivityrangesapplywhenimmunoassayresultswerecomparedwithsymptomsinducedduringnaturalor
controlledtargetorganchallengeprocedures[82].(See"Overviewofinvitroallergytests",sectionon
'Accuracy'.)
TheutilityofscreeningpanelsofIgEimmunoassayshasbeenevaluatedinthediagnosisofallergicrhinitis.
Suchtestingcanimprovediagnosticaccuracyand/ormanagement,whenskintestingisnotavailable[8385].
ThesepanelstypicallytestforIgEantibodiestocommonseasonalandperennialallergensandareintendedfor
usebygeneralists[81].However,thisapproachcanbecostlyifexcessivenumbersofimmunoassaysare
measuredoriftheallergensselectedarenotrelevanttothegeographicareainquestion.Alogicalapproach
wouldinvolveconsultinganallergyexpertintheareainitiallytoidentifyasmallnumberofimportantallergens
forthearea(eg,afewprominentpollens,animaldanders,moldsfordryenvironmentsanddustmitesforhumid
environments)[86].
SuggestivehistorywithnegativetestingOccasionally,apatientpresentswithahistoryandphysical
findingssuggestiveofallergicrhinitis,butskintestingandinvitrotestingarenegative.Mostcommonly,such
patientshavechronicnonallergicrhinitis,whichhassubtlydifferenthistoricalfeaturesandphysicalfindings,as
reviewedbelow.(See'Differentialdiagnosis'below.)
AnotherpossibilityisthatthepatientisproducingallergenspecificIgElocallyinthenasaltissues,butitisnot
reflectedinthesystemiccirculationorskin.Thisconditionissometimesreferredtoas"localallergicrhinitis"and
itisanareaofincreasingresearchinterest.Localallergicrhinitisisdiscussedseparately.(See"Chronic
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nonallergicrhinitis",sectionon'Evidenceforalocalizedallergicresponse'.)
Fortunately,patientswitheitherofthesedisordersmaybemanagedsimilarlytothosewithallergicrhinitis.(See
"Pharmacotherapyofallergicrhinitis",sectionon'Summaryandrecommendations'.)
UncommonlyusedtestsNasalcytologyanddirectinhalationalchallengewithallergenaretechniquesthat
arelargelylimitedtoresearchsettings.
NasalcytologyNasalcytologyisperformedbysomeinvestigatorstohelpdifferentiaterhinitisdueto
allergyfromthatduetoinfection,althoughitisrelativelynonspecificandinsensitive.Nasalsecretionsmaybe
obtainedwithacottonswaborbyaskingthepatienttoblowthenoseontowaxedpaperorcellophane.Wright
stainofnasalsecretionsusually,butnotalways,revealsapredominanceofeosinophilsincasesofallergic
rhinitis.Bycomparison,thepresenceofneutrophilssuggestsaninfectiousprocess.
Nasaleosinophiliamayalsobeseeninotherconditionsincluding:
Asthmawithoutsymptomsofnasalallergy
Nasalpolyposis,withorwithoutasthmaandaspirinsensitivity(see"Aspirinexacerbatedrespiratory
disease")
Nonallergicrhinitiswitheosinophiliasyndrome(NARES),asyndromeofmarkednasaleosinophiliaanda
propensityfornasalpolyps,butwithnegativeallergichistories,negativeskintests,andnoaspirin
sensitivity(see'Differentialdiagnosis'below)
Somealsoutilizenasalcytologytoassesstheresponsetoantiinflammatorymedications,therebyproviding
furthersupportforaparticulardiagnosis.Eosinophilia,forexample,shoulddecreasewiththerapyinpatients
withallergicrhinitis.
AllergenchallengeAlthoughnasalallergenchallengecandefinitivelyestablishthediagnosis,itis
clinicallyimpracticalandrarelyperformedoutsideofresearchsettings.Nasalchallengeproceduresare
discussedelsewhere.(See"Chronicnonallergicrhinitis",sectionon'Evidenceforalocalizedallergicresponse'
and"Occupationalrhinitis".)
UnprovendiagnostictestsThereareseveralunprovenorinappropriatediagnostictestingassaysthatare
beingofferedbyvarioustypesofproviderswithincreasingfrequency.Theseincludecytotoxictesting,
provocationneutralizationtesting,andspecificornonspecificimmunoglobulinG(IgG)determinations[87].The
resultsofthesemethodsarenotusefulfordiagnosisormanagement.
WHENTOREFERPatientswhosesymptomsaresevereorrefractorytotherapyshouldbereferredtoan
allergyspecialistforamoredefinitiveevaluation[88,89].Referraltoanallergyorpulmonaryspecialistisalso
usefulforpatientswithconcomitantallergicrhinitisandasthma,andanotolaryngologistmaybehelpfulin
managingpatientswithrecurrentepisodesofsinusitisorotitismedia.
DIFFERENTIALDIAGNOSISVariousotherdisorderscanmimicallergicrhinitisorcoexistwithitinolder
childrenandadults.
ChildrenundertwoyearsofageBecauseallergicsensitizationtakesafewyearstodevelop,other
disordersshouldbeconsideredinveryyoungchildrenwhohavepersistentrhinitissymptoms.(See'Natural
history'above.)
Theseincludeadenoidalhypertrophy,acuteorchronicsinusitis,congenitalabnormalities(choanalatresia),
foreignbodies,andnasalpolyps.(See"Thepediatricphysicalexamination:HEENT",sectionon'Nose'.)
OlderchildrenandadultsRhinitiscanresultfromeitherinflammatoryornoninflammatorycauses[90].
AcuteinfectiousrhinitisSymptomsofthecommoncoldvaryfrompatienttopatient,withrhinitisand
nasalcongestionbeingthemostcommon.Nasalobstruction,rhinorrhea,andsneezingareusuallypresent
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earlyinthecourseofthecold,althoughasoreor"scratchy"throatisfrequentlythemostbothersome
symptomonthefirstdayofillness.Thesorethroatisusuallyshortlived,andnasalsymptoms
predominatebythesecondandthirdday.Coughtypicallybecomestroublesomeonthefourthorfifthday
ofillness,bywhichtimethenasalsymptomsarelesssevere.(See"Thecommoncoldinadults:Diagnosis
andclinicalfeatures".)
Acutebacterialsinusitisdevelopsin0.5to2.5percentofadultpatientsafterviralupperrespiratorytract
infection.Viralsinusitisoccursmuchmorefrequently.Theclinicalpresentationofthepatientisoflimited
utilityindistinguishingcasesofpureviralrhinosinusitisfromthosewithsecondarybacterialinfection.
Thereappeartobenosignsandsymptomsofacuterespiratoryillnessthatarebothsensitiveandspecific
inmakingthisdistinction.(See"Acutesinusitisandrhinosinusitisinadults:Clinicalmanifestationsand
diagnosis".)
Symptomsand/orcomplaintsofacommoncoldthatlastformorethantwoweeksmaybeconfusedwith
thoseduetoallergicrhinitis.Aspreviouslymentioned,however,manypatientscommonlyhaveboth
sinusitisandallergicrhinitis,asettinginwhichthediagnosisandtreatmentofbothconditionsmustbe
entertained.(See"Acutesinusitisandrhinosinusitisinadults:Clinicalmanifestationsanddiagnosis".)
Theremainingdisordersdiscussedbelowresultfromchronicprocesses.
ChronicnonallergicrhinitisApproximately50percentofpatientswithchronicrhinitishavea
componentofnonallergicrhinitis[73,91].Chronicnonallergicrhinitisischaracterizedbyperennial
symptomsandmildorabsentnasalitchingandsneezing.Patientswiththisdisordercomplainofchronic
nasalcongestionand/orrhinorrheathatisintensifiedbyrapidchangesintemperatureandrelative
humidity,odors,oralcohol.Theyhavelittlenasalitchingorsneezinghowever,headaches,anosmia,and
sinusitisarecommon.Afamilyhistoryofallergyorallergicsymptomtriggersisuncommon.Negativeskin
teststoinhalantallergensareessentiallydiagnosticforanonallergicrhinitissyndrome.Syndromesof
nonallergicrhinitisincludevasomotorrhinitis,gustatoryrhinitis,andnonallergicrhinitiswithnasal
eosinophiliasyndrome.Thesearereviewedinmoredetailseparately.(See"Chronicnonallergicrhinitis".)
ChronicrhinosinusitisChronicrhinosinusitis(CRS)isdefinedasaninflammatoryconditioninvolving
theparanasalsinusesandliningsofthenasalpassagesthatlasts12weeksorlonger,despiteattemptsat
medicalmanagement.CRScancoexistwithallergicrhinitis.ThediagnosisofCRSrequiresanyTWOof
thefollowingsymptoms,presentforatleast12weeks:
Anteriorand/orposteriormucopurulentdrainage
Nasalobstruction
Facialpain,pressure,and/orfullness
Decreasedsenseofsmell
ConcomitantCRSshouldbeconsideredwhenapatientwithallergicrhinitisalsohastheabovementioned
symptomsandfailstoimprovewithtreatmentforallergicrhinitis.ThediagnosisofCRSisdiscussedin
greaterdetailelsewhere.(See"Chronicrhinosinusitis:Clinicalmanifestations,pathophysiology,and
diagnosis".)
RhinitismedicamentosaRhinitismedicamentosaisacomplicationofvasoconstrictornasalsprays
(whichmaydevelopwithaslittleasfivedaysofuse)orintranasalcocaineabuse.Chronicnasal
obstructionandnasalinflammationdevelopandaremanifestedasbeefyrednasalmembraneson
physicalexamination.Diagnosisdependsalmostentirelyontheappropriatehistory,characteristicphysical
examinationfindings,andpositiveresponsetotreatmentwithtopicalnasalglucocorticoids,whichis
usuallyrequiredtowithdrawsuccessfullyfromtheculpritmedication[9294].(See"Chronicnonallergic
rhinitis",sectionon'Medicationinducedrhinitis'.)
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RhinitisduetosystemicmedicationsAvarietyofsystemicmedicationscaninducenasalsymptoms.
Thisisincontrasttorhinitismedicamentosa,whichisaspecificsyndromethatresultsfromtheintranasal
applicationofcertaindrugs.
Classesofmedicationsthatcancausenasalsymptomsincludebirthcontrolpills,antihypertensivedrugs
(alphaadrenergicblockers,betaadrenergicblockers,angiotensinconvertingenzyme[ACE]inhibitors),
erectiledysfunctiondrugs,andnonsteroidalantiinflammatorydrugs(NSAIDs).Psychiatricmedicationsthat
havebeenimplicatedincludechlorpromazine,thioridazine,perphenazine,chlordiazepoxide,amitriptyline,
andalprazolam.Lastly,theimmunosuppressantscyclosporineandmycophenolicacidcancausenasal
symptoms[95].Rhinitissymptomscausedbythesemedicationsgenerallysubsidewithinafewweeksof
discontinuation.
AtrophicrhinitisAtrophicrhinitisisasyndromeofprogressiveatrophyofthenasalmucosausually
seeninolderadults.Suchindividualsreportchronicnasalcongestionandperceiveapersistentbadodor.
ThisconditionisassociatedwithmucosalcolonizationwithKlebsiellaozaenae.Avariantoccursinpatients
whohavehadmultiplesinussurgeriesresultinginlossofnormalmucociliaryfunction.Thisisdiscussed
separately.(See"Atrophicrhinosinusitis".)
RhinitisassociatedwithhormonalchangesRhinitisofpregnancyandrhinitisofhypothyroidism
reflectnasalobstructionthatoccursonahormonalbasis.Inthesesettings,thediagnosisisclinicalandis
supportedbynegativeskintestsorimprovedsymptomsuponresolutionortreatmentofthecausative
condition.(See"Respiratorytractchangesduringpregnancy"and"Clinicalmanifestationsof
hypothyroidism".)
UnilateralrhinitisornasalpolypsUnilateralrhinitisornasalpolypsareuncommoninuncomplicated
allergicrhinitis.Unilateralrhinitissuggeststhepossibilityofnasalobstructionbyaforeignbody,tumor,or
polyp,andthepresenceofnasalpolypssuggestsnonallergicrhinitiswitheosinophiliasyndrome(NARES),
chronicbacterialsinusitis,allergicfungalsinusitis,aspirinhypersensitivity,cysticfibrosis,orprimaryciliary
dyskinesia(immotileciliasyndrome).Fiberopticrhinoscopymaybehelpfulinthissetting.Increasing
evidencealsosuggeststhatthehistologyofthosewithrhinitiswithorwithoutnasalpolypsaredifferent,
witheosinophilsorneutrophilspredominatinginthosewithorwithoutpolyps,respectively[90].However,
allergicrhinosinusitisandNARESarebothconditionscharacterizedbynasaleosinophilia,butmost
patientswiththeseconditionslacknasalpolyps.(See"Chronicrhinosinusitis:Clinicalmanifestations,
pathophysiology,anddiagnosis"and"Fungalrhinosinusitis"and"Epidemiologyandclinicalmanifestations
ofinvasiveaspergillosis"and"Cysticfibrosis:Clinicalmanifestationsanddiagnosis".)
RhinitiswithimmunologicdisordersAnumberofsystemicautoimmunedisorderspresentwithnasal
symptomsorcanaffectnasalmucosa.Theseincludegranulomatosiswithpolyangiitis(Wegener's)and
relapsingpolychondritis:
Themostcommonpresentingsymptomsofgranulomatosiswithpolyangiitisincludepersistent
rhinorrhea,purulent/bloodynasaldischarge,oraland/ornasalulcers,polyarthralgias,myalgias,or
sinuspain.
Withrelapsingpolychondritis,symptomsofstuffiness,crusting,rhinorrhea,andonoccasion,
epistaxis,mayaccompanynasalcartilageinflammation,whichcanalsocompromiseolfaction.
Cartilagedestructionassociatedwithsustainedorrecurrentepisodesofinflammationcanresultina
characteristicsaddlenosedeformity.
Suchdisordersmaythereforepresentwithnasalsymptoms,withoutevidenceofsystemicdisease.
Thesedisordersarediagnosedbaseduponthecombinationofcharacteristichistologicandclinical
findings.(See"Clinicalmanifestationsanddiagnosisofgranulomatosiswithpolyangiitis(Wegener's)
andmicroscopicpolyangiitis"and"Clinicalmanifestationsofrelapsingpolychondritis".)
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INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.
Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.
BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticles
arewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationand
arecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Seasonalallergiesinadults(TheBasics)"and"Patient
information:Seasonalallergiesinchildren(TheBasics)"and"Patientinformation:Allergyskintesting(The
Basics)")
BeyondtheBasicstopic(see"Patientinformation:Allergicrhinitis(seasonalallergies)(Beyondthe
Basics)")
SUMMARY
Allergicrhinitisischaracterizedbyparoxysmsofsneezing,rhinorrhea,nasalobstruction,postnasal
drainage,anditchingoftheeyes,nose,andpalate.Moreinsidiouseffectsofthedisorderincludefatigue,
irritability,reducedperformanceatschoolandwork,anddepression.(See'Introductionandterminology'
aboveand'Clinicalmanifestations'above.)
Allergicrhinitisaffects10to30percentofchildrenandadultsintheUnitedStates.Theprevalenceis
increasinginindustrializedcountriesworldwide,particularlyinurbanareas.Althoughfrequently
underdiagnosedandundertreated,allergicrhinitisimposesasignificanteconomicburdenasaresultof
reducedschoolperformanceandworkproductivity,clinicianvisits,expenseofoverthecounterand
prescriptionmedications,andcostoftreatingrelatedconditions,suchassinusitisandasthma.(See
'Epidemiology'aboveand'Associatedconditions'above.)
Allergicrhinitismaybeclassifiedbytemporalpattern(intermittentorpersistent)andbyseverity(mildor
moderatesevere)(table1).(See'Patternsofsymptoms'above.)
Thediagnosisofallergicrhinitisismadeclinically,baseduponasuggestivehistory(includingpresenceof
riskfactors),characteristicsymptomsandsignsonphysicalexamination,and(ifindicated)theconfirmed
presenceofallergenspecificimmunoglobulinE(IgE).Symptomsshouldalsobereproducible(byhistory)
uponexposuretoallergenstowhichthepatientissensitized.(See'Diagnosis'above.)
Identificationofthespecificallergenstowhichthepatientissensitiveisnotnecessaryforsuccessful
treatmentinmanycases.However,patientswhosesymptomsaresevereorrefractorytotherapyshould
bereferredtoanallergyspecialistforamoredefinitiveevaluation.Properlyperformedskintestingisthe
bestmethodfordeterminingallergicsensitization.(See'Allergenspecifictesting'above.)
Thedifferentialdiagnosisofallergicrhinitisincludesacuteandchronicrhinosinusitis(CRS),chronic
nonallergicrhinitis,rhinitismedicamentosa,atrophicrhinitis,andrhinitisduetosystemicmedications.(See
'Differentialdiagnosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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86. KwongKY,EghrariSabetJS,MendozaGR,etal.ThebenefitsofspecificimmunoglobulinEtestinginthe
primarycaresetting.AmJManagCare201117Suppl17:S447.
87. MeasurementofspecificandnonspecificIgG4levelsasdiagnosticandprognostictestsforclinicalallergy.
AAAIBoardofDirectors.JAllergyClinImmunol199595:652.
88. WhiteP,SmithH,BakerN,etal.SymptomcontrolinpatientswithhayfeverinUKgeneralpractice:how
wellarewedoingandisthereaneedforallergenimmunotherapy?ClinExpAllergy199828:266.
89. HarmsenL,NolteH,BackerV.Theeffectofgeneralistandspecialistcareonqualityoflifeinasthma
patientswithandwithoutallergicrhinitis.IntArchAllergyImmunol2010152:288.
90. MeltzerEO,HamilosDL,HadleyJA,etal.Rhinosinusitis:establishingdefinitionsforclinicalresearchand
patientcare.JAllergyClinImmunol2004114:155.
91. SettipaneRA.Rhinitis:adoseofepidemiologicalreality.AllergyAsthmaProc200324:147.
92. RameyJT,BailenE,LockeyRF.Rhinitismedicamentosa.JInvestigAllergolClinImmunol200616:148.
93. PassliD,SalerniL,PassliGC,etal.Nasaldecongestantsinthetreatmentofchronicnasalobstruction:
efficacyandsafetyofuse.ExpertOpinDrugSaf20065:783.
94. GrafP.Rhinitismedicamentosa:areviewofcausesandtreatment.TreatRespirMed20054:21.
95. vanRijswijkJB,BlomHM,FokkensWJ.Idiopathicrhinitis,theongoingquest.Allergy200560:1471.
Topic7525Version11.0
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GRAPHICS
Classificationofallergicrhinitis
"Intermittent"meansthatthesymptomsarepresent:
Lessthanfourdaysaweek
Orforlessthanfourweeks
"Persistent"meansthatthesymptomsarepresent:
Morethanfourdaysaweek
Andformorethanfourweeks
"Mild"meansthatnoneofthefollowingitemsarepresent:
Sleepdisturbance
Impairmentofdailyactivities,leisureand/orsport
Impairmentofschoolorwork
Troublesomesymptoms
"Moderatesevere"meansthatoneormoreofthefollowingitemsarepresent:
Sleepdisturbance
Impairmentofdailyactivities,leisureand/orsport
Impairmentofschoolorwork
Troublesomesymptoms
Reproducedfrom:BousquetJ,VanCauwenbergeP,KhaltaevN,etal.Allergicrhinitisanditsimpacton
asthma.JAllergyClinImmunol2001108:S147.TableusedwiththepermissionofElsevierInc.All
rightsreserved.
Graphic85849Version1.0
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PeakpollenperiodsintheUnitedStates
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Allergicchild
Photographofafouryearoldallergicchildwith"allergicshiners,"
mouthbreathing,and"adenoidfacies."
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Acuteseasonalconjunctivitis
Acuteseasonalconjunctivitisclassicallypresentswitheyelidand
conjunctivalerythemaandswelling.Itisalmostalwaysbilateral.
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Samplequestions*forthediagnosisandinitialassessmentof
asthma
A"yes"answertoanyquestionsuggeststhatanasthmadiagnosisis
likely.
Inthepast12months,haveyou ...
Hadasuddensevereepisodeorrecurrentepisodesofcoughing,wheezing(highpitched
whistlingsoundswhenbreathingout),chesttightness,orshortnessofbreath?
Hadcoldsthat"gotothechest"ortakemorethan10daystogetover?
Hadcoughing,wheezing,orshortnessofbreathduringaparticularseasonortimeofthe
year?
Hadcoughing,wheezing,orshortnessofbreathincertainplacesorwhenexposedtocertain
things(eg,animals,tobaccosmoke,perfumes)?
Usedanymedicationsthathelpyoubreathebetter?Howoften?
Hadsymptomsrelievedwhenthemedicationsareused?
Inthepastfourweeks,haveyou hadcoughing,wheezing,orshortnessofbreath...
Atnightthathasawakenedyou?
Uponawakening?
Afterrunning,moderateexercise,orotherphysicalactivity?
*Thesequestionsareexamplesanddonotrepresentastandardizedassessmentordiagnostic
instrument.Thevalidityandreliabilityofthesequestionshavenotbeenassessed.
Or"yourchild,"ifaparent/caregiverisansweringthequestionsforachild.
Reproducedfrom:NationalHeart,Blood,andLungInstituteExpertPanelReport3(EPR3):Guidelines
fortheDiagnosisandManagementofAsthma.NIHPublicationno.084051,2007.
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Disclosures
Disclosures:RichardDdeShazo,MDNothingtodisclose.StephenFKemp,MDNothingtodisclose.
JonathanCorren,MDGrant/Research/ClinicalTrialSupport:Genentech(Asthma)Sanofi(Asthma)
Merck(Asthma)Amgen(Asthma).Speaker'sBureau:Genentech(Asthma)TEVA[Rhinitis
(beclomethasonedipropionate)].Consultant/AdvisoryBoards:Merck[Rhinitis(AIT(SLIT))].AnnaM
Feldweg,MDEmployeeofUpToDate,Inc.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,these
areaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferences
tobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsand
mustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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