Allergic rhinitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 21 Jun 2025

Last updated: 21 Mar 2025

Allergic rhinitis is an immunoglobulin E (IgE)-mediated inflammatory nasal condition resulting from allergen introduction in a sensitized individual.

Presumptive diagnosis of allergic rhinitis is usually clinical and is made if someone experiences one or more of rhinorrhea, sneezing, itching of nose/palate/eyes, or nasal congestion in response to allergen exposure. Cough is also a common symptom.

The diagnosis is confirmed with demonstration of specific IgE reactive to environmental allergens. Food allergy testing is not recommended in the routine evaluation of rhinitis.

Treatment includes allergen avoidance (reducing exposure to relevant allergens such as dander, dust mite, and pollen), pharmacotherapy, and immunotherapy.

Intranasal corticosteroids remain the single most effective class of medications for treating allergic rhinitis.

Immunotherapy is often recommended for patients with persistent symptoms.

Definition

Allergic rhinitis (AR) is an immunoglobulin E (IgE)-mediated inflammatory nasal condition resulting from allergen exposure in a sensitized individual. AR is a common inflammatory condition of the upper respiratory tract, characterized by nasal pruritus, sneezing, rhinorrhea, and nasal congestion. Frequently, there is associated palate, throat, ear, and eye itching as well as eye redness, puffiness, and watery discharge.

AR may sometimes be due to occupational or hobby exposures to proteins that do not commonly provoke IgE-mediated responses. Examples include woodworkers becoming sensitized to wood dusts, or food service workers becoming sensitized to grain dusts.

History and exam

Key diagnostic factors

sneezing
nasal pruritus

Full details

Other diagnostic factors

palate, throat, ear, and eye itching
eye redness, puffiness, and watery discharge
fatigue and irritability
nasal congestion
rhinorrhea
allergic shiners
conjunctival injection
ocular mucoid discharge
nasal crease
pale nasal mucosa
swelling of the nasal mucosa and turbinates
abundant clear nasal secretions
Dennie-Morgan lines (creases present under the lower eyelids)

Full details

Risk factors

other atopic conditions or family history of atopy
age <20 years
exposure to aeroallergens (pollen, molds, house dust mites, pollution)
exposure to animal dander
ethnicity
positive allergen skin-prick tests

Full details

Diagnostic tests

1st tests to order

therapeutic trial of antihistamine or intranasal corticosteroid

Full details

Tests to avoid

immunoglobulin G (lgG) testing
sinonasal imaging

Full details

Tests to consider

allergen skin-prick testing
in vitro specific IgE determination

Full details

Treatment algorithm

ACUTE

mild or intermittent symptoms

persistent and moderate to severe symptoms

ONGOING

usual therapy ineffective or poorly tolerated

Contributors

Authors

Gary C. Steven, MD, PhD, CPI, FAAAAI, FACAAI, FAPCR

Medical Director

American Academy of Allergy, Asthma & Immunology Registry

Assistant Clinical Professor of Medicine

Medical College of Wisconsin

Adjunct Clinical Instructor

College of Nursing

University of Wisconsin-Milwaukee

Allergy, Asthma & Sinus Center

Milwaukee

Disclosures

GCS has taken part in sponsored research for the ALK clinical trial of the house dust mite SLIT tablet for use in pediatric patients. He is a member of the Joint Task Force on Practice Parameters Workgroup on the Allergic Rhinitis Practice Parameter.

Acknowledgements

Dr Gary C. Steven would like to gratefully acknowledge Dr Alexander Greiner, a previous contributor to this topic.

Disclosures

AG has received grant/research support from: AstraZeneca; Boehringer Ingelheim; Cephalon Circassia Ltd; Clement Clarke Cytos biotechnology; GlaxoSmithKline; Glenmark Specialty, S.A.; Hoffman-LaRoche/Genentech; HRA/Novartis; Janssen Research & Development; Kalypsys , Inc.; Lupin; Merck; Mylan Pharmaceuticals, Inc.; Nestle (Nestec Ltd); Novartis Ono Pharmaceutical Co., Ltd.; Perrigo; Rigel Pharmaceuticals, Inc.; Roxane Laboratories Inc.; Shionogi Inc.; Sunovion TEVA Branded Pharmaceutical Products; UBC (United Biosource Corporation)/Amgen Pharmaceuticals; and sponsorship for pharmaceutical trials from Allergen Research Corporation/Aimmune Therapeutics, Inc. and AstraZeneca.

Peer reviewers

Mark Davis-Lorton, MD

Clinical Immunology Coordinator

Division of Rheumatology, Immunology and Allergy

Winthrop-University Hospital

Mineola

Disclosures

MDL declares that he has no competing interests.

Glenis Scadding, MD

Consultant Allergist/Rhinologist

Allergy & Rhinology Department

Royal National Throat, Nose and Ear Hospital

London

Disclosures

GS is a consultant/advisory board member for ALK, Britannia Pharmaceuticals, CMP Therapeutics, Grupo Uriach, GSK, Merck, Sanofi-Aventis, Schering Plough, and UCB. She has received research funds from ALK, GSK, UCB, and Schering Plough. She has given talks for ALK, GSK, Merck, Schering Plough, and UCB and has co-written articles for Schering Plough and GSK.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: a practice parameter update. J Allergy Clin Immunol. 2020 Oct;146(4):721-67.Full text Abstract

Scadding GK, Kariyawasam HH, Scadding G, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised edition 2017). Clin Exp Allergy. 2017 July;47(7):856-89.Full text Abstract

Wise SK, Lin SY, Toskala E, et al. International consensus statement on allergy and rhinology: allergic rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.Full text Abstract

Bousquet J, Schünemann HJ, Togias A, et al. Next-generation Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence. J Allergy Clin Immunol. 2020 Jan;145(1):70-80.e3.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Nonallergic rhinitis
- Acute sinusitis
- Chronic sinusitis
More Differentials
Guidelines
- Clinical practice guideline: immunotherapy for inhalant allergy
- Australasian guidelines for allergic rhinitis 2022
More Guidelines
Patient information
Hay fever
Hay fever: avoiding pollen and mold
More Patient information
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Allergic rhinitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to avoid

Tests to consider

Treatment algorithm

mild or intermittent symptoms

persistent and moderate to severe symptoms

usual therapy ineffective or poorly tolerated

Contributors

Authors

Gary C. Steven, MD, PhD, CPI, FAAAAI, FACAAI, FAPCR

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Mark Davis-Lorton, MD

Disclosures

Glenis Scadding, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice