Last reviewed:October 2019
Last updated:June  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • sneezing
  • nasal pruritus

Other diagnostic factors

  • palate, throat, ear, and eye itching
  • eye redness, puffiness, and watery discharge
  • fatigue and irritability
  • nasal congestion
  • rhinorrhoea
  • 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)

Risk factors

  • family history of atopy
  • age <20 years
  • positive allergen skin-prick tests
  • inadequate exposure to animals and other micro-organism-rich environments in early life
  • Western lifestyle
  • ethnicity
  • higher socio-economic status
  • environmental pollution
  • exposure to indoor allergens such as animal dander and dust mites
  • birth during a pollen season
  • lack of older siblings
  • heavy maternal smoking (20 or more cigarettes/day during the first year of life)
  • higher serum IgE levels (>100 IU/mL before age 6 years)
  • early introduction of foods or formula
  • breastfeeding
  • presence of other atopic conditions (eczema, food allergies, wheezing/asthma)

Diagnostic investigations

1st investigations to order

  • therapeutic trial of antihistamine or intranasal corticosteroid
Full details

Investigations to consider

  • allergen skin-prick testing
  • in vitro specific IgE determination
Full details

Treatment algorithm



Allergy and Asthma Medical Group and Research Center

Rady Children’s Hospital

University of California at San Diego School of Medicine

La Jolla



AG has received grant/research support from: Astra Zeneca; 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 Astra Zeneca.

Peer reviewersVIEW ALL

Clinical Immunology Coordinator

Division of Rheumatology, Immunology and Allergy

Winthrop-University Hospital




MDL declares that he has no competing interests.

Consultant Allergist/Rhinologist

Allergy & Rhinology Department

Royal National TNE Hospital




GS is a consultant/advisory board member for ALK, Britannia Pharmaceuticals, CMP Therapeutics, Groupo 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.

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