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Allergic rhinitis

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
  • Resources
Last reviewed: 14 Aug 2025
Last updated: 21 Mar 2025

Summary

Definition

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

WI

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

NY

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

UK

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.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

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.

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