Last reviewed: April 2018
Last updated: November  2017



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
  • mucosal pallor
  • swelling of the nasal mucosa and turbinates
  • abundant clear nasal secretions
  • Dennie-Morgan lines (creases present under the lower eyelids)
  • nasal polyps

Risk factors

  • family history of atopy
  • age <20 years
  • inadequate exposure to animals and other micro-organism-rich environments in early life
  • people of Asian origin living in the UK
  • African Americans living in the US
  • Puerto Rican people living in the US
  • higher socio-economic status
  • environmental pollution
  • birth during a pollen season
  • lack of older siblings or entry into daycare after 2 years
  • heavy maternal smoking (20 or more cigarettes/day during the first year of life)
  • exposure to indoor allergens such as animal dander and dust mites
  • higher serum IgE levels (>100 IU/mL before age 6 years)
  • positive allergen skin-prick tests
  • early introduction of foods or formula
  • Western lifestyle
  • 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
  • sweat test
Full details

Treatment algorithm


Authors VIEW ALL


Allergy and Asthma Medical Group and Research Center

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 reviewers VIEW 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.

Use of this content is subject to our disclaimer