Elementary school humor aside, I know what a bothersome thing rhinitis (inflammed nasal passages) can be. The poorly kept secret about allergists is that almost all of us have allergies and so we can empathize really well with our patients. I struggle with allergic rhinitis almost every day of the year (so does Dr. Haberle).
But you didn’t come here to learn about us. Pretty frequently I get to see patients who are really frustrated because their allergic rhinitis isn’t any better on over the counter allergy medications and they want the good stuff.
The best medicines are all available over the counter. Since July 2013 two different nasal steroid sprays, Triamcinolone (Nasocort) and Fluticasone (Flonase), have become available over the counter (OTC). These OTC versions are the same medication in the same dose that you get when you fill a prescription. It still might be less expensive to get a prescription depending on how your insurance covers these medications, but the OTC versions are just as good.
A concern I often hear: “I’ve tried several nose sprays and every anti-histamine [Diphenhydramine (Benadryl), Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine (Zyrtec)] and nothing has worked I need allergy shots.”
Not all that sneezes is allergy. Without getting too technical, “allergy” in the sense that Allergists and Immunologists use the term usually describes a type 1 hypersensitivity reaction involving IgE, mast cell degranulation and histamine. This reaction is really well characterized and it is what we are trying to treat with allergy medications. Unfortunately, there are lots of reasons why your nose may run or be congested that have nothing to do with this reaction. If that is the case allergy medications are generally really not as useful, some are completely useless.
Q: “How do I know if my miserable nose and sinuses are due to allergies?”
A: Your story means a lot to an allergist. It’s why we ask really specific questions when you tell us you have “all the allergic symptoms”.
What are your symptoms? Congestion, runny nose, and post nasal drip are common allergic symptoms, but they are also common non-allergic symptoms. Itching is uncommon to non-allergic causes. Itchy eyes, nose, and ears are big keys for me. If your eyes itch like crazy along with your runny nose then I’m a lot more confident we’re talking allergies. If you nose is really stuffy without itching then I start to wonder.
When did you start having symptoms? – Though not impossible most people develop allergies as children and have been dealing with them most of their lives. It’s not impossible to develop allergic symptoms as an adult, just less likely.
When are your symptoms? – Most people with allergies have a “season”. Common allergens are plant pollens and plants generally pollenate at specific times of the year. Even people who are allergic to “everything”, like me, have different symptoms depending on the season. If your nose knows no season then maybe it’s not allergies.
What makes them better? – Most people end up in my office because “nothing works” or common medications aren’t doing enough. I mentioned before “allergies” are a well characterized sequence of events. Because we know what is happening drug companies have been really aggressive about tracking down ways to stop the reaction itself and the effects of the reaction. The newer anti-histamines [Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine (Zyrtec)] are very potent and specific for the types of receptors that are key to causing runny nose and itch. Many folks think these medications aren’t doing anything until they stop them. It’s one of the helpful cheats we allergists use. We generally have people stop medications for a week before they see us in case we do skin testing. I’ve had countless patients tell me one of two stories. #1: “I didn’t think Loratadine was doing anything, but this past week has been extra miserable”. Not surprisingly these people are almost always allergic. #2: “Nothing has changed at all since I stopped my medications”. Not surprisingly these folks are very often NOT allergic.
What makes your symptoms worse? – This can be a little tricky. Many patients with allergic noses are also sensitive to irritants as well, but some patients get symptoms that are basically the same as allergies, but they get there through another route of things going wrong. Common culprits are
1) Strong smells: perfumes and cleaning agents.
2) Small particles: dust, cigarette smoke, exhaust fumes, molds, and mildews.
3) Activities: eating spicy foods, or strenuous exercise.
4) Meteorological: does your nose know when the weather is changing?
If these are the main triggers of your symptoms rather than a season I start to think hard about whether or not you are allergic.
Not being allergic isn’t the end of the world. I say this as a joke because patients often seem disappointed when I tell them they aren’t allergic. We can still figure out how to make you feel better.
If you are allergic, I’m sorry. I really am. We can work on that too.