Definition and epidemiology
Allergic rhinitis (AR) is an IgE-mediated inflammation of the nasal mucosa triggered by aeroallergen exposure, producing sneezing, rhinorrhoea, nasal itch and congestion. It is among the commonest chronic conditions of childhood, with prevalence estimates of 10–30% and a rising trend in Indian urban cohorts (ISAAC data). AR rarely presents before 2–3 years of age, peaks in school-age and adolescence, and clusters with the atopic march — eczema, food allergy and especially asthma. The “one airway, one disease” concept is central: up to 80% of children with asthma have rhinitis, and uncontrolled AR worsens asthma control.
Clinical features
Cardinal symptoms are paroxysmal sneezing, clear anterior rhinorrhoea, nasal obstruction and nasal/ocular pruritus, often with conjunctival involvement (allergic conjunctivitis). Examination signs include pale, boggy, oedematous turbinates, the allergic salute and a transverse nasal crease, allergic shiners (infraorbital venous congestion), Dennie–Morgan folds, and a “cobblestone” posterior pharynx. Mouth-breathing, snoring, anosmia, and impaired sleep, concentration and school performance are common downstream effects. Triggers may be seasonal (pollens) or perennial (house dust mite, cockroach, moulds, animal dander) — the latter dominant in India.
Diagnosis
Diagnosis is clinical, supported by allergen sensitisation testing (skin-prick or serum specific IgE) where it changes management or directs avoidance/immunotherapy. The ARIA framework classifies AR on two axes rather than the older seasonal/perennial split:
- Duration: intermittent (symptoms <4 days/week or <4 consecutive weeks) vs persistent (>4 days/week and >4 weeks).
- Severity: mild (normal sleep; no impairment of daily activities, sport, leisure, work or school; symptoms not troublesome) vs moderate–severe (one or more of those domains impaired).
See the full criteria: Allergic Rhinitis
Red flags
- Unilateral symptoms, blood-stained discharge or unilateral nasal mass — exclude foreign body (young children) or tumour
- Persistent purulent discharge, facial pain/swelling, fever — suspect rhinosinusitis
- Nasal polyps in a child — screen for cystic fibrosis and aspirin-exacerbated respiratory disease
- Anosmia, recurrent epistaxis, orbital or neurological signs
- Coexisting poorly controlled asthma or growth concern
Management overview
Management follows allergen avoidance, pharmacotherapy and, in selected cases, immunotherapy. Counsel on environmental control (dust-mite measures, pet and pollen avoidance, tobacco-smoke elimination). First-line pharmacotherapy is an intranasal corticosteroid, the most effective single agent for moderate–severe or persistent disease; second-generation oral or intranasal antihistamines suit milder, intermittent symptoms and the sneeze/itch phenotype. Add an intranasal antihistamine (or fixed combination), a leukotriene receptor antagonist (useful with comorbid asthma, weighing neuropsychiatric warnings), and saline irrigation as adjuncts. Reserve short courses of decongestants and avoid sedating first-generation antihistamines. Allergen immunotherapy (subcutaneous or sublingual) is disease-modifying for confirmed single-allergen drivers refractory to standard care. Treat comorbid asthma concurrently, and step therapy up or down by ARIA control.
References
- Brożek JL, et al. J Allergy Clin Immunol. 2017;140(4):950–958 (ARIA 2016 revision).
- Bousquet J, et al. Allergy. 2008;63(Suppl 86):8–160 (ARIA 2008 update).
- Wise SK, et al. ICAR-AR 2023 consensus statement.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.