Talk:Allergic rhinitis

Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 18 November 2019 and 14 December 2019. Further details are available on the course page. Student editor(s): Bdbwiki1990. Peer reviewers: Law527.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 13:53, 16 January 2022 (UTC)

Peer Review for bdbwiki1990

Overall I believe the article is solid. It delivers a concise message and chunk of information without being overbearing. I felt that the information provided is all relevant and nothing was distracting. As someone with Allergic rhinitis, I believe it hit the major points that I can think of. I believe it would be understandable to a non-medical person because it is not bogged down by details. It includes hyperlinks for various other pages that can help if someone does not understand the topic.

The article seems neutral and balanced. The only spot where there could be bias is in the alternative medicine section. I like that you included the one study where acupuncture may help a bit, but still reinforce the idea there is not a lot of overall data supporting it. I would carefully look at the last sentence, stating “evidence is poor” and see if that could be reworded to sound less biased. As a medical student myself, I want to reinforce evidence based as well, but this would be an area to look at and make sure the language doesn’t turn people away.

Citations are appropriate throughout the article except for in one section, Steroids for treatment. I believe this section could be improved upon and more sources added for it. Considering that the article states steroids are the preferred treatment, this section should have more information or at least equivalent to the antihistamine section. One other section that could be edited is the Epidemiology section since it is lacking currently. With some more information there, the article is on its way to being much improved thanks to your efforts.

Medical Student Work Plan

So far, most of my research and edits have been focused on the Treatment section (specifically Allergen Immunotherapy and Alternative Medicine), including one new image uploaded. I will continue to expand in this area over the week. In addition, I will also be editing the Diagnosis and Prevention sections. My final edits will be ready for submission by this Friday, 12/6. I do not believe I will edit the Causes section as originally planned-- this section seems to be well covered from the research I have gathered thus far. Bdbwiki1990 (talk) 16:06, 2 December 2019 (UTC)

I plan to prioritize the following sections: Diagnosis, Prevention, Causes, and Treatment (specifically Allergen Immunotherapy and Alternative Medicine). The immunotherapy section could use greater discussion on efficacy, in particular. The alternative medicine section could be expanded to include many other types of CAM and the most up to date studies regarding these treatments. Further information and comparison between skin testing and blood testing would also be helpful. Finally, I believe there is further discussion to be added on the "atopic triad" and peak pollen seasons with specific populations/regions here. I plan to use the following sources: Access Medicine, Clinical Key, PubMed and Uptodate. Bdbwiki1990 (talk) 20:01, 18 November 2019 (UTC)

Sounds like a good plan. Looking forward to seeing your changes. --Emilybrennan (talk) 13:58, 25 November 2019 (UTC)

Disjointed

The sentence starting with "Rinsing..." under "Management", is rather disjointed.

The sentance "In cases of allergic rhinitis, the most effective way to decrease allergic symptoms is to completely avoid the allergen." is a really stupid thing to say. The most effective way to comabat fear of flying, is to never get on an aeroplane.. — Preceding unsigned comment added by Treva26 (talk • contribs) 09:47, 15 August 2011 (UTC)

Though it may seem obvious, allergen avoidance should absolutely be mentioned as a way to decrease symptoms. Different strategies exist for avoiding different types of allergens. Prophylax (talk) 12:33, 16 August 2024 (UTC)

Dietary

Refs do not support this content.

It is postulated that allergic rhinitis (and other allergies) are the result of immune disorders and in some cases autoimmune disorders. While the cause of these disorders is not discovered in most patients, clinical experience suggests a dietary root cause, led by chronic tissue inflammation. Significant clinical evidence to suggest that diets high in carbohydrate (especially in individuals with concomitant high blood glucose levels), high in omega-6 fatty acids (due to metabolism via eicosanoid pathways) and high in gluten contribute directly to autoimmune disorders.

Doc James (talk · contribs · email) 03:34, 13 March 2011 (UTC)

References

Western

The word "Western" seems to be a euphemism for "european".

16 th

The Oxford English Dictionary says that the name hay-fever has been used since the 16th century. — Preceding unsigned comment added by 86.178.220.16 (talk) 14:10, 29 May 2011 (UTC)

Allergic rhinitis without specific symptoms

Some people have atypical symptoms from allergic rhinitis, such as no or almost no symptoms other than fatigue and malaise. I've been looking for a reference that mentions this. It seems to be common knowledge among the allergists I've seen. I found a webpage http://thebigl.web.officelive.com/Interpreter/V2/Content/allergic_rhinitis.html which does talk about this. I'm trying to find the source for their info.

Can anyone come up with a good reference for allergic rhinitis with no or almost no specific symptoms?

If someone goes to a doctor with fatigue and malaise without other symptoms, allergic rhinitis is a possibility. And I'd like to see a good reference for that, too. Puffysphere (talk) 17:39, 15 January 2012 (UTC)Puffysphere

Although fatigue and malaise could be a secondary symptom of allergic rhinitis, generally patients have other symptoms more characteristic for allergic rhinitis. If allergic rhinitis were included in the differential for "fatigue and malaise," you might as well include all chronic diseases in the differential. Prophylax (talk) 12:36, 16 August 2024 (UTC)

Local allergic rhinitis section

I made a new section on local allergic rhinitis.

I thought about making a separate page for LAR.

But the symptoms and treatment of LAR are the same so far as for allergic rhinitis (including allergy shots working!)

So clinically, LAR is a matter of a problem with the current diagnosis of allergic rhinitis - the standard allergy tests can be negative, but you can still have allergic rhinitis from a local allergy.

Physiologically, LAR is quite interesting. Classically allergies were supposed to involve the lymph nodes, so finding that an allergy can be generated locally is novel. This has been dubbed "entopy" (vs atopy). I don't know what evidence there is for entopy in other places in the body besides the nose (like possibly responsible for delayed food allergies), but an Entopy page would be a good idea. Puffysphere (talk) 23:02, 21 January 2012 (UTC)Puffysphere

Hay in hay-fever

"Ironically, in hay fever, there is neither any fever nor any hay, but since grasses shed their pollens into the air, at about the same time that hay is being cut, the common term hay fever is used."

This seems to suggest that hay itself can't cause hay fever? Surely pollen exists within hay?

- I am allergic to hay. It gives me a rash and also makes me sneeze. I have over 100 different allergies, and hay is one of them. My allergy to hay is different to my allergy to pollens though, which simply make me sneeze. My allergy to grass is different again, as that gives me a rash and makes me a sneeze. And my allergy to dust is different again, as it gives me a small but annoying rash isolated around the eyes, causing me to rub them for relief, leading to having red eyes.

- Put simply, I would say that all of these are distinct and very different types of symptoms. I agree that hay can be a part of it and that it is incorrect to ignore hay as part of allergic rhinitis.

- It also should be noted that some of my allergies do give me a fever, but those are food allergies. I am sure that in some people allergies to the kinds of things mentioned in this article could lead to fever though. 203.4.164.1 (talk) 23:35, 22 November 2012 (UTC)

There were so many problems with that sentence, I changed it. Since hay is not a plant, but an animal feed product made by cutting and drying grasses, a lot of it didn't make sense.

B.t.w, it's also technically incorrect to say that an allergy to hay, to pollen, and to grass, are three different things, since hay is made of grass, and the allergic reaction is to the pollen of the grass. Certainly though, there could be different reactions to different kinds of pollen and other allergens such as dust, and different ways they come into contact with the body.

IamNotU (talk) 15:28, 29 April 2013 (UTC)

Also just want to point out that food allergies are a distinct pathophysiologic entity from environmental allergies causing allergic rhinitis. Prophylax (talk) 12:56, 16 August 2024 (UTC)

Anti-histamines

The source for this information:

"First generation antihistamine drugs such as diphenhydramine cause drowsiness, but not second- and third-generation antihistamines such as cetirizine and loratadine.[15]"

must be suspect as I can truthfully state that cetirizine reduced me to a useless, depressed, sleep-lusting zombie (but a dry-nosed one!) for the several days that I took it this week while living in a pine forest. EdX20 (talk) 21:59, 27 May 2012 (UTC)

I agree, I think drowsiness is mentioned as a possible side effect for "nonsedating" antihistamines, cetirizine is especially bad for that. Go ahead and find a good reference and modify the article! Puffysphere (talk) 13:56, 12 February 2013 (UTC)

It can be hard to sleep with Hayfever... This might not be a bad thing... There is also a lot of other things that can cause you to become a "zombie"... Tiredness has a lot of Differentials you know... 134.148.64.206 (talk) 11:58, 9 October 2014 (UTC)

I've removed "cetirizine" and added "fexofenadine." Prophylax (talk) 12:57, 16 August 2024 (UTC)

It looks like the statement about cetirizine being less likely to cause drowsiness is still in the article. Cetirizine is known to cause drowsiness in some patients, so perhaps a better example of an antihistamine that causes the least drowsiness would be fexofenadine. Prophylax (talk) 12:41, 16 August 2024 (UTC)

I went ahead and deleted cetirizine and added fexofenadine as the example of the second generation antihistamine that is less sedating. Prophylax (talk) 12:45, 16 August 2024 (UTC)

"Hay fever" NOT "Hayfever" - Be careful!

Never ever write "Hayfever" because Google is currently showing that, when Google itself autocorrects to "Hay fever" with a space. Remember EVERYONE looks to Dr Wikipedia so it's important to get it right on here :) 134.148.64.206 (talk) 12:09, 9 October 2014 (UTC)

NEJM review

doi:10.1056/NEJMcp1412282 JFW | T@lk 10:08, 3 February 2015 (UTC)

Causation

I would question the statement in the introduction that "Allergic rhinitis is typically caused by environmental allergens". Hay fever is not caused by allergens, it is a reaction to allergens. The evidence appears to be that exposure to allergens when a child reduces the incidence of hay fever in later life. So rather than being caused by allergens, it is more accurate to say that the absence of exposure to environmental allergens when a child can result in a hyper reaction to allergens in adulthood.Royalcourtier (talk) 00:33, 10 November 2015 (UTC)

Yes good point. Should be triggered rather than caused. Doc James (talk · contribs · email) 07:49, 10 November 2015 (UTC)

Problem in Treatment section

This sentence in the Treatment section is incorrect: Intranasal corticosteroids are the preferred treatment if medications are required, with other options used only if these are not effective. I've tried to change it but it's been reverted twice. As I don't wish to edit-war, @Doc James: could you comment on how we can solve this issue? I appreciate that Antihistamines by mouth are suitable for occasional use with mild symptoms has been added, but that now seems somewhat contradictory to the first sentence.

The problem to me is that it's a rather black-and-white and over-general statement that antihistamines are in all cases only used after a corticosteroid spray has been tried and failed. That doesn't reflect the real-world situation - nor does it accurately reflect the source. The source does give the recommendation that "The initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone, with the use of second-line therapies for moderate to severe disease." However, at the end of the source article, there is a chart that clearly shows second-generation antihistamines being the first choice for mild intermittent symptoms. This is also the case in other treatment recommendations such as from the British Society for Allergy and Clinical Immunology, which the source cites in giving its recommendation. It's likely that for more persistent symptoms like hay fever, nasal steroid spray should be the first-line treatment. But consider someone with pet dander allergies, who is normally not exposed to the allergen. If they visit a friend or family with a pet, antihistamine tablets may well be the preferred treatment. In addition to rapid action, there may be factors of cost, availability, and convenience.

Second, the source is describing a treatment recommendation supported by the AAFP. It is not universally accepted, and does not necessarily reflect actual practice. At least one study concluded that, although it may be misguided, "Physicians prefer and more often use combination treatment with oral antihistamines and intranasal corticosteroids, regardless of the frequency and intensity of allergic rhinitis". The sentence presents one recommendation about how nasal allergies should be treated, as a fact about how they are treated in general. --IamNotU (talk) 01:22, 12 April 2018 (UTC)

Ref says "Intranasal corticosteroids are the most effective treatment and should be first-line therapy for mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g., nasal irrigation)."[1]

We should stick to review articles per WP:MEDRS.

The ref does say "In general, first- and second-generation antihistamines have been shown to be effective at relieving the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea, ocular symptoms), but are less effective than intranasal corticosteroids at treating nasal congestion. Because their onset of action is typically within 15 to 30 minutes and they are considered safe for children older than six months, antihistamines are useful for many patients with mild symptoms requiring “as needed” treatment."

Does not contradict that steroids are first line. Doc James (talk · contribs · email) 14:50, 12 April 2018 (UTC)

In addition to the mild-moderate-severe axis, there is the intermittent-persistent axis. The ref also gives an "algorithm for the treatment of allergic rhinitis", which shows Mild intermittent symptoms --> Second-generation oral or intranasal antihistamine, as needed. WP:MEDRS also lists as "ideal sources", "medical guidelines and position statements from national or international expert bodies" such as the BSACI guidelines cited by the AAFP source. Reliance on a single source when there are other reliable ones that contradict it (and certainly when the source itself contradicts the statement in the article!) may violate WP:NPOV in presenting medical/scientific consensus per WP:MEDSCI - especially when all three guidelines (BSACI, IPCRG, and JTFPP) cited by the AAFP, in support of the "initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone" recommendation, in fact say that for mild intermittent symptoms, antihistamines are first line - as does the AAFP guideline itself... --IamNotU (talk) 15:44, 21 April 2018 (UTC)

Actually, I found that there's an updated version of the reference, which now reads "Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life. More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation."[2] Exactly what I was saying. Also, the algorithm chart showing antihistamines as first line treatment for mild intermittent symptoms is much more prominent. I've replaced the citation in the article and edited the text accordingly. --IamNotU (talk) 20:57, 21 April 2018 (UTC)

References

Local allergenic rhinitis and nasal challenge

Updated the article to mention that this is mostly a European thing [3]. Spoke to an practicing allergenist loosely affiliated with the top West Coast United States hospital (University of California, San Francisco) in the United States (San Francisco) and he had never heard of nasal challenges, altho he was kind enough to peruse some of the material I provided. From reading something like EAACI Position paper on the standardization of nasal allergen challenges you'd think this was pretty standard ("In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental", but apparently not. The lack of use in the United States was also noted in 2005 at Nasal provocation testing as an international standard for evaluation of allergic and nonallergic rhinitis.. Further, The Regence Group won't cover it as it is listed in "Allergy Tests of Uncertain Efficacy". Aetna similarly considers it investigational [4]. Not that insurers are the best authorities on medical evidence. II | (t - c) 02:21, 20 April 2019 (UTC)

A Commons file used on this page has been nominated for deletion

The following Wikimedia Commons file used on this page has been nominated for deletion:

• Antihistamine therapy.jpg

Participate in the deletion discussion at the nomination page. —Community Tech bot (talk) 22:21, 3 December 2019 (UTC)

Repeating Section.

Can someone with a better understanding of Wikipedia article flow remove the section that is deemed redundant. I don't believe the introduction and history section need the same paragraph.

"The first accurate description is from the 10th-century physician Rhazes.[11] In 1859, Charles Blackley identified pollen as the cause.[12] In 1906, the mechanism was determined by Clemens von Pirquet.[10] The link with hay came about due to an early (and incorrect) theory that the symptoms were brought about by the smell of new hay." — Preceding unsigned comment added by 209.55.112.23 (talk) 19:37, 18 April 2022 (UTC)

Agreed. Perhaps someone should just remove it from the intro. Prophylax (talk) 12:49, 16 August 2024 (UTC)

Contradiction

The article states in the "Treatment" section:

"Mite-proof covers, air filters, and withholding certain foods in childhood do not have evidence supporting their effectiveness"

...while on the preceding section it says (1):

"Specific anti-allergy zippered covers on household items like pillows and mattresses have also proven to be effective in preventing dust mite allergies"

...and (2):

"Studies in young children have shown that there is higher risk of allergic rhinitis in those who have early exposure to foods or formula or" 209.124.216.94 (talk) 12:12, 12 November 2022 (UTC)

Regarding dust mites, perhaps the difference is covers are effective in "preventing" allergies but not "treating" them since they are an avoidance measure (ie, they don't remove a person's allergy to dust mites but can prevent symptoms by avoiding the allergen altogether). Prophylax (talk) 12:52, 16 August 2024 (UTC)

First paragraph of the Article

The last sentence in the first paragraph currently states: "Many people with allergic rhinitis also have asthma, allergic conjunctivitis, or atopic dermatitis."

While this is partly correct, a recently published research study (https://www.jacionline.org/article/S0091-6749(97)70126-X/fulltext) reported that "For years investigators have noted an association between allergic rhinitis and asthma, sinusitis, otitis media, possibly nasal polyposis, and recurrent respiratory tract infection".

Three quotes from this study are as follows: - Relationship between allergic rhinitis and asthma: Several reports indicate that the incidence of allergic rhinitis in asthmatic adults can be as high as 58%.

- Relationship between allergic rhinitis and sinusitis: Approximately 31 million Americans develop sinusitis each year. Investigators have linked allergy as a contributing factor in 25% to 30% of patients with acute maxillary sinusitis, with an expected incidence of 14% to 17% in control subjects.

- Link between allergic rhinitis and otitis media: The prevalence of nasal allergy in children with OME ranges from 35% to 50%

Given this, our suggestion is is to edit the last sentence of the first paragraph to say: "Many people with allergic rhinitis also have asthma, allergic conjunctivitis, atopic dermatitis, and asthma, sinusitis, otitis media, possibly nasal polyposis, or recurrent respiratory tract infection." We Duh People (talk) 00:17, 31 May 2023 (UTC)

Go ahead and edit this and cite the sources. Prophylax (talk) 12:54, 16 August 2024 (UTC)

Testing

Would it be appropriate to include more details about the different types of allergy testing that exist (eg, skin prick test, modified quantitative testing, intradermal dilution testing)? Prophylax (talk) 12:38, 16 August 2024 (UTC)

Signs and symptoms - physical exam findings

Under signs and symptoms, it would be nice to include intranasal physical exam findings that an otolaryngologist may see in the office. Prophylax (talk) 13:02, 16 August 2024 (UTC)

I went ahead and added a few of these findings with sources cited. Prophylax (talk) 13:06, 16 August 2024 (UTC)