A leading expert discusses triggers and treatments for allergic and non-allergic rhinitis.
Allergic and non-allergic rhinitis are extremely common and distressing conditions. Dr Jessica Tattersall discusses the importance of history in order to differentiate between the two and to maximise improvement. She also discusses the co-morbidities and updated management options. This is part two and the final part of this article.
Practice points
- Inflammatory types of rhinitis can be a type 2 hypersensitivity response without being IgE mediated. These types will respond well to steroids, especially combined with topical antihistamines. The triggers are similar to non-allergic rhinitis, plus smoke and occupational aspects.
- It is important to find out if there is a preventable cause in chronic non-inflammatory rhinitis, but it is still most likely idiopathic. Common triggers include things such as perfume, hairspray, cosmetics, antiperspirants, deodorants, any kind of aerosols, cleaning products, soaps, powders, candles, incense, scented flowers, paints and solvents.
- In occupational triggers, the inflammatory as well as non-inflammatory causes often occur together: “mixed rhinitis”. There is often with this condition a history of allergic rhinitis that has been worsened by the onset of non-allergic rhinitis, at roughly about the age of 30 to 35 years.
- Senile rhinitis (patients over 70 years) is a non-inflammatory rhinitis. Patients have no other symptoms apart from a profuse runny nose, and ipratropium bromide works brilliantly.
- Gustatory rhinitis is non-inflammatory and occurs only when eating spicy or other precipitating foods, is not associated with blockage, sneeze or itch, and ipratropium bromide works well.
- Far too much importance is put on the positive blood test or skin prick test in rhinitis, because the positive test does not equate to having the allergy; there must be a cause and effect and so the history is most important.
- It doesn’t matter if the rhinitis is more allergic or more non-allergic, because the corticosteroid, especially combined with an antihistamine, works well for both.
- For non-allergic rhinitis refractory to corticosteroids, our clinic uses capsaicin spray 4-5 times a day, at least 20 minutes apart, until the burning sensation ceases. That can take from five days to two weeks, then it is used periodically as maintenance. Warn the patient that it stings.
I am not going to go into the very complex neuropathic pathways that are thought to be at play in non-allergic rhinitis. Just be aware that there are inflammatory types and there are non-inflammatory types of pathways. It is a very complex, with several different systems potentially interacting with one another. I am going to try to keep it simple and talk about the difference between the non-inflammatory and the inflammatory types.
Causes of inflammatory and non-inflammatory rhinitis
Senile rhinitis is a good example of non-inflammatory rhinitis. These patients are generally over the age of 70. They have no other symptoms apart from a profuse runny nose; there’s no itch, there’s no sneezing, the nose doesn’t get blocked, it just runs like a tap. This is thought to be caused by dysregulation of the parasympathetic and the sympathetic nervous system. One medication, ipratropium bromide, works brilliantly to stop the running tap but it will not cover the other symptoms of sneezing, blockage or itch, so it will be no good in the patients with those other symptom profiles. However, in the elderly patient with this type of rhinitis, it will work very well. It also works well for the person with gustatory rhinitis, who has a runny nose only when eating spicy or other precipitating foods. Gustatory rhinitis is not associated with blockage and not associated with sneeze or itch.
Now, the inflammatory types of rhinitis can be a type 2 hypersensitivity response without being IgE mediated. These types are the ones that will respond well to steroids, and even better to combined steroids and topical antihistamines. The triggers are similar to those that you see for non-allergic rhinitis, as we touched on with gustatory and spicy foods, but you also get triggers such as cigarette smoke or occupational aspects.
In occupational triggers, you often have the inflammatory as well as non-inflammatory causes together. Examples of occupations with inflammatory triggers might be wheat flour for bakers, scientists who work with laboratory animals and health workers who use latex products. The occupational non-inflammatory triggers tend to be chemicals and fumes; for example, people who work with plastics and industrial paints, especially spray painters and workers in resin factories.
Drugs can also cause a non-inflammatory response. Cocaine is obviously known to cause rhinitis when misused. ACE inhibitors can cause rhinitis and, of course, intranasal decongestants, when overused, can cause rhinitis. Hormonal imbalances can also cause chronic rhinitis and the typical example of that is during pregnancy; this resolves once the baby is born.
Again, it is important to find out if there is a preventable cause in chronic non-inflammatory rhinitis. However, by far the most common kind of rhinitis seen is still idiopathic. Now, as the cause here is unknown, there is a hypothesis that there is some chronic inflammation at play, as well as neural symptoms being dysregulatory, with possible activation of the sensory C fibres in the nose. Hyper-reactivity is very common in these patients and the common triggers they complain of include things such as perfume, hairspray, cosmetics, antiperspirants, deodorants, any kind of aerosols, cleaning products, soaps, powders, candles, incense, scented flowers, as well as foul-smelling things like paints and solvents, and crude oils.
Some common causes
I want to highlight here triggers such as high air pollution, bushfires, weather changes, temperature and humidity changes, because Australia, especially in the lower eastern seaboard of Australia, often has these problems. People think the wind is bringing some sort of pollen, triggering their symptoms, when actually it is the wind change itself. Another thing to highlight here is the misconception of being allergic to mould, when it is actually the smell of damp and mildew causing the symptoms. So, it is a mistake too if the patient is IgE positive to mould, when really, they are just reacting to the smell of the moisture and high humidity in the air causing that decaying smell.
To complicate things even further, lots of patients have mixed conditions; they have a history of allergic rhinitis that has been worsened by the onset of non-allergic rhinitis, at roughly about the age of 30 to 35 years. These patients commonly present with a history of what used to be quite mild and controllable allergies that are worsening all of a sudden. So no longer are their symptoms apparent only when they are cleaning their house or during pollen season, but they are more frequent and now all year around. These patients are known to be sensitised to aeroallergens and there is probably a history of allergy there, even if it was quite mild.
Far too much importance is put on the positive skin prick test or the positive blood test at this stage, because the positive test does not equate to having the allergy; there must be a cause and effect associated. The history is what is really important in these people, because no test is going to give that answer for you; you need to have this demonstrated by the history. The complication is when you have to decide if it is the allergen that is really driving the symptoms, or has the non-allergic and the more irritant-based and environmentally based triggers taken over the driving of the disease progression.
A perfect example of this is a 40-year-old person with a history of seasonal grass pollen allergies who now is symptomatic all year around. We all know that specific grass pollens are not present all year around, so something else must be driving these symptoms at the other times of the year. Other examples include the 45-year-old cleaner who is always nasally irritated when at work … and it is very easy to think of a cleaner being irritated by house dust mite, when in fact it is actually the cleaning products they are made to use that are triggering their symptoms. The 55-year old secretary who finds everybody’s perfumes at work irritates her – she worsens when people put lilies on her desk and everyone else is fed up with her frequent throat clearing due to her post-nasal drip. These are very common presentations.
Managing non-allergic rhinitis
So, how do we manage non-allergic rhinitis? I have just made it sound really complicated and actually it is not. Firstly, you have assess if there is anything that we can lessen or remove that is a trigger, so people are not going to quit their jobs, but instead can obtain protective gear such as masks to keep them from breathing in scents and smells, or particles such as flour. If the rhinitis is drug induced, perhaps there can be a change in medication, or we can stabilise hormones, or get them to quit smoking (good luck with that one!). Of course, using unscented products and topical therapy are still the first line.
I wanted to highlight here again that the combination of a glucocorticoid and an antihistamine is by far the best chance you have of alleviating a patient’s symptoms. It doesn’t really matter if the rhinitis is more allergic or more non-allergic, because the medication works well for both. As a matter of fact, in the trials, azelastine was actually shown on its own to have some benefit, but using it in synergy with the corticosteroid promotes even better symptom treatment. If the cost is not prohibitive, this should be the first line.
Saline irrigation, if you can get the patient to use it, will also help the other medications work better. The patient might also benefit from immunotherapy; if you still think there is a strong allergic drive there, then it would be reasonable to refer once they have been started on initial therapy.
What about the patient with sub-optimal or no steroidal responsiveness? Capsaicin therapy … yes, capsaicin is the main component of the capsicum, or chili pepper. It has not been used already because it has a direct effect on the TrpV 1 (transient receptor potential vanilloid subtype 1) receptor, which is thought to be the main receptor in the nose causing allergic rhinitis through neurogenic pathways. It is very effective in non-allergic rhinitis, but there isn’t even a Cochrane review on capsaicin for non-allergic rhinitis. The exact mechanism is unclear, but it is assumed that it binds to the TrpV 1 receptor and renders it inactive.
So how do you obtain capsaicin spray? Many years ago, it was once on the chemists’ shelves; however, due probably to lack of use and lack of prescribing, it is no longer no longer stocked. It is still approved by the Therapeutic Goods Administration here as a food product. There are two types we can get in Australia: a spray or a capsule (which comes from the Netherlands). There is a United States distributor who does ship the spray here as they have a housing warehouse in Australia, so the product may be delivered quite quickly. However, there is less capsaicin in the spray than there is in capsule, and the capsule is more aligned with the product used in all the randomised control trials, at least according to dose. However, there are people who respond just as well to the spray and it is a good step-up therapy for the really sensitive patients while they are waiting for the capsules to come from the Netherlands. They are both reasonably priced at less than $20 a bottle.
There are various dosing regimens used in the various randomised control trials that were brought into that Cochrane review. In general, and in our clinic, we use the spray 4-5 times a day, at least 20 minutes apart, until the burning sensation ceases. That can take from five days up to two weeks, depending on how many of these receptors are active in the nose. Once this has been achieved, the patient can stop using the nasal capsaicin sprays so frequently; however, you do not really want the receptors to build back up again. Try to have the patient use it periodically, just to keep things under control. Now, whether they want to use it daily, twice a week or once a week, or just wait until symptoms return, is up to them. However, they might get a little bit more stinging. You must warn the patients about this sensation, as it will be quite burning. You have to remind them that is not actually hurting the inside of their nose and that it is doing its job, because if they are getting that sensation, it means that there’s something to actually benefit.
Take-home messages
The take-home messages are that both allergic and non-allergic rhinitis are common. They can hugely affect the sufferer’s quality of life and are very common as a mixed pattern in older adults. Non-allergic rhinitis can be inflammatory or non-inflammatory types. How you usually decide this is whether or not the patient is responding to anti-inflammatory medications, such as the combined intra-nasal corticosteroid and antihistamine treatment, or whether they are better off with the capsaicin spray. The history is the most important diagnostic tool you can use. The history is not only going to tell you whether this person has non-allergic and allergic rhinitis, something neither the skin prick test nor blood testing will decipher between. Intra-nasal corticosteroids combined with antihistamines are by far the best treatment we have to date for both types of rhinitis, but cost must be taken into consideration. Monotherapy with an intra-nasal corticosteroid is still better than an antihistamine tablet. When we think about cost, there are certain prescriptions in monotherapies that cost almost as much as the combined spray, so if the patient is going to pay more than $40 for a monotherapy, they are far better off on a dual therapy. When they weigh up the cost of antihistamines (these are not cheap), they might be better off with the nasal spray, and might not need the antihistamines after that. Keep a trial of capsaicin therapy in the back of your mind for patients who do not respond to intranasal steroids.
This is the final part of this article.
We would like to thank Dr Jessica Tattersall very much for her expertise and time.
This podcast originally ran on Healthed. To listen to the episode, please click here.
