Allergic rhinoconjunctivitis H10.1

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 29.10.2020

Definition
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Common occurrence of rhinitis allergica and conjunctivitis due to type 1 allergy mostly to pollen ( pollinosis) of grasses, cereals, trees, shrubs and herbs.

General therapy
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Avoidance of triggering allergens, see Table 1. Complete allergen elimination is rarely possible with aerogenically transmitted allergens, but allergen reduction is often sufficient.

Notice! In addition to alleviating symptoms, the treatment focuses on preventing the change of levels

from allergic rhinitis to bronchial asthma! In case of development of allergic asthma, treatment by the internist.

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External therapy
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Instill Nedocromil (e.g. Irtan eye drops) 1 drop twice a day into both conjunctival sacs.

Internal therapy
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Antihistamines: If local therapy is not sufficient, in acute attacks or prophylactically during the time of pollen flight, additional antihistamines such as desloratadine (e.g. Aerius) 1-2 tbl/day, levocetirizine (e.g. Xusal) 1-2 tbl/day or cetirizine (Zyrtec) 1 tbl/day p.o.
Glucocorticoids: Only in exceptional cases the pre-seasonal glucocorticoid depot injection in combination with methylprednisolone (e.g.) 80-120 mg is to be used.
Immunotherapy, specific: Besides the absolute absence of allergens, this is the only therapy approach that can significantly reduce the probability of bronchial asthma. The indication for specific immunotherapy is given in cases of pronounced clinical symptoms (prick test and high RAST class are only indicative, not decisive criteria). Indications may be: increase in respiratory problems from year to year, positive family history of obstructive respiratory diseases, incipient obstructive respiratory complaints during the last pollen count, low age. The indication is also given in the case of inadequate therapeutic effects due to measures of allergen elimination or symptomatic drug therapies as well as high allergen exposure (especially occupational).
Notice! Deterioration or provocation of atopic eczema by specific immunotherapy of allergic rhinitis is possible!
Extracts are available for house dust mites, pollen and animal epithelia (cat, horse). The efficacy varies for the different allergens: Good chances of success exist with specific immunotherapy against house dust mites (reduction of symptoms in about 90% of cases), moderate chances of success with pollen and doubtful chances of success with specific immunotherapy against animal epithelia.
Cave! Specific immunotherapy for patients with unspecific bronchial hyperreactivity!
In patients with unspecific bronchial hyperreactivity, immunotherapy is associated with the risk of severe asthmatic exacerbations. In these cases, the retention of inhaled glucocorticoid therapy is often the most sensible solution for the patient.
Selection of the allergen: Provocation testing (nasal/conjuctival) is generally recommended for the selection of the allergen and, in the case of specific immunotherapy against several plant groups, is indispensable for the identification of the allergen causing symptoms. More than 4 allergens of one plant group should not be added simultaneously to the hyposensitizing solution. As a rule, specific immunotherapy against a few allergens with the main responsibility also reduces the symptoms of other allergens, as these are also treated by cross-allergenicity.

Tables
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Allergenicity and effectiveness in allergic rhinitis

Allergen	allergenicity	Effectiveness
Pollen	Sleeping with windows closed	+
	Washing your hair before going to bed
	Do not leave clothes in the bedroom
	Pollen filter, pollen warning
	No physical exertion outdoors during the pollen flight

Fungal spores	Regular ventilation, especially during the winter months	++
	Air circulation even in hidden corners of the apartment
	Thermal insulation on the outer wall

House dust mites	Encasing	++
	Reduction of dust traps
	Reduction of the air humidity
	Fine filter in vacuum cleaner
	Acaricides

Animal Epithelia	Abolition of animals, especially for cat hair allergy	+
	Regular washing of the animal if maintained
	Thorough cleaning, especially of the upholstery

Other (coffee/rhizinus beans, latex, metal salts, flour, proteins, etc.)	Attempt to avoid allergens or reduce the concentration of allergens, especially in the workplace	(+)
	Internal implementation
	If necessary, change of profession after dermatological procedures

Note(s)
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Oral and intramuscular applications of glucocorticosteroids should be avoided in children for the treatment of rhinitis.

Literature
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Sennekamp J et al (2002) German Society for Allergology and Clinical Immunology (DGAI) and Medical Association of German Allergologists (ÄDA). AWMF Guidelines Register No. 061/013
Bachert et al (2003) Guidelines of the German Society for Allergology and Clinical Immunology (DGAI) in coordination with the German Dermatological Society (DDG). AWMF Guidelines Register No. 061/014