Ten tips on tackling hard-to-treat hay fever
Allergy GPSI Dr Adrian Morris’s tips on difficult-to-treat allergic rhinitis
Allergy GPSI Dr Adrian Morris's tips on difficult-to-treat allergic rhinitis
1 Start prophylactic antihistamines before the onset of the pollen season. Antihistamine medication is the mainstay of treatment in hay fever, either used alone or in combination with topical nasal steroids. Treatment is far more effective if used continuously throughout the season. Best results are achieved by starting treatment two weeks before the anticipated start of the pollen season – ideally mid-February for tree pollen and end of March for grass pollen.
2 Protect the nose by saline nasal douching and application of petroleum jelly. Physiological saline used as a nasal douche or spray has a soothing effect and may flush pollen out of the lower nasal passages. Application of a small amount of petroleum jelly to the lower nostril acts as a barrier and pollen trap. It also protects the skin around the nose from irritation.
3 Homeopathic and herbal treatments are disappointing in hay fever, and butterbur is the only treatment shown to be effective. Although popular with the general public, herbal and homeopathic remedies have produced disappointing results in meta-analyses. The only herbal treatment to stand up in clinical trials is butterbur (Petasites hybridus), which has been shown to have an efficacy similar to antihistamine1.
4 Advise patients to change their clothes, shower and wash their hair after a day out. Pollen grains become trapped on our clothing, skin and hair during the course of the day outdoors. At the end of the day when returning home, it helps to immediately change your clothing. Then shower and wash hair to remove all pollen grains and change into fresh clothing.
5 Advise patients to keep checking the anticipated daily pollen count. The daily pollen count is not an exact measure of ambient pollen; it is an estimate taking into account previous year's pollen counts and current atmospheric conditions. But it is a reasonably good indicator of whether a sufferer will have symptoms. On days when the pollen count is anticipated to be high it is best to remain indoors during the late morning (about 11am) and early evening (about 6pm) to reduce exposure to pollen during these peak periods.
6 Use a short course of oral steroids for acute hay fever treatment. This can be given if hay fever is severe and there is a special event such as an exam, wedding or another important commitment. Prednisolone 20mg daily for three days will give rapid symptom control in adults. The use of depot steroid injections is discouraged because of the greater likelihood of unwanted steroid side-effects.
7 A once daily teaspoonful of local honey – starting before the pollen season – seems to help some patients. This has never been scientifically confirmed, but many people are convinced it helps. Taking a teaspoonful of local honey starting four months before the pollen season and continuing into the pollen season can certainly do no harm. Local honey may temporarily induce oral desensitisation to pollen.
8 Washing should be tumble dried to reduce pollen exposure. Washing hung outdoors during the day will trap pollen grains and then trigger hay fever with subsequent exposure. Tumble drying will prevent pollen contamination. Bedroom windows should be kept closed during the day to prevent pollen blowing indoors.
9 Barrier methods help – including wraparound sunglasses, keeping car windows closed and switching air-conditioning on. Simple measures to reduce the amount of pollen exposure will all help. Sufferers should keep car windows closed and the air-conditioning switched on. Modern cars have pollen filters in the air-conditioning system. HEPA indoor filters help reduce the aeroallergen load in a bedroom.
10 Consider sublingual desensitisation immunotherapy (SLIT) to grass pollen if symptoms are not controlled by medication. The only effective cure is desensitisation immunotherapy using extracts of grass and tree pollen2. This can be administered by weekly subcutaneous injection or given orally by daily sublingual drops or tablets. Sublingual treatment is now available in the UK on prescription, but is expensive and efficacy is reliant on compliance. As a consequence, few PCTs will cover the cost of this treatment.
Dr Adrian Morris is an allergy GPSI in Surrey and clinical assistant in allergy at the Royal Brompton Hospital, London.
Competing interests: none declared
Scadding GK, Durham SR, Mirakian R et al. New BSACI Rhinitis Guidelines. Clinical and Experimental Allergy 2008;38:19-42.