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Hard-to-treat hay fever

Allergy GPSI Dr Adrian Morris's tips on refractory allergic rhinitis

1) Start prophylactic antihistamines before the pollen season. Antihistamines are the treatment mainstay – either alone or with topical nasal steroids. Treatment is far more effective if used throughout the season. Start 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) A once-daily teaspoonful of local honey – starting before the pollen season – seems to help some patients. This has never been scientifically confirmed, but taking a daily teaspoonful of local honey – starting four months before the pollen season and continuing into the pollen season – can certainly do no harm.

3) Patients should keep checking the anticipated daily pollen count. It's not an exact measure of ambient pollen – rather an estimate based on the previous year's pollen counts and current weather. But it's a reasonably good indicator of whether a sufferer will have symptoms. On high pollen days it's best to remain indoors during the late morning (about 11am) and early evening (about 6pm) to reduce exposure.

4) Protect the nose by saline nasal douching and applying petroleum jelly. Physiological saline nasal douche or spray is soothing and may flush pollen out. A small amount of petroleum jelly on the lower nostril is a barrier and pollen trap.

5) Barrier methods help. Simple measures – such as wearing wraparound sunglasses – will all help. Sufferers should keep car windows closed and the air-conditioning switched on. Newer cars have pollen filters in the air-conditioning system. HEPA indoor filters help in bedrooms.

6) Butterbur is the only complementary treatment shown to be effective.

Although popular, herbal and homeopathic remedies have produced disappointing results in meta-analyses and only butterbur stands up in clinical trials. It has been shown to have an efficacy similar to antihistamine (1).

7) Advise patients to change clothes, shower and wash their hair when they get home at the end of the day. Pollen grains become trapped on clothes, skin and hair and it helps to shower and wash hair to remove all pollen grains and change into fresh clothing.

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. Bedroom windows should be kept closed during the day.

9) A short course of oral steroids is an option for acute hay fever treatment. If hay fever is severe and there is a special event – such as an exam or wedding – prednisolone 20mg daily for three days will give rapid symptom control in adults. The use of depot steroid injections is discouraged.

10) Consider sublingual desensitisation immunotherapy to grass pollen if symptoms are not controlled by medication. The only effective cure is desensitisation immunotherapy using extracts of grass and tree pollen (2). 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 few PCTs will cover the cost.

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