Local Allergic Rhinitis

Local allergic rhinitis is an IgE-mediated allergic rhinitis confined to the nasal mucosa, with negative skin prick tests and negative serum specific IgE. It is often labelled non-allergic rhinitis.

Pathophysiology. Allergen specific IgE is made in the nasal mucosa, and nasal exposure triggers mast cell and eosinophil activation. Systemic IgE is absent, so conventional tests are negative.

It accounts for a substantial share of patients with non-allergic rhinitis, especially younger patients with seasonal or perennial symptoms. The common allergens are house dust mite, grass and olive pollen, and Alternaria.

Some patients later develop systemic sensitisation, and asthma coexists in a minority.

• Sneezing, itching, clear rhinorrhoea, nasal obstruction
• Ocular itching and watering in many
• Seasonal or perennial symptoms, with worsening on allergen exposure
• Reduced smell and postnasal drip
• Associated asthma or conjunctivitis
• Poor response to antihistamine in some

• History: triggers, season, family history, response to treatment.
• Skin prick tests and serum specific IgE: negative for the suspected allergens, which is the defining feature.
• Nasal allergen provocation test: a positive response (symptom score and a fall in nasal airflow or rise in nasal resistance by rhinomanometry or peak nasal inspiratory flow) after the suspected allergen.
• Nasal specific IgE and tryptase in nasal secretions, where available.
• Nasal endoscopy and imaging to exclude polyps, structural disease and sinusitis.
• Spirometry if asthma is suspected.

Differential diagnosis.

• Systemic allergic rhinitis
• Non-allergic rhinitis (vasomotor, irritant, hormonal)
• Non-allergic rhinitis with eosinophilia syndrome (NARES)
• Chronic rhinosinusitis with or without nasal polyps
• Medication rhinitis (decongestants, antihypertensives, aspirin)
• Structural obstruction (septal deviation, adenoid hypertrophy)

• Allergen avoidance: house dust mite measures (encasings, hot washing at 60 degrees Celsius), pollen avoidance in season.
• Intranasal corticosteroid daily: fluticasone furoate 110 microgram daily (2 sprays of 27.5 microgram in each nostril), or mometasone 200 microgram daily (2 sprays of 50 microgram in each nostril). Continue for 2 to 4 weeks to judge benefit, and reduce to the lowest effective dose.
• Intranasal antihistamine: azelastine 0.1%, 1 spray (137 microgram) in each nostril twice daily, used alone or with the corticosteroid for faster relief.
• Oral second generation antihistamine: cetirizine 10 mg once daily (children 1 to 5 years 2.5 mg twice daily; 6 to 11 years 5 mg twice daily), for ocular and sneezing symptoms.
• Saline nasal irrigation daily.
• Allergen immunotherapy (subcutaneous or sublingual) for the confirmed allergen is effective in selected patients, for example house dust mite or grass pollen, and runs for 3 years.
• Montelukast 10 mg orally at night if asthma coexists.
• Treat the cause of obstruction (polyps, structural problems) when found.

Special groups.

• Children: a diagnosis of local allergic rhinitis may be missed because skin tests are negative, so consider provocation testing before labelling as non-allergic.

Monitoring. Symptom score at each visit. Review every 3 to 6 months. Spirometry yearly if asthma is present. Review nasal examination at the start of intranasal corticosteroid and yearly.

Referral and escalation. Refer to allergy for suspected local allergic rhinitis when treatment fails, or for nasal provocation testing and immunotherapy. Urgent for unilateral obstruction, epistaxis or visual symptoms.