Seasonal allergies: Are You Allergic To Something In The Air?

Spring, like any other season, is filled with change and ritualistic behavior. My usual routine includes cleaning out the car, putting away the snowblower, planting a garden, and sharpening the mower blades. Sadly, I also have to deal with seasonal allergies (a.k.a. hay fever). Sneezing doesn’t bother me, but having an itchy, runny nose drives me crazy! The Center for Disease Control (CDC) estimates that 60 million Americans suffer from allergies each year, so I know I am not alone.¹ In this article we will take an in-depth look at allergies of the nose (allergic rhinitis) and eyes (allergic conjunctivitis). We will talk about common substances that cause allergies, medication options for controlling symptoms, and when to get your doctor involved.

Sections

Overview of airborne allergies

Choosing a medication

When to get your doctor involved

Overview of treatment options

References

Overview of airborne allergies

The air around you may look perfectly clear, but is actually full of small particles and chemicals that are constantly coming into contact with your nose and eyes. If a foreign substance is seen as a threat by the immune system this can lead to the development of an allergy. Allergy symptoms in the nose include sneezing, itching, runny nose, congestion, sinus pain, and post-nasal drip. Similarly, symptoms of the eyes include itching, redness, and watery eyes.

The severity of symptoms varies from person to person. Think about your own symptoms. Do they cause you to skip out on activities? Do they prevent you from sleeping? If you answered no to both your allergies are mild. If you answered yes to either question your allergies are moderate to severe.

Substances that cause allergies are called allergens. Pollen from trees, grasses, and ragweed are common outdoor allergens and things like pet dander and dust-mites are common indoor allergens.

Allergies can be placed in one of three categories based on how often you get symptoms and how long they last. Read the descriptions below and think about which category fits you best. It may provide clues to what you are allergic to and will help determine which medications are most appropriate for relieving symptoms.

Exposure Allergies (episodic)

Exposure allergies are infrequent and only appear when you put yourself in an environment that is outside of your normal routine. If you can fill in the blank for:

“Whenever I ___ my allergies flair up.”

you likely have an exposure based allergy.

Skip ahead to treatment options.

Seasonal Allergies (intermittent)

Allergies that flare up at certain times of the year are called seasonal allergies. Pollen from trees, grasses, and ragweed are the most common allergens, though mold spores can also be to blame depending on where you live. The severity of symptoms is highly dependent on how much pollen is floating around in the air. There are lots of different apps and tools you can use to check pollen counts in your area. I use the Weather Channel, but there is also pollen.com, which provides some really cool looking maps and in-depth information that can be tailored to your location.

Most cases of seasonal allergies can be treated with over the counter medications, but keeping windows closed and staying indoors during peak pollen days is also an option, especially if you have severe symptoms or asthma.

Chronic Allergies (persistent)

If you have allergy symptoms that bother you more than 4 days per week and it has been more than a month it may mean you have chronic allergies. Allergies that are persistent, especially when not connected to anything obvious like pet dander or seasonal pollen levels, can be very frustrating to figure out. Think about both your home and work environment.

At home the most common allergens are going to come from mold, dust-mites, or infestation of pests like cockroaches. Eliminating sources of allergens in your own home can really help. Removing extra carpeting and rugs along with regular cleaning using a vacuum with a high efficiency particulate air (HEPA) filter may help with dust-mites. In areas with mold consider adding additional ventilation or installing a dehumidifier. Be sure to regularly change the air filter in your HVAC system and if you can afford it, consider getting a HEPA filter installed.

Work can also be a source of chronic allergies. Dust from wood, latex, resins, adhesives, or chemicals are all potential allergens.

If you have long term or severe symptoms consider talking with your doctor about getting in to see an immunologist for testing. They are excellent detectives and offer care and expertise for more difficult cases.

Why do we get allergies in the first place?

Your immune system is in charge of preventing illness from foreign invaders like bacteria and viruses. To do its job correctly, the immune system has to be able to tell what substances in the body belong (cells, proteins, sugars, etc.) and which do not. When the immune system encounters something it doesn’t like, it mounts a response. Redness, itching, and swelling are mild symptoms of the immune system trying to do its job. The immune system isn’t perfect. When the immune system targets proteins that belong in the human body it leads to autoimmune disorders such as lupus and rheumatoid arthritis. When substances in food are involved it leads to food allergies (peanuts, strawberries, etc.) and when it’s something in the air, like pollen, it causes allergy symptoms in the eyes, nose, throat, and sometimes lungs.

Choosing A Medication

Treating Exposure Allergies (oral antihistamine)

For allergy episodes that only occur in specific situations, like when you visit a friend with a pet, a non-drowsy antihistamine is going to be your best bet for fast relief. The are four products currently on the market in this category: Claritin (loratadine), Allegra (fexofenadine) , Zyrtec (cetirizine), and Xyzal (levocetirizine). Any of these will work, but I usually recommend Claritin (loratadine) first. Allegra can be less effective when taken with fruit juices (orange, grapefruit, apple) and Zyrtec and Xyzal can sometimes make people drowsy even though they are in the non-drowsy family. To compare all have a look at the table under treatment options.

Pharmacist Favorite

What to expect

Non-drowsy antihistamines take about an hour or so to kick so give it some time. One dose should get you 24 hours of symptom relief.

Side effects with the non-drowsy antihistamines are uncommon, but headache is one to be on the lookout for. Despite the name, any of the non-drowsy antihistamines can actually make you sleepy, but it’s much less likely that first generation drugs like Benadryl (diphenhydramine).

An antihistamine alone will be enough for most cases of exposure allergies, but if you want to tackle symptoms from multiple angles I have separate suggestions for nasal congestion and eye drops.

Can I use one of the other antihistamines?

The first generation of antihistamines, which include products like Benadryl (diphenhydramine) and chlorpheniramine, are not any better than non-drowsy antihistamines, but cause more side effects. In addition to drowsiness, first generation antihistamines can cause dry mouth, dry eyes, and constipation. Patients 65 and older are more likely to have theses side effects and can also sometimes become mentally foggy or get confused.

Stick with the non-drowsy options unless you are also looking for something to help you sleep. First generation antihistamines are also used in popular sleep aids such as ZzzQuil (diphenhydramine) and Unisom (doxylamine). Read the active ingredients carefully. There is potential to use one product to treat two problems, but you don’t want to accidentally double up with dosing or mixing antihistamines.

Treating Seasonal Allergies (nasal steroid and/or oral antihistamine)

There are a number of great options for treating seasonally allergies out there. For mild cases of allergies a non-drowsy oral antihistamine like Claritin (loratidine) is the preferred choice. You can take your antihistamine daily during the season or just during peak pollen days if that’s when your symptoms flare up.

Steroid nasal sprays are the best option for people with moderate to severe allergies. They all work about the same, so have a look at the table below to compare options.

Pharmacist Favorite

Using a steroid nasal spray

Ideally you should start using your nasal spray a few weeks before the allergy season hits and use it daily throughout the season to minimize flare ups and symptoms. Read the package instructions for each product, but expect to start out with more frequent dosing when you first start using it, then backing off as symptoms improve (typically after the first week) or as directed on the packaging. Also, make sure you are using proper administration technique. Check out my tips below.

What to expect

Nasal steroids take time to work. You will likely see some symptom improvement in the first few days, but it may take a couple of weeks to get the maximum benefit.

Side effects for nasal steroids are often mild. If any of the medication reaches the back of your throat or tongue you may notice a bitter taste in your mouth. While not pleasant this is normal. The spray itself can cause a bit of discomfort or make you sneeze, and I always warn folks that you may become more susceptible to nose bleeds.

Adding on other drugs

If you are already suffering from allergy symptoms waiting for a nasal steroid to kick in can be torture. There are a few options.

For the absolute fastest relief you can add on Astepro nasal spray. It contains an antihistamine called azelastine that starts working about 30 minutes after you use it. Astepro is very effective and will also help with congestion. When using two nasal sprays try and space them 15-30 minutes apart. You want to maximize the amount of exposure your nose gets to each drug. Astepro doesn’t have any generics and is expensive, so I would personally skip this option.

As a more cost effective method consider adding on one of the non-drowsy antihistamines just until your nasal steroid kicks in. Again, my goto here is Claritin (loratadine).

Using a nasal steroid and and antihistamine daily for the entire allergy season is also an option, but usually reserved for cases when a nasal steroid alone is not enough.

There are also more targeted approaches to relieving nasal congestion and symptoms in the eyes if you need them.

There are a ton of combination products out there like Benadryl Allergy Plus Congestion that have an antihistamine and a decongestant, or Advil Allergy And Congestion Relief that include an antihistamine and a pain reliever and a decongestant. I recommend skipping these as well. Many contain the antihistamines that cause drowsiness, decongestants that don’t work (phenylephrine), or active ingredients you won’t need on a daily basis (pain relievers).

Treating Chronic Allergies (persistent)

Treating chronic allergies is identical to treating seasonal allergies, with one exception. Nasal steroids should always be the first thing you try (if possible), adding on non-drowsy antihistamines and other treatments as necessary. Scroll back up for details.

Treating Nasal Congestion (optional)

For nasal congestion you can consider adding on either a tablet taken by mouth or using a nasal spray.

For the fastest relief use a nasal spray like Afrin, Mucinex Sinus-Max, or Dristan, which contain the active ingredient oxymetazoline. Make sure to read my tips on proper nasal spray administration and don’t use it more than 3 days in a row. It’s very effective, but long term use can lead to rebound nasal congestion.

Pharmacist Favorite

You could also look into using the antihistamine nasal spray Astepro (azelastine). It’s a good option if you are already using a nasal steroid, but still have issues with congestion. It’s also a better option than the oxymetazoline nasal sprays if you have heart disease, uncontrolled blood pressure, diabetes, or an enlarged prostate.

For oral tablets choose a product like Sudafed Sinus Congestion, which has pseudoephedrine 30mg in each tablet. Sudafed also comes in 12 and 24 hour dosage forms, but I prefer the immediate release tablets. Pseudoephedrine is a stimulant and can keep you up at night, but the immediate release tablets only last 4-6 hours, so you can schedule your dosing closer to bedtime and are less likely to have trouble sleeping.

You can’t buy it online and will have to travel to a brick-and-mortar pharmacy to get it. It’s kept behind the counter in pharmacies because it can be used to manufacture the street drug methamphetamine (also known as meth, crystal meth, etc.). Don’t forget to bring your driver’s license or some other form of valid ID.

Skip products that have phenylepherine listed as an active ingredient (Sudafed PE, Benadryl Allergy Plus Congestion, Advil Sinus Congestion & Pain, etc.). Pharmacists have known for years that phenylepherine isn’t an effective nasal decongestant at the dosage found in over the counter products. The FDA started looking at this issue in 2023, so we may see changes at some point.

Treating Symptoms In The Eyes (optional)

Oral antihistamines and steroid nasal sprays actually help with itchy, red, or tearing eyes, but you can also add-on eye drops if you need them.

In general, I recommend any of the products that contain only an antihistamine. This includes products like Zaditor and Alway which contain ketotifen or one of the Pataday products which both contain olopatadine.

Pharmacist Favorite

Products with an antihistamine and a redness reliever are out there (e.g. Opcon-A), but I don’t generally recommend them. The redness reliever in those products can cause rebound redness and can’t be used for more than 3 days. (For a social event or picture an exception can be made.)

Skip out on the rest of the redness relievers. The antihistamine is the way to go and will help with redness as well.

When to get your doctor involved

Most cases of allergies involving symptoms in the nose and eyes can be effectively treated with over the counter products, but there are some exceptions.

See a physician or other health practitioner first for any of the following:

• treating allergies in children under 12
• if you are a woman and pregnant or breastfeeding
• if you have an uncontrolled lower respiratory disorder like asthma or COPD or if you have significant wheezing or trouble breathing in addition to your other allergy symptoms
• if you have ear pain, sinus pain, or think you may have bronchitis or some other kind of infection

Nasal symptoms can also be caused by other conditions. Here are some things to look out for that should point you more in the direction of seeing a doctor rather than treating yourself for allergy symptoms.

• drainage more in the back of the throat than the front
• symptoms only on one side of the face
• frequent nose bleeds
• little to no sneezing and/or itchiness
• lose your sense of smell

Lastly, if you have tried over the over the counter medications and are getting side effects or aren’t getting relief for your symptoms then a doctor’s visit is a good idea.

Overview of Treatment Options

Oral Antihistamines

Histamine is one of main messenger molecules used by the immune system. It promotes recruitment of cells that help fight infection, but is also largely responsible for symptoms such as sneezing, swelling, and itching.⁷ Antihistamines work by blocking the effects of histamine.

There are a lot of different antihistamine drugs, but to keep things simple we can divide them into two groups: drowsy and non-drowsy.

All products take about an hour to kick in. Products in the drowsy category usually work for between 4-6 hours where as non-drowsy antihistamines usually last a full day (12-24 hours).

Non-drowsy (second generation drugs)

The non-drowsy antihistamines are loratadine (Claritin), fexofenadine (Allegra), and to a lesser extent cetirizine (Zyrtec) and levocetirizine (Xyzal). Some people may experience drowsiness with cetirizine and levocetirizine, so opt for one of the other two if you need to be alert for work or are 65 or older. If you take fexofenadine (Allegra) avoid taking it with juices (grapefruit, apple, orange, etc.). Juices can decrease the absorption of fexofenadine and reduce its effectiveness.

Drowsy (first generation drugs)

The first generation of antihistamines have been around since the 1940’s.² They are effective at controlling allergy symptoms, but also have a lot more side effects (drowsiness, dry mouth, constipation, etc.). Diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton^a) are the only single ingredient products you will find advertised for allergy symptoms, but doxylamine (Unisom), which is advertized as a nighttime sleep aid, can be used to treat allergy symptoms as well. Since antihistamines are the primary active ingredients of nighttime sleep aids (e.g. ZzzQuil, Unisom) and frequently appear in cough and cold products make sure that you are not doubling up. Speak with your local pharmacist if you need help.

Don’t use these products if you need to be alert for work (e.g. truck drivers, machine operators), need to drive, or will be consuming alcohol or other depressants.

If you are over the age of 65 I would recommend avoiding these drugs altogether and using one of the non-drowsy products instead. Side effects from these medications are more common in adults over 65 and can impair your ability to think clearly.

Oral decongestants

There are two active ingredients used in nasal decongestant products: phenylepherine and pseudoephedrine. These drugs work by shrinking the blood vessels in your nose, which leads to decreased blood flow, tissue shrinkage, and opening of the nasal passages. Phenylepherine, at the 10mg dose present in OTC products, is not very effective and therefore not recommended. Pseudoephedrine is a better choice, but is kept at pharmacies behind the counter due to its illegal use manufacturing methamphetamine. Because of their effects on all blood vessels and not just the vessels in the nose, patients with heart disease, high blood pressure, thyroid disease, diabetes, or enlarged prostate should talk with a doctor before using these products.

Nasal Sprays

Administration Technique

There are a few things you need to know about how to administer nasal sprays to get maximum benefit and reduce the risk of injuring the sensitive tissues in your nose.^{4, 5}

1. Start by gently blowing your nose to clear out any mucus. The medication needs to contact and get absorbed by the tissues in your nose.

2. Shake and/or prime the sprayer if needed. The steroid nasal sprays should be shaken vigorously to make sure the medication is uniform and well mixed. The first time you use your sprayer you will need to prime it, which just means spray into the air till you get a nice mist.

3. Position your nose in line with your toes. Your head should be neutral. Not tilted back or tucked in.

4. Always spray the nostril opposite from the hand holding the sprayer. (left hand sprays right nostril, right hand sprays left nostril) The goal is to point the tip of the sprayer away from the center of your nose and slightly towards your ear.

5. Sniff not snort. A gentle sniff as you depress the sprayer or just after is what we are looking for.

Steroid nasal sprays

Steroid nasal sprays contain medicines known as corticosteroids. Corticosteroids put the brakes on the immune system. They work on many different cell types and prevent the formation and release of inflammatory chemicals such as histamine. Steroid nasal sprays start working on the first dose, but it can take a few days to start seeing symptom relief and a few weeks for maximum benefit.

There are four different products on the market: Flonase (fluticasone propionate), Flonase Sensimist (fluticasone furoate), Nasacort (triamcinolone acetonide), and budesonide^*.

Antihistamine nasal sprays

Astepro (azelastine) is currently the only antihistamine nasal spray on the market, but Patanase (olopatadine) could make the switch to OTC at some point. Azelastine, the antihistamine in Astepro, works by blocking the effects of histamine in the tissues of your nose. It can be used alone for allergy symptoms, but in most cases should be used as an add-on to help with congestion or if nasal steroids don’t provide enough relief on their own.³

Mast cell stabilizing nasal sprays

NasalCrom (cromolyn) is the only available mast cell stabilizer on the market. Mast cells are immune cells that release histamine when exposed to an allergen. Mast cell stabilizers prevent the release of histamine and the symptoms that follow. NasalCrom is effective, but does come with some drawbacks. It works best before symptoms start. It’s dosed 3-4 times daily (up to 6 if needed), which is less convenient than the steroid nasal sprays, which are just used once a day. It also takes 3 - 7 days to start really seeing benefit and up to 4 weeks for symptom relief.^{2, 6}

In spite of the drawbacks NasalCrom is a good option for some. If you have glaucoma or cataracts you shouldn’t use nasal steroids unless directed by your doctor, but NasalCrom is still an option. It’s also a good option for pregnant and nursing women diagnosed with allergic rhinitis. It is minimally absorbed and side effects in nursing infants have not been reported.²

Eye Drops

Antihistamine eye drops

Eye drops that contain only an antihistamine have one of two active ingredients: ketotifen (Zaditor, Alaway) or olopatidine (Pataday products). Antihistamine eye drops work by blocking the effects of histamine in your eye, which reduces redness, itching, and tearing.

Antihistamine and redness relieving combination eyes drops

Products that contain both an antihistamine and a redness reliever include Opcon-A, Naphcon A, and Visine Allergy Eye Relief Multi-Action. The redness relieving ingredients in these products can cause rebound redness, so it’s very important not to used these products for more than 3 days (72 hours).

Note: Steroid eye drops exist, but they are only available with a prescription from your doctor.

References