Allergic Rhinitis | MRCGP Topic Essentials

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Allergic Rhinitis | MRCGP Topic Essentials

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1. Why this matters for MRCGP

  • Allergic rhinitis is common, often under-treated, and affects sleep, school, work, concentration and quality of life.
  • AKT may test classification, red flags, treatment escalation, medicine age limits and safety warnings.
  • SCA may test the patient who has “just hay fever” but is sleeping badly, overusing decongestants, pregnant, breastfeeding, or has worsening asthma.
  • The GP risk is missing unilateral/bloody symptoms or giving unsafe practical medicine advice.

2. GP Bottom Line

  • Recognise: sneezing, nasal itching, rhinorrhoea and congestion, usually bilateral and linked to allergen exposure.
  • Urgency changes: unilateral symptoms, blood-stained nasal discharge, recurrent epistaxis or nasal pain need urgent two week wait ear, nose and throat referral.
  • Usual GP action: assess trigger, severity and impact; advise avoidance/saline; use antihistamines for mild/intermittent symptoms and intranasal corticosteroids for persistent or moderate–severe symptoms.
  • Key trap: xylometazoline or oxymetazoline decongestant sprays/drops are not first-line for allergic rhinitis, should not be used for more than 5 consecutive days, and should not be combined with other oral or nasal sympathomimetic decongestants.
MRCGP Topic Essential high-yield revision infographic.

3. 60 Second Exam Snapshot

  • Allergic rhinitis is an immunoglobulin E (IgE)-mediated inflammatory disorder of the nose.
  • Intermittent: symptoms less than 4 days/week or less than 4 weeks. Persistent: at least 4 days/week and at least 4 weeks.
  • Mild: no sleep or daily activity disturbance. Moderate–severe: sleep or daily activities affected.
  • Diagnosis is usually clinical, supported by nasal examination and response to first-line treatment.
  • Investigations are not routine when history is typical; allergy testing is selective and history-led.
  • Intranasal corticosteroids are most effective; maximal benefit may take up to 2 weeks.
  • Review after 2–4 weeks if symptoms persist.

4. Recognition and Diagnosis

Typical allergic rhinitis is suggested by sneezing, nasal itching, clear nasal discharge, congestion, postnasal drip, itching of the palate and cough. Symptoms usually develop within minutes of exposure and are typically bilateral.

Patterns help identify the likely trigger:

  • Tree pollen: early to late spring.
  • Grass pollen: late spring to early summer.
  • Weed pollen: early spring to early autumn.
  • House dust mite: all year, often worse on waking, may peak in autumn and spring.
  • Animal dander: symptoms after exposure; may be all year or occasional.
  • Occupational rhinitis: symptoms improve away from work, such as weekends or holidays.

Ask about asthma, eczema, allergic conjunctivitis, family history of atopy, pets, housing, occupation, previous over-the-counter treatment and medication that may cause or aggravate rhinitis. Drug causes or aggravators to ask about include intranasal decongestant overuse, alpha-blockers, ACE inhibitors, beta-blockers, aspirin/NSAIDs and cocaine.

Examination may show nasal speech, mouth-breathing, allergic shiners, a horizontal nasal crease, swollen greyish nasal mucosa and clear secretions. The nose may also look normal. In children, measure height on presentation if already on or starting corticosteroids, so growth can be monitored.

Features that reduce confidence in uncomplicated allergic rhinitis include unilateral symptoms, discoloured discharge, recurrent nosebleeds, facial or nasal pain, loss of smell, purulent discharge, nasal polyps, foreign body, structural abnormality, or continuous rhinitis symptoms under age 2.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

  • Allergic rhinitis is clinical: typical symptoms plus allergen exposure pattern.
  • Seasonal rhinitis may be called hay fever when caused by grass or tree pollen.
  • Perennial symptoms suggest house dust mite or animal dander, but symptoms vary by environment.
  • Occupational history must include job, duration before symptoms, exposures and improvement away from work.

Investigation / interpretation

  • A therapeutic trial of first-line treatment may be the first diagnostic tool when history is typical.
  • Specialist allergy testing may include skin prick testing or serum-specific IgE.
  • Skin prick testing has a high negative predictive value but may be suppressed by recent antihistamines, tricyclic antidepressants and topical corticosteroids.
  • A positive skin prick test alone does not prove the causative allergen without a supportive history.
  • Allergen-specific IgE blood testing in primary care should be guided by compatible history and used only if it changes management or is needed for referral; there is no role for broad “screening” with multiple tests.

Management / next best step

  • Mild, intermittent symptoms: intranasal antihistamine or non-sedating oral antihistamine.
  • Moderate–severe or persistent symptoms: regular intranasal corticosteroid during allergen exposure, or intranasal corticosteroid plus intranasal antihistamine.
  • If treatment fails, check adherence, self-management, spray/drop technique and alternative diagnosis before stepping up.

Medicines / safety

  • Intranasal antihistamines act fastest; azelastine is named in the source.
  • Intranasal corticosteroids are most effective; named examples include mometasone furoate, fluticasone furoate and fluticasone propionate.
  • Intranasal corticosteroid plus oral antihistamine is no more effective than intranasal corticosteroid alone.
  • Intranasal corticosteroid plus intranasal antihistamine is more effective than intranasal corticosteroid alone.
  • Combined oral and intranasal antihistamine use is not recommended.

Special groups

  • Pregnancy: start with allergen avoidance, barrier ointment and saline irrigation. If this is insufficient, consider topical options such as ocular mast cell stabilisers or intranasal corticosteroids. If an oral antihistamine is needed, loratadine or cetirizine are preferred. Decongestants are not recommended at any stage of pregnancy.
  • Breastfeeding: cetirizine or loratadine are preferred non-sedating antihistamines for full-term healthy infants; monitor the infant for drowsiness or feeding problems.
  • Children: In children, check age and product before advising or prescribing. Cetirizine and loratadine are supported from age 2; fexofenadine and intranasal azelastine from age 6; mometasone nasal spray from age 3; fluticasone propionate from age 4; fluticasone furoate / Avamys® from age 6; combined intranasal corticosteroid/antihistamine sprays and ipratropium nasal spray from age 12.

Follow-up / monitoring

  • Review after 2–4 weeks if symptoms persist.
  • Monitor height in children on prolonged intranasal corticosteroids; consider paediatric referral if growth slows.

6. SCA Consultation Essentials

This often presents as: “My hay fever is awful,” “The pharmacy tablets aren’t working,” “My child keeps sniffing,” or “I’m using a blocked-nose spray every day.”

Gather:

  • Symptom type: itch, sneeze, rhinorrhoea, congestion, eyes, cough.
  • Timing: seasonal, all-year, indoor/outdoor, morning, workplace.
  • Impact: sleep, school, work, concentration, mood, fatigue, leisure.
  • Atopy: asthma, eczema, allergic conjunctivitis and family history.
  • Treatment already tried: including decongestants and spray technique.
  • Red flags: one-sided symptoms, blood-stained discharge, recurrent epistaxis, nasal pain, facial pain, smell loss, visual disturbance.

Useful explanation pivot:

“Allergic rhinitis is not just a nuisance if it is affecting sleep, concentration or asthma. The treatment choice depends on severity and how often symptoms happen.”

Patient-centred but safe compromise: if they dislike sprays, acknowledge preference, but explain that intranasal corticosteroids are the most effective option for persistent or more troublesome symptoms.

7. Red Flags / Escalation / Referral

Urgent two week wait ENT referral

  • Unilateral symptoms.
  • Blood-stained nasal discharge.
  • Recurrent epistaxis.
  • Nasal pain.

ENT referral

  • Predominant nasal obstruction.
  • Structural abnormality, such as deviated nasal septum, making intranasal treatment difficult.
  • Nasal polyps should not be managed as routine hay fever. Arrange ENT initial review; in children, screen for cystic fibrosis and refer to ENT.
  • Loss of smell or visual disturbance, especially with unilateral symptoms, recurrent bloody discharge/nosebleeds or nasal pain, should prompt assessment for alternative or serious disease rather than routine hay fever management; consider ENT referral depending on clinical judgement.

Allergy specialist referral

  • Persistent symptoms despite optimal primary care management.
  • House dust mite or animal dander avoidance is being considered and allergy testing may be needed.
  • Patient wants to consider immunotherapy rather than long-term medicines.

Allergy or ENT referral

  • Diagnosis uncertain, depending on clinical judgement.

Urgent medical attention for medicine safety

  • Pseudoephedrine: sudden severe or thunderclap headache, sudden nausea/vomiting, confusion, seizures or visual disturbance.
  • Montelukast: new or worsening mood, sleep, behaviour changes or self-harm thoughts should prompt discontinuation and immediate medical advice.

8. What the GP Should Do Today

Assess

  • Confirm symptoms, duration, frequency, severity and impact.
  • Identify trigger pattern: pollen, house dust mite, animal dander, mould or workplace.
  • Ask about asthma and whether it is worsening.
  • Review current medicines and over-the-counter use, especially decongestant sprays.

Examine

  • Inspect nose for mucosal swelling, secretions, polyps, septal abnormality or foreign body.
  • Look for eye involvement and signs of sinusitis.
  • Measure height in children starting or already using corticosteroids.

Investigate

  • No routine test is needed if the history is typical.
  • Consider history-led allergen-specific IgE testing only if it changes management or is required before referral.

Treat / advise

  • Before advising or prescribing in children, check age and product suitability.
  • Give allergen avoidance advice where the trigger is identified.
  • Consider saline nasal irrigation using an over-the-counter spray, pump or squirt bottle.
  • Mild/intermittent: intranasal antihistamine or non-sedating oral antihistamine.
  • Moderate–severe/persistent: intranasal corticosteroid, or intranasal corticosteroid plus intranasal antihistamine.
  • Additional eye symptoms: antihistamine eye drops or chromone eye drops, with sodium cromoglycate and nedocromil named in the source.

Review

  • Review after 2–4 weeks if symptoms persist.
  • If not controlled, check adherence and technique before escalation or referral.

9. Practical Use in GP: How to Apply This Topic

Before use

  • Check age, pregnancy/breastfeeding, asthma history, red flags and current over-the-counter medicines.
  • Check whether the patient is using xylometazoline or oxymetazoline daily, beyond 5 days, together, or with pseudoephedrine, phenylephrine or ephedrine.
  • Check whether sprays/drops are being used correctly.

Starting / advising

  • For predictable recurrent symptoms controlled by intranasal corticosteroids, restart treatment 2 weeks before likely allergen re-exposure.
  • If the time of re-exposure is uncertain, start several weeks before the most likely time.
  • If symptoms are intermittent with no ongoing exposure, step down and stop when controlled; if persistent or exposure continues, continue or step up if not controlled.

Nasal spray technique

  1. Shake the container and look down.
  2. Use the right hand for the left nostril.
  3. Place the nozzle just inside the nose and aim towards the outside wall.
  4. Squeeze while breathing gently through the nose.
  5. Do not sniff.
  6. Change hands and repeat for the other nostril.

Nasal drop technique

  1. Blow the nose gently.
  2. Shake the container.
  3. Tilt the head backwards.
  4. Place drops in the nostril, keep the head tilted and sniff gently.
  5. Repeat for the other nostril if required.

Escalate / change if

  • Symptoms persist despite correct use and adherence.
  • There is sudden or severe congestion needing short-term add-on treatment.
  • Watery rhinorrhoea persists despite intranasal corticosteroid plus antihistamine.
  • Itching/sneezing persists despite monotherapy.
  • Red flags appear.

What not to invent

  • Homemade saline irrigation recipes — check BNF / local guidance.
  • Do not start immunotherapy in routine GP care; specialist assessment/referral required.

10. Medicines, Investigations and Intervention Safety

Intranasal corticosteroids

Used for moderate–severe or persistent symptoms, and when initial treatment is ineffective. Named low-systemic-absorption options include mometasone furoate, fluticasone furoate and fluticasone propionate. Mometasone is supported from age 3, fluticasone propionate from age 4, and fluticasone furoate / Avamys from age 6. Do not prescribe intranasal corticosteroids with recent nasal surgery, untreated nasal infection, or pulmonary tuberculosis. Use caution with immunosuppression, transfer from systemic corticosteroids, and high-dose or prolonged use because systemic absorption may occur. Monitor child height. Visual disturbance should prompt ophthalmology referral.

Intranasal antihistamine

Azelastine is named as the UK-licensed intranasal antihistamine for allergic rhinitis. It has the fastest onset but is less effective than intranasal corticosteroids. Bitter taste can occur if applied incorrectly; irritation, epistaxis, dizziness and drowsiness are also listed.

Oral non-sedating antihistamines

Named examples: cetirizine hydrochloride, loratadine and fexofenadine. They help mild/intermittent symptoms and are patient-preferred for some. Sedation can still occur: warn about driving, cycling, machinery and alcohol. Cetirizine has renal cautions and epilepsy caution. Loratadine has severe hepatic impairment caution. Fexofenadine has interaction issues with antacids and fruit juices.

Combined intranasal corticosteroid + antihistamine sprays

Dymista contains azelastine and fluticasone propionate. Ryaltris contains olopatadine and mometasone. Both are for age 12+. Use when monotherapy is insufficient or refractory symptoms persist. For combined intranasal corticosteroid/antihistamine sprays, also avoid use with hypersensitivity to active ingredients, untreated nasal infection, recent nasal surgery or trauma, or tuberculosis. Watch for taste changes, drowsiness, epistaxis, nasal symptoms, visual disturbance and systemic corticosteroid effects with prolonged use.

Intranasal decongestants

Xylometazoline and oxymetazoline are for short-term relief only and not first-line for allergic rhinitis. Avoid in children under 6. Do not use xylometazoline or oxymetazoline for more than 5 consecutive days, and do not use them together or with other oral or nasal sympathomimetic decongestants such as pseudoephedrine, phenylephrine or ephedrine. If the patient is already using a decongestant spray daily or feels unable to stop, explain the rebound cycle, review clinically, advise gradual withdrawal, consider alternative treatment and arrange follow-up. Prolonged use can cause rebound congestion, rhinitis medicamentosa and tachyphylaxis.

Pseudoephedrine

Pseudoephedrine is short-term only and should not be used in severe or uncontrolled hypertension or severe renal disease. Seek urgent medical attention for sudden severe/thunderclap headache, sudden nausea or vomiting, confusion, seizures or visual disturbance.

Ipratropium bromide nasal spray

For persistent watery rhinorrhoea despite intranasal corticosteroid and antihistamine, in adults and young people aged 12 or older. Avoid spraying near eyes. Cautions include cystic fibrosis, bladder outflow obstruction, prostatic hyperplasia and susceptibility to angle-closure glaucoma.

Montelukast

Montelukast is a leukotriene receptor antagonist for the narrow supported context of seasonal allergic rhinitis in people with asthma; check age and licence before prescribing. Warn about neuropsychiatric reactions; if new or worsening mood, sleep, behaviour changes or self-harm thoughts occur, discontinue montelukast and seek medical advice immediately.

Oral corticosteroid

For adults with severe uncontrolled symptoms significantly affecting quality of life, CKS gives prednisolone 0.5 mg/kg in the morning for 5–10 days. For children, seek specialist advice before considering oral corticosteroids.

Depot or intramuscular corticosteroid injections

Do not offer depot or intramuscular corticosteroid injections for allergic rhinitis; the supplied BSACI source states the risk-benefit profile is poor.

Immunotherapy

Specialist only. NICE TA1045 supports 12 standard quality house dust mite sublingual lyophilisate (SQ-HDM SLIT) for moderate to severe house dust mite allergic rhinitis in people aged 12–65 with clinical diagnosis, positive house dust mite sensitisation test, and symptoms persistent despite symptom-relieving medicine. NICE TA1087 supports Betula verrucosa for adults with moderate to severe allergic rhinitis or conjunctivitis caused by pollen from the birch homologous group, with symptoms despite symptom-relieving medicines and a positive sensitisation test.

11. How to Explain It to the Patient

  • “Your symptoms fit allergic rhinitis: the lining of the nose is reacting to something you are allergic to.”
  • “The treatment depends on how often it happens and how much it affects sleep, work, school or daily life.”
  • “Steroid nasal sprays are the most effective option for persistent symptoms, but they may take days to build up and up to 2 weeks for best effect.”
  • “Aim the spray slightly outwards, away from the middle of the nose, and don’t sniff hard afterwards.”
  • “Blocked-nose decongestant sprays can make congestion worse if used too long, so don’t use them for more than 5 days.”
  • “Please seek review if symptoms become one-sided, bloody, painful, or if treatments are not working.”

12. When the Plan Changes

  • If symptoms are mild, intermittent, or both.
    • Why this changes the plan: lower symptom burden and less persistent exposure.
    • What the GP does now: advise allergen avoidance/saline and consider intranasal antihistamine or non-sedating oral antihistamine.
  • If symptoms are moderate–severe or persistent.
    • Why this changes the plan: sleep or daily life is affected, or symptoms are frequent/prolonged.
    • What the GP does now: use regular intranasal corticosteroid, or intranasal corticosteroid plus intranasal antihistamine.
  • If symptoms persist after initial treatment.
    • Why this changes the plan: poor adherence, wrong technique or alternative diagnosis may be the real issue.
    • What the GP does now: check self-management, medicine use, spray/drop technique and red flags before stepping up.
  • If there is unilateral disease, blood-stained discharge, recurrent epistaxis or nasal pain.
    • Why this changes the plan: alternative or serious diagnosis is possible.
    • What the GP does now: arrange urgent two-week-wait ENT referral.
  • If the patient is pregnant.
    • Why this changes the plan: medicine choice changes.
    • What the GP does now: start with allergen avoidance, barrier ointment and saline irrigation. If insufficient, consider topical options such as ocular mast cell stabilisers or intranasal corticosteroids. If an oral antihistamine is needed, loratadine or cetirizine are preferred. Decongestants are not recommended at any stage of pregnancy.
  • If the patient wants immunotherapy.
    • Why this changes the plan: treatment requires objective sensitivity testing and specialist assessment.
    • What the GP does now: refer to an allergy specialist or relevant local pathway.

13. Common AKT / SCA Traps

  • Treating unilateral or bloody nasal symptoms as simple hay fever.
  • Ordering broad allergy screens without a compatible history or management consequence.
  • Assuming a positive IgE or skin prick test proves the cause without matching symptoms.
  • Forgetting occupational rhinitis when symptoms improve at weekends or holidays.
  • Missing drug-induced or drug-aggravated rhinitis, including decongestant overuse.
  • Escalating treatment without checking spray technique.
  • Adding oral antihistamine to intranasal corticosteroid expecting extra nasal benefit.
  • Combining oral and intranasal antihistamines despite the supplied warning.
  • Assuming any child from age 24 months can use named sprays or tablets without checking age and product.
  • Letting xylometazoline or oxymetazoline run beyond 5 days or be combined with other decongestants.
  • Managing nasal polyps as routine hay fever, especially in children.
  • Missing growth monitoring in children on prolonged intranasal corticosteroids.
  • Offering depot or intramuscular corticosteroid injections for allergic rhinitis.
  • Starting or explaining specialist immunotherapy as if it were routine GP prescribing.

14. Common Exam Angles

  • Angle: Teenager with “hay fever” affecting sleep and school.
    • Hidden challenge: severity classification.
    • What the candidate must not miss: moderate–severe symptoms favour intranasal corticosteroid or combination intranasal therapy.
  • Angle: Adult with one-sided blockage and blood-stained discharge.
    • Hidden challenge: not allergic rhinitis until proven otherwise.
    • What the candidate must not miss: urgent two-week-wait ENT referral.
  • Angle: Patient using blocked-nose spray daily.
    • Hidden challenge: rebound congestion and dependence cycle.
    • What the candidate must not miss: decongestants are short-term only; xylometazoline or oxymetazoline should not be used for more than 5 consecutive days or combined with other sympathomimetic decongestants.
  • Angle: Pregnant patient with severe hay fever.
    • Hidden challenge: special-group prescribing.
    • What the candidate must not miss: allergen avoidance, barrier ointment and saline first; topical options next if needed; loratadine or cetirizine if an oral antihistamine is needed; decongestants are not recommended.

15. 90 Second Audio Summary Script

Allergic rhinitis is an IgE-mediated nasal allergy causing sneezing, itching, runny nose and congestion. In the exam, think about pattern and impact. Is it seasonal pollen, perennial house dust mite or animal dander, or occupational symptoms that improve away from work?

Classify it by frequency and severity. Intermittent is less than 4 days a week or less than 4 weeks. Persistent is at least 4 days a week and at least 4 weeks. Moderate–severe means sleep or daily activities are affected.

Diagnosis is usually clinical. You do not need routine testing if the story is typical. Allergy testing should be history-led and useful for management or referral.

Initial management is allergen advice, possible saline irrigation, and medicines matched to severity. Mild intermittent symptoms can use an intranasal or non-sedating oral antihistamine. Persistent or moderate–severe symptoms need regular intranasal corticosteroid, or a combined intranasal corticosteroid and antihistamine spray. In children, always check age and product first, because not every option is supported from age 2.

If treatment fails, do not just keep adding medicines. Check adherence, technique, dose and alternative diagnosis. Review after 2 to 4 weeks if symptoms persist.

The big safety traps are unilateral or bloody symptoms, recurrent epistaxis or nasal pain: these need urgent two-week-wait ENT referral. Nasal polyps are not routine hay fever; arrange ENT initial review, and in children screen for cystic fibrosis and refer. Loss of smell or visual disturbance with concerning features should prompt assessment for alternative disease.

Do not overuse decongestants: xylometazoline or oxymetazoline should not be used for more than 5 consecutive days or with other oral or nasal sympathomimetic decongestants. Daily reliance needs clinical review, gradual withdrawal, alternative treatment and follow-up. In pregnancy, start with non-drug measures, then topical options if needed, and avoid decongestants. Montelukast is only for a narrow asthma-associated context and needs neuropsychiatric safety counselling. Immunotherapy requires specialist assessment and treatment; the GP role is referral, not initiation.

References

Important Disclaimer

This MedDigest MRCGP Topic Essentials is an independent educational and revision resource, created to support exam preparation only. It is not a clinical guideline, prescribing resource, or a substitute for your own professional judgment.

This content is designed to highlight exam-relevant clinical principles, management pathways, and consultation approaches in a concise format. Any example explanations, consultation wording, scenario angles, or summary scripts are illustrative and should not be used as stand-alone clinical advice.

This resource has not been produced, reviewed, or endorsed by NICE, the Royal College of General Practitioners, or any other official organisation.

Medicine and guidance change over time. For definitive recommendations, always consult the latest official guidance, the BNF, and your local clinical policies and referral pathways.

MedDigest and its authors accept no responsibility for any loss, harm, or adverse outcome arising from reliance on the information contained in this resource.

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