The sun's out, and here comes the pollen!

A much underestimated irritation!
Hay fever (also known as Seasonal Allergic Rhinitis, or SAR) is an extremely common allergic reaction to certain components of spring and summertime pollen – sadly, its symptoms are all too familiar to the 10 million or so UK sufferers who experience the classic spring/summer symptoms of runny nose, itchy nose, nasal congestion, throat itchiness, ear itchiness, and redness, puffiness and watering of the eyes. Unsurprisingly, prolonged hay fever can also lead to tiredness - sufferers often don’t sleep well -  and irritability; eventually, hay fever can lead to the sort of chronic emotional debility that results from any ongoing symptom, namely depression and anxiety, and the consequent reduction in the quality of life of the patient. (This quality-of-life reduction has been objectively measured as being comparable as to that caused by asthma, which can reduce life satisfaction scores considerably). Hay fever is a leading cause of absence from school and work. Unfortunately, because hay fever is not regarded as a “serious” or life-threatening illness, it may be overlooked and undertreated – happily, however, there is an increasing number of very effective treatments available and, if you have symptoms, it is definitely worth discussing this with your doctor.

What causes hayfever?
Hay fever is caused by the sufferer’s own immune system mounting an allergic reaction to proteins found within pollen (pollen is the fine powder which is released by plants as part of their reproductive cycle). The pollen protein – the “allergen” – is present in the air, and binds to the cells lining the nose (predominantly), mouth, throat and eyes, and irritates them. The hay fever sufferer’s immune system inappropriately interprets this irritation as an attack by a microbe, and releases inflammatory chemicals which are more appropriately released in response to infection – it is this inflammatory chemical response which causes the symptoms of hay fever. There are a number of underlying reasons why a person’s body might over-react to pollen proteins and mount an allergic response to them. One major risk factor for having hay fever is also having another co-called “atopic” condition such as asthma or eczema, which are very commonly seen as an “atopic trio” together. Other associations with hay fever are allergic conjunctivitis, sinusitis, food allergies, and middle ear infections with or without effusion (“glue ear”). Hay fever also runs in families, and is thought to be associated with exposure to cigarette smoke and diesel exhaust fumes in childhood.  Of the 1 in 5 of the UK population who suffer from hay fever, 80% will develop symptoms younger than 20, with a peak incidence at 13-14 years of age – just in time for some high-stakes exams!

Hayfever rogues gallery, aka know your enemy!!
In the UK, 90% of hay fever sufferers are allergic to Timothy and Rye grass pollen, which tends to be released in late spring and summer; 25% are allergic to tree pollen, such as that from oak, ash, cedar and birch trees, which tends to be released in early spring (interestingly, there is a cross-over between the pollen proteins of the birch tree and those proteins found in apples, peaches, plums and cherries, so people with hay fever may find that they are allergic to these fruits); a smaller percentage are allergic to weed pollen, which tends to be released in late summer/autumn (and sadly, it is perfectly possible to be allergic to all 3 pollen types). The weather tends to affect how much pollen is in the air (the so-called “pollen count”, which is a measure of how many grains of pollen are in each cubic metre of air, with “high” being over 50 and “very high” being over 150 – most people with hay fever begin to experience symptoms when the pollen count is “high” or above) with humid, windy weather being worst of all as pollen spreads very easily in these conditions (hay fever sufferers are the only ones hoping for rain in the summer, as this clears the pollen from the air!).

Hayfever management 101
There are a number of common-sense measures which can be employed to minimise the effects of pollen, and thus avoid symptoms. Rubbing some Vaseline inside the nostrils can help to trap pollen and stop it from getting into the nose. Wraparound sunglasses can minimise pollen contact with the eyes. Regular washing of clothes worn outside can clear them of pollen grains. Paying attention to the weather forecast, and staying inside when the pollen count is high, with the windows shut and any air conditioners in recycling mode, stops pollen from getting into the house, and using vacuum cleaners with HEPA (high-efficiency particulate arrestance) filters (or having a HEPA filter in the car or as part of an air purifying device at home) can reduce pollen exposure still further. But what if people don’t relish the idea of avoiding the great outdoors?

Time to bring in reinforcements…
As the term Seasonal Allergic Rhinitis (“rhinitis” simply means “inflammation of the nose”) implies, hay fever symptoms tend to be, for most people, predominantly nasal. Sufferers describe sneezing, a runny/itchy nose and nasal congestion (often, the nasal congestion is the worst symptom). For mild nasal symptoms only (“mild” symptoms are defined as not being “troublesome”, and not interfering with work, school, hobbies, or sleep), a first line treatment can be an intra-nasal antihistamine such as azelastine. If this doesn’t work, or the symptoms are more severe, and causing problems with daily life, then treatments can be stepped up accordingly. A commonly overlooked, but very effective, means of alleviating nasal symptoms of hay fever is irrigation of the nose with saline (salt water). This not only helps to clear nasal mucus, thus helping the symptoms on its own, but irrigation also helps other nasal treatments to penetrate the lining of the nose and to work better. There are several nasal saline sprays and nasal irrigation devices containing saline available to buy over-the-counter, which are inexpensive, well tolerated, and work well. Nasal irrigation is also very safe, and is appropriate for pregnant women to use.

A great adjunct to nasal saline irrigation, for moderate to severe hay fever, is the use of an intra-nasal steroid (INS) – INS is the single most effective class of treatment for hey fever, and tends to improve all nasal symptoms. The effects of INS take 6-8 hours to “kick in” and the most substantial benefit is felt after two weeks of continuous treatment, so it is advisable to start using INS a fortnight before hay fever season starts, rather than waiting for symptoms to appear. INS has a few side effects, including nasal burning, stinging and nosebleeds in an unfortunate 5-10% of users; however, the side effects people are often worried about, which can apply to oral or topical (cream) forms of steroid treatment, such as thinning of the skin, child growth retardation, bone thinning, or any other effects on the whole body (so-called “systemic” effects) do NOT occur with modern INS because the low “bio-availability” of the steroid means it doesn’t get into the system but stays in the nose. For the majority of people, INS is very effective – for those who don’t notice a substantial benefit, the problem is usually that they are not taking the INS regularly, but “as and when”; or, more commonly, that it is being taken incorrectly. The cardinal rule when using INS (or any nasal spray) is: DO NOT SNIFF. Sniffing simply means that the INS (along with nasal mucus) is swallowed and can’t work. To ensure the INS is being taken properly, the advice for users is to shake the bottle well, and look down – then, using the right hand for the left nostril, position the spray inside the nose pointing to the outside wall of the nostril – squirt twice in two difference directions, then swap hands and repeat in the other nostril.

If, despite the correct regular use of INS, nasal symptoms of hay fever persist, there are various other options available – these include a combination nasal spray containing both an antihistamine and a steroid, nasal ipratropium bromide, or nasal cromolyn. Sometimes, the nose is so badly congested that no nasal spray can get up inside the nose to work; under these circumstances, a short course of high-dose oral steroids may be required. Many people may resort to using decongestant medication, which acts to narrow the blood vessels in the nose using an adrenaline-like agent; this often works well initially, but isn’t an option in the long term as it can lead to tolerance (stops working so well) is used for more than a couple of weeks, and can even lead onto a rebound situation whereby the nasal mucosa becomes even more congested than it was before (“rhinitis medicamentosa”) – also, the side effects of the adrenaline (palpitation, anxiety, tremor, fast heart rate etc.) can be extremely unpleasant.

Anti-histamines- they are not all created equal…
Although nasal symptoms are the commonest reported hay fever problems, there are other non-nasal symptoms, such as watery itchy eyes, for which nasal sprays will do very little. An oral antihistamine of the so-called “second generation” such as cetirizine, or loratadine, are effective at helping general symptoms of hay fever, both nasal and non-nasal, and can be bought over the counter. Branded anti-histamines are no different to the much cheaper generic versions, and it’s largely a matter of personal preference – however, it is to be strongly recommended that older, “first-generation” antihistamines such as chlorphenamine (Piriton), promethazine or hydroxyzine be avoided – they are sedating and have been shown to impair judgement and reactions to the extent that they worsen driving skills and exam performance. (Hydroxyzine, in some cases, can also cause heart problems.) If in doubt, check with your pharmacist or doctor. Sodium cromoglycate or olopatadine eye drops can help with isolated eye symptoms. Montelukast, which reduces inflammation generally, can be given if hay fever coexists with asthma. As mentioned above, oral steroids can be used as a “rescue” medication in short bursts, particularly if the hay fever sufferer has (for example) a wedding or performance or exam to get through – however, if someone is requiring more than one course of oral steroids, per year, they may need to be referred onto a specialist. It is important to remember that hay fever sufferers need to keep on taking their INS even if they are also taking oral steroids – this will ensure control of the symptoms when the oral treatment stops. What is NOT recommended is the use of injectable steroids such as Kenalog, as the potential side effects (including bone breakdown) are more serious than the symptoms of hay fever.

More sophisticated treatments are available…
Specialist immunologists are available to offer their expertise to hay fever sufferers in some circumstances. If the diagnosis is in doubt (i.e. the symptoms are not clear-cut), then immunologists can perform skin prick testing to determine exactly what the allergen is that the person is reacting to (sometimes, for example, it might be mould rather than pollen, or the person may have a mixture of hay fever and another allergy). In addition, they are able to offer “desensitising immunotherapy” whereby small doses of allergen extract are deliberately given to hay fever sufferers to dampen down their immune response to pollen in hay fever season. This treatment has been shown to reduce symptoms, improve quality of life and reduce the need for medications – it is a “disease-modifying” treatment, and patients can enjoy many years of remission after stopping the treatment. Desensitising immunotherapy is available in certain specialist clinics for hay fever sufferers who have tried everything else and are still finding their lives blighted by their symptoms. The BSACI website will point you in the direction of your nearest clinic.

As ever, if you have any questions, please do make an appointment to see your doctor.