How to Prevent Spring Allergies

Melissa DeCapua, DNP, PMHNP-BC
Friday April 01, 2016
Now that spring has sprung, retail clinicians are likely seeing an influx of patients reporting seasonal allergy symptoms. Spring allergies, or allergic rhinitis (AR), affect 10% to 30% of the US population each year,1 impacting quality of life and the ability to function productively in work and school. Although intranasal corticosteroids can treat these symptoms effectively,2 it is better to prevent symptoms before they arise. This article reviews the pathogenesis, risk factors, epidemiology, assessment, diagnosis, and preventive treatment for AR.

Overview
AR is a common, chronic disorder that affects the respiratory tract.2 Also known as hay fever, pollinosis, and allergic rhinosinusitis, the condition often follows a temporal pattern in response to the following season-related allergens2:
  • Grass (timothy and Bermuda)
  • Weeds (ragweed)
  • Outdoor mold spores (Alternaria, Aspergillus, and Cladosporium)
  • Trees (birch, oak, maple, and mountain cedar)
Patients with AR typically arrive at the retail clinic with sneezing, itching, nasal congestion, and rhinorrhea. Their nasal mucosa will appear bluish, boggy, pale, and enlarged. Other signs include dark patches under the eyes from venous congestion, nasal crease, nasal polyps, and cobblestoning of the posterior oropharynx due to postnasal drip.2

Pathogenesis
Allergy symptoms arise due to an immunoglobulin– mediated response and mast cell histamine release. Histamine results in vasodilation, plasma exudation, and mucus production,3 and these triggers create the previously noted traditional presenting symptoms. Allergic inflammation develops within minutes of exposure and peaks 15 to 30 minutes later.3

Risk Factors
Risk factors for developing AR include a family history of atopy, higher socioeconomic class, and residence in an urban area (Table 14). Although no definitive evidence exists, tobacco smoke may also increase an individual’s risk. Despite popular belief, infant vaccinations and pet ownership are not associated with an increased risk.4



Epidemiology
Seasonal allergy is the 12th most common diagnosis made by primary care providers.5 Since the 1960s, the rate of AR has continued to rise so fast that genetic factors are unlikely to be causative. Instead, changes in home ventilation, a decline in physical activity, and alterations in diet have increased the number of people suffering from allergic diseases.6 The Natural Resources Defense Council also points to increased ozone smog and excessive ragweed pollen due to global warming as possible factors.7

Assessment and Diagnosis
Nurse practitioners and physician assistants diagnose AR based on the patient’s presentation, history, and exposure to allergens. The patient’s chief complaint will likely encompass sneezing, copious rhinorrhea, and persistent nasal congestion. Upon further questioning, clinicians may find additional related symptoms, such as postnasal drip, impaired sense of taste and smell, persistent cough, malaise, epistaxis, and nasal polyps.2

While obtaining the patient’s history of present illness, primary care provider should ask about the following4:
  • Pattern and duration of nasal symptoms
  • Environmental history
  • Precipitating factors such as known allergens
  • Coexisting conditions, such as asthma, sleep apnea, sinusitis, otitis media, and allergic conjunctivitis
The patient’s family history should be assessed for an atopic disorder, chronic sinus issues, and recurrent bronchitis. The patient also should be asked about the possible presence of mold and water damage in the home, occupational exposure to allergens, and tobacco use.4 During the review of systems, it may be helpful to include the symptoms’ effects on the patient’s quality of life in addition to standard assessment questions (Table 24).

The differential diagnosis should include nonallergic rhinitis syndromes, such as vasomotor, gustatory, atrophic, and drug-induced rhinitis (Table 38). The clinician should suspect a nonallergic cause if the patient presents with fever, cervical adenopathy, and purulent nasal discharge. A physical obstruction (eg, septal deviation, tumors, foreign body) can also cause symptoms that mimic AR. Other causes of abnormal nasal function include cystic fibrosis, primary ciliary dyskinesia, vasculitis, and cerebrospinal fluid rhinorrhea.2

Preventive Measures
Treating AR involves a holistic approach: allergen avoidance, medication, nasal saline irrigation, and complementary therapies, such as butterbur supplements and acupuncture.4 Results of newer research have also shown a link between adherence to a Mediterranean diet in childhood and reduced risk for AR.9

Allergen Avoidance
Avoiding allergen triggers can help minimize symptoms. Patients who are sensitive to spring pollen should be instructed to keep their house and car windows closed, stay inside on high-pollen days, never dry clothes outside, and shower before bed.4 Patients might benefit from downloading an allergy alert app for their smartphone in order to receive daily weather and allergy forecasts. The American Academy of Allergy, Asthma and Immunology’s National Allergy Bureau (aaaai.org/global/nab-pollen-counts) also publishes accurate pollen and mold levels across different regions of the United States.

If patients must go outside on high-pollen days, they should be encouraged to wear a mask or nasal filter, which can be purchased at a local pharmacy. Because pollen is most concentrated in the air during the early morning, patients should wait until midday to go outside, if possible. They should change their clothing whenever possible because pollen often clings to fabric long after the initial exposure. Patients should also vacuum their home and car frequently during allergy season to pick up excess pollen that has accumulated on the floor.4 



Current Issue

The Educated Patient

Bethany Rettberg, NPC
Practitioners should get a detailed medical history and conduct a thorough physical to treat sinus infections.
Jennifer L. Hofmann, MS, PA-C
Providing them with advice can improve control of the disease and reduce hospitalizations, morbidity, and unscheduled health care visits.
Emily C. Hayes, PharmD Candidate
Colds, coughs, and a relentless influx of sick patients in retail health clinics keep the health care providers who work there very busy.
Kristen Marjama, DNP, APRN-BC
Although the rate of foot and leg amputation has greatly declined over the past 2 decades, increasing awareness for macrovascular and microvascular complications of diabetes is essential because diabetes is the leading cause of lower-limb amputations in the United States.
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