Clinical Impact and Need for Specialized Treatment in Allergic Rhinitis

1. 1. Risk of Developing Comorbidities: Poorly controlled rhinitis is frequently associated with conjunctivitis and may potentiate the onset of chronic sinusitis, otitis, or sleep apnea. Furthermore, it is the primary risk factor for developing allergic asthma, a condition that requires early detection to prevent irreversible lung damage.

1. 1. Performance Impairment (Work and School): It is not merely a matter of discomfort. Nasal obstruction and poor rest significantly reduce concentration capacity and cognitive performance, impacting professional or academic life—a consequence often underestimated in pediatric patients.

1. 1. Precise Etiological Diagnosis: Treating symptoms alone is insufficient. It is essential to conduct a comprehensive allergological study (including molecular diagnostics if required) to identify the root cause and evaluate the potential for immunotherapy.

1. 1. Therapeutic Safety and Efficacy: The objective is to achieve total symptom control while minimizing side effects, avoiding the chronic use of decongestants or other medications with adverse effects, and, where indicated, prioritizing curative treatments such as allergy vaccines.

Clinical definition of Allergic Rhinitis

Allergic rhinitis is a chronic inflammatory disease of the nasal mucosa mediated by IgE antibodies. It significantly affects quality of life, work and school performance, and nocturnal rest. Unlike a common cold, its symptoms are persistent and triggered by exposure to specific allergens such as pollens (grasses, olive, Arizona cypress), dust mites, animal dander, or fungi.

In my clinical practice, I clearly differentiate between patients who only require symptomatic control and those who would benefit from etiological (curative) treatment via personalized immunotherapy.

Characteristic Symptoms

The clinical presentation usually involves a combination of:

• • Rhinorrhea: constant watery nasal secretion (dripping).

• • Nasal Obstruction: Airflow blockage forcing mouth breathing, especially at night.

• • Paroxysmal Sneezing: Series of repetitive sneezes, typically in the morning or after exposure to the allergen.

• • Naso-Ocular Pruritus: Intense itching in the nose, eyes (allergic conjunctivitis), and palate.

Specialized Treatment: Beyond Antihistamines

The management of rhinitis in private practice must go beyond temporary relief. My approach is based on three pillars:

1. Precise Molecular Diagnosis

Identify not only the source (e.g., pollen) but the specific causative protein through molecular analysis. This is vital for differentiating genuine allergies from irrelevant sensitizations.

Using modern molecular analysis techniques—which may be covered by your insurance or performed privately via an Alex2 test or similar—we can discover not only which pollen, mite, or animal you are allergic to, but exactly which proteins. Knowing the specific protein allows us to predict severity in some cases, but above all, it enables us to determine the specific type of allergy vaccine needed and its likelihood of success.

This is because vaccine manufacturers cannot produce a vaccine containing every type of protein a pollen possesses; they must create extracts focusing only on the major proteins of pollens or mites. Unfortunately, the research and development of these vaccines are very costly (primarily due to regulatory requirements). Consequently, to ensure profitability, laboratories manufacture vaccines designed to cover the majority of the population, rather than treating those sensitized to “rarer” proteins within, for example, the grass pollen family.

2. Allergen Immunotherapy (Vaccines)

It is the only treatment capable of modifying the natural course of the disease. Unlike medications that merely mask symptoms, immunotherapy “re-educates” the immune system to stop reacting to the allergen. It is indicated for patients where avoidance is impossible or pharmacological treatment is insufficient.

3. Tailored Pharmacotherapy

Use of second-generation (non-sedating) antihistamines and topical corticosteroids with low bioavailability to minimize systemic effects, optimizing the minimum effective dose.

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Comprehensive Private Consultation

The allergy consultation lasts between 30 and 50 minutes, allowing for a detailed medical history and a comprehensive approach that is impossible in overcrowded healthcare systems.

• • Fees: €150 (Consultation + Skin Tests if applicable).

• • Payment Method: Payment upon completion of the consultation.

• • Accepted Insurance: Adeslas (Plena/Extra policies with card), Nueva Mutua Sanitaria, and Reimbursement Insurance (an official report and invoice are issued).

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Frequently Asked Questions (FAQ)

Can allergic rhinitis be cured?

Rhinitis does not disappear on its own in adulthood. However, specific immunotherapy (vaccines) offers very high success rates, managing to reduce or eliminate the need for medication and prevent the development of secondary bronchial asthma.

Why don’t I improve with over-the-counter medications?

Many nasal decongestants (oxymetazoline) cause a rebound effect (rhinitis medicamentosa) if used for more than 5 days, worsening obstruction. Furthermore, if the underlying cause is not treated with immunotherapy, the patient enters a chronic cycle of medication.

When should I see an allergist?

If your symptoms last more than 2 weeks, interfere with sleep, or if over-the-counter antihistamines are not sufficient. It is critical to evaluate if there is associated asthma, as 40% of allergic rhinitis cases progress to asthma if not treated correctly.

Additionally, school-aged individuals would also benefit. In many cases, allergic rhinitis affects their academic performance without them being aware of it, since they have had these symptoms for many years and believe it is normal. In other words, it is like a child who cannot read the blackboard, and it takes years to realize they need glasses.

Every patient with accompanying asthma should also be seen by an allergist, as asthma can produce very serious complications with relative frequency.

Those presenting complications such as frequent nose and ear infections, loss of smell, or permanent obstruction should also be evaluated.

Why does allergic rhinitis occur?

The causes leading to allergic rhinitis are truly varied, but they share a common characteristic: it is triggered by proteins capable of remaining airborne for varying periods, such as pollens, fungi, dust mite molecules, and molecules from cats, dogs, and other animals.

In simple terms, at some point in our lives, our body’s defense system begins to recognize these molecules as harmful. Consequently, upon contact, it activates mechanisms to attack them. That is to say, it is a malfunction of our defense system that leads to this disease, in the same way we can become allergic to medications.

Allergy Zones in Spain:

In Spain, the trigger for your rhinitis varies drastically depending on your area of residence. Being allergic on the coast is not the same as in the central plateau:

• • Central Zone (Madrid/Castilla): Notable allergens include Arizona Cypress (Jan-Mar), Plane Tree (Plátano de Sombra), and Grasses (May-Jun).

• • South (Andalusia/Jaén): The Olive tree is the undisputed protagonist, causing very intense allergic reactions in spring.

• • Mediterranean Area: Pellitory (Parietaria) and Mites (favored by humidity) are frequent causes of perennial rhinitis.

• • North: Predominance of Mites and specific tree pollens such as Birch.

Allergy Zones in Europe: Know your environment

Many of my patients are expats or frequent travelers who notice their symptoms change drastically depending on the country. Europe has distinct pollen maps:

• • Northern & Central Europe (UK, Germany, Scandinavia): The dominant allergen in spring is the Birch Tree (Betula), followed by Timothy Grass in summer. If you suffer in London or Berlin in April, Birch is the likely culprit.

• • Mediterranean Basin (Italy, Greece, Southern France): Similar to Spain, the Olive Tree and Cypress are the main protagonists, causing intense symptoms that differ from Northern patterns.

• • Eastern Europe & Balkans: A major specific threat is Ragweed (Ambrosia), an invasive weed that causes severe rhinitis and asthma in late summer and autumn.

Regardless of where you live, identifying the exact geographic and molecular profile is vital to prescribing the correct and specific Immunotherapy (Vaccine) for your environment.

How does allergic rhinitis occur?

When you breathe in the allergen (pollen, mites, dander), it binds to specific antibodies on the surface of a defensive cell called a Mast Cell. Upon activation, this cell acts as a “biological bomb,” releasing inflammatory substances in two distinct phases:

1. 1. Immediate Phase (The Histamine Explosion): Occurs within the first few minutes. The mast cell explosively releases histamine, causing intense itching, bouts of sneezing, and runny nose.

1. 1. Late Phase (Cellular Inflammation): This is the phase often poorly treated. Hours later, the mast cell “calls” other inflammatory cells to the nasal mucosa, thickening it and causing that persistent obstruction or congestion that does not improve with antihistamines alone.

Why this is important for your treatment: Many patients get frustrated because common drugs only block the first phase (histamine). In my practice, the goal is to also treat that inflammatory “Late Phase” and, through vaccines, teach the mast cell to stop reacting.

Allergy Testing: Prick-Test and Molecular Diagnosis

First, remember that not all rhinitis is allergic. Therefore, your allergist must ask the appropriate questions and, if necessary, perform the corresponding tests to ensure that allergy is the cause of your symptoms. Additionally, bear in mind that some patients may have both allergic and non-allergic rhinitis.

This diagnosis is crucial as it determines whether the treatment you need should target the proteins and cell accumulation causing the allergy, or conversely, should be directed at other mechanisms or even require the help of other specialists, such as ENT surgeons. A sign that can give us a clue is that allergic rhinitis itches, whereas non-allergic rhinitis tends not to.

Treatment: Differences between Antihistamines and Vaccines

The treatment of allergic rhinitis must be based on two aspects:

– Avoidance of the protein causing the rhinitis

– Correct use of medications, avoiding adverse effects

Avoidance of the protein causing the rhinitis

A correct diagnosis helps us know if the protein causing your problem is a pollen, animal, fungus, dust mites, or others. Once identified, the simplest approach is avoidance; unfortunately, from a practical standpoint, this is not always possible. For example, we cannot control nature regarding pollens, completely eliminate dust to zero in the case of mites, or entirely avoid contact with animals.

Furthermore, sometimes removing the causative protein may require strict measures in your home, and it is your allergist who can indicate if such measures are necessary. An example of this: for a patient with mild allergic rhinitis due to dust mites, I would not recommend following all strict measures such as frequent vacuuming, removing carpets, sleeping with mite covers, and installing HEPA filters… whereas for a patient with severe rhinitis, the implementation of all these measures would need to be assessed individually.

Correct use of medications, avoiding adverse effects

– Antihistamines: As mentioned above, histamine is produced in the first phase and causes itching, sneezing, and runny nose; therefore, drugs that stop the effect of this protein will be useful for such symptoms but less useful for others. These drugs often have side effects, most notably drowsiness, and your allergist can help you choose the drug that resolves the problem without creating side effects. Additionally, as demonstrated in urticaria, doses can be increased.

– Nasal Sprays with Corticosteroids: Despite containing corticosteroids, they are very safe as they are deposited in the nose and are barely absorbed by the rest of the body. As previously mentioned, there is a late phase where cell accumulation occurs in the nose; nasal sprays with corticosteroids are effective precisely for this cell accumulation.

– Nasal Washes: Saline washes are an inexpensive remedy that helps remove the proteins causing problems from the nose, being useful in patients with mild symptoms or as a complement to other therapies.

– Allergy Vaccines or Immunotherapy: This treatment consists of administering progressive doses of the protein causing your problems. It is an effective treatment if used appropriately. It is indicated in cases that do not respond to pharmacological treatment and avoidance measures, or on an individual basis in other patients.

– Others: There are other drugs whose introduction your allergist should evaluate, including antileukotrienes, nasal antihistamines, ipratropium bromide, or cromolyn, among others. It should be noted that so-called nasal decongestants sold freely in pharmacies can produce very negative effects when treatment is prolonged for more than 5 days, notably causing rhinitis medicamentosa, which produces permanent nasal congestion that is very difficult to treat.

Scientific publications on Allergic Rhinitis:

By the author:

– “Role of nasal challenge and local eosinophilia in indirect exposure to cat in allergic rhinitis patients” :

– “Extensive Cross-reactivity Between Salsola kali and Salsola imbricata”

– “Association of molds and metrological parameters to frequency of severe asthma exacerbation” :

Other resources:

– Pollen levels (Spanish Society of Allergy and Clinical Immunology): https://www.polenes.com/home

– Latin American Society of Allergy, Asthma and Immunology: https://www.slaai.org/

– American Academy of Allergy Asthma and Immunology : https://www.aaaai.org/conditions-and-treatments/allergies