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Allergy or not?

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Is your nose constantly running? Do you suffer from uncontrollable bouts of sneezing? Or do you have a stuffy nose and sinus headache? Before you reach for the allergy medicine, talk with your doctor. You may not be suffering from allergies at all. Millions of people with these symptoms actually suffer from another condition known as non-allergic rhinitis.

Non-allergic Rhinitis, which is essentially a catchall term for a hypersensitive nose, afflicts as many as one-third of Americans, many of whom mistakenly assume they have allergies, says Dr. William Berger, an allergist in Mission Viejo, Calif.

This has Berger and other allergists concerned because as heavily advertised prescription allergy medications increase their reach among Americans, more and more of these non-allergic patients are taking them inappropriately.

Allergies vs. Non-allergic rhinitis

Rhinitis simply refers to the inflammation of the mucous membrane of the nose that causes sinus symptoms including sneezing, runny nose, postnasal drip, headache or stuffiness. This inflammation can be caused by allergic or non-allergic triggers.

Allergic rhinitis, which is often called “hay fever,” is the body’s immune system overreacting when it comes into contact with certain substances such a pollen or mold. When people with allergies inhale these substances, an allergic antibody treats them like dangerous invaders and gloms onto them. This triggers the release of histamines and other chemicals, which cause the trademark allergic response of sneezing, dripping nose, congestion and itchiness.

Non-allergic rhinitis, on the other hand, is caused by a whole host of factors, none of which has to do with with allergens or the immune system. It can be triggered by irritants such as smoke, perfume, pollution and spicy foods or changes in temperature, weather shifts and air pressure variations. In some people, it can follow a cold or result from certain medications, hormonal changes, overuse of over-the-counter decongestant sprays or structural abnormalities of the nasal passage. And in yet others, there’s no known cause.

Doctors don’t fully understand why, but such factors appear to damage the nerve endings and blood vessels in the nose and cause sneezing, dripping and stuffiness, says Berger, a clinical professor of pediatrics at the University of California, Irvine, and author of “Allergies and Asthma for Dummies.”

Dr. Robert Nathan, a spokesperson for the American College of Allergy, Asthma and Immunology, adds that there’s a third group of especially unlucky patients who have a combination of allergies and non-allergic rhinitis — so even after they deal with their allergies, they have a whole other set of unidentified triggers to try to get under control.

Telling the conditions apart

The symptoms of the two conditions are similar but there is a telltale difference: While patients with allergies usually experience some sort of itching of the eyes, ears, nose, throat, skin or roof of mouth, non-allergic rhinitis patients do not.

Also, people generally get allergies at the same time every year. Or for those with year-round allergies, there usually are known triggers such as cats or mold.

But Berger notes that changes in temperature and weather, which are common non-allergic triggers, often occur about the same time when pollen counts are high — early spring or fall — so non-allergic rhinitis can be easily confused with seasonal allergies.

He adds that the only way you know for sure is with allergy skin testing, where tiny amounts of potential allergens are lightly pricked or scratched into the skin to determine if a patient is allergic a substance.

Nathan, also a clinical professor of medicine at the University of Colorado Health Sciences Center in Denver, says he is seeing more and more non-allergic patients, not because the condition is on the rise, but because the patients are not helped by popular prescription non-sedating oral antihistamines such as Zyrtec, Allegra or Claritin.

Patients with runny noses during allergy season are often given these drugs by their primary care doctors, he says, but they don’t offer much relief for patients with non-allergic rhinitis. So these allergy drug “failures” are often the people who are sent to allergists. It’s not until allergists do skin testing and rule out allergies that non-allergic rhinitis is diagnosed.

“Forty percent of patients I see are non-allergic on testing,” Nathan says, but more often than not, patients with sinus symptoms assume they have allergies.

Patient confusion

One such patient, Melinda Fox, a 55-year-old-teacher in Laguna Niguel, Calif., suffered from a constantly running nose for years, thinking it was allergies.

“In the mornings, I would always have to keep running over to grab a Kleenex,” she recalls. “It’s hard to keep stopping in the middle of a lesson with 1st and 2nd graders to blow my nose.”

She used over-the-counter allergy medications to no avail — sometimes they would dry her up a bit but they’d leave her drowsy and her eyes feeling painfully dry. It wasn’t until she went to Berger for help that skin allergy tests revealed that she wasn’t allergic.

“It was a big surprise to me,” she says. “I just assumed I had allergies, no one ever talks about non-allergic reactions.”

Given the choice, Nathan says he’d take a diagnosis of allergies over non-allergic rhinitis any day.

“This is a condition I prefer patients not to have. If they’re allergic they can avoid the triggers or have allergy shots; if it’s an infection I can give them antibiotics; but if it’s non-allergic rhinitis, there’s no cure, just medication for symptom relief for the rest of their lives,” he says.

Treating non-allergic rhinitis

Though it is more difficult to treat than garden variety allergies, there are effective prescription medications for non-allergic rhinitis. Steroid nasal sprays such as Flonase or Rhinocort, which decrease swelling of the nose, are usually the first-line of therapy. And Astelin spray, a topical antihistamine with some anti-inflammatory properties, has been approved for non-allergic rhinitis. Plus, for patients with stuffiness, a decongestant is often added to the regimen.

Doctors say the major problem is that people with non-allergic rhinitis are often on the wrong medication — either their primary care doctor puts them on a prescription oral antihistamine or they self-medicate with over-the-counter drugs like Benadryl.

“Often people are put on Claritin when they have runny nose that may be non-allergic rhinitis or even a common cold,” says Dr. David Stempel, an allergist and researcher at Virginia Mason Medical Center in Seattle. “Doctors just need to go through the symptoms better — an extra 30 seconds to get more of patient history to distinguish between non-allergic rhinitis and allergies.”

Doctors discourage taking over-the-counter antihistamine like Benadryl for an extended period of time because it can cause significant sedation, and anyway, it isn’t likely to bring much relief to non-allergic sufferers.

When left untreated or when treated inappropriately, experts warn, non-allergic rhinitis can lead to other ailments, such as sinus problems, ear ailments and nasal polyps, which can cause constant congestion and difficulty sleeping.