From this pharmacy CPD module you will learn about:
- The different causes of hayfever and why it occurs
- Its common symptoms and when they typically occur
- The impact of hayfever on people’s quality of life
- Treatment and prevention of the symptoms of hayfever
Download a printable PDF of this module – including the five-minute test – here.
Perrigo has paid for this piece and has been involved in its creation and editing
What causes hayfever?
Hayfever, or seasonal allergic rhinitis, is caused by an inflammatory response of the nasal mucosa to allergens such as pollen. Typically, symptoms begin when pollen gets into the nose and throat, but the eyes can be affected as well.(1)
Grass pollen is the most common allergen, generally occurring from May to July. Other allergens include tree pollen, weed pollen, house dust mites, dander from animals – including cats, dogs and horses – and sometimes moulds.(2)
The allergic response is mediated by immunoglobulin E antibodies on the surface of mast cells, resulting in the release of compounds such as histamine, as well as leukotrienes, chemokines and cytokines, which act on nerves and blood vessels to produce the typical symptoms of hayfever.(3)
What are the symptoms?
Typical symptoms of hayfever are:
- itchy eyes
- sneezing; blocked/runny nose
- itchy nose, roof of the mouth or throat
- watering, red or swollen eyes (allergic conjunctivitis)
- headaches, blocked sinuses (the small air-filled cavities behind your cheekbones and forehead), earache.(4)
People with hayfever may also report:
- tiredness or fatigue
- post-nasal drip – the feeling of mucus running down the back of the throat that leads to swallowing or coughing.
The response to an allergen in people with allergic rhinitis occurs in two phases: an immediate reaction and a delayed reaction.
Symptoms such as sneezing will happen within minutes of being exposed to an allergen, as a result of histamine stimulating nerve endings. This is followed by an increase in nasal secretions, caused by vasodilation and glandular secretions in response to the release of histamine and other vasoactive compounds.
In some patients, the severity of symptoms may vary depending on the level of pollen a person is exposed to. For example, on days when the pollen count is high, symptoms may be worse than on days when the level of pollen in the atmosphere is low.
What are the stages of the allergic response?
How common is hayfever?
Hayfever is one of the most common allergic conditions, affecting a staggering 10 million people in England alone. Although you can get hayfever at any age, it affects between 10% and 15% of children and around one in four adults in the UK.(3)
Eighty per cent of people with seasonal allergic rhinitis (hayfever) are diagnosed with the condition before the age of 20. School-aged children and adolescents are more likely to have this form, while adults tend to have persistent or perennial allergic rhinitis,(5) which is often the result of a reaction to allergens in pet hair or house dust mite faeces.(6)
Allergic rhinitis has associations with atopic conditions, such as eczema or asthma. More than three-quarters of children with asthma also suffer from allergic rhinitis.(2) Indeed, allergic rhinitis is a risk factor for asthma, and may be a reason for poor control of asthma for some people.(5)
Patients with asthma who have hayfever may also have the following symptoms:(1)
- a tight feeling in their chest
- shortness of breath
Patients may find that their hayfever symptoms improve as they get older, with half of people reporting that they have some level of improvement after several years. For 10-20% of people, symptoms disappear completely.
However, according to guidelines by the non-governmental organisation Allergic Rhinitis and its Impact on Asthma (ARIA), hayfever is a condition that is likely to persist for a person’s entire life.(7)
Pollen count and hayfever
Pollen count is often seen in the weather forecast, but not everyone understands what the levels mean. The pollen count is the number of grains of pollen in one cubic metre of air. Air samples tend to be taken in buildings a couple of floors high, rather than at ground level.8 The pollen forecast is usually given as:
- low – less than 30 grains
- moderate – 30-49 grains
- high – 50-149 grains
- very high – 150 or more.
Although each patient will vary, hayfever tends to occur when pollen count is more than 50. The forecast may help your patients understand when they need to initiate their preventative treatment and undertake your practical tips.
What impact does hayfever have?
Hayfever can have a detrimental effect on people’s quality of life. For example, around half of people say the condition affects their sleep. This can lead to fatigue the following day, resulting in reduced alertness and concentration, as well as irritability.(9)
An online questionnaire-based study of 1,000 patients with seasonal allergic rhinitis conducted in 2011 found those with moderate or severe seasonal allergic rhinitis were absent from work because of their symptoms an average of 4.1 days a year. Those with mild symptoms were absent for 2.5 days a year.
Being absent from work is not the only work-related issue, as the survey revealed. Productivity at work was also affected. Patients with moderate or severe seasonal allergic rhinitis said their productivity was affected by their symptoms an average of 37.7 days a year and those with mild symptoms said it was affected on 21 days.(10) This study – published in the journal Clinical and Translational Allergy – helps reveal the extent to which hayfever can affect an individual’s life quality.
Act before symptoms progress
When customers are initially exposed to pollen, they may have no symptoms. Early warning signals could include an itchy or runny nose, sneezing or itchy eyes.
It is important to act either before symptoms develop or at the first signs, when symptoms are mild. The longer the exposure, the more severe the symptoms will become. Acting early could help prevent symptoms progressing and impacting on daily activities and quality of life.
What else could it be?
In general, diagnosis of hayfever can be made simply by the patient’s description of their symptoms. However, asking customers a number of questions will help pharmacy staff determine the difference between hayfever and other conditions, such as a cold.
Variation of symptoms through the seasons will help differentiate seasonal allergic rhinitis, where symptoms are typically suffered from the spring through to the autumn, from persistent allergic rhinitis, where symptoms are experienced year-round.
In addition, different seasons indicate different causes:
- tree pollen is common in early spring
- grass pollen is common in late spring and in summer
- dust mites and dander from pets can be bothersome year-round, but symptoms caused by dander might worsen in winter, when houses are more likely to be sealed from the elements
- fungal spores can be from sources in and out of the house and can occur year-round.
You should ensure that you and your staff ask patients about what medication they are taking, because some drugs may cause or aggravate rhinitis: alpha-blockers, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, chlorpromazine, aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Illicit drugs, such as cocaine, can also cause or aggravate rhinitis.
In addition, check for rebound nasal congestion. This occurs when a person stops taking a nasal decongestant, such as xylometazoline or ephedrine, which they have been using regularly for a long period of time (recommended use is no longer than a week).(6) However, there are those who question whether the phenomenon of rebound congestion is supported by the literature.(15)
Hayfever or cold?
Below are questions you can ask to help you and your customer tell the difference.(13,14)
|Do you have a runny nose? If so, what does the discharge look like?||Clear and watery discharge||Varies, but can be coloured (eg green or yellow)|
|Do you have itchy eyes, ears, nose or mouth?||Yes||No|
|Are you sneezing?||Sudden bouts that may be related to exposure to pollen||Occasionally|
|Do you have a temperature?||No||Yes|
|Do you have otherwise unexplained aches and pains?||No||Yes|
|How quickly did it develop?||Quickly||Gradually|
|How long does it last?||Persistent, over several weeks||Typically, between three to seven days and rarely more than a couple of weeks|
Treatment and prevention
There is a wide range of over-the-counter and prescription medicines available for managing hayfever symptoms. The following table helps break down the different types of therapy you would consider for preventing or treating hayfever in your patients.(8)
- These act to prevent the allergen (pollen) from entering the nasal passages and triggering a response.
- Options include petroleum jelly rubbed inside the nostrils and nasal sprays that coat the nasal lining.
- This class of medicine acts to block the action of histamine, which is released in response to allergen (eg pollen) exposure.
- They can be used as a treatment, in response to symptoms, or as a preventative – when a patient knows they will develop symptoms, such as on a day with an expected high pollen count.
- They are available in oral form (tablets and liquid) and although all may cause drowsiness, this is more likely to occur with first-generation antihistamines (chlorphenamine) compared with second-generation antihistamines (cetirizine and loratadine).
- Are available as drops or sprays.
- Reduce the inflammation and prevent symptoms of hayfever.
- Can cause nasal irritation.
- Are most effective if the patient starts using them a couple of weeks prior to allergen exposure.
- Are used to treat ocular symptoms including redness, itchiness and watering.
- Contain the mast cell stabiliser sodium cromoglicate.
Practical tips and hints
When in the house patients should:
- change out of outdoor clothing and
- shower or wash their hair following high pollen exposure
- close windows at night
- vacuum regularly, preferably with a high-efficiency particle arresting (HEPA) filter in place
- avoid keeping flowers in the house
- avoid drying washing outdoors when
- the pollen count is high or when cutting the grass, as this can bring pollen into the house.
When out and about patients should:
- avoid walking in grassy, open spaces, particularly during the early morning and early evening
- keep an eye on the weather forecast for information about pollen count levels and stay indoors when the pollen count is high (over 50 grains per cubic metre of air)
- install pollen filters in the car if they are not fitted already
- drive with windows closed
- consider wearing wraparound sunglasses to stop pollen getting in the eyes when outdoors.
Product information: Beconase Hayfever/Beconase Allergy (P) contains beclometasone dipropionate. For the prevention and treatment of allergic rhinitis, including hayfever, in adults over 18 years. Adults aged 18 and over: 2 sprays into each nostril morning and evening (400 micrograms/day). Not recommended for use in children and adolescents under 18 years. Contraindications: Known hypersensitivity to ingredients Caution: Recent nasal injury or surgery, pregnancy/lactation. Side effects: Rare cases of hypersensitivity reactions, dryness/irritation of the nose and throat, raised intra-ocular pressure, nasal septal perforation. PL number: PL 02855/0064. MAH: Omega Pharma Ltd, 32 Vauxhall Bridge Rd, London SW1V 2SA. RRP (ex VAT): £10.99 SPC: https://www.medicines.org.uk/emc/medicine/14212. Becodefence is a medical device. Always read the leaflet.
Product information: Beconase Hayfever Relief for Adults 0.05% Nasal Spray (GSL) contains beclometasone dipropionate. For the treatment of seasonal allergic rhinitis (hayfever) in adults over 18 years. Adults aged 18 and over: 2 sprays into each nostril morning and evening (400 micrograms/day). Not recommended for use in children and adolescents under 18 years. Contraindications: Known hypersensitivity to ingredients. Caution: Concomitant use of other corticosteroid treatments, recent nasal injury or surgery, pregnancy/lactation. Side effects: Rare cases of hypersensitivity reactions, dryness/irritation of the nose and throat, raised intra-ocular pressure, nasal septal perforation. PL number: PL 02855/0065. MAH: Omega Pharma Ltd, 32 Vauxhall Bridge Rd, London SW1V 2SA. RRP (ex. VAT): £7.99. SPC: https://www.medicines.org.uk/emc/medicine/13757
- NHS. Hay fever. (accessed 16 January 2019).
- Scadding GK. Optimal management of allergic rhinitis. Arch Dis Child 2015;100:576–82.
- Scadding GK, Kariyawasam HH, Scadding G, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy 2017;47:856–89.
- Allergy UK (accessed 16 January 2019).
- patient.info. Allergic rhinitis. (accessed 16 January 2019).
- National Institute for Health and Care Excellence Clinical Knowledge Summaries. Allergic rhinitis. (accessed 16 January 2019).
- Brozek J, Bousquet J, Baena-Cagnani C, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010;126(3):466–76.
- NHS inform. Hay fever. (accessed 16 January 2019).
- Lipworth B, Newton J, Ram B, et al. An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK: a consensus statement from an expert panel. NPJ Prim Care Respir Med 2017;27:3.
- Price D, Scadding G, Ryan D, et al. The hidden burden of adult allergic rhinitis: UK healthcare resource utilisation survey. Clin Transl Allergy 2015;5:39.
- Walker S, Khan-Wasti S, Fletcher M, et al. Seasonal allergic rhinitis is associated with a detrimental eﬀect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol 2007;120(2):381-7.
- Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol 1997;99:S742-9.
- Is it allergies or a cold? How to tell the difference. healthychildren.org (accessed 19 January 2019).
- Rutter P. Community pharmacy – symptoms diagnosis and treatment. Fourth edition. London: Elsevier, 2017.
- Mortuaire G, de Gabory L, François M, et al. Rebound congestion and rhinitis medicamentosa: nasal decongestants in clinical practice. Critical review of the literature by a medical panel. Eur Ann Otorhinolaryngol Head Neck Dis 2013;130(3):137–44.