Spring Allergy (Seasonal Allergic Rhinitis): Symptoms and Treatment

What Is Spring Allergy?

Hello, I am Dr. Emre Gecer. Spring allergy, also known as seasonal allergic rhinitis, is an IgE-mediated type I hypersensitivity reaction that develops in the nasal mucosa to airborne allergens (especially pollen). The immune system mistakenly perceives harmless pollens as a threat and initiates an inflammatory response.

Allergic rhinitis affects approximately 10-30% of the global population, and its prevalence has been increasing in recent years. It significantly reduces quality of life and can cause sleep disturbance, decreased work and school performance, social limitations, and psychological distress.

Pathophysiology: How Does an Allergic Response Develop?

The development of allergic rhinitis takes place in several stages:

1. Sensitization Phase

First exposure: The allergen (pollen) enters the nasal mucosa → it is processed by antigen-presenting cells → T helper 2 (Th2) lymphocytes are activated → B lymphocytes are stimulated to produce allergen-specific IgE antibodies → IgE antibodies bind to the surface of mast cells. There are no symptoms at this stage.

2. Early-Phase Response (Within Minutes)

Second exposure: The allergen binds to IgE on mast cells → mast cell degranulation → release of histamine, leukotrienes, prostaglandins, and tryptase → vasodilation (nasal congestion), mucus secretion (runny nose), stimulation of nerve endings (itching, sneezing).

3. Late-Phase Response (4-8 Hours Later)

Eosinophils, basophils, and Th2 lymphocytes accumulate at the site → chronic inflammation → ongoing nasal congestion, mucosal edema, and hyperreactivity. Therefore allergic rhinitis is not just an immediate reaction but a chronic inflammatory disease.

Seasonal vs Perennial Allergic Rhinitis

Seasonal Allergic Rhinitis (Spring Allergy)

Symptoms appear during certain periods of the year, in seasons when pollen counts are high:

• Spring (March-May): Tree pollens (pine, oak, beech, maple, olive)
• Summer (June-July): Grass pollens (meadow grass, barley, wheat)
• Autumn (August-October): Weed pollens (mugwort, dandelion, Parietaria)

Perennial (Year-Round) Allergic Rhinitis

Continues throughout the year due to indoor allergens such as house dust mites, animal dander (cat, dog), cockroach allergens, and mold spores.

In many patients seasonal and perennial allergic rhinitis can coexist, causing symptoms to persist throughout the year.

Symptoms of Spring Allergy

Nasal Symptoms

• Sneezing fits: In rapid succession, usually more prominent in the morning
• Clear, watery nasal discharge (rhinorrhea): Profuse, clear, water-like
• Nasal congestion: Blockage of variable severity in both nostrils
• Nasal itching: Often accompanied by itching of the palate and throat

Eye Symptoms (Allergic Conjunctivitis)

• Itchy eyes (the most prominent symptom)
• Redness and watering of the eyes
• Eyelid swelling
• Light sensitivity

Physical Examination Findings

• Allergic salute: Upward rubbing of the itchy nose with the palm
• Nasal crease (allergic crease): A horizontal line on the upper part of the nose caused by repeated nose rubbing
• Allergic shiners: Dark circles under the lower eyelids (due to venous congestion)
• Dennie-Morgan lines: Accentuated folds in the lower eyelids
• Nasal mucosa: Pale, bluish-white, edematous (distinct from the red mucosa seen in infectious rhinitis)

Diagnostic Methods

In most cases a detailed history and physical examination are sufficient for diagnosis. However, advanced testing is required to identify specific allergens and to plan immunotherapy.

Skin Prick Test

The most commonly used and most reliable allergy test. Standard allergen solutions are applied to the skin of the forearm and the resulting wheal and flare are evaluated after 15-20 minutes.

• Provides fast results (15-20 minutes)
• High sensitivity and specificity
• Allows multiple allergens to be tested at the same time
• Caution: Antihistamines must be stopped at least 5-7 days before testing

Specific IgE (RAST/ImmunoCAP)

Measurement of allergen-specific IgE antibody levels in a blood test. It is preferred when a skin test cannot be performed (widespread dermatitis, patients who cannot stop antihistamines).

Nasal Smear

Predominance of eosinophils in nasal secretions supports allergic rhinitis; predominance of neutrophils suggests infectious rhinitis.

Treatment Approaches

1. Allergen Avoidance

The first and most fundamental step of treatment. To reduce pollen exposure:

• Limit time spent outdoors on days with high pollen counts (windy, dry, sunny)
• Pollen levels are highest in the early morning (05:00-10:00); keep windows closed during these hours
• When you come home, change your clothes, take a shower, and wash your hair
• When driving, keep the windows closed and use a pollen-filter air conditioning system
• Use a HEPA-filtered air purifier
• Do not dry laundry outdoors
• Perform regular nasal rinsing (saline or a nasal douche) during the pollen season

2. Intranasal Corticosteroids

The first-line treatment for moderate-to-severe allergic rhinitis. They are the most effective drug class.

• Active ingredients: Mometasone furoate, fluticasone propionate, budesonide, triamcinolone
• Mechanism of action: Suppresses inflammation in the nasal mucosa; effectively reduces congestion, discharge, itching, and sneezing
• Use: Once or twice daily; requires regular use; full effect appears within 1-2 weeks
• Safety: Systemic side effects are minimal with topical use. The most common side effects are nasal dryness and epistaxis (nosebleed)
• Proper application technique: Tilt the head slightly forward and direct the spray away from the nasal septum (toward the lateral wall)

3. Oral Antihistamines

Effective for sneezing, itching, and runny nose; however, their effect on nasal congestion is limited.

• Second generation (non-sedating): Cetirizine, loratadine, desloratadine, fexofenadine, bilastine, levocetirizine — low risk of drowsiness, a single daily dose is sufficient
• First generation (sedating): Chlorpheniramine, diphenhydramine — cause drowsiness, not suitable for tasks requiring attention; rarely preferred today

Recommendation: In seasonal allergy, starting treatment before symptoms begin increases its effectiveness.

4. Antileukotriene Medications

Montelukast: As a leukotriene receptor antagonist it is effective for nasal congestion and accompanying asthma symptoms. It is particularly useful when allergic rhinitis and asthma coexist. However, it is not superior to nasal steroids alone and is generally used as an add-on therapy.

5. Decongestants

• Topical (oxymetazoline, xylometazoline): Rapid nasal decongestant effect; however, must not be used for more than 5-7 days — prolonged use causes rebound congestion (rhinitis medicamentosa)
• Oral (pseudoephedrine): Less potent but no rebound risk; contraindicated in hypertension, coronary artery disease, and prostatic hypertrophy

6. Eye Drops

If symptoms of allergic conjunctivitis are prominent:

• Antihistamine eye drops (olopatadine, ketotifen)
• Mast cell stabilizers (cromolyn sodium)
• Artificial tears (to dilute allergens)

7. Immunotherapy (Allergy Shots)

The only treatment that can modify the natural course of allergic rhinitis. It guides the immune system to develop tolerance to the allergen.

Subcutaneous Immunotherapy (SCIT)

• Injection of the allergen in increasing doses (usually 3-5 years)
• Many years of experience in clinical practice
• Administered in a medical setting because of the risk of anaphylaxis

Sublingual Immunotherapy (SLIT)

• Allergen tablets or drops are placed under the tongue
• Convenient for home use
• Lower risk of anaphylaxis compared with SCIT
• Efficacy has been well demonstrated for grass pollen and house dust mite allergy

Indications for immunotherapy: Inadequate response to drug therapy, drug side effects, the patient's preference not to take medication, coexisting allergic asthma.

Complications and Related Conditions

Sinusitis

Nasal mucosal edema caused by allergic rhinitis can obstruct the sinus ostia (openings) and predispose to secondary bacterial sinusitis. Allergic rhinitis is one of the most important risk factors for chronic rhinosinusitis.

Link with Asthma

There is a strong relationship between allergic rhinitis and asthma — the "united airway" concept. 20-40% of patients with allergic rhinitis have asthma; more than 80% of asthma patients have allergic rhinitis. Effective treatment of allergic rhinitis also improves asthma control.

Sleep Disturbance

Nasal congestion causes nighttime awakenings and decreased sleep quality. This leads to daytime sleepiness, difficulty concentrating, and reduced school/work performance.

Otitis Media

Middle ear effusion and otitis media (particularly in children) can develop because of impaired Eustachian tube function.

ARIA Guideline: Severity Classification

According to the ARIA (Allergic Rhinitis and its Impact on Asthma) guideline, the severity of allergic rhinitis is classified by two criteria:

• Intermittent: Symptoms last fewer than 4 days per week OR for less than 4 weeks
• Persistent: Symptoms last more than 4 days per week AND for more than 4 weeks
• Mild: No sleep disturbance, normal daily activities
• Moderate-severe: Sleep is disturbed, daily activities are affected, school/work performance declines

Conclusion

Spring allergy is a condition that seriously affects quality of life but can be successfully managed with accurate diagnosis and treatment. Allergen avoidance is the foundation of treatment; intranasal corticosteroids and second-generation antihistamines form first-line drug therapy. In refractory cases, immunotherapy is the only treatment option that can modify the natural history of the disease. Because allergic rhinitis can lead to complications such as asthma and sinusitis, early and effective treatment is important.

Wishing you healthy days.
Dr. Emre Gecer

References

• Cummings Otolaryngology: Head and Neck Surgery, 7th Edition
• Harrison's Principles of Internal Medicine, 22nd Edition
• Bousquet J, et al. ARIA 2016: Care pathways for allergen immunotherapy. Allergy. 2019
• Wheatley LM, Togias A. Clinical practice: Allergic rhinitis. N Engl J Med. 2015;372(5):456-463