Rhinitis: Global Overview

Rhinitis is a very common disease worldwide.

Global Resources in Allergy (GLORIA) - a worldwide dissemination of best practice guidelines for the treatment of allergic disease and the next WAO initiative to be posted on GAIN - will provide recommendations for the diagnosis and management of rhinitis for health professionals on a worldwide basis.

A survey of allergy experts from around the world demonstrates the similarities and differences in diagnostic and management practices that exist currently.

There are global differences in the prevalence of seasonal compared to perennial rhinitis.

Climatic differences within continents and countries influence the prevalence of seasonal and perennial rhinitis: perennial rhinitis predominates in coastal regions of Australia, whereas seasonal rhinitis commonly occurs inland.

In general, perennial rhinitis predominates in South America, Asia, Africa and Australia. Perennial and seasonal rhinitis occur commonly in the U.S.A. and Japan. Seasonal rhinitis predominates in Europe.

Worldwide, the allergens most commonly associated with allergic rhinitis are:

Worldwide, patients with allergic rhinitis are usually treated by allergists or oto-rhino-laryngologists.

General practitioners/family doctors are the health professionals next most likely to be involved in the management of allergic rhinitis, followed by pediatricians and general physicians.

Pharmacists play an important role in some countries where self-medication with non-prescription treatments is common.

Specialist nurses are rarely involved in the management of this common disease.

The Diagnosis of Allergic Rhinitis Worldwide

Symptoms described by the patient are most important in diagnosis.

Anterior rhinoscopy is routinely performed by oto-rhino-laryngologists and allergists. Fiberoptic rhinoscopy is performed by oto-rhino-laryngologists and some allergists.

Skin prick/puncture testing with allergen vaccines/extracts is the preferred confirmatory text.

Outside Europe, laboratory measurement of specific IgE is usually restricted to specific circumstances when, for example, the skin is badly affected by eczema or the patient is on treatment with antihistamines.

Nasal smears are sometimes used diagnostically.

The Management of Allergic Rhinitis Worldwide

All recommended treatment groups such as decongestants, antihistamines and topical/oral steroids are available in almost every country in the world. In many countries, the types available and the frequency of use are determined by cost.

Oral decongestants are widely used in the U.S.A. and in South America, less frequently in other countries, and rarely in Italy.

Treatment with topical decongestant sprays is universal, though only recommended for 7 days. Where topical decongestants are available for self-medication, overuse can occur, leading to the development of rhinitis medicamentosa.

Anti-allergic drugs such as sodium cromoglycate and nedocromil sodium are used primarily in children, and if the use of topical steroid has led to nasal bleeding.

Treatment with both first (sedating)- and second (less or non-sedating)- generation antihistamines is universal. First-generation antihistamines are most frequently used in self-medication and in less economically developed countries when cost is an important determinant.

Allergists and oto-rhino-larygologists more frequently prescribe second-generation antihistamines than non-specialists.

Treatment with topical steroids is universal as is the use of short courses of oral steroids.

Short courses of oral steroids are used in difficult-to-treat rhinitis and when rapid resolution of symptoms is necessary for social/educational reasons.

Injection allergen immunotherapy is available in almost all countries of the world. In most it is used widely, in some it is recommended only for more severe disease, while in the U.K. and Australia only a minority receive this treatment.

Sub-lingual swallow immunotherapy is rarely used outside Italy and France.

Management Protocols Worldwide

Oral second-generation antihistamines are the treatment of choice for mild seasonal rhinitis without nasal obstruction. In the U.S.A. and Europe, topical antihistamines are also used.

Mild seasonal rhinitis with nasal obstruction or mild perennial rhinitis is often treated with second-generation antihistamines alone (Italy), together with oral decongestants (U.S.A.), topical steroids alone (South Africa), but most commonly with the combination of second-generation antihistamines and topical steroids.

Moderately severe seasonal and perennial rhinitis are usually treated with the combination of second-generation antihistamines and topical steroids. In some countries allergen immunotherapy is also recommended (U.S.A., Japan, South America, Australia and some European countries).

Severe rhinitis is treated in the same way as moderately severe seasonal and perennial rhinitis, except that short courses of oral steroids are sometimes prescribed.

Leukotriene antagonists are, as yet, prescribed infrequently except in Japan.