Western Medicine

Allergic rhinitis is a condition which presents as frequent attacks of sneezing, nasal discharge or blockage of the nasal passages. It may be seasonal (a limited period of the year) or perennial (throughout the whole year).

Seasonal rhinitis is often called "hay fever" and is the most common of all allergic diseases. From 2 to 20 per cent of the population worldwide are thought to be affected by it. Prevalence is maximum in the teenage years; when up to 30 per cent of young people suffer symptoms in the summer months.

Chinese Medicine

Allergic rhinitis or hay fever is a disorder characterized by acute attacks of nasal itching, congestion, watery nasal discharge, and sneezing. The episodes occur frequently with short intervals, or remission periods, between attacks. Attacks commonly occur in the morning and at night. Affected individuals are completely normal between episodes. The disorder is due to a hypersensitivity reaction to certain substances that affect the mucous membranes of the nose and associated glands. The disease presents in both seasonal and perennial forms.

In the traditional Chinese medicine (TCM) classic Huang Di Nei Ning (The Yellow Emperor's Medicine Classic), a similarly described disease is referred to as "bi-qiu", or "qiu-ti". "Bi-qiu" means profuse watery nasal discharge; "qiu-ti" means sneezing and profuse watery nasal discharge.

From the TCM viewpoint, the nose has both respiratory and olfactory (smell) functions. It works closely with the lungs, kidneys, spleen, and meridians. The lungs open into the nose and nasal function is mainly dependent on the action of the lung energy, qi. The free movement of the lung qi keeps the nasal passages clear and maintains an accurate sense of smell. The governing meridian (Du Mai), a channel system of the midline controlled by the kidneys, passes through the nose. The kidneys thus communicate with the nose. The spleen is the primary organ of digestion and its main function is to transform food into essence (jing) . This is then transported to the lungs and heart where it is used to create qi and blood. Normal spleen function therefore facilitates proper functioning of the lungs; when the spleen is impaired, phlegm-related disorders may develop.

Click here to see the relationship of the nose with organs from TCM perspective

Western Medicine

Allergic rhinitis is due to a hypersensitivity reaction in the nasal mucous membranes of sensitive individuals to certain antigens.

1. Seasonal Allergic Rhinitis
   The antigens which cause the seasonal form of allergic rhinitis are pollens from grasses, flowers, wild plants or trees. Grass pollen is the most common of these seasonal allergens and give rise to the term hay fever.
2. Perennial Allergic Rhinitis
   In perennial allergic rhinitis, the reaction may be caused by specific antigens derived from house dust, fungal spores or animal dander (scurf). However, physical or chemical irritants, such as pungent odors or fumes, including strong perfumes, cold air and dry atmospheres can cause similar symptoms.

Chinese Medicine

Qi deficiency (internal factors)

A deficiency inherited at birth, chronic illness, over-exertion, improper diet, or emotional disturbances can damage the organs. Under-functioning of organs and an irregular flow of blood and qi make the body susceptible to illness. In allergic rhinitis, the lungs, spleen, and kidneys are the main organs which are involved.

1. Deficiency of lung qi The lungs and nose belong to same system: the lungs control the nose and the nose is the surface orifice of the lungs. Improper function of the lungs will affect the nose. The process also impairs the protective qi and enables the exogenous evils to invade the nose more easily. The result will be frequent episodes of nasal problems, such as obstruction, watery discharge, and sneezing.
2. Dysfunction of stomach and spleen When this occurs a decline in the formation of qi and blood results and the nose will lose its supply of nutrients. This causes a disorder of the nasal mucosa (mucous membranes) and nasal obstruction, watery discharge, and sneezing result. The sense of smell is also affected.
3. Deficiency of kidney qi When the kidneys fail to assist the lungs in using qi sent down to them from the lung and to regulate the fluid balance in the body, the circulation of qi and water become affected. Impairment of kidney function will result in inadequate kidney essence (jing) to maintain the functions of the nose. Symptoms will be seen such as a pale, swollen nasal mucosa, frequent episodes of nasal itching, sneezing, and watery discharge.

Invasion of exogenous evils (external factors)

Located in the center of the face, the nose from a TCM viewpoint is sited in the most yang part of the body. Exogenous yang evils, such as wind evil, can attack it easily. This invasion is usually accompanied by other evils such as the coldness, heat, or dampness evil. As the nose is the external opening of the lungs and helps the lungs to control the protective qi, when exogenous evils attack the qi, nasal disorders commonly occur.
Furthermore, when the body constitution is weak, such as when there is a deficiency of lung qi, or the protective qi is not strong enough, exogenous evils can attack the nose simultaneously and nasal disorders result. TCM considers acute or recent attacks of rhinitis or hay fever to be mainly the result of external factors, whereas chronic or frequent relapses are mainly due to internal factors.

Click here to see the causes of allergic rhinitis from TCM perspective

Western Medicine

Seasonal allergic rhinitis

The seasonal type of allergic rhinitis is characterized by the following:

• There are frequent sudden attacks of sneezing, with profuse watery nasal discharge and nasal obstruction.
• The attacks last for a few hours and are often accompanied by smarting and watering of the eyes and conjunctivitis
• In some patients, conjunctivitis may occur in the absence of nasal symptoms.
• The condition does not cause fever.
• Swelling of the nasal membranes may lead to headache because of obstruction of the sinuses that normally empty any discharge into the nasal cavity.

Seasonal rhinitis is mild in many persons who do not seek medical care, but it can be an exhausting illness for some because of continual sneezing, constant runny nose, and unremitting itching.

In the perennial variety the symptoms are similar but more continuous and generally less severe. Not surprisingly, persons with multiple clinical sensitivities often experience perennial rhinitis as well as one or more predictable seasonal flares.

Perennial allergic rhinitis

Perennial allergic rhinitis rarely is a source of dramatic symptoms. However, a persistent partially blocked nose can promote distressing complications, such as breathing through the mouth with resultant snoring and dry throat. Dark circles and puffiness often develop under the eyes. The swollen mucous membranes readily sustain bacterial infection, and obstruction of the nasal sinus openings is common; these lead to recurrent or chronic sinusitis. Drainage from sites of nasal infection promotes sore throat and can lead to bronchitis. In addition, especially in children, the Eustachian tubes, which open into the throat, are readily blocked by swollen mucous membranes, enlarged lymphoid tissue (eg, adenoids), or fluid. Without normal access to air, the middle ears develop negative pressure and fill with fluid, creating a chronic serious inflammation with at least temporary deafness and, often, recurrent middle ear infection.

Although allergic rhinitis sufferers tend to develop bronchial asthma with above-normal frequency, the extent of this increased risk remains unclear. In general, the risk of subsequent asthma appears to rise with increasing severity of rhinitis, with prominent chronic sinusitis and bronchial infection, and when asthma attacks have been experienced in the past.

Chinese Medicine

Chinese practitioners will collect the information they need to make a diagnosis through the process of consultation, assessing systemic symptoms, and then determining the disharmony pattern that fits the individual. The following are the usual types of disharmony patterns for allergic rhinitis:

1. Deficiency of lung qi, invasion by wind and coldness evilsIndividuals present with nasal itching, sneezing, congestion, and a watery discharge. Symptoms are usually triggered by being exposed to wind or a cold temperature in the morning. Systemic symptoms include pallor, shortness of breath, ease of sweating on exertion, and aversion to cold.
2. Lung and spleen deficiency, dampness accumulation in the noseIndividuals usually present with symptoms such as sneezing with watery discharge and moderately severe nasal obstruction. These can be accompanied by heaviness in the forehead or a pounding pain between the eyebrows. Other symptoms include a loss of sense of smell, fatigue, shortness of breath, aversion to cold, a heavy sensation in the limbs, abdominal fullness, a poor appetite, and diarrhea.
3. Depletion in kidney yang, lungs lose promoting and warmth support from the kidneysIndividuals suffer from nasal obstruction, sneezing with watery discharge, severe aversion to cold, and coldness in the limbs. The symptoms are usually triggered by a cold temperature. Other symptoms include dizziness, ringing in the ears, frequent nocturnal urination, impotence and premature ejaculation, and a hot sensation in the palms and soles of the feet.
4. Spleen deficiency, stagnation of phlegm evilIndividuals present with a more severe nasal obstruction, copious watery discharge, and discomfort from nasal itching. They may also experience heaviness in the head, weakness of the limbs, fullness and discomfort in the chest and gastric regions. They may produce copious white sticky sputum, and have a poor appetite, and diarrhea.
5. Invasion of wind and heat evils in the lungsTypical presentations of this type of disharmony pattern include frequent episodes of sneezing, nasal itching, and complete obstruction of the nasal orifices by a heavy discharge. When stimulated by foreign evils or heat evil, a copious watery discharge will develop. Periodic relapse and remission will occur. There will be general symptoms like fever, aversion to cold, headache, and sweating.

Western Medicine

The diagnosis of allergic rhinitis is established by the history and physical findings present during the symptomatic phase. Although the sneezing attacks, nasal discharge or blockage are characteristic, they are not unique to this disorder, and the symptoms of perennial rhinitis are similar to those of other conditions. The distinctive feature of allergic rhinitis is that compatible symptoms appear or worsen predictably in response to specific allergen exposures. (That is, a person develops a runny nose or sneezing whenever he/she is exposed to pollen etc.) Therefore, in diagnosis, careful analysis of factors precipitating rhinitis is of overriding importance.

Many persons with nonallergic "vasomotor" rhinitis have similar nasal stuffiness and marked nasal discharge. This group does not respond to identifiable allergens. Instead, their complaints relate largely to airborne irritants, extremes of temperature and humidity, pregnancy, stages of the menstrual cycle, and emotional factors. Here, stimulation of vasomotor control causes a change in the diameter of the blood vessels supplying the nose.

Clinical history

A clinical history of symptoms on exposure provides the clearest indication of causative agents in respiratory allergy.

• Variations in symptoms during and after travel can be very significant.
• The effects of overt exposure to house dust mites, animals and fur products, feathers, seed derivatives, silk, and so forth should be noted and recorded.
• When such casual observations are insufficient, history may be "created" by markedly increasing and/or reducing specific exposures, such as foods or house pets, for brief periods to observe the results.
• In addition, the time or place of symptom occurrence may furnish clues as to a cause that is not immediately evident. Specific pollen sensitivities may be deduced if the resulting symptoms can be dated precisely and "season" of prevalence for local airborne pollens are known. Similarly, recognition of the heavy fungus exposures associated with leaf collection, lawn care, and gardening as well as with hiking in tall vegetation helps to explain associated symptoms.

Skin testing

Skin tests eliciting a wheal-and-flare reaction can be useful and are widely performed. To test immediate reactivity to an allergen, a "prick test" is performed by pricking the skin through applied drops of a water-extract of a particular allergen. Small quantities of extracts can also be injected through the skin using a needle, but as this procedure may be hazardous in exquisitely sensitive persons, prick tests are usually done first. Only persons with negative reactions to the prick test are considered for the injection test. Few additional test procedures help evaluate respiratory allergy. Initial hopes that a blood test might help diagnosis have not been sustained.

Chinese Medicine

Based on the four examination technique, TCM practitioners make a diagnosis according to clinical symptoms and further characterize the disorder by the disharmony patterns displayed by each individual. At various stages of disease, different disharmony patterns are present and individuals with the same disease will be treated differently depending on the type of disharmony pattern they have.

In allergic rhinitis, the procedures used in TCM to differentiate between disharmony patterns can be explained as follows:

1. Deficiency of lung qi, invasion by wind and coldness evilsDue to a constitutional weakness, the individual is susceptible to influenza or other illnesses. In terms of TCM, this usually means that the individual does not have strong protective qi and this enables the wind evil and coldness evils to invade the nose easily. On examination, the nasal mucosa is pale and swollen, with a slight watery discharge. The tongue is pale and covered by white fur. The pulse is weak and feeble.
2. Lung and spleen deficiency, dampness accumulation in the noseWhen the lungs and spleen are deficient or under-functioning, an imbalance of body-fluid metabolism and dampness evil ccumulation results. Dampness evils flow through the meridians and accumulate in the nose to produce a swollen, pale nasal mucosa and excessive secretions. On examination, the nasal mucosa is clearly swollen and polyps (small growths) or similar changes may be seen. The tongue appears bulky, pink and furrowed, and is covered by white greasy fur. The pulse is weak and hesitant.
3. Depletion in kidney yang, lungs lose promoting and warmth support from the kidneysIn TCM, the kidney yang is considered to be the fundamental source of promotion and provision of warmth to the body. Depletion of kidney yang usually occurs after long-term or severe damage of organs. It leads to under-functioning of the organs, interrupted flow of qi and blood, and also affects the functioning of the lung and the nose. On examination, the tongue is pink and covered with moist white fur. The pulse is weak and thready.
4. Spleen deficiency, stagnation of phlegm evilTCM practitioners believe that the spleen and stomach are very vulnerable to an improper diet, invasion by exogenous evils, or the effects of other organ deficiencies. A deficiency or under-functioning of the spleen leads to a decline in qi and blood or acquired essence (jing) production. The consequence of this is that the body is malnourished and phlegm evil will accumulate. The effect on the nose is to cause it to lose its supply of nutrients and for the nasal mucosa to develop related syndromes. On examination, the tongue is pale and covered by white greasy fur. The pulse is slippery.
5. Invasion of wind and heat evils in the lungsWhen exogenous evils, like wind and heat, attack the protective qi, a nasal disorder usually presents as part of the lung-wei syndrome. On examination, the nasal mucosa is swollen, there is congestion, and some watery discharge, or the discharge may be slightly sticky and thick. The tongue is red and covered with thin fur that may be yellow. The pulse is floating and rapid.

Western Medicine

Treatment consists of environmental measures to avoid allergen exposure, drugs, and desensitization. For any disease with an inherent or hereditary component, prevention by avoidance of allergens is usually the most effective means of treatment. Avoidance is not always possible or practical, however, and so medications are needed to control symptoms. In some cases, the immune response itself can be altered by desensitization therapy.

Environmental measures

Avoidance of an allergen is recommended on the basis of a clinical history of symptomatic allergy and not because of a positive skin test alone. Appropriate measures in individual cases may include:

• the removal of household pets
• control of house dust exposure by frequent cleaning and avoidance of dust-collecting toys or other objects in patient's bedroom
• use of air-cleaning devices with high-efficiency particle filters
• dehumidification and repair of leaking pipes to prevent mold growth, and
• avoidance of pollen and outdoor molds.

Avoidance of pollen or molds is impossible unless the patient is able to stay in an air-conditioned home or office. Contact may be diminished by:

• wearing sunglasses
• driving with the car windows shut
• avoiding walks in the countryside (particularly in the late afternoon when the number of pollen grains is highest at ground level), and
• keeping the bedroom window shut at night.

These measures are rarely sufficient in themselves to control symptoms and additional drug therapy may be required. Exposure to pollen is generally lower at the seaside, where sea breezes keep pollen grains inland. In some cases, the patient might arrange a holiday trip to a pollen-free area during the peak pollen season.

In the cases of occupational allergy, every effort should be made to modify the patient's work routine and to employ industrial hygiene measures to avoid allergen exposure; however, if these measures fail, a change in the patient's job may be necessary.

Drug Treatment

1. AntihistaminesAntihistamines remain the most common therapy for rhinitis. They are particularly effective against sneezing, but are less effective against nasal discharge and have little influence on nasal blockage. The earlier antihistamines (eg, chlorpheniramine and promethazine) cause sedation. More recent drugs such as astemizole, cetirizine, loratidine, and terfenadine specifically target histamine receptors; they do not cross the blood-brain barrier and therefore do not cause drowsiness. The drugs in this group are more or less equally effective, but choice may be dictated by various cautions and interactions with medications being taken for other conditions. Advice over this should be sought.
2. DecongestantsDecongestant drugs are widely used for the treatment of nasal obstruction. They may be taken orally, or more commonly applied directly as nasal drops or sprays. If used for prolonged periods, rebound congestion can occur as tissues become resistant to the effects of the medication. This can often result in worse congestion than before. Local decongestants may be the only effective treatment for vasomotor rhinitis , but they should be used carefully to avoid rebound nasal obstruction. Usually, such preparations are prescribed for only a limited period to open the nasal airways for administration of other therapy, particularly topical corticosteroids.
3. Anti-inflammatory drugsTwo types of anti-inflammatory drug are used in the treatment of allergic rhinitis:
   • Sodium cromoglycate and nedocromil sodium. These drugs are thought to act by blocking inflammatory mediators. They are applied topically in spray or powder form and are used in the prevention and treatment of mild to moderate allergic rhinitis. They are safe for use in children and are very effective in the management of allergic conjunctivitis.
   • Corticosteroids. The most effective treatment for rhinitis is the use of small doses of topically administered corticosteroid preparations (eg, beclomethasone or fluticasone spray). The amount used is insufficient to cause systemic effects and the effect is primarily anti-inflammatory. Use of these preparations should be started prior to the beginning of seasonal symptoms. The combination of a topical corticosteroid with a non-sedative antihistamine taken regularly is particularly effective in preventing symptoms. Use of nasal corticosteroid sprays is generally safe, though minor burning and nosebleed can occur. Prolonged use should always be subject to periodic monitoring. Corticosteroid eye drops should be used very sparingly for brief periods only to control acute severe allergic conjunctivitis, with careful monitoring by an ophthalmologist.
4. DesensitizationAllergen injection therapy has been shown in many clinical trials to be effective in treating allergic rhinitis. However, because of the length of treatment required and the potential danger of serious reactions, injection treatment is only used in patients whose symptoms are uncontrolled despite appropriate environmental measures and symptomatic medication.

Chinese Medicine

Internal Therapy

Therapeutic aim:To warm up the lungs and aid the protective qi, eliminate wind evil and ventilate the nasal passages.

Prescription:

Therapeutic aim: To invigorate the spleen and replenish qi, clear updampness evil and ventilate the nasal passages.

Prescription:

Therapeutic aim: To warm up the kidneys and invigorate yang, benefit the lungs and stop discharge.

Prescription:

Therapeutic aim: To reinforce the spleen, clear up dampness evil and ventilate the nasal passages.

Prescription:

Therapeutic aim: To expel the heat and phlegm evils, ventilate the nasal passages and stop discharge.

Prescription:

External Therapy

Acupuncture

The use of acupuncture at the distal and proximal points, or along the meridians, helps to regulate the meridians and qi movement, facilitate the flow of lung qi and ventilate the nose.

Major acupuncture points: ying-xiang, shang-xing, he-liao, feng-chi and feng-fu..
Minor acupuncture points: bai-hui, yang-bai, cuan-zhu, pi-shu, shen-shu and zu-san-li.

Massage

Massage of the lumbar and sacral regions of the spine, especially massage of the acupuncture points ying-heung, shen-shu and ming-men, help to strength the yin and yang of the body and are commonly applied in nasal diseases.

Western Medicine

In the seasonal type of allergic rhinitis, an attempt should be made to reduce exposure to pollen. This can be accomplished, for example, by avoiding country districts and keeping indoors as much as possible with windows closed during the pollen season, especially when pollen count is high. The prevention of perennial rhinitis consists of avoiding, as far as possible, exposure to any identifiable causative factors.

If you are allergic, try to avoid common human allergens such as

dust mite	sea food
cat dander	pollen

Chinese Medicine

Living environment

• Attention should be paid to climatic changes. In the winter and autumn especially, it is important to avoid staying in environments with extreme temperature changes. Suitable clothes should be worn to prevent the invasion of exogenous evils.
• Exposure to stimulants should be avoided. These include irritant substances such as odor or dust. The living environment (home) should be cleaned regularly. Dry, sunny places should be chosen to live in whenever possible.
   Clean and warm environment
• Moderate and regular exercise will help strengthen the body's resistance.

Dietary management

From a TCM perspective, foods and drugs come from the same source, so foods can have similar properties and functions to those of drugs. Foods and drugs are classified into four characteristics and five tastes. The four characteristics refer to the healing nature of Chinese herbs. These properties are cold, hot, warm and cool. The five tastes are acrid, sweet, sour, bitter and salty.

• During attacks of allergic rhinitis certain foods should be eaten more frequently. These include foods that are acrid tasting, foods that promote warmth and sweating, and foods that facilitate the lung's dissemination functions. These foods help to eliminate the exogenous evils. Such foods include spring onions, ginger, or cilantro (fresh coriander).
  Spring onions and ginger help to eliminate the exogenous evils
• In general, excessive consumption of cold, greasy, and spicy foods should be avoided. Known sea-food or other foods that trigger the disorder should likewise not be eaten.
  Avoid known foods that trigger the disorder such as shrimp
• Foods which will tonify, eg, Chinese date, walnut, Chinese yam, dried mushrooms and mutton should be eaten. These foods help to invigorate the qi, cure deficiency, tonify the spleen, build up the body's resistance.
  Dried mushroom and walnut help to invigorate qi and built up resistance

Western Medicine

1. Chapel HM, Haeney MR, Misbath A, et al. Essentials of Clinical Immunology, 4th ed. Oxford: Blackwell Science, 1999: 224-5.
2. Crompton GK, Haslett C. Diseases of the respiratory system. In: Edwards CRW, Boucher IAD, Haslett C, et al, eds. Davidson's Principles and Practice of Medicine, 17th ed. Edinburgh: Churchill Livingstone, 1995:393.
3. Rusznak C, Davies RJ. ABC of allergies. British Medical Journal 1998;316:686-9.

Written By:
Dr Lily Holman MB MSc PhD, Senior Lecturer, Middlesex University, London, UK.

Translations:
Rose Tse, Integrated Chinese Medicine Holdings Ltd.

Editors:
Angela Collingwood, MSN Integrated Chinese Medicine Holdings Ltd.
Carol Dyer, BPharm, MRPharms, Integrated Chinese Medicine Holdings Ltd.
Rose Tse, Integrated Chinese Medicine Holdings Ltd.

Chinese Medicine

1. 陳國豐主編, 幹氏耳鼻咽喉口腔科學, 江蘇科技出版社 1999:183. Chen Guo-feng, ed. Gan's E.N.T. Stomatology. Jiang Su Science and Technology Publishing Co Ltd, 1999:183.
2. 王敏玉, 疏風活血沖劑治療過敏性鼻炎315例, 浙江中醫雜誌 1992;27(7):310.
3. Wang min-yu. 315 allergic rhinitis clinical cases treated by infusion for evacuating wind evils and promoting blood circulation. Zhejiang Chinese Medicine Journal 1992;27(7):310.
4. 吳成山, 過敏性鼻炎以痰飲論治初探, 陝西中醫 1996;17(12):544-5.
   Wu Cheng-shan. Exploring allergic rhinitis in treating phlegm and dampness evils. Shan Xi Chinese Medicine 1996;17(12):544-5.
5. 張恩勤等, 中醫臨床各科, 上海中醫學院出版社 1990:7.
   Zhang En-qin. Clinic of Traditional Chinese Medicine. Publishing House of Shanghai College of TCM, 1990:7.

Written By:
Dang Yi (黨毅) MD PhD, Professor, Beijing University of Chinese Medicine; Visiting Professor, Middlesex University, London, UK; Vice Director, Gourmet Food Institute of Health Care and Nutrition of Beijing, PRC.