An immune response to something harmless.
Allergic rhinitis is an IgE-mediated inflammatory response of the nasal mucosa to environmental allergens — pollen, dust mite, pet dander, mold, cockroach. The immune system identifies a harmless protein as a threat and mounts a sustained response: histamine release, mucosal swelling, mucus production, and ongoing inflammation. The body is doing what it's supposed to do, against something it shouldn't be doing it to.
Allergic rhinitis affects roughly twenty to thirty percent of adults in the United States and an even higher percentage of children. It's the most common chronic disease of the upper airway, and it sits at the front of a connected disease spectrum: untreated allergic rhinitis is a risk factor for asthma, for chronic sinusitis, and for sleep-disordered breathing. Treating it well doesn't just reduce sneezing — it slows progression to harder problems downstream.
Categorically:
- Seasonal allergic rhinitis ("hay fever") — triggered by outdoor pollens that vary by region and season. In the New York area: tree pollens in spring, grass pollens in early summer, ragweed and weed pollens in late summer through fall.
- Perennial allergic rhinitis — year-round symptoms triggered by indoor allergens (dust mites, pet dander, mold, cockroach). Symptoms often worsen at night because dust mite exposure is highest in bedding.
- Episodic allergic rhinitis — symptoms triggered by intermittent contact (e.g., visiting a friend's house with a cat).
Many patients have a combination — perennial baseline punctuated by seasonal exacerbations.
Beyond sneezing. Beyond a stuffy nose.
The classic symptoms of allergic rhinitis are sneezing, clear watery nasal discharge, itching of the nose and eyes, and nasal congestion. Less obvious presentations are common and frequently missed:
- Postnasal drip and chronic throat clearing — sometimes mistaken for laryngeal or gastroesophageal issues
- Allergic conjunctivitis — itchy, watery, red eyes, especially during outdoor exposure
- Allergic shiners — dark circles under the eyes from chronic venous congestion
- Mouth breathing and snoring — particularly in children, where chronic allergies can affect facial development
- Reduced exercise tolerance — from impaired nasal airflow
- Headaches — often misattributed to sinus disease when the cause is allergic mucosal swelling
- Reduced sense of smell — when inflammation involves the olfactory cleft
The hallmark feature that distinguishes allergic rhinitis from other forms of chronic rhinitis is itch — nasal, palatal, or ocular. Itching is the symptom most specifically associated with histamine release, and its presence (or absence) helps differentiate allergic from non-allergic chronic rhinitis.
Identify the specific triggers.
Empirically treating allergic rhinitis without knowing what someone is actually allergic to is the most common cause of partial response. The treatment ladder works much better when you know which rung to start on and what triggers to address.
History
Timing of symptoms (year-round vs. seasonal vs. exposure-triggered), environmental clues (worse at night, worse outside, worse around pets), prior treatments and response, comorbid conditions (asthma, eczema, food allergies, anaphylaxis), and family history. Most diagnoses are made from the conversation, with testing used to confirm and quantify.
Skin prick testing
The most common allergy test. Small amounts of allergen extract are placed on the skin (forearm or back) and lightly pricked through. Reactions are read at fifteen minutes. The test covers a standardized panel of regional pollens, dust mites, pets, molds, and cockroach. Skin testing requires holding antihistamines for several days before the test, so it's scheduled in advance.
Specific IgE blood testing
Measures antibody levels against individual allergens from a single blood draw. Used when skin testing isn't appropriate — severe eczema covering the test area, history of anaphylaxis, or inability to hold antihistamines. The results are comparable to skin testing in most cases.
Nasal endoscopy
Performed at the same visit to identify structural contributors (deviated septum, turbinate hypertrophy), to rule out polyps or other inflammatory disease, and to assess whether allergies have progressed into chronic sinus disease that needs separate management.
The full set of options.
Step 1 — Allergen avoidance
The first lever is reducing exposure to the specific allergens identified on testing. For dust mite-allergic patients: encasings on mattresses and pillows, hot-water washing of bedding weekly, reduced carpeting in bedrooms. For pollen-allergic patients: closing windows during peak pollen times, showering after outdoor exposure, sunglasses outdoors. For pet-allergic patients: keeping pets out of the bedroom (the realistic version of avoidance for most pet owners). Environmental controls rarely eliminate symptoms but consistently reduce the medication needed.
Step 2 — Saline irrigation
Daily high-volume saline irrigation physically clears allergens and inflammatory mediators from the nasal mucosa. It's safe, low-cost, and modestly effective on its own — and significantly amplifies the effect of every other medical therapy on this ladder.
Step 3 — Intranasal corticosteroids
The single most effective category of medication for moderate-to-severe allergic rhinitis. Fluticasone, mometasone, triamcinolone, and budesonide — most now available over the counter — reduce all major symptoms: congestion, itch, sneezing, and discharge. They take three to seven days to reach full effect, so they work best when used consistently (every day during the relevant season for seasonal allergies; year-round for perennial). Modern formulations have minimal systemic absorption and are safe for long-term daily use.
Step 4 — Second-generation oral antihistamines
Cetirizine, loratadine, levocetirizine, fexofenadine, and desloratadine. Effective for itch, sneezing, and rhinorrhea; less effective for congestion. Non-sedating in most patients, especially fexofenadine and loratadine. First-generation antihistamines (diphenhydramine) are generally avoided in chronic use because of sedation, anticholinergic side effects, and tachyphylaxis.
Step 5 — Intranasal antihistamines
Azelastine and olopatadine — delivered as a nasal spray — provide faster symptom relief than oral antihistamines and add benefit when combined with intranasal steroids. The combination of intranasal steroid plus intranasal antihistamine (sometimes available as a single combination product) is the most effective medical regimen for moderate-to-severe allergic rhinitis.
Step 6 — Leukotriene receptor antagonists
Montelukast is approved for allergic rhinitis but is generally reserved for patients with comorbid asthma or those who can't tolerate other agents. The FDA's black-box warning for neuropsychiatric side effects (sleep disturbance, mood changes) prompts careful patient selection and counseling. It's an option, not a first-line therapy.
Step 7 — Allergen immunotherapy
The only treatment that modifies the underlying disease rather than just suppressing symptoms. Immunotherapy gradually retrains the immune system to tolerate specific allergens. Two delivery routes:
- Subcutaneous immunotherapy (SCIT, "allergy shots") — weekly injections during a build-up phase (typically four to six months), then monthly maintenance for three to five years. Most effective and broadest in coverage; requires in-office visits because of rare anaphylaxis risk.
- Sublingual immunotherapy (SLIT) — daily drops or tablets placed under the tongue at home. FDA-approved tablets exist for ragweed, grass, and dust mite. Slightly less effective than SCIT but more convenient, with a strong safety profile suitable for home use.
The case for immunotherapy is that the benefit persists for many years after stopping treatment, where medications work only while you're taking them. For patients with multi-allergen disease, progression toward sinus complications, or simply tired of being on year-round medication, immunotherapy is the most disease-modifying option in the field.
Step 8 — Biologic therapy (selected cases)
Omalizumab (anti-IgE) is FDA-approved for severe allergic asthma with comorbid allergic rhinitis. It's not first-line for isolated allergic rhinitis, but for patients with severe allergic disease that crosses respiratory compartments — and particularly those who have failed other modalities — it's part of the toolkit.
The bridge to chronic sinusitis.
Untreated or undertreated allergic rhinitis is a meaningful risk factor for chronic sinus disease. Sustained inflammation narrows the natural sinus drainage pathways, creating an environment where mucus stagnates, bacterial biofilms form, and acute infections recur. Over time, what started as nasal allergies can transition into chronic rhinosinusitis, with or without nasal polyps.
Patients who arrive with both — significant allergies and established sinus inflammation — need a paired treatment plan: allergic control as the foundation, plus appropriate sinus management on top. Treating only one half typically delivers partial relief at best.
The reverse is also true. Patients with chronic sinus disease who never had their underlying allergies addressed often see better long-term outcomes once both are managed together. Allergy testing in CRS patients without an obvious atopic history is reasonable when sinus surgery alone hasn't produced durable improvement.
Common questions, direct answers.
Should I see an ENT or an allergist for nasal allergies?
Both manage allergic rhinitis, with overlapping skill sets. ENT specialists are particularly valuable when allergies are accompanied by structural nasal issues (deviated septum, turbinate hypertrophy), chronic sinus disease, polyps, or persistent symptoms despite medical therapy — because surgical and procedural options become part of the management plan. For patients with prominent asthma, food allergies, or anaphylaxis, an allergist-immunologist is often the primary specialist. In complex cases, the two specialties co-manage.
What's the difference between skin testing and blood testing for allergies?
Skin prick testing involves placing small amounts of allergens on the skin (usually the forearm or back) and measuring the local reaction after about fifteen minutes. It's sensitive, specific, and done in a single visit. Specific IgE blood testing measures antibody levels against individual allergens from a single blood draw — useful when skin testing isn't possible (severe eczema, antihistamine use that can't be paused, history of anaphylaxis). For most patients, skin testing is the first choice; blood testing is the alternative when skin testing isn't appropriate.
Do intranasal steroid sprays really work?
Yes — intranasal corticosteroids are the most effective single-agent therapy for moderate-to-severe allergic rhinitis. They reduce congestion, itch, sneezing, and runny nose. They take three to seven days to reach full effect, so they work best when used consistently rather than as-needed. Modern formulations (fluticasone, mometasone, triamcinolone, budesonide) have minimal systemic absorption and are safe for long-term daily use.
What is allergy immunotherapy, and is it worth doing?
Allergy immunotherapy gradually desensitizes the immune system to specific allergens. It comes in two forms: subcutaneous immunotherapy (SCIT, weekly-to-monthly injections in the office) and sublingual immunotherapy (SLIT, daily drops or tablets taken at home). Both require commitment — typically three to five years of treatment — but produce durable benefit that persists after stopping, often for many years. Immunotherapy is the only treatment that modifies the underlying allergic disease rather than just suppressing symptoms. It is particularly valuable for patients whose allergies progress into chronic sinus disease or asthma.
What's the difference between allergic rhinitis and chronic sinusitis?
Allergic rhinitis is inflammation of the nasal mucosa driven by IgE-mediated allergic response — typically with prominent itch, sneezing, and watery discharge. Chronic rhinosinusitis is sustained inflammation of the sinuses themselves, lasting twelve weeks or longer, often with thick discharge, facial pressure, and reduced smell. The two conditions are linked: untreated allergic rhinitis is a risk factor for chronic sinusitis, and the two can coexist. A careful exam plus nasal endoscopy distinguishes them — and treatment of underlying allergies often improves coexisting sinus disease.
I've been told my allergies are "just allergies" — is there ever a reason to do more?
Yes, in several scenarios: when symptoms aren't controlled on appropriate medical therapy, when there are persistent nasal symptoms outside the expected allergy seasons, when sinus pressure or recurrent infections are part of the picture, when sleep is being affected, when polyps or anatomic obstruction may be contributing, and when immunotherapy candidacy has not been discussed. Allergic rhinitis is highly treatable — symptoms that drag on for years usually mean someone hasn't run through the full ladder of options yet.
Recent media coverage on NYC allergies.
Dr. Iloreta is frequently called by New York City media for expert commentary on the city's allergy seasons and on differentiating allergies from upper-respiratory illnesses.
- NY1 · News All Day — "Doctor shares tips for managing allergies in the city" (April 2026)
- TODAY · Health — "How to differentiate between seasonal allergies and coronavirus"