Hayfever

Hay fever is an allergic reaction to pollen. When the tiny pollen particles come into contact with the cells that line your mouth, nose, eyes and throat, they irritate them and trigger an allergic reaction.

When you have an allergic reaction, your body overreacts to something it perceives as a threat. In hay fever, the allergen (the substance you’re allergic to) is pollen. Your immune system (the body’s natural defence) responds as if it were being attacked by a virus and produces antibodies (IgE).

The immune system releases chemicals designed to prevent the spread of what it wrongly perceives to be an infection. These chemicals cause the symptoms of the allergic reaction, such as watering eyes and a runny nose.

Risk factors

It’s unclear what causes the immune system to react in this way, but there are several factors that can increase your risk of developing hay fever. They include:

• Having asthma or another allergic condition, such as eczema
• Having a family history of hay fever
• Being exposed to tobacco smoke and diesel exhaust particles during early childhood

Research suggests that pollution, such as cigarette smoke or car exhaust fumes, can make allergies worse.

In the UK, around 90% of people with hay fever are allergic to Timothy and Rye grass pollen. Around 25% are allergic to tree pollens including oak, ash, cedar and birch (people with an allergy to birch often also experience an allergic reaction to apples, peaches, plums and cherries because these types of fruit contain similar protein to birch pollen). Weeds such as dock, mugwort and nettles can also trigger hay fever although this is less common and tends to occur during the autumn months.

It is possible to be allergic to more than one type of pollen at the same time.

The weather will also affect how much pollen plants release and how much it’s spread around. On humid and windy days pollen spreads easily whilst on rainy days it is cleared from the air more easily.

During the pollen season, plants start to release pollen early in the morning. As the day gets warmer and more flowers open the pollen levels rise so on warm sunny days the pollen count will be highest in the early evening.

The Pollen Count

The pollen count is the number of grains of pollen in one cubic metre of air and hay fever symptoms are likely to be worse if the pollen count is high.

Hay fever symptoms often begin when the pollen count is over 50.

The pollen count is usually given as part of the weather forecast during the spring and summer months.

The pollen forecast is usually given as:

• Low – less than 30 grains of pollen in every cubic metre of air
• Moderate – 30 to 49 grains of pollen in every cubic metre of air
• High – 50 to 149 grains of pollen in every cubic metre of air
• Very high – 150 or more grains of pollen in every cubic metre of air

Check the pollen forecast on the Met Office website

Hay fever symptoms vary in severity and may be worse some years, depending on the weather conditions and pollen count.

The time of year your symptoms start will depend on the types of pollen you’re allergic to.

The common symptoms of hay fever include:

• sneezing and coughing
• a runny or blocked nose
• itchy, red or watery eyes
• itchy throat, mouth, nose and ears
• loss of smell
• pain around your temples and forehead
• headache
• earache
• feeling tired

If you have asthma, you might also:

• have a tight feeling in your chest
• be short of breath
• wheeze and cough

Hay fever will last for weeks or months, unlike a cold, which usually goes away after 1 to 2 weeks.

Hay fever can lead to complications such as sinusitis and middle ear infections (Otitis Media).

Hay fever can usually be diagnosed from the appearance of typical symptoms that occur during the hay fever season. It is more common if you have a history of asthma or eczema.

Formal allergy testing is not usually required to establish the diagnosis which can be determined from the history and symptoms alone. The role of allergy testing is usually reserved for cases in which the symptom pattern is unusual or particularly severe (see “When to consult your GP”).

Keeping a diary of your symptoms and when they occur can also help in establishing the diagnosis.

Formal diagnosis of hay fever by a doctor is not usually necessary unless the symptoms are unusual or are sufficient to interfere with daily activities despite the regular use of over-the-counter medications (see below).

Unusual symptoms that require further investigation/assessment include:

• Unilateral (one sided) symptoms
• Persistent blood-stained nasal discharge
• Persistent purulent (containing pus) nasal discharge

If your symptoms do not improve using a daily antihistamine and/or topical allergy medications (such as nasal sprays and eye drops), and your symptoms affect you carrying out everyday tasks, seek advice from a healthcare professional such as a pharmacist, your GP or practice nurse. As per recent guidance, your GP will not prescribe antihistamines, nasal sprays or eye drops – please see your Pharmacist for more information.

There is currently no cure for hay fever and, whilst it cannot be prevented, the symptoms can be significantly reduced with appropriate adjustments to lifestyle coupled with over the counter (i.e., without prescription) medication.

Lifestyle measures

If possible, stay indoors when the pollen count is high (over 50). The tips below may help to reduce your exposure to pollen.

• Keep windows and doors shut in your house. If it gets too warm, draw the curtains to keep out the sun and lower the temperature.
• Don’t keep fresh flowers in the house.
• Vacuum regularly, ideally using a machine with a high-efficiency particle arresting (HEPA) filter.
• Damp dust regularly. Dusting with a wet cloth, rather than a dry one, will collect the dust and stop any pollen being spread around.
• Keep pets out of the house during the hay fever season. If your pet does come indoors, wash them regularly to remove any pollen from their fur.
• Don’t smoke or let other people smoke in your house. Smoking and breathing in other people’s smoke will irritate the lining of your nose, eyes, throat and airways, making your symptoms worse.
• If possible, avoid drying clothes outside. This will help to stop pollen being brought into your house.

If you need to go outside or you’re travelling, the tips below may help to reduce your exposure to pollen.

• Avoid cutting grass, playing or walking in grassy areas and camping – particularly in the early morning, evening and at night, when the pollen count is at its highest.
• Wear wraparound sunglasses to stop pollen getting in your eyes.
• Take a shower and change your clothes after being outdoors to remove the pollen on your body.
• Keep car windows closed. You can buy a pollen filter for the air vents in your car, which will need to be changed every time the car is serviced.

Nasal barrier balm:

Apply to the rim of the nostril to prevent allergens and irritants from going up the nose.

Skin wipes:

Skin wipes can be used to remove pollen from skin, use with caution as they may irritate sensitive skin.

Saline drops/sprays:

Saline (salt water) nasal drops and sprays are used to wash out any allergens that may be irritating the nose (nasal douching) and can help loosen nasal congestion. These are available over the counter from your local pharmacist (e.g, Calpol saline nasal spray, Olbas nasal spray, Snufflebabe nasal spray & Sterimar) and are suitable for children.

In line with national guidance, NHS Devon does not support routine prescribing for mild to moderate hay fever as it is an uncomplicated condition that can usually be managed without medical intervention. This includes antihistamines, nasal sprays and eye drops indicated for this use.

Experience from the Peninsula Immunology and Allergy Service suggests that 70% of patients referred by their GP with severe symptoms of seasonal allergic rhinitis (hay fever) achieve satisfactory symptom control using non-sedating antihistamines and/or regular intranasal corticosteroids alone.

Antihistamines

Most people with hay fever will be able to manage their symptoms by taking a daily long-acting, non-sedating antihistamine such as Acrivastine, Cetirizine, Loratadine or Mometasone.

Antihistamines work by blocking the action of the chemical histamine, which the body releases when it thinks it’s under attack from an allergen. This stops or reduces the symptoms of allergic reactions such as hay fever.

Antihistamines are available over the counter (without prescription) in tablet and syrup form and are recommended for adults and children over the age of two years.

Speak to your pharmacist if you are unsure which products are suitable for you or your child’s symptoms.

For best effect, daily antihistamines should be started 2 weeks before the usual onset of hay fever symptoms and continued regularly throughout the pollen season(s).

Topical antihistamine preparations (eye drops and nasal sprays) are also available.

When hay fever symptoms remain troublesome despite regular oral (by mouth) antihistamines, topical treatment should be considered. There is good evidence that nasal steroid sprays offer an effective alternative to antihistamines, particularly in moderate and severe hay fever.

Surprisingly, there is less evidence to suggest that combining antihistamine and nasal steroid treatments provides a significant benefit over the use of one or other treatment on its’ own, although considering a trial of combining these treatments may be worthwhile if symptoms are particularly stubborn.

Nasal steroids

Steroid nasal sprays are available for hay fever over the counter for adults (> 18 yrs) but only on prescription from a GP for use in children due to potential side effects. They are very effective at reducing the inflammation associated with the ‘stuffy nose’ feeling of hay fever and may also help to reduce eye symptoms as well as supressing the allergic response that underpins hay fever.

Steroid nasal drops are also available.

Unlike decongestants, steroid nasal sprays take several days of regular use before they take full effect. Continuous use for prolonged periods (i.e., more than a couple of months) and/or overuse can lead to drying of the lining of the nostrils and even to nose bleeds, so it is advised that you consult your GP or pharmacist before using them on a long-term basis.

Over the counter products include:

• Beconase (beclomethasone)
• Benacort 64 (budesonide)
• Clarinaze (mometasone)
• Nasacort (triamcinolone)
• Pirinase (fluticasone)

It is important to take your nasal spray correctly to get the most benefit from your medication. This includes tilting your head forwards when using the spray rather than tipped back as most people assume.

The British Society for Allergy & Clinical Immunology (BSACI) has produced a patient information leaflet which details the correct use of steroid nasal sprays and can be downloaded from their website:

BSACI: how to apply a nasal spray.

Nasal decongestants

Hay fever can cause a blocked nose. A decongestant, in the form of a nasal spray, can relieve this. Decongestants reduce the swelling of the blood vessels in your nose, which opens your nasal passage and makes breathing easier.

Your pharmacist can recommend a suitable nasal decongestant. Check the ingredients, as some decongestants also contain antihistamine. If they do, they may relieve other symptoms as well. If not, the decongestant will only relieve your blocked nose.

Nasal decongestants shouldn’t be used regularly for longer than 7 days. They may cause dryness and irritation in your nasal passage and can make the symptoms of congestion worse (this is known as rebound congestion or rhinitis medicamentosa).

Eye drops

Eye drops are available from your pharmacist to treat the hay fever symptoms that affect your eyes, such as redness, itchiness and watering (allergic conjunctivitis). The drops contain antihistamine, such as azelastine and olopatadine, to reduce the inflammation in your eyes, which will relieve the symptoms.

Eye drops containing the active ingredient sodium cromoglicate are the most widely used and have been shown to be extremely safe. Sodium Cromoglicate is what is known as a mast cell stabiliser. It blocks the release of the chemicals employed by the immune system that cause the troublesome symptoms. Check the patient information leaflet for the correct way to use them. Some may cause side effects, such as a stinging or burning sensation in your eyes.

Steroid tablets

If you require rapid short-term relief from severe symptoms – for example, if you have an exam or driving test coming up – your GP may prescribe a course of corticosteroid tablets for 5 to 7 days.

The use of corticosteroids for longer than 10 days isn’t recommended, because the longer you take steroid tablets the more likely it is you’ll begin to experience unpleasant side effects, such as:

• Weight gain
• Changes in mood, such as feeling irritable
• Acne

Steroid Injections

Whilst intramuscular injection of long-acting corticosteroids have been used to treat hay fever in the past, these are no longer regarded as an appropriate treatment. This is due to a combination of poor efficacy and the increased risk of complications and side-effects compared to the other treatments currently available, particularly when performed repeatedly.

Other treatments

Montelukast is a Leukotriene receptor antagonist (LTRA) that modulates (reduces) the effects of the body’s inflammatory response. It is a tablet taken once daily that is primarily used to treat asthma but can also be effective at reducing the symptoms of hay fever in people who are asthmatic.

Immunotherapy (desensitisation) involves gradually introducing you to small amounts of the allergen (the substance you’re allergic to), such as pollen, and monitoring your allergic reaction in a controlled environment.

Immunotherapy is only carried out in specialist medical centres, in case a serious allergic reaction, known as anaphylaxis, occurs.

The allergen can be given to you as:

• An injection into your skin – this is known as systemic injection immunotherapy (SIT)
• A tablet (Grazax) that dissolves under your tongue – this is known as sublingual immunotherapy (SLIT)

If you have been referred for a specialist opinion your details will be reviewed and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found using the links below.

How long will I wait?

If a hospital assessment and/or treatment is clinically recommended your information will be sent to a specialist. Click below to find out more about waiting times for routine hospital assessment and/or treatment.

• Waiting times
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