Allergic Rhinitis: What Actually Works (Intranasal Steroids First)

What is it?

An IgE-mediated response to allergens (pollens, dust mites, pet dander) causing sneezing, itchy/watery eyes, runny nose, and congestion—often seasonal (e.g., ragweed late summer–fall).

What’s first-line?

Intranasal corticosteroids (INCS) are the preferred first-line for persistent/moderate symptoms. Expect best congestion relief with daily use; peak effect in 1–2 weeks.

What if INCS isn’t enough?

Layer a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine) or intranasal antihistamine (azelastine). Combination INCS + intranasal antihistamine can help severe cases. Eye symptoms: ketotifen OTC; consider olopatadine Rx.

Practical measures

Saline rinses (distilled/boiled/filtered water), HEPA filtration, windows closed on high-pollen days, shower before bed.

When to be seen in person

Unilateral obstruction, recurrent nosebleeds, severe facial pain, or uncontrolled asthma symptoms.

TeleDirectMD model (adult-only)

We set a stepwise plan, add prescriptions when needed, and schedule seasonal tune-ups.

Practical plan (copy/paste)

·         Start INCS daily; add oral or intranasal antihistamine if needed.

·         Eye symptoms: ketotifen; consider olopatadine if persistent.

·         Saline rinses 1–2×/day; manage exposures (keep windows closed on high-pollen days).

Myth vs Reality

·         Myth: Antihistamines beat nasal steroids. → Reality: For congestion, INCS work better.

·         Myth: Nasal steroids cause rebound. → Reality: Rebound is from topical decongestants, not INCS.

·         Myth: If it’s green, it’s infection. → Reality: Color doesn’t equal bacteria; pattern/seasonality matter.

Evidence & Further Reading (Last verified: August 22, 2025)

·         AAAAI/ACAAI — Rhinitis Practice Parameter (2020)

·         AAFP — Treatment of Allergic Rhinitis; Rapid Evidence Review (2023)

AAFA — Ragweed season timing