With spring in full swing, many of us are looking forward to longer days, warmer weather and more chances to enjoy the great outdoors.
Unfortunately, for millions of hayfever sufferers across the nation, it can be hard to feel full of the joys of the season if your eyes are itchy and you can’t stop sneezing.
“Hayfever is a very common allergy affecting around one in four adults and one in 10 children in the UK,” says Margaret Kelman, acting head of clinical services at Allergy UK. “The number of people affected has trebled in the last 30 years. The condition is becoming more common, partly due to better diagnosis but also due to climate change, with warmer temperatures causing pollen seasons to start earlier and last longer.”
Pharmacy staff may also sometimes hear the condition referred to as ‘allergic rhinitis’. “They’re used interchangeably, for sure,” says professor Stephen Till, an allergy specialist and a spokesperson for the British Society for Allergy & Clinical Immunology (BSACI). “The thing about allergic rhinitis is that just refers to the nasal symptoms, whereas hayfever encompasses the wider symptoms.”
These might also include:
- Red, itchy or watering eyes
- Itching of the throat, mouth and ears
- Loss of smell.
Anyone can be affected by hayfever, according to Margaret, but it’s more common in young adults. “Allergic rhinitis is more likely to occur when there is an immediate family history of atopy (i.e., one or more of asthma, allergic rhinitis, eczema, etc). Often there is a seasonal pattern to symptoms that can be linked to a particular pollen group,” she explains.
“Allergies can develop at any age, although as we go into our senior years the immune system becomes less reactive, and so allergies are not as common as when we are younger. People with known atopy are more likely to develop other allergic conditions – for example, asthma and allergic rhinitis.”
Taking its toll
While some hayfever patients experience mild discomfort, for others it can mean months of misery. “Hayfever can have a huge impact on quality of life if it is not treated or well managed,” explains Margaret. “Having severe hayfever can affect someone’s ability to participate in outdoor activities, affect their mental health and even have a detrimental impact on careers, especially for someone who works outdoors. It can lead to increased irritability, lack of sleep, and affect someone’s ability to concentrate at work or school and to carry out simple tasks.”
Margaret adds that 90 per cent of people with asthma have allergic rhinitis. “In people with asthma, there is an increased risk of worsening asthma symptoms and hospitalisation with poorly treated hayfever. This can also lead to recurrent sinus infections and the development of asthma, especially in children.”
There are people with hayfever who also develop seasonal asthma symptoms, says professor Till. “Sometimes these are patients who don’t have asthma at any other time of the year. On certain days when the pollen count is really high, and perhaps they’re outdoors or something like that, people do develop asthma attacks in summer or tree pollen season. That’s something we see fairly commonly. If patients with hayfever develop wheezing or chest tightness or difficulty breathing, they really need to seek medical attention as they may need treatment for asthma for that period of the year. Sometimes patients can even end up needing care in A&E.”
So what are the main hayfever culprits – and how do they vary by season? “Grass pollen is the most common allergen, but tree and weed pollens can also cause the allergic reaction we know as hayfever, especially birch pollen,” says Margaret. “Typically, hayfever triggered by grass pollen will start to affect people during May and June, but hayfever can start as early as February/March if you are allergic to tree pollen. While some people with hayfever react to one type of pollen during the ‘season’ and then feel better later in the year, it is also possible to be affected by more than one type, leading to many months of allergic rhinitis symptoms.”
In some cases, you may encounter customers whose hayfever has been triggered for the first time. But what causes some patients to suddenly experience symptoms when they’ve never done so before?
“I suspect that some of these individuals may have already been sensitised to the pollen – in other words, they already had the antibodies that react to it – but possibly the tendency for pollen counts to become higher for longer has unmasked the allergy,” says professor Till. “It has been proposed that higher pollen counts could possibly be linked with climate change.”
Having been involved with allergy since the early 90s, professor Till says we’re seeing many more people now who are allergic to tree pollen, such as from silver birch trees. “Why exactly tree pollen allergy has increased is not well understood. There are various theories – about local authorities planting more birch trees around, possibly also a climate element too – but it’s very difficult to tie down these factors.”
“It is worth noting that after a person has become sensitised to a pollen, then on subsequent seasonal exposures their symptoms may become worse, especially if the symptoms aren’t treated adequately,” adds Margaret. Allergy UK has a handy pollen calendar on its website, identifying the different strains and when they are at their peak.
“Hayfever can have a huge impact on quality of life if it is not treated or well managed”
“Antihistamines are the first line of treatment for hayfever and can reduce the symptoms of nasal discharge and itch, especially in the nose, eyes, ears and palate,” says Margaret. “It is recommended to use a daily, long-acting, non-sedating antihistamine.”
Examples of these include cetirizine, loratadine and fexofenadine.
Considerations should include “comorbidities, therapeutic index, age, interaction with other drugs (choosing drugs that aren’t metabolised in the liver) and side effect profile, allergies (people can have a drug allergy to certain antihistamines and ingredients in antihistamines) and patient choice and experience,” adds Margaret.
Allergic conjunctivitis frequently coincides with allergic rhinitis, says Margaret. “Saline eye drops can help to soothe the symptoms of hayfever, which cause eyes to itch, be watery, red and irritable. Antihistamine or mast cell stabiliser eye drops are also available where symptoms are more troublesome.”
While there are nasal sprays available to purchase in the pharmacy, Margaret advises that individuals requiring treatment for undiagnosed chronic nasal congestion should first see their GP. “Medical examination of the nasal cavity to establish the cause of nasal congestion is essential before treatment commences, and regular review for side effects and efficacy of treatment should be in place.
In children, regular measurement of growth and weight is required, especially where corticosteroids are also used to treat asthma, eczema, etc. Nasal corticosteroids can be very effective in reducing the inflammation that causes nasal congestion in hayfever and often can provide relief for eye symptoms as well, but ideally should be taken at least two to three weeks before the hayfever season to become fully effective.”
Decongestion nasal sprays are not usually useful in the management of hayfever, says Margaret, and should only be used for very short term congestion of the nose, otherwise they can cause worsening symptoms.
“Sterile saline nasal douching and irrigation can help soothe inflammation in the nose and clear the nasal passage of any impurities and allergens,” says Margaret.
“Non-perfumed barrier balms or ointments can be applied to the rim of the nostril and help catch any pollen/allergens before they get into the nasal passages and trigger allergy symptoms. They are also useful to protect the skin around the nose (from the constant blowing) or eyes (watery eyes can cause the skin to become irritated).
“Skin wipes can be useful to help wipe pollen from the face until washing facilities are available, but they should be used with caution in individuals with sensitive skin and eczema.”
Beyond the pharmacy, patients who are badly affected by hayfever may benefit from seeing a specialist. “It’s not performed through pharmacies, but as allergists, we also routinely perform allergen desensitisation or immunotherapy,” says professor Till. “Historically shots of pollen were injected regularly to try to desensitise the immune system, but increasingly we’re giving this as a dissolvable tablet under the tongue.
This is a treatment that you have to plan in advance – it should be initiated around three or four months before the pollen season starts – but this approach can be highly effective for patients with severe hayfever, especially if the other medications do not work adequately. A big advantage is that this addresses the underlying cause of the allergy. If you continue immunotherapy for three years, you have the potential to reduce the allergic response in the longer term even after the treatment is finished. You are changing the underlying immune response to the pollen.”
Professor Till advises that people with severe hayfever should be referred by their GP to an allergy clinic in the first instance (though private treatment is also available).
Self care steps
As well as helping patients to find the most suitable treatments for them, pharmacy teams can also offer support by highlighting useful resources, knowing when to refer (see boxout), sharing practical tips – and debunking myths. “Old wives’ tale remedies, such as local honey, don’t work,” says professor Till. “There have been research studies looking
However, the following self-care measures might prove helpful for hayfever sufferers:
- Wear wraparound sunglasses and a hat with a wide brim when outside to keep pollen allergens off the face and hair
- Don’t let pollen linger. “If you’ve been outdoors for prolonged periods, shower, wash your hair and change your clothing, especially before bed,” says Margaret. “Cleaning your eyelashes will also help to avoid pollen and allergens rubbing off on to your pillow,” says Edel Duffy, head of medical for Fusion Allergy Nasal Spray.
- Reduce pollen in the home. Keep windows closed (most importantly in the early morning and evening, when the count is higher), avoid drying laundry outside, and wipe pets’ coats with a damp microfibre cloth when they’ve been outdoors, says Margaret. “Avoid bringing pollen into your house by taking your shoes off at the door,” adds Edel
- Go easy on the gardening. “Avoid outdoor activities that expose you to pollen, such as mowing lawns or raking leaves,” says Margaret
- Keep an eye on the pollen count. Forewarned is forearmed, so stay up to date by checking the daily forecast online.
When to refer
According to Allergy UK’s Margaret Kelman, hayfever patients should visit their GP if:
- Their symptoms are worsening or not improving when taking a daily antihistamine and/or other allergy medications
- Symptoms last more than two weeks and affect the individual’s daily activities, sleep or carrying out everyday tasks
- They have nasal blockage that does not respond to treatment.
Margaret says that red flags requiring urgent medical attention include:
- Difficulty breathing in someone with no history of asthma
- Worsening asthma symptoms
- Nasal pain
- Recurrent epistaxis (nosebleed) or discharge with heavy bleeding
- Unilateral nasal discharge.