Allergic rhinitis-an overview with Homoeopathic therapeutics

Dr Shirurkar Manali Ramchandra

ABSTRACT
Allergic rhinitis is a significant global health issue, affecting millions worldwide, particularly in high-income countries, where prevalence rates can reach up to 50%. Despite its frequent occurrence, the condition is often underdiagnosed, contributing to an underestimated burden. The condition is characterized by nasal symptoms such as rhinorrhea, sneezing, itching, and congestion, along with ocular symptoms. These symptoms impair quality of life by disrupting sleep, causing fatigue, and reducing productivity. The pathophysiology of allergic rhinitis involves both early and late phase immune responses, leading to chronic inflammation in the nasal mucosa.

The management of allergic rhinitis typically focuses on symptom relief and improving the quality of life, which is often impacted by the disorder. Homoeopathy offers a holistic approach to managing allergic rhinitis, with remedies such as Allium cepa, Arsenic album, Natrum muriaticum, and others, aiming to not only alleviate symptoms but also restore overall well-being. Homoeopathic treatments target both acute and chronic manifestations of allergic rhinitis, providing individualized care based on the specific symptoms and constitution of the patient.

This article provides an overview of the clinical features, pathophysiology, diagnostic methods, and homoeopathic management strategies for allergic rhinitis, emphasizing the potential for holistic treatment to improve patient outcomes.

INTRODUCTION
Allergic rhinitis is a global burden that causes major illness and disability worldwide. Allergic rhinitis is a growing public health and economic problem. The prevalence of the disease remains low though the disease occurs frequently because majority of the cases go undiagnosed or most population surveys rely on physician-diagnosed rhinitis for their data, possibly underestimating the actual frequency with which rhinitis occurs¹.

Allergic rhinitis is one of the most common chronic conditions in high-income countries, with a prevalence of up to 50% in some countries². According to WHO, the global burden of allergic rhinitis was estimated to be 400 million³. A survey by All India Co-ordinated Project on aeroallergens and human health, New Delhi, 2000, showed that 20–30 % of the population suffers from allergic rhinitis and that 15 % develop asthma⁴.

Allergic rhinitis is an inflammatory condition of nasal mucosa clinically characterized by –rhinorrhea, sneezing, nasal itching, and nasal congestion. Allergic rhinitis symptoms result in sleep disturbance, fatigue, depressed mood and cognitive function compromise that impairs quality of life and productivity⁴.

Many other disorders treatment may be centered on preventing death or future morbidity but the goal of treatment of allergic rhinitis is to improve a patient’s well-being, or quality of life. However, until recently, the treatment of allergic rhinitis has been concentrated on symptom improvement without much focus on how this has affected patient’s well-being.

Since the 1990s, there has been an increase in trend towards assessing the impact of allergic rhinitis on the quality of life of individuals with allergic rhinitis. It is now recognized that allergic rhinitis frequently has a significant impact on quality of life, and as a result evaluations are often included in clinical trials⁵.

Homoeopathic materia medica contains numerous medicines which have similar symptoms that of allergic rhinitis. Application of homoeopathic medicines will not only cure the sick from the sickness but also will improve the quality of life deteriorated due to sickness.

DEFINITION
“Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced after allergen exposure by an IgE- mediated inflammation” per ‘Allergic rhinitis and its impact on asthma’ (ARIA).

Symptoms that of Allergic Rhinitis include nasal itching, sneezing, rhinorrhea, and nasal congestion. Symptoms involving the eyes, ears and throat including postnasal drainage are commonly accompanied with Allergic Rhinitis. Ocular symptoms are, frequent itching, redness of the eyes and tearing. Itching of the palate, postnasal drip and cough are other common symptoms⁶.

EPIDEMIOLOGY
According to WHO, the global burden of allergic rhinitis was estimated to be 400 million³. Allergic rhinitis often begins early in life, with a prevalence of more than 5% at 3 years of age⁷.

Depending on the demographic, study design, and geographic region, there were wide variations in the prevalence of AR throughout Asia. Numerous studies have shown a high correlation between a number of risk variables and the manifestation of the disease. When several risk levels were assessed, the following factors—family income, family size, daily personal computer usage time, parental and personal education attainment, and stress level—showed some degree of biological gradient influence. This implies that a variety of individual and familial factors may have a significant impact on the manifestation and presentation of AR⁸.

India is the residence of approximately 20% of the world’s population, totaling 1.35 billion individuals. 20-30% of the Indian population are said to be suffering from allergic rhinitis with the prevalence further increasing⁴.

PATHOPHYSIOLOGY
Previously considered to be a condition affecting the nose and nasal passages, allergic rhinitis may actually be a part of a systemic airway disease that affects the respiratory system as a whole. The upper and lower respiratory tracts have intricate relationships in terms of physiology, function, and immunity. Both tracts contain a ciliated epithelium comprising of goblet cells that secrete mucous, which filter the air coming inside and protect structures within the airways. The sub mucosa of the upper and lower airway tracts includes a set of mucus glands, supporting cells, nerves and inflammatory cells. The sheer fact that rhinitis and asthma often coexist provides evidence that allergen stimulation of the upper airways not only leads in an area inflammatory response but also in inflammatory processes inside the lower airways.¹⁰

Sensitization to allergens
Antigen presenting cells (APCs), such as dendritic cells in the mucosal surface, process and display certain peptides derived from allergens on the major histocompatibility complex (MHC) class II molecule.10 The ligand of T-cell receptors on naive CD4+ T cells is this MHC class II molecule and antigen complex, which causes the cells to differentiate into allergen-specific Th2 cells. Many cytokines released by activated Th2 cells cause B cells to flip isotypes and produce certain IgE, as well as the growth of neutrophils, mast cells, and eosinophils. Mast cells or basophils have high-affinity IgE receptors that are bound by produced antigen-specific IgE.

Early and late reactions
When AR patients are exposed to allergens, allergic reactions develop in 2 different patterns according to time sequence. One is the early reaction, in which sneezing and rhinorrhoea develops in 30 minutes and disappears. The other is known as the late reaction, which appears as nasal blockage about six hours after allergen exposure and gradually goes away. Mast cells initial reaction to irritating allergens is known as type I hypersensitivity. Histamine, prostaglandins, and leukotrienes are only a few of the chemical mediators secreted by activated mast cells that cause nasal symptoms. The primary mechanism in the late reaction, which is brought on by chemical mediators generated in the early response, is eosinophil chemotaxis, in contrast to the early reaction. The principal symptom of AR patients is nasal obstruction, which is caused by a number of inflammatory cells, including mast cells, T cells, eosinophils, and eosinophils, migrating to the nasal mucosa where they fragment and remodel normal nasal tissue.

Neurogenic inflammation
The so-called retrograde axonal reflex occurs when sensory nerve fibres are activated by nonspecific stimuli and stimulate both sensory afferent and surrounding efferent fibres when respiratory epithelium is destroyed and nerve endings are exposed by cytotoxic proteins from eosinophils. As a result, the sensory nerve fibres release neuropeptides such substance P and neurokinin A, which cause smooth muscle contraction, goblet cell mucous secretion, and capillary plasma exudation. We refer to this process as neurogenic inflammation.

Non-specific hyperresponsiveness
Non-specific hyperresponsiveness is one of the clinical characteristics of allergic inflammation. Nasal symptoms include sneezing, rhinorrhoea, nasal itching, and blockage are brought on by eosinophilic infiltration and mucosal deterioration, which leads the mucosa to become hyperactive to typical stimuli.15 This is not an immunological response connected to IgE. Patients with AR have increased hypersensitivity to specific allergens as well as non-specific stimuli like tobacco or cold, dry air.¹¹

Early phase response
The early, immediate or first phase response occurs within minutes of subjection to the allergen in sensitized individuals and lasts for about 2-3 hours. One of the essential elements of the early phase response is mast cell degranulation. A hypersensitive person’s nasal mucosa contains a large number of mast cells, which can readily become triggered following re-exposure to allergens. When the specific allergen cross-links the allergen-specific IgE bound to the mast cell surface, the mast cells degranulate, releasing a range of pre-existing and freshly created mediators that trigger the first phase reaction. The primary mediator of AR, histamine, causes the Vth nerve’s (trigeminal) nerve terminals to fire, which causes sneeze. Additionally, histamine stimulates the mucous glands, resulting in mucus secretion (rhinorrhoea). Histamine, leukotrienes and prostaglandins acts on the blood vessels which results in nasal congestion.

Late phase response
The first phase response, which typically happens 4-6 hours after antigen stimulation, is followed by the late phase, also known as the second phase. Sneezing and rhinorrhoea are among the symptoms that worsen during this period, but the main one is a prolonged nasal congestion that lasts for roughly 18 to 24 hours. This phase is characterized by an inflammatory cellular influx, primarily composed of basophils, eosinophils, and T lymphocytes, and is primarily inflammatory in nature. Leukotrienes, kinins, and histamine are only a few of the mediators that these cells release, all of which contribute to the development of the late phase and the persistence of symptoms. Mast cells produce and release a variety of cytokines and chemokines, including IL-4 and IL-13. The expression of adhesion molecules on endothelial cells is upregulated by cytokines, which promotes basophil, T lymphocyte, and eosinophil infiltration into the nasal mucosa. Furthermore, Thymus, chemokines, and activation T lymphocytes, basophils, and eosinophils are all attracted to epithelial cells by the controlled chemokine they produce. The nasal mucosa’s infiltrated eosinophils’ lifespan is prolonged by other cytokines, primarily secreted by epithelial cells. These include granulocyte macrophage colony stimulating factor (GM-CSF) and IL-5 from mast cells and T lymphocytes. According to recent research, mast cells also support the late phase response by upregulating GM-CSF and RANTES in nasal epithelial cells, which is caused by histamine and tryptase, and by working in concert with TNF-α and IL-4/IL-13. Other mediators released like eosinophil cationic protein, platelet activating factor, major basic protein also are involved within the late phase response.¹²

CLASSIFICATION OF ALLERGIC RHINITIS

According to the Allergic Rhinitis and its Impact on Asthma (ARIA guidelines), allergic rhinitis can be classified:

Based on Etiology

• IgE-Mediated (Allergic) rhinitis- It is characterized by inflammation of the nasal mucosa driven by IgE antibodies, leading to eosinophilic and Th2-cell infiltration of the nasal lining. It can further be categorized as intermittent or persistent.
• Autonomic rhinitis- It is related to the autonomic nervous system and encompasses conditions such as vasomotor rhinitis, drug-induced rhinitis (rhinitis medicamentosa), rhinitis associated with hypothyroidism, hormonal-related rhinitis, and non-allergic rhinitis with eosinophilia syndrome (NARES).
• Infectious rhinitis- It is triggered by various infections, with viral infections being the most common. It can also result from bacterial or fungal infections, with symptoms arising due to the inflammatory and immune responses to these pathogens.
• Idiopathic rhinitis presents a challenge as its cause or origin cannot be determined, making it difficult to identify a specific trigger or etiology for this type of rhinitis.¹³

Based on symptom duration and severity

• Intermittent Allergic Rhinitis- It refers to symptoms occurring for less than four days a week or less than four consecutive weeks.
• Persistent Allergic Rhinitis- It is characterized by symptoms persisting for four days a week or more and lasting for at least four consecutive weeks.
• Mild Allergic Rhinitis- In this type, the symptoms have a minimal impact on the quality of life and
• Moderate-to-severe Allergic Rhinitis- In this type, the symptoms significantly affect the individual’s quality of life.¹⁴

In modern times, Allergic rhinitis is classified into – occupational and local allergic rhinitis

Occupational Allergic Rhinitis
Occupational rhinitis is as an inflammatory disease of the nose that’s due to a specific work environment and not to stimuli faced outside the workplace.

Local Allergic Rhinitis
It is denoted by a localized allergic response in the nasal mucosa in the absence of proof of systemic atopy.  By definition, Individuals with Local allergic Rhinitis have a negative skin test and/or in vitro test for IgE, but have evidence of local IgE production in the nasal mucosa.¹⁰

CLINICAL FEATURES OF ALLERGIC RHINITIS
AR is characterized by the presence of nasal and non-nasal symptoms. Nasal symptoms include anterior or posterior rhinorrhoea, sneezing, nasal blockage and/or itching of the nose. Non-nasal symptoms are characterized by ocular symptoms such as itching and redness of the eyes and lachrymation which frequently occurs in AR patients. Other symptoms include itching of the palate, postnasal drip and cough. These symptoms may persist for hours after allergic reaction upon the exposure of allergens that cause mucosal inflammation.¹⁵ Chronic nasal blockage and rhinorrhoea can result in excoriation from frequent manipulation of the external nares and a persistent transverse hyper- or hypopigmented furrow across the junction of the middle and lower thirds of the nasal bridge. This happens where the skin naturally creases (the “allergic salute”) when the tip of the nose is pushed forward with the palm, creating a transverse nasal crease as a result. Another typical sign of allergic rhinitis is post-nasal drip, which happens when the nasal mucosa produces too much mucus, which builds up in the posterior pharynx and causes coughing, frequent swallowing, or halitosis. Approximately 5% of people with allergic rhinitis develop nasal polyps.¹⁶

DIAGNOSIS OF ALLERGIC RHINITIS
Allergic rhinitis is largely a clinical diagnosis made based on a thorough history and physical. Allergic rhinitis often goes undetected by clinicians in the primary setting as it is a long-standing condition. Patients suffering from AR may not seek medical treatment and frequently fail to recognize its impact on their daily lives. AR is largely a clinical diagnosis which is made by considering a detailed history that is supported by examination findings.¹⁷

According to Allergic rhinitis and its impact on asthma (ARIA) 2008 (revised in 2016) in collaboration with World Health Organization – If 2 or more of following symptoms are present for at least one hour per day for more than 2 weeks in a year, confirms the diagnosis of Allergic rhinitis

• • • •  watery anterior rhinorrhoea
      • sneezing especially paroxysmal
      • nasal obstruction
      • nasal pruritis
      • conjunctivitis – present /not present.¹⁸

Diagnostic tests

• Allergy tests, both in vivo and in vitro, focus on detecting free or bound IgE. Allergen standardization has led to effective diagnostic vaccinations for common inhalant allergens, improving allergy diagnosis.
• Immediate hypersensitivity skin tests are commonly employed to show an IgE-mediated allergic response. These tests are crucial for diagnosing allergies. Properly done tests can provide valuable confirmation for allergy diagnosis. Trained health experts should perform and interpret these complex procedures.
• A CT scan is performed to rule out chronic rhinosinusitis, tumors, or any other complications.⁴
• Skin prick tests (SPT) – recommended for regular diagnosis of allergic or non-allergic rhinitis, with a high negative predictive value. It helps in determining instant reactivity to specific allergens. Interpretation should be based on clinical history.
• Serum total and specific IgE – may be necessary when skin tests are not possible or when the SPT and clinical history produce confusing results. Total IgE alone can be perplexing, but it can help interpret particular IgE.
• Cytology – There is no consistency in the processes used to acquire cells for cytology from secretions, scrapings, cotton buds, or brushings, nor are there standards for evaluating cell counts. However, the presence of eosinophils in the sample may indicate inflammation. Nasal smears are often utilized.
• RAST – Radioallergosorbent testing is significant and has comparable usefulness to skin prick tests. It measures allergen-specific IgE in serum.
• Radiology – While not usually recommended for uncomplicated rhinitis, it might be useful for assessing probable structural abnormalities or identifying complications or co-morbidities. A
• Nasal challenge – with allergens is important, particularly for diagnosing occupational rhinitis and doing research. It is not often offered outside of specialty centers.¹⁹
• Absolute Eosinophil count (AEC) – is a valuable test for diagnosis of Allergic Rhinitis. AEC is an easy, simple, non-invasive, reliable test, valuable and very economical. Association between absolute Eosinophil count and clinical severity of symptoms has been proven by many studies.⁵²The number of eosinophils obtained can be helpful in some cases when combined with other factors. At present, eosinophil is believed to play a major role in allergic diseases such. Eosinophils account for only 1-3% of peripheral blood leukocytes and the upper limit of normal range is 350 cells/mm3 of blood. Eosinophilia occurs in a variety of disorders and is classified arbitrarily into mild (351-1500 cells/mm3), moderate (>1500-5000 cells/mm3) and severe (>5000 cells /mm3). In AR, eosinophils are found both in peripheral blood and nasal tissue.²⁰

HOMOEOPATHIC MANAGEMENT OF ALLERGIC RHINITIS

Allium cepa

Coryza,with acrid nasal discharge and laryngeal symptoms. It is indicated for profuse and watery discharge from nose, with sneezing. There is fluent coryza with running of water from eyes. Discharges from eyes are bland, intense burning in the eyes. Increased frequency of sneezing, watery discharge drips from the nose excoriates lip and wings of nose, Spring coryza, Coryza with sneezing, every year in August, colds, in damp, cold weather. Burning in the nose.^{21, 22}

Arsenic Album

Fluent coryza; discharge is thin, watery and excoriating. Nose feels stopped or obstructed swelling and burning in nose. Indicated in Hay fever; violent sneezing with great dryness in nostrils, worse in the open air; better indoors. There is no relief on sneezing, cannot bear the sight or smell of food. There is burning and redness in the eyes with acrid lachrymation and intense photophobia.^{22, 23}

Arsenicum iodatum

Discharge is thin, watery, irritating and excoriating from the anterior and posterior nares, sneezing with a constant desire to sneeze. There is irritation and tingling in the nose, nose drips, acrid causing redness of upper lip, chronic nasal catarrah, and swollen nose. Discharge irritates membrane from which it flows & over which it flows. It is indicated in Influenza, hay fever. There is pain over root of nose. Scrofulous ophthalmia.²¹

Ammonium Carbonicum

Discharge is sharp, watery and burning. There is stoppage of nostrils at night, with long continuous coryza. Difficulty to breathe through nose at night has to breathe through mouth. Tip of nose congested. Catarrah, that starts in the nose. There is continous urge to sneeze, epistaxis after washing the face and after eating. Burning of eyes with aversion to light, sore canthi.^{21, 23}

Dulcamara 

There is complete stoppage of nose. Cannot breathe through nose. Stuffs up when there is a cold rain. Least cold air stops the nose, wants to keep the nose warm, better by hot wet clothes Profuse coryza with constant sneezing that is brought in rains. It is indicated in, hay fever with profuse, watery discharge from the eyes, worse in the open air, better by staying in closed rooms. Every cold settles in eyes.^{21, 23}

Euphrasia

It is useful in catarrhal affections of the mucous membranes especially of the eyes and nose. There is profuse, fluent coryza by the day and obstruction at night, also abundant secretion of mucus from anterior and posterior nares. The discharge from the eyes is acrid whereas it is bland from the nose. There is profuse lachrymation. Watery eyes. ^{21, 22}

Natrum Muriaticum

Coryza which is violent and fluent lasts for one to three days, followed by obstruction of the nose which makes it difficult to breathe. There is alternate fluent and dry coryza. Discharge is thin and watery like raw white of egg. Violent sneezing and coryza. Sneezing which starts early in the morning. It is unfailing for stopping a cold commencing from sneezing, also for internal soreness of the nose, dryness. Tears stream down face which is acrid, burning. Heavy eyelids.^21,23

Sabadilla

Sneezing is spasmodic in nature with runny nose. Severe frontal pains and redness of eyes and lachrymation along with coryza. Nostrils are stuffed up, causing labored inspirations. There is snoring, itching and bleeding from nose. Sensitive to the smell of garlic. Coryza is wrose from odor of flowers. Stubborn, lingering coryza.²³

Nux vomica

It is indicated for stuffing up of nose, especially at night and in outdoors, stuffy colds, snuffles, after exposure to dry and cold atmosphere. Coryza fluent at daytime, dry and stuffed up at night. Nose stopped, but runs water on one side, insupportable itching of nose, and obstruction of nose on one side only.  There is acrid discharge from nose with a stuffed up feeling. It is given for itching in the ear throughout the Eustachian tube. Smell before nose, like old cheese or burning sulphur. Sneezing violent, abortive, from intense crawling in nostrils. It is given for troublesome catarrah which usually comes on very early in morning. Bloodshot eyes, lachrymation from affected side.^{22, 23}

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Dr Shirurkar Manali Ramchandra
PG Scholar, Department Of Practice of Medicine
Government Homoeopathic College & Hospital Bangalore- 560079
UGO of Dr Praveen Kumar PD
shirurkarmanali@gmail.com