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Cockroaches are a major source of urban allergens; their saliva, feces, and body parts all have been implicated. To eliminate cockroaches, patients should be encouraged to keep kitchen areas clean, to keep stored food tightly sealed, and to treat infested areas with baits or pesticides. Pollutants (e.g., ozone, diesel fumes) are an additional concern in urban environments. Pollutants such as diesel exhaust particles are especially irritating to the respira- tory tract and have been shown to increase the severity of allergic rhinitis. Patients whose allergies are triggered by air pollutants should be aware of the air quality index (AQI) (a measure of five major air pollutants per 24 hours) and should plan outdoor activities when the AQI is low. In general, trees produce pollen in spring, grasses in early summer, and ragweed from mid-August to the first fall frost. Knowledge of pollen counts (the number of pollen grains per
is sensitized to aeroallergens but is not necessary for the initial diagnosis. Imaging is not usually warranted in the diagnosis unless a concomitant condition such as chronic rhi- nosinusitis is suspected or there is a history of facial trauma or features to suggest anatomic abnormalities. Additionally, a positive response to a therapeutic trial of either topical nasal glucocorticoids or topical antihistamines does not conclusively establish a diagnosis of allergic rhinitis, due to these agents also being effective in the treatment of nonallergic rhinitis.
NON-PHARMACOLOGICAL APPROACH TO ALLERGIC RHINITIS
Allergen avoidance is the primary nonpharmacologic method for allergic rhinitis. Avoidance strategies ultimately depend on the specific allergen. House-dust mites (Dermatophagoides
cubic meter per 24 hours) helps patients plan outdoor activities. Most patients are symptomatic when pollen counts are very high, and only very sensitive patients have symptoms when pollen counts are low. Pollen counts are highest early in the morning and lowest after rainstorms clear the air. Avoiding outdoor activi- ties when pollen counts are high and closing house and car win- dows reduce pollen exposure. Ventilation systems with high-ef- ficiency particulate air (HEPA) filters remove pollen, mold spores, and cat allergens from house- hold air but not fecal particles from house-dust mites, which settle to the floor too quickly to be filtered. Filters need to be changed regularly to main- tain effectiveness. The systems are expensive and not effec- tive for all patients. HEPA filters are also found in some vacuum cleaners. Weekly vacuuming of carpets, drapes, and uphol- stery with a HEPA filter-equipped vacuum cleaner may help reduce household allergens, including those from house-dust mites. Nasal wetting agents (e.g., saline, propylene, polyethylene
spp), found in all but the driest regions of the United States, thrive in warm, humid environments. The main allergen is a fecal gly- coprotein, but other mite proteins and proteases are also allergenic. Avoidance strategies, targeted at reducing the mite population, include lowering the household humidity to less than 40%, applying acaricides, and reducing mite-har- boring dust by removing carpets, upholstered furniture, stuffed ani- mals, and bookshelves from the patient’s bedroom and other rooms if possible. Mite populations in bedding are reduced by encas- ing the mattress, box springs, and pillows with mite-impermeable materials. Bedding that cannot be encased should be washed at least weekly in hot (131oF) water; bedding that cannot be encased or laundered should be discarded. Outdoor mold spores are prevalent in late summer and fall, especially on calm, clear, dry days. Alternaria and Cladosporium are common out- door allergenic molds; Penicillium and Aspergillus are common indoor molds. Avoiding activities that dis- turb decaying plants (e.g., raking leaves) lessens exposure to outdoor
glycol sprays, gels) or nasal irrigation with warm saline (iso- tonic or hypertonic) delivered using a syringe or Neti pot may relieve nasal mucosal irritation and dryness, thus decreas- ing nasal stuffiness, rhinorrhea, and sneezing. That process also aids in the removal of dried, encrusted, or thick mucus from the nose. No significant adverse effects have been noted with the use of nasal wetting agents. Mild stinging or burning has been noted with saline irrigation. Only distilled, sterile, or boiled tap water should be used to prepare nasal irrigation solutions because of the risk of rare but serious infections.
mold. Indoor mold exposure is minimized by lowering household humidity, removing houseplants, venting food preparation areas and bathrooms, repairing damp basement or crawl spaces, and frequently applying fungicide to obviously moldy areas. Cat-derived allergens (the Fel d1 family of proteins, secreted through sebaceous glands in the skin) are small and light, and they stay airborne for several hours. Cat allergens can be found in the home months after the cat is removed. Although unproven, weekly cat baths may reduce the allergen load.
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