Analysis

How to help patients cope with hay fever

Symptoms can be debilitating, but the condition is often under-recognised and poorly managed
Hay fever

Though symptoms can be debilitating, the condition is often under-recognised and poorly managed

  • Hay fever is caused when the body makes allergic antibodies to pollen and it is experienced by about a third of UK adults
  • The severity of symptoms varies widely and management plans should be matched to individual needs
  • How to advise patients on simple steps they can take to improve their quality of life

About a third of adults and children in the UK are believed to have allergic rhinitis, the uncomfortable condition better known as hay fever.

In the spring and summer, huge numbers of people experience hay fever symptoms, including itchy, watery and red eyes, itchy throat, sneezing, tiredness and a blocked or runny nose.

Difficulties getting appropriate advice and help for hay fever

The condition may be

...

Though symptoms can be debilitating, the condition is often under-recognised and poorly managed

  • Hay fever is caused when the body makes allergic antibodies to pollen and it is experienced by about a third of UK adults
  • The severity of symptoms varies widely and management plans should be matched to individual needs
  • How to advise patients on simple steps they can take to improve their quality of life

Picture: iStock

About a third of adults and children in the UK are believed to have allergic rhinitis, the uncomfortable condition better known as hay fever.

In the spring and summer, huge numbers of people experience hay fever symptoms, including itchy, watery and red eyes, itchy throat, sneezing, tiredness and a blocked or runny nose.

Difficulties getting appropriate advice and help for hay fever

The condition may be common, but getting the right advice is not always as straightforward as it should be.

Guidance from the British Society for Allergy and Clinical Immunology (BSACI) says that, despite being the most common immunological disease, hay fever is ‘still subject to under-recognition and poor management’.

Hay fever is caused when the body makes allergic antibodies (IgE) to pollen, according to Allergy UK.

Grass pollen is the most common hay fever allergen in the UK, generally present between May and July and accounting for about 90% of hay fever cases. But pollen from trees, especially birch, from February to June, and weeds, between June and September, can also cause an allergic reaction.

In perennial allergic rhinitis the symptoms continue all year round and usually relate to indoor allergens, such as house dust mites, pets or mould.

Severity of symptoms varies wildly, but they can be debilitating 


Amena Warner: 'Uncontrolled hay
fever can affect academic achievement'

While hay fever for some people is a relatively minor ailment, it can have a significant impact on quality of life, and needs to be adequately recognised by healthcare staff, says Amena Warner, head of clinical services at Allergy UK.

‘One of the things with hay fever is it can be so variable,’ she says. 

‘In one person it can be a very mild problem and they can go to the chemist and get over-the-counter antihistamines, while for other people it is so significant it affects their quality of life.

‘It can affect their work, their social lives and schooling for children. There is good evidence that uncontrolled hay fever can lead to children dropping a grade when taking an exam. And nearly every single exam takes place in high pollen season.’

Hay fever symptoms: what to look out for


Picture: iStock

Symptoms can include:

  • Itchy eyes and/or throat
  • Sneezing, and blocked or runny nose
  • Watering, red eyes (known as allergic conjunctivitis)
  • Headache, blocked sinuses
  • Shortness of breath
  • Tiredness
  • The sensation of mucus running down the back of the throat

Source: Allergy UK 

 

Practical ways to minimise hay fever symptoms

Up to 57% of adults and 88% of children with allergic rhinitis have trouble sleeping, leading to daytime fatigue and decreased cognitive functioning, according to the World Allergy Organization’s White Book on Allergy.

It also says that irritability, anxiety, depression, frustration, self-consciousness and lower energy, motivation, alertness and ability to concentrate are commonly present in people with allergic rhinitis.

‘It is important not to trivialise hay fever. As an inflammatory response that involves the airway, it is important that it is well managed, especially in those with asthma’

Janette Bartle, allergy nurse specialist (ENT)

BSACI says diagnosis rests on taking an adequate detailed history and supplementing this with examination and, if necessary, specific allergy tests. The timing of symptoms in relation to possible allergen exposure is important.

Following diagnosis, advising people on self-management is key, Ms Warner says. There are some simple practical steps that all people affected should take when pollen counts are high, such as closing windows and doors.

Some of these steps can also be taken to reduce pollen levels inside healthcare settings, Ms Warner says.

Training for primary care professionals

Allergy UK runs free one-day master classes, aimed at primary care staff, on different aspects of care for those affected by allergies. BSACI also runs a programme of training events.

As most patients will be seen in primary care, education for practice nurses is important, Ms Warner says. ‘For a lot of primary care professionals, allergy has never been on their agenda, so it needs to be demystified, and that is what we hope to do with our training.’

Managing hay fever: simple steps your patients can take

  • Monitor pollen forecasts daily and stay indoors wherever possible when the count is high (generally on warmer, dry days). Rain washes pollen from the air so the pollen count should be lower on cooler, wet days
  • On high pollen days, shower and wash your hair when you get home and change your clothes
  • Avoid drying clothes outside when pollen counts are high
  • Apply an effective allergen barrier balm around the edge of each nostril to trap or block pollens and other allergens, as this can help prevent a reaction
  • Wear sunglasses when outside to protect eyes from pollen
  • Place your pillow under the bed covers during the day to stop pollen getting on it

Source: Allergy UK

 

Effective management of hay fever in conjunction with asthma


Janette Bartle: 'Tailor advice to
patients' symptoms'

Allergy nurse specialist (ENT) Janette Bartle, of Ipswich Hospital, says nurses need to listen carefully to patients during assessments to tailor advice to their symptoms.

It is particularly important that hay fever is well managed when a patient has asthma, as uncontrolled allergic rhinitis can exacerbate dangerous symptoms. ‘Practice nurses should be asking patients whether they have allergic rhinitis during their annual asthma review, and checking that it is well managed,’ she says.

When it comes to treatment, an occasional antihistamine tablet can be sufficient for people with very mild symptoms, she says.

BSACI guidelines recommend nasal corticosteroids as the treatment of choice for moderate to severe hay fever. Combination therapy using intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second-line treatment.

The guidance Allergic Rhinitis and its Impact on Asthma provides targeted treatment advice.


The benefits of daily nasal douching

Ms Bartle recommends that nurses encourage patients with regular symptoms to begin daily nasal douching, followed by a steroid nasal spray, a couple of weeks before the pollen they are allergic to is expected to emerge.

Nasal douching with saline solution, either home-made or shop bought, cleans out mucus and pollen, and leaves the mucus membranes of the nose clear to absorb the steroid spray. 

To perform nasal douching, the patient can sniff the solution into their nose from a mug or their cupped hand. No specialist equipment is required, although there are a range of products available that may aid the procedure, such as medical squeeze bottles and ready-mixed saline solution sprays.

When it comes to using nasal sprays, practice nurses need to teach patients how to do it effectively, Ms Bartle says.

‘Using the opposite hand to the nostril in which they will apply the spray, patients should place the end of the spray bottle just inside the nostril, aiming it away from the nasal septum,’ she says. ‘Do not sniff while spraying, because sniffing hard causes the medication to pass straight through the nasal cavity and be swallowed, rendering it ineffective. It is not necessary to block the other nostril while activating the spray.’

When to consider immunotherapy

Immunotherapy is a well-established treatment for severe allergies where symptoms cannot be controlled.

It is a way of reprogramming the immune system to stop adverse reactions to an allergen.

It has been shown to reduce severe symptoms and improve quality of life, according to Allergy UK.

Immunotherapy for hay fever can be given through an injection of allergen extract into the skin (usually in the upper arm), or it can be given orally (either in drops or tablet form placed under the tongue).

Injections can only be carried out in specialist centres at hospitals by highly experienced staff, so that side effects can be monitored and promptly treated.

There are a number of different regimens, including short courses of 4-6 injections before the start of the hay fever season. For long-term benefits, immunotherapy is best given over three consecutive years.

Source: Allergy UK

 

Treatment should be tailored to the individual 

Ms Bartle also recommends the use of non-medicated pollen barriers, which include silicon powder and gel nasal sprays which are puffed or squirted inside the nose, or creams which are rubbed around the outside of the nose. 

‘From a nursing point of view it is about listening to the patient, helping them identify what is the biggest issue and guiding them to the right treatment,’ Ms Bartle says.

‘I strongly recommend that people carry out regular nasal douching and use the steroid sprays to control nasal congestion, and include antihistamine tablets when itchy, sneezy symptoms become excessive during high pollen release times. I encourage patients to check daily pollen levels on the Met Office website so they know when their symptoms are likely to be more severe.’

‘Hay fever can be debilitating – but we take a positive approach to it’

For Emma Wood, spring heralds the arrival of unpleasant symptoms, including itchy, streaming eyes and nose, skin rashes and swelling.

The 13-year-old has lived with a host of severe allergies, including to grass and tree pollen, since she was born.


Emma Wood has had severe
allergies since birth

Her mother Katie says the family have come up with a range of tactics that minimise the distressing symptoms.

Emma, who lives in West Sussex, uses a nasal spray every day, which she has been taught to use properly so it effectively coats the membrane lining of the nose, and also takes an antihistamine tablet.

‘As soon as she comes in from school or from being outside, Emma showers and washes her hair and changes her clothes to get rid of pollen. She immediately feels much better after doing this,’ Ms Wood says.

‘I don’t dry her clothes outside in the spring or summer, as they would get coated in pollen, and she has to avoid our dog during the hay fever season, as he carries pollen in his fur. We keep windows and doors shut as much as possible, to try and limit the amount of pollen that gets in the house.’

When the pollen count is high, Emma will often have to stay inside during breaks at school.

While some of her other allergies are more serious and require her to carry an EpiPen in case of anaphylactic shock, hay fever still has a big impact on her quality of life.

‘We take a very positive approach to Emma’s allergies, and she can do everything her friends can, although with some adaptions,’ Ms Wood says. ‘But hay fever can be debilitating and it is not always recognised as such. It is tough for a teenager to look different at school, so it is hard when all your school friends are outside at lunchtime sitting on the grass and you are stuck inside, or need the window shut in a classroom during a lesson.’ 

 

Next steps when symptoms are severe

Hay fever needs to be taken seriously, Ms Bartle says.

‘It is important not to trivialise it. It is an inflammatory response in the body that involves the airway, so it is important that it is well managed, especially in those with asthma. I find that treating nasal symptoms often controls and reduces all other allergy symptoms.’

For more severe cases, a referral to an allergy specialist centre may be required.

But Allergy UK warns that access is not always straightforward. ‘There are long waits, not enough allergists, and not enough people doing immunotherapy,’ Allergy UK’s Ms Warner says.

‘It is about trying to find a centre with a reasonable travelling time without having too long a wait.’


Erin Dean is a health journalist


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