CL, a nine-year-old with allergic rhinitis

CL’s mother brought him to the clinic with concerns about his persistent ill health. She reported frequent doctor visits over the past two years, during which he was prescribed antibiotics and even steroid syrup. Despite this, his symptoms persisted, leaving her increasingly worried.

The primary issue was CL’s sneezing, particularly in the mornings. This was disruptive to both his home life and school performance. For CL, the sneezing was compounded by a blocked nose and a constant sensation of phlegm at the back of his throat. He frequently attempted to clear his throat to mitigate this symptom, though this was largely ineffective. At night, his blocked nose disturbed his sleep, and his mother noted that he was snoring. Occasionally, he experienced itching during the night.

History

CL had eczema as a baby and young child, which improved with age but flared up occasionally. Over the past year, his skin has become drier, with intermittent eczema flare-ups. He has never been diagnosed with asthma and remains physically active, though he coughs when unwell, often in an attempt to clear mucus.

Born via caesarean section in Pretoria, CL was breastfed for three months. He was a healthy baby, apart from the early skin issues. His sneezing and blocked nose began around the age of four. Three years before the consultation, the family relocated from Pretoria to George, moving into a house with carpeted bedrooms. They did not perceive the house to be damp and had an outdoor dog.

Family history

CL was an only child. His mother had asthma, and his father suffered from allergic rhinitis.

Previous treatments

CL had been prescribed nasal sprays in the past, which provided temporary relief but did not resolve his symptoms. During severe episodes, the family used intranasal decongestant sprays but limited their use to five days, aware that there might be potential side effects. Antihistamines helped to reduce his sneezing but caused drowsiness, which affected CL’s concentration at school. Teachers had noted that he often appeared tired and struggled to focus.

Examination results

CL had a long, pale face, dark circles under his eyes (allergic shiners), and a nasal crease from frequent nose rubbing (nasal salute). He repeatedly touched his nose due to itching and clicked his tongue to alleviate throat irritation. His lips were dry, and he breathed through his mouth throughout the consultation.

Dental examination revealed malocclusion and a mild overbite; his mother noted that braces may be required. Inside his nose, the inferior turbinates were pale and enlarged. His throat showed a cobblestone appearance, and his skin was dry, with visible scarring on his forearms and at the back of his knees.

Diagnosis and allergy testing

CL stopped taking antihistamines five days before the consultation to enable accurate allergy testing. Skin prick tests revealed allergies to house dust mites (including the Blomia tropicalis variant), grass pollen, oak tree pollen, and the mould Alternaria.

Based on his history, symptoms, and test results, CL was diagnosed with chronic allergic rhinitis.

“Antihistamines helped to reduce his sneezing but caused drowsiness, which affected CL’s concentration at school, and teachers had noted that he often appeared tired and struggled to focus.”

Treatment plan

1. Education

CL’s mother was informed that allergic rhinitis is a chronic condition, not curable but manageable. Indoor allergens, particularly house dust mites and mould, are present year-round, with mould exposure more prevalent in coastal and damp areas like George. Additionally, the longer and more complex pollination seasons in George exacerbated his symptoms.

2. Intranasal steroids and nasal hygiene

An intranasal steroid spray is the cornerstone of treatment for chronic inflammation. Proper application technique is crucial:

Use a saline spray or douche to clear mucus before applying the steroid.
Blow the nose, then spray laterally using opposite hands for each nostril.
This routine should be maintained throughout the year to manage symptoms effectively.

3. Antihistamines

CL was prescribed a second-generation antihistamine (in this case rupatadine) to avoid the sedative effects associated with first-generation options. Rupatadine is particularly beneficial due to its ability to block platelet-activating factor, a key mediator of nasal congestion and chronic atopic inflammation. It also helps alleviate skin itching, improving CL’s overall quality of life.

While rupatadine may be used for persistent allergic rhinitis , this antihistamine may be used for symptomatic relief once symptoms are well controlled.

4. Skin care

Daily use of a high-quality emollient is essential to manage CL’s eczema and prevent dry skin. During flare-ups, a topical steroid ointment may be applied for up to seven days. For long-term control, non-steroidal alternatives, such as PDE4 inhibitors or calcineurin inhibitors, would be considered.

5. Environmental control

Targeted advice was provided to reduce exposure to identified allergens:

Regularly wash bedding in hot water to reduce house dust mites.
Use mite-proof covers for mattresses and pillows.
Minimise carpeting and fabric upholstery in bedrooms.
Ensure adequate ventilation to reduce mould growth.

6. Follow-up and monitoring

Regular follow-up consultations every six months are necessary to monitor CL’s progress and adjust treatment as needed. Signs of potential asthma, such as coughing during exercise or at night when not ill, must be closely observed. Spirometry testing can be performed if asthma is suspected.

7. Immunotherapy

If symptoms persist and the medication burden remains high, specific allergen immunotherapy would be considered. This three-year treatment could desensitise CL to grass pollen, improving his quality of life and enabling him to enjoy outdoor activities without significant symptoms. It is, however, expensive.

Conclusion

With a comprehensive treatment plan combining education, intranasal steroids, second-generation antihistamines, and environmental control measures, CL’s symptoms should improve significantly. The goal is to enhance his quality of life, improve concentration at school, and reduce the risk of developing asthma in the future. Regular monitoring and a proactive approach will ensure his condition remains well-managed.

Dr Corli Lodder is the founder of the Allergy and Asthma Clinic in George in the Western Cape. She is a GP with a special interest in allergic disease. She has been a member of the SA Allergic Rhinitis Working Group since 2006, where she is involved in drafting guidelines for the treatment of AR in South Africa.

To watch a webinar recently presented by Dr Lodder, please click here The webinar, entitled 'When a mast cell degranulates: Implications for AR and urticaria', is accredited for 1 General CPD point.