What is the point of treating hayfever?
The objective should be to let you lead a normal life. For this it is not necessary to remove every last symptom, but just to make the symptoms mild enough so that they do not interfere with your life.
Your treatment should depend on:
How bad your hayfever is.
Bad hayfever may need three or more treatments at once. Mild hayfever needs only an antihistamine or perhaps a nasal spray. Very mild hayfever may need no treatment, depending on how well you need to be to do your tasks.
What your most troublesome symptoms are.
A nasal spray if your nose is the main problem, an antihistamine plus eye drops if your eyes bear the brunt.
What your needs are; how effective the treatment needs to be to let you do what you need to do.
For example, if you are an actress on television you may need more treatment to be able to do your job well than if your job is not in the public eye. If you are taking exams, or having a job interview, you will also need the very best treatment.
Starting treatment early can keep your hayfever mild.
One of the nasty things about hayfever is that the hayfever itself makes your nose inflamed and sensitive. So as the season goes on you may get worse trouble from the same amount of pollen. Some treatments prevent this from happening, for example the nose sprays which have steroids in them. So starting your treatment just before you expect your hayfever season to start, can mean you need less treatment to get a good result.
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What treatments are there for hayfever?
There are many treatments, but just a few kinds are the most important ones. Here is a list.
Avoiding pollen
There may be some useful things you could do, from closing windows to going abroad, or even wearing special spectacles.
Antihistamine tablets, capsules, or liquid medicines
The simplest treatment. These help all the symptoms of hayfever, and the latest ones have excellent safety. But they may not treat all your symptoms well enough on their own.
'Antiallergic' nasal sprays or eye drops
A confusing name, as the other medicines in the list also act against allergy.
Two of these medicines, cromoglycate (Rynacrom ® & Vividrin ® nasal sprays, also other names) and nedocromil (Tilarin ® nasal spray, Rapitil ® eye drops), are similar to each other, work, and have very good safety.
A third medicine, lodoxamide (Alomide ® ) is an alternative which serves the same purpose.
Like the antihistamine sprays and drops they are used especially when people do not want to use steroid sprays or drops. As eye drops they are important because steroid eye drops do cause serious side effects.
Antihistamines, sprays or drops for your nose or eyes
Work about as well as the antiallergic drugs. Like them, they only help in the nose or eyes, where they are applied.
Steroid sprays or drops
Very effective and safe for the nose only. Steroid eye drops are very effective but can have serious side effects.
Decongestant sprays
Can help a lot over a short period of up to a few days, but cause worse trouble than you started with if you use them for longer.
Decongestant tablets
They definitely help blockage of the nose, but have side effects especially in people with high blood pressure or a number of other medical conditions. At least one of them, phenylpropanolamine, seems to carry a small risk of causing a stroke due to bleeding in the brain, at least when people take it as a slimming drug (definitely not recommended by us). Some antihistamine tablets or capsules have a decongestant in them.
Steroid tablets or injections
Work very well but have side effects. Should be used only for short periods when all else fails and it is really important to suppress symptoms, e.g. for exams, weddings, interviews.
Desensitising injections
Widely used throughout the world but hardly used in Britain, these can help hayfever when the best you can achieve with other treatments is not good enough.
What a lot of treatments! Should I use them all?
No! At least not unless your hayfever is truly terrible, and probably not then either. If your hayfever is as bad as that you had better see a recognised allergy specialist.
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The treatments in more detail
The following is based on treatments available in Britain.
Avoiding pollen
You may be able to help the problem by avoiding the cause. For example:
Plan important activities to avoid the pollen season
Plan your summer holiday in a country with less pollen, or at a time when you will not be disabled by hayfever. Otherwise, keep doors and windows shut during the high pollen season; this has a tremendous effect in lowering indoor pollen exposure.
If you can work in an air conditioned building this may help a lot.
If you drive a lot, putting an electrostatic air filter in the car's ventilation system will probably help. This is simply a felt-like cloth with special fibres which have an electrostatic charge. I am told that all cars now being made have provision for putting such a filter into the air intake. An air-conditioned car may also be very good because of the air filtering which it provides.
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Antihistamine tablets, capsules, or liquid medicines
Antihistamines, usually as tablets, are the basic treatment of hayfever. Their great advantage is that nowadays taking one tablet a day will treat the symptoms in the nose and the eyes and the ear and throat. Sprays and drops of any kind cannot do this. The only other medicines which help so many of the symptoms are steroid tablets, and they have far more side effects and so should only be used for short periods when there is a serious need. So antihistamines are excellent all-round treatments.
There are two main kinds of antihistamines to take by mouth:
Older antihistamines, which cause sleepiness
Newer antihistamines, which cause little or no sleepiness
Our advice is: don't take the older antihistamines which cause sleepiness, unless your doctor prescribes them because you need a tablet to help you sleep. They may be cheap, but there is clear evidence that they may cause road accidents and hinder learning by children in school. The newer antihistamines work just as well and, at least at normal doses, have no measurable harmful effect on driving or learning. The older antihistamines have these harmful effects even in people who do not notice sleepiness from the tablets.
Even preschool children should not have the older antihistamines in our opinion, again unless there is a specific reason why a doctor prescribes them in order to cause sedation or sleepiness. One reason for doing so is to reduce scratching in children with eczema.
The newer low-sedating antihistamines are at least as effective for hayfever. They cost more, but are still on the whole reasonably priced.
Examples of the newer and safer antihistamines
Official name Trade names Available without prescription in UK
acrivastine Semprex, Benadryl Allergy Relief Capsules Yes
cetirizine Zirtec, Zyrtec Yes
fexofenadine Telfast 120 (UK), Allegra (USA) No
loratadine Clarityn, Clarityne, Claritin Yes
mizolastine Mizollen No
desloratadine Neoclarityn No
Terfenadine and astemizole have been withdrawn and if you have old supplies we advise that you should check with your doctor before using them. Under rare circumstances they caused death from an abnormal heart rhythm. Click on terfenadine to find out more. The currently available antihistamines do not have this problem.
These antihistamines differ in a number of ways, such as the size of the tablets, the length of time for which they act, how effective they are, the extent to which they may still have a slight tendency to cause sleepiness (though all are vastly better than old antihistamines for this) and in price. Your doctor should be able to recommend one. Fexofenadine (Telfast 120) is a development from terfenadine, which was for many years the best-selling modern antihistamine. It was turned into fexofenadine in the body, so in effect people have been treated with fexofenadine since terfenadine was introduced 17 years ago. This long experience is a safety advantage. The switch from terfenadine to fexofenadine solved the one known significant safety problem with terfenadine. Acrivastine is claimed to work more quickly than the others, although they all work within an hour under most circumstances. But acrivastine needs to be taken three times daily, whilst all the others can be taken once a day. Mizolastine is a relative newcomer, but has shown good effectiveness in trials. Other antihistamines are under development.
It is a problem that older antihistamines, which do cause drowsiness, are still on sale without prescription. Even if they are cheaper, we think drowsiness is an unacceptable side effect in hayfever and strongly recommend that you stick to one of the modern low-sedating ones.
Are antihistamines safe if you are pregnant?
A lot of research has been done to check the safety of the commonly used older (sedating) antihistamines in pregnancy. The researchers found no evidence of harm to unborn babies. In the case of the newer low-sedating versions it has not been possible to do systematic research. But some of them have been used such a lot that I think it is perfectly reasobable to assume that they are safe enough during pregnancy. The reason for this is that many women become pregnant without knowing it until their pregnancies are well advanced. A proportion of these women will inevitably take medicines including antihistamines. In real life some babies are of course born with malformations whether the mother takes medicines or not. When a malformed baby is born, both the parents and the doctors are bound to enquire whether the mother took any drugs during the critical stages of the baby's development. So the fact that we have not heard of any bad effects related to pregnancy is good evidence for safety in the case of the most used new antihistamines.
Although fexofenadine is a fairly new medicine, it has been around for much longer than seems to be the case because its widely used predecessor, terfenadine, was turned into fexofenadine in the body. Similarly, desloratadine is produced in the body when people take its long-used predecessor loratadine, so desloratadine is also likely to be safe in pregnancy. In both cases the dose of the new drug may produce higher concentrations in the body than were previously achieved (I am not certain of this), perhaps justifying caution. My guess is that this is not likely to be important. Levocetirizine, also a new drug, is present in its forerunner cetirizine at the same dose.
In summary, there is no way of being absolutely sure, but all three of these new drugs have a much longer track record than you might think, and no hazard in pregnancy has been shown. So it is worth discussing with your doctor whether the benefit and risk are such that you could consider taking them. Even with such advice, the final decision must be your own. With my own patients, there is a limit to the amount of suffering I expect an expectant mum to put up with to avoid any possible small undiscovered risk.
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'Antiallergic' nasal sprays or eye drops
Two main medicines, cromoglycate and nedocromil, both of which work and have very good safety. Like the antihistamine sprays and drops they are used especially when people do not want to use steroid sprays or drops which do cause serious side effects.
Eye drops STING a bit if your eyes are inflamed. Don't worry about this; it soon goes away. The reason for the stinging is not the medicine, but the germ-killing antiseptic which has to he in the drops to make sure that they are safe to use even for people who have other eye problems as well as allergy. After you have been using the eye drops for some days they should be working, and your eyes should be less sensitive to this. If you really can't stand the stinging, then probably no eye drops will suit you and you'll probably prefer tablets.
Nose sprays may sting as well. This may vary from product to product, so it is worth experimenting. It is not specially a problem with the 'antiallergic' nose sprays.
Examples of 'antiallergic' drops or sprays
Official name Trade names
disodium cromoglycate nasal spray Rynacrom, other brands
disodium cromoglycate eye drops Opticrom, other brands
nedocromil sodium nasal spray Tilarin
nedocromil sodium eye drops Rapitil
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Antihistamine sprays or drops for your nose or eyes
Work about as well as the antiallergic sprays and drops, and have about the same advantages and disadvantages. Of course they also work only in your nose or eyes.
If they work for you, fine. You're getting a good result without taking tablets which get to your whole body. You may like that aspect. You're also using a medicine which is not a steroid. In your nose, the steroid sprays really are tremendously safe and work like no other spray, but you might still prefer not to use a steroid if an antihistamine or antiallergic spray suits you.
But steroids in your eyes really are a bad idea if there is another medicine which will do the job.
So there is definitely a place for the antiallergic and the antihistamine drops and sprays.
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Steroid sprays for your nose
No other kind of spray is so effective in the nose. Particularly, steroid sprays seem to work better against blockage of your nose from allergy than antihistamines do.
But the nose is a complicated thing. Inside, it looks a little bit like the inside of a walnut. Since you're trying to cover the lining with spray through two little holes, your nostrils, you may not be very successful in covering the whole of the lining. There's a way round this problem; we hope to describe it with pictures.
Meanwhile, A USEFUL TIP FOR USING ANY NASAL SPRAY which is a watery liquid. It could help if you've found sprays not much use in the past.
Blow your nose first if necessary
Tilt your head forward rather a lot: look at your feet
Hold the spray so that the spout points straight up
Spray one or two puffs into each nostril whilst sniffing for each puff
Immediately get into a position so that your head is truly UPSIDE DOWN. Either kneel with your head between your knees, or lie across your bed with the edge of the bed behind your shoulder blades and your head tipped backwards until it is upside-down. You may need some practice and the help of a family member watching from the side to make sure your head really is truly upside down.
Stay in this position for at least 30 seconds, sniffing in and out briskly and repeatedly to really spread the drops around inside your nose.
That's it. You can get up now.
If you do this right, the first thing you'll notice is that the liquid no longer trickles down your throat like it used to. That means that the liquid has at least stayed in your nose, which is where you want it. Give it a try if you've found sprays didn't work too well for you in the past.
But don't make life complicated if you don't need to. If the ordinary way works, stick with it.
How did you get on? OK, you can try it tomorrow.
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'STICKY' SPRAYS: Nasacort is a steroid spray which is formulated to stick to the lining of your nose instead of just running out. It is liquid when sprayed, but becomes jelly-like when it stops moving so fast. This should make it work better, and it is more convenient than the gymnastics I have just been describing. Other manufacturers claim that their steroid sprays also do this. Our suggestion: find out what works for you.
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And now YET ANOTHER USEFUL TIP FOR STEROID SPRAY USERS. If your nose has been really badly affected by hayfever before, START USING YOUR STEROID SPRAY BEFORE YOU EXPECT YOUR HAYFEVER SEASON TO START.
Why? Well, it's to do with the way steroids work. Over a period of days, they prevent a build-up of inflammation in your nose which starts even before you notice any serious trouble. An inflamed nose is a sensitive nose, which will make you sneeze when you look into the sunlight or when you're trying to impress someone. So don't let it get inflamed in the first place. Keep the thing under control, and keep your cool.
There's a lot of scientific stuff behind this advice, but you don't want to be bothered with all that right now, do you? It works.
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Do steroid nasal sprays have side effects?
They are wonderfully safe. Why? Well, firstly the dose is low. You just spray them where you want them so you don't need to use much as far as the whole body is concerned. Secondly, the steroids in the sprays are 'biodegradable'. They break down very quickly in the body, so they don't have time to cause side effects. The way this works is that the manufacturers choose steroids which are very easily split by enzymes in the liver. This means they work in your nose but not once they get into your bloodstream, because they simply don't hang around there long enough.
But do they have bad effects in your nose? After all, that is where they work. Certainly when they were invented doctors rather expected that the lining of the nose might become thin. But time has shown that this is not a problem. Amazingly, microscope examination of the lining of the nose after many years of spraying steroids show that the lining is more healthy after the steroids than after the inflammation of the nose which steroids remedy.
During pregnancy we know that steroid nasal sprays in normal doses are safe for your unborn baby, because the same medicines have been used widely for asthma without harm to babies.
These are the main side effects which we do know about:
STINGING IN THE NOSE from nasal sprays is a problem for a few people. The different brands differ in how much they sting. The stinging does no harm, and will get better if you persevere, because over days your nose will become less inflamed as you use the spray, and so less sensitive to the stinging.
For a few people this does not seem to work. For them, STEROID POWDERS IN THE NOSE are better. They contain no preservative. Unfortunately they are not available in Britain. In other countries the Astra Nasal Turbuhaler is the answer to this problem.
In Britain, you could try a steroid powder inhaler intended for asthma sniffed into your nose if your doctor agrees. This is not ideal, but may work. If you find it really necessary, improvise some kind of home-made adaptor to make it fit your nostril better.
NOSE BLEEDS are uncommon, and often temporary and not serious. If you get these and they really bother you, see an Ear, Nose and Throat surgeon, who may sort the problem out. There may be some delicate blood vessels in your nose which you can get rid of by having them cauterised.
Some doctors think that steroid sprays in the nose can cause problems if you use them too soon after a nose operation. Others think the damage was just caused by people pushing the spray nozzle against the spot which had just been operated on. Your surgeon will advise you.
Thrush in the nose. This is rare indeed. Don't worry about it. I have never seen it. It is a yeast infection, not really terribly serious in an otherwise healthy person, and goes away if you stop the treatment.
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Steroid eye drops
Steroid eye drops are very effective but can have serious side effects. So we don't like prescribing them for hayfever. But sometimes they are a good choice for a short time. What side effects? Increased pressure in the eyes (glaucoma), cloudiness of the lens in the eye (cataracts), and damage to the cornea, the transparent front covering of the eye. Blindness is a possible result of all three.
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Decongestant sprays
Can help a lot over a short period of up to a few days, but cause worse trouble than you started with if you use them for longer.
What happens is that they give you marvellous relief of the blockage in your nose. Only when they wear off, not all that long afterwards, your nose is blocked again. If anything, it's a bit more blocked than before you used the decongestant. This goes on, and if you carry on long enough you will have a worse blocked nose than you have ever had before, and it will seem that you have to use the spray all the time to be able to breathe at all through your nose.
The only remedy is to stop using the decongestant, put up with a very badly blocked nose, and get back to the state you would have been in if you had never used it. This will be better than the state you got yourself into with the decongestant spray.
All this does not happen with steroid or antiallergic or antihistamine sprays. They are safe. Only the decongestants make you worse than before.
Scuba divers may be tempted to use decongestant sprays to prevent pain in their ears during the descent. This has been considered potentially dangerous, as the spray may be wearing off by the time you return towards the surface, trapping compressed air in the middle ear where it might cause burst eardrums. There is also the argument that if you think you need such a spray you are not medically fit to dive. Scuba diving without adequate training and information is dangerous; consult a doctor expert in the medical aspects of diving if in the least doubt.
But there is a proper place for decongestant sprays after all. They can be useful for short periods, up to a few days if necessary. Perhaps they may help if you use them just before the descent at the end of an air journey, because the spray may help you 'clear your ears' by swallowing, so that you don't get pain in your ears because of large pressure differences between the inside and the outside of your ear drum. You can buy decongestant sprays in some airport shops.
Decongestant sprays may help you get started with a steroid spray which would otherwise just not get into your nose. Don't be afraid of them if your doctor recommends them for short periods.
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Decongestant tablets
can help, but the risks are considered potentially serious by some authorities
They definitely help blockage of the nose, but there is some evidence that on rare occasions they have devastating side effects. There is strong evidence that at least one of them, phenylpropanolamine, can cause strokes due to bleeding in the brain when it is used as a slimming aid (we don't recommend this use), and and weaker evidence that it can do this when taken in cough and cold remedies. For more information see an article in the New England Journal of Medicine prepublished on the web. An article in the British Medical Journal also gives information on this. They can cause trouble especially in people with high blood pressure or a number of other medical conditions. They cause difficulty in sleeping in some people. Many people have found them helpful, and the tablets don't cause the same nose trouble which people get from nasal sprays. But the US Food and Drug Administration (FDA) has recommended that phenylpropanolamine should be withdrawn voluntarily from non-prescription medicines because of the risk of strokes. Sadly, we agree that this is prudent.
Decongestants are put into some tablets or capsules together with an antihistamine, and tests show that these combined tablets work better for quite a lot of people. But the the evidence about phenylpropanolamine has dampened my limited enthusiasm for these. Some of these combined tablets contain old out-of-date antihistamines which cause sleepiness. Taking a mixture of one medicine which makes you sleepy and another which wakes you up does not make you normal, but probably more abnormal than if you took either alone. So if you decide to take the risk from the decongestant (or don't believe there is a significant risk), at least stick to one with a nonsedating antihistamine.
If you do wish to take decongestants by mouth, consult your doctor first, rather than just buying them without consultation. Do not exceed the recommended dose.
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Steroid tablets or injections
Work very well but have side effects. Should be used only for short periods when all else fails and it is really important to suppress symptoms, e.g. for exams, weddings, interviews.
Definitely worth using, under a doctor's supervision, if hayfever would otherwise interfere with your ability to function at a critical time in your life.
Our preference, quite definitely, is for tablets, not injections. Why inject something if taking small tablets works just as well? With tablets the dose can be adjusted and kept to a minimum. If it suddenly starts to rain for days on end, you won't need much or any. Steroids do have side effects. When your crisis or important event is over, you can stop taking the steroid tablets. The injections which doctors usually use are so-called 'depot steroids' which are supposed to stay around for a long time, whether you still need them or not.
Steroid injections sometimes cause 'fat atrophy', making a dent in your buttock which may look odd if you wear a swimsuit. Rarely they can cause an abscess. Though rare, this is extremely unpleasant. Another rare side effect of injections is anaphylaxis, an allergic reaction which may be life-threatening. Although tablets have caused anaphylaxis too, that is vastly more rare still and is likely to be less serious. Tablets are safer on all counts.
The argument for the injections is that some people find them convenient. But frankly, if tablets are too inconvenient for you, do you seriously need this treatment?
If your doctor is not sure what dose of steroid tablets to prescribe, we suggest two ways of looking at this.
The first is that short courses of steroid tablets are often prescribed for asthma which has temporarily become worse; a similar course would do for you. You could be treated as if you had a moderate worsening of asthma requiring a moderate dose of steroid tablets.
The other is to start with 20 or 30 milligrams of prednisolone daily for one to three days and then reduce to 20, 15 or 10 mg daily in the morning. Keep dose at the minimum which gives adequate control, but increase again if control is not adequate. It is unusual to need this treatment for more than 2 or 3 weeks. Once the need has passed, stop without bothering to reduce the dose gradually.
Remember, use steroid tablets only to enable you to function normally in an important part of your life. The aim is not to remove every last symptom unless that is really important for you, e.g. if you are an actor or singer and hayfever during filming or singing would ruin a critically important performance. Stop the steroids when the important event is over, or when the worst part of the pollen season subsides, whichever comes earlier. Refer to a pollen count graph to see when the bad part of the pollen season is. For the middle of the UK you will find a good one on our hayfever page.
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Desensitising injections
Widely used throughout the world but hardly used in Britain. They do work, however, and can help hayfever when the best you can do with other treatments is not good enough.
You really should have advice from an allergy specialist before you embark on this. It is a time-consuming treatment, especially the way we do it in Britain, and there is a very small risk of death from the treatment. But then lots of other things we do, like travelling by car, have a small risk of death. You do however want to be driven by a good driver, and likewise, desensitisation should be prescribed and supervised by an expert.
The other thing the expert may be able to do for you is to help you really get the best out of all the other treatments, and you may find that you then don't want desensitising injections.
Desensitising injections are not a cure. They make the symptoms less, which may well mean they are perfectly bearable or easily treated with the other medicines.
In Britain most specialists would not desensitise with a mixture of things you are allergic to. For grass pollen hayfever they would only give you grass pollen injections, for example. Also, in Britain we insist on giving the injections in a hospital environment so that you can have swift and efficient treatment if you have a life-threatening allergic reaction. This and the one-hour wait after each injection makes it even more time-consuming.