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The Informed Parent

Allergic vs Vasomotor Rhinitis

by John H. Samson, M.D., F.A.A.P.
Published on Apr. 23, 2004

Question: My 7-year-old son always seems to have a cold. He has a clear runny nose for days at a time and usually does not have a fever. He seems to feel all right except for the cold symptoms. Is it worthwhile taking him in to see his doctor, or is he just susceptible to colds?

Answer: This is an extremely common pediatric problem. Yet, the solution of it is not always as simple as the parents would like.

First, children do not have chronic colds. A cold, meaning a viral infection of the nose and throat, lasts on an average of five days. The average elementary school child gets about three to five colds per year. Whether they are treated or not, they improve readily. I would, therefore, like to remove the word "cold" from your question because I think it is misleading to you. What he has is a chronic or recurrent watery discharge from his nose, with nasal congestion. This is also known as serous (clear discharge) rhinitis (inflammation of the nose).

To digress for a moment: it disturbs me when I hear someone say that it is worthless to give parents or patients medical terminology because they cannot "handle it". I am convinced from my practice experience that they can "handle it" if we explain it to them. Thus, in this discussion I will refer to chronic serous rhinitis as a condition your son has.

Now we must look at the common causes of this condition. The two most common causes are allergy and vasomotor over-reactiveness of the tissue lining of the nose and throat. The latter condition involves over-reaction to an irritating stimulus or environmental change.

In allergic rhinitis the child has antibodies (specific proteins) in the blood stream that react with specific substances and provoke the body to release factors that cause the lining of the nose to swell, itch and produce excess mucus. In vasomotor rhinitis the irritating substance affects the lining of the nose directly. No antibodies are needed. Everyone is aware of allergies to airborne pollen, dust, fungus, animal dander, and food. The patient inhales, eats, or touches the substance he is allergic to. It enters the blood stream and the reaction occurs. I find that many parents are not aware of the non-allergic vasomotor rhinitis. This condition is provoked by sudden changes in environmental temperature, changes in flower scents, smoke, vapors from volatile liquids, as well as anxiety and fatigue. I am sure you have heard someone tell you, "I’m allergic to air conditioners" or "I’m allergic to perfume" or "Every time the weather changes I get allergies". These people are describing non-allergic, vasomotor rhinitis. The specific reaction they complain about may have no relation to allergy.

When confronted with this type of patient the physician must separate allergy from non-allergy. The treatment varies between the two diagnoses. Both patients would look the same. Thus, the physician might resort to laboratory tests and allergy skin tests to separate the two conditions. At times the two co-exist in the same patient. Thus, your physician may find clear-cut evidence of allergy, manage the allergy component perfectly, and still have some symptoms. These then must be controlled separately from the allergy management.

Ignoring the problem is not wise, as these children tend to get secondary infections in the nose and ears due to the congestion. Furthermore, if allergy is the problem, not only the nose but the child’s general well being may be affected. Irritability, headaches, poor school performance and mild behavior problems may also present in association with the allergy.

Management of the patient frequently necessitates addressing both conditions with separate medications. For the acute phase, allergic conditions respond best to antihistamines and the vasomotor patients are controlled most efficiently with decongestants. Many over-the-counter medications are combinations of antihistamines and decongestants. This shotgun approach certainly works in the patient with combined allergic/vasomotor rhinitis. For those with the pure form of either condition an extra drug is being given unnecessarily, albeit without causing harm.

To prevent these conditions and keep the patient symptom-free nasal inhalers have proven very effective and safe. Microdose cortisone nasal inhalers are available by prescription. They are remarkably effective in controlling the roller coaster clinical picture of runny nose, congestion and finally secondary infection as seen in patients with allergic rhinitis. If used in the proper dose range they provoke no side effects usually associated with cortisone therapy.

Cromolin Sodium (i.e. Nasalcrom) is a non-cortisone nasal spray that is effective in preventing vasomotor nasal congestion. It appears less effective in protecting the truly allergic patient.

These two types of nasal sprays have absolutely changed the management of the chronic runny nose. The microdose steroid has been an almost miraculous protector against airborne nasal allergies. Since it is topical it does not prevent the non-nasal symptoms (i.e. rashes, itchy eyes, etc.) that can be associated with airborne allergies. The patient with non-allergic chronic nasal congestion can be equally benefited by the use of Nasalcrom.

As I already mentioned some patients need to use both if the conditions co-exist in the same patient. There is no question that consulting your child’s physician is very helpful. The doctor can delineate the type of chronic rhinitis it is. If it is allergic, vasomotor or combined you can be directed to the most efficient modalities of diagnosis and therapy.

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