When Your Allergic Rhinitis Is NOT Allergic

non-allergic rhinitis and allergic rhinitis

Non-Allergic Rhinitis

Most of the readers of this blog site are familiar with the symptoms of rhinitis:

  • Stuffy nose – nasal congestion
  • Runny nose – “rhinorrhea”
  • Phlegm in the throat – “post-nasal drip”

Most of us make the assumption that these are signs of allergies – allergic rhinitis – that these symptoms result from an allergic reaction to something in our environment.

If that is true, we should be able to detect the triggers – the “allergens” – by allergy testing.

Severe allergic reaction can result in swelling of the lining of the nose and of the eyes.

When I was a kid, my allergies were so bad that my eyes would swell shut, and I would miss school. A bit like the image of the boy, above. Allergy testing and immunotherapy (“allergy shots”) changed my life for the better.

But what can we conclude when people have these signs and symptoms, but all of their allergy testing is negative?

The term used is “non-allergic rhinitis”.

Possible causes of non-allergic rhinitis include:

  • Environmental irritants. Particulate pollutants, dust, smog, secondhand smoke, chemical fumes, can all cause rhinitis without true allergies. In children, one of the most common sources of environmental irritants that I have found in my clinics is the chlorinated pool.
  • Hormonal changes. Women, and especially pregnant women, can experience non-allergic rhinitis as a result of hormonal changes. See my article on Rhinitis of Pregnancy for how to manage that.
  • Infections. A common cause of nonallergic rhinitis is a viral infection – a cold or the flu. This should clear up within 2 weeks. Infectious rhinitis can become chronic, and usually includes a sinus infection – chronic rhino-sinusitis.
  • Foods and drinks. Some foods can cause rhinitis and swelling of the nasal membranes – with resulting nasal congestion –  without true allergies.
  • Medications. Some medications can cause nonallergic rhinitis. Examples include the non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin and ibuprofen, blood pressure medications or heart medications.
  • Over-use of nasal decongestant sprays (oxymetazoline) can cause rebound nasal congestion – “rhinitis medicamentosa”. Click on this link for a Review of Rhinitis Medicamentosa.

Complications from non-allergic rhinitis include:

  • Nasal Polyps. These are benign growths that develop from the nasal and sinus lining. These can block sinus openings and even obstruct the nasal airway, making it difficult to breathe. An Otolarngologist (Ear, Nose & Throat Doctor) should evaluate an growth in the nose or sinuses.
  • Chronis rhino-sinusitis (CRS). Prolonged swelling of the nasal and sinus lining can block the sinus openings, increasing the risk of developing sinusitis. Sinusitis lasting longer than 3 months is considered “chronic sinusitis”. It is nearly always associated with chronic rhinitis too, and the term chronic rhino-sinusitis has been adopted by experts.
  • Ear Infections. Chronic swelling of the nasal lining tissues (mucosa) is often associated with inflammation and swelling of the Eustachian tube lining as well. Dysfunction of the eustabhian tubes will result in middle ear infections – otitis media.
  • Decreased quality of life. Chronic rhinitis, or CRS, have been shown to severely and negatively impact quality of life – as much or even more than other chronic diseases that we think of as severely affecting quality of life: diabetes or heart conditions. Here is my 5-Step Program to eliminate CRS.

All of these complications should be evaluated by an Otolaryngologist.

Are there symptoms that help distinguish Allergic Rhinitis from Non-allergic Rhinitis?

The short answer is “not really”, or at least, “not much”.

Along with my colleagues at Nationwide Children’s Hospital (Dr. Elizabeth Erwin) and the University of Virginia Health System (Dr. Larry Borish), we had evaluated over 150 children with chronic rhinitis. We performed allergy testing on them, assessed the volume of their nasal airways using technology called “acoustic rhinometry,” and had their parents describe all of their signs and symptoms through a detailed questionnaire.

Bottom line? The only symptom that separated the children with rhinitis and detectable allergies (positive allergy tests) from those with non-allergic rhinitis was itching – itchy eyes, specifically. This study is in press, to be published in the American Journal of Rhinology and Allergy.

When severe, the itchy, irritated eyes swell shut – like mine did when I was a wee lad, and like the photo of the boy above.

So, if your little boogorhead has itchy eyes, consider allergy testing.

What good is allergy testing?

Well, defining exactly what your boogorhead is allergic to gives you the option of desensitization – immunotherapy.

That involves gradually introducing the allergen in increasing amounts to help build a tolerance – allergy shots, or even drops under the tongue (sublingual immunotherapy, or SLIT).

We haven’t touched on the possibility that you can have an allergic reaction to an allergen that we simply do not test or. That is, allergy tests look for reactions to common allergens found in nature. Oddly, they do not look for allergic reactions to things that are common in the human environment, but which are synthesized – the various chemicals or additives in the dyes used to color our clothing, furniture, wall-coverings.

So, I conclude that many people with severe rhinitis that fits all the signs and symptoms of Allergic Rhinitis, but who have completely negative allergy tests, might still be reacting to some allergen in their environment that we cannot test for. Perhaps I will explore this further in a future post. I also plan to review all of the many ways that we can test for allergies.

When your rhinitis is truly not allergy-related, the search for the cause should begin. Find the irritant(s) responsible for your rhinitis. Eliminate it / them from your environment. Consider the many ways to reduce toxins and irritants in your life, reviewed here previously.

As always, I am an evangelist for regular nasal saline rinsing for optimal nasal hygiene.

For both allergic and non-allergic rhinitis, saline rinses will be beneficial!



Image Credit: Image by James Heilman, MD:  under creativecommons license, via Wikimedia Commons.

Epidemiologic Analysis of Chronic Rhinitis in Pediatric Patients. Erwin EA, Faust RA, Borish L. In press, American Journal of Rhinology and Allergy, 2011.


Until next time, please, “be excellent to one another.”

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  1. I have had sinus headaches all my life and never knew that hormones could play a role in them. You mention pregnancy, would PMS and Menopause also play a role in them? I hear of women who no longer get the headaches after menopause. Was hoping I had something to look forward to.

    • Russell A. Faust, PhD, MD says:

      Hi Lisa,
      Yes, hormonal balance does influence rhinitis and nasal congestion – including a woman’s monthly cycle, and changes associated with menopause. Perhaps there is something to look forward to after all?
      Thanks for visiting, and for taking time to contribute.
      RF (boogs)

  2. Hello doc,
    You have a fabulous and very informative website. I have a couple questions related to my 5 year old:
    1. He has had stuffy nose and morning cough since he was 2 or 3 years old. Recently he had a wheezing incident and so we had him allergy tested. How accurate are these tests? I have heard of food allergy tests being very inaccurate. He tested allergic to grass, trees and milk. Milk seemed so unlikely to me since he has it regularly without any digestive issues
    2. I have heard great reviews of Sinupret for allergy and even asthma. What is your experience with it?
    3. is there a good natural allergy medication out there which can be used in addition to nasal rinses.


    • Russell A. Faust, PhD, MD says:

      Hi Monika,
      Most allergy tests are not great for children. Their accuracy seems to increase with age throughout childhood, but they are especially inaccurate for younger children. I have no personal experience with Sinupret, although I have had enough parents report benefits from Sinupret that I endorse it on my site. The best addition to nasal saline rinses is Manuka honey, in my opinion. It is such a soothing additive, and has such strong anti-microbial properties, that I recommend it highly. In addition, I use Xylitol in my own saline rinses as an anti-microbial additive. I also carry a small plastic squeeze-bottle of saline containing Xylitol in my pocket, and spray a couple toots every couple hours for optimal nasal hygiene and to reduce the incidence of URI’s. The only one that I am aware of is from Xlear.com – both Manuka and the Xlear products are listed on the boogordoctor’s Amazon Store, over on the right column of this blog. There are some decent books listed there too.
      Thanks for visiting and for sharing. Please do come back and keep us updated on how your little boogorhead is doing :))

  3. Tellyrow says:

    Hi Dr. Faust,

    Do you have any recommendations for reducing nasal irritation from chlorinated pools (other than avoiding the pool!)?

    My son’s class has been taking swimming lessons as part of their physical education program. For his lesson last week, I told him to blow his nose and use his XLEAR after he gets out of the pool and I reminded him to do the same for this week. Your thoughts on this?

    Many thanks!

    • Russell A. Faust, PhD, MD says:

      RE: chemical rhinitis from chlorinated pools

      I see this commonly in my clinics – especially those kids who are on swim teams, or those who spend every day in the pool during their summer break. Public pools are especially heavily chlorinated for safety reasons. The downside of that is the inflammation that chlorine causes, especially to the mucus membranes. The result: chemical rhinitis. As you point out, the most effective solution is avoidance. The next most effective remedy is to rinse those chemicals away: nasal saline rinses. For those kids who are on swim teams and have associated chemical rhinitis, I recommend rinsing twice per day: once in the morning, and again immediately following swim practice in the pool. The goals is optimal nasal hygiene. Put simply: keep it clean and clear from pollutants, chemicals (chlorine). Your idea of using the Xlear spray throughout the day also helps with that goal of optimal nasal hygiene.

      Best success!

  4. Dr. Faust,

    After exposure to high levels of indoor molds (as confirmed by testing of samples), I believe I am now allergic to mold. I had delayed reactions to skin scratches with molds, but the blood test was negative, so the allergist did not want to treat this with shots. As long as I am indoors, my eyes are constantly wet and itchy, with red patches under. Its actually worse after I shower, particularly if the towel I use is not newly clean. It’s driving me crazy! Antihistamines do little. Is there an allergist somewhere who will hunt for elusive causes, allergens – especially molds – not normally tested with blood or skin tests?

    • Russell A. Faust, PhD, MD says:

      Hi Aimee,
      Sorry to hear about your struggles.
      I don’t have a precise answer for you, but I do know that the Mayo Clinic has been very innovative with respect to mold (fungus) detection and elimination. Do a search for “Mayo Clinic” and “Jens Ponikau” and “fungus”.
      Thank you for reading, and please keep us updated here!

  5. There’s “local allergic rhinitis”, meaning people can have IgE-mediated allergies with negative reactions to skin and blood tests. There’s a CME course online at http://www.jiaci.org/issues/vol20issue5/cme.pdf
    The same authors recently investigated the prevalence of LAR and found about 25% of people with rhinitis have LAR: http://www.ncbi.nlm.nih.gov/pubmed/22913574
    I’m sure I have dog and mold allergies, even though my skin and blood allergy tests recently have been negative. I’ve repeatedly done experiments where I went to live in a motel and I got well, then I exposed myself to dogs and I got sick. Also I know because of repeated experiences with getting sick after accidental exposures to dogs.
    I used to have allergies according to skin and blood tests. I tried for years to get over my allergies with allergy shots, but the allergy shots would make me sick so I was never able to build up a tolerance.
    Ironically, now I could probably get allergy shots, because I no longer feel sick after allergy testing. Allergy shots might work for LAR: http://www.ncbi.nlm.nih.gov/pubmed/21277626
    But most allergists wouldn’t give allergy shots if skin and blood tests are negative. If you know of any venturesome allergists who would try this, I would be interested.

    • Russell A. Faust, PhD, MD says:

      THANK YOU so much for contributing these links. I just LOVE that the community of readers here is this engaged and informed! The problem that I have with allergy testing is that at least 50% of people with NO allergy symptoms will “test positive.” Conversely, many people who clearly have strong allergies by clinical picture will “test negative.” What that tells me is that our tests – and our entire understanding (mis-understanding?) of the mechanism of “allergies” is incomplete, at best. There are a couple populations of allergists – those who are trained through internal medicine or pediatrics (and certified by the AAAI), and those who reach allergy training through otolaryngology (and who are certified by the ABO and AAOA). The perspective of each group has its strong points, but I have met more allergists in the latter group who have a more humble recognition that we don’t quite ‘get it’ when it comes to allergies and testing. If you can find an allergist who offers SLIT (the sub-lingual immunotherapy alternative to shots), they often have a more nuanced appreciation of these issues. My only advice would be to seek out an allergist who offers SLIT and get there opinion.
      Thanks again for sharing, and please keep me updated.

  6. Yes, local allergic rhinitis seems extremely important for allergists and ENT’s to know about. It means that allergy meds are appropriate for many people with “nonallergic rhinitis”.
    There’s a 2010 review article http://www.ncbi.nlm.nih.gov/pubmed/20642577 that summarizes the research on local allergies in various organs. For some people, nonallergic asthma might have an allergic cause. Similarly, “delayed food allergies”, the kind where a groggy, foggy state comes on from 1/2 hr to about 4 hrs after eating the food – especially after an elimination diet – might be from local allergies in the GI tract. Perhaps the symptoms are from other parts of the immune system that mobilized to prevent a local allergy from becoming a systemic food allergy. From the review article, it seems that local allergies might result from chronic exposure, the “mucous associated lymphoid tissue” gets more developed and may become capable of generating allergic reactions all by itself. Also there might be excessive mast cells from chronic exposure to allergens. The article mentions that the excessive mast cells might soak up the IgE in the blood, so that blood levels of IgE go back to normal – while the actual allergic reaction is getting worse!
    A lot of allergists aren’t keeping up with the research, a blog like http://allergynotes.blogspot.com which has summaries of recent research written by an academic allergist, would take a few minutes a day to read, and help keep them up to date. It’s been extremely frustrating that I have to try to analyze and cope with my immune problems myself – WHILE in a chronic bleary semiconscious state from allergies! I have autoimmune problems, probably celiac disease and I do have Hashimoto’s (autoimmune thyroid disease). It seems like celiac disease might worsen allergy problems by encouraging “mucosal immunity” – the various mucous membranes apparently communicate immune reactions to each other, (somewhat?) separately from the antibodies in the blood.
    I was mysteriously ill for 4 years, with this bleary semiconscious state – quite disabling – that turned out to be from dog (and mold) allergies. It gradually got worse, and when I found out about the dog allergy and started to avoid dog allergens, I became VERY sensitive to dog dander! I wear a mask almost all the time when I’m out in public, because dogs pop up everywhere! People carry little dogs in their purses, they have big dogs sitting in cars in the parking lot, they take dogs into stores … without a mask, I get sick every few days from this kind of thing, and I stay sick for several days. And the mask only helps a little bit. Dog dander particles are very small, so HEPA filters tend to not be very good at filtering them out.
    I might have a local IgE dog allergy, because I get a hazy feeling within seconds of being exposed. The review article mentions other possible mechanisms, like “variable free light chains”, for LAR.
    I built a kennel for my dog to get her out of the house, I’m hoping I can recover from the allergy if I avoid dog allergen well enough. The air in my house is contaminated with dog dander, so I have to wear an airline respirator in my house, that pumps outside air to a facemask that I wear. I’m MUCH too sensitive to get by with air purifiers.
    Maybe a university medical center would be able to diagnose what’s going on with me, but I don’t know if that would help, unless I could get allergy shots. I take a lot of allergy meds anyway, and they help some.
    I tried allergy drops (SLIT), but I had one of my food reactions to the allergy drop, even though I did my best to not swallow any of the drop, by washing my mouth out with water after taking the drop, and spitting it out. So I think the ” delayed food allergies” might happen partly in the mouth! The food reactions are worse than inhalant reactions, they affect me psychologically and inhalant reactions don’t, so I had to stop the allergy drops.
    Local allergies might explain a lot, like “toxic mold” reactions. Also the body has innate immune reactions to molds. Allergists told me to look for mold in my house, and I did find a rotting wall below ground level. Possibly the mold caused this awful dog allergy by irritating my nasal tissues.
    Probably a lot of people with “CFS” actually have allergies, they might be local allergies and hard to diagnose.

    • Russell A. Faust, PhD, MD says:

      Hi Laura,
      Thank you for sharing those links! I had not seen the review on local allergy, and I love allergynotes.
      I appreciate your readership, and hope that you are able to connect with an allergist nearby who can help bring you back to optimal health!

  7. Hi I have a little boy who is now 7 years old. He has been under an immunologist at the RCH since he was three for low IGg, IGm, IGa and IGe immunoglobin levels. He also suffers from a snuffly nose that he finds really hard to blow and constantly grunts or clears his throat. I have had him allergy test to no avail. They say he has inflammed nasal passages and he gets very tired all the time. He has been prescribed Avamys but I personally prefer to give him Claratine and use a saline nasal spray. He always seems a lot worse after swimming lessons so I am wondering if Chlorine is affecting him? He also seems a lot worse when he is environments where there are pine trees and liquid amber trees. Does it sound like I am treating him correctly? Does it sound like rhinitis to you and are those trees known to be triggers? Also do you think he should see an ear nose and throat specialist?

    • Russell A. Faust, PhD, MD says:

      Hi Melissa,
      I am honored to have your trust.
      Sorry to hear about your little guy’s troubles.
      If he has immunological issues (low Ig levels of various sub-classes), he may not mount a measurable allergy response, even if he does have allergies. That’s okay. He may still benefit from symptom remedies. He may even benefit from immuno-therapy such as “allergy shots” or “allergy drops”.
      Bottom line: if this were my little boy, I would get him to a more “holistic” physician. Preferably an ENT doc, or – if that is just not available – a Naturopath. Someone who will treat the whole person, and not just say that “his allergy tests are negative, go away”.
      Thank you for reading, thanks for sharing.
      Please keep us updated so that we can all learn from your experience.

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  9. dog walker says:

    Nice post. I was checking constantly this blog and I am impressed!

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  10. Jhong Dela Rapa says:

    I have this problem before.. elementary to highschool I have this rhinitis… but now I’m 4years free for rhinitis… I’m so happy now.. :)

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