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Key facts
- Knowledge of key signs and symptoms can help pharmacists to distinguish hay fever from common respiratory viral infections such as colds, flu and Covid-19
- Antihistamines, corticosteroid nasal sprays and anti-allergy eye drops are effective OTC treatment options for hay fever
- Allergen avoidance is also an important component of overall hay fever self-care.
Learning objectives
After reading this feature you should be able to:
- Know how to distinguish hay fever from viral infections
- Advise hay fever sufferers on self-care measures that can help them to avoid pollen exposure
- Recommend effective OTC products in order to provide optimal relief from hay fever symptoms.
With spring being so mild and dry, many people are uccumbing to seasonal infections such as Covid-19, colds and flu. This can make distinguishing the early onset of hay fever symptoms from those of common respiratory viruses challenging.
A recent survey carried out by Allergy UK has highlighted the concerns that hay fever sufferers themselves have when it comes to telling the difference between their normal symptoms and signs of an underlying infection instead. In this survey of more than 3,000 people with hay fever, 56 per cent said they felt anxious that their allergic symptoms might be mistaken for Covid-19 by others.
In reality, of course, hay fever is not an infection at all but an over-response by the body’s immune system to the tiny grains of pollen released by grass, trees and other plants. Mistakenly thinking it is fighting off an intruder, the immune system triggers an allergic response, with the release of histamine and other chemicals leading to symptoms such as sneezing, a runny or blocked nose, and itchy, red and watery eyes.
“We are now in the early stages of the pollen season so many patients with allergies will be starting to have symptoms,” notes Allergy UK. “We would recommend treating hay fever proactively to minimise symptoms.”
Distinguishing symptoms
Drilling down into someone’s specific signs and symptoms can help to distinguish hay fever from common viral respiratory infections.
While hay fever may be associated with an occasional irritant cough caused by mucus running from the nose into the back of the throat, the cough associated with Covid-19 tends to be persistent and prolonged. Covid-19 is also associated with a range of other symptoms, which may include loss of taste or smell, sore throat, headache, fatigue and GI signs such as diarrhoea.
Covid and flu are both typically associated with a fever, where patients may complain of feeling hot, experiencing chills/shivers or body aches. In contrast, elevated body temperature is not a symptom of hay fever – despite its name.
Hay fever symptoms also tend to follow a predictable seasonal pattern linked to the pollen count. Although Covid-19, like hay fever, may produce a runny nose, the itchy nasal symptoms, sneezing and eye irritation that are the hallmarks of hay fever are not typical of coronavirus.
Another key clue is that hay fever should respond to treatment with antihistamines and nasal sprays, whereas viral respiratory infections will not.
“We are now in the early stages of the pollen season so many patients with allergies will be starting to display symptoms”
Allergen avoidance
As pollen levels begin to rise across the UK, many customers will visit the pharmacy seeking advice on hay fever treatment. This includes established sufferers making their annual pilgrimage to the pharmacy to stock up on hay fever treatments, as well as those who may be experiencing hay fever symptoms for the first time.
Pharmacy teams should be equipped to provide advice to hay fever sufferers – old and new – on effective OTC treatments as well as allergen avoidance.
Pollen avoidance is one of the key steps that everyone can take to help reduce the severity and impact of their hay fever symptoms. Anecdotal evidence gathered during the Covid-19 pandemic suggests that mask wearing may have helped to reduce the severity of hay fever symptoms by acting as a barrier to inhaled pollen allergens.
During the spring and summer months, patients should therefore be encouraged to take proactive steps to mitigate their own exposure to pollen – acknowledging that this is sometimes easier said than done.
The main hay fever season in the UK is considered to run from May all the way through to September, but grass pollen, one of the most problematic allergens, typically peaks around June/July time. Levels of pollen from trees such as elder, elm, hazel, and especially birch, begin to increase from February onwards and persist through to June. Nettle and weed pollen is more abundant later in the season, around August and September.
When the pollen count is high, people should be advised to keep windows and doors shut, particularly in the early evening. When outside, wearing wraparound sunglasses, a wide-brimmed hat or a face mask can help to prevent pollen gaining entry into the airways or the eyes.
After coming in from the outdoors, people should be encouraged to remove and shake off their outer clothing, and ideally shower and change their clothes completely to wash off the pollen and avoid taking it into the house.
HEPA filters, which are able to trap the minute powdery grains of pollen, can be purchased for use in the home or may be attached to vacuum cleaners or car vents.
Other common sense steps to help sufferers mitigate the impact of hay fever include avoiding mowing or walking on grass where possible, not keeping fresh cut flowers in the house and not drying clothes outdoors, where they can attract and catch pollen from the air. It is also good practice to vacuum regularly and dust with a damp cloth during the hay fever season to help remove pollen that has made its way into the house.
Climate change prompts new allergy training for GPs
Significant developments in healthcare and the increasing impact of climate change means that GPs across the UK are to receive updated training in allergy and immunology.
According to the British Society for Allergy & Clinical Immunology (BSACI), climate change and environmental factors are increasingly being recognised as determinants for the allergen landscape.
The society says that rising temperatures and higher ambient C02 levels are causing plants and trees to flower earlier, resulting in lengthening pollen seasons. On average, spring flowers and trees are blooming a month earlier than they did 50 years ago, says BSACI. And according to Met Office data, the average January temperature has increased by 0.9 degrees Celsius over the past half decade, with 2024 having the warmest January on record.
From August this year, the updated GP curriculum will include training on how accelerating climate change is exacerbating respiratory health and allergies. “While allergy is already included in the curriculum, greater emphasis will be given to allergy and immunology due to significant developments in climate change that can no longer be ignored,” says BSACI.
Treatment options
“With 44 per cent of people relying on the advice of pharmacists when it comes to OTC products, it is important for them to distinguish between hay fever, colds and Covid-19, especially when advising on OTC treatment,” says Olbas brand manager Rachel Ramsden.
“Given the high level of trust in pharmacists and consumers’ preference for branded products, it is essential for pharmacies to stock a range of trusted OTC brands that provide reliable relief.”
Effective treatment of hay fever relies on preventing the release of histamine and/or minimising its systemic effects. Antihistamines are therefore the cornerstone of OTC treatment. These agents usually get to work quickly, allowing sufferers to take them when symptoms become troublesome, and are relied upon by many during the spring/summer months.
Modern hay fever products typically contain newer antihistamine drugs such as loratadine, cetirizine and fexofenadine, in preference to their older drowsiness-inducing cousins like chlorphenamine.
Antihistamines are available in a choice of oral formulations – tablets, capsules and syrups – and many products now boast a longer duration of action, enabling them to be taken just once daily.
Nasal symptoms
For patients with nasal congestion as their primary hay fever symptom, steroid nasal sprays can be used instead of antihistamines or alongside them. However, they are only suitable for adults aged 18 years or over. These products contain corticosteroids as their active ingredient; common examples include beclometasone, fluticascone, budesonide and mometasone.
An advantage of nasal sprays is that they directly target the source of the problem, at the site where pollen enters the body via the airways, acting within the nose to reduce swelling and inflammation. They may also offer some relief from non-nasal symptoms such as watering and itchy eyes.
For optimal results, people should be encouraged to begin using steroid nasal sprays before the hay fever season begins as they can take a few days to become effective.
Most products advise administering the spray both in the morning and in the evening. They should then be used daily in order to keep hay fever symptoms at bay, for a maximum period as indicated by the product label (usually no more than three months).
Another OTC option for relieving the nasal discomfort associated with hay fever are nasal decongestants, which act to relieve nasal stuffiness by shrinking the blood vessels in the nose, which become inflamed by allergens. These contain ingredients such as oxymetazoline and xylometazoline.
They should only be used for short periods because symptoms can reappear when their use is stopped – so-called rebound congestion. Patients should therefore be counselled only to use these products for a maximum of seven days.
Another option for clearing the nose are saline nasal washes, which can help to flush out allergens and moisturise the nasal passages, thus easing congestion and relieving hay fever symptoms. As they are drug-free and do not constrict blood vessels, there is generally no risk of rebound congestion with these products.
Eye symptoms
For some hay fever sufferers, eye symptoms can prove particularly bothersome. Fortunately, targeted treatment is available in the form of OTC eye drops containing the mast cell stabiliser sodium cromoglicate. This works by inhibiting the degranulation of inflammatory white blood cells called mast cells, thereby preventing the release of histamine and helping to ameliorate some of the ocular symptoms of hay fever.
Eye drops containing sodium cromoglicate are not suitable for use while wearing soft contact lenses as they may alter the colour of the lens.
Customers should therefore be advised to remove contact lenses prior to application and to wait at least 15 minutes before reinsertion, following the instructions on the individual product label.
Eye drops can be used in conjunction with other hay fever treatments, including antihistamines, steroid nasal sprays and saline nasal washes.
Red flags and cautions
- Wheezing, tight chestedness or breathlessness: These symptoms may be suggestive of more complex underlying respiratory issues. Patients should be referred to their GP for investigation.
- No improvement in symptoms or worsening symptoms: Patients who have tried OTC medications but whose symptoms have not improved or have worsened should be referred for further medical care. Some oral steroid treatments are available on prescription for hay fever, as are stronger doses of antihistamines.
For patients with severe hay fever, there is also the potential option of pollen immunotherapy, where small amounts of pollen are delivered by injection over a period of months to slowly build up tolerance to the allergen. However, this treatment is delivered by specialist services which are not available in all parts of the UK. - Pregnancy: Although most OTC hay fever treatments are suitable for use during pregnancy, some restrictions do apply. For example, decongestants are not normally used in pregnancy as they could reduce blood flow in the placenta and to the baby itself.
It is advisable for pregnant customers to adopt a stepwise approach to managing hay fever, starting with non-pharmacological treatments and progressing onto medication only if required.
Non-pharmacological treatments include nasal irrigation with saline, a barrier ointment around the nostrils and use of non-medicated eye washes to relieve discomfort in the eyes. If these prove ineffective, the first step on the pharmacological treatment ladder should be topical agents in the form of intranasal beclometasone or ocular mast cell stabilisers.
If local topical therapy fails to control the symptoms, oral antihistamines may be considered, with non-sedating types preferred because of the risks associated with drowsiness.
Loratadine is usually recommended as the first choice antihistamine for use in pregnant women. As human pregnancy data for fexofenadine remains limited, it should be reserved for cases where no other suitable treatment option is available.
Useful resources
- Allergy UK: allergyuk.org
- British Society for Allergy & Clinical Immunology (BSACI): bsaci.org
- Specialist Pharmacy Service information on treating allergic rhinitis during pregnancy: sps.nhs.uk/articles/hayfever-or-allergic-rhinitis-treatment-during-pregnancy
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