4 tips for dealing with a ferocious allergy season

It’s a sneezy, snotty, itchy-eyed time for many Americans — perhaps more so than ever before. Seasonal allergies are the effects of the immune system’s overreaction to pollen spewed into the air by trees, grasses, and ragweed, most commonly in the spring (although really, year-round). Climate change is making allergy season worse: As warm seasons get warmer and last longer, more plants release more pollen for longer periods. Although the risk of developing allergies is hereditary, experts suspect higher pollen levels are tipping more genetically prone adults into developing seasonal allergies for the first time. If your airways are among the afflicted, you know that finding relief can be a challenge. There’s lots of advice and an overwhelming array of products out there, and it’s sometimes hard to know what’s true and where to begin. Here are a few tips for thinking through what’s causing your symptoms and what to do to stop the streams of liquid constantly coming out of your head. Not everything that makes your nose run is allergies Lots of things make people sneezy and snotty — who cares what the reason is? Well, you should. One of the biggest mistakes people make in the course of seeking relief from allergy symptoms is thinking they have an allergy when they don’t, says Jonathan Bernstein, a Cincinnati allergist and lead author on a recently published review article on allergic nasal symptoms. “So first and foremost, are they diagnosed properly?” When an allergic response is responsible for nasal symptoms, what’s happening in the background is an invisible biochemical cascade involving lots of moving parts, many of which are the targets of allergy medications. It’s a very different process from what happens when airways are just irritated (for example, by dust, smoke, or perfume), infected (as with a cold or another infection), or reacting to changes in temperature or pressure. Therefore, treating a non-allergic cause with an allergy medicine won’t work and can lead to unnecessary side effects, expense, and frustration. Allergic reactions to pollen don’t usually happen the first time you’re exposed to it. The first time your immune system meets those tiny particles, it merely determines that particular type of pollen is an outsider it doesn’t like. Your immune system might react a little bit in the moment, perhaps with a little sneezing and a mild runny nose. The most consequential work it’s doing at this stage is teaching the rest of your immune system to overreact next time the invader shows up and storing the memory of that invader in memory cells. This part of the allergic response is called sensitization. The next time your immune system meets that pollen, it’s primed — and it reacts fast, unleashing hellfire on the invader within 30 to 60 minutes. Some of the key players in this quick response are mast cells, which release histamine. This chemical dilates the nasal blood vessels, causing inflammation; gooses the sensory nerves in the face, causing sneezing and nasal itching; and stimulates mucus-producing glands in the nose, leading to water, water everywhere. One way to tell your symptoms aren’t allergic is by taking note of what they include: If a fever accompanies irritated airways, it’s more likely you have an infection (likely a viral cold) than allergies. Also, if your symptoms don’t respond well to allergy medications, that’s a good clue you might not be dealing with an allergy, says David Shulan, a retired allergist who used to practice in Albany, New York. When medications seem variably effective — or if they’re effective but you can’t figure out what you’re allergic to or your symptoms are severe — he says a helpful next step might be allergy testing. Severe symptoms are subjective, says Pedro Lamothe, a pulmonologist who treats and researches allergic asthma and lung disease at Emory University in Atlanta. “If the symptoms are resistant to treatment [or] are impacting your daily life because you can’t be going outside, because you can’t do your job,” he says, “that’s the definition of severe symptoms.” If you do get allergy testing, it’s best to get it done by a physician who’s an allergy specialist. “You have to correlate it with the individual’s history and their exposure,” Bernstein says. Letting allergy symptoms run their course won’t “build immunity” to the allergen. It just makes it worse next time. It’s not uncommon for people with seasonal allergy symptoms to just ride them out. The reasons for this vary, but sometimes, people power through because they believe doing so will make future allergic reactions land softer. That’s the opposite of the truth, says Lamothe. More allergic reactions just means more sensitization — that is, more opportunities for your immune system to learn how to overreact to a stimulus and to store that information so it can react even more ferociously next time. Letting allergic reactions run their course won’t make you stronger, he says, “You’re going to make your allergic responses stronger.” Another consequence of waiting to treat an allergic reaction: You’ll ultimately need much more medication to subdue your symptoms in their later stages than if you’d treated the response in its earlier stages. “These medications are much more effective at preventing the symptoms that are getting rid of them once they’ve already started,” says Lamothe. It’s best to stop the allergic reaction before the cascade gets into motion and before the immune system gets too smart for your own good — and it’s ideal to prevent the reaction altogether, says Lamothe. He recommends people with persistent seasonal symptoms actually start taking their medications before allergy season starts. In the relatively temperate climes of Georgia, that might mean starting the medications in February. Taking a proactive approach is particularly important for people with seasonal allergy-related asthma, which can be life-threatening. Asthma is effectively an allergic reaction localized to the lungs; in allergy-related asthma, the allergic reaction starts with the upper airways — the nose, mouth, and throat — and extends to the lungs, leading to wheezing, coughing, and shortness of breath. If you have seasonal allergies that lead to breathing problems, take note of how often you use your asthma medications, says Cherie Zachary, an allergist who practices in Minneapolis. If you’re using a rescue medication (like an albuterol inhaler) more than three times a week or you’ve needed to take an oral steroid like prednisone more than once in the past year, get additional help controlling both your asthma and your allergies, she says. People with allergy-induced asthma sometimes get so used to breathing poorly during certain seasons — or even year-round — that they forget it’s not normal to feel breathless at baseline. That may be especially true when many others around them also aren’t breathing well. Older patients may also have had bad experiences with ineffective treatments or with the medical system that administers them, leading them to put off getting care even when they’re feeling really ill. That should no longer be a deterrent. “We have good treatments now for allergies and asthma, which we certainly didn’t have 35 years ago,” says Zachary. The higher your risk of allergy-related asthma, the lower your threshold should be to seek care if you’re having uncontrolled symptoms during allergy season, she says. “Especially for the asthma patients, don’t ignore your symptoms.” Certain risk groups are more likely to have life-threatening outcomes from pollen exposure and should have a lower threshold for getting treatment Seasonal allergies play out differently in different racial and ethnic groups in the US. White adults are more likely to be diagnosed with seasonal allergies than are others, but in one study, Black people were twice as likely as white people to end up in an emergency room with pollen-related asthma exacerbations. More broadly, Black and Puerto Rican Americans are more likely than others to have asthma of any type, including severe and life-threatening flares. The reasons for these disparities are complicated, but are in part related to how well people’s allergies are controlled on a day-to-day basis — which is itself related to issues of insurance coverage and health care access and trust. Environmental factors may also be at play: Exposure to industrial toxins and air pollution is thought to increase people’s risk of developing allergies and asthma, including the kinds related to pollen. Higher concentrations of these pollutants in neighborhoods and workplaces where people of color live could in part explain the higher prevalence of seasonal allergies — and their most severe consequences — in these groups. “When you look at the risk factors and you look at redlining, they really do correlate,” says Zachary. Your first-line allergy medication might not be one you take by mouth The best treatment for allergies is prevention, and experts have lots of strategies for reducing your face time with whichever allergen is your particular nemesis. Shulan suggests minimizing your time outdoors during peak pollen time, which is typically around midday; there’s usually less pollen in the air before dawn, after sunset, and during or immediately after rain. You can also try wearing a face mask outdoors if the air temperature doesn’t make it intolerable, says Lamothe. As best you can, avoid tracking pollen into your home: Wipe down your face (including eyebrows and any facial hair), change your clothes and remove your shoes when coming home (and keep them outside the bedroom), and consider removing makeup, which pollen loves to stick to. Keeping bedroom windows closed and running an air conditioner with or without a separate air filtration unit can also help minimize nighttime symptoms. If you typically hang your clothes outside to dry, avoid doing so during allergy season. Cleaning the surfaces of your upper airways with saline nasal spray or nasal irrigation (like with a Neti pot) can also be helpful. While some people advocate eating local honey to reduce allergy symptoms, several experts told me there isn’t great data to support this practice, but “the placebo effect is remarkably powerful,” said Shulan. Even with these preventive measures, many people need pharmaceutical help to manage their symptoms, and the array of over-the-counter allergy medicines to choose from is literally dizzying. For many people with moderate to severe seasonal allergies, a nasal spray containing a corticosteroid is a good place to start, says Lamothe. These include fluticasone (Flonase), triamcinolone (Nasacort) mometasone (Nasonex), and budesonide (Benacort). Unlike steroids taken by mouth, these act only on the interior surfaces of the nostril and upper airways where they land, so they’re relatively low-risk. Still, aim the nozzle outward when you spray to avoid drenching the nasal septum, which can lead to nosebleeds. It might take a few days to feel relief from these medications, so don’t expect immediate results. Antihistamines are faster-acting and are available as nasal sprays, eye drops, and oral medications. Again, the formulations you don’t take by mouth are less likely to have systemic effects. Modern, second-generation oral antihistamines — which include cetirizine (Zyrtec), fexofenadine (Allegra), and loratadine (Claritin) — are much less likely to cause sleepiness than diphenhydramine (Benadryl), the most common of their first-generation counterparts. Some people find cetirizine somewhat sedating; levocetirizine dihydrochloride (Xyzal), a variant of the drug, avoids this effect. Although some people appreciate the sedating effects of Benadryl, experts advise against taking it on a regular basis due to emerging data about its associations with dementia. They also recommend caution with decongestants: Occasional doses of pseudoephedrine are safe for many adults, but they can raise blood pressure and heart rate and are not safe for children. Antihistamine nasal sprays like oxymetazoline (Afrin) are dependency-forming and should not be used for more than a few days running. If allergy meds aren’t controlling your symptoms or you need more medication than you want to take to control your symptoms, immunotherapy might be an option for you, says Shulan. Most people know this treatment as allergy shots, which involve getting progressively higher amounts of the protein you’re allergic to injected under your skin until your immune system stops overreacting to it, usually for around three to five years. More recent oral formulations mean this treatment can be administered without needles for certain allergies. To date, the Food and Drug Administration has approved oral immunotherapy to treat people allergic to ragweed, grasses, and dust mites. Oral allergy drops are also on the retail market, often marketed as a “natural” solution to allergies. However, these often-pricey products are not FDA-approved and the evidence to show they make things better and not worse just isn’t there, says Zachary. “Natural is not always neutral,” she says.