On physical examination, the mucosa of the turbinates is usually pale or violaceous because of venous engorgement—in contrast to the erythema of viral rhinitis. Nasal polyps, which are yellowish boggy masses of hypertrophic mucosa, may be seen.

Treatment is symptomatic in most cases. Oral decongestants alone (eg, pseudoephedrine, 60–120 mg orally three or four times daily) are usually helpful, although antihistamines more specifically counteract allergic mechanisms. Numerous over-the-counter preparations are available. Common antihistamines include brompheniramine or chlorpheniramine (4 mg orally every 6–8 hours, or 8–12 mg orally every 8–12 hours as a sustained-release tablet) and clemastine (1.34–2.68 mg orally twice daily). Nonsedating long-acting antihistamines such as loratidine (10 mg orally daily) or fexofenadine (60 mg orally twice daily), though expensive and by prescription, are especially helpful in patients intolerant of the drowsiness associated with many other classes of antihistamines. Astemizole and terfenadine have been associated with sudden death from presumed QT prolongation, especially in patients receiving erythromycin or ketoconazole concomitantly, and thus should be avoided.

Nasal corticosteroid sprays such as beclomethasone (42 mg/spray) and flunisolide (25 mg/spray) are often remarkably effective if used appropriately. These sprays should be administered as two activations into each nostril twice daily for 1 month. Compliance is poor unless patients know that improvement usually does not begin until 1–2 weeks after starting therapy. Intranasal steroids have a role in seasonal allergies in shrinking nasal polyps, often eliminating the need for surgery. Intranasal cromolyn may be useful, especially when administered before expected contact with an offending allergen.

Maintaining an allergen-free environment by covering pillows and mattresses with plastic covers, substituting synthetic materials (foam mattress, acrylics) for animal products (wool, horsehair), and removing dust-collecting household fixtures (carpets, drapes, bedspreads, wicker) is worth the attempt to help more troubled patients. Air purifiers and dust filters (such as Bionair models) may also aid in maintaining an allergen-free environment. When symptoms are extremely bothersome, a search for offending allergens may prove helpful. This can either be done by skin testing or by serum RAST testing. Desensitization by gradually increasing subdermal exposure to identified allergens may be tried in selected patients, with variable results.