Allergic shiners

Allergic shiners also called allergic facies or periorbital venous congestion are blue-gray or purple discoloration under the lower eyelids, are considered important signs of allergic rhinitis ¹. In children with allergic rhinitis, the blue-gray to purple discoloration beneath the lower eyelids is referred to as allergic shiners, which are believed to be caused by venous stasis resulting from nasal congestion ². Allergic shiners appear as dark circles under the eyes and resemble bruises or “black eyes.” Allergic shiners causes include nasal congestion, inflammatory diseases of the conjunctiva, trauma to the forehead or nose, face surgery, and malignancy ². Allergic rhinitis is inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold or flakes of skin from certain animals. Allergic rhinitis is a very common condition, estimated to affect around 1 in every 5 people.

The term allergic shiners was coined by Marks in 1954 ³. He found that dark eye shadows could be observed bilaterally in most children with perennial allergic rhinitis. In 1963 ⁴, he further stated that many of the allergic shiners resulted from long-standing perennial allergic rhinitis. Since then, allergic shiners have been widely considered important signs of allergic rhinitis ⁵. However, there was no objective or quantitative tool to verify these clinical observations. In addition, whether shiners fluctuated according to the symptoms of allergic rhinitis remained unclear ⁶.

Allergic shiners key points

• Allergic rhinitis may be diagnosed by the presence of nasal itching, sneezing, nasal congestion, rhinorrhea and post-nasal drip. Symptoms can arise within minutes of allergen exposure and may last for a couple of hours.
• Allergic rhinitis can be seasonal (hayfever), perennial (persistent) or perennial with seasonal exacerbations.
• Minimizing exposure to confirmed allergens may assist in reducing symptoms in some people.
• There is an increased prevalence of asthma amongst patients with persistent and/or severe rhinitis.
• Unilateral rhinorrhea may signify a malignancy, an antrochoanal polyp or a foreign body, or simply septal deviation.
• Results of allergy tests should always be considered with a patient’s clinical history. Positive tests do not automatically prove the allergen is causing the symptoms.
• Pharmacological management depends on predominant symptoms and severity.
• Intranasal corticosteroids sprays or combined intranasal/antihistamine sprays are recommended preventer treatments.
• Effective treatment of allergic rhinitis is important in management of asthma.
• If patients are allergic to pollen, recommend staying indoors during thunderstorms in pollen seasons and use preventer treatments.
• Referral to a specialist should be considered when severe or inadequately controlled allergic rhinitis persists and consideration is being made for allergen immunotherapy.
• Allergen immunotherapy is effective in reducing the frequency and severity of symptoms of allergic rhinitis.

Allergic shiners causes

Allergic shiners causes include nasal congestion, inflammatory diseases of the conjunctiva, trauma to the forehead or nose, face surgery, and malignancy ².

Allergic rhinitis is a common condition that is caused by an allergic immune response to inhaled allergens. Atopy, high socioeconomic status, environmental pollution, birth during a pollen season, early weaning and maternal smoking are risk factors for allergic rhinitis.

Up to 80% of patients with allergic rhinitis develop symptoms before the age of 20 ⁷. Symptoms include inflammation of the nasal mucosa which results in sneezing, runny nose (rhinorrhea), nasal congestion, itching and sometimes reduced ability to smell and to detect odors (hyposmia). Allergic rhinitis may also be associated with inflammation of other mucous membranes and may be related to sinusitis, rhinosinusitis and allergicconjunctivitis ⁷. Eye symptoms are common in seasonal allergic rhinitis and may be present in up to 50% of cases of perennial rhinitis ⁷. Symptoms can arise within minutes of allergen exposure and may last for a couple of hours. Allergic conjunctivitis may also be present, occurring as a result of the nasal-ocular reflex as well as allergen contact with the conjunctival mucosa. In those with seasonal allergic rhinitis related to birch pollen, it is worth considering the possibility of an associated oral allergy syndrome ⁷.

Allergic rhinitis also is thought to be related to a similar hypersensitivity response in allergic asthma — allergic and non-allergic rhinitis are risk factors for developing asthma. There is an increased prevalence of asthma among patients with persistent or severe rhinitis.

Allergic rhinitis can have a significant impact on quality of life, for example it may cause poor sleep, affect schooling and affect work attendance ⁸.

Allergic rhinitis can be seasonal (hayfever), perennial (persistent) or perennial with seasonal exacerbations. Seasonal allergic rhinitis is related to sensitivity to pollens and perennial allergic rhinitis is related to allergens such as dust mites and animal dander. The Allergic Rhinitis and its Impact on Asthma (ARIA) guideline classifies allergic rhinitis into intermittent or persistent cases that may be mild or moderate-severe ⁷.

Allergic shiners prevention

The best way to prevent allergic rhinitis is to avoid the allergen that causes it. Avoiding walking in grassy open spaces in the early morning and evening as well as keeping windows shut in cars and buildings can help to reduce the risk of pollen exposure. But this is not always easy. Allergens, such as dust mites, are not always easy to spot and can breed in even the cleanest house.

It can also be difficult to avoid coming into contact with pets, particularly if they belong to friends and family.

Below is some advice to help you avoid the most common allergens.

House dust mites

Dust mites are one of the biggest causes of allergies. They’re microscopic insects that breed in household dust.

To help limit the number of mites in your house, you should:

• consider buying allergy-proof covers for mattresses, duvets and pillows
• choose wood or hard vinyl floor coverings instead of carpet
• fit roller blinds that can be easily wiped clean
• regularly clean cushions, soft toys, curtains and upholstered furniture, either by washing or vacuuming them
• use synthetic pillows and acrylic duvets instead of woollen blankets or feather bedding
• use a vacuum cleaner fitted with a high-efficiency particulate air (HEPA) filter – it can remove more dust than ordinary vacuum cleaners
• use a clean damp cloth to wipe surfaces – dry dusting can spread allergens further

Concentrate your efforts on controlling dust mites in the areas of your home where you spend most time, such as the bedroom and living room.

Pets

It’s not pet fur that causes an allergic reaction, but exposure to flakes of their dead skin, saliva and dried urine.

If you cannot permanently remove a pet from the house, you may find the following tips useful:

• keep pets outside as much as possible or limit them to 1 room, preferably one without carpet
• do not allow pets in bedrooms
• wash pets at least once a fortnight
• groom dogs regularly outside
• regularly wash bedding and soft furnishings your pet has been on

If you’re visiting a friend or relative with a pet, ask them not to dust or vacuum on the day you’re visiting because it’ll disturb allergens into the air.

Taking an antihistamine medicine 1 hour before you enter a house with a pet can help reduce your symptoms.

Pollen

Different plants and trees pollinate at different times of the year, so when you get allergic rhinitis will depend on what sort of pollens you’re allergic to.

Most people are affected during the spring and summer months because this is when most trees and plants pollinate.

To avoid exposure to pollen, you may find the following tips useful:

• check weather reports for the pollen count and stay indoors when it’s high
• avoid line-drying clothes and bedding when the pollen count is high
• wear wraparound sunglasses to protect your eyes from pollen
• keep doors and windows shut during mid-morning and early evening, when there’s most pollen in the air
• shower, wash your hair and change your clothes after being outside
• avoid grassy areas, such as parks and fields, when possible
• if you have a lawn, consider asking someone else to cut the grass for you

Mold spores

Molds can grow on any decaying matter, both in and outside the house. The molds themselves are not allergens, but the spores they release are.

Spores are released when there’s a sudden rise in temperature in a moist environment, such as when central heating is turned on in a damp house or wet clothes are dried next to a fireplace.

To help prevent mold spores, you should:

• keep your home dry and well ventilated
• when showering or cooking, open windows but keep internal doors closed to prevent damp air spreading through the house, and use extractor fans
• avoid drying clothes indoors, storing clothes in damp cupboards and packing clothes too tightly in wardrobes
• deal with any damp and condensation in your home

Allergic shiners symptoms

Allergic rhinitis typically causes cold-like symptoms, such as sneezing, itchiness and a blocked or runny nose. These symptoms usually start soon after being exposed to an allergen.

Some people only get allergic rhinitis for a few months at a time because they’re sensitive to seasonal allergens, such as tree or grass pollen. Other people get allergic rhinitis all year round.

Most people with allergic rhinitis have mild symptoms that can be easily and effectively treated.

But for some people symptoms can be severe and persistent, causing sleep problems and interfering with everyday life.

The symptoms of allergic rhinitis occasionally improve with time, but this can take many years and it’s unlikely that the condition will disappear completely.

Allergic shiners complications

If you have allergic rhinitis, there’s a risk you could develop further problems. A blocked or runny nose can result in difficulty sleeping, drowsiness during the daytime, irritability and problems concentrating.

Allergic rhinitis can also make symptoms of asthma worse.

The inflammation associated with allergic rhinitis can also sometimes lead to other conditions, such as nasal polyps, sinusitis and middle ear infections.

Nasal polyps

Nasal polyps are swellings that grow in the lining inside your nose or sinuses, the small cavities above and behind your nose. Nasal polyps are caused by inflammation of the membranes of the nose and sometimes develop as a result of rhinitis.

Nasal polyps are shaped like teardrops when they’re growing and look like a grape on a stem when fully grown. They vary in size and can be yellow, grey or pink. They can grow on their own or in clusters, and usually affect both nostrils.

If nasal polyps grow large enough, or in clusters, they can interfere with your breathing, reduce your sense of smell and block your sinuses, which can lead to sinusitis.

Small nasal polyps can be shrunk using steroid nasal sprays so they do not cause an obstruction in your nose. Large polyps may need to be surgically removed.

Sinusitis

Sinusitis is a common complication of rhinitis. It’s where the sinuses become inflamed or infected. The sinuses naturally produce mucus, which usually drains into your nose through small channels. But if the drainage channels are inflamed or blocked (for example, because of rhinitis or nasal polyps), the mucus cannot drain away and may become infected.

Common symptoms of sinusitis include:

• a blocked nose, making it difficult to breathe through your nose
• a runny nose
• mucus that drips from the back of your nose down your throat
• a reduced sense of smell or taste
• a feeling of fullness, pressure or pain in the face
• snoring
• your airways becoming temporarily blocked while you’re asleep, which can disturb your sleep (obstructive sleep apnea)

Painkillers, such as acetaminophen (paracetamol), ibuprofen or aspirin, can be used to help reduce any pain and discomfort in your face. But these medications are not suitable for everyone, so check the leaflet that comes with them before using them.

For example, children under the age of 16 should not take aspirin and ibuprofen is not recommended for people with asthma or a history of stomach ulcers. Speak to a doctor or pharmacist if you’re unsure.

Antibiotics may also be recommended if your sinuses become infected with bacteria.

If you have long-term sinusitis, surgery may be needed to improve the drainage of your sinuses.

Middle ear infections

Middle ear infections can also develop as a complication of nasal problems, including allergic rhinitis. These infections can occur if rhinitis causes a problem with the Eustachian tube, which connects the back of the nose and middle ear, at the back of the nose. If this tube does not function properly, fluid can build up in the middle ear behind the ear drum and become infected. There’s also the possibility of infection at the back of the nose spreading to the ear through the Eustachian tube.

The main symptoms of a middle ear infection include:

• earache
• a high temperature
• being sick
• a lack of energy
• slight hearing loss

Ear infections often clear up within a couple of days, but paracetamol or ibuprofen can be used to help relieve fever and pain.

Antibiotics may also be prescribed if the symptoms persist or are particularly severe.

Allergic shiners diagnosis

Allergic rhinitis may be diagnosed by the presence of nasal itching, sneezing, nasal congestion, rhinorrhea, post-nasal drip and sometimes reduced ability to smell and to detect odors (hyposmia).

History and clinical examination

A careful history should include when symptoms start and whether there are factors that precede the onset of symptoms. This may identify triggers for allergic rhinitis in the home or the workplace. Pets and house dust mites may be factors at home, and at work there may be occupational allergens ⁹.

If occupational rhinitis is suspected, it may be possible to prevent progression to occupational asthma. Resolution of symptoms while the patient is on holiday may suggest an environmental cause for allergic rhinitis. Rhinitis symptoms may also be attributable to Churg-Strauss syndrome, Wegener’s granulomatosis and sarcoidosis ⁷, so systemic review and clinical examination is important.

Clinical examination findings may include; mouth breathing, a horizontal nasal crease across the nose, surgical scars, polyps, crusting, mucosal congestion and nasal discharge.

Investigations

The diagnosis may be confirmed by detecting specific IgE to airborne allergens, through skin-prick testing or on serum. This is particularly relevant if allergen-specific immunotherapy is being considered. Allergic rhinitis is often related to house dust mites as well as grass and tree pollens.

The 2 main allergy tests are:

• a skin prick test – where the allergen is placed on your arm and the surface of the skin is pricked with a needle to introduce the allergen to your immune system; if you’re allergic to the substance, a small itchy spot (welt) will appear
• a blood test – to check for the immunoglobulin E (IgE) antibody in your blood; your immune system produces this antibody in response to a suspected allergen

Commercial allergy testing kits are not recommended because the testing is often of a lower standard than that provided by an accredited private clinic.

It’s also important that the test results are interpreted by a qualified healthcare professional with detailed knowledge of your symptoms and medical history.

Further tests

In some cases further hospital tests may be needed to check for complications, such as nasal polyps or sinusitis.

For example, you may need:

• a nasal endoscopy – where a thin tube with a light source and video camera at 1 end (endoscope) is inserted up your nose so your doctor can see inside your nose
• a nasal inspiratory flow test – where a small device is placed over your mouth and nose to measure the air flow when you inhale through your nose
• a CT scan – a scan that uses X-rays and a computer to create detailed images of the inside of the body

Allergic shiners treatment

Treatment for allergic rhinitis depends on how severe your symptoms are and how much they’re affecting your everyday activities. In most cases treatment aims to relieve symptoms, such as sneezing and a blocked or runny nose.

If you have mild allergic rhinitis, you can often treat the symptoms yourself. It’s possible to treat the symptoms of mild allergic rhinitis with medicines you buy from a pharmacy or shop, such as long-acting non-sedating antihistamines. If possible, try to reduce exposure to the allergen that triggers the condition.

Pregnancy-induced rhinitis occurs in up to 20% of women and this is usually self-limiting ¹⁰. Decongestants should be avoided in pregnancy, but antihistamines may be considered ¹⁰.

You should visit your doctor if your symptoms are more severe and affecting your quality of life, or if self-help measures have not worked.

Cleaning your nasal passages

There is some evidence supporting the use of nasal lavage ⁷. Regularly cleaning your nasal passages with a salt water solution, known as nasal douching or irrigation, can also help by keeping your nose free of irritants.

You can do this by using a solution made with sachets bought from a pharmacy.

Small syringes or pots that often look like small horns or teapots are also available to help flush the solution around the inside of your nose.

To rinse your nose:

• stand over a sink, cup the palm of 1 hand and pour a small amount of the solution into it
• sniff the water into 1 nostril at a time
• repeat this until your nose feels comfortable (you may not need to use all of the solution)

While you do this, some solution may pass into your throat through the back of your nose.

The solution is harmless if swallowed, but try to spit out as much of it as possible.

Nasal irrigation can be carried out as often as necessary, but a fresh solution should be made each time.

Medication

Medication will not cure your allergy, but it can be used to treat the common symptoms. If your symptoms are caused by seasonal allergens, such as pollen, you should be able to stop taking your medication after the risk of exposure has passed.

Visit your doctor if your symptoms do not respond to medication after 2 weeks.

Medical management is guided by the frequency and severity of symptoms as well as the impact on quality of life.

Corticosteroids

If you have frequent or persistent symptoms and you have a nasal blockage or nasal polyps, your doctor may recommend a nasal spray or drops containing corticosteroids. Intranasal corticosteroids are the mainstay of treatment ¹¹. They may be used for moderate to severe allergic rhinitis and are the most effective agents (more effective than antihistamines used with an anti-leukotriene) ⁷.

Corticosteroids help reduce inflammation and swelling. They take longer to work than antihistamines, but their effects last longer.

Intranasal corticosteroids are helpful where the predominant symptom is nasal blockage and congestion,4 but they may improve conjunctival symptoms as well. Intranasal corticosteroids may exert their peak effect after several hours or days, however, maximum effectiveness is usually achieved after two to four weeks ¹². Commonly used preparations include fluticasone and mometasone ⁷.

Side effects from inhaled corticosteroids are rare, but can include nasal dryness, irritation and nosebleeds.

Oral steroids may be considered if symptoms are severe. If you have a particularly severe bout of symptoms and need rapid relief, your doctor may prescribe a short course of corticosteroid tablets lasting 5 to 10 days. Moreover, oral corticosteroids can alleviate symptoms for important events such as examinations. Patients should be advised to re-attend within two to four weeks if their symptoms are not controlled.

Antihistamines

Antihistamines relieve symptoms of allergic rhinitis by blocking the action of a chemical called histamine, which the body releases when it thinks it’s under attack from an allergen.

Oral antihistamines have a more rapid onset of action than nasal corticosteroids. Second-generation antihistamines including cetirizine and loratadine are associated with fewer adverse side effects. Oral antihistamines may be useful in patients with intermittent, mild symptoms of allergic rhinitis and in those who present with sneezing or rhinorrhoea.4 However, an intranasal corticosteroid is likely to be more effective.

You can buy antihistamine tablets from your pharmacist without a prescription, but antihistamine nasal sprays are only available with a prescription.

Antihistamines can sometimes cause drowsiness. If you’re taking them for the first time, see how you react to them before driving or operating heavy machinery.

In particular, antihistamines can cause drowsiness if you drink alcohol while taking them

Intranasal antihistamines may help with sneezing, itching and rhinorrhea. Azelastine is an intranasal antihistamine licensed for the treatment of allergic rhinitis. There is a rapid onset of action that may last up to 4 hours.

Adverse effects include epistaxis, nasal irritation and sedation. The use of intranasal antihistamines is limited by their cost and side-effect profile when compared with second generation oral antihistamines. Furthermore, intranasal antihistamines are less effective than intranasal corticosteroids. Combination therapy with intranasal corticosteroids and an antihistamine or leukotriene receptor antagonist is no more effective than monotherapy with intranasal corticosteroids ¹².

Add-on treatments

If allergic rhinitis does not respond to treatment, your doctor may choose to add to your original treatment.

They may suggest:

• increasing the dose of your corticosteroid nasal spray
• using a short-term course of a decongestant nasal spray to take with your other medication
• combining antihistamine tablets with corticosteroid nasal sprays, and possibly decongestants
• using a nasal spray that contains a medicine called ipratropium, which will help reduce nasal discharge and make breathing easier
• using a leukotriene receptor antagonist medication, which blocks the effects of chemicals called leukotrienes that are released during an allergic reaction

If you do not respond to the add-on treatments, you may be referred to a specialist for further assessment and treatment.

Sodium cromoglicate and nedocromil sodium may help with nasal symptoms but are considered less effective than intranasal corticosteroids ¹³. Anticholinergics such as ipratropium bromide may help with rhinorrhea. Decongestants such as ephedrine and xylometazoline may help with nasal congestion but are associated with rhinitis medicamentosa if used inappropriately ¹³. The anti-leukotriene montelukast is approved for allergic rhinitis in association with asthma ⁷.

Immunotherapy

In selected cases, if symptomatic control is not achieved, sublingual or subcutaneous immunotherapy also known as hyposensitization or desensitization, may used for some allergies.

Immunotherapy is only suitable for people with certain types of allergies, such as hay fever, and is usually only considered if your symptoms are severe. Immunotherapy can reduce symptoms of allergic rhinitis and prevent asthma. Immunotherapy may result in remission of allergic rhinitis and reduce the risk of progression to asthma ¹⁴. Moreover the risk of developing new sensitisations to allergens is reduced ¹⁴. Allergen immunotherapy is the only disease-modifying intervention available ¹⁵.

Immunotherapy involves gradually introducing more and more of the allergen into your body to make your immune system less sensitive to it ⁷.

The allergen is often injected under the skin of your upper arm (subcutaneous immunotherapy). Injections are given at weekly intervals, with a slightly increased dose each time.

Immunotherapy can also be carried out using tablets that contain an allergen, such as grass pollen, which are placed under your tongue.

When a dose is reached that’s effective in reducing your allergic reaction (the maintenance dose), you’ll need to continue with the injections or tablets for up to 3 years.

Immunotherapy should only be carried out under the close supervision of a specially trained doctor, as there’s a risk it may cause a serious allergic reaction.

References

1. Quillen, D.M. and Feller, D.B. Diagnosing rhinitis: allergic vs. nonallergic. Am Fam Physician. 2006; 73: 1583–1590
2. Lai, L., Casale, T.B., and Stokes, J. Pediatric allergic rhinitis: treatment. Immunol Allergy Clin North Am. 2005; 25: 283–299
3. Marks, M.B. Photo of eye depression. in: W.T. Vaughan, J.R. Black (Eds.) Practice of allergy. C.V. Mosby Co, Philadelphia; 1954: 1023
4. Marks, M.B. Significance of discoloration in the lower orbitopalpebral grooves in allergic children (allergic shiners). Ann Allergy. 1963; 21: 26–32
5. Prenner, B.M. and Schenkel, E. Allergic rhinitis: treatment based on patient profiles. Am J Med. 2006; 119: 230–237
6. Quantitative assessment of allergic shiners in children with allergic rhinitis. J ALLERGY CLIN IMMUNOLMARCH 2009 March 2009Volume 123, Issue 3, Pages 665–671.e6 https://doi.org/10.1016/j.jaci.2008.12.1108
7. Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic Rhinitis. Lancet 2011;378:2112-22
8. Steinsvaag SK. Allergic rhinitis: an updated overview. Curr Allergy Asthma Rep. 2012;12:99-103.
9. Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy 2008;38:19–42.
10. Angier E, Willington J, Scadding G, Holmes S, Walke S. Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Primary Care Respiratory Journal 2010;19:217-22.
11. Carr WW. New therapeutic options for allergic rhinitis: back to the future with intranasal corticosteroid aerosols. Am J Rhinol Allergy. 2013; 27:309-13.
12. Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician. 2010; 81:1440-6.
13. Meltzer EO. Pharmacotherapeutic strategies for allergic rhinitis: matching treatment to symptoms, disease progression, and associated conditions. Allergy Asthma Proc 2013;34:301-11.
14. Petalas K, Durham SR. Allergen immunotherapy for allergic rhinitis. Rhinology. 2013;51:99-110.
15. Uzzaman A, Story R. Chapter 5: Allergic rhinitis. Allergy Asthma Proc. 2012; Suppl 1:S15-8.