Allergic rhinitis — the one that isn't a cold

In brief

• Allergic rhinitis is not a cold but allergic inflammation of the nasal lining, in Singapore usually triggered by house dust mite.
• A steroid nasal spray is the most effective single treatment, but full benefit takes 1–2 weeks of daily use.
• Antihistamine tablets work within 1–3 hours for sneezing, itch and runny nose; a combined spray works fastest.
• Use decongestant sprays such as Iliadin or Otrivin for no more than 5 days in a row.
• One-sided blockage, recurrent nosebleeds, foul-smelling discharge, facial pain or visual changes need a different assessment.
• Allergen immunotherapy, taken over 3–5 years, is the closest thing to a cure.

We diagnose and manage allergic rhinitis as a long-term condition at our Punggol clinic. Book a chronic-care appointment.

What is allergic rhinitis?

Allergic rhinitis (AR) is an IgE-mediated inflammation of the nasal lining in response to an allergen, in Singapore most often house dust mite. The allergen makes cells in the nose release histamine and other inflammatory chemicals. This causes runny nose, blocked nose, sneezing and itchy nose.

Many people also get itchy, watery, red eyes. That is allergic conjunctivitis, which often travels with AR and has its own guide.

AR affects around 30% of people locally. A recent local study estimated that about 85% are undiagnosed and 73% untreated, many with moderate-to-severe symptoms. Many assume for years that they “always catch colds” or have a “sensitive nose”.

AR belongs to the atopic triad with eczema and asthma. Having one makes the other two more likely.

AR is classified by timing:

• Perennial: year-round, from indoor allergens (dust mites, pet dander, moulds). This is the main form in Singapore.
• Seasonal: pollen-driven. Common in temperate countries, uncommon locally.

And by impact:

• Intermittent (fewer than 4 days a week, or fewer than 4 consecutive weeks) or persistent (≥4 days a week and ≥4 consecutive weeks)
• Mild (not troublesome) or moderate-severe (affecting sleep, daily activities, leisure, sport, school or work)

AR is not a cold, though the symptoms overlap. That confusion is the main reason so many people go untreated for years.

What triggers it in Singapore — the dust mite connection

Singapore’s warm, humid climate is ideal for house dust mites (HDM). Over 80% of people with allergic airway disease in Singapore are sensitised to them. Three species dominate:

• Dermatophagoides pteronyssinus (European house dust mite)
• Dermatophagoides farinae (American house dust mite)
• Blomia tropicalis, abundant in the tropics and an important local allergen that many overseas labs don’t routinely test

The mites are harmless. Symptoms come from a protein in their droppings, and to a lesser extent their body fragments. Mites live wherever people shed skin: mattresses, pillows, bolsters, sheets, sofas, soft toys and carpets. They flourish when humidity is above 50%.

If symptoms persist, consider other indoor triggers:

• Pet dander (cat, dog, rabbit, hamster)
• Cockroach allergen, more common in older buildings
• Mould spores from damp bathrooms, air-conditioning condensate and poorly ventilated corners

Pollen-driven AR is uncommon in Singapore. We occasionally see it in people sensitised while living in a temperate country.

Allergic rhinitis vs “always catching a cold”

These features usually tell the two apart:

If your “colds” keep coming back, last for months, itch constantly and settle with an antihistamine, they aren’t colds.

Other kinds of rhinitis — and why the diagnosis matters

Not every runny or blocked nose is allergic. Before treating, we consider:

• Infective rhinitis: a viral upper respiratory tract infection (see Colds, coughs and sore throats). It is shorter, often with whole-body symptoms, and the discharge often turns purulent.
• Vasomotor (non-allergic) rhinitis: the nose over-reacts to temperature change (e.g. entering an air-conditioned room), strong smells, spicy food, alcohol or smoke. Itch is mild or absent, and the eyes are not involved. Antihistamines work less well. Treatment is trigger avoidance, saline rinses, and sometimes an intranasal corticosteroid or anticholinergic spray.
• Hormonal rhinitis: pregnancy is the classic example. Symptoms settle after delivery.
• Drug-induced rhinitis: topical decongestant sprays (oxymetazoline — Iliadin; xylometazoline — Otrivin) used beyond a few days cause rebound congestion (rhinitis medicamentosa). ACE inhibitors, some beta-blockers and NSAIDs can also cause nasal symptoms.
• Occupational rhinitis: triggered at work, for example by flour in bakers, latex, cleaning agents or chemicals. It is usually better at weekends and on holiday.
• Structural causes: a deviated septum, nasal polyps, or enlarged adenoids in children. These block the nose without the allergic features.

Treatment differs: rhinitis medicamentosa needs the spray stopped, and nasal polyps may need specialist assessment.

Figuring out your triggers

People differ in what sets them off. Ask yourself:

• When are symptoms worst? On waking is a strong dust-mite sign. Also check: after making the bed, entering an air-conditioned car or room, visiting a home with pets, at work, or while cleaning.
• When do they ease? On holiday abroad, after a night away, or at the beach or pool?
• Where are you worse? Pet homes, old bookshops, dusty storerooms, carpeted hotel rooms, libraries, construction sites.
• Irritants also worsen symptoms: cigarette smoke, strong perfume, incense, vehicle exhaust, scented cleaning products.

A symptom diary over 2–3 weeks, noting when symptoms flare, where you were and what you did, is often more useful than any blood test.

How we diagnose it

We usually diagnose AR from history and examination. Formal testing is not routinely needed.

The typical pattern is at least two of runny nose, blocked nose, itchy nose or sneezing, on at least two consecutive days, lasting more than an hour on most days. Itchy, red, watery eyes often come with it.

On examination we may see:

• An “allergic salute” crease: a line across the lower nose from rubbing it upwards, common in children
• Allergic shiners: darker skin under the eyes
• Habitual mouth-breathing
• A pale, boggy nasal lining with clear, watery discharge, unlike the red, inflamed lining of a viral infection
• Middle-ear fluid or a retracted eardrum, more often in children
• Redness or swelling of the conjunctiva (the lining of the eye)

A personal or family history of eczema, asthma or food allergy makes AR more likely, because these conditions share an allergic tendency.

A note on young children — the “atopic march”

Allergies in children tend to appear in a set order:

1. Atopic dermatitis (eczema), often in the first year of life
2. Food allergy, which may follow
3. Allergic rhinitis, typically from around 2 years of age
4. Asthma, in the preschool years or later

This is the atopic march. Sensitisation takes time, so true AR before age 2 is uncommon. A child under 2 with a persistently runny or blocked nose is more likely to have something else: repeated viral infections, enlarged adenoids, non-allergic rhinitis or a structural cause. Bring them for a consultation to find the cause, rather than reaching for an antihistamine by reflex.

Red flags — when the pattern isn’t quite right

These features need a different assessment rather than assuming AR:

• One-sided nasal blockage or discharge
• Recurrent nosebleeds, especially if severe or one-sided
• Purulent or foul-smelling discharge
• Recurrent sinus infections
• Facial pain, orbital pain, swelling or visual changes
• Steady worsening despite optimised treatment

They can point to structural problems (deviated septum, polyps), chronic rhinosinusitis, a foreign body in a child, or rarer conditions that need ENT assessment.

Testing — usually not needed, sometimes helpful

Allergy testing is not routinely needed to diagnose AR. It helps most when:

• The diagnosis is still unclear after history and examination
• Symptoms persist or stay severe despite properly used first-line treatment
• We are considering allergen immunotherapy, which needs a specific trigger identified
• Several atopic conditions coexist and knowing the allergen would change management

Two tests are common:

• Skin prick test (SPT): allergen extract is pricked into the forearm skin, and an itchy bump appears within 15–20 minutes if you are sensitised. It is fast, cheap per allergen and tests many allergens at once. You must stop antihistamines for several days first, and it needs healthy skin, so not during an eczema flare. Whole-body reactions are very rare but possible.
• Specific IgE blood test (sIgE): measures allergen-specific antibodies in the blood. You can stay on antihistamines, it works during a skin flare, and it is safer. Results take a few days, it costs more, and it is slightly less sensitive.

Both tests show sensitisation, not necessarily clinical allergy, so a result only counts if it matches your history. Broad panels are rarely useful in Singapore because dust mite dominates. We test the allergens your history suggests.

Why treat it — what you get back

AR isn’t life-threatening, but it costs more day to day than most people realise. Good treatment commonly brings back:

• Sleep. Most people fall asleep faster, wake less and snore less, and feel much less tired by day.
• Nose breathing. Chronic mouth-breathing dries the mouth, worsens dental plaque and contributes to sore throats. In children it can affect facial growth and dental alignment.
• Smell and taste. Congestion dulls smell, and taste depends largely on smell. Many people only notice the loss when it returns.
• Sport, school and work. Children with poorly controlled AR do measurably worse at school and sport, and are drowsier by day. Adults report better concentration and energy.
• Other atopic conditions. Good AR control often improves asthma and reduces sinus infections and, in children, middle-ear problems.
• Headache and facial pressure. Often blamed on sinusitis, these frequently settle once the rhinitis is treated.
• Less embarrassment. Constant sniffing, sneezing and throat-clearing carry a social cost that many people are glad to lose.

Treatment — three main options

Three classes of medication are first-line. The choice depends on your symptoms, how fast you need relief, tablet or spray preference, and cost.

Intranasal corticosteroid spray (INCS)

A small dose of corticosteroid sprayed onto the nasal lining. It is the most effective single treatment for AR, especially for congestion. Common options in Singapore:

• Fluticasone propionate — Flixonase
• Fluticasone furoate — Avamys
• Mometasone — Nasonex (subsidised under government schemes)
• Beclomethasone — Beconase
• Budesonide — Rhinocort
• Triamcinolone — Nasacort

Some improvement comes within 6–12 hours, but full benefit takes 1–2 weeks of daily use. People who stop after three days often think it “didn’t work”, when it had not had time to.

INCS is much safer than oral steroids, because very little reaches the bloodstream (see below). Side effects are local: mild irritation or dryness and occasional light nosebleeds, usually helped by better technique.

Second-generation oral antihistamines

A tablet or syrup, usually once a day. They work within 1–3 hours, faster than INCS, and help sneezing, itch and runny nose. They are less effective for congestion. Common options in Singapore:

• Cetirizine — Zyrtec, Alerid (subsidised)
• Loratadine — Clarityn (subsidised)
• Desloratadine — Aerius
• Levocetirizine — Xyzal
• Fexofenadine — Telfast
• Bilastine — Bilaxten (a newer second-generation option, with minimal sedation)

They cause much less drowsiness than the older first-generation antihistamines (below), though people vary. Cetirizine and levocetirizine are slightly more likely to cause drowsiness. Loratadine, desloratadine, fexofenadine and bilastine tend to be the least sedating.

Combined intranasal corticosteroid + antihistamine spray (INCS+INAH)

One spray containing both. It is the fastest of the three (effect within 30 minutes, maximal over 2–3 days) and the most effective for moderate-to-severe symptoms. Options in Singapore:

• Fluticasone + azelastine — Dymista
• Mometasone + olopatadine — Ryaltris

We use it as a step up when INCS alone isn’t enough, or first-line when severe symptoms need fast relief. The drawbacks are cost (not currently subsidised) and a brief bitter aftertaste from azelastine, usually manageable with correct technique.

Switching, stepping up, stepping down

Continue treatment until symptoms settle, then we discuss stepping down rather than stopping abruptly. If AR returns, restart at the dose that worked. If control stays poor despite consistent, correct use, we usually consider:

• Oral antihistamine → INCS
• INCS → INCS+INAH combination
• Adding saline rinses or a short course of topical decongestant

What we generally don’t recommend

These were once common but are no longer first-line for AR:

• First-generation oral antihistamines: chlorpheniramine (Piriton), hydroxyzine, promethazine (Phenergan), ketotifen. They enter the brain and cause drowsiness and anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision). They impair driving and school performance, and in older adults are linked to confusion and falls. They still have uses (acute urticaria, some allergic reactions, short-term sedation), but not for chronic AR.
• Montelukast (Singulair) as routine AR treatment: less effective than INCS or oral antihistamines for AR alone. The Health Sciences Authority has an advisory on its neuropsychiatric side effects (mood change, agitation, sleep disturbance, rarely suicidal thoughts). It has a role as an add-on when AR coexists with asthma, where we weigh and discuss the risks openly.
• Long-term oral corticosteroids: the wrong trade-off for a chronic condition. Their side effects (blood pressure, blood glucose, bone, cataracts, weight gain) outweigh the benefit when good alternatives exist.
• Oral decongestants on their own (pseudoephedrine, phenylephrine): little benefit beyond congestion, with side effects such as raised blood pressure, palpitations, insomnia and urinary retention. A few days combined with an antihistamine can help severe congestion, but not long term.

A conversation about steroids

Many people are wary of a “steroid” spray, often after seeing relatives on long-term prednisolone. It is a fair concern.

• A nasal spray is not a steroid tablet. A daily spray contains roughly 1/50th to 1/100th of a typical oral prednisolone dose. It acts on the nasal lining rather than circulating in the blood.
• Long-term INCS at the recommended dose has a well-established safety record over decades, including in children followed for growth.
• Dryness and occasional spotting of blood usually come from aiming at the septum. Better technique manages them.
• Not treating has its own cost: years of symptoms, poor sleep, and sometimes worsening asthma or sinus disease.

Please raise any concerns. Some people do best on INCS plus an antihistamine, some on an antihistamine alone, and a few on immunotherapy.

How to use a nasal spray correctly

Technique largely decides whether a spray works.

1. Blow your nose to clear it.
2. Shake the bottle.
3. Prime a new bottle with a few sprays into the air until a fine mist appears (follow your product’s instructions).
4. Tilt your head slightly forward, not back.
5. Use the opposite hand to the nostril: left hand for the right nostril, right hand for the left. This angles the nozzle away from the septum (the middle wall of the nose), the most sensitive area and the usual source of spray nosebleeds.
6. Aim outward, towards the outer corner of the eye on the same side, not straight up.
7. Breathe in gently through your nose as you press. A hard sniff sends the medicine down your throat.
8. Don’t blow your nose for 15 minutes afterwards.

A bitter taste in the throat usually means the spray ran down the back of the nose. Adjust the angle and sniff more gently.

Saline nasal rinses

Salt-water rinses from a squeeze bottle (NeilMed Sinus Rinse) or small spray (FESS, Sterimar, Sinugas) are a safe, inexpensive add-on to any medication. They wash out allergens, thin mucus and improve control. They are especially useful:

• Before an INCS spray, so it coats the lining better
• During a viral infection on top of AR, when congestion spikes
• In children, who tolerate small sprays better than large-volume rinses
• In pregnancy, to minimise medication

For large-volume rinses, use distilled, previously boiled or sterile water, never tap water, because of a rare but serious risk of nasal infection. Buffered salt sachets are cheap and widely available.

Topical nasal decongestant sprays — short-term tool only

Oxymetazoline (Iliadin) and xylometazoline (Otrivin) shrink swollen nasal blood vessels within minutes. They help for a few days of severe congestion: during a viral infection on top of AR, to help you sleep, or to let an INCS spray reach the lining.

Use them for no more than 5 consecutive days. After that the nose becomes dependent on the spray, and congestion rebounds worse each time it wears off (rhinitis medicamentosa). We regularly see people who have used these sprays several times a day for years. Breaking the cycle takes weeks, often with an INCS spray to bridge it.

Iliadin comes in three age-specific strengths in Singapore:

• Iliadin Baby 0.01%: up to 1 year old
• Iliadin Children 0.025%: 1 to 6 years
• Iliadin Adult 0.05%: 6 years and up

The 5-day rule applies to all of them.

Reducing house dust mite exposure

Avoiding dust mites alone is unlikely to control moderate-to-severe AR. The evidence is modest, and most people need medication. But these measures are cheap and low-risk, and can help, especially with sleep, since most exposure happens in bed.

Worth doing:

• Encase the mattress, pillow and bolster in tightly woven dust-mite-proof covers (pore size below 10 microns). Look for certified brands rather than generic claims.
• Wash bedding weekly in hot water (above 60°C), or use a hot dryer cycle.
• Remove bedroom carpets and rugs where feasible. Hard floors are easier to keep dust-free.
• Cut down soft toys, cushions and fabric wall hangings in bedrooms. A soft toy sealed in a bag in the freezer overnight, once a week, kills mites.
• Vacuum weekly with a HEPA-filter vacuum. Allergen stays airborne for about 20 minutes after vacuuming or bed-making, so avoid exercising in that room then if you are sensitive.
• Keep humidity down. Mites thrive above 50% humidity. Air-conditioned bedrooms usually fall below that. Dehumidifiers are rarely needed.

Usually not worth the money: expensive “allergy” air purifiers (limited evidence for rhinitis), chemical anti-mite sprays (short-lived and possibly irritating), and replacing furniture wholesale.

Is there a cure? — allergen immunotherapy

Standard medicines control AR but don’t cure it. The closest thing to a disease-modifying treatment is allergen immunotherapy (AIT).

What it is

AIT gradually re-educates the immune system. Over a long period you receive increasing doses of the allergen you are sensitised to, until the immune overreaction shrinks. There are two routes:

• Subcutaneous immunotherapy (SCIT): injections under the skin, weekly at a specialist clinic during a build-up phase (3–6 months), then monthly for maintenance.
• Sublingual immunotherapy (SLIT): a daily tablet or drops under the tongue, taken at home. House dust mite SLIT tablets registered in many countries include Acarizax (SQ HDM) and Actair. Availability in Singapore changes over time; your specialist will advise.

Realistic expectations

• Commitment: at least 3 years, often 3–5 years, for a lasting effect.
• Effect: in well-selected people with dust-mite AR, it meaningfully reduces symptoms in most, and many can cut down or stop other medicines. It is not guaranteed; a minority benefit little.
• Lasting benefit: unlike tablets and sprays, its benefit can last for years after the course ends. That is why it is the closest thing to a “cure”.
• Side effects: SCIT carries a small risk of a whole-body allergic reaction, so injections are given in a specialist clinic with observation afterwards. SLIT is safer in this respect. Its side effects are mostly local (itching or slight swelling under the tongue) and usually settle.

Who should think about it

Worth considering if:

• You have persistent moderate-to-severe AR despite well-used first-line treatment
• A specific allergen matching your symptoms has been identified, usually by SPT or sIgE
• You can commit to a multi-year schedule
• You have mild asthma driven by the same allergen (immunotherapy may help both)

Less suitable if:

• Symptoms are well controlled on minimal medication
• Asthma is poorly controlled (a relative contraindication for SCIT)
• You are pregnant: starting is usually deferred, though established maintenance is often continued if safe
• You have certain immune or cardiovascular conditions, which need specialist assessment

The pathway

Immunotherapy is specialist-led. If it suits you, we usually:

1. Confirm the main allergen with SPT or sIgE
2. Optimise standard medication first to set a baseline
3. Refer you to an allergy, immunology or ENT specialist experienced in immunotherapy
4. Continue your general primary care alongside

We are happy to discuss it at any stage, including early.

When we’d consider specialist referral

Most AR is managed well in primary care. ENT, allergy or immunology referral adds value when:

• Symptoms persist or stay severe despite optimised medication, especially if sleep, school or work suffer
• Nasal polyps are suspected or seen
• Chronic rhinosinusitis doesn’t settle with appropriate treatment
• There are structural problems, such as marked septal deviation or enlarged adenoids in children
• There are red flags: one-sided symptoms, recurrent nosebleeds, facial pain, visual changes
• You are considering allergen immunotherapy
• Asthma is also poorly controlled, where a joint review sometimes helps

A brief note on pregnancy

AR often worsens in pregnancy, partly from hormonal effects on the nasal lining and partly because perennial AR continues regardless. Our usual approach:

• Saline rinses first, safe throughout pregnancy
• An intranasal corticosteroid if needed. Budesonide has the most safety data and is our usual first choice.
• Second-generation oral antihistamines: loratadine and cetirizine have the most reassuring safety data and are generally acceptable, at the lowest effective dose
• Avoid oral decongestants (pseudoephedrine), especially in the first trimester
• Avoid first-generation antihistamines as a rule
• Topical decongestants only briefly, if at all

Dust-mite measures taken in pregnancy may help both your symptoms and your baby’s future nose and asthma health.

The Singapore context — schemes that help

• Healthier SG Chronic Tier: if you are enrolled with us and hold a CHAS, Pioneer Generation or Merdeka Generation card, selected chronic-disease medicines (including some INCS and oral antihistamines) cost about the same as at polyclinics.
• Community Health Assist Scheme (CHAS): means-tested subsidies for consultations and selected medicines at participating GP clinics. More at chas.sg.
• MediSave: usable for chronic disease consultations and selected medicines under the MediSave500/700 scheme, up to the annual withdrawal limit (currently $500, or $700 for complex chronic conditions). From January 2027 the limits rise to $700 / $1,000 and the scheme is renamed the MediSave Chronic and Preventive Care scheme.
• Primary Care Networks (PCN): KTMC is part of Class PCN, which supports nurse counselling and chronic disease registry tracking.

Get in touch

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Email — admin@ktmc.sg

References

Guidelines

• Agency for Care Effectiveness (ACE). Allergic rhinitis — diagnosis and management. ACE Clinical Guideline, Ministry of Health, Singapore. May 2026. ace-hta.gov.sg
• Bousquet J, Schünemann HJ, Togias A, et al. Next-generation Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence. J Allergy Clin Immunol. 2020;145(1):70-80.
• Wise SK, Damask C, Roland LT, et al. International consensus statement on allergy and rhinology: Allergic rhinitis — 2023. Int Forum Allergy Rhinol. 2023;13(4):293–859.

Singapore epidemiology and dust mite sensitisation

• Wang XS, Tan TN, Shek LP, et al. The prevalence of asthma and allergies in Singapore; data from two ISAAC surveys seven years apart. Arch Dis Child. 2004;89:423–426.
• Chew FT, Lim SH, Goh DY, Lee BW. Sensitization to local dust-mite fauna in Singapore. Allergy. 1999;54:1150–1159.
• Andiappan AK, Puan KJ, Lee B, et al. Allergic airway diseases in a tropical urban environment are driven by dominant mono-specific sensitization against house dust mites. Allergy. 2014;69:501–509.

Pharmacotherapy

• Penagos M, Compalati E, Tarantini F, et al. Efficacy of mometasone furoate nasal spray in the treatment of allergic rhinitis. Meta-analysis of randomized, double-blind, placebo-controlled clinical trials. Allergy. 2008;63:1280–1291.
• Meltzer EO, LaForce C, Ratner P, et al. MP29-02 (a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate) in the treatment of seasonal allergic rhinitis. Allergy Asthma Proc. 2012;33:324–332.
• Health Sciences Authority, Singapore. Drug Safety Information — advisory on montelukast and neuropsychiatric effects. hsa.gov.sg

Allergen immunotherapy

• Dhami S, Nurmatov U, Arasi S, et al. Allergen immunotherapy for allergic rhinoconjunctivitis: a systematic review and meta-analysis. Allergy. 2017;72:1597–1631.
• Demoly P, Emminger W, Rehm D, et al. Effective treatment of house dust mite-induced allergic rhinitis with 2 doses of the SQ HDM SLIT-tablet: results from a randomized, double-blind, placebo-controlled phase III trial. J Allergy Clin Immunol. 2016;137(2):444–451.

National programmes

• Ministry of Health, Singapore. Healthier SG and Chronic Tier information. healthiersg.gov.sg
• Community Health Assist Scheme. chas.sg
• Ministry of Health, Singapore. Keeping healthcare affordable — MediSave500/700 limits rising to $700 / $1,000 and scheme renamed MediSave Chronic and Preventive Care from 1 January 2027. 5 March 2026. moh.gov.sg

This information is for general education only and is not a substitute for medical advice. Allergic rhinitis management must be individualised to your symptom pattern, triggers, and response to treatment — please speak with our team about what’s right for you. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.