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Wise et al.

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secretion, and nasal hyperresponsiveness to the same or different allergens. Additionally, even in the absence of overt symptoms, IgE has an increased presence in the lymphoid tissue of the atopic patient, which can result in persistent mucosal inflammation. 12

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III.B. Allergic rhinitis classification

Seasonal vs perennial allergic rhinitis— The Allergic Rhinitis and its Impact on Asthma (ARIA) proposals have categorized AR by presumed cause and seasonal vs perennial presentation. Classically, this has included seasonal AR (SAR; hay fever) and perennial allergic rhinitis (PAR). 7 SAR is triggered by a wide assortment of outdoor allergens, especially pollens. 7 PAR is commonly brought about by indoor allergens that are present through-out the year, such as dust mites, molds, insects (cock-roaches), and animal dander. 7 Intermittent vs persistent allergic rhinitis— The classification of “seasonal” and “perennial” AR can often be in conflict, as manifestations of perennial allergy may not occur throughout the entire year. This is particularly the case for patients allergic to house dust mites (HDM), who may demonstrate mild or moderate/severe intermittent allergic rhinitis (IAR). 9,13-15 In addition, because of the priming effect on the nasal mucosa initiated by low levels of pollen allergens 16-21 and minimal persistent nasal inflammation in patients with “symptom-free rhinitis,” 14,22,23 symptoms may not occur entirely in conjunction with the allergen season, therefore resulting in nonspecific exacerbations. Air pollution may also contribute to alterations in allergen sensitivity, resulting in varying degrees of symptoms depending on location and air quality. 24 Furthermore, individuals sensitized to multiple pollens may have symptoms across several seasons while individuals with PAR may encounter symptoms for short periods of time with frequent, repetitive relapses. Because of the issues outlined above, ARIA proposed a new method of classification based on the length and recurrence of the symptom manifestations. 25 IAR is characterized by symptoms for less than 4 days per week or less than 4 consecutive weeks. Persistent AR (PER) is characterized by symptoms occurring more than 4 days per week for at least 4 consecutive weeks; therefore, PER patients are symptomatic most of the time. 26 It has been recommended that the previous categories of seasonal and perennial AR (ie, SAR and PAR) not be used along with the new classification of IAR and PER, as they do not represent the same stratification of the disease state. As such, IAR and PER are not synonymous with seasonal and perennial. 25,27-30 In describing AR, one should determine which classification scheme best conveys the message that he/she wishes to relay: seasonal/perennial or intermittent/persistent. Severity of allergic rhinitis— AR can result in significant disturbances in quality of life (QOL), sleep, exercise tolerance, productivity, and social functioning. The ARIA guidelines have likewise proposed the stratification of severity (mild and moderate-severe) in view of these disabilities. 13 (See section VII. Disease Burden for additional information on this topic.)

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.