Living with undiagnosed allergic rhinitis

Allergic rhinitis is a highly prevalent respiratory disease, with as many as 40% of the world’s population being affected (Tong & Lin, 2014) – but are there more people suffering the symptoms of allergic rhinitis that remain undiagnosed?

Undiagnosed allergic rhinitis could be more common than you think. Surveys from Europe and the USA have revealed that allergic rhinitis is undiagnosed in approximately one-third of adults. In addition, the surveys also revealed that only 12% of patients with allergic rhinitis sought prescription treatment (Malone et al., 1997; Nolte et al., 2006).

Allergic rhinitis left undiagnosed, or undertreated can lead to increased risk of comorbidities such as asthma, otitis media, lymphoid hypertrophy with obstructive sleep apnoea, and worsen allergic rhinitis symptoms (Stewart, 2008).

With the clear need for better diagnosis, Dr Glenis Scadding shares her opinions on why she believes many patients have uncontrolled allergic rhinitis.

Primary care physicians (PCPs) and pharmacists are often the first to assess potential allergic rhinitis symptoms. However, confirmation of allergic rhinitis requires a referral to a specialist and is commonly overlooked.

Hoping to aid this referral decision, Galimberti et al. investigated the probability of a positive skin prick test (SPT) in response to a self-reporting questionnaire. The Respiratory Allergy Prediction (RAP) test consisted of 9 questions relating to allergic rhinitis symptoms (figure1).

To test the efficacy of the RAP test, a total of 401 patients with suspected allergic rhinitis answered the questionnaire pre- and post-SPT. Allergic rhinitis was diagnosed in 91% of patients, and 77.8% of patients showed a positive STP result. Interestingly, in this study asthma was diagnosed in 35.7% of patients; Dr Glenis Scadding mentioned, approximately 80% of patients with asthma also have allergic rhinitis, highlighting how the two diseases often cross over and both should be considered when diagnosing the condition.

From the statistical analysis, Galimberti et al. reported that answering yes to questions 4, 6 and 8 gave a probability of having a positive SPT result of 85%. An even higher probability was seen when answering yes to questions 4, 6, and 8, and answering no to question 1 – 94.6%. Given the high probability of the latter combination of answers, it has been proposed that questions 1, 4, 6, and 8 make up the RAP test in future testing and clinical practice.

R A P test

Figure 1: RAP test (Galimberti et al., 2015).

Dr Scadding highlighted that patients with asthma are rarely asked about their upper airway, it is hoped that the RAP test will guide PCPs and pharmacists to refer those patients who are most likely to have undiagnosed allergic rhinitis in the future.

In the coming months we will be looking at how undiagnosed allergic rhinitis affects asthma control and the potential socioeconomic benefits of treating the two conditions together.


Malone DC, Lawson KA, Smith DH, Arrighi HM, Battista C. A cost of illness study of allergic rhinitis in the United States. J Allergy Clin Immunol. 1997;99:22–7.

Nolte H, Nepper-Christensen S, Backer V. Unawareness and undertreatment of asthma and allergic rhinitis in a general population. Respir Med. 2006;100:354–62.

Tong MCF, Lin JSC. Epidemiology of allergic rhinitis throughout the world. Global atlas of allergic rhinitis and chronic rhinosinusitis. 2014;62–3.

Galimberti M, Passalacqua G, Incorvaia C, Castella V, Costantino MT, Cucchi B, et al. Catching allergy by a simple questionnaire. World Allergy Organ J. 2015;8:16.

Stewart, MG. Identification and management of undiagnosed and undertreated allergic rhinitis in adults and children. Clin Exp Allergy. 2008;38:751–60.


Publications (3)
  • Living with undiagnosed allergic rhinitis

    View the latest expert opinions from Dr Glenis Scadding, consultant allergist and rhinologist, discussing the burden undiagnosed allergic rhinitis creates and how this could be improved using positive skin prick and PAP testing.

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