by Bob Flaws, Dipl. Ac. & C.H., Lic. Ac., FNAAOM, FRCHM

Keywords: Chinese medicine, Chinese herbal medicine, allergic rhinitis, hayfever

Western medicine & hayfever

The technical name for hayfever is allergic rhinitis. Rhinitis is defined as inflammation of the nasal membranes and is characterized by a symptom complex that consists of any combination of the following: sneezing, nasal congestion, nasal itching, and rhinorrhea. The eyes, ears, sinuses, and throat can also be involved. Allergic rhinitis is the most common cause of rhinitis. It is an extremely common condition, affecting approximately 20% of the American population or 40 million men, women, and children. While allergic rhinitis is not a life_threatening condition, complications can occur and the condition can significantly impair quality of life. The total direct and indirect cost of allergic rhinitis has recently been estimated at $5.3 billion per year in the U.S.

Pathophysiology:

Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The nose invariably is involved, and the other organs are affected in certain individuals. Inflammation of the mucous membranes is characterized by a complex interaction of inflammatory mediators but ultimately is triggered by an immunoglobulin E (IgE)Ðmediated response to an extrinsic protein. The tendency to develop allergic, or IgE_mediated, reactions to extrinsic allergens (proteins capable of causing an allergic reaction) has a genetic component. In susceptible individuals, exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against these proteins. This specific IgE coats the surface of mast cells which are present in the nasal mucosa. When the specific protein (e.g., a specific pollen grain) is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators.

The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin. The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2. These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea (i.e., nasal congestion, sneezing, itching, redness, tearing, swelling, ear pressure, and postnasal drip). Mucous glands are stimulated, leading to increased secretions. Vascular permeability is increased, leading to plasma exudation. Vasodilation occurs, leading to congestion and pressure. Sensory nerves are stimulated, leading to sneezing and itching. All of these events can occur in minutes. Hence, this reaction is called the early or immediate phase of the reaction.

Over 4_8 hours, these mediators, through a complex interplay of events, lead to the recruitment of other inflammatory cells to the mucosa, such as neutrophils, eosinophils, lymphocytes, and macrophages. This results in continued inflammation, termed the late_phase response. The symptoms of the late_phase response are similar to those of the early phase but less sneezing and itching and more congestion and mucus production tend to occur. The late phase may persist for hours or days. Systemic effects, including fatigue, sleepiness, and malaise, can occur from the inflammatory response. These symptoms often contribute to impaired quality of life. Symptoms such as fatigue, drowsiness (due to the disease or to medications), and malaise can lead to impaired work and school performance, missed school or work days, and traffic accidents.

Complications:

A number of complications which can lead to increased morbidity or even mortality can occur secondary to allergic rhinitis. These include otitis media, eustachian tube dysfunction, acute sinusitis, and chronic sinusitis. Allergic rhinitis can also be associated with a number of comorbid conditions, including asthma, atopic dermatitis, and nasal polyps. Evidence now suggests that uncontrolled allergic rhinitis can actually worsen the inflammation associated with asthma or atopic dermatitis.

Epidemiology:

Allergic rhinitis occurs in persons of all races. Prevalence of allergic rhinitis seems to vary among different populations and cultures, which may be due to genetic differences, geographic factors or environmental differences, or other population_based factors. In childhood, allergic rhinitis is more common in boys than in girls, but in adulthood, the prevalence is approximately equal between men and women. Onset of allergic rhinitis is common in childhood, adolescence, and early adult years, with a mean age of onset 8_11 years, but allergic rhinitis may occur in persons of any age. In 80% of cases, allergic rhinitis develops by age 20 years. The prevalence of allergic rhinitis has been reported to be as high as 40% in children, subsequently decreasing with age. In the geriatric population, rhinitis is less commonly allergic in nature.

Hayfever appears to be a recently developed disease. Researchers in the late 1980s could find no systematic reference to it earlier than the 16th century, and until the 1830s, the only form recognized was the "rose cold" or "rose fever." By 1860, an anonymous writer cited by Salter commented on "...the more general and more severe development of hay_fever which appears to have recently occurred." In a similar vein, Blackley wrote in 1873 that "hay_fever has...been considerably on the increase," was most common among the educated and upper classes, and was uncommon among farm workers _ a pattern matching that found by Aberg and by the Australian National Health Survey in 1989. By the turn of the 20th century, hayfever associations were being formed with thousands of members. More recently, hayfever prevalence has continued to increase in line with that seen for asthma.

Types of allergens:

Seasonal allergic rhinitis is commonly caused by allergy to seasonal pollens and outdoor molds. Tree pollens, which vary by geographic location, are typically present in high counts during the spring, although some species produce their pollens in the fall. Common tree families associated with allergic rhinitis include birch, oak, maple, cedar, olive, and elm. Grass pollens also vary by geographic location. Most of the common grass species are associated with allergic rhinitis, including Kentucky bluegrass, orchard, redtop, timothy, vernal, meadow fescue, Bermuda, and perennial rye. A number of these grasses are cross_reactive, meaning that they have similar antigenic structures (i.e., proteins recognized by specific IgE in allergic sensitization). Consequently, a person who is allergic to one species is also likely to be sensitive to a number of other species. The grass pollens are most prominent from the late spring through the fall but can be present year_round in warmer climates. Weed pollens also vary geographically. Many of the weeds, such as short ragweed, which is a common cause of allergic rhinitis in much of the United States, are most prominent in the late summer and fall. Other weed pollens are present year_round, particularly in warmer climates. Common weeds associated with allergic rhinitis include short ragweed, western ragweed, pigweed, sage, mugwort, yellowdock, sheep sorrel, English plantain, lamb's quarters, and Russian thistle.

Indoor and outdoor molds can also be allergens resulting in allergic rhinitis. Atmospheric conditions can affect the growth and dispersion of a number of molds. Therefore, their airborne prevalence may vary depending on climate and season. For example, Alternaria and Cladosporium are particularly prevalent in the dry and windy conditions of the Great Plains states where they grow on grasses and grains. Their dispersion often peaks on sunny afternoons. They are virtually absent when snow is on the ground in winter, and they peak in the summer months and early fall. Aspergillus and Penicillium can be found both outdoors and indoors (particularly in humid households), with variable growth depending on the season or climate. Their spores can also be dispersed in dry conditions.

Perennial allergic rhinitis is typically caused by allergens within the home but can also be caused by outdoor allergens that are present year_round. In warmer climates, grass pollens can be present throughout the year. In some climates, individuals may be symptomatic due to trees and grasses in the warmer months and molds and weeds in the winter. In the United States, two major house dust mite species are associated with allergic rhinitis. These are Dermatophagoides farinae and Dermatophagoides pteronyssinus. These mites feed on organic material in households, particularly the skin that is shed from humans and pets. They can be found in carpets, upholstered furniture, pillows, mattresses, comforters, and stuffed toys. While they thrive in warmer temperatures and high humidity, they can be found year_round in many households. On the other hand, dust mites are rare in arid climates. Allergy to indoor pets is a common cause of perennial allergic rhinitis. Cat and dog allergies are encountered most commonly in allergy practice, although allergy has been reported to occur with most of the furry animals and birds that are kept as indoor pets. While cockroach allergy is most frequently considered a cause of asthma, particularly in the inner city, it can also cause perennial allergic rhinitis in infested households. Rodent infestation may also be associated with allergic sensitization.

Sporadic allergic rhinitis, intermittent brief episodes of allergic rhinitis, is caused by intermittent exposure to an allergen. Often, this is due to pets or animals to which a person is not usually exposed. Sporadic allergic rhinitis can also be due to pollens, molds, or indoor allergens to which a person is not usually exposed. While allergy to specific foods can cause rhinitis, an individual affected by food allergy also usually has some combination of gastrointestinal, skin, and lung involvement. In this situation, the history findings usually suggest an association with a particular food. Watery rhinorrhea occurring shortly after eating may be vasomotor (and not allergic) in nature, mediated via the vagus nerve. (This often is called gustatory rhinitis.)

Occupational allergic rhinitis, which is caused by exposure to allergens in the workplace, can be sporadic, seasonal, or perennial. People who work near animals (e.g., veterinarians, laboratory researchers, farm workers) might have episodic symptoms when exposed to certain animals, daily symptoms while at the workplace, or even continual symptoms (which can persist in the evenings and weekends with severe sensitivity due to persistent late_phase inflammation). Some workers who may have seasonal symptoms include farmers, agricultural workers (exposure to pollens, animals, mold spores, and grains), and other outdoor workers. Other significant occupational allergens that may cause allergic rhinitis include wood dust, latex (due to inhalation of powder from gloves), acid anhydrides, glues, and psyllium (e.g., nursing home workers who administer it as medication).

Western medical diagnosis & treatment:

The Western medical diagnosis of allergic rhinitis is based on the patient's history, their presenting signs and symptoms, and allergy skin tests (immediate hypersensitivity testing). Sensitivity to virtually all of the allergens that cause allergic rhinitis can be determined with skin testing. Total serum IgE is a measurement of the total level of IgE in the blood (regardless of specificity). While patients with allergic rhinitis are more likely to have an elevated total IgE level than the normal population, this test is neither sensitive nor specific for allergic rhinitis. As many as 50% of patients with allergic rhinitis have normal levels of total IgE, while 20% of nonaffected individuals can have elevated total IgE levels. Therefore, this test is generally not used alone to establish the diagnosis of allergic rhinitis, but the results can be helpful in some cases when combined with other factors. As with the total serum IgE, an elevated eosinophil count supports the diagnosis of allergic rhinitis, but it is neither sensitive nor specific for the diagnosis. However, the results of this test can also sometimes be helpful when combined with other factors.

The Western medical management of allergic rhinitis consists of three categories of treatment, 1) environmental control measures and allergen avoidance, 2) pharmacological management, and 3) immunotherapy. Environmental control measures and allergen avoidance involve both the avoidance of known allergens (substances to which the patient has IgE_mediated hypersensitivity) and avoidance of nonspecific or irritant triggers. Most cases of allergic rhinitis respond to pharmacotherapy. Patients with intermittent symptoms are often treated adequately with oral antihistamines, decongestants, or both as needed. Regular use of an intranasal steroid spray may be more appropriate for patients with chronic symptoms. Daily use of an antihistamine, decongestant, or both can be considered either instead of or in addition to nasal steroids. The newer, second_generation (i.e., non-sedating) antihistamines are usually preferable to avoid sedation and other adverse effects associated with the older, first_generation antihistamines. Ocular antihistamine drops (for eye symptoms), intranasal antihistamine sprays, intranasal cromolyn, intranasal anticholinergic sprays, and short courses of oral corticosteroids (reserved for severe, acute episodes only) may also provide relief. Immunotherapy (or desensitization) consists of subcutaneous high_dose allergy shots given with a hypodermic needle for reducing symptoms and the need for medication. Success rates have been demonstrated to be as high as 80_90% for certain allergens. However, this is a long_term process. Noticeable improvement is often not observed for 6_12 months, and, if helpful, therapy should be continued for 3_5 years. Further, immunotherapy is not without risk because severe systemic allergic reactions can sometimes occur. Therefore, it is not for everyone.

Chinese medicine & hayfever

According to Chinese medical theory, everyone who suffers from allergic rhinitis has has a defensive qi insecurity. In Chinese medicine, the defensive qi protects the surface of the body from attack and invasion by various types of pathogens. When the defensive qi is sufficient, pathogens cannot enter the body to cause disease. Therefore, the Nei Jing (Inner Classic), the "bible" of Chinese medicine states, "If evil enter, the righteous must be deficient." Unseen airborne pathogens, such as pollen, molds, dander, etc., are called wind evils. (Like wind, they are invisible but their effect can be felt.) In any group of people exposed to such wind evils, only a percentage develop symptoms of disease. These are the people whose defensive qi was deficient and insecure and, therefore, allowed the wind evils to penetrate. Wind evils typically enter the upper body through the mouth and nose. The nose is the orifice of the lungs, and wind evils that enter the nose tend to lodge in the lungs. When such wind evils lodge in the lungs, they prevent the lung qi or energy from carrying out its normal physiological functions. The functions of the lung qi are to descend and downbear fluids in the body. Therefore, if wind evils, such as allergens, inhibit the lung qi from descending and downbearing fluids, these fluids may back up within the lungs, eventually to spillover from the orifice of the nose in the form of mucous.

This tendency toward runny nose is complicated by another given within Chinese medicine in terms of allergic rhinitis. Everyone with allergic rhinitis has what is called deep-lying or hidden phlegm in their lungs. Hidden phlegm means that the phlegm is not apparent normally but only becomes apparent when provoked by certain disease mechanisms. In Chinese medicine, there is a well-known statement of fact: "The spleen is the root of phlegm engenderment; the lungs are the place where phlegm is stored." This saying is further based on the fact that it is the Chinese concept of the spleen that is primarily responsible for the movement and transformation of water fluids in the body. If, for any reason, the spleen becomes vacuous and weak, it may fail to move and transform water fluids. These water fluids collect and transform into damp evils (i.e., pathological dampness). If dampness lingers and endures, it may further congeal into phlegm. Thus phlegm is then typically stored in the lungs even though it is "produced" in the spleen. To tie things together, the Chinese concept of the spleen is also responsible for the creation of the defensive qi. This means that people with a vacuous, weak spleen tends to have both a lot of phlegm dampness and a deficiency of defensive qi. Further, it is a statement in fact that children's spleens are inherently immature and that their qi is weak and insufficient. This helps explain why the prime incidence of allergic rhinitis comes in the late childhood years and early adolescence. It also helps explain why some people "outgrow" their allergies. As the person's spleen qi becomes stronger, their defensive qi likewise becomes more secure and they produce less phlegm and dampness.

This theory also helps to explain why hayfever is a relatively recent phenomenon in human medical history. According to Chinese medical theory, because the spleen is the main organ in charge of digestion, it is very greatly influenced by diet. In particular, the spleen is averse to dampness. This means that external or environmental dampness may cause damage to spleen. However, dampness can also be internally engendered. Based on Chinese dietary theory, certain foods tend to engender fluids more than other foods. Such foods tend to be sweeter and also oilier. As most people today know, the amount of sweets, fats, and oils in the human diet have radically increased in the last 150 years. This is change in diet exactly parallels the rise in hayfever in the developed nations of the world. To exacerbate matters, excessive or inappropriate use of antibiotics can also damage the Chinese idea of the spleen. Similarly, overwork and too much stress can contribute to a general decrease in qi (including defensive qi), while too little physical exercise may contribute to the accumulation of phlegm and dampness. Here we have a picture of modern life in the West. Therefore, it makes perfect sense in terms of Chinese medicine that hayfever and other related allergies seem to be on the rise in the West.

What can Chinese medicine do about this?

In Chinese medicine, the treatment principles for eliminating allergic rhinitis are to 1) fortify the spleen and boost the qi, 2) dispel wind and eliminate evils, and 3) transform phlegm and dry dampness. These principles deal with the root and branches of allergic rhinitis. Spleen qi vacuity weakness is the root of this condition, while a defensive qi vacuity and deep-lying phlegm are its branches. Within Chinese medicine, there are many well-know herbs which can accomplish these various aims. For instance, Huang Qi (Radix Astragali Membranacei), Dang Shen (Radix Codonopsitis Pilosulae), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Fu Ling (Sclerotium Poriae Cocos), Shan Yao (Radix Dioscoreae Oppositae), Wu Wei Zi (Fructus Schisandrae Chinensis), and Yi Yi Ren (Semen Coicis Lachryma-jobi) can fortify the spleen and boost the qi, while BaI Zhu (Rhizoma Atractylodis Macrocephalae), Cang Zhu (Rhizoma Atractylodis), Fu Ling (Sclerotium Poriae Cocos), Ze Xie (Rhizoma Alismatis), Jie Geng (Radix Platycodi Grandiflori), Ban Xia (Rhizoma Pinelliae Ternatae), Qian Hu (Radix Peucedani), Gan Jiang (dry Rhizoma Zingiberis Officinalis), Sheng Jiang (uncooked Rhizoma Zingiberis Officinalis), Chen Pi (Pericarpium Citri Reticulatae) can transform phlegm and eliminate dampness. Chinese herbs which can dispel wind and eliminate evils include Jing Jie Sui (Herba Seu Flos Schizonepetae Tenuifoliae), Fang Feng (Radix Ledebouriellae Divaricatae), Chan Tui (Periostracum Cicadae), Xin Yi Hua (Flos Magnoliae Lileflorae), Cang Er Zi (Fructus Xanthii Sibirici), and Bo He (Herba Menthae Haplocalycis).

When Chinese doctors use these kinds of medicinals to treat allergic rhinitis, they combine them into multi-ingredient formulas. Such formulas can be further divided into two types: formulas to prevent seasonal allergic rhinitis and formulas to remedially treat during a paroxysmal attack. For instance, Modified Astragalus & Ginseng is a Chinese herbal formula originally created almost 1,000 years ago by the great Chinese medical doctor Li Dong-yuan. When taken 4-6 weeks before the onset of seasonal allergic rhinitis, it can help eliminate or decrease such attacks. Within this formula, Huang Qi, Dang Shen, Bai Zhu, Cang Zhu, Wu Wei Zi, and Da Zao (Fructus Zizyphi Jujubae ) fortify the spleen and boost the qi. Bai Zhu, Cang Zhu, Ban Xia, Chen Pi, and Sheng Jiang transform phlegm and eliminate dampness. In addition, Huang Qi, Wu Wei Zi, Shan Zhu Yu, and Wu Mei (Fructus Pruni Mume) specifically supplement and secure the defensive qi, while Fang Feng gently out-thrusts any lingering wind evils. Dang Gui (Radix Angelicae Sinensis), Chai Hu (Radix Bupleuri), Sheng Ma (Rhizoma Cimicifugae), Huang Bai (Cortex Phellodendri), and Gan Cao (Radix Glycyrrhizae Uralensis) help to harmonize the formula and insure that it regulates the immune system as a whole at the same time as being specifically antihistaminic and muycolytic. For instance, while this formula is decongestant and mucolytic, the inclusion of Mai Men Dong and Dang Gui helps insure that this formula will not cause dry mouth and excessive thirst like many Western decongestants.

AllerEase is a Chinese herbal formula which is specifically for the remedial treatment of acute allergic rhinitis. It also contains a number of the above three classes of Chinese herbs. Within it, Dang Shen, Huang Qi, Yi Yi Ren, Bai Zhu, and Shan Yao supplement the lungs, spleen, and kidneys, the three viscera which govern water metabolism in the body. He Zi (Fructus Terminaliae Chebulae) and Wu Wei Zi secure the lungs and specifically stop runny nose. Fang Feng and Jing Jie Sui relatively gently dispel wind evils from the exterior while not damaging the defensive qi. Xin Yi Hua and Bo He open the orifices and free the flow of the nose, thus relieving nasal congestion. Chan Tui dispels wind and stops itching. Jie Geng guides the other medicinals to the lungs and also transforms phlegm. Gan Jiang warms the lungs and transforms phlegm. The combination of Yi Yi Ren and Ze Xie seeps dampness via urination and, therefore, helps Bai Zhu eliminate dampness. Gan Cao (Radix Glycyrrhizae Uralensis) harmonizes all the other medicinals in the formula at the same time as helping fortify the spleen and supplement the qi. From the Western pharmacological point of view, AllerEase regulates the immune system and is antihistaminic, mucolytic, and decongestant.

Research outcomes:

In China, 33 patients with wind cold allergic rhinitis and an underlying lung-spleen vacuity were given a single course of treatment with this formula and then followed for six months. In six cases, their symptoms disappeared and did not recur for the full six months of the study. In 23 cases, their symptoms recurred after more than three months but less than six months. However, repeat treatment was able to eliminate their symptoms. Only four cases got no effect. Thus the total effectiveness of this formula was 87.8%.

Proper diet & lifestyle:

As stated above, the rise in incidence in hayfever is due to a combination of changed diet, too much stress and fatigue, and too little physical exercise. While Chinese herbs can go a long way to redressing these disease-causing agents, the best therapeutic effects are achieved by a combination of Chinese herbs and right diet and lifestyle. Right diet typically means eliminating or drastically reducing sugar and sweets, including fruit juices, cutting out or seriously cutting back on refined carbohydrates, eating less dairy products, such as milk, yogurt, and cheese, and consuming less fermented foods, such as bread, cheese, vinegar, and alcohol. All these foods very powerfully engender fluids in the body and, therefore, have the potential, when overeaten, of damaging the Chinese concept of the spleen. Right lifestyle means getting plenty of rest and avoiding unnecessary stress coordinated with sufficient physical exercise. Not only will such a diet and lifestyle help eliminate allergic rhinitis, it will also help reduce weight, lower cholesterol, and prevent heart disease and diabetes with all of their many complications.

Modified Astragalus & Ginseng and AllerEase are available for sale in North American through Imperial Secrets Herbs of Boulder, CO.

About Bob Flaws

Bob Flaws is one of the world's premier practitioners of and authorities on Chinese medicine. Author and translator of almost 100 books and hundreds of articles, Bob trained at the Shanghai College of Chinese Medicine and has been in practice for 26 years. He regularly lectures throughout the world to both students and practitioners and is a contributing editor for The Townsend Letter for Doctors & Patients..