For many of us, hay fever means reaching for antihistamines when the pollen count rises. But what happens when conventional treatments are no longer enough? Dr José Costa, Senior Allergy Consultant, explains why allergen immunotherapy offers a different approach — one designed to change the immune system’s response rather than simply manage the symptoms.
For millions of people, hay fever is treated as an irritating but relatively minor part of spring and summer: a few weeks of sneezing, itchy eyes and antihistamines tucked into a handbag, bathroom cabinet or desk drawer. Yet for those living with more severe allergic rhinitis, the impact can extend far beyond seasonal inconvenience, affecting sleep, concentration, work, exercise and overall quality of life.
When standard over-the-counter or prescription treatments are not controlling symptoms, or hay fever is beginning to have a significant impact on everyday life, it may be time to seek further medical advice. This is particularly important when symptoms extend beyond the familiar runny nose and itchy eyes and include breathing difficulties, asthma-like symptoms or persistent changes to the voice.
For some people, the next conversation may be about allergen immunotherapy, a treatment that takes a very different approach from simply relieving symptoms.
Training the immune system
Antihistamines, nasal sprays and other conventional treatments are principally used to manage the body’s response to an allergen. Immunotherapy instead aims to alter that response over time by repeatedly exposing the immune system to controlled amounts of the substance causing the allergy.
The objective is to encourage the immune system to develop greater tolerance, so that subsequent exposure to pollen, house dust mites or another relevant allergen provokes a less severe reaction.
Allergen immunotherapy can broadly be delivered in two ways. Subcutaneous immunotherapy, or SCIT, involves injections under the skin, while sublingual immunotherapy, known as SLIT, is administered under the tongue, usually as a tablet or liquid preparation.
Treatment is a long-term commitment rather than a quick seasonal intervention. Courses commonly continue for around three years, with the aim of achieving benefits that can persist after treatment has finished.
For Dr José Costa, Senior Allergy Consultant, this distinction is important. Rather than thinking about hay fever solely as something that needs to be suppressed every time symptoms appear, immunotherapy asks whether it is possible to influence the underlying allergic response itself.
When should immunotherapy be considered?
Immunotherapy isn’t something every person with occasional hay fever will need. Many people manage their symptoms successfully with measures such as antihistamines and nasal treatments, alongside practical strategies for reducing allergen exposure.
However, when symptoms remain troublesome despite appropriate conventional treatment, significantly interfere with someone’s quality of life or are associated with other respiratory problems, specialist assessment may be appropriate.
Clinical evidence supports allergen immunotherapy as an established treatment for certain respiratory allergies, although suitability depends upon identifying the relevant allergen and assessing the individual patient’s symptoms, medical history and response to previous treatment.
The relationship between allergic rhinitis and asthma is another reason Dr Costa believes persistent airborne allergies deserve greater attention. The nose and lungs are not entirely separate systems, and allergic disease affecting the upper airways can coexist with, and be associated with, problems lower down the respiratory tract.
This becomes particularly important when considering children and young people. Research continues to investigate whether treating respiratory allergies earlier may influence the subsequent development or progression of other allergic conditions. It is an evolving area of medicine, and one in which the long-term consequences of allergy are increasingly part of the conversation rather than focusing exclusively on today’s symptoms.
Under the tongue or under the skin?
Both subcutaneous and sublingual immunotherapy are established approaches, and the appropriate treatment will depend on the individual patient, their particular allergy and the options available to them.
In his own clinical practice, Dr Costa often favours sublingual immunotherapy. One reason is practicality. SCIT requires injections in a clinical setting and subsequent observation because of the possibility of systemic allergic reactions. SLIT has a different safety profile and, following appropriate medical assessment and initiation of treatment, can generally be continued by the patient at home.
This can make a considerable difference when treatment is required regularly over several years. Instead of repeatedly travelling to a clinic for injections, patients can incorporate their treatment into everyday life.
There is also the simple matter of preference. Some people dislike injections, particularly when they are required regularly. For children, people who are uncomfortable around needles or anyone for whom frequent clinic visits would prove difficult, an under-the-tongue treatment may be more acceptable.
That doesn’t mean SLIT will automatically be the right option for everyone. Immunotherapy is a medical treatment and should follow appropriate allergy testing, diagnosis and specialist assessment. The choice between approaches should ultimately be made according to the individual rather than convenience alone.
The hidden cost of living with allergies
There is another reason to look more closely at how we manage severe allergic rhinitis: its effects don’t necessarily stop when someone leaves the doctor’s surgery.
Poorly controlled symptoms can disrupt sleep, reduce concentration and make exercise, outdoor activities and everyday routines more difficult. At work, the impact may manifest itself through absence, but also through presenteeism — turning up while feeling unwell and functioning below normal capacity.
Research into the economic burden of allergic rhinitis suggests that this loss of productivity can create substantial costs for employers and the wider economy. Dr Costa argues that this should form part of the discussion around greater access to effective long-term allergy treatment.
There is a family impact too. Living with significant allergy symptoms can influence plans, holidays, sleep, school, outdoor activities and the routines of other people in the household. This is particularly evident when a child has significant allergies and parents find themselves constantly thinking about exposure, symptoms and medication.
Quality of life, therefore, is an important measure of successful allergy treatment. The question isn’t simply whether someone sneezes less frequently. It is whether they sleep better, concentrate more easily, feel comfortable exercising outdoors and spend less time organising their life around their allergy.
A treatment with more than a century of history
Although immunotherapy may sound like a relatively modern approach, its history stretches back more than a century. British physicians Leonard Noon and John Freeman conducted pioneering work at St Mary’s Hospital in London in the early 20th century, exploring whether controlled exposure to pollen extracts could reduce hay fever symptoms.
The principle established through that early work — gradually modifying the body’s response to an allergen — remains at the heart of allergen immunotherapy today, although treatments, dosing, testing and our understanding of the immune system have advanced considerably.
Yet despite its long history, immunotherapy is still far less familiar to the general public than antihistamines or nasal sprays.
Dr Costa believes this deserves greater discussion, particularly for people who have spent years accepting severe hay fever or other respiratory allergies as something they simply have to endure.
It also raises a broader question about the way we approach chronic health conditions. Should healthcare concentrate predominantly on repeatedly managing symptoms, or should we be looking more closely at interventions that may change the longer-term course of disease where appropriate?
There is no single answer, and immunotherapy is neither suitable nor necessary for every person with hay fever. It also requires commitment: treatment extends over years rather than weeks, and specialist diagnosis and monitoring remain important.
But for someone whose summer is routinely defined by poor sleep, streaming eyes, breathing difficulties and an inability to enjoy being outside, knowing that there may be another option can itself be significant.
Perhaps that is the real reason we need to take hay fever more seriously. What appears to be a minor seasonal inconvenience from the outside can have a surprisingly substantial impact on the person experiencing it. Treating allergy well isn’t simply about stopping someone from sneezing. It is about giving them back the parts of everyday life that allergy has gradually begun to take away.
Considering allergen immunotherapy?
If hay fever or another suspected airborne allergy remains difficult to control despite appropriate treatment, particularly where symptoms are affecting breathing, sleep or everyday quality of life, speak to your GP or an appropriately qualified allergy specialist. Allergen immunotherapy requires specialist assessment and is not suitable for everyone.
Discover: thechildrensallergy.co.uk
This feature is intended for general information and should not replace individual medical advice.
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