# Allergic Rhinitis and the Atopic March

> Allergic rhinitis and the atopic march for NEET-PG Medicine, covering ARIA classification, stepwise intranasal and oral therapy, and links with asthma and eczema.

- Canonical URL: https://prepelephant.com/topics/neet-pg/medicine/allergic-rhinitis-and-atopic-march
- Exam / course: NEET-PG · Subject: Medicine
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-14
- Last updated: 2026-10-14
- Reference basis: Harrison's Principles of Internal Medicine; Dhingra's Diseases of Ear, Nose and Throat
- How to cite: "Allergic Rhinitis and the Atopic March", PrepElephant, https://prepelephant.com/topics/neet-pg/medicine/allergic-rhinitis-and-atopic-march

## Direct answer

Allergic rhinitis is IgE-mediated inflammation of the nasal mucosa that causes sneezing, itching, rhinorrhoea and nasal obstruction, and it is one of the commonest manifestations of atopy. The atopic march describes the sequence in which eczema often precedes food allergy, asthma and allergic rhinitis during childhood. Intranasal corticosteroids are the most effective first-line therapy for moderate to severe symptoms.

## What you must remember

- **Symptoms:** sneezing, nasal itching, watery rhinorrhoea and obstruction, often with itchy, watery eyes.
- **ARIA classification:** intermittent or persistent by duration, and mild or moderate to severe by impact on sleep, work and school.
- **Atopic march:** eczema, then food allergy, asthma and allergic rhinitis, with filaggrin gene mutations raising the risk of early eczema.
- **One airway concept:** the upper and lower airways are treated as one unit, so controlling rhinitis can improve asthma.
- **Diagnosis:** a clinical history supported by skin prick testing or serum specific IgE for relevant allergens.
- **First-line therapy:** intranasal corticosteroids, the most effective option for nasal symptoms, including obstruction.
- **Second-line therapy:** non-sedating oral H1 antihistamines such as cetirizine, loratadine or fexofenadine; montelukast is less effective than intranasal steroids.
- **Immunotherapy:** considered for moderate to severe disease that drugs do not control.

## A stepwise approach to controlling rhinitis

A 9-year-old boy with perennial sneezing, nasal blockage and a dust-triggered cough needs control of both the nose and the lower airway. The steps below follow the stepwise model, moving up to the next step only when symptoms persist.

1. **Confirm the diagnosis:** take a history of triggers and seasonality, and confirm sensitisation with skin prick testing or specific IgE.
2. **Reduce exposure:** use dust mite covers, reduce pets and damp, and avoid known triggers where practical.
3. **Start an intranasal corticosteroid:** use it daily, since full effect takes several days, and it treats congestion as well as sneezing.
4. **Add an oral antihistamine:** a non-sedating second-generation agent helps sneezing, itching and watery discharge, and it can be taken alongside the nasal spray.
5. **Add a leukotriene antagonist or intranasal antihistamine:** these are options when symptoms stay uncontrolled, and montelukast carries a boxed warning for neuropsychiatric effects.
6. **Refer for immunotherapy:** consider allergen immunotherapy for moderate to severe symptoms that drugs do not control, and review the asthma in parallel.

## Where students lose marks

Most errors involve choosing the wrong first-line drug or misreading the atopic march.

- **Trap:** choosing oral antihistamines as first-line for nasal blockage — **Correct:** intranasal corticosteroids are the most effective treatment for obstruction, while antihistamines mainly relieve sneezing and itching.
- **Trap:** assuming every child with eczema will develop asthma — **Correct:** the atopic march is a common sequence rather than an obligate one, and many children do not progress.
- **Trap:** treating the nose and ignoring the asthma — **Correct:** uncontrolled rhinitis worsens asthma, so both airways need assessment and control.
- **Trap:** prescribing a sedating antihistamine to a driver or student — **Correct:** non-sedating second-generation antihistamines are preferred because sedation impairs performance.

## Frequently asked questions

### What is the atopic march?

The atopic march is the sequence in which atopic disease tends to appear in childhood, typically beginning with eczema and followed by food allergy, asthma and allergic rhinitis. It is a common pattern rather than an obligate one. Filaggrin gene mutations are among the factors linked with the early stages.

### Which first-line drug is most effective for allergic rhinitis?

Intranasal corticosteroids are the most effective first-line drugs for allergic rhinitis, particularly for nasal congestion. They act directly on nasal inflammation and need daily use for full effect. Oral antihistamines are often added for sneezing and itching.

### How does ARIA classify allergic rhinitis?

ARIA classifies allergic rhinitis as intermittent or persistent by duration of symptoms, and as mild or moderate to severe by their impact on sleep, daily activities and school or work. This classification guides the step of therapy the patient needs. It replaces the older seasonal and perennial division.

### Why are the upper and lower airways considered one unit?

The upper and lower airways are considered one unit because allergic inflammation in the nose is linked with inflammation in the bronchi. Poorly controlled allergic rhinitis can worsen asthma, and treating rhinitis can improve asthma control. This is why both are assessed together in clinical practice.