Allergic rhinitis or hay fever is the most common manifestation of atopic diseases. It is the inflammation of the mucous membranes of the nasal airways.  It takes place when theÂ oversensitive immune systemÂ attacks the foreign materials or allergens that are inhaled causing an allergic reaction with symptoms such as sneezing and a runny nose.
The number of allergic rhinitis sufferers between men and women is quite the same.  Hay fever can be seasonal or all year long (perennial) if theÂ allergenÂ stays throughout the year since allergens like dust mites and animal dander are available during all seasons. Allergic rhinitis may not be a fatal disease but can cause other severe complications like sinusitis, turbinate hypertrophy, atopic dermatitis, and ear infections. 
Fig. 1 Nose of a patient with allergic rhinitis
Most allergies are treatable but not curable.  The same goes for allergic rhinitis. Thus, the main goals of treating allergic rhinitis are to alleviate symptoms, improve quality of life and prevent comorbidities.
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Fig. 2 http://www.mynasya.com/allergicrhinitis.html
Although the prevalence of allergic rhinitis may vary among different countries, the number of allergic rhinitis patients is shown to increase quite significantly worldwide. In England and Wales for instance, the percentage of allergic rhinitis patients increased from 0.5% in 1995 to 2.4% in 2007. Therefore, even though allergic rhintis is not a life threatening disease, it should not be taken for granted. In this report, I would like to discuss the possible treatments for allergic rhinitis.
A possible solution
Most experts consider allergen immunotherapy as the most efficient way to bring continuing relief of allergy symptoms. Through this therapy, the immune system will aim to increase tolerance to the allergens that incite allergy symptoms. It is usually suggested for people who suffer from rigorous allergies or for those who have to put up with allergy symptoms more than 3 months every year. This type of therapy does not merely cure allergies, but reduce sensitivity to certain allergens.
In the simplest terms, an allergy occurs when an immune response results in exaggerated or inappropriate reactions harmful to the host. Once allergens such as dust mites and pollens are inhaled, the body starts to produce antibodies calledÂ Immunoglobulin E (IgE). (11) These antibodies then travel to cells that release chemicals, producing an allergic reaction. Immunotherapy helps to "reprogram" the immune system to ensure that the body will not overreact when exposed to the offending allergen(s). This is achieved by exposing a patient's immune system to the increasingly larger doses of an allergen extract repetitively over a long period of time until a target dose is established. This process is done every week over a period of many months, or even years. The body will become less sensitive or defiant to the trigger and at the same time decreasing allergyÂ symptoms, or in some cases can even forbidding asthma from developing. (11)
Immunotherapy can be done either subcutaneously or sublingually;
Subcutaneous Immunotherapy (allergy shots)
-A small amount of allergen is delivered by injections under the skin usually the upper arm.
Fig. 3 http://www.theasthmacenter.org/index.php/newsletter/allergy_shots/
Sublingual immunotherapy (allergy drops)
-A small amount of allergen is administered under the tongue (either in drops, tablets, or spray) for two minutes then either swallowed or spat out.Â
Fig. 4 http://www.allergyri.com/allergydrops.php
Sublingual immunotherapy is an alternative way for those who dislike injection. Besides having less side effects than subcutaneous immunotherapy, sublingual immunotherapy also can be taken at home. This is clearly an advantage for patients as they can just stay at home while doing the therapy.
Nevertheless, while sublingual immunotherapy for hay fever is becoming increasingly common in Europe,Â no sublingual immunotherapy products have yet been approved in the United States. 
After a full course of allergy shots, up to 80 to 90 percent of patients have reduced allergy symptoms, and in many cases their allergies have completely ceased.  A meta-analysis of 18 published studies concerning 789 patients reached a conclusion that immunotherapy is highly effective in the treating allergic rhinitis.(13) However, allergen immunotherapy has not been proven effective in treating food allergy. 
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"In addition to its long-term sustained efficacy, immunotherapy is the only treatment proved to alter the course of allergic disease as demonstrated by its association with significant reductions in the likelihood that children with AR will develop asthma and new sensitizations to aeroallergens," write Cheryl Hankin, PhD, from BioMedEcon LLC, Moss Beach, California, and colleagues.Â 
Benefits and Risks
Immunotherapy, instead of being very beneficial in treating allergic rhinitis, it can also harm the patients if not done properly using the right doses.Â Even though the immunotherapy program lasts in quite a long period (about three to five years), most patients will experience long-term improvement after desensitization is discontinued, lasting many years and sometimes lifelong.Â However, this treatment also imposes side effects to human health. Some patients may have similar reactions as having an allergy after the therapy like skin itchiness, coughing, sneezing and watery eyes. These symptoms range from mild, severe, and to life threatening condition like anaphylaxis. In this case, patients may have sudden drop in blood pressure, unconsciousness and possibly be fatal. Even though this rarely happens, that is why patients are asked to stay under doctor's consultation about half an hour after an allergy shot.
Current studies prove that patients can avoid from developing new allergies, and reduce the possibility of developing asthma in children with nasal allergies through subcutaneous immunotherapy.  Nevertheless, allergy shots are not suitable for everyone. People with heart problems, severe asthma, pregnant women, children under the age of five and people who are under beta blocker medication are not recommended for this treatment. However, allergy shots can be continued during pregnancy if treatment is started before conception.
American College of Allergy, Asthma, and Immunology (ACAAI) states that the overall annual direct and indirect costs of both allergic rhinitis and asthma are up to several billion dollars in which medications alone account for over a billion dollars each year. Besides that, the meta-analyses conducted have shown that immunotherapy decreases the need for drugs in patients with allergic rhinitis by 80%. 
Based on a study carried out in United States, it is estimated that the medication cost for perennial allergic rhinitis is $1,200 per year while the calculated cost for the first year of immunotherapy is approximately $800, and costs for subsequent years range from $170 to $290.  This shows that for a patient with perennial allergic rhinitis, immunotherapy would help to reduce total costs for over six years by $1,300 to $2,900. 
Based on the above findings, it may seem that immunotherapy is costly during the early period of treatment but in the long term, it is proved that immunotherapy helps to lower the costs of the treatment for allergic rhinitis compared to medications.
Social and economic implications
Social impact arises as patients with allergic rhinitis often have various feelings especially during allergy seasons. Patients may have low self-esteem and this may affect their performances at school or work due to their constant symptoms. Table below shows the percentages of how patients feel during allergy seasons in America.
Fig. 5 http://emedicine.medscape.com/article/889259-overview
Fig. 6 http://emedicine.medscape.com/article/889259-overview
People with severe allergy symptoms often fail to attend schools or work places. Based on pie chart above, more than 50% patients in America agree that allergy interfere their work or caused them to miss work. This in total could contribute to less productivity and thus could affect our country's economy.
In addition, it is estimated that allergic rhinitis results in 3.5 million lost workdays and 2 million missed school days annually and within that number, about 10 000 children were absent from school due to allergic rhinitis on any given day.  Parents' productivity or absence from work may also be affected depending on a child's age. In United States for example, the total annual figure for adults and children rises to an estimated 28 million days of restricted activity or reduced productivity due to allergic rhinitis. 
Allergic rhinitis also contributes to highest mean productivity loss per employee per year compared to other diseases. Therefore, it is proven that allergic rhinitis is a financial burden to countries all over the world.
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Fig. 7 http://managedhealthcareexecutive.modernmedicine.com/mhe/Productivity/The-Impact-of-Allergic-Rhinitis-On-Employee-Health/ArticleStandard/Article/detail/134316
There are several types of medications that can be used to treat allergic rhinitis such as antihistamines, corticosteroids, decongestants, antileukotrienes and mast cell stabilizers.  They can be in the form of nasal spray or oral therapies. The most commonly used drugs are:
Antihistamines block histamine and may relieve itching, sneezing and runny nose
Corticosteroids control inflammation and reduce all symptoms of allergic rhinitis, including itching, sneezing, runny nose and stuffiness.
These medications normally provide best results when used together. Compared to immunotherapy, inhaled steroids, antihistamines, and other allergy drugs (which usually must be taken daily) treat the resulting symptoms due to the allergy trigger, but not the allergens themselves.
Prevention is better than cure. After all, avoiding any allergen that can cause allergy symptoms can be more effective than taking medicines or undergoing therapy. However, sometimes it is not possible to completely eliminate the allergens such as pollens due to their widespread presence in the air.  But still the presence of these allergens can be minimised by:
Dusting regularly and washing bed linens in hot water to control dust and mites.
Restricting pets to certain areas of our home in order to reduce animal dander and other pet allergens.
Controlling indoor molds. For example, by cleaning bathtubs and showers monthly.
Avoiding outdoor pollens. Whenever pollen counts are high, it is better to stay inside the house.
Fig. 8 Insertion of a catheter into the swelling inferior turbinate http://www.enttoday.org/SpringboardWebApp/userfiles/entt/image/2006_06_09.gif
Chronic rhinitis can cause swelling in the turbinate which in some cases may become persistent, this condition is called turbinate hypertrophy. Once this occurs, medications and therapies may not be able to reduce allergy symptoms anymore. Thus, patients can opt for surgeries which can be done in several ways. One of the surgeries that can be conducted is radiofrequency volumetric tissue reduction (RFVTR). RFVTR or also called Somnoplasty is done by inserting a radiofrequency catheter into head of the turbinate where the inflammation occurs. The tissues at the inserted area will coagulate as the catheter is heated with maximum temperature of 60ËšC to 90ËšC. As the coagulated wound heals, the tissues start to shrink and over four to six weeks, a tissue volume reduction becomes significant.
Evaluation of references
From the website http://www.webmd.com/allergies/tc/allergic-rhinitis-overview, a lot of information regarding allergic rhinitis is published here. Most of the information I gain is from this website is highly reliable as the information on medical and scientific findings and researches is always being updated. Furthermore, most of my findings are also from websites like www.Medscape.comÂ and www.eMedicine.com which are one of the WebMD Professional Networks. Besides that, this website is also accredited by Utilization ReviewÂ HYPERLINK "http://www.google.com.my/url?sa=t&source=web&cd=1&ved=0CBgQFjAA&url=http://www.urac.org/&ei=YlOaTKedGoq6vQOy-uXfBA&usg=AFQjCNFfHl2eJnE94HFHplFmqfPt5UkrVw"AccreditationHYPERLINK "http://www.google.com.my/url?sa=t&source=web&cd=1&ved=0CBgQFjAA&url=http://www.urac.org/&ei=YlOaTKedGoq6vQOy-uXfBA&usg=AFQjCNFfHl2eJnE94HFHplFmqfPt5UkrVw"Â Committee (HYPERLINK "http://www.google.com.my/url?sa=t&source=web&cd=1&ved=0CBgQFjAA&url=http://www.urac.org/&ei=YlOaTKedGoq6vQOy-uXfBA&usg=AFQjCNFfHl2eJnE94HFHplFmqfPt5UkrVw"URACHYPERLINK "http://www.google.com.my/url?sa=t&source=web&cd=1&ved=0CBgQFjAA&url=http://www.urac.org/&ei=YlOaTKedGoq6vQOy-uXfBA&usg=AFQjCNFfHl2eJnE94HFHplFmqfPt5UkrVw"), also known as American Accreditation HealthCare Commission, a very established non-profit organization. This website provides the fundamental information on allergic rhinitis like its symptoms, causes and treatments.
Another source that supports this website is http://en.wikipedia.org/wiki/Allergic_rhinitis
The second website which I found very informative is
http://www.aaaai.org/patients/publicedmat/tips/whatareallergyshots.stm which is monitored by theÂ United States' largest medical organization, American Academy of Allergy, Asthma & ImmunologyÂ (AAAAI) which specializes in allergy and immunology. This website focuses on allergy shots as one possible treatment for allergic rhinitis and some healthy tips for people with nasal allergies in order to live a normal life without undesirable symptoms.
One source that shows same information is http://asthma.about.com/od/asthmaallergyconnection/p/immunotherapy.htm
Besides that, a book entitled Allergy Frontier: Therapy and Prevention Volume 5 written by Ruby Pawankar, Stephen T. Holgate, and Lanny J. Rosenwasser gives a lot of details about sublingual immunotherapy from page 216 to 244. It is also up-to-date as this book is published in 2009. However, this book does not explain much detail on subcutaneous immunotherapy.