To date, several international guidelines are available for the diagnosis and treatment of AR, in different parts of the world.123456789 Of these, 7 have been written by specialist groups from Europe, UK, USA, Canada, Japan and Australia for the management of AR patients from the respective countries, whereas 2 guidelines —Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines and the World Allergy Organization (WAO) White Book on Allergy: Update 2013 (www.worldallergy.org)—have been prepared as evidence-based documents in consultation with experts from all over the world.

Compared to the published international AR guidelines, the criteria for the diagnosis and therapeutic evaluation of AR in China were established by specialist groups and organized by the Editorial Board of the Chinese Journal of Otorhinolaryngology early in 1990. In view of the rapid growth of the prevalence and misconceptions of AR during clinical practice, these guidelines were subsequently updated by Chinese Guideline for AR workshops held in Haikou in 1997, in Lanzhou in 2004, in Wuyishan in 200910 and in Tianjin in 2015.11 Moreover, a clinical practice for children with AR was developed by a group of specialists at a workshop held in Chongqing in 2012.12 However, these Chinese guidelines for AR have been published mostly in Mandarin Chinese in the Chinese Journal of Otorhinolaryngology Head Neck Surgery. In view of the large number of original articles as well as well-controlled clinical trials of Chinese AR patients that have been published in many peer-reviewed international journals by Chinese researchers and authors over the past 2 decades, our knowledge and understanding of the epidemiology, pathophysiologic mechanisms, diagnosis, management and comorbidities of AR have been broadened substantially. Consequently, the Chinese Society of Allergy organized a workshop of the experts working in the different fields of AR management in China to develop the most updated Chinese Guidelines for the diagnosis and treatment of AR, using evidence-based models, as has been the case in the development of the ARIA international guidelines. Importantly, these guidelines have also been developed in English in order that they can be readily accessed for reference by the non-Chinese speaking international fraternity.

AR belongs to the category of ‘Bi Qiu’ in Traditional Chinese Medicine (TCM). ‘Bi Qiu’ refers to the disease which is characterised by sudden nasal itching, sneezing, rhinorrhea and nasal blockage. Thus, AR, vasomotor rhinitis and other similar diseases are all included in the ‘Bi Qiu’ category.

In ancient Chinese literature, the word ‘Bi Qiu’ was first found in the book of ‘Huangdi Neijing’ (Western Han Dynasty, 99 B.C.–26 B.C.). ‘Bi Qiu’ had several alternative terms such as ‘Qiu,’ ‘Ti,’ ‘Qiu Bi’ and ‘Runny nose’ and the record of the disease can be dated back to the book of ‘Rites’ (Western Han Dynasty, about 100 B.C.). The article of ‘Yue Ling’ in ‘Rites’ documented that “In the last month of autumn, if the summer practices were observed, there would be great floods in the states. Then the winter stores would be affected and there would be many patients with sneezing and runny nose”; thus indicating that the ancient Chinese people recognized the existence of a close relationship between AR and natural environment/climate events. Indeed, the ancient physicians believed that the main pathophysiology of AR was the dysfunction of ‘Zang-Fu,’ including the lungs, spleen and/or kidneys, in addition to external pathogenic factors like Wind-Evil, Cold-Evil, or other unusual pathogens. Although several ancient TCM literature has discussed AR from different aspects, ‘Su Wen’ in ‘Huangdi Neijing’ suggested that “(kidney) Deficiency would result in dysfunction of 9 orifices, and deficiency in the upper part and excess in the lower part of the body would manifest as runny nose and incessant lacrimation.” ‘Tai Ping Sheng Hui Fang’ (Song Dynasty, 992 A.D.) suggested that “the lung had its specific opening in the nose. When lung Cold affected nose ascending meridian, the runny nose would happen. Thus, the cause of AR was Deficiency, Excess, Cold or Heat, involving the ‘Zang-Fu’, organs of the lungs, spleen and/or kidneys.”

While Western medicine was introduced into China about a century ago and has flourished since then, TCM has existed for almost all of China's 5,000-year history and still plays an important role in the Chinese medical system. TCM employs several treatment approaches in the management of AR including Chinese herbs taken orally or applied externally, acupuncture and the ‘Daoyin (an ancient body-mind exercise aimed at health care as well as physical and spiritual purification)’. Each treatment can be used either alone or in combination, and generally complies with the theory of ‘where there is a syndrome, there is a treatment,’ suggesting that different therapies and measures should be used according to the disease characteristics of the patient. Indeed, to date a large number of clinical studies have confirmed the effectiveness and safety of TCM in the treatment of AR.

An ever increasing number of original articles and clinical trials have been published in peer-reviewed journals by Chinese researchers over the past 2 decades. This has substantially broadened our knowledge and database on the epidemiology, mechanisms, diagnoses, managements and comorbidities of AR, especially in Chinese subjects. Thus, in order to disseminate this knowledge and promote further research and clinical practice on the management of AR in China, the executive/organizing committee of the Chinese Society of Allergy decided that it was necessary to extensively review and summarize current literature, using an evidence-based model. Furthermore, it was also necessary to review the characteristics and current practice of clinical diagnosis and treatment of AR in China. Although Chinese guidelines for AR have been in existence since 1991 and subsequently updated several times, none of them have been published in English in any international peer-reviewed journal. Consensus among the Chinese professionals and practitioners indicated that the Chinese guidelines for AR had to be published in English from a Chinese viewpoint on the disease to be communicated to the international professionals and practitioners involved in the treatment of AR.

It is appreciated that since the recommendations in the Chinese guidelines were originally proposed by attendees at a workshop, these guidelines need to be validated and revised by both Chinese and international experts from all over the world. It is anticipated that the Chinese guidelines for AR published in English will serve as a reference for the treatment of AR by physicians, healthcare professionals and organizations involved in the treatment of AR in China and facilitate the development of relevant local standard of care documents for patients. Additionally, the guidelines will be updated every 2 years, adding relevant data and information from newly published papers in peer-reviewed journals and thus developing the guideline into a state-of-the-art document for specialists as well as for the general practitioner and other healthcare professionals. Consequently, it is expected that this document will encourage researchers and professionals to submit and publish their research in relevant peer-reviewed journals as well as update their knowledge of AR. Overall, the aim of this document is to provide an evidence-based document on the diagnosis and management of AR across China, using a stepwise approach in line with other AR treatment guidelines.

Epidemiologic studies have revealed that the prevalence of AR has increased progressively in more-developed countries and currently affects up to 40% of the population worldwide.1314 A high prevalence of AR has also been recorded in the developed nations of the Northern Hemisphere, with 23%–30% of the population affected in Europe1516 and 12%–30% in the US.17 The great diversity of AR prevalence is found in the non-Western populations of the Southern Hemisphere, with wide inter- and intraregional variations ranging from 2.9% to 54.1% between countries.18 The global rising trend of AR has been observed in the past few decades and the AR prevalence has varied widely particularly in developing nations.2 The increase in AR prevalence has been linked with increased urbanization and improvements in living standards, which have contributed to increased exposure to a variety of indoor and outdoor pollutants and allergens, the potentiating effects of which cannot be ignored on respiratory disorders. Although the prevalence and possible factors responsible for the etiologies of AR have been well documented in many developed countries, there is comparatively little information available for developing countries.19 Large-scale coordinated studies specifically designed to estimate the prevalence of AR in regions with different environmental factors and climates are also required.

AR is one of the most common allergic disorders globally and affects 10% to 40% of the world's population.7 While the majority of epidemiologic data come from surveys of AR prevalence conducted mainly in Europe and North America, and to a lesser extent in the developed Asian countries, relatively little epidemiologic data are available on AR prevalence in especially adults in China. One nationwide population-based study has assessed self-reported AR using validated questionnaire-based telephone interviews in over 38,000 adult in 11 major cities across China.20 The interviews were conducted from September 2004 to May 2005 and the authors demonstrated that the prevalence of AR was highly variable, ranging from 8.7% in Beijing in North China to 24.1% in Urumqi in Northwest China. Compared to adults, however, more data are available from studies investigating the prevalence of AR in children in China. The majority of such studies have investigated the prevalence of AR in combination with asthma and eczema using the standardized and appropriately translated versions of the International Study of Asthma and Allergies in Childhood (ISAAC) protocols,212223 with only 1 nationwide study reporting the prevalence of specifically AR in children in China.24 In this study, a total of 23,791 children aged 6–13 years in 8 metropolitan capital cities of provinces in 4 regions were surveyed between November and December of 2005, using a cluster-stratified sampling method. The study demonstrated that the mean prevalence of childhood AR was 9.8% and ranged from 3.9% in Xi'an in Central China to 16.8% in Guangzhou in South China. The published data on the prevalence of AR in children and adults in China suggest that industrialization and the gross output of industries in most of the developed cities may reflect the prevalence of AR in certain cities in China. Moreover, these studies are limited due to nonuniform standardized study methods and diagnosis systems, which lead to biased comparisons among the studies.25

Compared to availability of progressive data for AR prevalence in many countries all over the world, there are insufficient comparable epidemiologic data for AR in China. As one of the largest countries in the world with a population of around 1.3 billion citizens, China has different topographic, climatic and economic conditions, which influence the lifestyle and exposure to allergens in different regions across the country. Thus, while the epidemiologic changes in AR prevalence is not unexpected due to the topographical and climatic conditions, the transition in socioeconomic status of many regions and individuals, particularly as a consequence of rapid urbanization and changes to a Western lifestyle over the past few years, appears to have further influenced the prevalence of AR. The influence of rapid urbanization and changes to a Western lifestyle has often impacted AR prevalence adversely in China as in the developed Western countries. However, a more comprehensive study involving subjects from 18 major cities in China has recently reported that there was an overall increase in the prevalence of self-reported AR in the general Chinese adult population during a 6-year period spanning from 2005 to 2011.26 Compared to the national survey in 2005, the standardized prevalence of adult AR in the 18 major cities was 17.6% in 2011, with the highest prevalence of 23% recorded in Shanghai and the lowest prevalence of 9.8% recorded in Chengdu. These findings suggest that the prevalence of AR in China has not yet reached a plateau (Fig. 1). Other recent studies have focused on the prevalence of AR in almost 800 million people living in the rural areas of China. One study demonstrated that in North China while the prevalence of adult self-reported AR was significantly higher in the rural area than in the urban area (19.1% vs 13.5%), the prevalence of confirmable AR in these areas were 6.2% and 7.2%, respectively.27 For preschool children, the prevalence of clinical AR in Beijing was found to be 19.5% in the urban areas and 10.8% in the rural areas.28 However, these studies indicate that the limited availability of local health services and the unmet need for the diagnosis and therapy of AR in rural areas of China should be given greater consideration in the future. A multicenter investigation has evaluated the clinical features of 11,004 AR patients from 13 allergy centers in Central China.29 The study showed that 9.7% of all patients had intermittent mild AR, 3.1% persistent mild AR, 33.9% intermittent moderate-severe AR, and 53.3% persistent moderate-severe AR. Furthermore, 61.6% and 42.2% of the patients had concomitant ocular and lower respiratory symptoms, respectively.29 Collectively, these studies illustrate that AR is both a common and a growing national concern in China. They further indicate that future epidemiologic studies of AR in China performed at the national level should aim to assess the true prevalence of AR as demonstrate by a clinical diagnosis of AR confirmed by allergen-related examinations and employing standardized methodology across all centers involved in the study.

Exposure to inhalant allergens is the primary inducer of AR symptoms; with particularly the aeroallergens, which include both outdoor and indoor allergens, being the most common allergens. Outdoor allergens, which mainly include pollen and fungi, are positively associated with the development of seasonal/intermittent AR, whereas indoor allergens, which typically include mites, animal dander, cockroach and fungi, are the major cause of perennial/persistent AR. Although exposure to certain occupational allergens may also lead to AR, exposure to food allergens rarely causes isolated nasal allergy symptoms.711 Due to the effect of geographic, climatic and humanistic factors, the types of allergens inducing AR vary significantly among regions. Identifying major local allergens is thus the first step to AR management involving diagnosis, prevention and allergen-specific immunotherapy (AIT).

In 1964, Voorhorst39 discovered that the allergenic properties of house dust originated from the component of mites. The first mite allergen was isolated by Fain in 1966 from the genus Dermatophagoides pteronyssinus (Der p), and since then more species of mites have been discovered.40,41 In China, Chan and colleagues42 have contributed greatly to the identification of diverse Dermatophagoides farina (Der f) allergens by proteomics. The novel allergens from Der f such as Der f 25 (triosephosphate isomerase), Der f 26 (myosin alkali light chain), Der f 27 (serpin), Der f 28 (heat shock protein), Der f 29 (cyclophilin), Der f 30 (ferritin), Der f 31 (cofilin), Der f 32 (pyrophosphate) and Der f 33 (alpha-tubulin) have greatly extended the spectrum of dust mite allergens,43 and the findings from Liu and colleagues61 could be of benefit for the guidance on more effective diagnosis and AIT of HDM respiratory allergy in China.

Pollen is a common aeroallergen worldwide. Ragweed allergen was described by Carl Linnaeus in the 18th century,44 but since then more highly allergenic pollen inducing seasonal allergic symptoms in respiratory tract have been discovered all over the world including China. In the 1950s, it was first reported that the genus Artemisia was the most important source of allergenic pollen in North China.45 Many new pollen allergens have subsequently been described in China. Indeed, during the mid-1980s to early 1990s, nearly 80 provincial- and municipal-level hospitals participated in a national epidemic survey on anemophilous allergenic pollen, resulting in the publication of a book entitled “A National Survey of Airborne and Allergenic Pollen in China” in 1991. This book summarizes the geographical distribution and drift patterns of airborne allergenic pollen by regions in mainland China and is designed for reference by clinicians involved in the treatment of allergic disease. It is worth noting that increasing urbanization and alien plant invasion have led to emergence of different trends in diffusion of pollen allergen.

Zhang and colleagues25 reviewed the pattern of sensitization to inhalant allergens among AR patients in mainland China and found that the prevalence and type of aeroallergens were different among various cities and regions. A survey by Li and colleagues46 of 6,304 patients suffering from asthma and/or rhinitis in 17 cities from 4 regions of China showed that the overall prevalence of positive skin prick responses was highest for Der f (59.0%), Der p (57.6%), and Blomia tropicalis (40.7%), and lowest for mixed mould IV (4.4%), mixed grass pollen (3.5%), and mixed tree pollen (2.2%). The prevalence of sensitization to other allergens ranged from 16.1% for American cockroach, 14.0% for dog, 11.5% for Blatella germanica, 11.3% for Artemisia vulgaris, 10.3% for cat, 6.5% for Ambrosia artemisifolia, and 6.3% for mixed mould I.46 Moreover, this study showed that the prevalence of sensitization to allergens were different between adults and children, with Der p and Der f reported as the predominant aeroallergens in perennial/persistent AR individuals in China. The prevalence of positive skin prick test results to Der p in Qingdao, Zhengzhou, Xiamen, and Guangzhou have been reported to be 69.6% (66.4%), 86.32% (87.54%), 76.56% (77.16%), and 72.84% (76.36%), respectively.47 We still reviewed 146 published reports documenting the prevalence of sensitization to Der p and Der f among 89,779 AR patients from 7 major regions across China, and drafted a nationwide epidemiologic map to better represent the patterns of sensitization to Der p and Der f in these regions (Fig. 2). This map indicated that overall sensitization to the 2 allergens is fairly similar, although the order of regional distribution for positive sensitization rates was South> Central> East> Southwest> Northwest> Northeast> North. These data suggested an obvious geographic difference of the prevalence of sensitization to dust mites, demonstrating a trend of decrease from south and east to north and west in China. It is likely that the complicated geographic environment, climate, human activity, and air pollution contribute to these regional differences in the pattern of allergen sensitization. Nevertheless, an overall upward trend in the prevalence of sensitization to dust mites in China has been observed in recent decades, and this may be related to the rapid change towards a “Western lifestyle.”

Airborne pollen is the most frequent and seasonal cause of AR in the western and northern regions of China. The existence of a considerable regional difference in the distribution of pollen species and counts is due to the geographic and vegetation differences in China; thus Artemisia pollen is the most common allergenic one in the northern part of the Yangtze River (Beijing, Xinjiang, Shanxi, Shandong, Shenyang, Lanzhou, and Ningxia) in China. Tables 1, 2 show the geographic distribution of tree, grass, and atrazine pollen in different regions in China.4849 Thus, availability of this information and establishment of national real-time monitoring of atmospheric pollen may make the prevention and treatment of AR patients with pollen allergy and seasonal migration possible.

With improvements in living standards, pet ownership has become more prevalent in China. The number of domestic pets in China has increased 9-fold in 2013 compared to 2003. One survey showed that the positive serum sIgE rates of cat and dog allergens in AR child patients in Shanghai were 6.9% and 28.2%, respectively.50 Wang and colleagues51 conducted a 10-year retrospective study to investigate the trends in the prevalence of sensitization to common aeroallergens among AR patients in Guangzhou, the largest city in South China. The authors showed that the prevalence of sensitization to cat hair and dog dander had increased nearly 2-fold during the past decade, suggesting the importance of controlling the pet ownership and introducing SIT for pet allergy.51

The direct and indirect costs associated with the management of AR are a huge burden on the society.52 Data from the National Bureau of Statistics of China (http://www.stats.gov.cn/) indicate that there were 1.37 billion people in China at the end of 2014. A recent report showed that the standardized prevalence of self-reported AR is 17.6% in 18 major cities of China, and the prevalence of self-reported asthma 28% in the AR population.26 From these data, it is estimated that 0.24 billion people could be affected by AR and of these 67.51 million people could have AR combined with asthma (ARS).

Although there is no report of the direct cost of AR in China to date, a study by Chen and colleagues53 estimated that the direct cost of an ARS patient receiving subcutaneous immunotherapy (SCIT) or a specific medical treatment in Wuhan, China in 2013 was $982 and $259 per year, respectively. Since the income and economy of Wuhan represent the average levels of China, using the data of Chen and colleagues53 it is possible to estimate that the total societal cost in China could be $17.49 billion per year for all ARS patients if they received only medicinal therapy and no immunotherapy.

Furthermore, as the average disposable income of Wuhan was $4,451 per person in 2013 (http://www.whtj.gov.cn/), it can be estimated that as the cost of SCIT is not included in most medical insurance, the patients would have to spend 22% of their disposable income for their treatment involving SCIT.

In addition to the direct costs, there are considerable indirect costs such as decreased work productivity, workdays (adults) or school days (children) absent due to illness.54 Expenses managing the comorbidities of AR such as sinusitis, bronchitis and otitis media should also be considered “hidden” costs of AR.55

AR is an important and serious public health problem not just because of its high prevalence but also because it adversely impacts patients' quality of life (QOL) with respect to work productivity, school performance, social life, and mental and psychologic states. The disease burden comes from the morbidity of nasal symptoms, numerous comorbidities, and the impairment of multiple domains of QOL. Patients report that the disorder has a marked detrimental effect on their sleep, social life, and attendance and functioning at school and work,56 and patients also experience other psychologic symptoms that include fatigue, mood changes, anxiety, and depression.5758 Yin and colleagues59 found that symptoms of AR could cause great discomfort in the patient's daily functioning, including playing a satisfactory role in family, and professional and social life. Furthermore, nasal symptoms were significantly associated with anxiety, and emotion and behavior problems. A previous study on QOL of AR patients, using several instruments including the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), Eysenck personality questionnaire (EPQ), self-rating anxiety scale (SAS) and self-rating depression scale (SDS), showed that the patients' health status declined in all domains, especially in general health perceptions, physical role functioning, and emotional role functioning.60 Furthermore, although the patients had no obvious differences in personality characteristics, the tendency to develop anxiety, but not depressive emotion, was observed. A study by Liu and colleagues61 using the Chinese version of SF-36 has also demonstrated pronounced decrements in general health, role-emotional, and role-physical dimensions in mild AR patients, whereas significant impairments were noted in all domains in patients with moderate to severe AR. In the latter group, the impairments were most pronounced in general health, role-emotional and social function domains. Similarly, in a more recent prospective cohort study of patients with moderate/severe AR, using visual analogue scale (VAS) and AR Control Test (ARCT) demonstrated impairments in sleep in 86.9%, work life in 84.9%, social activities in 81%, and physical activities in 90.1% of the patients.62 Indeed, nasal symptoms including stuffy/blocked nose, runny nose, sneezing and post nasal drip, as well as the consequential practical problems, including inconvenience of having to carry tissues or handkerchief, need to rub nose/eyes, and need to blow the nose repeatedly, have been shown to be the most troublesome aspects of AR.63 Li and colleagues64 employed the rhinoconjunctivitis quality of life questionnaire (RQLQ) to assess the QOL in AR patients according to the sensitization profile for relevant aeroallergens in North China and showed that this was worse in patients sensitized to tree pollens or weed pollens than in those sensitized to HDMs. Although QOL of the patients was not significantly correlated with the level of specific IgE to the causative allergen, the QOL varied with the allergen responsible for symptoms.64 A study using Symptom Checklist-90 (SCL-90) has shown the SCL-90 scores to be significantly higher for the obsessive-compulsive, hostility, somatisation, and psychoticism dimensions in AR patients than in healthy controls.65 This study further indicated that the psychologic status of AR patients worsens with comorbid asthma. However, the effect of gender is somewhat unclear. A study by Xi and colleagues65 did not demonstrated effect of gender on SCL-90 scores of AR patients, whereas a study by Lv and colleagues66 demonstrated poorer psychologic functioning in female patients with moderate-to-severe persistent AR than in nonallergic women. VAS and RQLQ have also been employed to assess symptom severity and QOL, respectively, in Chinese children with AR.67 As for the adults, nasal symptoms were the most impairing aspect of QOL, with nasal itching and sneezing the main factors affecting the quality of sleep. While the quality of sleep may affect non-hay fever symptoms and emotions, rhinorrhea appeared to be the main factor causing embarrassment to the child. VAS was significantly correlated with RQLQ, and skin prick tests (SPTs) results correlated with both VAS and RQLQ, suggesting a close relationship between the allergen level and symptom severity/QOL.67 Song and colleagues58 investigated the effect of AR in 814 middle school students aged 10 to17 years enrolled from 4 schools in Changsha city, using VAS, to assess the effect of AR on sleep, emotion, and memory of these students. The rates of students reporting a moderate-to-severe impact of AR symptoms on sleep, emotion, and memory were 47.14%, 14.29%, and 27.14%, respectively, compared to 21.96%, 6.83%, and 11.28%, respectively, for children without AR. The authors suggested that AR significantly decreased the sleep quality and memory of these students, while emotional issues were increased with the onset of AR.58 AR has also been shown to impact on the sleep and attention in children and to decrease the QOL of children.68 Similar to these findings in Chinese AR patients, the symptoms of AR have also been shown to impair the QOL of patients from diverse regions of the world by adversely impacting on sleep, daily activities, physical and mental status, and social functioning.69 Poor sleep leads to fatigue and daytime somnolence, resulting in decreased performance, productivity, and social functioning as well as increased risk of associated diseases. A study from Europe has recently suggested that the severity of AR adversely impacts on patients' QOL to a greater degree than the duration of disease.70 Effects of gender, marital status, residential area, and duration of symptoms have also been shown to significantly impact on the patient's well-being.71 QOL of children with AR has been shown to be severely compromised due to frequent night awakenings, easy fatigue, defects of language, and irritability, which all have a negative influence on learning abilities. Indeed, AR may negatively impact on the QOL of the whole family because it could interfere with social life and financial costs.72

Although AR is not life-threatening, the serious negative influence of the disease on the patient's quality of life and psychologic status has received more attention in recent years. Several studies have investigated the influence of psychosocial factors on atopic disorders and the effect of atopic disorders on mental health, demonstrating that there is a significant bidirectional relationship between psychosocial factors and future atopic disorders as well as between atopic disorders and future poor mental health.73 Cuffel and colleagues74 carried out a questionnaire survey of 85,298 people and reported that the incidences of anxiety and depression in AR patients were 1.41 and 1.7 times, respectively, that of the general population. Several studies have shown an association between the risk of suicide during the hay fever season and seasonal pollen counts.7576 Sansone and colleagues76 reviewed the studies investigating the relationships between allergies and anxiety/mood syndrome and found that the majority of studies (9 of 11 studies on anxiety syndromes, and 10 of 12 studies on depressive syndromes) indicated associations between allergies and anxiety/mood syndromes. One population-based study has suggested that AR may even be a risk factor for suicide.77 Similarly, some studies have investigated the psychologic effects of AR in Chinese subjects. Xi and colleagues65 used the SCL-90 to study psychologic characteristics between AR patients and nonallergic individuals and demonstrated that there were significant differences between the 2 groups; with the SCL-90 scores for somatization, compulsion, interpersonal sensitivity, hostility, and psychosis being higher in the AR patients. In another study, Lv and colleagues61 assessed the psychologic aspects of Chinese female outpatients with moderate-to-severe persistent AR and nonpsychometric adult females, using the Minnesota Multiphasic Personality Inventory (MMPI). The authors concluded that women with AR have poor psychologic functioning as indicated by poorer MMPI scores for hypochondriasis, depression, hysteria, psych asthenia, schizophrenia and social introversion. Moreover, the women with AR felt depressed and unhappy, and were more likely to be pessimistic about the future. Some exhibited apprehensive behavior, and even anger and resentment because they had likely experienced many hours in hospital and felt misunderstood by physicians as well as by family members or others, and had a greater tendency to be alone. Another study by these authors has indicated that the psychologic status of seasonal AR patients was likely to be influenced markedly by the symptoms of AR, such as nasal obstruction and nasal itching.78 Collectively, these findings suggest that allergists should target both allergic diseases and subsequent psychologic disorders as a whole, rather than treat them as separate disease entities.

AR is a symptomatic disorder of the nose, which is defined as an infectious inflammation associated with IgE-mediated inflammatory response to allergens. The symptoms of AR includes paroxysmal sneezing, rhinorrhea, nasal congestion and itchin.4781179

The classification of AR in China has been adjusted continually following a long period of research and discussion. According to the original classification in 1997, AR was divided into 2 categories: perennial (the onset of symptoms is all year round and symptoms last for at least 6 months per year) and seasonal (the onset of symptom is seasonal). In order to adapt to the situation in China, the classification was subsequently modified into 4 categories by combining the traditional classification with the classified standard recommended by ARIA in 2004: seasonal intermittent, seasonal persistent, perennial intermittent, and perennial persistent.80 Furthermore, the severity of AR was classified as mild (the symptoms are not interfering with sleep, daily activities, physical exercise, entertainment, work and study) and moderate-severe (the symptoms are disturbing and severely affected patients' life mentioned above) in accordance with the ARIA classification. Thus, the classification was modified to being intermittent (<4 days/week or <4 weeks/year) or persistent (≥4 days/week and ≥4 weeks/year) by the frequency of symptoms and to being mild (the symptoms are not interfering with quality of the patient's life) or moderate-severe (the symptoms cause severe impairments in quality of life of patients) according to the severity of symptoms.10 More recently, the classification of AR has been further modified by the addition of the type of allergen in 2016.11

Taking the Chinese patients' situation and international common classification into consideration, AR can thus be classified in 3 ways as shown in Table 3.

As the duration of aeroallergen pollen season depends on climatic conditions and geographic location, in some areas where the aeroallergen pollen season is year-round, this causes difficulty in classifying AR by the type of allergen. Thus, in such areas AR is divided into the seasonal, perennial or the mixed (perennial with seasonal exacerbations) types.79

The classification of AR by the frequency of symptoms also has some limitations.4 It is particularly difficult to sort out patients with perennial symptoms, but for less than 4 days/week (more like “persistent”), into “intermittent” AR type.

The appropriate classification of AR should thus take into consideration different geographic conditions and patients' situations, and needs to be continuously improved accordingly.

Local AR (LAR) is a newly described form of AR. LAR patients have typical clinical symptoms of AR, but without classic systemic atopy.81 In LAR patients, nasal symptoms, local sIgE production, and type 2 response-dominated inflammation in nasal mucosa can be induced during natural exposure to aeroallergens or by nasal provocation test (NPT).82

LAR affects about 47% of patients previously diagnosed as non-AR.81 Key features for the differential diagnosis of LAR and AR are shown in Table 4. LAR shares similar clinical symptoms, including rhinorrhea, nasal obstruction and itching, sneezing, and associated ocular symptoms, with AR; however, SPT and serum sIgE are negative for LAR patients. On the contrary, similar to AR patients, NPT is able to induce positive immediate, late, and dual nasal symptoms accompanied by increased levels of sIgE, tryptase, and eosinophil cationic protein (ECP) in the nasal secretions of LAR patients.83 NPT can be evaluated by assessing the change in nasal volume (NV) using acoustic rhinometry, and nasal symptoms can be score using a VAS system. A 30% increase in the total VAS plus a 30% decrease in the volume of nasal cavity from 2 to 6 cm (NV 2–6 cm) is considered a positive response.84 The release of ECP and tryptase is significantly up-regulated in the nasal secretion as early as 15 minutes after challenge and can last for 24 hours with a gradual increase. In some patients, sIgE can be detected in nasal secretion at baseline, and local sIgE levels can be further rapidly increased after NPT.85 Due to the lack of standardized provocation reagents in China and the potential side effects of NPT, NPT is only carried out in a laboratory, and seldom in the clinic. Thus, the prevalence of LAR in China is not clear and this disease entity has not been widely recognized by Chinese physicians. Patients with LAR may present persistent or intermittent symptoms, with severity classified as mild, moderate or severe, similar to AR patients.81 Indeed, a prospective follow-up study has recently shown that only a small number of individuals with LAR may evolve to typical AR with systemic atopy, suggesting that LAR is more likely a distinct entity.86

A diagnostic flowchart for LAR is summarized in Fig. 3.

In recent years, nutrition has been thought to play a role in the pathogenesis of AR,256257258 with several studies from China and other countries demonstrating a relationship between AR and nutrition.123256259260

The mechanisms underlying the effects of nutrition in the pathogenesis of AR are poorly understood, but epigenetic modulation261 and immunobiologic processes258262 may be involved. Epigenetic modulation (including DNA methylation, histone modifications and miRNA) refers to chemical reactions that switch parts of the genome on and off, thereby changing gene expression,261 which may influence AR-related immune responses. Evidence of nutrition-induced epigenetic changes in patients with allergy and atopy has been found for nutrients, including folic acid and fish oil, and in obesity itself.261 As for immunobiologic processes, immunoregulatory effects and airway epithelial cell responses appeared to be involved when AR patients or AR animal models were exposed to some nutrients such as ginger,258 vitamin D and vitamin E.262

On the other hand, epidemiologic studies have noted associations between deficiency in microbial exposure in early life and increasing risk of allergies in childhood. After neonates are born, microbes begin to colonize in their oral, respiratory and gut tracts. The microbial communities, in turn, are influenced by an array of environmental factors, early life local microbial exposures, delivery mode,263 diet,259 antimicrobial administration, physiologic factors, mental stress, etc, which are characterized by fluctuating microbial diversity. The neonatal gut microbiome plays an instrumental role in the development and function of childhood immune system,264 with the interaction between intestinal flora in early life and the mucosal immune system influencing the induction of immune tolerance or immune imbalance.

Microbial colonization patterns in very early life may influence immune development and function in key-time mode.265 Neonatal immune cells are different from mature cells and can learn to tolerate the symbiotic bacteria in an age-dependent manner. Once the critical ‘window of opportunity’ of immunologic development is missed, intestinal immune development cannot be fully achieved in the adult and subsequently allergic disease develops.

Differential diagnosis of AR is broad and somewhat complex. Inflammation of nasal mucosa and the symptoms of sneezing, itching, rhinorrhea and nasal congestion need to be identified appropriately based on a careful history and targeted examinations.

Rhinitis severity is based on the impact of disease on QOL. QOL measurements are the best approximation of the burden of disease on the patient with AR, particularly as a quantifiable measure of a patient's perception of the impact of his/her disease and its treatment on his/her daily life, physical/psychological/social functioning and general well-being.69327 QOL appears to be moderately correlated with the more classic outcome variables used in clinical trials, such as daily symptom scores and nasal hyperreactivity. The effect of AR on QOL also runs parallel with the effect on conventional medical outcome measures. Generic or disease-specific questionnaires estimate QOL and are widely used both in clinical practice and in research. The choice of questionnaire should depend on the task at hand. The findings of different specific instruments of questionnaire can be combined for scheduled purpose.

Psychologic status is evaluated by the Self-reporting Inventory, which has been recognized as having satisfactory reliability, validity and utility. Psychologic status evaluation methods can be divided into 2 sides, which involve mental health evaluation and personality tests.

Mental health evaluation has been widely applied in the field of clinical medicine and includes the following items:

The common personality tests involve the following 2 categories:

All the above-mentioned mental assessment scales are in Chinese and can be found at http://www.bnufr.com/ceping/test. The physician should issue the username and password to subjects completing these assessment scales.

The therapeutic principle of AR involves a comprehensive approach including environmental control, pharmacotherapy, AIT and patient education.7

These 4 key elements combine the prevention and treatment of AR. As an important part of prevention and treatment strategy, environmental control should focus on avoidance or reduction of various allergens as well as air pollutants; however, existing measures are often difficult to achieve complete control of AR. Pharmacotherapy and AIT are the main treatments for AR. Although AR is currently not completely curable, standardized comprehensive therapy can achieve optimal symptom control and significant improvement in the QOL of patients.334 Individualized approach to the education of the patient, as well as disease management and follow-up, appears to be of importance.

Individuals exposed to high concentrations of indoor allergens (e.g. HDMs and animal dander) may benefit from multifaceted avoidance measures after environmental counseling.7333 A Cochrane systematic review has shown that house dust mite avoidance measures can reduce allergen load and improve symptoms of perennial AR.335 However, the authors of this review concluded that due to the small sample size of clinical trials and the poor quality of the evidence, it is still difficult to provide precise recommendations. A Chinese multicenter, randomized, placebo-controlled, crossover study has demonstrated that pollen blocker cream is effective in relieving nasal symptoms and improving QOL in both adults and children with perennial AR due to HDM.336 Moreover, a systematic review and meta-analysis suggests that interventions to prevent and remediate indoor dampness and mold may reduce the risk of AR.337

During outdoor activities in season with a high load of pollens, patients sensitive to pollen should avoid the peak of allergenic pollens spread in the air to reduce AR symptoms attack.

For individuals exposed to pollens in a natural environment, we recommend some allergen-controling tools (e.g. special masks, glasses, nasal filters, pollen blocker cream, nasal cellulose powder), which can reduce nasal inhalation or conjunctival contact of the allergenic pollen and relieve nasal and ocular symptoms.7338339340341

Medical therapy is successful in a majority of patients with AR, but there are still a large number of patients who fail medical treatment. The effectiveness of surgical treatment for refractory AR has been demonstrated in several studies.471472473474 There is still no gold standard surgical treatment for intractable AR, but the following rules are suggested: 1) strictly follow indications and contraindications of operations, and 2) select the proper surgical procedures and techniques based on a patient's anatomy, severity of disease and comorbidities.

Acupuncture is a traditional form of Chinese medicine, which can be traced back to 2,500 years ago, and more recently it has been widely used as a therapeutic modality for various otolaryngologic disorders.490491 The latest American Clinical Practice Guideline for AR published in 2015, recommends that acupuncture be offered as an option for patients with interest in nonpharmacologic approaches to management of AR.492493 Several recent international randomized controlled trials have also confirmed the efficacy of acupuncture in the treatment on AR.492493

In conventional acupuncture for nasal inflammatory disease, needles are punctured at specific acupoints (termed Xuewei in Chinese) in the body and gently manipulated until the patient feels “de-qi sensation” (i.e. subjective feeling for patients are soreness, numbness heavy or distension, and objective feeling for acupuncturist is heavy and tight feeling under the fingers).

The interest in probiotic and its potential benefits in the prevention and treatment of diseases, including allergic diseases, are significantly increasing worldwide. Regrettably, apart from data from a few animal experiments519520 and investigations of some other diseases,521522 there is relatively little information on the use of probiotics in the treatment of allergic disease in China. Moreover, the available evidence is not strong enough to verify a preventive and therapeutic role of probiotics in allergy,523 and studies from other parts of the world have provided widely different data,524 probably due to differences in many aspects of study design, for example, the use of different probiotic strains/combinations and different dosage/timing as well as different demographic and genetic backgrounds. A recent meta-analysis has shown that the use of multistrain probiotics appeared to be most effective for eczema prevention, although no cogent evidence of its preventive effect has been shown for other allergic manifestations.525 To date, experts have not reached a consensus regarding the recommendation of probiotics for allergy prevention and treatment. There are still needs strong evidence based on adequately powered, well-designed, randomized, controlled trials and a more standardized approaches to support their use before final clinical recommendations on specific strains, dosage and timing can be given.

Subjective assessment of symptoms of AR is generally based on scores for 4 nasal symptoms (sneezing, rhinorrhea, nasal itching and nasal obstruction) and 2 ocular symptoms (ocular itching/grittiness/redness and ocular tearing).276 For patients with concomitant asthma, symptom scores for wheezing, cough, shortness of breath and chest distress are also evaluated.

Four-point scale or VAS is used to quantify the above assessments.276

Medication scores are usually used in AR patients that are undergoing AIT or surgical treatment. The assessment should also be reported on a daily basis and scored per day276 as follows:

When the AR patient also suffers from asthma, the score should also be calculated per day as follows:

The authorized Chinese version of RQLQ327 is suggested for use in the subjective assessment of the QOL in AR patients. Different versions of the RQLQ are available for use according to different ages as follows: (1) adults ≥18 years: Standard RQLQ328331; (2) 13–17 years: Adolescent RQLQ329; and (3) 6–12 years: Pediatric RQLQ.330