Version May 2024
INTRODUCTION — Complementary and alternative medicine (CAM) therapies for allergic rhinitis and conjunctivitis include Chinese herbal medicine (CHM), Ayurvedic medicine, other single and multiple herb preparations, acupuncture, homeopathy, and several other modalities. CAM therapies continue to gain popularity in the United States and throughout the world for the treatment of asthma and allergies.
This review is limited to those therapies about which there is published literature specifically concerning the treatment of allergic rhinitis/conjunctivitis. These therapies include traditional Chinese medicine (TCM), acupuncture, Ayurvedic medicine, a variety of herbal therapies, and several others. CAM therapies have also been studied in the treatment of chronic rhinosinusitis, although the evidence base is relatively weak [1].
CAM therapies for allergic rhinitis/conjunctivitis are discussed in this topic review. CHM for allergic diseases and CAM therapies for asthma are reviewed separately. (See "Chinese herbal medicine for the treatment of allergic diseases" and "Investigational agents for asthma".)
OVERVIEW — CAM is commonly defined as a group of diverse medical and health care systems, practices, and products that are not generally considered part of the conventional allopathic medical practices. Complementary therapies are used together with conventional allopathic medicine, while alternative therapies are used in place of conventional medicine. More general reviews of the principles of various CAM therapies are also found separately. (See "Overview of herbal medicine and dietary supplements" and "Complementary and integrative health in pediatrics" and "Overview of the clinical uses of acupuncture" and "Homeopathy".)
Popularity — More than 20 percent of the United States population appears to suffer from an atopic disorder, such as asthma, allergic rhinitis, and atopic dermatitis, and over 42 percent of people (both adults and children) have used CAM for their atopic disorder [2,3]. The popularity of CAM therapies for allergic disease is even greater in some European countries [4]. Thus, it is important to ask patients about the use of CAM therapies in a nonjudgmental manner [5].
Over the past few decades, there has been a growing interest in CAM in Western countries because of the reputed effectiveness, low cost, and favorable safety profiles of some therapies. In a 2018 survey of allergists, 81 percent responded that they had patients using CAM therapies, with more using CAM therapies than vitamin supplements [6]. Over 60 percent of responding allergists had encountered patients with adverse effects from the use of CAM therapies. Patients are often interested in alternative therapy, either because conventional therapies are unsatisfactory or because of concerns about side effects of synthetic drugs [7-9]. The chronic nature of allergic diseases and the paucity of preventive or curative treatments also stimulate interest in CAM therapies [10]. There are marked cultural differences in use of CAM (eg, patients from Southeast Asia commonly use herbal remedies for allergic rhinitis) [11].
Barriers to integration with allopathic medicine — One of the major concerns with CAM is that it is perceived to be "natural" and therefore safe by patients, but an analysis of safety reporting in randomized trials of CAM found that reporting of adverse effects was largely inadequate [12]. Improvement in safety reporting would facilitate integration into routine patient care. However, until this materializes, health care providers can familiarize themselves as much as possible with the available scientific literature on CAM. Evidence-based information of CAM therapies is available through several internet sites. (See "Overview of herbal medicine and dietary supplements", section on 'Internet evidence-based resources'.)
Given the high prevalence of allergic diseases and associated costs of the CAM treatments, high-quality data about these therapies are needed so that practice guidelines can be established. In the United States, the National Center for Complementary and Integrative Health has been tasked with evaluating mechanisms, efficacy, and safety of botanical medicines through basic science studies, clinical research, and the establishment of dedicated botanical research centers [13].
The design of randomized, placebo-controlled studies in CAM is complicated by difficulties in blinding, creating an appropriate placebo (particularly for acupuncture), and designing a control treatment when the mechanisms of actions of the modality in question are poorly delineated (such as homeopathy). Additionally, the difference in philosophy of CAM interventions from conventional health care allows for significant variation in the way CAM modalities are practiced (ie, therapies are often individualized for a particular patient and his/her specific disease state). Finally, the efficacy of CAM therapies may be heavily influenced by the patient's perception of his/her interaction with the provider, which is often more personal than the interaction between patients and allopathic health care providers. Thus, results may vary significantly among CAM providers, and studies of CAM must also account for the influence of the patient-provider relationship.
TRADITIONAL CHINESE MEDICINE — Traditional Chinese medicine (TCM) includes herbal therapy, acupuncture, massage, and dietary therapy. These practices originated in China and have been used in East Asia for centuries as a part of mainstream medical care.
There are several Chinese herbal remedies for allergic rhinitis [14]. A systematic review of studies of Chinese herbal medicine (CHM) for allergic rhinitis identified 12 randomized, controlled trials published in 11 articles up until March 2017 [15]. Significant heterogeneity was noted among the studies. The meta-analysis showed that CHM significantly improved quality of life compared with placebo, but there was no difference in symptoms of itchy nose, sneezing, or total nasal symptom scores. Adverse events were reported as an outcome in only one of the included studies.
A 2021 systematic review of oral CHM used for allergic rhinitis, which included 17 randomized trials, demonstrated a trend in improving total nasal symptom scores, individual symptom scores (rhinorrhea, nasal congestion, sneezing, and nasal itching), and quality of life, compared with antihistamines (loratadine and chlorpheniramine) [16]. Adverse effects were minimal. However, conclusions were limited by the poor quality of trial designs. Additional studies including larger sample sizes with well-characterized patients are needed before firm conclusions regarding safety and efficacy can be drawn.
ACUPUNCTURE AND ACUPRESSURE — Acupuncture is a component of traditional Chinese medicine (TCM) that was originally thought to work on the principle of redistribution of qi, the life energy. In TCM, disease is believed to originate from an imbalance of qi or poor flow of qi. The difficulties in designing trials of acupuncture are reviewed elsewhere. (See "Overview of the clinical uses of acupuncture", section on 'Basic theory' and "Overview of the clinical uses of acupuncture".)
Studies of acupuncture for the treatment of allergic rhinitis have shown mixed results, with the most rigorous studies showing very modest clinical benefit [17-22]. A 2015 practice guideline suggested the potential use of acupuncture but included limited data supporting its use in allergic rhinitis or allergic conjunctivitis [23].
●A systematic review identified 116 potentially relevant articles, of which 12 met criteria for inclusion by studying needle acupuncture, examining clinically relevant outcomes, and including a control, sham, or comparator treatment group [17]. The results were different for seasonal and perennial allergic rhinitis. There were no effects on seasonal symptoms, although some benefit was apparent for perennial symptoms. The magnitude of effect could not be estimated, although drug therapy could not be reduced as a result of acupuncture in either type of rhinitis.
●A subsequent randomized, controlled trial demonstrated statistically significant but clinically modest improvement in the primary endpoint of total nasal symptom score after the fourth week of treatment. Improvement was not sustained one week after completion of the four-week course but was surprisingly present three weeks later [18].
●In a multicenter, randomized trial of 422 patients with seasonal allergic rhinitis to birch and grass pollen, ACUpuncture in Seasonal Allergic Rhinitis (ACUSAR), subjects were treated with eight weeks of acupuncture with rescue antihistamine (RA), sham acupuncture with RA, or RA alone [19]. Rhinitis-related quality of life (QOL) and antihistamine use were measured after the eight weeks of treatment, an additional eight weeks later, and one year later. When compared with sham acupuncture with RA and RA alone, acupuncture with RA resulted in an improvement of 0.5 points and a reduction in medication use of 0.7 points, where one point was equivalent to taking one less 10 mg cetirizine tablet daily. Thus, the benefit was statistically significant but of questionable clinical importance. In a cost-effectiveness analysis of these data, the authors concluded that while acupuncture did cause small improvements in QOL, it was very expensive and may not be a cost-effective intervention for allergic rhinitis [24].
Critique of the protocol used in ACUSAR included the use of more needles in the acupuncture patients versus the sham patients (16 compared with 10) and a larger fraction of patients in the acupuncture arm having high expectations for acupuncture efficacy at baseline (85 versus 73 percent) [25]. In addition, the study was performed in two centers in South Korea and China, and pollen counts during the years of treatment and observation, which can dramatically influence results, were not reported.
In summary, the best trials of acupuncture for allergic rhinitis support limited benefit. In a 2015 revision of the clinical practice guidelines for allergic rhinitis published by the American Academy of Otolaryngology-Head and Neck Surgery, a low level of confidence is cited in the evidence support for acupuncture as a treatment option [23]. Acupuncture may be a reasonable option for interested patients with relatively mild disease who wish to minimize medication use and find the cost of therapy acceptable.
Acupressure is similar to acupuncture but does not involve needles. Stainless steel pellets in adhesive discs are applied to specified points (acupoints) on the ear, and the pellets are pressed firmly into the skin. In a randomized, sham-controlled trial, ear acupressure was studied for the treatment of mild-to-moderate perennial allergic rhinitis in 245 adults for 8 weeks, with 12 weeks of follow-up [26]. Subjects were treated for 5 to 10 minutes weekly by a practitioner in a clinic and instructed to perform the therapy three times daily at home for 10 seconds per session. There was a small but statistically significant improvement in sneezing and QOL in the acupressure group after eight weeks, with additional improvements in most measures of nasal symptoms at the end of the follow-up period compared with the sham group. These findings are interesting, although additional studies will be required to make more definitive recommendations about the utility of this therapy.
AYURVEDA — Ayurvedic medicine is a medical tradition originating from India and derived from the teachings of ancient Hindu healers, which first appeared in text between 1500 and 1000 BC. Like traditional Chinese medicine, Ayurvedic therapeutic interventions include yoga, meditation, breathing exercises, and herbal preparations. In its truest form, Ayurveda exists for the "promotion of health" rather than the treatment of specific disease states that have already begun to affect the body.
Ayurvedic herbal therapies have been evaluated in the treatment of allergic rhinitis. One is a mixture of seven Indian herbs (Albizia lebbeck, Terminalia chebula, T. bellerica, Phyllanthus emblica, Piper nigrum, P. longum, and Zingiber officinale) with antihistaminic and anti-inflammatory properties in vitro [27]. In an experimental model using the nonspecific mast cell degranulating agent 48/80 ("antihistamine model"), the mixture appeared to be equivalent to cetirizine. In the best human study, the mixture was compared with placebo in 545 adult patients with allergic rhinitis [28]. Clinically significant effects were noted at 6 and 12 weeks, which included 10 to 20 percent improvement in congestion, rhinorrhea, and sneezing, compared with the placebo group in those patients in randomized protocols. Adverse effects were almost twice that of placebo and were largely mild gastrointestinal issues (eg, gastritis, discomfort, and dryness of mouth). This product is commercially available.
HERBAL THERAPIES (SYSTEMIC) — A variety of herbal preparations may be used by patients with allergic rhinitis and conjunctivitis, although scientific evaluation of herbal products has been limited, and only those that have been evaluated in published clinical trials are reviewed here. A 2007 systematic review identified 16 randomized, controlled trials that met eligibility criteria [29]. The agents discussed in this section are listed by their English names and their Latin or pharmacopeial names.
Most herbal preparations contain several components, each with potentially varying physiologic and pharmacologic properties. However, herbal therapies that differ by name may contain identical components and thus, share similar clinical effects and adverse effects. This is important when trying to analyze studies that attribute a clinical or physiologic property to a specific herbal preparation.
In many countries, herbal medicines are minimally regulated and uncommonly monitored for adverse events by national surveillance systems. However, the increasing popularity of herbal medicines has led to concerns over their safety, quality, and efficacy on the part of health authorities and the general public. In response to these concerns, the World Health Organization has published formal monographs on selected medicinal plants to establish quality standards of herbal products and outline the parameters for their safe and effective use [30]. Safety issues surrounding the use of herbal medications are reviewed elsewhere. (See "Overview of herbal medicine and dietary supplements" and "Hepatotoxicity due to herbal medications and dietary supplements".)
Choice of brand — Patients who use herbs often ask their providers what brand should be used. Lack of regulatory reform in the herbal industry makes it difficult for the clinician to provide an informed response. One option is to recommend brands that have been tested by independent sources and found to meet minimum quality criteria. For ethical reasons, supplements sold through practitioners' offices or multilevel marketing plans should be avoided.
Children and pregnant or lactating women — Very few studies of herbal therapies have been conducted on infants and children or in pregnant and lactating women [31]. Issues of particular concern include proper dosing in young children and greater susceptibility of fetuses and children to potential contaminants. Therefore, we discourage the use of herbal therapies in these patient groups.
Specific herbal agents
Butterbur (Petasites hybridus) — Extracts from the root of butterbur (Petasites hybridus) contain petasins, compounds that are believed to possess medicinal properties possibly by altering the leukotriene pathway [32]. A systematic review of small but randomized trials comparing herbal therapies with either placebo or active drugs found evidence of efficacy based upon six double-blind, randomized, controlled trials [29]. In three of these, butterbur compared favorably with standard doses of nonsedating antihistamines (cetirizine, 10 mg daily and fexofenadine, 180 mg daily) [33-35]. Butterbur preparations are available under a variety of brand names.
Multiple portions of the butterbur plant can contain pyrrolizidine alkaloids, compounds that have hepatotoxic and potentially mutagenic and carcinogenic effects in humans [36,37]. At least 40 reports have appeared worldwide concerning hepatotoxicity with use of butterbur [38]. Most cases of pyrrolizidine alkaloid toxicity result in moderate-to-severe liver damage. Early signs and symptoms include nausea and acute upper abdominal pain, while more advanced toxicity may present with abdominal distension, jaundice, and the development of ascites. In some cases, if ingestion continues, the toxicity can lead to hepatic fibrosis and potentially, fatal cirrhosis. Manufacturing processes can reduce the content of alkaloids, and consumers should choose products that are labeled as low in pyrrolizidine alkaloids. However, they should also be aware of this potential hazard and be advised about early symptoms.
Tinospora cordifolia — An Indian herbal product containing extract from the stem of Tinospora cordifolia was studied in a double-blind, randomized trial of 75 patients with allergic rhinitis [39]. Those receiving T. cordifolia (at a dose of 300 mg three times daily for eight weeks) reported statistically significant improvement in sneezing, nasal discharge, nasal obstruction, and nasal pruritus, compared with those receiving placebo. The drug was well-tolerated, although it caused an increase in total blood leukocyte count in 70 percent of patients in the active treatment group, compared with 11 percent of those receiving placebo (a statistically significant difference). This was attributed to a possible "immunostimulatory" effect by the authors. There have been limited reports of hepatic toxicity, although several in vitro analyses performed by a manufacturer were reassuring [40,41].
Menthol — Menthol can be used as a topical therapy for rhinitis due to its coolant effect. It can also help cough associated with respiratory infections [42]. Menthol acts through the menthol and cold receptor, transient receptor potential channel melastatin 8 (TRPM8), in normal human nasal mucosa [43-46]. Studies demonstrate the role of TRPM8 in regulating nasal patency and airway resistance, in allergic responses of mast cells, and it was found to be increased in patients with nasal polyposis and chronic rhinosinusitis [47,48]. Menthol has been used in various formulations (eg, lozenges, nasal sprays, vapo-rubs, inhalers, and cough syrups).
Cinnamon bark, Spanish needle, and acerola — A combination of cinnamon bark extract, dehydrated Spanish needle (Bidens pilosa) leaf and stem, and acerola fruit concentrate (at a dose of 450 mg three times daily) was compared with loratadine (10 mg once daily) and placebo in a randomized, double-blind, crossover study of 20 subjects with allergic rhinitis and sensitization to Timothy grass pollen [49]. Subjects took each study medication for two days and then underwent a nasal allergen challenge procedure with Timothy grass pollen, after which nasal symptoms were assessed and nasal lavage fluid was examined for allergic mediators. Only loratadine significantly reduced symptoms acutely during the challenge, although both the botanical product and loratadine significantly reduced nasal symptoms two to eight hours after the challenge, compared with placebo. The magnitude of effect with both treatments was clinically significant. The botanical product appears to inhibit the production of prostaglandin D2 following challenge, which may suggest a steroid-like impact that affects the late-phase response of allergic inflammation. Long-term use has not been studied. This product is commercially available [50].
Cinnamon bark — In a randomized double-blind study, a nasal spray containing 100 mcg/100 microL of a polyphenol-rich standardized extract of cinnamon bark (Cinnamomum zeylanicum) was assessed in seasonal allergic rhinitis patients with a treatment over seven days. The nasal spray extract of standardized extract of cinnamon bark over seven days reduced symptom severity and improved quality of life, work productivity, and regular daily activities in participants [51].
Mint family — The Lamiaceae family, or mint family, is a diverse plant family which encompasses more than 7000 species that have been widely employed as ethnomedicine against allergic inflammatory skin diseases and allergic asthma in traditional practices. Phytochemical analysis of the Lamiaceae family has reported the presence of flavonoids, flavones, flavanones, flavonoid glycosides, monoterpenes, diterpenes, triterpenoids, essential oil, and fatty acids. Numerous investigations have highlighted the anti-allergic activities of Lamiaceae species with their active principles and crude extracts [52].
Benifuuki green tea — Benifuuki green tea is a specific cultivar that is rich in O-methylated epigallocatechin-3-O-(3-O-methyl) gallate or O-methylated epigallocatechin gallate (EGCG), a compound that has antiallergy properties [53-56]. In a randomized trial of 51 adults with Japanese cedar pollinosis, one-half of the group was assigned to drink 700 mL of Benifuuki tea daily, while the others drank a tea that does not contain O-methylated EGCG [56,57]. In the group drinking Benifuuki tea, the symptoms of pollinosis were significantly reduced, quality of life was improved, and the seasonal increase in peripheral blood eosinophils seen in the control group was suppressed. Although the effects were not sufficiently large to suggest that the tea could replace conventional therapies, the authors suggested that Benifuuki tea could be a useful adjunctive treatment.
Yupingfeng granules — Yupingfeng granules contain Astragalus membranaceus, Atractylodes, and Pastinaca sativa. In one study, 118 patients were randomized to cromoglycate drops combined with Yupingfeng granules or cromoglycate alone. In the combined group, 92 percent experienced control of symptoms, compared with 75 percent with cromoglycate alone [58].
Ginseng — In a randomized trial of 59 patients, fermented red ginseng was compared with placebo for effects on total nasal symptoms, rhinitis quality of life (QOL), immediate skin prick tests, and immunoglobulin (Ig)E levels over the course of four weeks [59]. Although there was no significant difference in the nasal symptoms scores, fermented red ginseng resulted in significant improvement in nasal congestion, rhinitis QOL, and reduced immediate cutaneous reactivity. Total serum IgE increased in the control group, while remaining the same in the treatment group [59]. In a subsequent study of the effect of Korean red ginseng on a murine model of nasal allergic inflammation, T helper type 2 cytokines were reduced [60].
Tonggyu-tang — Tonggyu-tang is a Korean herbal therapy comprised of 16 herbs that, in animal models, inhibits the proinflammatory cytokines interleukin (IL)-4, IL-6, IL-8, and tumor necrosis factor-alpha through inhibition of various signaling pathways in mast cells and keratinocytes [61].
NASAL SPRAYS, POWDERS, AND OINTMENTS — Nasal sprays containing either dilute capsaicin or inert cellulose have demonstrated efficacy in randomized, controlled trials. Similarly, nasal sprays containing a combination of eucalyptol, mint, and cinnamon extracts are becoming more common in the treatment of allergic rhinitis patients.
Capsaicin (Capsicum annum) — Capsaicin, derived from red peppers, is believed to act in other forms of rhinitis by desensitizing nasal nerve fibers and reducing nasal hyper-responsiveness [62]. In a randomized study of 42 patients with allergic and nonallergic rhinitis, an intranasal solution of capsaicin and eucalyptol (added to reduce the burning sensation that some patients experience with capsaicin) used twice per day for two weeks was compared with placebo [63]. There was a statistically greater reduction in total nasal symptom score, with the greatest improvement in nasal congestion, sinus pain and pressure, and headache, while the reduction in sneezing, rhinorrhea, and postnasal drip did not differ between the active and placebo groups. This product is commercially available [64].
Cellulose powder — The intranasal application of inert, micronized cellulose powder has been proposed to block mucosal allergen absorption. Some products suggest application every three hours. Products are available in many countries [65]. Some efficacy has been demonstrated in a small number of randomized, controlled trials [66-69]. The largest included 53 children (ages 8 to 18 years) with birch pollen-allergic rhinitis who were randomized to cellulose powder or a control preparation of lactose powder [68]. Subjects were monitored for symptoms throughout the birch pollen season for one year. There was a significant reduction in total symptom scores from the nose and specifically, for rhinorrhea, without adverse effects. However, another randomized trial of 20 subjects with a crossover design found no benefit [70]. This study evaluated patients with seasonal grass or ragweed allergy who were treated with a nasal spray containing cellulose powder or placebo and then nasally challenged. There was no significant reduction in peak nasal inspiratory flow, total nasal symptoms, or number of sneezes.
Cellulose nasal powders have been available for nearly 25 years in some countries (United Kingdom). As far as the author and editors are aware, there are no reports of adverse effects with prolonged use. It seems logical that these products would interfere with the absorption of other nasal sprays used to treat allergic rhinitis, so if symptom control worsens on the combination, then the combination should be avoided.
Allergen-absorbing ointment — Another method of blocking allergen absorption into the nasal mucosa makes use of a petrolatum-based ointment containing long-chain hydrocarbons [71]. In a randomized, controlled, crossover study, 115 adult and pediatric subjects with perennial allergic rhinitis and sensitivities to dust mites and other allergens were assigned to active treatment or a placebo ointment. Ointments were applied three times daily, each for a 14-day period. No other allergy therapies were allowed. There was a large placebo effect, which may have been due to allergen-blocking properties in the placebo gel (containing carboxymethylcellulose), although there was a significantly greater improvement in total nasal symptom scores in the active treatment group. Other smaller studies have also shown efficacy with the same or similar ointments [72-75]. However, comparative studies with allopathic treatments, such as intranasal glucocorticoids or oral antihistamines, are lacking.
CAM THERAPIES WITH MINIMAL EVIDENCE OF EFFICACY — A variety of other herbal preparations, homeopathic products, and miscellaneous therapies have been suggested for the treatment of allergic rhinitis or conjunctivitis. However, studies have either been of low quality or failed to show benefit.
Homeopathy — Meta-analyses and systematic reviews have repeatedly concluded that homeopathy is not different from placebo in the treatment of any medical disorder, including allergic rhinitis [76]. Homeopathy works on the principle of treatment with "similars." The remedies prescribed by homeopathic practitioners are essentially extremely dilute solutions of drugs known to cause the very symptoms that are to be treated. However, some products labeled as "homeopathic" can in fact contain substantial amounts of active ingredients and therefore, could cause side effects and drug interactions. (See "Homeopathy".)
Other herbal preparations — Other herbal preparations, for which evidence of efficacy for allergic rhinitis/conjunctivitis is limited or lacking include quercetin, stinging nettle, Perilla frutescens, Ginkgo biloba, milk thistle, and grape seed extract.
●Quercetin – Bioflavonoids, such as quercetin, have been of interest in the treatment of allergic diseases based upon studies showing that these compounds could act as mast cell-stabilizing agents, inhibiting the release of histamine, interleukin-8, and tumor necrosis factor and inhibiting the formation of prostaglandin D2 in a dose-dependent fashion [77]. Quercetin is one of the components of an Artemisia abrotanum intranasal spray that was administered to 12 patients with allergic rhinitis, conjunctivitis, or asthma in a small uncontrolled study [78]. All subjects reported improvement in symptoms within five minutes of application, which lasted several hours. Ocular symptoms also improved with intranasal application. Quercetin is also found in Spanish needle. (See 'Cinnamon bark, Spanish needle, and acerola' above.)
●Stinging nettle (Urtica dioica) – Extracts from the root and leaves of stinging nettle (Radix urticae), which has hairs containing histamine and other pruritogenic compounds, have been used to treat allergic rhinitis. A very small clinical effect was noted in one randomized trial [79].
Stinging nettle has no known contraindications or drug interactions, although contact with fresh leaves causes allergic-type reactions, such as urticaria and burning and itching upon application to mucosal surfaces, and ingestion is known to cause mild gastrointestinal disturbances and rare diarrhea. It is also used homeopathically. (See 'Homeopathy' above.)
●Perilla frutescens – P. frutescens is an Asian herb. Two doses of a preparation enriched for rosmarinic acid was compared with placebo in a randomized, controlled trial of 29 patients with seasonal allergic rhinoconjunctivitis [80]. A significant difference was seen in quality of life (QOL) between the higher dose P. frutescens and placebo after three weeks of treatment, although specific nasal and ocular symptoms were not statistically different.
●Eucalyptus – The steam distillation of eucalyptus leaves generates an oil rich in 1,8-cineole. A clinical study showed that five minutes of inhalation resulted in the sensation of cooling and increased nasal airflow [81]. Eucalyptus preparations have been studied as a nasal decongestant during acute infectious rhinitis when applied in conjunction with camphor, menthol, or steam, with improvements in symptoms [82].
●Ginkgo biloba – There are limited studies in support of the treatment of allergic rhinitis and conjunctivitis [83,84] using solutions of Ginkgo biloba extract, although one study did reflect a positive trend for the treatment of allergic conjunctivitis when applying the extract topically [84].
●Milk thistle – Silybum marianum, or silymarin, is a compound extracted from milk thistle. It has antioxidant and antifibrotic properties and has been most extensively studied in the treatment of liver disease [85]. One study showed that subjects with allergic rhinitis treated with cetirizine, who also took silymarin, had reduced symptoms compared with those taking antihistamine alone [86]. However, this herbal agent has been known to inhibit cytochrome P450 2C8 and 2C9, and alterations in drug levels are of a major concern, as it has been shown to decrease the trough concentrations of indinavir in humans [87,88].
●Grape seed extract – Grape seed extract has antioxidant properties and is marketed for the treatment of a variety of illnesses. However, a placebo-controlled study of patients with allergic rhinitis did not demonstrate any positive effects [89].
Laser therapies — Laser therapies deliver light energy to specific targets, including endobronchial tissues, tympanic membranes, blood, and skin. Laser therapy is described with various terms in the literature, including laser ablation, photodynamic therapy of bronchial tissue, endobronchial helium-neon laser irradiation, and laseropuncture (laser acupuncture) [90-97].
There are no controlled trials of laser therapies for the treatment of allergic rhinitis. An uncontrolled series described 42 patients with refractory rhinitis (allergic and nonallergic) who received a single diode laser treatment under local anesthesia [98]. Twenty-five reported subjective improvement in nasal symptomatology, especially nasal congestion/obstruction, and positive effects on QOL up to six years later. Nonallergic rhinitis has also been treated with laser therapy [99].
Other types of treatments — Several other CAM therapies have been studied in respiratory or inflammatory diseases but not specifically in allergic rhinitis. These include apitherapy (ie, bee sting therapy), behavior modification techniques, and speleo- or halotherapy (ie, cave air therapy and salt inhalation therapy, respectively). Thus, these are not discussed further.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.):
●Basics topic (see "Patient education: Complementary and alternative medicine (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Popularity – It is prudent to ask patients about the use of complementary and alternative medicine (CAM) in a nonjudgmental manner because a significant percentage of patients have tried or are actively using these therapies to treat allergic disorders. The lack of well-designed studies makes it difficult for clinicians to recommend CAM therapies with confidence. However, patients who do wish to pursue CAM should consider the financial costs (which may be substantial) and be aware that CAM products are not monitored in the ways prescription medications are. (See 'Overview' above.)
●Traditional Chinese Medicine – Traditional Chinese medicine (TCM) includes herbal therapy, acupuncture, massage, and dietary therapy. The use of TCM for allergic rhinitis is reviewed elsewhere. (See "Chinese herbal medicine for the treatment of allergic diseases", section on 'Therapy for allergic rhinitis and conjunctivitis'.)
●Acupuncture – Studies of acupuncture for the treatment of allergic rhinitis have shown modest benefit, although it is difficult to estimate the size of the effect in most positive studies. (See 'Acupuncture and acupressure' above.)
●Herbal therapies – There are several herbal therapies that have demonstrated efficacy, including Ayurvedic mixes, butterbur, and Tinospora cordifolia. Patients interested in these therapies should become familiar with the reported side effects and understand that these products are not systematically monitored for safety by drug regulatory bodies. We suggest that pregnant and nursing patients be advised to avoid herbal therapies (Grade 2C). (See 'Herbal therapies (systemic)' above.)
•Patients who seek advice about what brand of herbal medicine to use can be referred to independent sources. (See 'Choice of brand' above.)
•Nasal sprays consisting of dilute solutions of capsaicin have shown efficacy for allergic rhinitis in randomized trials when administered several times daily. (See 'Nasal sprays, powders, and ointments' above.)
•A variety of other herbal preparations, homeopathic products, and miscellaneous therapies have been suggested for the treatment of allergic rhinitis or conjunctivitis. However, studies have either been of low quality or failed to show benefit. (See 'CAM therapies with minimal evidence of efficacy' above.)
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