Allergic Rhinitis

The nose runs, the eyes stream, the palate itches until the patient rubs it raw with the tongue. Allergic rhinitis is not one disease but a set of provocations, pollen and dust, animal dander, cold air, a bunch of freshly cut lilies on the counter, met by a self-governing principle that has learned to react in a particular idiom. The remedy fits the idiom.

Understanding Allergic Rhinitis Through a Homeopathic Lens

For the practising homeopath, the presenting complaint of hay fever or perennial rhinitis opens the case rather than closing it. Two patients arrive with what a clinic ledger will call the same diagnosis. One sneezes in paroxysms of ten and twelve, spasmodic, unstoppable, and cannot tolerate the smell of garlic in the kitchen; her palate itches so violently she rubs at it with her tongue. The other has a coryza that always sets in on the left, cannot bear a scarf touching her throat, and wakes from a nap worse than she lay down. The two are not the same case. The register of self-expression is entirely different, and the remedies that meet them share almost nothing.

Terrain matters more than the pollen count. A slim, always-too-hot patient who eats voraciously and still loses weight lives on different ground than the phlegmatic, exhausted subject whose discharges set in for the winter and never really cleared. The trigger describes the occasion; the case lies below it. Prescribing at the level of the trigger produces at best palliation.

Several of the plants used in this differential, Sabadilla and Sanguinaria among them, also have herbal and low-decimal uses at Ø or D1 that lie outside what we describe here. Everything that follows applies to the classical homeopathic use, 30C and above, where the dynamic preparation meets the self-governing principle and no crude molecule is present. Where a safety or pharmacology finding exists on a crude drug, it applies to the herbal register only and needs to be stated as such.

Six remedies cover the great majority of well-observed cases. They divide first by sidedness, then by the character of the discharge, the modalities of odour and air, and the mental state that runs alongside.

Top Remedies for Allergic Rhinitis

Sabadilla

Keynote: paroxysmal sneezing with fluent coryza, worse from the odour of flowers, better from warm drinks.

Where a hay fever case turns on violent, spasmodic sneezing, Sabadilla is usually the first remedy to think of. The paroxysms come in bursts, one after the other, until the eyes stream and the head aches from the exertion. Copious watery discharge runs from the nose. What sets this coryza apart from other coryzas is what provokes it: the odour of flowers, sometimes even the thought of flowers, will bring on the paroxysm afresh. Clarke's picture of the intolerance of garlic sits inside this same vaso-motor over-reactivity, and the itching of the soft palate, rubbed raw by the tongue, is a keynote very few other remedies share.

The chill sits underneath everything. Sabadilla is a chilly remedy. Warm food, warm drink, being wrapped up, all relieve; open cold air aggravates; the throat, when sore, is helped by hot drinks and hurt by empty swallowing. Boericke lists the tendency of the coryza to be worse in the forenoon and periodic in its return. Sensitive people, light hair, fair complexion, easily startled by mental exertion. Thinking itself brings on the headache.

Worse: cold air; open air; forenoon; new and full moon; odour of flowers; mental exertion; wine.

Better: heat; warm food and drink; being wrapped; swallowing; quick motion of the affected part.

Prescribed classically at 30C in the acute paroxysm, repeated as the situation demands; 200C for well-marked periodic returns.

Lachesis muta

Sidedness carries the diagnosis. Lachesis rhinitis is left-sided, or begins on the left and travels to the right. The coryza is often accompanied by the classic Lachesis intolerance of anything close about the throat, a scarf, a collar, a necklace; the loosening of the collar is the first movement on entering the consulting room. Sleep does not restore this patient. Sleep worsens everything. They wake from a nap with the coryza worse than when they lay down. Hering's observation that Lachesis symptoms develop in sleep and wake the patient is one of the surest keynotes in the materia medica.

Discharges relieve. The nosebleed that eases the headache, the leucorrhoea that eases the depression, the menstrual flow that eases the premenstrual gloom, all are of a piece with the rhinitis that improves once the flow is fluent and worsens when it is suppressed. Antihistamine suppression, or a cold in the head that will not run, produces exactly the state Lachesis meets. Loquacity, one thought running into the next story, jealousy that surfaces during allergic season, hot flushes concurrent with the coryza. Menopausal hay fever with hot flushes and left-sided pressure at the root of the nose is Lachesis territory.

Worse: after sleep; on waking; pressure at throat or waist; heat; spring; suppressed discharges.

Better: onset of discharge; open air; cold drinks; loosening the clothing.

30C for a well-defined acute; 200C or higher where the case has the classical mental register and the constitution is Lachesis throughout.

Bromium

Where Lachesis is left-sided and worse for sleep, Bromium is also predominantly left-sided but with a wholly different signature at the nose. Both Clarke and Boericke describe the tickling, smarting sensation "as from cobwebs" at the tip of the nose, the fan-like motion of the alae, and the pressure at the root of the nose. The coryza is acrid, burning, with violent sneezing and soreness of the nose itself; the nosebleed, when it comes, tends to relieve the chest. Stoppage sits on the right nostril while the acrid discharge streams from the left.

The unmistakable modality is the sea. Bromium subjects are better at sea, worse on coming ashore. The old picture, sailors ashore developing asthma who recover as soon as they return to the ship, has held up for a century and a half. Warmth, particularly the damp warmth of a heated room, aggravates. Exercise, riding on horseback, movement in cool air, all relieve. Blondes, fair skin, scrofulous children with glands stony and hard but slow to suppurate. When the rhinitis of such a child begins to travel down and involve the larynx, when the cough becomes croupy, when there is hoarseness on being overheated, Bromium comes forward strongly.

Worse: warmth; warm damp air; overheating; being chilled when hot; sitting; evening.

Better: motion; open air; riding; sea air; a spontaneous nosebleed.

30C in the acute; low potencies where a strongly glandular child needs longer-acting work, according to the case.

Carbo vegetabilis

At first glance Carbo vegetabilis does not belong in an allergic rhinitis differential. It is not the remedy of the acute paroxysmal group. It belongs to the group of patients whose rhinitis has become chronic, whose reactive vitality is low, and whose case reads "never well since". A viral coryza three winters ago that never quite cleared, and each subsequent spring the nasal picture returns weaker, with more prostration and less power to throw the discharge.

The keynote is want of reaction. Blueness of the extremities, cold breath, cold sweat on the forehead. The patient wants to be fanned even while cold, a paradox that always startles the beginner and always confirms Carbo veg once observed. Old catarrhs of long standing. A whooping-cough that left behind chronic bronchial irritation which then flares each allergy season. Gastric complaints run in parallel: distension of the upper abdomen, better belching, aversion to fatty food and milk, cannot bear tight clothing at the waist. This is the terrain of the elderly patient, of the exhausted mother, of the schoolgirl whose spring hay fever has become an autumn hay fever and a winter cough and an all-year weakness.

Worse: evening; warm damp air; fatty food and wine; lying down; loss of fluids.

Better: being fanned; belching; cool air passing over the face; elevating the feet.

30C when clear indications appear in an allergic exacerbation; 200C in a chronic constitutional prescription, cautiously, in a patient of low vitality where over-repetition palliates and buries the case.

Iodium

Iodium rhinitis is the coryza of the thin, dark, always-too-hot, always-hungry patient. Boericke's line, "loses flesh, yet hungry and eating well", is the terrain. There is a dull pressure at the root of the nose and in the frontal sinus during the coryza. The catarrh is acute, easily involving all mucous membranes. Left alone it will extend rapidly to the larynx and lungs. The cough that follows is short, dry, irritating, worse at night.

The mental state is telling and often the deciding factor. Iodium cannot be still. Anxiety comes on the moment activity stops. Anxious if he does not eat, better once eating, worse in a warm room, better walking in the open air. The children are hyperactive, the adults restless, hurried, obliged to change position from anxiety at the heart. The lymphatic glands are enlarged. Adenoid vegetations in children with the same catarrhal register. Thyroid history, personal or familial, deepens the indication rather than muddying it. Where the other remedies of this differential are chilly or seek warmth, Iodium wants cold air on the skin and cold water to drink, cannot sit still in a heated room, and thrives outdoors even in a north wind.

Worse: warmth; heated rooms; rest; quiet; exertion (which produces easy sweat).

Better: cold air; motion in open air; eating; walking; cold bathing.

30C for the acute catarrhal exacerbation. Higher potencies with care, and only where the constitutional picture is clear; the remedy can act very rapidly on the metabolism.

Sanguinaria canadensis

The right-sided complement to Lachesis and Bromium. Sanguinaria canadensis governs a rhinitis that in Clarke's classical description sits between hay fever and sinusitis. The rose cold is Sanguinaria's proper occupation. Sick and faint from the odour of flowers, hectic redness of the cheeks, burning of the palms and soles, headaches that begin in the occiput and travel forward, ascending to end over the right eye. In many cases the coryza is followed by a diarrhoea as the mucous membrane changes register; Clarke lists this transition as one of the remedy's characteristic notes.

The chronic form of the picture is important. The nasal membrane becomes dry and congested. Sensitivity to odours persists between attacks. Nasal polyps form. A history of loss or perversion of the sense of smell, the peculiar note that things smell like roasted onion, is diagnostic when it appears. Menopausal hay fever with hot flushes, right-sided pressure at the root of the nose, palms burning at night and thrust out from under the covers, is a classic Sanguinaria case as often as it is a Lachesis case; the sidedness usually settles it.

Worse: right side; touch; motion; raising the arms; light; sun; odours; sweets; menopause; 3 a.m.

Better: acids and sour things; vomiting or passing flatus; cool air; darkness; sleep; lying on the left side or on the back.

30C in the acute rose cold; 200C where the picture is chronic and constitutional with the right-sided and menopausal register.

Clinical Guidance

A schoolteacher in her early forties came for chronic spring rhinitis of six years' standing. She had learned to work through it, but this year she had lost her voice teaching outdoors on a school open day among the lime blossom. The paroxysms of sneezing were what she described first, "twelve or fourteen in a row, and the last three hurt". What decided the case was not the sneezing but the confession, made only when asked, that she had taken to holding her breath when passing a flower shop, and that she had once come home with a bunch of freesias from a colleague and put them straight into the shed without unwrapping them. Sabadilla 30C, four doses spaced across the day, cut the paroxysms by the following morning. A dose of 200C a week later held her clear for the season. The practitioner has to ask about flowers by name.

Case-taking in allergic rhinitis is a search for the individual idiom. Ask which side began. Ask what worsens the discharge and what improves it, and separately, what worsens the state of mind of the patient during the attack. Ask about sleep, before and after; about the throat and whether anything about the neck feels tight; about heated rooms and cold air; about the smell of specific things, cooking, tobacco, perfume, cut grass. The information decides the remedy.

Repertorisation should proceed from the strong, peculiar and characteristic symptoms in Hahnemann's sense, not from the catarrhal totality alone, which will lead to the polychrests every time. Boenninghausen's method, taking one peculiar modality and one peculiar mental state and one clear concomitant, will separate Sabadilla from Sanguinaria in a case where the noses look almost identical. Sidedness, response to sleep, response to warmth, response to open air, and the presence or absence of a clear flower-odour aggravation cover most of the differential above.

On potency and repetition, the acute paroxysm of hay fever calls for 30C repeated as the situation demands and ceased on improvement. Chronic constitutional prescribing in perennial rhinitis calls for a single dose of 200C or higher, watching, and repeating only when the action of the previous dose has clearly ceased and the same picture returns. Palliative repetition of a well-selected remedy at low potency across an entire pollen season is an old and legitimate practice; it should not be confused with constitutional cure, but it has its clinical place, especially in the Carbo veg and Iodium terrains where the reactive vitality will not tolerate a deep-acting single dose.

For related material on the terrain of the respiratory system, and on the method of matching the remedy to the individual idiom through the totality of symptoms, see the linked references.

Frequently Asked Questions

How is homeopathic prescribing for allergic rhinitis different from taking an antihistamine?

An antihistamine interrupts one link in the pathway of a reaction that has already begun. A well-selected remedy meets the self-governing principle of the patient at the level at which the whole reaction is being generated. The remedy is chosen by matching the patient's individual expression, sidedness, modalities, mental state, concomitants, to the picture of the materia medica. When the prescription is correct the pattern of susceptibility across the season shifts, and in constitutional work the shift extends across seasons; palliation of the acute symptom sits alongside that as a lesser benefit.

Is the remedy chosen by the trigger or by the symptom picture?

By the symptom picture. Two patients allergic to birch pollen may need entirely different remedies because the way they express the allergy is different. The trigger names the occasion. The remedy that fits the case will often fit whatever trigger the next season brings.

What potency is appropriate for hay fever?

For a well-marked acute paroxysm, 30C repeated according to response is a reliable general rule. Where the picture is clearly constitutional and the terrain fits the remedy in depth, a single dose of 200C or higher, given at the beginning of the season and repeated only when its action is exhausted, works better than repeated low potencies. Prescribers new to a remedy should stay with 30C until they know the case.

When several of these remedies seem to fit, what settles the choice?

Three questions usually decide the case. Which side did it begin on. What is the patient's state after sleep. How does the patient stand warmth. Left-sided, worse after sleep, cannot bear a scarf: Lachesis. Left-sided with cobweb tickling, worse warm rooms, better at sea: Bromium. Right-sided, worse from the odour of flowers, with a headache running from occiput forward: Sanguinaria. Paroxysmal sneezing, worse cold air, better warm drinks, aggravated by the smell of flowers: Sabadilla. Cold and blue, wanting to be fanned even while chilled, old catarrh that will not clear: Carbo veg. Thin, hot, restless, hungry, better in cold air and by walking: Iodium.

References

• Hahnemann S. Organon of the Medical Art. 6th edition.
• Boericke W. Pocket Manual of Homoeopathic Materia Medica.
• Clarke JH. A Dictionary of Practical Materia Medica.
• Hering C. The Guiding Symptoms of Our Materia Medica.
• Boenninghausen CMF von. Therapeutic Pocket Book.
• Murphy R. Nature's Materia Medica.