Not Every Runny Nose Is Allergic: Rethinking the Overdiagnosis of Allergic Rhinitis

For decades, sneezing, nasal congestion, and runny noses have been reflexively attributed to “allergies” in both primary care and ENT clinics. But what if this diagnostic shorthand is doing patients a disservice? Chronic rhinitis—a broad term covering persistent nasal symptoms—comes in various forms, and not all are allergic in nature.
Yet, many patients walk into clinics, get handed an “allergic rhinitis” label, and walk out with antihistamines and nasal steroids, regardless of their actual trigger. The overdiagnosis of allergic rhinitis may be more widespread than we think, leading to ineffective treatment, patient frustration, and missed underlying conditions.

Let’s dissect why this misclassification happens, what chronic rhinitis really is, and how doctors can get better at distinguishing its subtypes.

Chronic Rhinitis: A Diverse Umbrella

The term “chronic rhinitis” encompasses several distinct conditions, broadly categorized into:

Allergic rhinitis (AR): IgE-mediated inflammation triggered by allergens like pollen, dust mites, or animal dander.

Non-allergic rhinitis (NAR): Includes vasomotor rhinitis, hormonal rhinitis, gustatory rhinitis, drug-induced rhinitis, and idiopathic types.

Mixed rhinitis: A combination of allergic and non-allergic components.

Infectious rhinitis: Often overlooked in chronic cases.

Each has a different pathophysiology, diagnostic pathway, and management protocol. But many are lumped into the allergic bin simply because they look and sound similar.

The Allure of the Allergy Label

Why do doctors overdiagnose allergic rhinitis?

Time constraints play a major role—quick labeling leads to quick prescribing. The symptom overlap doesn’t help; a runny nose and sneezing are often seen as synonymous with allergies. Patients often enter the consultation already convinced they have “hay fever” and expect confirmation.

There’s also an over-reliance on antihistamine response. If a patient feels better on antihistamines, the assumption is that it confirms an allergic cause. But this non-specific symptom relief can be misleading.

Overdiagnosis is especially likely in primary care settings or telemedicine, where objective allergy testing is not routinely pursued.

The Problem with Overdiagnosis

Mislabeling chronic rhinitis as allergic isn’t harmless—it carries real clinical consequences.

Non-allergic rhinitis often doesn’t respond to antihistamines, so prescribing them can be futile. Polypharmacy becomes a slippery slope, with patients taking multiple medications—antihistamines, decongestants, leukotriene antagonists, nasal steroids—while getting no real relief.

Diagnosis delays are common. Important conditions such as vasomotor rhinitis, rhinitis medicamentosa, or chronic sinusitis may be missed. Children might go years without evaluation for anatomical issues like adenoidal hypertrophy or choanal atresia because the “allergy” label sticks.

Lifestyle alterations also follow. Patients unnecessarily avoid pets, dust, or certain foods, operating under false assumptions about their triggers.

What Does the Data Say?

Epidemiological studies show that up to 50% of chronic rhinitis cases are non-allergic. Yet allergic rhinitis remains the default diagnosis. The gap between prevalence and testing is staggering.

In many regions, fewer than 10% of rhinitis patients undergo confirmatory tests like:

• Skin prick testing
  
  
• Serum-specific IgE panels
  
  
• Nasal cytology
  

Without testing, the diagnosis is speculative. Treatment, then, is often anecdotal and misdirected.

The Role of Nasal Cytology and History

The gold standard of rhinitis diagnosis starts with history and, when available, nasal cytology.

Presence of eosinophils can suggest allergic rhinitis or NARES (non-allergic rhinitis with eosinophilia). Neutrophils may indicate infectious or irritant rhinitis. Absence of inflammatory cells may suggest vasomotor rhinitis.

Key history clues that point to non-allergic rhinitis include:

• Adult onset
  
  
• Year-round symptoms without seasonal pattern
  
  
• No personal or family history of atopy
  
  
• Triggers like strong odors, cold air, or spicy food
  

Unfortunately, these nuances often get missed in quick consults or rushed follow-ups.

The Impact of Commercial Allergen Marketing

The pharmaceutical industry contributes heavily to the allergy-first narrative.

Mass marketing campaigns aggressively promote antihistamines and intranasal corticosteroids. Allergen immunotherapy (AIT) is increasingly marketed and prescribed, even in patients lacking confirmed allergies.

Direct-to-consumer advertisements push patients to self-label as “allergy sufferers,” influencing their expectations when they see a doctor. This pre-conditioning leads to confirmation bias and sometimes inappropriate therapy.

Clinical Guidelines Call for Better Differentiation

Leading organizations like ARIA and AAAAI have clear messages:

• Don’t default to allergic rhinitis
  
  
• Always consider non-allergic subtypes
  
  
• Use testing when possible to confirm etiology
  

Despite this, guideline adherence in clinical practice remains inconsistent. The temptation to “treat and hope for improvement” still dominates day-to-day medicine.

When the Treatment Doesn’t Work

Therapeutic failure should always prompt a re-evaluation of the initial diagnosis.

If a patient remains symptomatic despite:

• Oral antihistamines
  
  
• Nasal corticosteroids
  
  
• Saline nasal rinses
  

Then it’s time to consider alternate diagnoses:

• Vasomotor or other non-allergic rhinitis
  
  
• Structural issues like a deviated septum or nasal polyps
  
  
• Chronic sinusitis or post-nasal drip
  
  
• Central sensitization or other functional disorders
  

Stacking additional medications won’t solve a misdiagnosis. The answer lies in changing the question.

The Importance of Education and Language

Doctors should be mindful of the language they use during consultations. Telling someone they “have allergies” without definitive evidence can lead to:

• Years of incorrect self-management
  
  
• Resistance to accurate diagnoses later on
  
  
• Unnecessary dependence on medications
  

A better approach might be to say, “Your symptoms could be due to several causes, and we need to investigate further before confirming allergies.”

This opens the door for better diagnostics and reduces false certainty.

So What Should Doctors Do Differently?

To improve diagnostic accuracy and reduce allergic rhinitis overdiagnosis:

• Take a thorough, structured history focused on patterns, triggers, and timing
  
  
• Use screening tools or questionnaires when formal testing isn’t available
  
  
• Refer for allergy testing when symptoms are persistent or unclear
  
  
• Educate patients about non-allergic rhinitis and set expectations
  
  
• Reevaluate the diagnosis if symptoms persist despite guideline-directed therapy
  

A few extra minutes spent on history and clarification could save months—or even years—of unnecessary treatment and frustration.

Conclusion: Not Every Runny Nose is Allergic

Overdiagnosis of allergic rhinitis is not a trivial mistake—it leads to prolonged suffering, misdirected treatments, and sometimes significant quality-of-life compromises.

For doctors and medical students, the lesson is clear: resist the urge to label too quickly. True clinical skill lies not in how fast you prescribe, but how accurately you diagnose. After all, not every sniffle, sneeze, or stuffy nose is caused by allergy—and our patients deserve more than a one-size-fits-all approach.