A Doctor's Guide to Managing Fall Allergy Season

As fall allergy season overlaps with lingering summer heat and, in some regions, wildfire smoke, distinguishing ragweed and mold symptoms from smoke-related irritation isn't always straightforward. Heather Swanson, M.D., regional medical officer at CareMore Health, breaks down the key differences, such as itching as the telltale sign of allergy versus the cough, sore throat and burning eyes that are more typical of smoke exposure, and explains when overlapping symptoms call for more than just allergy medicine.

Swanson also lays out a practical treatment ladder, from over-the-counter antihistamines and nasal sprays to when it's time to discuss allergen immunotherapy, along with guidance on managing outdoor exposure during peak pollen hours. She addresses the warning signs that symptoms may be more than seasonal allergies and offers a clear-eyed take on which home air-quality tools, like HEPA filters and dehumidifiers, are actually worth investing in, based on a person's specific allergy triggers.

Fall allergy season is starting to overlap with late summer heat and, in some regions, wildfire smoke. How can people tell whether their symptoms are from ragweed and mold or something else entirely, and does it even matter for how they treat it?

Heather Swanson, M.D.: Fall allergy season often overlaps with heat and, in some places, wildfire smoke. Here is what you need to know about telling your symptoms apart, treating them and knowing when to call.

• Itching is the key clue for allergies. Itchy eyes, nose or throat, along with sneezing and a runny nose, point to ragweed or mold allergy.
• Symptoms that come and go with the season, or that flare when you're outside, doing yard work or on high-pollen days, also suggest allergy.
• Smoke exposure, on the other hand, usually causes cough, sore throat and burning or irritated eyes without much itching. These symptoms tend to get worse on hazy, high-pollution days and improve when you go inside.
• If smoke brings on wheezing, chest tightness or shortness of breath, that's a sign it may be affecting your lungs, like asthma, not just your nose. This needs more than allergy medicine.

Ragweed pollen can travel hundreds of miles, so avoidance alone often isn't realistic. Walk us through your go-to treatment ladder, from antihistamines and nasal sprays, to when you'd start talking to a patient about immunotherapy.

HS: The good news: for nose and eye symptoms, the starting treatments overlap a lot, so you often don't need to know the exact cause before treating it.

• Mild or occasional symptoms: an as-needed allergy pill (like cetirizine, fexofenadine or loratadine) or a nasal antihistamine spray works well and acts fast.
• Moderate to more constant symptoms: a daily nasal steroid spray [like fluticasone or mometasone] is the single most effective option and treats congestion, sneezing, itching and a runny nose.
• Still not controlled: adding a nasal antihistamine spray [azelastine] to your nasal steroid spray works better than adding a plain allergy pill. A 2- to 4-week course of a nasal decongestant spray with a nasal steroid may be recommended by your provider to help with bad congestion. Note that a nasal decongestant alone shouldn’t be used for more than 3 to 5 consecutive days. Rinsing your nose with saline can also help by washing out pollen.
• Give any new plan about 2 to 4 weeks before deciding if it's working.
• Older allergy pills like diphenhydramine [Benadryl] cause more drowsiness and side effects than newer ones, so newer pills are generally preferred.

If you're still having symptoms despite using the sprays and pills correctly, or if you'd rather not take daily medication long-term, it's worth talking with your clinician about allergen immunotherapy [allergy shots or, for ragweed, an under-the-tongue tablet]. This requires confirming your specific allergy first with a skin or blood test.

A few things worth knowing:

• Unlike medicines, the benefit can last for years after you stop treatment and it may lower the chance of developing asthma or new allergies.
• For ragweed specifically, both shots and an FDA-approved tablet have strong evidence of benefit.
• The tablet is taken at home after your first dose is given in the office, but only treats one allergen; shots can cover several allergies at once but require regular office visits.
• If choosing the tablet for ragweed, it should be started 8 to 12 weeks [ideally, around 4 months] before ragweed season begins.
• A full course usually takes 3 to 5 years, and if it hasn't helped by the end of the first year, it's usually not worth continuing.

How closely should people be watching daily pollen counts, and what does "managing outdoor time" look like in practice? For example, are there better times of day to exercise or run errands during peak ragweed season?

HS: There's no strict pollen number that means "stay inside.” Counts are best used to plan ahead rather than as a hard rule.

• For ragweed, pollen is actually lowest early in the morning [around 6 a.m.] and builds to its highest levels around midday to early afternoon. So, exercising or running errands earlier in the day is usually better than during midday.
• Rain washes pollen out of the air, so the hours after rainfall tend to be lower-pollen. Windy, dry days raise pollen levels, and it's best to avoid being outside during or right after a thunderstorm.
• If you have asthma along with allergies, keeping a closer eye on both pollen and air quality is worthwhile, since combined exposure can trigger flares.
• Helpful habits during peak season: keep windows closed and use air conditioning, avoid mowing or freshly cut grass, wear wraparound sunglasses and consider a mask outdoors — a regular mask is fine for pollen, but an N95 is needed for wildfire smoke.
• After being outside, shower, wash your hair and change your clothes to avoid carrying pollen indoors.
• You don't need to avoid the outdoors altogether; shifting the timing of activity and rinsing off afterward matters more than staying inside all day.

What's the tipping point where you tell a patient it's time to stop relying on over-the-counter remedies and come in to see you? Are there warning signs that suggest it's more than "just allergies"?

HS: See your clinician if:

• Your symptoms haven't improved after using an over-the-counter nasal steroid spray plus an antihistamine correctly for 2 to 4 weeks.
• You find yourself needing a decongestant nasal spray for more than a few days in a row, or relying often on decongestant pills — these can cause rebound congestion or raise blood pressure.
• You develop wheezing, chest tightness, shortness of breath or a cough that doesn't go away. These may point to asthma, which needs more than allergy pills.
• You notice symptoms only on one side of your nose, frequent nosebleeds, loss of smell, facial pain or a lump. These aren't typical allergy symptoms and need evaluation.
• Your symptoms last more than 10 days or improve and then suddenly get worse with thick, colored mucus and fever. This can [indicate] a sinus infection rather than allergies.
• Your symptoms started after age 45 with no history of allergies, don't follow a season and are triggered mainly by strong smells or weather changes. This may be a different condition [nonallergic rhinitis] that responds better to nasal sprays than to allergy pills.
• You lose weight without trying, have night sweats or notice a one-sided lump — these need prompt evaluation.

Seek emergency care right away if, after any allergen exposure, you develop a sudden reaction involving throat tightness, hoarseness, difficulty breathing, swelling of the lips or tongue, dizziness or fainting, along with hives or stomach symptoms. This is anaphylaxis, and it needs immediate epinephrine and emergency care, not just allergy medicine.

Indoor air quality comes up a lot this time of year. What's your advice on HEPA filters and home cleaning? Is this something every allergy sufferer needs, or only certain patients?

HS: These tools help some people more than others, depending on what you're allergic to.

• HEPA air filters remove things that float in the air, like pet dander, mold spores and smoke particles. They make the most sense if you're allergic to pets or mold, or during wildfire smoke. They do little for dust mites, since mite allergen is heavier and settles out of the air quickly rather than floating around.
• Dehumidifiers lower moisture in the air, which is what dust mites and mold need to grow, so they're the better match for dust mite allergy. That said, getting humidity low enough to really shrink mite populations is difficult in practice, so results are often modest.
• If your main allergy is outdoor ragweed pollen, keeping windows closed and running the air conditioner does more good than either device, since the pollen source is outside, not inside.
• For mold allergy, especially after water damage, fixing the moisture problem [drying out and repairing the area] matters more than any device; air filters and dehumidifiers are just add-ons.
• Either device works best alongside other steps, such as allergy-proof mattress covers and washing bedding in hot water to kill dust mites, rather than by itself.
• None of these home measures replaces your nasal spray and medication plan; they're add-ons, not substitutes.

Confirming exactly what you're allergic to — through a simple skin or blood test — can help you and your clinician decide which of these home measures are worth the investment for you.