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Complementary and alternative therapies for allergic rhinitis

and conjunctivitis
Author: Leonard Bielory, MD
Section Editor: Jonathan Corren, MD
Deputy Editor: Anna M Feldweg, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2021. | This topic last updated: Jun 12, 2020.

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 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
alternative medicine in pediatrics" and "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 [1,2]. The popularity of CAM therapies for
allergic disease is even greater in some European countries [3]. Thus, it is important to ask patients about
the use of CAM therapies in a nonjudgmental manner [4].

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 [5]. 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 [6-8]. The chronic nature of allergic diseases and the paucity of preventive or
curative treatments also stimulate interest in CAM therapies [9]. There are marked cultural differences in
use of CAM (eg, patients from Southeast Asia commonly use herbal remedies for allergic rhinitis) [10].

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 [11]. 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 [12].

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.

TCM treatments for allergic rhinitis and conjunctivitis are reviewed separately. (See "Chinese herbal
medicine for the treatment of allergic diseases", section on 'Therapy for allergic rhinitis and
conjunctivitis'.)

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 "Acupuncture", section on 'Basic theory' and "Acupuncture", section on 'Difficulties in
research'.)

Studies of acupuncture for the treatment of allergic rhinitis have shown mixed results, with the most
rigorous studies showing very modest clinical benefit [13-18]. A 2015 practice guideline suggested the
potential use of acupuncture but included limited data supporting its use in allergic rhinitis or allergic
conjunctivitis [19].

● 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 [13]. 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 [14].

● 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 [15]. 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 [20].

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) [21]. 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.
(See "Acupuncture", section on 'Trials for conditions other than pain'.)

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 [19]. 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 [22]. 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 [23]. 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 [24]. 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 [25]. 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 [26]. 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 [27]. 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 [28]. 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 [25]. In three of these, butterbur compared favorably with standard doses of nonsedating
antihistamines (cetirizine, 10 mg daily and fexofenadine, 180 mg daily) [29-31]. 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 [32,33]. At least 40 reports
have appeared worldwide concerning hepatotoxicity with use of butterbur [34]. 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 [35]. 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 [36,37].

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 [38]. 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 [39].

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 [40].

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 [41].

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 [42-45]. 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 [45,46]. 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 [47].

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 [48]. 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 [48]. 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 [49].

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 [50].

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 [51]. 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 [52]. 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 [53].

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 [54]. Some efficacy has been demonstrated in a small number of randomized,
controlled trials [55-58]. 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 [57].
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 [59]. 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 [60]. 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 [61-64]. 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 [65].
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 [66]. 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 [67]. 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 [68].

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 [69]. 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 [70]. 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 [71].

● Menthol – Menthol can be used as a topical therapy for rhinitis due to its coolant effect. Menthol acts
through the menthol and cold receptor, "transient receptor potential channel melastatin 8," in normal
human nasal mucosa [72,73].

● Ginkgo biloba – There are limited studies in support of the treatment of allergic rhinitis and
conjunctivitis [74,75] 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 [75].

● 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 [76]. One study showed that subjects with allergic rhinitis treated with cetirizine, who also
took silymarin, had reduced symptoms compared with those taking antihistamine alone [77].
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 [78,79].

● 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 [80].

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) [81-88].

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 [89]. 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 [90].

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

● 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 (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'.)

● 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.)

● 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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REFERENCES

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Allergy Asthma Rep 2009; 9:121.
2. McClafferty H, Vohra S, Bailey M, et al. Pediatric Integrative Medicine. Pediatrics 2017; 140.
3. Schäfer T. Epidemiology of complementary alternative medicine for asthma and allergy in Europe
and Germany. Ann Allergy Asthma Immunol 2004; 93:S5.

4. Kern J, Bielory L. Complementary and alternative therapy (CAM) in the treatment of allergic rhinitis.
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Topic 16359 Version 13.0

Contributor Disclosures
Leonard Bielory, MD Nothing to disclose Jonathan Corren, MD Grant/Research/Clinical Trial Support: AstraZeneca
[Severe asthma]; Genentech [anti-ST2 in asthma]; Novartis [Asthma]; Regeneron [Allergic rhinitis, atopic dermatitis,
eosinophilic esophagitis]; Stallergenes [Allergic rhinitis]. Consultant/Advisory Boards: Genentech [Asthma]; Novartis
[Asthma]; Regeneron [Asthma, nasal polyps]; Sanofi [Asthma, nasal polyps]; TEVA [Asthma]. Speaker's Bureau:
AstraZeneca [Asthma]; Genentech [Asthma]; Sanofi [Asthma, nasal polyps]. Anna M Feldweg, MD Nothing to disclose

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