Localized Allergic Rhinitis: When Allergy Tests Are Negative

I stood in front of a hall full of ENT doctors and shared one of my challenges of being an Allergist.

It is when a patient comes in to the clinic with an itchy nose, frequent sneezing and constantly blowing their nose to clear their mucus.

They describe how their nose just won’t stop running, making their daily life miserable. With confidence, I tell them, “You have allergic rhinitis.”

But then, their allergy test comes back negative.

And suddenly, I look foolish.

When Allergy Tests Say “No,” but Symptoms Say “Yes”

For years, we’ve relied on skin prick tests and blood tests (specific IgE tests) to diagnose allergic rhinitis. These tests detect the presence of IgE antibodies in response to allergens like dust mites, pollen, and pet dander. If the test is positive, it confirms an allergy. Simple, right?

But what if the test is negative? Does that mean the patient isn’t allergic? Not necessarily.

Enter Localized Allergic Rhinitis (LAR)—a condition where the immune system produces allergic IgE antibodies, but only in the nasal lining. These antibodies are not detectable in the bloodstream or on the skin, which means standard allergy tests come back negative.

In other words, patients with LAR experience all the classic allergy symptoms but slip through the cracks of traditional testing.

How is Localized Allergic Rhinitis Diagnosed?

Since standard allergy tests fail to detect LAR, how do we confirm the diagnosis?

Nasal Allergen Provocation Test (NAPT) – This is the gold standard. A small amount of allergen is introduced into the nose, and we observe for a localized allergic reaction (sneezing, congestion, increased nasal secretions). If symptoms appear, it confirms LAR.
Clinical History & Response to Treatment – Often, we make a clinical diagnosis based on symptoms and their response to allergy medications. If a patient with negative allergy tests improves significantly with intranasal steroids or antihistamines, it strongly suggests LAR.

How is Localized Allergic Rhinitis Different from Typical Allergic Rhinitis?

Treatment: Managing LAR Effectively

The good news? Localized Allergic Rhinitis is treatable!

✔ Intranasal Steroids (e.g., Fluticasone, Mometasone) – These reduce inflammation and nasal symptoms, making them the first-line treatment.

✔ Antihistamines (e.g., Azelastine, Loratadine) – They block histamine, providing relief from itching and sneezing.

✔ Nasal Irrigation – Saline sprays or rinses help clear allergens and mucus, reducing irritation.

✔ Allergen Immunotherapy (AIT, Allergy Shots or Sublingual Tablets) – This is where it gets even more interesting. Even though standard allergy tests are negative, studies have shown that LAR patients can still benefit from immunotherapy! Over time, this can reduce symptoms and modify the immune system’s response to allergens.

Why This Matters

LAR is more common than we once thought, yet it remains underdiagnosed because traditional testing fails to detect it. If you’ve ever been told you don’t have allergies despite having all the symptoms, LAR might be the missing piece of the puzzle.

Final Thoughts

Diagnosing allergic rhinitis isn’t just about running tests—it’s about understanding the patient’s symptoms, response to treatment, and considering conditions like LAR. So the next time someone tells you your allergy test is negative, don’t be too quick to dismiss your symptoms.

Because sometimes, allergies hide in plain sight.

If you need help for your allergic rhinitis symptoms, Contact the Allergy Immunology Clinic, we can help you.

Localized Allergic Rhinitis: When Allergy Tests Are Negative