Epidemiology of Vasomotor Rhinitis
© World Allergy Organization; licensee BioMed Central Ltd. 2009
Published: 15 June 2009
Vasomotor rhinitis is the most common form of nonallergic rhinitis, comprising approximately 71% of all nonallergic rhinitis conditions. Although the epidemiology of this subtype of nonallergic rhinitis has not been definitively studied, it is estimated that 14 million Americans suffer from vasomotor rhinitis, with a worldwide prevalence approaching 320 million.
Keywordsvasomotor rhinitis epidemiology nonallergic rhinopathy nonallergic rhinitis
Challenges in Determining the Prevalence of Vasomotor Rhinitis
Agreement on VMR definition
Requirement to rule out all other forms of rhinitis
Requirement to rule out chronic rhinosinusitis
Skin testing or determination of serum-specific IgE is required
Local IgE production without systemic detection may be present (entopy)
Sinus imaging is rarely assessed in large epidemiologic studies
Nasal cytology is rarely assessed in large epidemiologic studies
Diagnostic Tests to Exclude Other Forms of Rhinitis
CT imaging of the paranasal sinuses
Assays for specific IgE sensitivity
(a) Skin testing
(b) Serum testing
(c) Local (nasal) testing (entopy)
Intranasal allergen challenge
Ingestion challenge (gustatory rhinitis)
Thyroid function testing
A literature search was performed using the following terms: vasomotor rhinitis, nonallergic rhinitis, idiopathic rhinitis, nonallergic noninfectious rhinitis, prevalence, and epidemiology. On the basis of this search and pertinent review articles, the reported prevalence rates of NAR and subtypes were compiled and the prevalence of VMR was extrapolated.
Relative prevalence rates of allergic rhinitis versus nonallergic rhinitis
Relative Rhinitis Prevalence by Author: Allergic Versus Nonallergic
Mullarkey et al
No history of allergen exacerbation. Negative skin tests or <2 PSTs unsupported by history and an IgE level <50 U/mL
Negative SPTs and IDs to 36 allergens
Negative skin tests
Leynaert et al
Negative SPTs to 9 allergens
Settipane et al
Negative skin tests
Mercer et al
Negative SPTs to 20 allergens
Bachert et al
Mølgaard et al
Negative SPTs to 10 allergens
Schatz et al †
Despite the fact that some of these studies were performed in allergy outpatient settings, which would be anticipated to skew the reported prevalence rates toward the diagnosis of AR, the findings are fairly consistent and independent of the setting performed. These 9 studies, when added in total, are heavily influenced by the enormity of the data from Schatz et al, but when analyzed independently of the Schatz data, they reveal a relative prevalence rate of 76% allergic and 24% nonallergic--closely approximating a 3:1 ratio.
Prevalence of VMR in a Nonallergic Rhinitis Population by Study
N (% Female)
Mean Age (Population)
Definition of VMR
VMR % (n, VMR/n, NAR)
Mullarkey et al
73 (sex not reported)
37.5 (VMR); 25.1 (AR)
Nasal congestion and/or rhinorrhea persisting for ≥3 months, with no Hx of allergen exacerbation; negative skin tests or <2 positive skin tests unsupported by Hx; IgE <50 U/mL; <25% eosinophils
Nasal Sx persisting for ≥1 year with no cause determined; negative skin test; <5% eosinophils on nasal smear
Settipane and Klein
Nasal congestion/rhinorrhea persisting for ≥3 months; negative skin tests; normal IgE; <5% eosinophils on nasal smear
Estimated prevalence of nonallergic rhinitis in the United States and worldwide
The data from rhinitis epidemiology studies suggest that the ratio of AR prevalence (pure and mixed combined) to that of pure NAR is 3:1. This ratio can be extrapolated to determine a conservative estimate of the prevalence of NAR in the United States based on established prevalence rates of AR. If the assumption is made that 20% of the population suffers from AR, then on the basis of current population estimates for the United States of just more than 300 million, the US prevalence of AR is 60 million people. Applying the 3:1 (AR/NAR) ratio, approximately 20 million Americans would be expected to suffer from NAR (or approximately 7% of the total population). Given a current world population of 6.75 billion, similar extrapolation suggests that approximately 450 million people suffer from NAR worldwide. It is not known whether VMR is equally prevalent throughout the world and whether local weather (humidity), climate, air pollution, or genetic factors affect VMR prevalence.
Estimated prevalence of VMR in the United States and worldwide
The studies by Mullarkey, Enberg, and Settipane unanimously support VMR as the most common NAR subtype, making up approximately 71% of NAR diagnoses, with NARES making up the majority of the remaining NAR conditions. Applying the 71% frequency of VMR occurrence to the 20 million Americans who suffer from NAR, it would be estimated that VMR affects 14 million people in the United States. Applying the same frequency to the 450 million worldwide population suffering from NAR yields an estimate of a worldwide prevalence of VMR of 320 million.
Further characterization of VMR
VMR is often described as being characterized by nonallergic symptom triggers, including weather (changes in temperature or relative humidity), alcohol, tobacco smoke, dusts, automotive emission fumes, nonspecific irritant stimuli such as chlorine, and odors such as bleach, perfume, or solvents. Unfortunately, no epidemiologic data exist to further categorize VMR based on trigger type. Sex and age demographic data specific to VMR is limited, but can be extrapolated from NAR data, suggesting a female predominance and an older population for NAR than for AR[4–6, 8, 14]. However, the trend toward female predominance remains unproven; it is possible that a study selection bias may have resulted if, as suspected, more females than males entered studies because of an increased likelihood to seek rhinitis care.
Data regarding the prevalence of rhinitis, regardless of the type, are difficult to interpret. Contributing to this challenge is the observation that most population surveys have flawed designs. Because skin testing or determination of serum-specific IgE is infrequently assessed in large epidemiologic studies, allergic causation is often not accurately differentiated from nonallergic causation. However, on the basis of the data that has been reported, it is clear that VMR is, by far, the most common subtype of NAR with a significant burden of illness in the United States and worldwide.
Received grant/research support from GlaxoSmithKline (GSK), Sanofi-Aventis Pharmaceuticals, Meda Pharmaceuticals, and Alcon Laboratories. He is a consultant, or on an advisory board or the speakers bureau, for GlaxoSmithKline (GSK), Sanofi-Aventis Pharmaceuticals, and Alcon Laboratories.
Presented at a roundtable conference held in December 2008 in Washington, DC. The meeting was sponsored by the TREAT Foundation (Washington, DC) and supported through an unrestricted educational grant from Meda Pharmaceuticals. The funding company did not have any input into the development of the meeting or the series, and the company was not represented at the roundtable meeting.
- Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, et al: Joint Task Force on Practice; American Academy of Allergy, Asthma & Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008, 122 (2 Suppl): S1-S84.View ArticlePubMedGoogle Scholar
- Rondón C, Romero JJ, López S, Antúnez C, Martín-Casañez E, et al: Local IgE production and positive nasal provocation test in patients with persistent nonallergic rhinitis. J Allergy Clin Immunol. 2007, 119: 899-905. 10.1016/j.jaci.2007.01.006.View ArticlePubMedGoogle Scholar
- Bernstein J: Characteristics of nonallergic vasomotor rhinitis. World Allergy Org J. 2009, 2: 102-105. 10.1097/WOX.0b013e3181a8e389. [serial online]View ArticleGoogle Scholar
- Bernstein IL, Li JT, Bernstein DI, Hamilton R, Spector SL, et al: American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008, 100 (3 Suppl 3): S1-148.Google Scholar
- Benninger M, Kaliner M, Farrar J: Proposed inclusion/exclusion criteria for nonallergic rhinopathy. World Allergy Org J. 2009, 2 [serial online],Google Scholar
- Mullarkey MF, Hill JS, Webb DR: Allergic and nonallergic rhinitis: their characterization with attention to the meaning of nasal eosinophilia. J Allergy Clin Immunol. 1980, 65: 122-126. 10.1016/0091-6749(80)90196-7.View ArticlePubMedGoogle Scholar
- Enberg RN: Perennial nonallergic rhinitis: a retrospective review. Ann Allergy. 1989, 63: 513-516.PubMedGoogle Scholar
- Togias A: Age relationships and clinical features of nonallergic rhinitis. J Allergy Clin Immunol. 1990, 85: 182-Google Scholar
- Settipane RA, Lieberman P: Update on non-allergic Rhinitis. Ann Allergy Asthma Immunol. 2001, 86: 494-507. 10.1016/S1081-1206(10)62896-7.View ArticlePubMedGoogle Scholar
- Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F: Perennial rhinitis: an independent risk factor for asthma in nonatopic subjects. Results from the European Community Respiratory Health Survey. J Allergy Clin Immunol. 1999, 104: 301-304. 10.1016/S0091-6749(99)70370-2.View ArticlePubMedGoogle Scholar
- Settipane RA: Rhinitis: a dose of epidemiological reality. Allergy Asthma Proc. 2003, 24: 147-154.PubMedGoogle Scholar
- Mercer MJ, van der Linde GP, Joubert G: Rhinitis (allergic and nonallergic) in an atopic pediatric referral population in the grass-lands of inland South Africa. Ann Allergy Asthma Immunol. 2002, 89: 503-512. 10.1016/S1081-1206(10)62089-3.View ArticlePubMedGoogle Scholar
- Bachert C, van Cauwenberge P, Olbrecht J, van Schoor J: Prevalence, classification and perception of allergic and nonallergic rhinitis in Belgium. Allergy. 2006, 61: 693-698. 10.1111/j.1398-9995.2006.01054.x.View ArticlePubMedGoogle Scholar
- Mølgaard E, Thomsen SF, Lund T, Pedersen L, Nolte H, Backer V: Differences between allergic and nonallergic rhinitis in a large sample of adolescents and adults. Allergy. 2007, 62: 1033-1037. 10.1111/j.1398-9995.2007.01355.x.View ArticlePubMedGoogle Scholar
- Schatz M, Zeiger RS, Chen W, Yang SJ, Corrao MA, Quinn VP: The burden of rhinitis in a managed care organization. Ann Allergy Asthma Immunol. 2008, 101: 240-247. 10.1016/S1081-1206(10)60488-7.View ArticlePubMedGoogle Scholar
- Settipane GA, Klein DE: Non allergic rhinitis: demography of eosinophils in nasal smear, blood total eosinophil counts and IgE levels. N Engl Reg Allergy Proc. 1985, 6: 363-366. 10.2500/108854185779109124.View ArticlePubMedGoogle Scholar
- Settipane RA, Charnock DR: Epidemiology of rhinitis: allergic and nonallergic. Clin Allergy Immunol. 2007, 19: 23-34.PubMedGoogle Scholar
- U.S. and World Population Clocks - POPClocks [database online]. 2006, Washington, DC: Census Bureau, Population Division, Updated November 22, 2006. Available at: http://www.census.gov/main/www/popclock.html. Accessed January 03, 2009
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