Doctor Q&A: Antihistamines are not helping my hay fever, what can I do? Dr Renée Hoenderkamp answers all your burning questions

I have Morton's neuroma and I have tried everything. Even surgery. Are there any options I have left to stop my foot pain? 

Now this question made me sit up and feel your pain – literally. I have, or so I thought, tried everything, bar surgery which I have been avoiding for the very reason you have, ongoing pain!

A Morton's neuroma is not a true neuroma (a benign growth). It is a nerve that becomes over thickened and surrounded with fibrous tissue in the space between the bones leading to toes three and four. There is a tendency for it to form together with a fluid-filled bag, or bursa. A neuroma-bursa complex is the body’s attempt to protect the nerve, but actually causes more pain. It can make wearing shoes of almost any description painful and standing for any period.

Treatments start conservatively with footwear (wider, supportive, flat, padded, custom orthotics), to steroid injections and then radiofrequency, ultrasound, cryosurgery, or surgery. As a woman who loves to wear heels and having tried all conservative methods and steroid injections I have been looking for a solution. I have narrowed this down to surgery to cryotherapy. Your question confirms my decision to try cryotherapy. So why?

Surgery is designed to remove the neuroma through a small incision above the area on the top of the foot. The normal risks of surgery are always present (infection etc) however once healing has completed up to 85 percent of people will have no pain. For the unlucky 15 percent like you however, the pain can continue. This can be due to scar tissue, a stump neuroma (irritation of the nerve end), and complex regional pain syndrome (CRPS).

If your pain is caused by scar tissue it is possible to have a steroid injection or even revision surgery to treat this. Similarly stump neuromas can also be treated with steroid injections. This is no guaranteed to ending the pain but it can help. Sadly CRPS is poorly understood and hard to treat and a multi-disciplinary pain clinic would need to have input. So for you, the first and most important step will be getting a diagnosis for the source of your ongoing pain and the treatment plan will follow from there.

I am opting for cryotherapy at The Mortons Neuroma Centre later this month and I will share the results on my Instagram. It’s a newish treatment where a probe is inserted into the neuroma to kill it using cryotherapy. Watch this space!

There is good info on all of the above here and hopefully your ongoing pain will have a cause which can be treated. Good luck.

I take antihistamines every day but my hay fever is still causing me grief. What would you recommend? 

This is a very common issue I hear from patients in my GP surgery as spring arrives. According to Allergy UK, hay fever affects over a quarter of adults. An allergy to seasonal pollen, hay fever is most commonly experienced over the summer, due to grass pollen. However, it can also strike at any time of the year, when different pollens, e.g. tree pollen in spring and weed pollens in late summer, present.

Some people cope quite easily with an antihistamine, but others such as yourself really struggle with combination symptoms such as nose and eye symptoms, include sneezing, a runny nose, itchy eyes and throat. It can be really debilitating for many people, making everyday life miserable and almost intolerable with people avoiding social events, everyday activities and things many take for granted.

While there is currently no cure for hay fever, effective and easily accessible treatments are available and my most important answer for you today is combine them all!

Quite often people with hay fever think that if they have itchy eyes, then eye drops are enough. Equally, if they have nasal congestions, a nasal spray is enough. It often isn’t and if you combine treatments they work together to keep stubborn symptoms at bay. So my first suggestion is always to combine, eye drops (sodium cromoglycate), an antihistamine (loratadine or cetirizine) and a steroid nasal spray (Beconase). These are all available over the counter, so no need to wait for a GP appointment (in fact GP’s are now told to not prescribe for moderate hay fever and to direct patients to self care).

It may seem odd to use a nasal spray if you only have eye symptoms but the combination is what makes the difference! And start using them three weeks before your pollen season begins, whenever that is.

Now a few caveats: don’t ever be tempted to use nasal decongestant sprays (with xylometazoline or pseudopehrine) as tempting as they are, after more than three days usage they will make things worse. But an oral decongestant with pseudoephrine in can be used without this worry.

If these over the counter remedies are still not working then you can speak to your GP about a Leukotriene modifier (Montelukast). This is a prescription tablet taken to block the action of leukotrienes which are immune system chemicals that cause allergy symptoms.

If these solutions don’t work, some people suggest more natural remedies such as eating honey from your local area to sensitise yourself to local pollen, lining the inside of your nose with Vaseline to prevent to pollen doing its work at your mucous membranes, acupuncture, probiotics, daily vitamin C and herbal remedies. Good luck!

I have phlegm in the back of my throat constantly. What’s causing this?  

This is a great question and one I hear very often as a London-based GP. I say London because I am convinced that this problem is often exacerbated by pollution, especially as patients often tell me that when they go to the sea or the mountains things improve!

This does of course depend on the initial cause of the problem, and there are many so let's have a look at the two most common because, as we often say in GP circles, common things are common!

Post nasal drip

Your nose is a clever organ that makes mucus to help clear infections and allergens, or in response to irritants such as cold weather. Mucus can drip from the front of the nose, but can just as likely drip from the back of the nose and travel down towards the throat. This can sometimes be felt as an irritant causing you to constantly clear your throat, cause a husky voice or even taste/smell badly. I

t commonly happens after any cold or upper respiratory tract infection and it is not commonly known that it can last for up to eight weeks and so too the cough that often comes with it. Often worse in the morning as the mucus collects overnight and needs good clearance. For some with allergic (atopic) tendencies it can be an ongoing problem that needs an ongoing solution. This is often called chronic catarrh. Causes can include a cold or other infections, allergic rhinitis, non-allergic rhinitis or even be a sign of nasal polyps. Sometimes it can be tricky to define the cause but keeping a diary of when it happens, time of year/day/activities can highlight potential triggers.

For all cases, regular nasal washes with a neti pot or similar (I use NeilMed Sinus rinse) helps clear mucus and can alleviate pain being caused by the pressure of built up mucus. Overuse of nasal decongestants (with xylometazoline or pseudopehrine), e.g. for more than three days, can and usually does make things worse, even though they feel great when being used, they are often a self fulfilling prophesy and are too tempting to put down, so I tell patients to never use them.

If allergy is at work, a daily antihistamine is a must. Then add to this, or alone if no allergy, a steroid nasal spray such as Beconase. And it is critical you know how to use one as it won’t work if it isn’t staying at the top of your nasal passage to do google “how to use a steroids nasal spray”!

Reflux

Another common cause of throat clearing is laryngopharyngeal reflux. This happens when the normal acid in your stomach that helps digest food flows backward up the oesophagus (food tube) that links throat to stomach. On its way up it can burn and it may hit the vocal cords or throat, causing irritation and mucus production.

Not everyone with reflux notices a burning sensation in the throat or have heartburn, a classic sign of gastro-oesophageal reflux disease or GERD. Some people just have an urge to constantly clear their throat or may have a persistent cough.

To test for this you can try an over the counter acid reducing medication such as Gaviscon or Nexium (omeprazole). If this solves the problem then its time to look at diet and avoid stomach irritants such as tomatoes, spicy food, alcohol, caffeine, chocolate, peppermint and smoking and to get your weight to a healthy BMI (18.5-25) as weight plays an important role in increasing intra-abdominal pressure which in turn pushes your stomach and acid upwards!

For both of these causes, if you try the suggested solutions for a couple of weeks and nothing changes, you should see your doctor as there are many other potential causes, however rare and I have linked a good summary article below2. If you have a husky/change of voice for more than four weeks, it is crucially important to do so.