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Study of vitamin C therapy in allergic rhinitis

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p> Background: Vitamin C has a therapeutic role in allergic rhinitis by reduction of oxidative stress and inflammation. The present study has been undertaken to evaluate the improvement or otherwise in the clinical manifestations of allergic rhinitis, following supplementation of this vitamin. Methods: 40 subjects of allergic rhinitis were selected from the allergy clinics of Dayanand medical college and hospital. The study period was one and a half year. Vitamin C in the dose of 1 gm per day was administered in the case group and in the placebo group a sugar tablet was administered by the oral route. Plasma levels of ascorbic acid and its effect on the symptoms and signs of rhinitis were recorded. Results: The mean duration of illness in the patients with allergic rhinitis was 10.15±3.4 years, with 25 patients having duration of less than 10 years, 10 patients were with of illness between 10 to 20 years and 5 having duration more than 20 years. The most common complaint in patients with allergic rhinitis was of nasal obstruction (57.5%). All the patients who showed improvement had increase in plasma ascorbic after the respective treatment but not all the patients showing increase in plasma ascorbic acid post-treatment showed improvement. Conclusions: Vitamin C ameliorates the signs and symptoms of allergic rhinitis by raising the plasma ascorbic acid levels.</p
International Journal of Otorhinolaryngology and Head and Neck Surgery | November 2020 | Vol 6 | Issue 11 Page 1951
International Journal of Otorhinolaryngology and Head and Neck Surgery
Munjal M et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Nov;6(11):1951-1955
http://www.ijorl.com
pISSN 2454-5929 | eISSN 2454-5937
Original Research Article
Study of vitamin C therapy in allergic rhinitis
Manish Munjal1*, Atul Singh1, Ajit Singh Khurana1, Navjot Bajwa2,
Shubham Munjal2, Neha Dhawan1, Gurkaran Waraich1
INTRODUCTION
Individuals with allergic rhinitis present with rhinorhea,
sneezing, nasal obstruction, anosmia and sometimes with
associated, middle ear effusion, pharyngitis, laryngitis,
irritation in the eyes, headache, asthma and
gastrointestinal upset.1
Antioxidants like vitamin C, tocopherols and carotenoids
have a protective effect in allergic rhinitis and allergic
sensitisationm. Individuals with increased intake of
vitamin C have fewer symptoms of allergic rhinitis.
Dietary intakes of citrus fruit too have been shown to
reduce the episode of shortness of breath. Moreover
vitamin C supplementation enhances the resistance to
post exertional upper respiratory tract infections in
athletes and reduces the severity in sedentary individuals.
Aim of the study
To study the effect of vitamin C on plasma ascorbic acid
and features of allergic rhinitis.
METHODS
40 subjects of allergic rhinitis were selected from the
allergy clinic of Dayanand medical college and hospital
in a period of one and a half years (June 2009 to
December 2010).
ABSTRACT
Background: Vitamin C has a therapeutic role in allergic rhinitis by reduction of oxidative stress and inflammation.
The present study has been undertaken to evaluate the improvement or otherwise in the clinical manifestations of
allergic rhinitis, following supplementation of this vitamin.
Methods: 40 subjects of allergic rhinitis were selected from the allergy clinics of Dayanand medical college and
hospital. The study period was one and a half year. Vitamin C in the dose of 1 gm per day was administered in the
case group and in the placebo group a sugar tablet was administered by the oral route. Plasma levels of ascorbic acid
and its effect on the symptoms and signs of rhinitis were recorded.
Results: The mean duration of illness in the patients with allergic rhinitis was 10.15±3.4 years, with 25 patients
having duration of less than 10 years, 10 patients were with of illness between 10 to 20 years and 5 having duration
more than 20 years. The most common complaint in patients with allergic rhinitis was of nasal obstruction (57.5%).
All the patients who showed improvement had increase in plasma ascorbic after the respective treatment but not all
the patients showing increase in plasma ascorbic acid post-treatment showed improvement.
Conclusions: Vitamin C ameliorates the signs and symptoms of allergic rhinitis by raising the plasma ascorbic acid
levels.
Keywords: Vitamin C, Allergic rhinitis, Ascorbic acid, Clinical features
1Department of ENT, 2Department of Biochemistry, Dayanand Medical College, Ludhiana, Punjab, India
Received: 20 July 2020
Revised: 12 September 2020
Accepted: 15 September 2020
*Correspondence:
Dr. Manish Munjal,
E-mail: manishmunjaldr@yahoo.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: https://dx.doi.org/10.18203/issn.2454-5929.ijohns20204616
Munjal M et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Nov;6(11):1951-1955
International Journal of Otorhinolaryngology and Head and Neck Surgery | November 2020 | Vol 6 | Issue 11 Page 1952
Study design
The present study was a prospective controlled study with
the experimental group and the control group. The
experimental group was divided into; group I: case group
(20 subjects) and group II: placebo group (20 subjects).
Vitamin C was administered orally in the dose of 1
gm/day for 7 days and plasma levels were estimated after
supplementation. Simultaneously their symptoms and
signs were recorded and compared to previous findings.
A sugar tablet was administered by oral route, twice a
day for 7 days and the plasma levels were estimated and
clinical manifestations compared.
Due care was taken that the subjects did not take any
vitamin C supplementation, antihistamines or
decongestants prior to plasma level estimation. Plasma
levels of ascorbic acid was estimated by 2,6-
dichlorophenol indophenols titration. Healthy 20 subjects
without any complaints were included in the control
group, for measuring levels of plasma ascorbic acid.
An inclusive criterion was patients with allergic rhinitis.
Exclusive criteria were patients with fungal rhino-
sinusitis and patients on long duration steroid oral or
nasal sprays.
Statistical analysis
All statistical calculations were done using statistical
package of social sciences (SPSS) 17 version statistical
program for Microsoft windows (SPSS Inc. 2008. version
17.0, Chicago).
RESULTS
The mean duration of illness in the patients with allergic
rhinitis was 10.15±3.4 years, with 25 patients having
duration of less than 10 years, 10 patients of illness
between 10 to 20 years and 5 were having duration more
than 20 years (Table 1).
Table 1: Duration of illness in patients with allergic
rhinitis.
Duration of illness (years)
<10
10-20
>20
The most common complaint in patients with allergic was
of nasal obstruction (57.5%), the next in order of
frequency was of rhinorrhea (47. 5%), sneezing (37 5%)
and postnasal dripping (27. 5%) (Table 2).
Patients with allergic rhinitis showed overall relief with
vitamin C treatment, with all patients having complaints
of sneezing, lacrimation, itching and malaise getting
moderate to complete relief with the treatment (Table 3).
Table 2: The presenting complaints of patients with
allergic rhinitis.
Symptoms
N (%)
Nasal obstruction
23 (57.5)
Rhinorrheoa
29 (47.5)
Sneezing
15 (37.5)
Post nasal dripping
11 (27.5)
Lacrimation
10 (25)
Itching (palatal etc.)
10 (25)
Malaise
10 (25)
Headache
9 (22.5)
Associated nasobronchial allergies or
asthma
7 (17.5)
Skin manifestation
3 (7.5)
Fever
3 (7.5)
Ear aches
1 (1.5)
Table 3: Response to vitamin C treatment in the case
group as based clinical assessment.
Features
Total
Improve-
ment
N (%)
No
improve
-ment
N (%).
Nasal obstruction
12
11 (91.66)
1 (8.33)
Rhinorrheoa
10
8 (80)
2 (20)
Sneezing
8
8 (100)
0 (0)
Post nasal dripping
6
5 (83.33)
1 (16.66)
Lacrimation
4
4 (100)
0 (0)
Itching
6
6 (100)
0 (0)
Malaise
5
5 (100)
0 (0)
Headache
4
2 (50)
2 (50)
Associated
nasobronchial
allergies
3
2 (66.66)
1 (33.33)
Skin manifestation
1
0 (0)
1 (100)
Fever
2
1 (50)
1 (50)
Ear aches
1
0 (0)
1 (100)
Excessive mucus
secretions
7
6 (85.71)
1 (14.28)
Pale mucosa
5
4 (80)
1 (20)
DISCUSSION
In present study the most common complaint in the
patients with allergic rhinitis was nasal obstruction
(57.5%). The next presentation in order of frequency was
rhinorrhea (47.5%), sneezing (37.5%), post nasal
dripping (27.5%), lacrimation, itching and malaise (25%
each). Thacker analyzed 170 patients of allergic rhinitis
and found that 27% had asthma, 8% had GIT symptoms,
13% had ear symptoms, 7% had hoarseness, 10% had
pharyngitis, 23% headache, 7 % had anosomia, and 7%
had eye syndromes.1 Wilson et al in their study of 26
Munjal M et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Nov;6(11):1951-1955
International Journal of Otorhinolaryngology and Head and Neck Surgery | November 2020 | Vol 6 | Issue 11 Page 1953
patients, out of which 11 were atopic patients, found that
nasal obstruction was the commonest symptom.
Rhinorrhea and sneezing were more common in atopic
patients.2 Smith stated that four of five patients with
allergic rhinitis have predominantly nasal symptoms.3
Symptoms of patients suffering from allergic rhinitis in
the present study were compared with a study on nasal
allergy by Craddock (Table 4).4
Table 4: Comparison of presenting complaints with
Craddock et al study.
Symptoms
% of
patients in
present
study
% of
patients in
study by
Craddock
Nasal obstruction
57.5
60
Rhinorrheoa
47.5
-
Sneezing
37.5
40
Post nasal dripping
27.5
40
Lacrimation
25.0
-
Itching
(palatal/eyes)
25.0
15
Malaise
25.0
32.5
Headache
22.5
28.75
Associated
nasobronchial
allergy/asthma etc.
17.5
20
Skin manifestation
7.5
7.5
Fever
7.5
-
Ear aches
1.5
6.25
Analysis with reference to effect on clinical features of
allergic rhinitis
The most common findings in patients with allergic
rhinitis in our study was deviation in nasal septum
(47.5%). Various other clinical features were excess
mucus production (35%), hypertrophy of turbinate(s)
(30%), pale blue mucosa (22.5%), mulberry cushion
(20%) and polypi (5%). 25% of the patients had
essentially normal examination. Thacker as early as 1946
found that 53% of patients had pale, boggy turbinates,
3% had hypertrophic rhinitis.1 Craddock found that the
patients presenting with nasal allergy most commonly
had normal nasal examination (38.755). Other features in
order to frequency were excess mucus production
(36.25%), pale mucosa (27.5%), and hypertrophy
(13.75%), polypi (10%).4 Smith documented that 60% of
the patients with allergic rhinitis had classically pale blue
tone of nasal mucosa.3 Clinical findings in 40 patients of
allergic rhinitis observed in this study were compared
with a previous study (Table 5).
Analysis with reference to effect on plasma ascorbic
acid levels
The mean plasma ascorbic acid level in control group
was 20.45±3.58 mg/L. The mean plasma ascorbic acid
level in pre vitamin C case group was 15.45±3.59 mg/L
and in post vitamin C treatment it was 23.20±5.55 mg/L.
The placebo group had mean plasma ascorbic acid level
as 13.85±2.92 mg/L before placebo treatment and this
level was 15.15±3.67 after placebo treatment. The mean
levels of plasma ascorbic acid as estimated in this study is
analysed in (Table 6).
Table 5: Comparison of clinical features with study by
Craddock et al.
Symptoms
% of patients
in present
study
% of
patients in
study by
Craddock
Deviated nasal
septum
47.5
-
Excess mucus
production
35.0
36.2
Hypertrophy of
turbinates
30
13.7
Essentially normal
25
38.7
Pale blue nasal
mucosa
22.5
27.5
Vomerine cushion/
Mulberry
appearance
20.0
-
Polypi
5
10
Effect of treatment (vitamin C and placebo)
In our study patients with allergic rhinitis showed overall
relief with vitamin C treatment, with all patients having
complaints of sneezing, lacrimation, itching and malaise
getting moderate to complete relief with the treatment.
But with the placebo treatment there was no overall
improvement in the symptoms of the patients.
Out of the 20 patients with allergic rhinitis in the case
group, 17 (85%) improved with vitamin C treatment and
3 (15%) showed no improvement. But in placebo group
85% of the patients had no overall relief.
All the patients who had improvement with the respective
treatment showed increase in the level of plasma ascorbic
acid after the said treatment vis-à-vis- pre-treatment level.
Thus, all the patients who showed improvement has
increase in plasma ascorbic after the respective treatment
but not all the patients showing increase in plasma
ascorbic acid post-treatment showed improvement.
Mahindra et al found that the patients who were given
vitamin C supplementation of 500 mg 1 BDx1 week had
shown rise in plasma ascorbic acid and this coincided
with subjective and objective improvement in allergic
rhinitis.5
Wilson et al studied the effect of daily administration of
vitamin C on symptom association and on the incidence,
Munjal M et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Nov;6(11):1951-1955
International Journal of Otorhinolaryngology and Head and Neck Surgery | November 2020 | Vol 6 | Issue 11 Page 1954
duration, severity and total intensity of the symptom in
common cold. They found that the vitamin C reduces
symptom association and alters the frequency of toxic
and catarrhal complexes. The severity of symptoms of
cold were reflected more accurately by changes in plasma
ascorbic acid concentrations.6 Baird et al study of 362
healthy subjects found that there was a 14 to 21 %
reduction in total symptoms due to common cold that
were supplemented with vitamin C. Ascorbic acid also
increased the number of “episode-free” subjects.
Table 6: Statistical significance of plasma ascorbic
acid in various groups.
Comparison of levels of
plasma ascorbic acid in
various groups
t value
P value
Pre vitamin C vs. control
4.299
p<0.01
Pre vs. post vitamin C cases
5.11
p<0.01
Post vitamin C vs. control
1.815
Not
significant
Pre placebo vs. control
6.23
p<0.01
Pre placebo vs. post placebo
1.20
Not
significant
Post placebo vs. control
4.506
p<0.01
Table 7: Effect of vitamin C and placebo treatment.
Group (n=20)
Improvement
in patients
N (%)
No Improvement
in patients
N (%)
After vitamin
C treatment
17 (85%)
3 (15%)
After placebo
treatment
3 (15%)
17 (85%)
Total
20
20
Table 8: Patients showing increase in plasma ascorbic
acid.
Variables
Improved
No
Improvement
Total patients with increase in plasma ascorbic acid
33
20
13
Patients showing improvement in signs and
symptoms.
Total patients with
improvement
Increase in
plasma ascorbic
acid
No increase in
plasma
ascorbic acid
20
20
0
Munjal et al recorded that in allergic rhinitis there is
unsaturated state of body ascorbic acid, which is
confirmed by increased utilization of ascorbic acid after
supplementation. This unsaturated state of body was
more in acute stage of disease.8 Iris Kompauer et al study
found a negative association between plasma total
carotenoids and the prevalence of allergic rhinitis, with
odds ratio other single carotenoids, tocopherols and
vitamin C were unrelated to allergic rhinitis. Allergic
sensitisation was negatively associated with plasma γ-
tocopherol, no other antioxidant was significantly related
to allergic sensitisation.9
Peters EM study provides evidence that vitamin C
supplementation may enhance resistance to the post-race
upper respiratory tract infections that occur commonly in
competitive ultra-marathon runners and may reduce the
severity of such infections in those who are sedentary.10
Vitamin C in mega doses administered before or after the
appearance of cold and flu symptoms relieved and
prevented the symptoms in the test population compared
with the control group.11
In the present study, patients with allergic rhinitis showed
overall relief with vitamin C supplementation, with all
subjects with complaints of sneezing, lacrimation, itching
and malaise getting moderate to complete relief with the
treatment. But with the placebo treatment there was no
overall improvement in the symptoms of the patients. All
the patients who showed improvement in their
manifestations of allergic rhinitis had increase in the
plasma ascorbic acid after the respective treatment.
CONCLUSION
Vitamin C ameliorates the signs and symptoms of allergic
rhinitis, by raising the plasma ascorbic acid levels.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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1. Thacker EA. Nasal obstruction. JAMA. 1946;131:
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2. Wilson J, Karen R, Donald S, Peng LY, Joan D,
Ross B, et al. Nasal histamine and heparin in
chronic rhinitis. Ann Otol Rhinol Laryngol. 1988;
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3. Middletone E, Smith JM. Allergy principles and
practice. 3rd ed. Missouri: Mosby; 1988:891-929.
4. Craddock WH. Perennial nasal allergy: a review of
eighty cases. Annals of Otology, Rhinology &
Laryngology. 1949;58(3):671-9.
5. Mahindra M. Study of serum and urinary ascorbic
acid levels in case of allergic rhinitis. JOL. 1967;
19:130.
6. Wilson CW, Loh HS. Common cold and vitamin C.
Lancet. 1973;7801: 638-41.
7. Baird IM, Hughes RE, Wilson Hk, Davies JEW,
Howard AN. The effects of ascorbic acid and
flavonoids on the occurrence of symptoms normally
associated with the common cold. Am J Clin Nutr.
1979;32:1686.
Munjal M et al. Int J Otorhinolaryngol Head Neck Surg. 2020 Nov;6(11):1951-1955
International Journal of Otorhinolaryngology and Head and Neck Surgery | November 2020 | Vol 6 | Issue 11 Page 1955
8. Munjal KR, Tankwal M, Gogia JS. Estimation of
ascorbic levels in blood and urine in cases of
allergic rhinitis. Ind J Otolary. 1985;37(3):85-6.
9. Kompauer I, Heinrich J, Wolfram G, Linseisen J.
Association of carotenoids, tocopherols and vitamin
C in plasma with allergic rhinitis and allergic
sensitization in adults. Public health nutrition. 2006;
9(4):472-9.
10. Peters EM, Goetzsche JM, Grobbelaar B, Noakes
TD. Vitamin C supplementation reduces the
incidence of post race symptoms of upper-
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Cite this article as: Munjal M, Singh A, Khurana
AS, Bajwa N, Munjal S, Dhawan N, et al. Study of
vitamin C therapy in allergic rhinitis. Int J
Otorhinolaryngol Head Neck Surg 2020;6:1951-5.
... Seo et al. performed a large cross-sectional study involving 4554 children in Seoul and had shown that Vitamin C consumption reduced AR symptoms in children but did not affect the serum IgE level [16]. A randomized controlled trial has shown that increase in plasma ascorbic acid was related to reduced AR symptoms [17]. ...
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PurposeWe conducted this study to estimate the prevalence of complementary and alternative medicines (CAM) usage among allergic rhinitis (AR) patients in Malaysia and understand the practice of CAM usage among them. We also included a literature review on the commonly used CAM for AR.MethodsA cross-sectional study which included a questionnaire-based study and information of allergic rhinitis from patient’s clinic records. Patients with AR who attended the ORL-HNS department in Hospital Universiti Sains Malaysia and Hospital Sultanah Aminah, Malaysia were enrolled after consented, on a first-come first-serve basis as convenience sampling from July 2020 until February 2021. A pre-tested self-administered, 16-item questionnaire in Malay language was distributed to the participants. The questionnaire consists of a set of 16 questions with subsets to enquire about the sociodemographic data and pattern of usage of CAM and its effectiveness.Results372 patients were enrolled in this study consisting of 217 (58.3%) female and 155 (41.7%) male patients. 231 (62.1%) participants had used CAM for AR in the past 10 years. A higher proportion of females (p = 0.015) and those with higher income (p = 0.004) had used CAM. Among the users, 87.9% found CAM to be effective. No differences were found in terms of age (p = 0.888) and education level (p = 0.057) for CAM usage.ConclusionCAM is widely used in Malaysia to alleviate AR symptoms, with a large proportion of users think it is effective. Therefore, more researches should be conducted to provide evidence and guidance to integrate CAM into AR management.
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Summary 1. Plasma and Urinary ascorbic acid levels in a series of 14 normal cases and 35 cases of acute allergic rhinitis, have been reported. 2. The mean value of ascorbic acid, in plasma and urine in the entire series of allergic rhinitis and normal cases has also been indicated. 3. The lower values in allergic rhinitis cases may be attributed to the greater utilisation of ascorbic acid resulting in tissue unsaturation. 4. The levels of plasma and urinary ascorbic acid seem to decrease as the age advance. 5. Heavy medication with Vitamin C produced a rise in the Blood and urinary ascorbic acid levels which coincided with subjective and objective improvement of the allergic condition.
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A controlled study was made of the effects of natural orange juice, synthetic orange juice, and placebo in the prevention of the common cold; both natural and synthetic orange juices contained 80 mg of ascorbic acid daily. Three-hundred sixty-two healthy normal young adult volunteers, ages 17 to 25 years, were studied for 72 days with 97% of participants completing the trial. There was a 14 to 21% reduction in total symptoms due to the common cold in the supplemented groups that was statistically significant (P less than 0.05). Ascorbic acid supplementation also increased the number of "episode-free" subjects. However, the clinical usefulness of the results does not support prophylactic ascorbic acid supplements in the well-nourished adult. The results in this study with both natural and synthetic orange juice of physiological content of ascorbic acid, are similar to those obtained using a "megadose" of ascorbic acid.
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Histamine and heparin, both free and cellular, were assayed in the nasal mucosa of 11 atopic and 15 nonatopic patients undergoing turbinectomy for chronic rhinitis. There was no significant difference between the free and cellular histamine levels of the atopic and nonatopic patients. There was also no significant difference between the free heparin levels of atopic and nonatopic patients. Mean cellular heparin was, however, significantly greater in the nonatopic group. This finding, together with the results of mast cell counting, suggests either that in atopic patients heparin stores are already depleted prior to turbinectomy, or that in nonatopic individuals nasal mast cells contain an excess of heparin in nonreleasable stores.
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The effect of daily administration of placebo or 200 or 500 mg. tablets of vitamin C on symptom association and on the incidence, duration, severity, and total intensity of the symptoms in the common cold has been studied. The metabolism of ascorbic acid during the common cold, and after disappearance of all the symptoms, has been investigated by examining the plasma and leucocyte ascorbic-acid concentrations after a loading dose of 500 mg. vitamin C. Cold symptoms tend to dissociate into toxic and catarrhal complexes, the complexity and frequency of which differ between boys and girls. Vitamin C reduces symptom association and alters the frequency of toxic and catarrhal complexes. It significantly reduces the severity and total intensity of colds in girls, but does not benefit cold symptoms in boys at a daily dose of 500 mg. During colds, especially of the catarrhal variety, ascorbic acid is transferred out of the leucocytes into the plasma, where it is rapidly metabolised in both sexes, but this effect is more pronounced in females. There is a significant positive correlation between metabolic utilisation of ascorbic acid during colds and intensity of cold symptoms.
Allergy principles and practice
  • E Middletone
  • J M Smith
Middletone E, Smith JM. Allergy principles and practice. 3rd ed. Missouri: Mosby; 1988:891-929.