Allergic rhinitis in primary care: Navigating diagnostic uncertainty, treatment failure and referral

Abstract Allergic rhinitis is usually first recognised and treated in primary care, where decisions often precede allergen testing or specialist assessment. The challenge is not simply identifying classic allergic symptoms, but distinguishing clinically relevant allergy from sensitisation, nonallergic rhinitis, chronic rhinosinusitis and structural disease; selecting treatment according to burden; and recognising when apparent treatment failure reflects poor adherence, incorrect intranasal spray technique or an alternative diagnosis. This practice-oriented Review translates current guideline and consensus evidence into a decision sequence for first-contact care. It focuses on when a clinical diagnosis is sufficient, when targeted skin-prick or serum allergen-specific IgE testing will change management, how to optimise intranasal treatment, and how to separate allergy/immunology from otolaryngology referral pathways. The aim is to reduce indiscriminate testing, unnecessary treatment escalation and delayed referral while preserving the longitudinal advantages of primary care.