What is AFRS?

Allergic fungal rhinosinusitis (AFRS) is a chronic (ongoing) inflammatory sinus condition in which the immune system overreacts to fungi in the air such as mold or yeast (hypersensitivity response). This reaction causes thick mucus, swelling, and blocked sinuses.

AFRS can impact daily living by:

• Making it hard to breathe through your nose.
• Making it hard to smell and taste food.
• Causing sleep problems.
• Leading to frustration and stress.

Common AFRS Symptoms

Some symptoms of AFRS are similar to a regular sinus infection.

• Swelling (inflammation) in the nose
• Constant blocked nose (nasal congestion)
• Runny nose
• Post-nasal drip
• Sinus pressure and headaches
• Loss of smell
• Thick mucus (peanut butter-like mucus)

AFRS can affect just one side of the nose/sinuses. In severe cases, AFRS can even cause bone erosion and potential visual disturbance.

About 5-15% of people with chronic rhinosinusitis have AFRS.

How AFRS Differs From Other Sinus Issues

Allergic fungal rhinosinusitis (AFRS) is different from most sinus infections. Typical sinus infections happen when viruses or bacteria get into your sinuses and cause an infection. AFRS, on the other hand, isn’t caused by germs taking over. Instead, it happens when your body overreacts to fungi (like mold) in the air.

Regular sinus infections are generally short-term, but AFRS causes ongoing, chronic symptoms.

AFRS Testing and Diagnosis

First, your doctor will do a physical exam and ask about your symptoms and medical history.

Tests for AFRS may include:

• CT scan: a special 3D X-ray that takes detailed photos of the nasal and sinus passageways (when available)
• Endoscopy: a nasal exam with a small camera to look inside your sinuses
• Mucus or Tissue Lab Testing (Biopsy): The lab tests small samples of mucus or tissue to see exactly what caused the inflammation.

Use our My AFRS Visit Card when you are meeting with your doctor or healthcare provider. It can help you to better communicate your symptoms and remember to ask important questions.

Causes of AFRS

AFRS happens when someone has an overly sensitive (allergic) immune system that reacts to fungi. Most people with healthy immune systems tolerate the same fungi with no problem.

Some factors can contribute to this reaction in people with AFRS.

• Genetics: Some people are born with an overly sensitive immune system that reacts to small fungal spores.
• Environment: Warm, humid climates can trigger infections for people with AFRS.
• Poor sinus drainage: Narrow sinus passages and inflammation can keep mucus from draining well. This can trap mold spores in the sinuses. In some people, the body’s immune system overreacts to the trapped mold, leading to the inflammation seen in AFRS.
• Smoking cannabis or using hookah: These have been linked to AFRS. Both harbor mold particles and can expose the airways to mold. They can also weaken the tiny hair-like structures (cilia) in the airways that help clear out harmful particles. While the evidence linking cannabis or hookah use directly to AFRS is limited and not conclusive, these exposures may represent potential risk factors.

Overlapping (Comorbid) Health Conditions

Comorbid conditions are other health conditions someone has with AFRS. Usually, these conditions happen because of the same allergic responses in the body.

Common comorbid conditions include:

• Asthma
• Allergic rhinitis (hay fever)
• Nasal polyps
• Chronic sinusitis

It is common for people with AFRS to have a history of allergic diseases, like allergic rhinitis and asthma. These conditions all involve an overactive immune response to things in the environment.

AFRS is also linked to nasal polyps, which are soft, noncancerous lumps in the nose that can trap mucus and make it harder to breathe.

Some people may also have chronic swelling, like chronic sinusitis.

When these health conditions happen at the same time, symptoms can become worse and harder to control.

How to Manage AFRS Long-Term

To manage AFRS long-term, you’ll need to work with a healthcare team that includes your primary provider, an ear, nose, and throat (ENT) doctor, and an allergy specialist.

Managing AFRS requires a long-term plan to prevent swelling and inflammation and keep mucus from building up again. Since your immune system stays overreactive to fungi in the air, you must have a daily routine to keep your sinuses clear.

Your healthcare team can help you develop a plan.

• Nasal rinses: Use daily nasal rinses of saline (salt water) to flush out the “trap.” These rinses clean out fungi and thick mucus to keep them from building up and causing an infection.
• Steroids: Your doctor might prescribe a steroid medicine (topical or pill form) for your nasal passage to keep the swelling down.
• Biologics: Biologics are medicines that can keep your immune system from overreacting to the mold/fungus. They don’t only clear out the sinuses; they can also change how your immune system reacts to fungi. There is currently one biologic approved globally for AFRS (dupilumab).
• Manage your allergies: Since AFRS is an allergic hypersensitivity reaction, managing your other allergies is very important. Your doctor may recommend medication or an allergy shot.
• Surgery: You might need sinus surgery if treatments aren’t working or if you have blockage from nasal polyps.

Why AFRS Often Returns

AFRS often comes back because it’s a chronic condition, and not a short-term sinus infection. Even after your symptoms are controlled with surgery or medications, the body still has a reaction to fungal spores that are always in the air. When you breathe these spores, they get into your sinus lining. If your sinuses don’t drain them, the fungus gets trapped, and the infection can come back.

Barriers to Optimal Outcomes

Getting the best results with AFRS can be hard because it’s a chronic condition that usually needs ongoing care. Some common barriers can make it harder. One common barrier is that it can keep coming back. Even with treatment, it can recur over time, making it frustrating and hard to manage.

AFRS can be difficult to diagnose. Since AFRS can look like other sinus infections, doctors might not recognize it right away, which leads to a delay in getting the right treatment and worsening symptoms.

Inconsistent access to guidelines-based care is also a barrier to getting the best treatment plan. AFRS requires a specialized team with multiple doctors (primary care, ENT, and allergy doctors). Some doctors are unfamiliar with AFRS, which can lead to a delayed diagnosis and treatment plan. Even with a diagnosis, there are no guidelines specific to AFRS, which means treatment is less consistent, and the right treatment gets delayed.

Some patients may not have access to specialist doctors or might have financial barriers due to health insurance or the cost of treatments.

Missing follow-up appointments is another common barrier. People with AFRS require regular checkups to make sure it stays under control. Doctors can help notice a “buildup” before you start to feel symptoms, so it’s very important not to miss appointments.

Environmental triggers, like mold or other fungi, can keep causing inflammation. If they’re not well managed, they can make it harder for treatments to work, and symptoms can keep coming back.

Treatment can be complicated. Treatment plans sometimes require surgery and daily long-term medications, like steroids. Since there isn’t a cure, managing AFRS long-term is critical, and patients need to stick to the treatment plan. Without following the plan closely, symptoms can come back or get worse.

Steroid overuse can also cause problems. Although steroids work to reduce inflammation, using them too often can lead to side effects, like a higher risk of infection, high blood pressure, weight gain, and weakened bones.

Tips for Success and Living Well With AFRS

Living with AFRS takes ongoing care, but many people can manage symptoms well with the right habits and follow up.

• Keep up with follow-up appointments. Routine visits with your ENT or allergy doctor can help catch flare-ups early.
• Use daily treatments as directed. Nasal sprays, rinses, and other medications work best when used as your doctor prescribed.
• Use saline rinses often to help clear mucus and irritants from your nasal passages.
• Manage allergies. Work with your allergy doctor to manage allergies, which can lower inflammation and reduce sinus problems. You may consider discussing immunotherapy (e.g., allergy shots) against molds, to boost tolerance of allergens so the body does not overreact.
• Avoid triggers when possible. Avoid triggers, like dust, mold, and smoked marijuana as much as you can.
• Keep track of symptoms, and watch for early signs. Tell your doctor if you notice the return of congestion, thick mucus, or sinus pressure, so you can get early treatment.
• Take steroids only as prescribed. Steroids can reduce inflammation, but taking them too often can cause other health problems. Never take them more often than prescribed by your doctor.
• Keep a healthy home by keeping your house dry, and use air filters (HEPA filters) to reduce fungi in the air you breathe.
• Use healthy lifestyle habits with medical care. Although they’re not a treatment for AFRS, a balanced diet and exercise with your treatment plan can help boost your immune system and improve overall health and quality of life.

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This educational content has been made possible with the support of Sanofi and Regeneron.