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What are allergies?

When people say they have “allergies,” they are often referring to the symptoms of runny nose, sneezing and watery eyes that can occur during the warmer months as a result of an allergic reaction to pollens in the air. But allergies are really a more general term referring to a problem with the immune system. The body’s immune system is a mechanism the body has to defend itself against foreign, potentially harmful, invaders such as bacteria and viruses that can cause disease. The body often produces antibodies (proteins called immunoglobulin E or IgE) to those invaders to help protect itself from harm the next time that invader presents itself to that person. If one is allergic (usually determined by the genes you inherited from your parents), it means that you are one of the 20-25% of the population that responds to actually harmless substances such as animals, pollens, dust mites, foods, molds by producing these antibodies to “defend” itself against something that would not cause any symptoms. Thus, being allergic is not a defect in the immune system, it is really the immune system working overboard unnecessarily.

Individuals can be allergic to many things they come in contact with – whether inhaled (pollens, animal dander, dust mites, molds), ingested (foods, medications, chemicals such as food dyes and preservatives), contacted with (latex, chemicals, fabrics, metals), or injected with (insect stings or bites, medications, contrast dyes for medical tests ). When these substances enter the body again, the body (viewing them as potentially harmful) mobilizes its defenses and “sends out” an army of fighters – different chemicals and cells to fight it off, but it is these chemicals (such as histamine) and cells that cause the symptoms of allergies, resulting in itchiness, mucous congestion and areas of swelling. You then take antihistamines and other medications to counteract this, depending on where and what the problem is (congestion in your nose and eyes being allergic rhinitis or conjunctivitis, congestion in your chest being asthma, or a reaction on your skin being hives or eczema).

These allergic problems can start at any time in your life, although it is most common to see eczema and food allergies start in infancy, asthma in toddler years and nasal allergies in early school years. Hives and medication allergies can occur at any age.

Ways to Control Allergies

The most effective way to control allergies is by prevention – avoidance of the substance you are allergic to. This is sometimes easy, often difficult. If it has been determined you are allergic to a food or medicine, avoidance takes care of the problem. If it’s a food like strawberries, it can be relatively easy to avoid. If the food is wheat, it is obviously more difficult. Substances like pollens, molds and dust mites are difficult to avoid but your physician can discuss ways of dealing with this (keeping windows closed in the summer, showering when coming home after exposure on a high pollen day, avoiding musty areas, using pillow and mattress zippered cases to decrease dust mite contact). Animal avoidance is usually not an option in patients who own an animal, but routine bathing of the animal and limiting the animal to certain areas of the house (away from the bedroom) can be helpful. These and other possibilities should be discussed with your doctor, depending what you are allergic to.

The most common way of dealing with allergic symptoms is with the use of medications. Whether one has pollen-related “hay fever” or animal-triggered allergic rhinitis, there are a large variety of antihistamines, decongestants, cortisone sprays and eye medications that can be helpful. Asthma medications have steadily been improving over the past ten years and good control is usually possible, although some patients need to be on medications on a routine daily basis. Steady control of skin problems can be more of a challenge, but there are many good possibilities. Discussions with your doctor will help determine what the best course is for your treatment plan.

For some types of allergic problems, when the above techniques are not successful enough, or when symptoms are more annoying, a course of allergen immunotherapy injections (“allergy shots”) can be very helpful to get symptoms under control, decreasing the amounts of medications needed. This is often an effective and helpful longer-term solution to allergic problems, decreasing symptoms and dependence on medications. This too can be discussed with your physician, concerning the appropriateness in your case and the probabilities of success.

Once your doctor takes your history, examines you, suggests appropriate tests for your situation and discusses those results with you after the tests are completed, your physician can then formulate the best treatment plan for you. All of the above can usually result in your allergies being controlled and a more symptom-free life attained.

Allergy Testing

Early testing for allergies started in the beginning of the 20th century by placing something an individual might be allergic to into their eye and observing swelling and itchiness along with fluid production that would occur. This obviously resulted in rather disagreeable symptoms so that by the 1920’s skin testing became more popular and is what is primarily still used today. Solutions of various allergens (substances that can cause allergic reactions) can be dropped on the skin (usually on the back) and then the skin is lightly scratched or “pricked” and an allergic reaction consisting of itchiness, swelling and redness is observed over a twenty minute period. If this does not result in any reaction, an intradermal test can then be done (typically on the arm) in which a very small amount of the antigen is injected into the top surface of the skin and an allergic reaction is looked for. These skin tests are typically done to pollens, animals, molds, dust mites, stinging insects and foods, but can also be done for latex, local anesthetics, vaccines and a small number of medications, particularly antibiotics.

Skin testing can be done in our office to determine what is causing the patient’s symptoms. With the patient having avoided taking (for a few days) any antihistamines or anti-inflammatory drugs (such as aspirin and ibuprofen) which can negate the skin test results, the skin tests are done and the reactions recorded. This information can be extremely helpful in determining what a patient is allergic to and thereby deciding upon a treatment plan to help decrease that patient’s allergic contacts and symptoms in the future. If it is determined that a course of allergy injections is appropriate and necessary, the skin test results tell us what should be placed in those injections. At times when skin testing is not possible (such as when a patient is taking several medications that could interfere with the skin testing but cannot be stopped, or when the patient has severe extensive eczema so that there is no clear area of skin to place the tests on), alternative blood tests (RAST tests) can be done that can give similar information concerning that patient’s allergies.

Some skin allergic problems result in a delayed reaction to contact with a variety of substances. In these cases, “patch” testing can be done in which some of the possibly offending material is placed on the skin, a bandage patch is placed over it and the skin is then reviewed 48-72 hours later, looking for an area of redness and inflammation.

Challenge testing is also possible for a limited number of food additives and preservatives and medications. In these cases, tiny amounts of the substance are ingested under careful supervision. The amounts are then slowly increased over a few hours and reactions are recorded if occurring.

About Allergy Drugs

Allergy medications can be divided into those that provide symptomatic relief and those that prevent symptoms.

Symptomatic medications include antihistamines, decongestants, ß-adrenergic agents, theophyline, and anticholinergics.

Antihistamines block the interaction between histamine and histamine-specific receptors. Histamine is only one of the mediators that cause allergy symptoms. Therefore they only partially control symptoms. In general they will help to control itching, sneezing, runny nose and hives. Antihistamines can be divided into 1st generation which generally have a quick onset of action but have more side effects most notably sedation. These include Benadryl (diphenhydramine), Atarax (hydoroxyzine), and Chlortrimetron (chlorpheniramine). 2nd generation antihistamines have minimized sedation but have longer onset of action. These include Claritin (loratidine), Zyrtec (cetirizine), Allegra (fexofenadine), Xyzal (levocetirizine), and Clarinex (dexloratidine).

Other side effects inclue cardiac arrhythmias if taken in excess. Some of the newer antihistamines including cetirizine and fexofenadine have minimized this side effect.

Topical antihistamines are also now available in nasal spray form. Astepro© and Patanase© provide another option for allergy patients and can be used on an as needed basis.

Decongestants blood vessels in the nasal passageways that help to alleviate stuffiness. They are often found in combination with antihistamines with the letter D following the antihistamine. Claritin-D, Zyrtec-D, Allegra-D are examples of these combination medications. Unfortunately, oral decongestants produce side effects that limit their use. These include insomnia, tremor, nervousness, and difficulty urinating in males. Several over the counter nasal sprays such as Afrin and Neo-Synephrine contain decongestants which provide quick relief of stuffiness but beware as these can cause a debilitating rebound congestion and are contraindicated for treatment of chronic allergy symptoms.

Beta adrenergic agents are used for rapid relief of asthma symptoms. They are most often used in an inhaled form. The most common of these medications is albuterol HFA found in several brands. Albuterol can also be used in a nebulizer for treatment of acute asthma symptoms. Oral forms of albuterol are available but used infrequently due to side effects. Albuterol can cause increased heart rate, tremors, and increased anxiety. Other brands of shot acting broncholdilators incude Maxair and Xopenex. These can be tried in patients who do not tolerate albuterol. Long acting Beta adrenergic agents are available but should always be used in combination with preventative anti-inflammatory medication.

Theophyline has been used for asthma symptoms for over 50 years. It is still used occasionally as an adjunct medications to control asthma. It is important to monitor blood levels of this medication to prevent side effects. There are several drug interactions that also need to be closely monitored while on this medication.

Anticholinergics such as atropine or its derivative ipratropium (Atrovent) have a bronchodilator effect and is also a nasal decongestant. Ipratropium is available in an inhaler, nebulized solution, and a nasal spray. These medications decrease mucous production and are a mild decongestant.

Preventative medications include corticosteroids, mast cell stabilizers, leukotriene modifiers, and immunomodulators.

Corticosteroids are the most potent anti-inflammatory medications available for treatment of allergies and asthma. Unfortunately taking long term oral corticosteroids (Prednisone/Medrol) result in severe side effects. The use of oral corticosteroids should be limited for severe asthma and allergy problems and used on a short term basis. The development of inhaled corticosteroids revolutionized the treatment of asthma and asthma. If used judiciously they are extremely safe and minimize symptoms of asthma and allergic rhinitis. These medications eliminate the underlying pathology of asthma and allergic rhinitis that is inflammation. Side effects of inhaled corticosteroids include hoarseness and oral thrush. Rinsing your mouth lessens these effects. Side effects of intranasal corticosteroids include nasal bleeding and rarely perforation of nasal septum. This can be minimized by proper use technique.

Leukotriene Modifiers block the synthesis of mediators called leukotrienes that contribute to airway inflammation in the nasal passageways and bronchial tubes. These medications including Singulair, Accolate and Zyflo have few side effects although monitoring of liver functions is recommended with Zyflo. Singulair is also approved as a pretreat for exercise induced asthma and allergic rhinitis.

Xolair (omalizamab) is an immunomodulator that prevents the binding of IgE (allergy) antibodies to its receptor on mast cells. This in effect prevents the allergic cascade leading to severe inflammation in airways. Xolair is only approved for severe asthma that is not controlled with traditional medications. It is given in an injection on an every 2 or 4 week interval. Other immunomodulators are being investigated which will probably change treatment options over the next several years.

Allergic Rhinitis

Recurrent or chronic nasal congestion, runny nose, itching of the nose, and sneezing may sound like a minor medical problem; but do you know that this condition is one of the leading causes of decreased work and school productivity, sleep disturbance, and recurrent ear and sinus infections.

Allergic conjunctivitis

  • Not only are the symptoms of eye allergies annoying with itching and watering of the eyes; but the redness and swelling is noticeable and alarming to others who may be concerned you have “pink eye”. Children are often sent home with these symptoms as the school is concerned about having epidemics of “pink eye”.
  • Several conditions mimic eye allergies and it is crucial to quickly differentiate between them.

Food Allergies

One of the common presenting complaints of our patients is concern over food allergies. Allergic and adverse reactions are indeed a mixed bag. Classic food allergies to nuts or shellfish are easy to identify since they usually cause immediate itching, hives, throat closing, etc. However, adverse reactions to foods are more difficult to pinpoint. We will conduct testing that has been proven to be scientifically accurate. If needed allergy elimination diets will also be used for diagnosis.

Drug and Latex Allergies

  • Numerous different reactions can occur with medications. These can include immediate reactions with hives or anaphylaxis or delayed reactions that usually cause rash. Some of these reactions only occur in light exposed areas of the skin.
  • Medications can also cause adverse reactions due to autoimmune response.
  • Latex allergies have surged over the last 20 years. They are common in health care workers, patients with urological (bladder) disorders, and those in the latex industry.
  • Patients with certain food allergies such as bananas, and avocados are more likely to develop latex allergy.

Stinging Insect Allergies

  • Symptoms of a non-allergic insect sting include redness, swelling and/or itching at the site of the sting.
  • Symptoms of a Severe Allegic Reaction occur in a small number of people with venom allergy and stings may be cause a life-threatening or anaphylactic reaction. Symptoms may include two or more of the following: itching and hives, swelling in the throat or tongue, difficulty breathing, dizziness, stomach cramps, nausea or diarrhea. In severe cases, a rapid fall in blood pressure may result in shock and loss of consciousness. Anaphylaxis is a medical emergency and may be fatal. If you have these symptoms after an insect sting, get emergency medical.
  • An allergist is the best physician to diagnose stinging insect allergy and provide a treatment plan designed to keep you safe and healthy.
  • To avoid stinging insects, it is important to identify them.
    • Yellow Jackets – nests are made of a paper-maché like material and are usually located underground, but can sometimes be found in the walls of frame buildings, cracks in masonry or woodpiles.
    • Honeybees and bumble bees are non-aggressive and will only sting when provoked. However, Africanized honeybees (AKA “killer bees”) found in the Southwestern United States are more aggressive and may sting in swarms. Domesticated honeybees live in man-made hives, while wild honeybees live in colonies or “honeycombs” in hollow trees or cavities of buildings.
    • Paper wasps – nests are usually made of a paper-like material that forms a circular comb of cells which opens downward. The nests are often located under eaves, behind shutters, or in shrubs or woodpiles.
    • Hornets – usually larger than yellow jackets. Their nests are gray or brown, football-shaped and made of a paper material similar to that of yellow jackets’ nests. Hornets’ nests are usually found high above ground on branches of trees, in shrubbery, on gables or in tree hollows.