The Online Allergist

Information About Pet Allergies

According to published studies, between 10-15% of the general population are allergic to cats and dogs. This high incidence of animal allergy, coupled with the fact that approximately 50-70% of homes have a dog or cat living indoors, makes pet allergy a major health consideration. It has been estimated that of the two million people allergic to cats, at least 1/3 of them live with at least one cat in the home. And, to make matters worse for the allergic individual, many homes where there are no indoor pets will still contain enough allergenic pet proteins to cause allergic reactions.

What Is It About My Pet That I Am Allergic To It?

Allergy to cats is twice as common as allergy to dogs. Regardless of the animal or species, it is likely that the cause of the allergic reaction is not the hair or fur at all. One highly allergenic source is the dander or old skin scales of the animal. These particles are deposited wherever the pet goes - on the bed, the couch, and in the carpet. Dander allergens are extremely small and easily become airborne, eventually depositing themselves and clinging to furniture, draperies, wall coverings, and even the walls themselves. Because of its stickiness, the allergenic dander can remain in the house for six to twelve months or longer after the animal has been removed from the house.

In cats and dogs, saliva and urine are also potential sources of allergens. They are deposited on the fur through licking and urination. When the hair or fur dries, the microscopic particles flake off, become airborne, and become readily accessible to the airway of the allergic individual.

The major cat allergen is called Fel d 1, and is formed in the sebaceous glands of the skin and is present in saliva. Fel d 1 is deposited on the fur from sebaceous gland secretions and through saliva when cats lick themselves clean. The major dog allergen has been identified as Can f1.

What Kind of Symptoms Might a Pet Cause?

Some people who are allergic to animals will begin to have symptoms immediately upon entering a home or room where a pet resides. Symptoms might include the acute onset of itchy, watery eyes, itchy nose and throat, sneezing, runny nose, and nasal congestion. Even asthma symptoms, including coughing, wheezing, tightness of the chest, and difficulty breathing can be induced almost immediately upon exposure. Unfortunately, if one is sensitive enough, it does not take a lot of animal dander to cause an allergic reaction. The allergen is so small and light that it remains airborne for long periods of time, making it readily available to be breathed in and begin causing a problem.

On the other hand, many pet allergic individuals will not react acutely when exposed to an animal. Because of constant exposure, they may react, over time, by having daily, chronic symptoms such as persistent nasal congestion, runny nose, itchy eyes, nose, and palate, as well as coughing, wheezing, or shortness of breath.

Are Certain Dogs and Cats “Non-allergenic”?

Unfortunately, there are no known breeds of either cats or dogs that do not produce allergenic dander. It must be remembered that allergies can also be produced by exposure to proteins in pet hair, saliva, and urine. Therefore, every cat or dog has the potential for causing allergies. Patients often comment that “I am allergic to my neighbor’s cat or dog, but I am not allergic to my own”. This may be explained by some species differences, or possibly due to some desensitization which may have taken place with one’s own pet. Bottom line: If you are allergic to dogs or cats, it is not advisable to own one, even if it is from a species that reportedly produces less allergen.

Can I Be Having Symptoms From Pet Allergies Even If I Do Not Have a Pet?

Even if you have never had an indoor pet, it is likely that you have detectable pet allergen in your home, and maybe even enough to be causing chronic respiratory symptoms. Since dander is very small, light, and sticky, it can attach itself to your or your child’s clothes and be deposited in your house unknowingly. And if one has outdoor animals, their allergens will inevitably be carried into the home by those who have direct contact with the animal, especially children.

An important fact to remember is that many school classrooms have dog and cat allergens in high enough concentration to cause allergic reactions.  It has also been reported that in some school classrooms, there is as much cat and dog allergen as in homes where cats and dogs reside!

What Does Your Allergist Recommend?

The cornerstone of allergy treatment is to avoid or minimize exposure to known allergens to the maximum degree possible. Therefore, when an allergy specialist confirms the diagnosis of pet induced allergy, the doctor has the difficult task of making it clear that the patient will likely continue to have allergic reactions as long as the pet remains in the home.

Recommending that the pet be removed from the home can be a difficult task, as families become emotionally attached to their pets, and the pet is commonly described as “a member of the family”. Most doctors know that family pets often win out and remain in the home, so the doctor can only suggest the best ways to live with the pet.If the pet does remain in the house, it is not unreasonable for the allergist to insist that the animal never come in the bedroom of the allergic sufferer. This “compromise” can be helpful, although generally not curative. The allergic individual should endeavor to create a totally allergy free zone in his or her bedroom, the room where one spends a great percentage of their life.

What Else Can Be Done About Ridding Your Home of Animal Dander?

The bedroom of a pet allergic individual should be cleaned frequently. All hard surfaces in the bedroom should be wiped with a moist cloth to remove the small and sticky animal dander which has likely adhered floors, carpets, walls, furniture, ceiling fans, lamp shades, and even ceilings. In addition, every part of your home, especially the bedroom, should be vacuumed with a HEPA vacuum cleaner. If you have hard surface floors, they should be mopped weekly. In addition, it may be helpful to run a HEPA air cleaner in the bedroom. Pets should be washed or treated with a dander removal product every two weeks. This removes much of the allergenic dander from the fur before it becomes airborne.

Food Allergies

Food allergies can be one of the most frustrating and complex allergy issues facing physicians, patients, and families. Considering the unlimited number of foods (and food additives) that are consumed; the variable time between ingestion and the allergic reaction; and the varied and often subtle symptoms which result; it seems miraculous when the food that is causing the symptoms is actually identified.

Although an individual may be allergic to any food, there are eight foods that account for 90% of all food allergic reactions. These are: milk, eggs, peanut, tree nuts, fish, shellfish, soy, and wheat.

The Prevalence of Food Allergies

Approximately 4% of Americans are estimated to have food allergies. The prevalence of food allergies is highest (6-8%) in infants and young children under three years old. Fortunately, the incidence of documented food allergies decreases with age, probably due to the development of tolerance in children allergic to milk, wheat, soy, and eggs. Of the 2.5% of children allergic to milk, approximately 80% will “outgrow” their allergy by five years of age. Of all of the foods, peanuts are least likely to be outgrown. Recent studies have shown that only about 20% of children will lose their hypersensitivity to peanuts.

The Different Types of Food Allergies

For purposes of simplicity, food allergies can be divided into two types: the immediate hypersensitivity reaction and the delayed hypersensitivity reaction.

Immediate Hypersensitivity Food Reactions

The immediate allergic reaction is the best understood, most easily diagnosed, but the most serious of all allergic reactions.  This reaction represents the “classic” allergic reaction.  At the cellular level, an allergen (the food protein) comes in contact with an IgE antibody specific to that food, resulting in the release of histamine and a multitude of other chemical mediators. Once released into the tissues and circulation, these mediators cause an immediate allergic reaction. 

This reaction, which generally occurs within minutes after ingestion of the allergenic food, can be relatively mild or severe. Symptoms of a relatively mild to moderate reaction might include a rash (urticaria, commonly referred to as hives), itching, generalized redness of the skin, heat, facial or eyelid swelling, nausea, abdominal cramping, vomiting and/or diarrhea. Such reactions are generally treated with a quick acting antihistamine and generally run their course over a few minutes to hours.

The most severe allergic reactions, or anaphylaxis, generally have a rather quick onset after the food is eaten. Symptoms might include those mentioned above, but, can rapidly progress to difficulty breathing (chest tightness due to bronchial constriction and swelling of the airways), a drop in blood pressure leading to shock, and even death. Anaphylaxis, or impending anaphylaxis, must be treated immediately. Epinephrine (adrenaline), which is available for self administration, must be given immediately, and repeated, if necessary. This represents a true medical emergency and should never be taken lightly.

Any person who has possibly experienced an immediate allergic reaction to a food should consult a board certified allergist. The allergist will likely test the patient, either through the skin or blood, in order to identify or confirm the allergenic food. Once it has been determined which food(s) caused the immediate allergic reaction, the allergist will consult with the patient and family about the elimination of the food(s) from the diet and the management of any further reactions.

Delayed Hypersensitivity Food Reactions

A delayed food allergy reaction, while less dangerous in terms of one’s immediate health, can be much more difficult to diagnose and treat. As the name implies, there is often a delay of usually hours to days between the time of ingestion and the onset of symptoms, making the history less valuable in establishing a cause and effect relationship.

Part of the difficulty in diagnosing these reactions is that there is not yet available a reliable allergy test which can accurately diagnose or predict a delayed reaction. Allergy skin testing and RAST or ImmunoCap blood tests are not helpful, as they measure only the IgE antibody, the antibody responsible for immediate reactions. Research has not yet identified the antibody or antibodies responsible for delayed reactions, although there has been considerable interest and research in the possible role of the IgG antibody in the delayed allergic reaction. There is now a blood test available to measure this antibody, but its reliability as a predictor of delayed allergy has not yet been established. 

The optimal method of determining whether one is suffering from a delayed hypersensitivity reaction, and to which food(s), is the elimination diet. Elimination or reduction of symptoms after the avoidance of the offending food(s) from the diet may take weeks to see, therefore, one must be very patient. The most common foods likely to cause delayed reactions are milk and dairy products, and wheat and other grains. 

The symptoms resulting from a delayed reaction can involve several organ systems and may be quite subtle in their presentation. In addition to more classic allergy symptoms such as nasal congestion, runny nose, rash (eczema or hives), etc, delayed reactions may present with symptoms such as frequent headaches, recurrent or chronic abdominal pain, lethargy, irritability, dark circles under the eyes, limb pain, and recurrent ear or sinus infections, to name a few.

Can Babies and Infants be Allergic to Foods?

Food allergies in babies and infants can be especially challenging. Symptoms of a food allergy may include colic (irritability), excessive spitting (even projectile vomiting), rashes including eczema or hives, nasal symptoms including
congestion and/or runny nose, coughing or wheezing, diarrhea (sometimes bloody), constipation, and even poor weight gain.

If a baby under a year of age is truly allergic, it is almost always caused by a food. And, the food most likely to be responsible is cow’s milk. It is important to know that 20-30% of milk allergic babies are also allergic to soy. 

It is also possible for babies who are exclusively breast fed to be allergic to a food protein being passed through the nursing mother’s milk. In such a case, it is likely that the baby is reacting to a food eaten by the nursing mother, such as milk and/or dairy products.

Can One be Allergic to More Than One Food in a Food Family?

It is also important to be aware that many foods can cross react with other foods within the same food group or family. Familiarity of food groups is a must for the food allergic individual.

The Treatment of Food Allergies

The treatment of food allergies can be summarized in one word - avoidance. As simple as this may sound, avoidance of many foods is very difficult. Shopping can be quite challenging, especially at first, as it will require close scrutiny of the multiple ingredients included, especially in packaged and commercial foods. Eating out of one’s home, such as in restaurants, at school, or others’ homes requires extreme diligence and curiosity about the foods served. In those people allergic to multiple foods, a consultation with a dietician is sometimes very helpful in designing safe diets. Your allergist will be very helpful in recommending the multiple resources available to help with these challenging issues.

Food Families

Allergy to one member of a food family can mean allergy to other members of the same botanical family because of shared or cross-reactive allergens.  While many people contend that they are allergic to all seafood, fruits, starches, greasy foods, or spices, in reality they are allergic to a particular food family.  For example, the following food items are not in the same food families, so an individual could be allergic to one food, but not the other.

Examples of foods that are not in the same food family:

• Tuna and shrimp
• Wheat and buckwheat
• Crab and clam
• Peanut and other nuts
• Coffee and tea
• White potato and sweet potato
• Black and red pepper
• Raisin (grape) and prune (plum)

Examples of foods that are in the same food family:

• Apple and pear
• Pea, bean, and peanut
• Beet and spinach
• Onion, garlic, and asparagus
• Walnut and pecan
• Peach and plum
• Wheat, corn, and other grains
• Chocolate and cola drinks
• Cucumber and melons
• Carrot and celery

For a downloadable PDF of over 200 foods and their food family classification, click here (opens as a PDF).

For a downloadable PDF of food families and the foods that they contain, click here (opens as a PDF).

Food Additives and Spice Allergy

There are literally hundreds of food additives including colors, flavors, and preservatives, that are added to the foods we eat everyday in order to enhance the flavor, change the color or texture, or to increase the shelf-life of the food product.  Most individuals will come into contact with many of these additives every day as a part of a normal, balanced diet. 

Like anything we ingest, there is always the potential for an adverse reaction, including both immunologic (allergic), and non-immunologically (non-allergic) reactions. The range of symptoms attributed to food dyes and additives is diverse, but may include classical allergy symptoms such as anaphylaxis, asthma, hives, rash, and nasal symptoms, as well as non-allergic symptoms such as headache, behavioral changes, digestive difficulties, and fatigue.

In general, dyes and additives very rarely cause a true allergic reaction. There is much circumstantial description of symptoms attributed to various additives or colorants, but controlled trials that have examined this issue have been inconclusive in establishing a cause and effect relationship. There is, however, evidence supporting the fact that some additives can provoke an antibody mediated reaction that would be considered an “allergy”.

The following is a summary of agents that have shown the most convincing evidence of true allergic reactions, and agents which cause symptoms that are not the result of an allergy, and are best characterized as an adverse reaction.

Natural Colorants

Two agents in particular have demonstrated proof that a true allergic reaction can result from their use.  One of these is Carmine, a crimson/wine red/pink natural color derived from the pulverized, dried bodies of female Coccus cacti insects. 

The red dye contains residual insect body protein, and this has been shown to cause a true allergy as mediated by a specific antibody.  Carmine has been linked to asthma induced from inhalation of the dry powder.  Interestingly, this has been reported to occur primarily in men. 

Anaphylaxis, on the other hand, has been shown almost exclusively in females who presumably become sensitized to this agent through its use in makeup and cosmetics. As a result of this sensitization,  ingestion of carmine containing items can subsequently result in serious allergic reactions.

The other agent which can induce an allergic reaction is Annatto.  Annatto is a yellow colored powder derived from the seed of the Bixia orrellana bush.  Most people have been exposed to annatto, as it is used to color dairy products, as well as confections, soda, and processed goods.  This is the agent responsible for the distinctive color in cheese, and butter, and macaroni. Outside of the U.S. it is used in meats as well.

Annatto allergy has been demonstrated on standard allergy scratch tests, as well as specialized research laboratory tests, in sensitive individuals.

Other natural colorants that have shown more limited evidence of true allergic reactions include saffron (asthma, anaphylaxis), anthocyanins in grapes (anaphylaxis to grape containing products including certain wines), and paprika.

Certified Colors

There have been several clinical trials that have looked at whether colorants can cause symptoms including allergy and behavioral changes.  None of these trials have shown any evidence that such an association exists, though anecdotally, there are many parents and individuals who are convinced that one does indeed exist.

Yellow dyes were implicated in some of the earliest reports of possible colorant induced allergy.  Tartrazine (FD&C Yellow #5) has been linked to reports of chronic hives, asthma, and cross-reactivity in aspirin allergic patients.  Chronic hives was studied in oder to determine if chronic hives could be “unmasked” by allergy to tartrazine.  Again, no evidence exists that supports such associations.  In fact, in cases where the dye appeared to cause allergy symptoms, further analysis determined that the symptoms may have resulted from confounding or coincidental causes, such as withholding chronic medication.

Tartrazine has also been shown to have no clinical cross reactivity in inducing hives in aspirin/ibuprofen allergic patients, and consequently, there is no contraindication to this dye in an aspirin sensitive patient. Its role in inducing asthma also has not been supported by medical evidence. One randomized, placebo controlled trial did suggest that very high doses (>10 times that encountered in use in a medication dose) of tartrazine may induce hyperactivity in children, though this effect was not seen at low doses commonly used commercially in foods or medicines. Contact reactions to tartrazine, as well as other certified dyes, are a recognized entity.

Other certified colors questionably linked to allergy include FD&C#40 (Red 40) and FD&C yellow #27.

Spices

Since spices are derived from plants, there are some case reports of symptoms resulting from spice allergy.  Many of these spices share the very same proteins to those found in certain pollens, and have theoretical ability to induce a phenomenon called the “oral allergy syndrome”, which rarely results in a serious allergic reaction.  Occupational inhalation of several spices has been associated with reports of asthma attacks.

Sesame and other similar seeds such as poppy, commonly used as spices, share common allergenic proteins and are increasing in the U.S. as a cause of serious allergic reactions.  Sesame and other seed allergies are very clearly antibody mediated, with reliable cutaneous as well as blood tests available to aid in the diagnosis.

Because spices often have aromatic properties, contact with the skin can induce irritation through direct tissue damage.  Spices can also cause contact dermatitis similar to a Nickel allergy or poison ivy type reaction.  In general, spice induced reactions are uncommon, and anaphylaxis or major allergy symptoms from spices are rare.  Testing to these agents is best done with fresh specimens, but this is a non-standardized process, and the test may irritate the skin making interpretation difficult.  Avoidance of spice agents is also a somewhat daunting task, given their common use in the American diet.

Antioxidants

BHT and BHA are two popular synthetic antioxidants used in foods to help preserve texture, especially in animal fats.  In 1958, they were declared generally regarded as safe for use in food.  Animal toxicology studies have shown BHT may induce immunologically mediated lung damage and fibrosis, but alternatively, both BHT and BHA have been shown to be protective for certain types of malignancy, and possibly possess anti-atherosclerotic properties.  These effects have not been demonstrated in humans.  In case reports, both have been implicated in inducing asthma and chronic hives, but other studies have not supported this association.  Otherwise, BHT/BHA is linked to contact reactions.

MSG

Monosodium Glutamate (MSG) is a very controversial additive found commonly in Chinese food, though it is certainly not limited to this type of cuisine.  In 1968, a physician published a letter to the editor of The New England Journal of Medicine detailing an odd constellation of neurological symptoms experienced when eating at a Chinese restaurant, suggesting that MSG could be the causative agent.  Thus, a major controversy which still exists today was sparked.

At high doses in humans, nausea can result and several case reports suggest that MSG exacerbated asthma. Others have suggested that hives may be attributed to MSG.  Though difficult to perform, several challenge studies have shown no evidence of an MSG symptom complex, or even symptom development.  Asthma studies showed a similar lack of evidence to support an association with MSG, as have the few studies done to explore the role of MSG in provoking chronic hives.  MSG causing headache has been studied,  but was not shown to have a significant association, despite widespread belief to the contrary.

In summary, MSG probably does not cause symptoms based on controlled studies, but high doses may infrequently be associated with symptom development, especially headaches.

Sulfites

Sulfites are widely used as a preservative.  Unlike many other additives, sulfites do have a well defined role as provoking asthma, although not as commonly as originally thought.  Asthma has been demonstrated after sulfite administration in several studies, and fatal reactions have been described.  The association is much better established in adults than in children.  It is not known exactly how sulfites trigger asthma, but positive skin tests have occurred, implying that it is an antibody mediated reaction. 

Sulfites affect only about 5% of asthmatics and tends to be more common in those with more severe and persistent asthma.  Most experts recommend a controlled challenge to confirm symptoms after a history of a reaction.  In such individuals, avoidance of sulfite containing items is strongly encouraged.  Interestingly, epinephrine devices (EpiPen® or Twinject®) do contain small amounts of sulfites, but the medication is still effective (and highly recommended) to treat a sulfite induced reaction. 

Sulfite sensitive individuals with asthma do have a certain degree of tolerance to sulfites, abut certain foods are more dangerous than others, especially acidic foods.  Foods with less than 10-50 ppm sulfites are far less likely to induce a reaction, but this has not been readily tested.  Avoidance is highly recommended, as is confirmation of the reactivity with an oral challenge under the watchful eye of an allergist.

Benzoates and Parabens

These items are common preservatives in wide use in food and other products.  Both have been implicated in chronic urticaria, but there has been no evidence to suggest an association with asthma.  Paraben use in local anesthetics has been attributed in systemic reactions, and parabens are known to cause contact dermatitis.

Diagnosis of a Suspected Dye or Additive Allergy

It is very difficult to identify the particular food additive in question as the true culprit in precipitating a reaction, especially since there are many other items that could also be responsible.  of great help to an allergist evaluating such a complaint is a clear, concise history of exposure to the particular item consistently causing symptoms. 

If symptoms are intermittent despite exposure, it is highly unlikely that a relationship exists.  Certain allergic diseases, such as chronic hives, have a sporadic nature, and often patients note more coincidental occurrence of symptoms after exposure to a particular food that leads them to believe there is a causal relationship.  However, it is more common that after a period of prolonged observation, such as with a food diary, that such a pattern will prove not to be evident.

When there is evidence for a possible relationship that the dye or additive is the most likely culprit, skin testing may be indicated.  In general, a negative prick test is approximately 95% predictive that there is no antibody mediated allergy.  However, the limited availability of testing agents may limit the evaluation.  Natural colorants are more readily available. Both carmine and annatto extract are available for testing in applicable cases.

For complaints of additive induced asthma, bronchial challenge is a valid test and there are testing protocols available.  In addition, open or blinded challenges may be the preferred method of confirming or denying reactivity, but these should only be undertaken under direct supervision by a allergist.  This type of challenge should never be undertaken at home or without proper medical supervision, as anaphylaxis could result.

Food Additives and Spice Allergy Conclusions

Even though there are a variety of chemicals added to the foods we eat, the overwhelming majority of these items are tolerated without any adverse reactions.  In summary, with the exception of carmine and annatto, certain spices (sesame and seeds), and sulfites in certain asthmatics, there is very little evidence supporting the notion that food dyes and additives cause adverse reactivity. 

However, there continues to be a segment of the population, including some physicians, who believe that these items are directly responsible for causing symptoms.  Avoidance is the recommended treatment, but because of the ubiquitous nature of these items in the American diet, this task can prove challenging. 

It is recommended that patients who believe that they are allergic or intolerant of a particular additive or dye should consult an allergist for a more formal evaluation of this problem.

Immunotherapy

Immunotherapy, also called desensitization or hypo-sensitization, is a form of treatment wherein extracts of allergens (pollens, dust, molds, etc.) are introduced into the body to induce an immunologic response, resulting in the eventual reduction or elimination of the allergic reaction.

Indications for Immunotherapy

Not all allergic patients need immunotherapy.  The decision as to who would benefit from this treatment depends on the nature of the allergy, i.e., what the allergic patient is allergic to and the severity of the allergic symptoms.  Also, immunotherapy is indicated for patients allergic to substances which they cannot avoid.  The appropriateness of immunotherapy will be determined only after careful consideration of all of these factors.

It should be realized, however, that immunotherapy, although very effective, is never the sole modality in the treatment of the allergic individual.  Immunotherapy is just one component of a comprehensive approach which may also include environmental control, and, when necessary, the use of medicines.  A carefully balanced approach will offer the patient the best chance for a resolution of the allergic problem. 

How Immunotherapy Works

To understand how immunotherapy works, a brief explanation of the allergic response is necessary.  In the simplest terms, an allergy is the immune system’s overreaction to things to which it ordinarily should not react, such as dust mites and pollen. 

Immunotherapy is intended to “reprogram” the immune system so that it no longer over responds when exposed to the offending allergen(s).  This is accomplished by repeatedly exposing one’s immune system to the allergens over a long period of time.  Like with any immunization, such as polio, tetanus, or pertussis, the actual administration of the substance causes the immune system to create antibodies against the substance administered.

Types of Immunotherapy

Traditionally, the “gold standard” of immunotherapy has been in the form of injections of the allergen into the subcutaneous tissue of the upper arm, so called allergy shots. Allergy shots are presently the preferred form of immunotherapy by the vast majority of board certified allergists.

There has been increasing evidence in the medical literature suggesting that sublingual (under the tongue) immunotherapy may be equally as effective and safer than traditional allergy shots. Sublingual immunotherapy (SLIT) has been used in Europe for years and clinical trials are now underway in the U.S. to establish their efficacy and safety.

What to Expect From Immunotherapy

Immunotherapy is effective in reducing or eliminating allergic symptoms in the vast majority of patients appropriately placed on this therapy.  In most patients, desensitization offers slow, steady, and significant improvements within six to 12 months after initiation of treatment.  Some people report relief only after a few weeks to months, although this is unusual.  If a patient fails to receive significant improvement within 18 months, then this treatment should be reassessed. Most patients complete the immunotherapy program in three to five years. Most have long-term improvement after desensitization is discontinued, lasting many years and sometimes lifelong.

Immunotherapy Reactions

Because allergy injections contain substances to which the patient is allergic, there is always a chance, although small, of an allergic reaction.  The reactions to allergy shots can be divided into three categories:

Local reactions:

It is not unusual for one to have a small local reaction at the site of the injection.  This usually consists of minor swelling, redness, and itching.  Reactions less than the size of a quarter are generally not significant, but should be mentioned to the allergy nurse prior to one’s next injection.  Large local reactions may indicate that the allergy serum is too strong and adjustments of the dosage may need to be made at various times during the course of immunotherapy.

Systemic reactions:

A systemic reaction is defined as one which occurs distant from the injection site and may involve multiple organ systems.  They occur on rare occasions in highly sensitive individuals, or when individuals are receiving increased natural exposure to their allergens, such as occurs in pollen sensitive individuals during the spring and fall.  These reactions may include generalized redness, itching, sneezing, runny nose, hives, coughing, wheezing and difficulty breathing.  Even though very serious allergic reactions have been described in the medical literature, including a drop in blood pressure (shock) and even death, these are extremely rare.
Systemic reactions can almost always be averted by prompt recognition and treatment of symptoms.  It is for these rare allergic reactions that all patients are required to wait in a physician’s office 20 to 30 minutes after an allergy injection.

Delayed reactions:

Delayed reactions are usually local, but on rare occasions, can be systemic. They usually begin several hours after an allergy shot, but may be delayed as long as 24 hours.  These symptoms are generally mild, but may include local itching, swelling and pain at the injection site, nasal symptoms, or wheezing.

When to Delay Immunotherapy

For an individual who is experiencing an acute or ongoing allergic reaction, such as hay fever, asthma, or hives, then an additional injection of allergen may increase the risk of a reaction.  If one is unsure as to whether the injection should be given, one should consult the injection nurse and a decision will be made as to whether the dose should be decreased, or whether the injection should be postponed.

An injection should not be given if the patient has had a significant fever within 24 hours.  If asthmatic patients are experiencing any wheezing or respiratory distress, the injection should not be given.  Injections should be postponed at least twenty four hours after receiving a flu shot, tetanus shot, or any type of immunization.  One should avoid vigorous exercise one hour prior to and one hour after an allergy shot.

Can Immunotherapy be Self Administered?

The answer is a simple NO.  Even though the chances of an allergic reaction are very low, it is essential that the injection be given in a physician’s office where an unexpected reaction could be quickly treated.  Injections should be given only by those experienced in treating allergic emergencies.  Patients should never give themselves an allergy injection!

What to do When an Allergy Shot is Missed

For all practical purposes, nothing.  One’s overall response to desensitization is dependent upon the cumulative dose of allergen received over a long period of time, not an individual dose.  Therefore, if an occasional injection is missed, the overall program will not be affected. Everyone will miss an injection once in a while due to illness, vacations, or unforeseen events, and this is to be expected.  On the other hand, one should be very diligent in receiving their injections on schedule as much as possible.

Do I really Need to Wait 20 the 30 minutes After an Allergy Shot?

Yes!  As mentioned previously, allergic reactions to the injections are very rare, but they do happen.  Most of these reactions will become evident within 20 to 30 minutes. Therefore, after receiving your allergy shot, you must wait in the allergist office for 20 to 30 minutes.

Medicines That Interfere With Immunotherapy

Some medicines used to treat high blood pressure, heart rhythm disturbances, and headaches, can make the treatment of an allergic reaction more difficult.  These medicines, called beta blockers, are widely used. Some commonly prescribed beta-blockers include:

• Acebutolol hydrochloride (Sectral).
• Atenolol (Tenormin).
• Betaxolol (Kerlone).
• Bisoprolol (Zebeta).
• Carteolol (Ocupress).
• Carvedilol (Coreg).
• Esmolol (Brevibloc).
• Labetalol (such as Normodyne or Trandate).
• Metoprolol (such as Lopressor or Toprol XL).
• Nadolol (Corgard).
• Penbutolol sulfate (Levatol).
• Pindolol (Visken).
• Propranolol (Inderal).
• Sotalol (Betapace AF).
• Timolol (Blocadren).

If you are taking one of these medicines, report this information to your allergist or the allergy nurse and hopefully an alternative medicine can be found so that the immunotherapy program can be continued.

Immunotherapy During Pregnancy

Pregnancy is not a contraindication to allergy shots.  However, initiation of desensitization is not recommended during pregnancy.  For those who become pregnant after starting immunotherapy, studies indicate that allergy shots are safe to continue, but the dose should be held constant.

Is it Worthwhile to Receive Immunotherapy?

In the majority of cases, the answer is definitely yes.  Allergy symptoms can vary from mild to severe and can cause chronic symptoms of the eyes, ears, nose, throat, lungs, and skin, leading to a compromised quality of life.  In addition, allergies are of one of the leading causes of days missed from school and work, and overall loss of productivity.  If it has been determined that desensitization can play a very important role in your or your child’s comprehensive allergy program, stick with it.  You will likely be very pleased with the results.

Environmental Control

Environmental control is the first and best step toward better allergy control.

If you have dust mite allergies, encasings for the mattress and pillows are an absolute must according to most allergists. This is because mite-proof encasings will create a complete barrier between the dust mite allergic individual and dust mites, which are found by the millions in mattresses, pillows, and comforters. Without encasings, as you move during sleep the allergenic by-products of the mites are stirred up from your bedding and are breathed directly into the nose and lungs. With encasings, this harmful process is stopped. The invisible particles are blocked by the encasing and are no longer breathed in all night.

Contrary to popular belief, so called “hypoallergenic” pillows need to be encased as well, because the phrase “hypoallergenic” only means that the materials used to construct the pillow are less likely to cause an allergic reaction. Dust mites are still found in these pillows.

In the past, people have resisted encasings because they were made of plastic or vinyl and were crinkly and hot. But softer and more durable fabric encasings are now available that eliminate these discomfort problems. Some of the newest mite-proof encasings use tightly woven, soft, comfortable fabric to protect you from this powerful allergen. In fact, these breathable encasings are so cool and comfortable that most people do not even realize they are sleeping on them. 

Washing of Sheets, Blankets, and Mattress Pads

Eliminating dust mites and their allergen from
sheets, blankets, comforters and mattress pads is really quite simple. Just wash these items every 10-14 days in hot (130 degree F) water. Washing in hot water kills the microscopic mite and effectively removes the allergen.

High quality blankets and laundry additives are available which will eliminate mites even in cold water. If washing your comforter is impractical, you can encase your comforter just like you would your mattress. By the way, it is important to know that dust mites are common to almost all households and have little to do with good or bad housekeeping.  Most that are available can take 50 or more washings and still look and feel like new.

Vent Filters

Vent filters are inexpensive filtering kits that cover incoming air conditioning and heat air vents. They are designed to minimize all kinds of airborne allergens from entering a room from other areas of the house via the ductwork. Although not as efficient as a true
HEPA air cleaners, they are a great and inexpensive start.

HEPA Air Cleaners

High Efficiency Particulate Air (HEPA) cleaners are considered to be the gold standard in room air cleaning. One powerful unit can easily reduce offending airborne allergen in a room by 90% and keep the room clean as long as it remains running.

HEPA air cleaners do not lose efficiency and require only occasional filter changes. It is important to know that dust mite allergen is removed only while airborne, i.e., for only 20 minutes or so after disturbance. The continuous air movement from the HEPA filter has a ventilation effect. It moves allergens into the air cleaner, thereby continuously reducing the reservoir of allergens in room air to help you avoid these offending particles. 

HEPA air cleaners come with different power levels. Air cleaning power is very important and is measured in air changes per hour (the number of times per hour the entire volume of air in the room can be filtered). The more often the air is cleaned in the room, the fewer allergens remain.

Cleaning a room’s air ten or more times per hour is ideal. However, most experts agree HEPA air cleaners should have the capacity to clean your bedroom’s air no less than six times per hour. Beware of weak HEPA air cleaners that clean a room’s air less than five times per hour. Despite having a HEPA filter, such units simply do not have the power to pull air from more than a few feet away. The remainder of the air in the room stays unfiltered and loaded with allergens. Recent advancements in technology are producing powerful machines that are actually very quiet while running, even on the highest speed.

Anti-Allergen Sprays & Anti-Allergen Powders

Sold under several labels, there are products available that denature (neutralize) dust mites and other indoor allergens in carpets and upholstered furniture. These sprays do not kill dust mites, so the mites continue to produce the allergen, making more frequent treatments necessary. Some of these sprays use a 3% tannic acid solution while others use newer technologies. There are also several types of powders designed for use on carpeting since it is a favorite place for mites to live. Another way to control allergens in your carpet is frequent vacuuming, but consider using special bags or a HEPA vacuum cleaner for best results.

Pet Allergy Avoidance

Needless to say, the best treatment for pet allergy is not to have an indoor pet. If that is not possible, do not let your pet sleep in the same room with you, and ideally, the pet should never come in the bedroom.

Pets should be washed or treated with a dander removal product every two weeks. This removes much of the allergenic dander from the fur before it becomes airborne. True HEPA air cleaning and vacuuming will further reduce the presence of this allergen.

Controlling Humidity

High humidity (above 45-50%) promotes dust mite and mold spore growth. Running an air conditioner or high-efficiency dehumidifier can help reduce humidity levels. Kits are available that test for the presence of molds. It is also wise to use a humidity gauge to monitor moisture levels in your home.

Mold and Mildew Prevention

Mold spore allergies are common because spores grow readily in showers, bath rooms, basements, etc. The airborne spores can be avoided with good continuous air cleaning, but preventing mold spores from growing is also important. Normal cleaning with soap and water or using chlorine bleach is not a long term way of eliminating mold and mildew. Plus, the use of harsh chemicals can be bad for your health as you breathe them in during cleaning.

There are now strong, non-toxic,biodegradable cleaners that are very easy to use and take very little effort. Such measures are especially important for homes with mold problems in basements and crawl spaces. Furnace systems in those areas can actually pull in these mold spores and distribute them throughout the house via the duct system. Preventatives are inexpensive and simple to use.

Whole House Air Filters & Cleaners

There are furnace filters that are used in place of inexpensive, fiberglass, disposable filters and, they do a much better job of filtering the air in the home. Although not as efficient as true HEPA air cleaners, they do cover a larger area. Since they cannot filter unless the furnace fan runs, it is advisable to run the furnace fan often to get maximum filtration.

There are two main types available: Permanent and Pleated. The permanent types are a good long-term investment, will usually last the life of your furnace and require monthly washing. Pleated furnace filters are by far the best filters. These are not washable and have to be changed every 3 months or so depending on the brand. There are other methods for filtering the air in your entire home, but they are usually very expensive and require installation by a professional technician.

If you decide to use a furnace filter, you may still want to cover the vents in your bedroom, because the air has to travel through the ductwork where it can gather any number of allergens. A word about built-in “electronic” air cleaners: These cleaners are sold under several brand names, require separate power to operate and are installed by heating and air companies. These units lose efficiency rapidly after only 20 to 30 hours of use. Unless the dust collection plate element is washed at least weekly - instead of the “recommended” monthly or quarterly - little or no filtering will take place. Also, these units are very expensive. A much more economical solution might be having several room HEPA air cleaners and space them out in the home to get “whole-house” air cleaning that does not require weekly maintenance.

HEPA Vacuum Cleaners

Most vacuum cleaners cannot retain particles under 10-20 microns in size. The dust collection bag is simply too porous. Because airborne allergen particles range in size from 1 to 15 microns - much smaller than most vacuums can trap - the millions of particles expelled through a vacuum cleaner bag can be dangerous for allergy sufferers.

The real problem is that this harmful, microscopic dust is never picked up and stays in the home to accumulate year after year. True HEPA vacuum cleaners are 99.97% efficient down to 0.30 microns, so they pick up allergens permanently without sending them back out into the room.

The decision to buy an allergy vacuum cleaner should be based on filtering efficiency, not the various “bells and whistles” available. Even a water-based machine can only filter down to about 10 microns which means millions of microscopic particles escape back into the room. Many companies currently make true HEPA vacuum cleaners in both canister and upright styles. Models are also available without bags but allergy sufferers must empty them carefully, without causing an allergenic dust cloud. 

Other Allergy Tips For Your Home and Car

• Stay away from moldy places.
• Cut down overgrown shrubbery.
• Wear a mask when working in the yard.
• Remove mold and mildew from your roof and deck with a biodegradable cleaner.
• Avoid sleeping in basement rooms or apartments.
• Outdoor allergens, such as pollen and mold spores will find their way into living areas, so keep your house and car closed during the “allergy season” and be sure to wash your clothes after being outside.
• Run air conditioners and air cleaners as much as possible. Air cleaners are now available for your car, too.
• If you open the windows of your home, consider using window screen filters. These filters are effective on outdoor pollen and provide a tight fit around the window frame.

Stinging Insect Allergies

The first reports of stinging insect allergy came from the Middle East thousands of years ago.  Even at that time, people understood that a small insect, such as a bee or a wasp, had the potential to cause serious illness or even death. Today, physicians, and in particular allergy specialists, are equipped to diagnose and protect individuals with stinging insect allergies. 

Classification of Reactions to Stinging Insects

The venom of stinging insects such as bees, yellow jackets, wasps, or hornets contains several chemicals which, when introduced through a sting, causes local tissue damage and the release of histamine.  The resulting tissue damage is largely responsible for the pain, swelling, redness, and itching that we experience at the site of a sting. Although most local reactions are mild and cause swelling and inflammation localized around the sting site, the area of swelling and inflammation can be quite large. For example, one may be stung on the finger, yet the swelling may progress to include the entire arm. Both of these reactions, by virtue of the fact that they are contiguous with the sting site, are considered local allergic reactions.

The most severe type of insect sting reaction is called a systemic or anaphylactic reaction.  This reaction occurs in individuals who have had prior stings by similar insects and have become sensitized to the stinging insect venom.  The sensitization stimulates the immune system to develop allergic antibodies (IgE) that circulate and bind the venom protein upon future stings.  The binding of IgE to the venom protein can trigger a severe anaphylactic reaction consisting of hives, throat closing, wheezing, difficulty breathing, a drop in blood pressure (shock), and possibly death.  Such reactions require emergency treatment and a delay in treatment can be catastrophic. 
 

Diagnosis of Stinging Insect Allergy

An allergist will likely identify the insect responsible for stinging insect allergy with specialized allergy testing. This type of testing is generally reserved for individuals who have had a previous systemic reaction.  Allergists perform skin testing to common stinging insects including honey bees, wasps, hornets and yellow jackets. Imported fire ants can also cause an anaphylactic reaction and testing is also available for this insect.

Based on the test results, your allergy specialist will determine the risk for future reactions and whether immunotherapy, or desensitization therapy, is indicated.  Unfortunately, many patients never have their allergic reactions evaluated by an allergist, thus placing them at risk for severe reactions with subsequent stings.

Treatment of Stinging Insect Allergies

Upon being stung, one should check whether the stinger is still in the skin (only the honey bee leaves its stinger). If it is, it should be removed immediately. One should avoid squeezing the venom sac as this may introduce more venom into the skin. Rather, it should be scraped off of the skin with a finger nail, a credit card, or another sharp object. Ice should then be placed on the sting site, and a rapid acting antihistamine, such as diphenhydramine (Benadryl) should be administered.  Minor local reactions should resolve spontaneously, although the swelling and inflammation may persist for several days.

Systemic reactions require immediate and intensive treatment.  If a patient has any signs of a systemic reaction, emergency medical help should be called (911), and, if available, self-injectable epinephrine should be given immediately.  If the reaction is persistent, the dose may need to be repeated.  Antihistamines should also be given immediately.  In addition, steroids may be needed to prevent a late or delayed reaction after the initial systemic reaction. The most important concept to remember about a systemic reaction to an insect sting is to not delay treatment. This is a true and serious allergic emergency and should be treated accordingly. 

Stinging Insect Allergy Follow-up

It is also critical that one follow up with an allergist after a systemic reaction.  Your allergist will prescribe an auto-injector containing epinephrine or adrenaline (EpiPen or EpiPen Jr or Twinject) which should accompany one at all times. These devices allow one to self-inject if they should be stung again and exhibit symptoms suggesting an impending systemic reaction.

Any person who has had a systemic reaction to a stinging or biting insect should be referred to an allergy specialist.  Allergists have been trained to treat insect sting allergies using a desensitization procedure called venom immunotherapy.  Venom immunotherapy works by introducing small amounts of the insect venom that caused the patient’s reaction in order for the immune system to develop a tolerance to future stings.  It is extremely effective for most insect sting allergies such as bees, hornets, wasps or fire ants, and is highly effective in preventing future systemic reactions.  The treatment is considered safe and works relatively quickly.  Any individual who has had a systemic reaction should ask his or her physician for a referral to an allergist in order to determine whether venom immunotherapy is appropriate. 

Stinging Insect Precautions

General precautions for insect allergic individuals include:

• Not walking barefoot outside
• Not wearing bright colored clothing that could attract insects
• Not drinking sugary beverages outside which also may attract stinging insects
• Avoid areas where insects tend to frequent such as flower gardens and picnic areas

Exercise Induced Asthma

What is exercise induced asthma?

Asthma is a common condition that affects millions of people worldwide.  Common symptoms of asthma include coughing, wheezing, chest tightness, and shortness of breath.  Those whose symptoms are precipitated by exercise are often diagnosed with exercise induced asthma (EIA) or sports induced asthma.  Exercise induced asthma is caused by the lungs’ response to cold, dry air.  Physicians believe it is the quick change in temperature or moisture that irritates the muscles in the lining of the lungs, resulting in coughing and the sensation of chest tightening.  At times, EIA may present only with the symptom of coughing. EIA, especially if untreated, can limit one’s ability to participate in sports or vigorous exercise.

How is exercise induced asthma diagnosed?

In most cases, EIA can be diagnosed by history and most specifically by the timing of the symptoms.  Symptoms of cough or wheezing typically occur after the first 5-10 minutes of activity and usually improve when the individual stops exercising.  Sometimes the symptoms are only present when the exercising individual is exposed to very cold or dry air.  Pulmonary function tests are commonly normal at baseline, and it is sometimes necessary for a physician to perform pulmonary function tests before and after exercise to help make the diagnosis.  A trial of medication may be prescribed to ascertain whether it improves or eliminates the symptoms of EIA.

How is EIA treated?

Patients with EIA should always perform a slow warm up and cool down prior to exercise to help prevent bronchospasm.  Physicians may prescribe a short acting beta agonist medication such as albuterol which should be used 15-30 minutes before exercise.  This medication alone is quite effective in most individuals.  Other medications such as Cromolyn (Intal), Nedocromil (Tilade) and occasionally Singulair (Montelukast) have been shown to be helpful in preventing symptoms.  It should be noted that in patients with more persistent asthma, an important approach may be to treat the underlying inflammation caused by allergies.

With proper treatment, most patients with EIA should be able to participate in sports and healthy amounts of exercise.  Swimming is often recommended for asthmatics since they are exposed to warm moist air.  Other sports that asthmatics might tolerate include those that require short bursts of exercise such as baseball, football, and short track events.  Leisurely biking or walking are also recommended.

Many asthmatics have participated in sports at the highest levels of competition, including professional football players Jerome Bettis and Emmett Smith.  Professional basketball Dominque Wilkens and Juwan Howard have excelled in spite of their asthma.  Asthmatic athletes from the United States who have won Olympic medals include Nancy Hogshead (swimming), Greg Louganis (diving) and Jackie Joyner-Kersee (track and field).

Speak with an allergy or asthma specialist today if you or your child have symptoms of exercise induced asthma. Chances are excellent that with proper care, patients with exercise induced asthma can reach their physical and exercise potential.

Food Protein Induced Enterocolitis Syndrome (FPIES)

Food Protein Induced Enterocolitis Syndrome, commonly known as FPIES, is a relatively rare, but potentially severe condition in newborns and infants. This condition often presents in the first few weeks or months of life, or at an older age in the exclusively breastfed baby. In exclusively nursing infants, symptoms may first present upon the introduction of commercial formula or solid foods such as cereals, which typically contain cow’s milk, soy, or another offending protein. Symptoms occur only when the newborn or infant has ingested the offending protein, and does not occur from breast milk, regardless of the maternal diet.

Symptoms typically present shortly after the ingestion of the food protein to which the child is sensitive, commonly within two hours of ingestion, but they may be delayed as long as 8 hours. Symptoms are exclusively gastrointestinal, with the most common symptoms being vomiting and diarrhea. Unlike an allergic reaction, this non-allergic reaction is not accompanied by cutaneous symptoms such as itching, hives, or swelling; nor are there respiratory symptoms such as congestion, coughing, wheezing, or difficulty breathing. Symptoms of FPIES can vary between mild and severe. When mild, minor diarrhea or mild to moderate colic symptoms may predominate. When severe, profuse vomiting and diarrhea occurs, and emergency treatment should include the replacement of fluids due to the possible rapid onset of dehydration, and even shock. Corticosteroids are sometimes administered, but the injection of epinephrine is of no benefit during this reaction.

Contrary to popular belief, FPIES is not an allergy; rather it is a gastrointestinal intolerance to a food protein. Therefore, this condition cannot be diagnosed by allergy testing, either by skin testing or by blood testing. The clinical diagnosis is generally made by a clinical history consistent with typical symptoms after eating a given food. The diagnosis is generally confirmed if and when symptoms occur each time the food is introduced to the child.

The most common foods to the cause this condition are milk and soy. However, other solid foods may also precipitate symptoms, including cereal grains (rice, oats, barley), legumes (peas, beans, lentils), and poultry such as chicken and turkey. It should be remembered that any food can cause FPIES, even in trace amounts.

Upon removing the offending food, all FPIES symptoms subside. Treatment of this condition consists solely of avoidance of the offending food. It is generally recommended that if a child has FPIES caused by cow’s milk protein formula, that soy formulas also he avoided due to the fact that soy is also a common cause of this syndrome.

Typically this condition resolves by 3 years of age. It is recommended that parents not attempt to determine if the child can tolerate the offending food at home; rather, it is recommended that an allergist or pediatrician attempt to introduce the food under close medical supervision.

Eosinophilic Esophagitis

Eosinophilic Esophagitis (EE) is a condition that was literally unheard of 20 years ago. However, over the last five years, the recognition and diagnosis of this condition has risen dramatically. It is difficult to say whether the increased frequency of EE is due to an increased level of suspicion, to better diagnostic techniques, or whether the disease has actually become more common.

EE is an allergic reaction localized to the esophagus, the tube that transports food from the throat to the stomach. The classic pathologic feature of this condition is the presence of eosinophils, a normal and benign cell that circulates in the blood and is occasionally found in the tissues. Eosinophils are not normally found in the esophagus, but in this condition, eosinophils accumulate in the lining of the esophagus in response to a food allergy and there they release chemical mediators leading to local inflammation.

EE commonly affects people who have a family history of allergy, especially food allergies, and conditions such as eczema and asthma. It is most common in children. Most adults who develop EE are generally diagnosed in the third or fourth decade of life. Males are affected three times more commonly than females.

Common symptoms of this condition include heartburn or reflux symptoms that do not improve with medication, difficulty swallowing, nausea and/or vomiting, poor appetite, a sensation of food getting stuck in the throat, abdominal or chest pain, and in more severe cases, malnutrition. Diagnosis is confirmed by endoscopy, a procedure during which a gastroenterologist inserts a flexible scope to into the esophagus for direct visualization. The presence of “furrows”, “rings” or “white spots” is highly suggestive of EE. The diagnosis is confirmed by biopsy, after which small tissue samples are examined microscopically for the presence of eosinophils. The presence of any eosinophils in the esophagus confirms the diagnosis.

Eosinophilic Esophagitis is now known to be caused by allergy to a food or multiple foods.  Therefore, if the diagnosis of EE is confirmed, allergy testing to foods by either the prick method or through the blood is necessary in order to try to identify which foods are responsible for the esophageal inflammation. Occasionally, patch testing to foods can be helpful. If a food allergy cannot be diagnosed by testing, an elimination diet may be necessary to help identify the causative agents. Common food allergens to be avoided include milk, soy, wheat, eggs, peanuts, tree nuts, fish and shellfish. Sometimes an elemental formula may be recommended, after which foods are slowly reintroduced into the diet one by one to ascertain the food(s) responsible for symptoms.

Once food allergies have been diagnosed, elimination of the causative food from the diet is commonly the only treatment necessary to resolve symptoms. Medications such as swallowed topical steroids may also be helpful in reducing the inflammation in the esophagus.

Reading Food Labels to Prevent Food Allergic Reactions

A growing number of individuals have a food allergy, estimated to affect 2 percent of adults and 5 percent of infants and children in the United States.  Food allergic reactions can be unpredictable in their severity and can occur after consuming small amounts of the food protein.  Approximately 30,000 people require emergency room treatment and 150 Americans die each year due to allergic reactions to food.  At present, there is no cure for food allergies and avoidance of the inciting food thus remains essential in disease management.  Reading food labels is an important part of everyday life for adults and children with food allergies.

In 2004, Congress passed the Food Allergen Labeling and Consumer Protection Act (FALCPA) to make it easier for food allergic consumers and their caregivers to identify and avoid foods that contain major food allergens.  Effective January 1, 2006 the Food and Drug Administration (FDA) began to require that food labels clearly state whether food products contain any ingredients that contain protein derived from the eight major allergenic foods.  These include milk, egg, peanuts, tree nuts (such as almonds, cashew, and walnuts), fish, shellfish (such as crab, lobster, and shrimp), soy, and wheat.  Although there are many other food allergens, the above foods account for more than 90 percent of all documented food allergies in the United States and represent the foods most likely to result in severe or life-threatening reactions.

This law applies only to packaged foods that are regulated by the FDA.  Fresh fruits and vegetables are exempt, as are refined oils derived from one of the eight major food allergens.  Meat, poultry, and egg products are regulated by the United States Department of Agriculture (USDA).  The labeling requirements also extend to retail and food service establishments, such as bakeries and carry out restaurants, that package and label products for human consumption.  However, the requirements do not apply to foods that are placed in a container in response to a consumer’s request, such as the box used to provide a deli item ordered by a consumer.

The FDA also requires that manufacturers list ingredients in terms that are understandable to the average consumer.  This new labeling will be especially helpful to children who must learn to recognize the presence of substances they must avoid.  For example, if a product contains the milk-derived protein, casein, the product’s label will have to use the term “milk” in addition to the term “casein”.  It is also required that the type of allergen is specified.  For example, the specific type of tree nut (e.g., almond, walnut), fish (e.g., cod, tuna), or shellfish (e.g., crab, shrimp) must be included on the food label.  Flavorings, colorings, or spices that contain a major food allergen must also be identified.

Although the new food-labeling law is a significant advance for people with food allergies, it also raises some questions.  The law requires food allergens to be identified even in the smallest amounts.  As a result, many food manufacturers are listing any and all possible food allergens, even if the allergens might not be present.  This may make it difficult for people with food allergies to discriminate if a product contains enough milk or soy, for example, to cause an allergic reaction.  Consequently, studies show that consumers with food allergy are actually becoming less avoidant of products with advisory labels.

A recent study confirmed that numerous food products have advisory labeling that can be confusing for consumers with food allergy.  For example, only crustacean shellfish are included under this legislation, whereas mollusks (such as squid, clams, mussels, and oysters) are excluded from regulatory labeling.  In addition, nonspecific terms (such as spices, natural flavors, and flavors) are frequently used without being linked to an allergen or ingredient.  Other labeling uncertainties include the lack of identification of the type of flour (e.g., soy, wheat, rice) or tree nut contained in a food.  Increasing the specificity of advisory labels can improve the consumer’s ability to choose safe food products without unnecessary dietary restrictions.

Even though the laws designed to aid the food allergic individual are not perfect, they do help to identify potential allergens and all efforts should be made to read labels carefully. 

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Delayed Food Allergy Syndrome

The “Delayed Food Allergy Syndrome” (DFAS) is a valid and useful concept which unifies into one diagnosis symptoms so diverse and nonspecific that they are seldom thought of as a unit or as allergic. This condition occurs most frequently in childhood, but can also occur in teens and adults.  Many physicians, and even some allergists, are unaware of the Delayed Food Allergy Syndrome or are doubtful of its validity. In spite of the fact that there is little data from medical research about this condition, it has gained its greatest acceptance amongst allergists who care for children.

What Are The Most Common Symptoms?

DFAS can manifest itself in many different ways and in many organ systems. The seven most common signs and symptoms in approximate order of frequency are:

1. Respiratory tract allergy (nasal symptoms or asthma)
2. Abdominal discomfort (stomachaches)
3. Headaches
4. Tenseness and irritability
5. Facial pallor and dark circles under the eyes
6. Tiredness and easy fatigability
7. Musculoskeletal pain (“growing pains”)

Like most syndromes, the Delayed Food Allergy Syndrome often occurs in incomplete or partial forms.  Only rarely are all seven of the major signs and symptoms present.  One can, however, expect three to four of them to become evident in the medical history, if one inquires carefully.

While respiratory tract allergy and fatigability may be more or less constant, the other complaints are likely to be intermittent.  Headache and stomachache for example, can be assumed to occur sooner or later in almost everyone, but it is their greater than expected frequency that may be significant.  Individually, each of the above symptoms may be due to many different causes.  When they present in combination, however, the possibility of the DFAS should be considered.

Less frequent symptoms which have been described with the Delayed Food Allergy Syndrome include cervical gland enlargement, constipation, loose stools or diarrhea, impaired hearing, bed wetting, and mildly elevated temperature.

Causes of DFAS

This syndrome is usually thought to be due to a food allergy. By far, the food most commonly responsible for this delayed allergy is milk. Both parents and physicians find it difficult to believe that foods eaten almost daily, such as milk, wheat, corn, or chocolate can be responsible for the occurrence of such seemingly unlikely symptoms. Particularly difficult to understand is the tendencies for the Allergy Tension Fatigue Syndrome to become more evident in the winter, and in some cases to almost disappear in summer despite no significant change in diet.

Diagnosis of DFAS

At the present time there is no readily available test which can reliably identify the allergens responsible for the delayed onset type of food allergy responsible for DAFS.  Allergy skin testing or RAST or ImmunoCap blood tests are not helpful, as they measure only the IgE antibody, the antibody responsible for immediate allergic reactions. Research has not yet identified the antibody or antibodies responsible for delayed reactions, although there has been considerable interest and research in the possible role of the IgG antibody in the delayed allergic reaction. There is now a blood test available to measure this antibody, but its reliability as a predictor of delayed allergy has not yet been established. 

The diagnosis of this type of food allergy is made by initiating an elimination diet and observing a decrease or elimination of symptoms. It is often recommended that the suspected food be totally eliminated from the diet for four week. If there is a significant improvement in symptoms, the physician may recommend that the food be reintroduced into the diet in order to see if the symptoms recur. If so, the food is once again eliminated. The elimination diet and challenge, therefore, if properly carried out, is the most reliable diagnostic tool in making the diagnosis.

Treatment of DFAS

If and when a food is identified as the causative agent, the food should be totally eliminated from the diet. In less severe cases, it may not be necessary for the food to be totally eliminated from the diet on a long term basis. Many food allergic patients with DFAS can tolerate minimal amounts of the allergens without developing symptoms. Exceeding one’s threshold of tolerance will, however, precipitate symptoms.

DFAS Summary

In summary, the Delayed Food Allergy Syndrome presents with a constellation of symptoms which, when appearing together, suggest to the allergist the possibility of a delayed onset food allergy, especially to milk.  It is more common than is generally appreciated. It may accompany inhalant allergy, and explain inadequate response to the treatment of inhalant allergies such as a poor response to immunotherapy.

As a final note, it should be mentioned that food allergy is usually familial.  The knowledge may greatly aid its recognition in a particular patient as well as other members of the family. 

Back to School With Asthma

Did you know that asthma exacerbation tends to peak during the fall months as children return to school?  Studies have shown that children often experience a worsening of asthma and asthmatic symptoms after returning to school from summer vacation.  The number of hospitalizations and emergency department visits for asthma attacks reaches a peak approximately two weeks after the start of the school year.  This has been referred to as the “September epidemic.”

Multiple factors likely contribute to this seasonality of asthma exacerbation.  The incidence of viral illnesses does increase with exposure to other children at school.  In addition, children with asthma are particularly susceptible to experiencing a virally-induced exacerbation if they are not receiving any asthma controller therapy.  Asthma controller medications which can be helpful in preventing asthma flare-ups include Singulair and inhaled corticosteroids such as Pulmicort, Flovent, and Advair.  In contrast, albuterol or Xopenex provide short-term relief, but do not result in long term control.

Your child may benefit from receiving an asthma controller medication if there are frequent symptoms, such as coughing, wheezing, or activity limitation, or if albuterol is needed more than twice weekly.  If you have already been prescribed a controller medication, it is important to take it on a daily basis, even if you are feeling well.  Proper inhaler technique is also critical to ensure that the medication is being delivered to your lungs.  Consult How To Videos for step-by-step instructions on inhaler and spacer technique. 

There is also likely a synergistic interaction between allergies and the effect of respiratory viruses.  Environmental controls thus remain an important part of asthma care.  Avoid or minimize exposure to allergens that your child is sensitive to, such as animal dander, pollen, and dust mites.  If your child is allergic to a family pet and you are unable to remove it from the home, keep your pet out of the bedroom and opt for hardwood floors rather than carpeting.  Cat dander is particularly sticky and adheres to clothes, carpeting and furniture for extended periods.  Exposure to cat dander can thus also occur in the school environment.

Pollen exposure can be minimized by using air conditioning and keeping the windows closed at home and in the car.  Showering or bathing at bedtime also helps to wash away pollen before sleeping in bed at night.  To reduce dust mite exposure, place dust mite covers over your pillows, mattress and box spring and keep stuffed animals off the bed.  If you are unsure whether your child has allergies, skin testing may be performed to identify specific allergens for your child.

Cat Allergies

From an allergist’s perspective, the truly cat allergic and symptomatic individual can represent one of the most challenging aspects to one’s clinical practice. The fact that so many families have indoor cats and the fact that the cat allergen itself represents one of the most potent allergens on the face of the earth, it is clear evidence that number of individuals sensitized to the allergen and who subsequently become symptomatic have increased dramatically. The challenge to the allergist is even more acute when one recognizes the fact that, in so many cases, pets become bona fide family members, and the suggestion of removing one’s pets from the home is often met with a nonnegotiable response to the recommendations of the allergist.

From a patient’s perspective, the realization that their symptoms or their child’s symptoms are being caused by their cat can be devastating.

The emotional impact of this realization is often met with denial, and subsequent avoidance of sound medical advice. A caring allergist will recognize these strong emotions and will work with the patient and family to, when possible, design an environmental control program with which the patient can take charge of improving his or her care.

It is the nature of the cat allergen itself which makes it so difficult to deal with. The allergen is extremely potent and in a highly allergic individual, it does not take much exposure to induce very bothersome, and sometimes severe, allergy symptoms. Besides the potency issue, cat allergen is extremely light and becomes airborne, therefore readily accessible to the eyes, nose and lungs of the allergic patient. The allergen is also very sticky, and therefore can be found just about anywhere that a cat resides; on the furniture, walls, carpeting, floors, bed, etc. Needless to say, the amount of cat allergen in homes where cats reside is plentiful and often problematic, but cat allergen is virtually everywhere! It can be found in very significant concentrations in school classrooms where children bring the allergen on their clothes, in places of business, in homes where a cat does not reside, and even in allergists’ offices!

Contrary to popular belief, the sole source of the allergen on cats is not the hair or fur. It is also present in the dander (skin scales), the urine, and the saliva. Also false is the notion that there are hypo-allergenic cats. Although some species have been reported to be less allergenic than others, all cats have the potential of inducing allergy symptoms in the highly sensitized individual.

Environmental control is the most important treatment modality in dealing with cat induced allergy symptoms, which can be as mild and inconsequential as minimal nasal and eye symptoms, or as severe as life threatening cat induced asthma, and everything in between. It is the severity of these symptoms which will likely guide your allergist when making recommendations to the patient and family of the cat allergic individual.

When a cat allergic child or adult experiences chronic asthma symptoms or has evidence of chronic airway inflammation and swelling as measured by spirometry (lung function studies), the necessary, albeit sometimes emotionally painful step, is the removal of the cat(s) from the home, with subsequent thorough cleaning. Compromise approaches, such as keeping the cat out of the bedroom and avoiding direct contact, are likely not to be helpful. Not to remove the cat(s) from the homes will likely result in the patients needing to take multiple asthma medications on a daily basis just to maintain an acceptable level of lung function, and the frequent or chronic use of corticosteroid (prednisone, methyprednisolone) medication.

For less severe symptoms which do not involve asthma, compromise approaches can be helpful. These suggestions would likely include the recommendation that the cat(s) never go in the bedroom, avoiding direct contact, thorough and frequent cleaning of the home and the cat, use of medications, and possibly immunotherapy (allergy shots or desensitization).

It is extremely important that one create an allergy-free zone for the allergic patient. Since one spends approximately one third of their life in one’s bedroom, it is obvious the the allergy-free area should be the bedroom. Specific recommendations might include:

• The cat(s) should never, ever, ever, ever be allowed to into the bedroom of the allergic individual. Cats are like radioactivity—wherever they go they leave their trouble behind. Keep the bedroom door closed and clean the bedroom frequently and thoroughly.
• Place a HEPA filtration system in the bedroom of the allergic individual.
• Because the cat allergen is extremely sticky, it is important that the furniture, walls and all woodwork be scrubbed on a frequent basis.
• Remove all carpeting in the house, especially the bedroom of the allergic child. If you must have carpet, have it steam cleaned frequently.
• Since forced air heating and air conditioning can spread cat allergen throughout the house, cover all vents with filtering material such as cheesecloth or filters designed specifically for allergies.
• If the allergic individual must do the housecleaning (not recommended), wear a dust mask. To remove the most allergen from the environment, use a vacuum with HEPA filtration system.
• Washing cat weekly can reduce the quantity of surface allergens.
• Have someone without cat allergy brush the pet outdoors to remove the dander. This individual should also clean the litter box.

Seafood Allergy

Seafood is one of the most common causes of severe allergy reactions in adults. Approximately 12 million Americans suffer from food allergies, with 6.9 million allergic to fish and/or shellfish.

A seafood allergy occurs when the immune system mistakenly interprets the proteins contained fish or shellfish as a harmful substance. When a person with this allergy comes in contact with seafood, the body produces antibodies to fight the harmful substance, and this triggers an allergic reaction.

Allergic reactions to fish most commonly occur upon ingestion, but can also be triggered by the inhalation of fish protein while being cooked, or upon direct contact to the skin. The most common reactions include rash (atopic dermatitis), redness and swelling around the mouth, hives (urticaria), wheezing and difficulty breathing, stomachache, cramping, diarrhea or vomiting, asthma, and in extreme cases, anaphylaxis. Seafood allergy, if not treated promptly, can be fatal.  Severe reactions generally occur within minutes after consuming the allergen.

Unlike most food allergies which appear in childhood and resolve later in life, seafood allergy commonly persists throughout adulthood. And, unlike many other foods, the onset of fish allergy is common during adulthood. Women are affected more commonly than men.

Classifications of Seafood

Seafood causing allergic reactions can be classified into three groups:

• Fish
• Shellfish
• Mollusks

Fish:
Included in this group are the bony fish which commonly cause allergic reactions such as cod, salmon, pollock, snapper, eel, and tilapia, to name just a few, and cartilaginous fish such as shark.

The most allergenic fish is thought to be cod. Some fish, specifically tuna and mackerel, are considered to be less allergenic than others. But, because of the high frequency of cross-reactivity, individuals with allergies to one type of fish are likely to have allergies to others. This cross-reactivity is caused by the protein parvalbumin that is present in many fish. For this reason, most people with an allergy to one fish are advised to avoid all fish, including eel and shark. Many fish allergic individuals can eat shellfish and/or mollusks, and vice versa, but one must be allergy tested before assuming that there is not an allergy to more than one seafood group.

Shellfish or Crustaceans:
This category includes shrimp, lobster, crayfish, prawn, and crabs. Tropomyosin, the protein that most commonly causes shellfish allergies, is also found in dust mites and cockroaches, and there is some evidence of cross-reactivity between shellfish and some insects.

Mollusks:
Clams, oysters, scallops, abalone, cockle, cuttlefish, escargot (snails), octopus, squid, and mussels are included in this category.

Less Obvious Sources of Seafood Allergens

Individuals with seafood allergy must be especially diligent about avoiding the ingestion of seafood proteins which may be in other foods. The list below, although not inclusive, demonstrates how widespread the presence of fish is in the foods we commonly eat.

• Worcestershire sauce: Contains fish (anchovies).
• Steak sauce: May contain seafood.
• Caesar salad: Often contains anchovies either on the salad or in the dressing.
• Caviar: Made of fish eggs.
• Marinara sauce: Sometimes contains anchovies.
• Roe: Unfertilized fish eggs.
• Surimi (a type of imitation crab popular in some Asian restaurants): Contains fish proteins for added flavoring.
• Hot dogs, bologna and ham: Can contain fish flavoring (surimi).
• Pizza toppings: Sometimes contains anchovies.
• Fried rice and spring rolls: May contain shrimp.
• Caponata (a Sicilian relish): Can contain anchovies.
• Gelatin-based foods (e.g., marshmallows): May contain seafood.
• Pet fish food: This dried substance is made of brine shrimp and other seafood. It can easily become airborne and, if inhaled, may trigger symptoms in some people with seafood allergies.
• Pet food: Dog and cat food may contain seafood.

Glucosamine, a dietary supplement sometimes recommended for patients with arthritis, is often made from the shells of crustaceans. The proteins that are most likely to cause food allergies are not found in the shell, and recent studies have indicated that glucosamine is safe for people with shellfish allergies; however, if you are concerned, you can try vegetarian glucosamine.

Another potential source of shellfish allergens is Omega-3 supplements, which are often made from seafood. The most common source used to manufacture these is fish (mostly cod liver), but check ingredients on the label before you take these.

Masqueraders of Seafood Allergy

There are conditions which can mimic an allergic reaction to seafood. The following two examples are illustrative.  Anisakis simplex allergy and infestation can masquerade as an allergic reaction. Anisakis simplex is a fish parasite which is found world-wide, and infests a variety of hosts along the food chain. Between 5 and 80 % of fish samples have been found to be infested in various studies. Cooking at high temperatures or storage in industrial freezers is
required to kill the parasite. Anisakis can cause two major problems in humans: allergic reactions and infection with the parasite.

Anisakis simplex allergy resembles other allergic reactions to food. Allergic reactions to Anisakis simplex should be suspected when allergic-like reactions occur after eating seafood, yet the results of skin tests to seafood are negative. Reactions often occur intermittently after eating seafood, rather than on every occasion.

Anisakis simplex infection, or anisakiasis, results from eating raw or undercooked seafood such as sushi. Infection can cause nausea, vomiting, and abdominal pain. Diagnosis is based on seeing the parasite using a fiberoptic telescope during endoscopy.

While not all reactions to seafood are allergic in origin, some can resemble allergic reactions. Scrombroid fish poisoning is a classic example. Scombroid fish poisoning is an allergic-like reaction that occurs after eating foods with high histamine content.

Scombroid poisoning is caused by the ingestion of scombroid and scombroid-like marine fish species that have begun to spoil with the growth of particular types of bacteria, generally due to the lack of proper refrigeration. Fish most commonly involved are members of the scombridae family (tunas and mackerels) and a few non-scombridae relatives (bluefish, dolphin or mahi-mahi, and amberjack).

The suspect toxin is an elevated level of histamine generated by bacterial breakdown of substances in the muscle protein. This natural spoilage process is thought to release additional by-products, which cause the toxic effect. Unfortunately, freezing, cooking, smoking, curing or canning does not destroy the potential toxins.

Affected fish often have a metallic or peppery taste. Symptoms usually commence within 30 minutes of eating. Because the symptoms are caused by the chemical histamine, they can be identical to an allergic reaction. The most common symptoms include flushing, itching, urticaria or hives, nausea, vomiting, abdominal cramps, dizziness, palpitations and headache. Severe episodes may result in wheezing and a drop in blood pressure.

Reading Seafood Labels

As one of the “big eight” most common food allergens, fish is covered under the Food Allergy Labeling and Consumer Protection Act (FALCPA). This requires that manufacturers label the presence of fish in clear language on food labels, either in the list of ingredients or following the word “contains” after the ingredient list. Fish is not a particularly common hidden ingredient and generally appears as its own species in ingredient lists. But people with fish allergies should learn the names of many different types of fish for maximum safety in reading labels.

Be careful!

There are recorded instances of inhalation reactions due to aerosolized fish proteins, so people with fish allergies should avoid hibachi-style communal grill restaurants if fish is on the menu. Seafood restaurants and sushi bars are high risks for cross-contamination due to the close proximity of fish and non-fish items. Another source of potential cross-contamination is frying oil; if fish has been fried in oil, people with fish allergies should avoid eating any other food fried in the same oil.

Corn Allergy

Corn is a cereal grain with proteins that are similar to those in other cereal grains such as wheat. Unlike wheat, which is a common food allergen, allergic reactions to corn are much less common. Most corn allergy reactions are mild, but severe reactions have been reported. These reports include anaphylaxis after the ingestion of corn or corn-related foods, as well as severe reactions after exposure to cornstarch in surgical gloves.

Corn allergic reactions can occur as a result of eating both raw and cooked corn. Those with corn allergy may also react to corn pollen (typically with allergic rhinitis and/or asthma), grass pollen, and cornstarch. As with other food allergies, avoidance of corn and corn-related foods is the main way to prevent future reactions. 

It is important to remember that food manufacturers may change the ingredients in the product without warning. It is a good idea to always read the product label before consuming the product. It is much easier to prevent a food-allergic reaction than to treat one.

Foods That Contain Corn

Corn and corn products are commonly found in our diets, especially as sweeteners and starch.

Food Label Items That Contain Corn

• Corn
• Corn flour
• Cornmeal Popcorn
• Maize
• Hominy
• Grits

Foods That May Contain Trace Amounts of Corn Protein

these foods are less likely to cause sensitivity

• Baking powder
• Gum (vegetable)
• Caramel coloring
• Glucose (commercially prepared)
• Cornstarch
• Powdered sugar
• Corn sugar
• Starch (food, vegetable, modified food starch)
• Corn sweetener
• Sorbitol
• Dextrose

Food Items That Can Be Used Instead of Corn

• Aspartame
• Potato starch
• Fruit juices
• Tapioca
• Honey
• Wheat starch
• Beet or cane sugar
• Soda
• Maple syrup
• Cream of tartar
• Rice starch

Substitutes For Corn-derived Products

• Baking powder: 1 tsp. baking powder can be replaced with 1 1/4 tsp. cream of tartar and 1/2 tsp. baking soda
• Corn oil: coconut, olive, sunflower, safflower, butter
• Corn syrup: molasses, sorghum, honey
• Cornstarch: potato, arrowroot, rice, all-purpose flour to thicken gravy
• Powdered sugar: substitute with white granulated sugar mixed in blender until powdery

Anaphylaxis

Anaphylaxis is the most severe of all allergic reactions and can result in difficulty breathing, a sudden drop in blood pressure with subsequent loss of consciousness, and even death. Anaphylaxis is a medical emergency that requires immediate recognition, prompt medical treatment, and follow up care by an allergist.

It has been estimated that up to 15% of the population is at risk for anaphylaxis. Anaphylaxis can occur within minutes after exposure to a substance to which one is severely allergic. The most common substances that trigger anaphylaxis are foods, medications, and insect stings.

Causes of Anaphylaxis

Anaphylaxis is triggered when an allergen (food, medicine, insect venom, etc.) comes in contact with antibodies (IgE) in the blood or tissues previously formed by prior exposure to the allergen. This antigen-antibody reaction results in a rapid cascade of cellular events leading to the immediate release of large amounts of histamine and other chemical mediators.

These chemical mediators, when exposed to the smooth muscles of the lungs, can quickly lead to constriction of the bronchial smooth muscle causing wheezing, tightness, and difficulty breathing. Exposure to blood vessels generally causes urticaria, or hives, and can lead to vasodilatation of the peripheral circulation resulting in low blood pressure and possibly shock. Reactions usually begin within seconds to minutes of exposure, but may be delayed. In general, the quicker the onset of symptoms, the more severe the reaction may be. Sometimes symptoms resolve, only to recur or progress a few hours later.

Symptoms of Anaphylaxis

Anaphylaxis is, by definition, “systemic”. It therefore can affect multiple organ systems, including the skin, respiratory, circulatory, and gastrointestinal systems. Symptoms of anaphylaxis can vary from mild to severe, and are potentially deadly.

The following is a list of possible symptoms that may occur alone, or in any combination:

• Skin: hives, swelling, itch, generalized warmth and redness
• Breathing: wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, nasal congestion/hay fever-like symptoms
• Gastrointestinal: nausea, pain/cramps, vomiting, diarrhea, itchy mouth/throat, difficulty swallowing
• Circulation: pale/blue color, poor pulse, passing-out, dizzy/ lightheaded, low blood pressure, shock
• Other: anxiety, feeling of “impending doom”, red/itchy/watery eyes, headache, cramping of the uterus

Substances That Trigger Anaphylactic Reactions

A recent study done at the Mayo Clinic found that food allergy is the most common cause of anaphylaxis. In their study of patients presenting to the emergency room over a ten year period, 33% of anaphylaxis cases were caused by foods. Insect stings accounted for 19% and medications caused 14% of all anaphylactic reactions.

• Foods: Essentially any food can trigger an allergic reaction, but the most common ones that cause severe anaphylaxis are: peanuts, tree nuts (e.g., walnut, pecan, almonds, cashew, Brazil nut), shellfish, fish, milk, and eggs.
• Stinging insects:The venom of stinging insects such as yellow jackets, honeybees, wasps, hornets are common causes of anaphylaxis, as is the biting fire ant in certain geographical areas of the U.S.
• Medications: Virtually any medication can trigger an allergic reaction. Common categories of drugs that cause anaphylaxis are aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS), antibiotics, and anti-seizure medicines. Medical therapies such as certain post-surgery fluids, vaccines, blood and blood products, radio-contrast dyes, pain medications, and other drugs may cause anaphylaxis or anaphylactoid (anaphylaxis-like) reactions.
• Latex: Some products made from natural latex from the rubber tree contain allergens that can trigger reactions in sensitive individuals. The greatest danger of severe reactions occurs when latex comes into contact with moist areas of the body during examinations or internal surfaces during surgery.
• Exercise: Although rare, exercise can also trigger anaphylaxis. Oddly enough, it does not occur after every exercise session. In some cases, only occurs after eating certain foods prior to exercise.
• Other: Anaphylaxis has rarely been associated with exposure to seminal fluid, hormones, and exposure to extreme temperatures. When no cause is found it is termed idiopathic anaphylaxis.

Treatment and Prevention of Anaphylaxis

In addition to the administration of rapid acting antihistamines, the effective medical treatment of anaphylaxis requires the immediate administration of epinephrine (adrenalin). The quicker epinephrine is given to the onset of symptoms, the better likelihood of successful treatment. It is sometimes necessary to give a second or even a third dose if symptoms persist. While medical treatment is being initiated, medical assistance should be sought as further therapy may be necessary. Even after receiving immediate medical treatment on site, one should be transported to a medical facility or hospital for further evaluation.

Follow Up After Anaphylaxis

Any person who has had an anaphylaxis episode should consult an allergist in order to:

1. determine if you have had, or are at risk for anaphylaxis
2. determine what allergen(s) may cause your reaction
3. advise you as to whether or not any medications you are taking might make anaphylactic episodes worse or interfere with treatment and suggest alternatives
4. teach you how to avoid the allergen(s)
5. provide education about recognizing symptoms of an anaphylaxis
6. create a written emergency treatment plan for use by you and others
7. teach you how to use self-injectable epinephrine
8. prescribe self-injectable epinephrine
9. offer the most up-to-date therapies to treat and/or prevent subsequent reactions

How To Use An Inhaler

How to Use an Inhaler

1. Shake the inhaler well before use (3 or 4 shakes).
2. Remove the cap.
3. Breathe out, away from your inhaler.
4. Bring the inhaler to your mouth.  Place it in your mouth between your teeth and close your lips around it.
5. Press teh top of your inahler once.  Immediately take a slow deep breath, pulling the aerosol deep into the lungs.
6. Remove the inhaler from your mouth, close your lips, hold your breath for about 10 seconds, then breathe out.
7. If you need a second puff, wait 30-60 seconds, shake your inhaler again, and repeat steps 3-6.

Sesame Allergy

The sesame seed, tiny in size, represents a growing danger as a food that can cause severe allergies.  Sesame is in a family of seeds that also includes poppy seed, flaxseed, sunflower seed, buckwheat, mustard, and pine nut. (Pine nut is generally perceived to be a tree nut in the culinary sense, but in fact, it is a seed).  In the entire family of seeds however, sesame causes the majority of allergic reactions. And, the incidence of sesame allergy is on the rise.  This is likely due to the increase in popularity in the use of seeds, including sesame, in the American and Mediterranean diet.

Sesame allergy shares many similar properties in terms of the clinical allergy symptoms, severity, and persistence with peanut, tree nut, and shellfish allergies.  Despite these similar characteristics, sesame is not “yet” considered one of the “big 8” food allergens.  As a result, it has not received much attention as a dangerous allergen until recently.

Why Sesame Allergy is Such a Problem

Certain types of diets, most notably the Mediterranean diet, use sesame in a variety of applications, including oils, pastes, confections, baked goods, and cosmetic products.  This latter application often goes unnoticed by consumers.  Sesame use, in particular, in the United States has rapidly increased in recent years and ranges from use in obvious sources such as hamburger buns, bagels, and other baked goods, to more hidden uses such as lip balm.

However, just increased use of sesame as an ingredient within certain cultures is not the sole cause for a rise in allergy to sesame.  For instance, a society like India, whose culture uses sesame frequently in the diet, has a low rate of sesame allergy while others, like Israel, have a high rate of allergy. This has led investigators to study the effects of how food processing affects rates of allergy, which likely explains why there are wide cultural variations in rates of peanut and tree nut allergy, as well as sesame allergy.

Processing techniques like dry-roasting or dehydrogenation alter the chemical structure of sesame (peanut and tree nuts as well) and allow more surface area to be exposed that can be recognized in a susceptible individual.  Other processes, like boiling, do not result in such alterations.  Therefore, it is very likely that more aggressive processing of the sesame within certain cultures has contributed to the rise in this allergy.

Causes of Sesame Allergy

Sesame and other seeds are plant derived products, and have a number of different proteins that can cause an allergic response.  Unfortunately, patients can react to one or all of the different proteins.  Most of the allergenic proteins in sesame are shared by many plant derived foods, including peanut, legumes (including soybean), tree nuts, buckwheat, mustard seeds, kiwi, and certain spices.

The major allergens in sesame are seed storage proteins, vicilins, and oleosins.  Moreover, oleosins, found mainly in sesame oil, have been shown to be poorly detectable via skin testing, making diagnosis in oleosin sensitive individuals difficult, and requiring use of specific allergy blood tests or other research methods.

Oleosins have been found in carrot, shiso (a Chinese spice), peanut, and soybean.  This sharing of similar proteins among different foods can elicit cross-reactivity among allergic individuals.

It is important to note, however, that not all of the cross-reactivity causes clinical allergy.  Which protein elicits the reaction is also a matter of how the seed is processed, which has already discussed.  Unfortunately, in the case of sesame, the major allergen proteins do not break apart even after high temperature processing or human digestion, creating many scenarios for potential allergy. 

Factors Affecting Onset of Sesame Allergy

Recent food allergy surveys in England and Australia found that sesame allergy was more commonly reported than allergy to any tree nut, and an Israeli study found that sesame allergy was more commonly reported than peanut allergy.  Compared to the big 8 allergens in the United States (milk, egg, soy, peanut, tree nut, shellfish, fish, wheat), there is far less reported sesame allergy.

Outside of the United States, sesame allergy often occurs by age two, but this is highly influenced by countries that feed their young a sesame rich diet.  In the United States, sensitization to sesame is seen in young children, although not to the same extent as in certain countries like Israel.  There is data indicating that sesame allergy is less frequent in the 15-20 year old age group.  In contrast to low rates in teenagers, sesame allergy is being detected at a higher than expected rate in adults, although it is unknown if these individuals developed new sesame allergy or this was just previously undetected. 

As detailed in the preceding paragraph, processing may be the most significant factor influencing sesame allergy, as is the case with tree nuts and peanut.  This fact may ultimately influence any conclusion that can be drawn about the natural history of this allergen.  As well, there is some difference in the amount of allergen content among the 3 varieties of sesame seeds, with white seeds containing more allergen than the black or brown variants.  Regardless, it is abundantly clear that despite protein content differences, all 3 seed types induce allergic reactions in sensitive individuals, and all 3 should be avoided in sesame allergic individuals.  Sesame seed, flour, noodle, meal and oil all contain very potent allergen amounts, and there is no safe form or preparation of sesame for a sesame allergic individual to come in contact with.

Sesame Allergic Reactions and Symptoms

Sesame is associated with life-threatening anaphylaxis in susceptible individuals!  Again, this is very similar to tree nut, peanut, and shellfish allergy, and sesame sensitive individuals are recommended to avoid any amount of contact.  Clinical allergy can manifest as eczema, contact dermatitis, asthma, hives, and oral allergy syndrome.  Symptoms have been noted to affect the eyes, nose, mouth, lips, tongue, throat, lungs, skin, GI tract, bladder, and the circulation including the heart.

Examples of How Sesame is Utilized in Commercial Products

Note:  this list is adapted from Gangur et al, Ann Allergy Asthma Immunol 2005, and only provides examples of how sesame can be found in foodstuff.

• Bakery goods:  hamburger buns, pizza crust, wafers, bread/rolls/breadsticks, pastries, pretzels, Italian bread, bagels, crackers, biscuits, sandwich bread, cookies/candy
• Noodles and as meal or flour, pastes from ground seeds
• Snacks:  Chocolate, protein bars, candy, ice cream, ice cream cones
• Condiments:  salad dressing, directly as a salad bar topping or garnish, sauces and cooking oils
• Ethnic food:  falafel, tahini, simit (Turkish pretzels)
• Margarine
• Pharmaceutical:  ointments, balms, injections (progesterone), plasters, liniments, capsules, emulsions, eye products
• Cosmetic:  lipstick, lip balm, body oil, soap, moisturization cream

Sesame Allergy Diagnosis and Treatment

Like any other food allergy, the treatment of choice for a systemic allergic reaction is epinephrine (EpiPen® or Twinject®) plus an antihistamine.  Sesame allergic individuals are at risk for potential life threatening allergic reactions and should have a personal source of self-injectable epinephrine with them at all times.  Strict avoidance is very strongly recommended, and care should be taken to avoid potential cross-contamination from preparation surfaces, cooking utensils, pots, pans, plates, and surfaces.

Hand washing after eating is recommended from anyone who dines with any food allergic individual, including sesame allergic.  It may be beneficial to avoid certain cultural/ethnic restaurants that may use a lot of sesame in preparing their food.  Sesame allergic individuals must take care to avoid unintended exposure through the numerous pharmaceutical and cosmetic use of sesame.

To test for sesame allergy, processed extracts are available for application as a skin test.  Because there are several sesame protein allergens that exist, and not all of them have been proven to be captured on skin testing, allergy blood tests (RAST or ImmunoCAP®) are highly recommended if the skin test is negative.  It is well established that there is a high degree of cross-reactivity to sesame with peanut, tree nut, legumes, and other seeds, but not all of this is clinically relevant.  Many allergists therefore chose to screen sesame allergic individuals with the blood test for the presence of cross reactivity with these other foods, and vice versa.

Sesame is an allergen on the rise in western countries, such as the United States.  The European Union and the Canadian Food Inspection Agency have recently put sesame on their allergen watch lists, but the FDA has yet to do the same.  This means that sesame does not have to be labeled in “plain English” on packaged goods produced and sold in the United States.  Because sesame allergy has not been as well identified and studied as some of the other allergens, more research is needed to define the characteristics of this entity.  Very little about the long term outcome is known, except that nearly 80% of sesame allergic individuals taking part in an Israeli study retained their allergy into adulthood. 

Oral Allergy Syndrome

The Oral Allergy Syndrome is the most common food-related allergy in adults.  In actuality, this is not a direct food allergy, but rather represents cross-reactivity between distant remnants of tree or weed pollen still found in certain fruits and vegetables.  Therefore, this phenomenon is only seen in tree and weed allergic patients, and is limited to ingestion of only uncooked fruits or vegetables.  It is perhaps more aptly named the pollen-food syndrome.

Oral Allergy Syndrome Symptoms

The symptoms of oral allergy syndrome are classically itching and swelling of the lips, mouth, tongue, and throat within several minutes of ingestion of uncooked fruits and vegetables. The itchiness of the throat commonly results in the patient trying to relieve this symptom by rubbing the tongue against the soft palate making a characteristic “clucking” sound. Symptoms are almost always localized to the upper oral tract, but in limited instances, could involve generalized allergy symptoms.  The vast majority of patients experience symptoms within five minutes of ingestion.  Depending on the time of year, the presentation can be affected by the particular pollen season.

Oral Allergy Syndrome Causes

Symptoms result from digestion of fruit or vegetable proteins that cross-react with antibodies that also recognize tree or weed pollen proteins. It should be emphasized that this is not a direct allergy against a fruit or vegetable, though often this is the defining complaint that precipitates referral to an allergy specialist.  Therefore, allergy testing is generally not necessary because it rarely yields a positive result as there is no sensitization that has occurred to the food itself, but only to the cross-reactive pollen.

Who is Affected by Oral Allergy Syndrome?

By definition, persons with oral allergy syndrome have allergy to either tree or weed pollen.  Historically, this syndrome was first associated with birch tree pollen allergy, and subsequently with both mugwort and ragweed pollen allergy. We now recognize that it can occur in individuals allergic to any tree or any weed species.  Several studies have examined the extent of this problem in tree or weed pollen allergic individuals, with estimates ranging from 25%-75% of such individuals reporting this phenomenon.  While this is generally though of as an adult phenomenon, it is seen in children as well.

Foods That Cause Oral Allergy Syndrome

Essentially, any raw fruit or vegetable can potentially elicit symptoms in tree or weed allergic individuals. 

However, this has been described most often with the following:

• Birch tree pollen allergy may cause symptoms upon the ingestion of apple, pear, apricot, and almond and, to to a lesser extent with celery, carrot, hazelnut, soy, and peanut.
• Birch pollen allergic patients have also been observed to have cross-reactivity to latex, grass, olive tree, and mugwort pollen.
• Mugwort pollen may cause symptoms upon the ingestion to celery,  and to a lesser extent with mustard, anise, coriander, cumin, fennel, and parsley.
• Celery attributed symptoms are also seen in areas where birch is prevalent as well, as there is a high degree of cross reactivity.
• Ragweed allergy commonly causes symptoms upon the ingestion of foods in the gourd melon family members such as watermelon, cantaloupe, honeydew, zucchini, and cucumber, as well as with banana.
• There are also reports with peach, plantain, and saffron. This is not limited to just ragweed, but can include other weed family members.

It is also important to mention a related entity, the Latex-Fruit Syndrome, which operates under very similar circumstances.  Latex is tree derived and its primary allergen shares similarities with fruit proteins.  Latex is an omnipresent allergen in the environment, and there is high degree of contact in day to day activities.

The following food proteins have demonstrated cross reactivity with latex proteins:

• melon
• banana
• avocado
• chestnut
• kiwi
• potato
• bell pepper
• mango
• papaya
• passion fruit
• tomato
• celery

Oral Allergy Syndrome Treatment

The tried and true management strategy for a food allergy, no matter what the cause, is avoidance.  However, most individuals do not have symptoms after ingesting cooked fruits and vegetables, as the heating process breaks down the allergenic proteins.

Many allergists recommended that individuals with oral allergy syndrome carry an EpiPen® or Twinject® device with them, to protect against throat symptoms, or the extremely rare case that may lead to anaphylaxis.  Immunotherapy, or allergy shots, may seem like a logical and effective treatment, however several studies have not proven beneficial for oral allergy syndrome, though they are a well-established, highly effective treatment for pollen induced allergic rhinitis.  Therefore, allergy shots are not offered as a specific treatment, although many patients on allergy shots for allergic rhinitis may see some improvement in oral allergy syndrome symptoms.

Allergy Diagnosis

To help you manage your or your child’s allergy symptoms most effectively, your allergist must first determine what is causing your allergy. Once the specific allergen(s) causing symptoms have been identified through allergy testing, you and your allergist can develop a treatment plan aimed at controlling or eliminating your allergy symptoms.

Allergy testing can be performed on the skin or through the blood, but most allergists prefer skin testing because the patient can be tested to large numbers of allergens at one visit and the results are available immediately.

Skin Testing

Prick Testing
Allergists usually begin with prick (also called percutaneous) testing. Using a plastic “pick”, or a device called a multitest, the surface of the skin is lightly pricked and the allergen, previously placed on the tip of the device, is introduced into the skin.

After this simple application of the allergen(s), one waits 15-20 minutes in order to see if there is a skin reaction in the form of a wheal (swelling) or a flare (redness). The size of the reaction is then measured to determine the degree of allergy. The larger the skin reaction, the stronger the allergy.

This test is usually performed on the back, but it may be performed on the forearm. This test may include one or more relevant allergens, or a standard panel of the most common allergens including trees, grasses, weeds, and molds, dust mites, and pet hair. Foods are also tested by this method.

Most patients tolerate percutaneous testing extremely well. There is no pain involved but young children sometimes report minor discomfort. The most common complaint is itching from wheals that can develop over 15 to 20 minutes. These wheals and itching usually resolve over thirty minutes.

Intradermal Testing
Intradermal tests are usually performed if the patient does not demonstrate significant reactivity on prick testing of suspected allergens. This test introduces a stronger concentration of allergen under the skin, and will often diagnose allergies that the percutaneous test did not reveal.

Intradermal testing involves injecting, with a very tiny needle, a small amount of allergen under the skin of the arm. These tests are mildly uncomfortable and are commonly described as momentarily stinging like an ant bite. Because of this, only a handful of tests are usually performed by this method. Like prick testing, results are determined by measuring the size of the wheals which develop over 10-15 minutes. Intradermal testing is generally used for the diagnosis of inhalant, venom, or drug allergies, but is not used for testing to foods.

Blood Testing

Sometimes your allergist may do a blood test, called a RAST (radioallergosorbent) test or ImmunoCAP test.

These blood tests are accurate predictors of allergy, but they have some disadvantages to skin testing:

1. The test involves drawing blood
2. It generally costs more than skin testing if large numbers of allergens are being tested
3. The results are not immediately available

Allergy tests through the blood are generally used in cases in which skin tests can not be performed, such as with very young children, in patients taking certain medications which may interfere with the results, or those with skin conditions that may interfere with skin testing. 

Other Allergy Testing Techniques

Challenge testing: Challenge testing involves introducing small amounts of the suspected allergen by the oral, inhaled or other routes. With the exception of food and medication, challenges are rarely performed. When they are performed, they must be closely supervised by an allergist.

Elimination/Challenge tests: This method is utilized most often with foods or medicines. The patient is instructed to modify his/her diet to totally avoid the suspected allergen for a period of time. If the patient sees significant improvement while avoiding the suspected allergen (food or medicine), he/she is then sometimes “challenged” by reintroducing the allergen in order to see if the symptoms can be reproduced.

Patch testing: This form of testing is indicated to help ascertain the cause of skin contact allergy, or contact dermatitis.  Adhesive patches, treated with usually a number of different chemicals or skin sensitizers to which people are most commonly allergic, are applied to the back. The skin is then examined for possible local reactions at least twice, usually at 48 hours after application of the patch, and again two or three days later.

Unreliable tests: There are other types of allergy testing methods that the American Academy of Allergy, Asthma, and Immunology considers to be unacceptable.

These unreliable allergy testing methods are:

• Applied kinesiology (allergy testing through muscle relaxation)
• Cytotoxicity testing
• Urine autoinjection
• Skin titration (Rinkel method)
• Provocative and neutralization (subcutaneous) testing or sublingual provocation

Xolair

Uses of Xolair

Xolair (Omalizumab) belongs to a class of medications called “biologic therapies”.  Xolair acts early in the allergic-inflammatory process in people with allergic asthma by blocking the allergy antibody IgE from causing the reactions that can lead to asthma attacks and symptoms.

Xolair is a medication used to treat very severe allergic asthma.  Usually after being on this medication for a period of time, asthma symptoms improve and patients can decrease the use of some of their asthma medications.

Taking Xolair

This medication is administered as a subcutaneous (under the skin) injection. Xolair injections are usually given once or twice a month.  The dose is based on one’s allergy antibody level and weight.  The injections are usually administered at your allergist’s office, but they can be given under the direction of a home health care company at your home.  Your physician will help decide how long to take this medication based on your response and level of asthma control.

Do not discontinue any of your asthma medications after starting Xolair without first speaking to your physician.

Xolair Side Effects and Warnings

Xolair is usually well tolerated.  The most common reported side effects include, but are not limited to:

• Injection-site reaction
• Viral infections
• Upper respiratory tract infection
• Sinusitis
• Headache
• Sore throat
• A rare side effect reported with Xolair is anaphylaxis (severe allergic reaction).

Malignant neoplasm was observed in 20 of 4127 (0.5%) patients treated with XOLAIR compared with 5 of 2236 (0.2%) control patients in clinical studies.

• The observed malignancies in patients treated with XOLAIR were a variety of types, with breast, non-melanoma skin, prostate, melanoma, and parotid occurring more than once, and five other types occurring once each.
• The majority of patients were observed for less than 1 year
• The impact of longer exposure to XOLAIR or use in patients at higher risk of malignancy is unknown

Oral Steroids

Uses of Oral Steroids

Oral steroids or injectable steroids are potent anti-inflammatory medications.  They work by turning off the body’s production of mediators that cause inflammation and subsequent symptoms of swelling, irritation, itching and pain.  Common conditions that require the use of oral or injectable steroids include asthma, moderate to severe allergic reactions, including allergic rhinoconjunctivitis and hives, as well as severe sinus conditions and skin reactions.  They are strong medications that usually start working within hours to days.

Taking Oral Steroids

It is important that you take these medications exactly how your physician prescribes them. They are most often given for periods of several days to two weeks, but some patients may require longer courses. If taken for longer than a week or two, your physician will likely recommend a weaning schedule. This schedule will instruct you or your child to take a gradually smaller dose each day to allow your body to gradually wean off the medication.  Steroids can be given as an injection or administered in tablet or liquid forms.

The most common corticosteroids prescribed are prednisone and methylprednisolone.

Oral Steroid Side Effects and Warnings

Oral or injectable steroids that are prescribed by physicians treating allergies or asthma are not related to performance enhancing medications (anabolic steroids) used by athletes or body builders.

Despite rumors to the contrary, steroids are safe medications when taken for short periods of time. They can also be used safely on a recurrent basis, although your allergist will monitor the amount of steroids prescribed and will try to minimize their use.

Steroids can have both short and long term side effects.  Short term side effects can include, but are not limited to, increased appetite, weight gain or fluid retention (usually temporary), red or flushed cheeks, mood changes and irritability, stomachache, and possibly temporary elevations of blood pressure or blood sugar levels.
 
If it is recommended that you or your child need to be on long term, daily corticosteroids, your physician will discuss with you the benefits and risks of long term use. Long term side effects can include, but are not limited to: weight gain, osteoporosis, fractures of the bones, cataracts, increased intra ocular pressure or glaucoma.  Patients on long term steroids (months to years) may experience easy bruising, thinness of the skin, hair growth and increased blood pressure.

Since steroids can temporarily lower your resistance to infections, they should be avoided, or minimized, with known infections such as chicken pox, shingles, or influenza.

In general, oral steroids should be taken with meals to minimize any stomach discomfort.

Nasal Corticosteroids

Uses of Nasal Steroid Sprays

Nasal corticosteroids, or nasal steroid sprays, are one of the most effective medicines used to treat allergic and non-allergic rhinitis, as well as nasal polyps and chronic sinusitis. They are designed to reduce inflammation in the mucosal lining of the nose.  Nasal corticosteroids work by turning off the production of mediators that cause inflammation, swelling, and mucous production. When taken regularly as a preventative, they can even decrease nasal “hyper- reactivity”, or the tendency for the nose to react upon exposure to allergens or non-allergic irritants.
 

Taking of Nasal Corticosteroids

Because nasal steroids are preventative, or prophylactic, they should be taken daily and over long periods of time, exactly as prescribed by your physician. Most nasal corticosteroids are dosed once daily. Patients can usually expect to see results from nasal coritcosteroids within one to two weeks.

Nasal Steroid Spray Side Effects and Warnings

Nasal steroids are considered very safe, even for long term use.  Chronic use of the recommended doses of nasal steroids rarely causes systemic symptoms. However, the occasional nose bleed is not uncommon, particularly when the relative humidity is very low. This is most common in the winter months when the heat is on. The likelihood of such nose bleeds can be reduced by directing the nasal inhaler nosepiece toward the lateral (outside) walls of the nose and away from the nasal septum (the cartilage dividing the nostrils).

Your allergist will periodically examine the nasal cavity of individuals on long-term nasal steroids looking for the very uncommon complication of mucosal ulceration.

Nasal Steroids are not related to performance enhancing medications (anabolic steroids) sometimes used by athletes or body builders.

Leukotriene Modifiers

Uses of Leukotriene Modifiers

Leukotriene modifiers (LTMs) are medications designed to block a chemical mediator in our body (leukotrienes) that causes mucous production, swelling of the lining of the sinuses and lungs, spasm of the lungs, and recruitment of cells that contribute to allergic inflammation.  Some leukotriene modifiers work by blocking production of leukotrienes while others block the receptor for the inflammatory mediators.

Leukotriene modifiers are approved to treat both nasal allergies and asthma.  Leukotriene Modifiers are available in the form of a pill or chewable tablet, however there is one leukotriene modifier that also comes as granules that can be mixed in food for young children.

Currently available leukotriene modifiers are:

• Singulair (Montelukast)
• Accolate (Zafirlukast)
• Zyflo (Zileuton)

Taking Leukotrience Modifiers

Take this medication exactly as instructed by your physician.  Leukotriene modifiers are used as a preventative for allergy or asthma symptoms and therefore should be taken daily.

Leukotriene Modifiers Side Effects and Warnings

Singulair (Montelukast) is well tolerated, can be taken with most other medications, and has a very good safety profile.

Accolate (Zafirlukast) has been associated with liver damage on rare occasions. If Accolate is taken concurrently with certain other medications, the effects of either drug could be increased, decreased, or altered. It is especially important to check with your doctor before combining Accolate with the following:

• Aspirin
• Blood-thinning drugs such as Coumadin
• Carbamazepine (Tegretol)
• Cyclosporine (Sandimmune, Neoral)
• Erythromycin
• Heart and blood pressure medications called calcium channel blockers, including Calan, Cardizem, and Procardia
• Phenytoin (Dilantin)
• Theophylline (Theo-Dur, others)
• Tolbutamide (Orinase)

Although rare, Zyflo (Zileuton) has been associated with elevations in liver function tests. All patients should have liver functions checked before they start this medication, as well as periodically during its use.  If Zyflo (Zileuton) is taken with certain other drugs, the effects of either could be increased or altered.

It is especially important to check with your doctor before combining Zyflo (Zileuton) with the following:

• Theophylline
• Coumadin
• Propranolol

Overall the most common side effects reported for these medications include:

• sinusitis
• upper respiratory infection
• sinus headache
• cough
• nosebleeds
• headache
• tiredness
• stomach ache
• ear infections

Inhaled Steroids

Uses of Inhaled Steroids

Inhaled corticosteroids (ICS) are one of the most effective medicines used to treat recurrent or chronic asthma. They are designed to reduce inflammation in the bronchial tubes of individuals with asthma.  ICS work by turning off the lung’s production of mediators that cause inflammation, swelling, mucous production, and eventual constriction or blockage of the medium to small airways in the lungs.

When taken regularly, they will even decrease bronchial “hyper-reactivity”, or the tendency for the bronchial tubes of asthmatic patients to spasm or constrict when exposed to allergens or irritants.

Inhaled corticosteroids are available in a meter dose inhaler (MDI or “puffer”) form, a dry powder inhaler, or as a nebulized medication.

How should you take this medication?

Because inhaled corticosteroids are preventative, or prophylactic, they should be taken daily and over long periods of time, exactly as prescribed by your physician. Most inhaled corticosteroids are dosed once or twice daily. Patients can usually expect to see results from ICS within one to two weeks. These medications should not be used for acute or sudden onset of asthma symptoms.

Your physician or nurse will direct you or your child in proper inhaler on nebulizer technique.  For young children, a spacer device (aerochamber or Inspirease) may be recommended to help facilitate delivery of medication to the lungs.  All patients should rinse their mouth and throat out with water or mouthwash after using these medications in order to prevent minor side effects, such as oral thrush.

Inhaled Steroids Side Effects and Warnings

In general, inhaled corticosteroids are considered quite safe. Because the medicine is inhaled directly into the lungs, resulting in minimal systemic absorption, and the fact that the dose delivered is so small, steroid side effects are minimized. The most common adverse effects include sore throat, hoarse or husky voice, and thrush (yeast infection of the throat).  Rinsing thoroughly after each use will minimize the likelihood of these side effects.

High dose and long term use of medications in the steroid family may affect bone growth, the density or strength of bones, and promote the growth of cataracts.  Patients on high doses of inhaled corticosteroids should have their growth monitored (for children), as well as bone density testing eye exams periodically. 

For the overwhelming majority of children who are on inhaled corticosteroids for asthma and/or nasal steroids for rhinitis, or nasal disease, height will not be affected. There is some evidence that children on inhaled corticosteroids may actually have some decrease in growth velocity in the first year of treatment. However, other studies of large numbers of children have shown that with years of inhaled corticosteroid use, expected final adult height was attained.

Bronchodilators

The Use of Bronchodilators

Bronchodilators are asthma medications designed to relieve asthma symptoms by relaxing the muscles that tighten around the airways. They act rapidly (usually within fifteen minutes to one hour) opening the airways, letting more air come in and out of the lungs. As a result, breathing improves. Bronchodilators also help clear mucus from the lungs. As the airways open, the mucus moves more freely and can be coughed out more easily.

Brochodilator Delivery

Most bronchodilators are delivered to the lungs by a metered dose inhaler (MDI), dry powder inhaler device, or by nebulization.  Meter dose inhalers are sometimes used with a spacer or chamber device to help facilitate delivery of medication, especially in children.  In younger children, your physician may prescribe a bronchodilator to be used in a nebulizer (a machine that aerosolizes or mists a liquid form of the medication).  Nebulization treatments can also be extremely helpful during an asthma exacerbation.

Types of Bronchodilators

Bronchodilator medicines, also called beta 2-agonists, come in both a short and long acting preparation.  The short acting forms are recommended to be used for “rescue” or to relieve the acute symptoms of coughing, wheezing or shortness of breath.  Short acting bronchodilators may be helpful for patients with exercise induced asthma if used approximately ten to fifteen minutes prior to exertion.

Short Acting Inhaled Bronchodilators

• Albuterol (Proventil HFA, Ventolin HFA, Accuneb)
• Alupent
• Combivent (combines a beta 2-agonist and an anticholinergic, see below)
• Duoneb (combines a beta 2-agonist and an anticholinergic, see below)
• Maxair
• Tornalate
• Ventolin
• Xoponex

Atrovent is another type of bronchodilator called an anti-cholinergic drug. It is available in both a metered dose inhaler and nebulizer solution. For asthma, it works best when used with a short-acting beta 2-agonist bronchodilator. It is important to note that it is not a quick relief medicine because it takes about 60 minutes before it begins to work. It is generally not as effective as beta 2 agonists in treating asthma.

Long-acting Beta 2-agonists Bronchodilators

 
The long-acting forms of beta 2-agonists are used to provide control, not immediate relief, of asthma. These drugs take longer to begin to work, but their effects last longer, even up to 12 hours. The long acting forms are designed to be almost exclusively used in conjunction with an inhaled steroid and often come in the same inhaler as a combination product (Advair, Symbicort).  Long acting bronchodilators should be used exactly how your doctor prescribes them, usually once or twice a day and on long term basis.

Long-acting Beta 2-agonists Bronchodilators include:

• Advair (combines salmeterol, a beta 2-agonist and fluticasone, an   anti-inflammatory drug)
• Serevent (salmeterol)
• Foradil (fomoterol)

Side Effects of Bronchodilators and Warnings

Patients taking bronchodilators have reported nervousness, shakiness, rapid heart rate or palpitations.  On rare occasions, patients may complain of headache or nausea.  Exceeding the recommended dose can elevate blood pressure or heart rate.

Theophylline

Theophylline is another type of bronchodilator that is occasionally used in difficult-to-control or severe asthma. Although it is rarely prescribed, it is sold under the brand names Uniphyl, Theo-Dur, Slo-Bid, and Theo-24, and is available as a pill or liquid. It is long-acting and is used to prevent asthma attacks. Theophylline must be taken daily to be effective.

Possible Theophylline side effects include:

• Nausea and/or vomiting
• Diarrhea
• Stomach ache
• Headache
• Rapid or irregular heartbeat
• Muscle cramps
• Jittery or nervous feeling
• Hyperactivity

Antihistamines

Uses of Antihistamines

Antihistamines are medications prescribed to treat multiple allergic conditions, including seasonal and year round nasal allergies, itching, hives, eczema, and allergic reactions.  Antihistamines work by blocking the action of histamine, a substance produced by our bodies during allergic reactions.  Histamine is the major chemical mediator responsible for many allergy symptoms including itchiness, sneezing, runny nose or eyes, and swellings.  Antihistamines commonly come in pill or liquid form but occasionally may be given during an emergency as an injection.  Some of these antihistamines are commonly combined with a decongestant such as pseudoephedrine.

Common antihistamines include:

• chlorpheniramine (Chlor-Trimeton)
• brompheniramine (Bromfed, Bromfenex, and Dimetane)
• clemastine (Tavist)
• diphenhydramine (Benadryl)
• hydroxyzine (Atarax)
• loratadine (Claritin, Alavert)
• fexofenadine (Allegra)
• cetirizine (Zyrtec)
• levocetirizine (Xyzal)

Taking Antihistamines

Antihistamines should be taken exactly as your doctor prescribes or recommends them.  They can be used on an as needed basis since they tend to have a rapid onset of action.  For patients with more severe allergic symptoms, antihistamines may be utilized on a daily basis.

Side Effects of Antihistamines and Warnings

Possible side effects of antihistamines generally include:

• sleepiness
• fatigue
• nervousness
• agitation
• dry mouth and eyes
• difficulty urinating
• thickening of mucous
• difficulty breathing
• upset stomach

Patients with these conditions may need to avoid antihistamines:

• Enlarged prostate
• Urinary tract blockage or difficult urination - Antihistamines may make urinary problems worse
• Glaucoma
• Intestinal obstruction
• Liver disease
• Kidney disease
• Antihistamines should be used with caution if patients are taking any of these medications
• Erythromycin
• Ketoconazole
• Central nervous system (CNS) depressants (medicines that cause drowsiness)
• Monoamine oxidase (MAO) inhibitors

Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your health care professional.

Common Allergy Symptoms

You can spot them from across the room - tissue in hand, sneezing, sniffling, blowing their nose, tearing, and rubbing their eyes. This is a common presentation for millions of children and adults who suffer from the misery of allergies. If fortunate, these symptoms are but a minor inconvenience, but, if severe, they can significantly affect one’s quality of life.

Allergies involving the nose (rhinitis) and eyes (conjunctivitis) are almost always caused by contact of an offending “allergen” to the mucous membrane lining of the nose or eyes. Constant exposure for the allergic individual can cause daily symptoms, resulting in what your physician would diagnose as persistent, chronic, or perennial allergic rhinitis. Common allergens responsible for these chronic symptoms may include house dust mites, mold spores, indoor pets, cockroach allergen, or feathers.

Symptoms of allergic rhinitis can also be acute or intermittent, presenting only when one is exposed to a relevant allergen. One of the most common presentations of allergies is seasonal allergic rhinitis or “hay fever”. As its name implies, symptoms will present during the pollen seasons, most typically in the spring during the tree and grass pollinating times, and in the fall when ragweed and other weed pollens are present.

The most common allergy symptoms from inhaled allergens, which may be present daily or intermittently, include:

• Itchy, swollen, red, tearing eyes
• Itching of the nose, ears, eyes, or throat
• Runny nose
• Sneezing
• Nasal congestion
• Persistent post-nasal drip

Food allergies can present with many different symptoms. They can range from mild to serious and they can present immediately or be delayed. Common symptoms may include:

• Tingling and itching of the mouth, lips, and throat
• Stomach cramping, diarrhea, or vomiting
• Skin rashes including urticaria (hives), swelling, or worsening of eczema
• Stuffy nose,  runny nose, or post-nasal drip
• Wheezing, tightness in the chest, or difficulty breathing

Children usually have the same symptoms as adults. Newborns and infants, on the other hand, often exhibit irritability (colic), increased spitting, and even projectile vomiting upon ingestion of a food allergen. Many infants and children diagnosed as having reflux are later found to have food allergies.

The most severe allergic reaction is called anaphylaxis. The most common causes of anaphylaxis include the ingestion of a highly allergenic food, such as peanuts, tree nuts, and shell-fish, or a medicine. The sting of a yellow jacket, wasp, hornet, or honeybee, or the bite of a fire ant can also result in a severe allergic reaction in a susceptible individual.

The symptoms of anaphylaxis vary from person to person. For some, they may be mild and include only generalized itching and urticaria (hives). In more severe reactions, however, they can include involvement of the respiratory, circulatory, and digestive systems, and can be fatal if not treated quickly and aggressively by the administration of epinephrine. Epinephrine can be self injected with the use of an EpiPen or Twinject. Symptoms of full blown anaphylaxis may include:

• Difficulty breathing
• Hives or swelling
• Tightness of the throat
• Hoarse voice
• Nausea
• Vomiting
• Abdominal pain
• Diarrhea
• Dizziness
• Low blood pressure
• Cardiac arrest
• Shock

Allergy symptoms can be obvious or quite subtle. If you or your child have recurrent, chronic, or difficult to treat symptoms which may be caused by allergies, consult a board certified allergist for diagnosis and treatment.

Childhood Asthma

Asthma is one of the most common medical problems in childhood.  According to statistics from the National Institutes of Health and the National Center for Health Statistics, asthma affects over six million children under the age of eighteen and is the third leading cause of pediatric hospitalizations. 

The direct medical costs of this condition have exceeded eleven billion dollars and the indirect costs (lost productivity of parents, for example) add another five billion in costs.  Childhood deaths from asthma are rare, but over four thousand people in the United States die each year from this disease.  Allergy specialists play a vital and crucial role in treating childhood asthma, and more importantly, preventing asthma symptoms. 

Symptoms of Asthma in Children

Asthma usually presents within the first few years of life. It commonly has its onset associated with an upper respiratory tract infection which may be caused by a variety of viruses, including the respiratory syncytial virus (RSV).  Children often present with the most prominent symptom being coughing, although wheezing and difficulty breathing may be present. 

Frequently, asthma symptoms are worse at night, and they can be precipitated or made worse with play/exertion, or emotions such as crying or laughter.  Shortness of breath and difficulty breathing are also common symptoms and may occur ten to fifteen minutes after exercise or play begins. 

If there is obstruction to breathing, small children may have flaring of the nostrils and some asthmatics will speak in short sentences or become agitated during episodes.  It is important to note that many asthmatics, especially children, may not recognize or report the signs of an asthma attack until they become quite severe.

Causes of Asthma

Upper respiratory tract infections, most frequently the common cold, are common triggers of asthma episodes in young children.  Allergies also play an important role in asthma attacks and in their chronic symptoms.  Common allergens include dust, dust mites, cat and dog dander, mold, cockroach, and seasonal pollens. 

Children with asthma are particularly susceptible to second-hand cigarette smoke.  Research has shown tobacco smoke directly correlates with wheezing early in life, as well as sick visits to the doctor and hospitalizations.  Poor air quality, strong odors such as household cleaners, and other airborne irritants play a role in many asthma exacerbations in young children. 

Diagnosis of Asthma in Children

Many children are diagnosed early in life with “Reactive Airways Disease (RAD) or “Recurrent Bronchitis”. It will be necessary for your allergist to take a detailed history of a child’s symptoms, perform a physical exam, and their response to medications in order to establish or confirm the diagnosis of asthma.  Chest x-rays are sometimes helpful in ruling out other causes of wheezing.  The allergist will also use pulmonary function testing to help decide on the diagnosis and the severity of a child’s asthma. 

Pulmonary function testing involves the patient blowing into a computer and can be used in children usually by the time they are over five or six years old.  Allergies often play a role in asthma for young children and your allergist may use allergy skin testing in the office to dust mites, mold, pollen, etc in order to help decide on the diagnosis. Based on this information, your allergist will then recommend a comprehensive treatment plan for your child with the goal of reducing or eliminating asthma symptoms.

Asthma Treatment For Children

Your asthma specialist’s goal is to control your child’s asthma symptoms and to allow him or her to live, play, and sleep without limitations.  A peak flow meter may be recommended as well as an asthma action plan.  Often times the specialist will educate parents on the proper use of inhalers, spacer devices such as the aerochamber and nebulizers.  Reliever medications such as beta agonists may be prescribed. 

For chronic symptoms, controller, or asthma preventative medications such as inhaled steroids on leukotriene blockers are often used.  Your asthma specialist follows specific guidelines set forth by the National Institutes of Health for young children with asthma. 

Prevention or further control of symptoms is helped by avoiding allergens and other airborne irritants, such as cigarette smoke and air pollution.

Asthma

The word asthma is derived from Greek and is literally translated as “panting” or “shortdrawn breath”. If you or your child has ever experienced an asthma attack, this translation seems quite appropriate. Yet asthma specialists are quick to point out that most asthma patients have more subtle symptoms and, only rarely, experience asthma “attacks”.

It is now recognized that the one thing that all asthmatics have in common is airway inflammation, resulting in hyper-responsiveness of the lungs to allergic and/or non-allergic stimuli. This inflammation occurs primarily in the medium to smaller bronchial tubes and, if untreated and persistent, can create a pattern of obstruction throughout the lungs.

This obstruction is caused by swelling of the lining of the bronchial tubes and mucous production within the bronchial tubes themselves, and/or by bronchial constriction, which is caused by the muscles around the bronchial tubes tightening and squeezing.

Both of these phenomena - the swelling and mucous production inside the tubes and the muscular tightening on the outside of the tubes- lead to airway obstruction, with subsequent wheezing, tightness in the chest, and difficulty breathing.

However, it is extremely important to recognize that all asthmatic patients will not present with signs and symptoms of airway obstruction. Patients with mild asthma, especially children, may present with a cough, and no other symptoms. Asthma represents a spectrum of severity, from mild to severe.

The presenting symptoms can vary from an exercise induced cough or a frequent nighttime cough in the mildest asthmatics, to severe breathing difficulties requiring hospitalizations in the most severe asthmatics.  Asthma is a common disease. In the United States, about 20 million people have been diagnosed with asthma; nearly 9 million of them are children.

Causes of Asthma

Because of the inflammation which occurs in the lining of the bronchial tubes, the airways of asthmatics tend to be highly reactive to a variety of stimuli, both allergic and non-allergic.

Allergies are one of the primary causes of asthma symptoms, especially in children. Although we tend to think of asthma as a disease of the lungs, physicians now realize our immune system is truly the driving force behind this condition. If a person has a genetic tendency for allergies and asthma, then any number of environmental triggers can play a role.

Common allergic triggers of asthma include:

• dust mites
• mold and mildew
• pet dander
• feathers
• cockroach
• weed, tree, and grass pollens
• occasionally certain foods

The response to allergens can be immediate (within minutes to hours), with the primary symptoms being caused by constriction by the bronchial smooth muscles. Exposure to allergens can also cause a slow build up of symptoms (days or weeks) as they fuel the inflammatory process. Often the springtime or autumn will bring exposure to large amounts of pollen that cause acute symptoms such coughing or wheezing, which may be short lived or persistent throughout the season. Patients also commonly report a worsening of preexisting asthma weeks or months after they purchase a new pet.

Approximately one half of all asthmatics have non-allergic asthma, i.e., their symptoms are brought on not by allergens, but by exposure to non-allergic triggers, or irritants. The classic non-allergic triggers would include: an upper respiratory viral infections (the common cold), exercise, laughter; cold air, exposure to cigarette smoke and other strong smells (perfumes, aerosols, cleaning products, etc.), and changes in the weather.

Recent research has shown more allergic asthma in urban versus rural areas. Some scientists believe the migration of people from farms and away from the tough and dirty environment of agricultural living has left our immune systems soft and unchallenged. They hypothesize that the “allergic” side of our immune systems has been allowed to over react since we no longer have to fight off other infectious diseases such as TB, or be exposed to the germs from the farm.

Asthma Diagnosis

The best way to determine if you or your child has asthma is to speak with your doctor. Your doctor, or an allergy and asthma specialist, will take a careful history looking for symptoms of airway inflammation. A careful exam of the entire respiratory and cardiac systems will also be performed. The asthma specialist will often have you or your child perform a lung function test by blowing into a spirometer to measure any airway obstruction.

Since allergies play a large role in asthma, allergy testing will be indicated in many cases.  Your doctor may also need to rule out other causes of breathing difficulties by checking on the health of your lungs and heart with X-rays or an EKG. Sometimes other conditions may induce asthma-like symptoms such as pneumonia, bronchitis, sinus infections, gastro-esophageal reflux (GERD), or heart disease, just to name a few.

The diagnosis of asthma in infants and young children can be especially challenging, due to the fact that lung function testing in young children is difficult. Therefore, the diagnosis of asthma may become evident only with the passage of time. Commonly, infants and young children are often diagnosed with “reactive airways disease” (RAD), which may eventually be confirmed as asthma. A strong family history may lead doctors to diagnosis asthma at an earlier age.

Asthma Treatment

Allergy and asthma specialist should be actively involved in formulating a comprehensive program to best manage your asthma. Depending on several factors, such as the frequently and severity of symptoms, and the objective measurement of lung function, your asthma specialist will decide whether one needs to be on daily (controller or preventative) medication(s), or, on an as needed (rescue) medication.

Controller Medications
Controller medications are usually prescribed for patients who have asthma symptoms consistently at least two or three days per week. Patients who require rescue medication to control night time cough or daily shortness of breath are commonly placed on these preventative medications.

Inhaled Corticosteroids
Physicians have found inhaled corticosteroids (ICS) to be the most effective controller medications. They are effective in controlling symptoms of asthma and improve lung function by reducing the inflammatory component of asthma. Due to the fact that these are prophylactic medications, they must be taken daily, exactly as prescribed. They are NOT to be used to treat an acute or sudden attack of symptoms. They have a very good safety profile and are appropriate even for young children and senior citizens.

Non-Steroidal Ani-inflammatory Medications
There are also non-steroidal anti-inflammatory medications available, but they are generally less effective than ICS in preventing symptoms.

These medications include:

• leukotriene blockers
• theophylline
• cromolyn
• nedocromil
• long acting bronchodilators

All of these medications are given on a daily basis and some may be taken in combination with ICS to provide additional control.

Bronchodilators
Rescue medications, often referred to as bronchodilators, are designed to provide immediate relief of bronchial constriction.

Examples of these medications include:

• albuterol
• xopenex
• adrenaline/epinephrine
• ipratropium

They may be given as inhalers or aerosolized to be used in a nebulizer.

Oral or Injectable Steroids
Oral or injectable steroids are often prescribed to rapidly reduce the airway inflammation during acute or chronic asthma. Contrary to popular belief, corticosteroids are extremely safe if given for short periods of time, even for several weeks. Long term use of steroids, on the other hand, can be associated with significant side effects. The use of these, and all medications, should be discussed with the prescribing physician.

Immunotherapy
An allergy and asthma specialist may recommend immunotherapy therapy for patients who have difficulty controlling their allergies and/or asthma. Allergy injection therapy works making the immune system more tolerant to the allergen(s) and thus decreasing the hyper responsiveness of the airway to allergens in the environment. Studies suggest that immunotherapy can be effective in preventing an allergic individual from developing asthma, or, by preventing asthma from getting worse.

Xolair
Xolair (Omilazimub) is a new treatment for asthma that is designed to help patients with the most severe asthma. It works by blocking the body’s overproduction of allergy antibodies. This form of therapy is generally reserved for the most severe asthma patients and usually is prescribed by an asthma or lung specialist.

Action Plan
Finally, a team approach with your physician may include an asthma action plan. Your doctor may give you a list of symptoms with corresponding recommendations about when to start medications, or when to seek medical attention. In addition, the action plan may include monitoring lung function at home with a peak flow meter. Peak flow meters are simple tube devices that measure airway obstruction by quantifying how much air a patient can blow out of his/her lungs.

This information may reveal worsening air flow, and acting on this information could likely prevent worsening asthma or an acute asthma attack.

Vasomotor Rhinitis

Vasomotor rhinitis (VMR), also called non-allergic rhinitis, is a form of chronic nasal inflammation characterized by nasal congestion, post nasal drip, runny nose, headaches, sinus pain and pressure or ear plugging. Examination of the nose usually reveals mild to moderate nasal obstruction due to swelling in the lining of the nasal passages and swelling of the nasal turbinates. This chronic low-grade inflammation results in “hyper-responsiveness” of the lining of the nose upon inhalation of a variety of nonspecific airborne irritants.

The differentiation between allergic and non-allergic rhinitis is not always readily apparent. An accurate diagnosis can be made only after a history which reveals the typical non-allergic triggers and after ruling out allergies by appropriate testing. On rare occasions, allergic and non-allergic rhinitis can co-exist.

Vasomotor rhinitis most commonly begins after puberty, usually in the second or third decade of life. It generally presents with mild symptoms but it may worsen in early adulthood. Symptoms may come and go or they may remain relatively constant for years. Rarely do symptoms become severe, although they can be chronic and bothersome enough to affect one’s quality of life. The symptoms are generally year-round and are somewhat better in the summer because of more stable weather and temperature conditions.

Causes of Vasomotor Rhinitis

The actual cause of this abnormality is unknown, although a hormonal etiology is suspected due to the fact that the vast majority of those with VMR are women. The onset of vasomotor rhinitis may be secondary to a viral illness, hormonal changes, or persistent exposure to nasal irritants.

Patients with chronic vasomotor rhinitis are more prone to develop nasal and sinus infections, ‘bad colds’, cough and headaches. With long-standing severe nasal inflammation, enlargement of the nasal turbinates or nasal polyps may occasionally develop. In the majority of cases, vasomotor rhinitis runs a benign, uncomplicated course.

Vasomotor Rhinitis Irritants

There are many nonspecific irritants which typically bother patients with VMR including tobacco smoke, perfumes, cleaning solutions, paint fumes, exhaust, air pollution, potpourri, new carpet, new fabrics, and other odors. Changes in the weather, i.e., changes in humidity, barometric pressure, and rapid changes in temperature can also bring on symptoms in susceptible individuals. Nasal symptoms can also occur after stimuli as mild chilling, drafts, cold feet, or other mild body temperature changes. Emotional responses of anger, fright, or even unpleasant anticipation and stress may make symptoms worse.

There is generally an absence of symptoms on exposure to various pollens, except during times of excessive pollen exposure when the pollen itself can act as an irritant, not an allergen. Dust, mold spores, and dander allergens should not bother one with VMR unless there is a concomitant allergy.

Vasomotor Rhinitis Treatment

Patients are more comfortable with the chronic use of a medication, such as nasal steroids, and avoidance of bothersome irritating factors. A cure is usually not obtainable, but a decrease in symptoms can be expected with the use of medications.

Sinusitis

Sinusitis is the inflammation of one or more of the paranasal sinuses, which may be the result of infection by bacteria, viruses, or fungi, or the result of allergic or autoimmune inflammation. Each year, over 36 million adults and children develop sinusitis. 

Nasal sinuses are hollow, air-filled cavities within the cheek bones that are lined with mucous membranes. Each of the four pairs of sinuses is connected to the nose in order to allowing mucus to drain and air to circulate. The primary function of these sinuses is to warm, moisten, and filter the inspired air. Healthy sinuses are sterile, meaning that they are devoid of bacteria, viruses, or other infectious agents.

Types of Sinusitis

Sinusitis can be divided into the following categories: acute, in which symptoms last less than four weeks; sub-acute, with symptoms lasting from 4 to 8 weeks; chronic sinusitis, with symptoms that last eight weeks or longer. Recurrent sinusitis is characterized by three or more episodes of acute sinusitis per year.

Sinusitis Symptoms

Acute sinusitis usually presents with symptoms of a common cold that do not seem to improve after 7-10 days. These symptoms may include:

• Nasal congestion and discharge
• Sore throat and postnasal drip (fluid dripping down the back of your throat, especially at night or when you lie down)
• Headache—pressure-like pain behind the eyes, toothache, or facial tenderness
• Cough, often worse at night
• Fever (may be present)
• Bad breath
• Fatigue and generally not feeling well

Symptoms of chronic sinusitis may be the same as acute sinusitis, but tend to be milder and more subtle. They may include:

• chronic nasal congestion
• post-nasal drip
• loss of smell and taste
• coughing

Causes of Sinusitis

Infection of the sinuses usually starts with a viral upper respiratory infection, commonly known as the common cold. The cold virus can cause damage to the lining of the sinus, predisposing the tissues to colonization with bacteria, a virus, or fungal spores. When infected by a pathogen or inflamed by allergies, the sinuses may become blocked with mucus or by swelling of the mucosal lining. In addition, if the small hairs, or cilia, located in the lining of the sinuses are not working properly, the mucus will not be efficiently removed from the sinuses, resulting in mucus accumulation and thickening, with resultant sinusitis.

Although viral upper respiratory infections are the most common cause of acute sinusitis, people with uncontrolled allergies have a higher likelihood of developing sinusitis.

Allergies trigger inflammation of the nose and lining of the sinuses, resulting in swelling and obstruction of the mucus flow patterns. This inflammation also prevents the sinus cavities from clearing out bacteria, and increases the chances of developing secondary bacterial sinusitis.

Patients with chronic sinusitis should be evaluated for structural problems in the nose. Narrow drainage passages, polyps, tumors, or a severe deviated nasal septum may predispose to one developing sinusitis. Surgical intervention is sometimes needed to correct these problems.

Sinusitis Diagnosis

Most cases of acute sinusitis can be diagnosed clinically, without the need for laboratory tests or x-rays. However, a simple sinus x-ray can confirm the diagnosis.  To make a diagnosis of chronic sinusitis, a physician will often need to take a detailed history and perform a physical examination. The physician will likely need to order imaging studies including a CT scan (which makes multiple precise images of the sinus cavities), or an MRI. A sampling of the nasal secretions or lining can sometimes be helpful in identifying the causative infective agent. Allergy testing may also be indicated when trying to identify an underlying predisposition to recurrent or chronic sinusitis.

As part of a complete examination, it may also be necessary to directly visualize the area where the sinuses and middle ear drain into the nose. This endoscopic examination is a simple and quick office procedure which involves inserting a narrow, flexible fiberoptic scope into the nasal cavity through the nostrils.

Treatment of Sinusitis

The treatment of both acute and chronic sinusitis generally requires a combination of therapies, with the goals of eliminating infection, reducing swelling and inflammation, and promoting drainage. In addition to prescribing an antibiotic when it is suspected that the sinusitis is caused by bacteria, your physician may prescribe a medication to reduce blockage or control allergies.  Nasal and sinus irrigation is highly recommended.  This is critical step to keeping the sinus passages open and promoting drainage. This medicine may be a decongestant, an expectorant (mucus-thinning medicine), or a cortisone nasal spray.

A short course of five days or less of a decongestant nose spray can be extremely helpful in keeping the nasal passages open, especially in acute sinusitis. Oral or injectable steroids are sometimes prescribed to reduce the inflammation in the mucosal lining of the sinuses, therefore enhancing drainage. The treatment of sinusitis can often be augmented by nasal irrigations with a buffered saline (salt water) solution. Breathing in hot, moist air can also help liquefy the sinus contents to promote drainage.

Allergic individuals may require long-term treatment to control and reduce nasal and sinus inflammation in order to prevent the development of sinusitis. This treatment may include environmental control measures to reduce exposure to allergens, the use of medicine to minimize allergic inflammation, and/or immunotherapy. Patients with vasomotor or non-allergic rhinitis are also at a higher risk for sinusitis due to chronic airway inflammation. Besides using anti-inflammatory nose sprays, these individuals should avoid environmental irritants such as tobacco smoke and strong odors, which may increase symptoms.

Consultation with an ear, nose, and throat physician may be necessary for recurrent or difficult to treat chronic sinusitis. One or more obstructed and infected sinuses which does not respond to aggressive medical therapy may require surgical intervention.

Pollen Allergy

During the Spring and the Fall seasons, it is estimated that 36 million Americans suffer from pollen allergies.  These pollen allergies typically present themselves as Hay fever, otherwise known as seasonal allergic rhinitis or pollinosis.

Pollen Allergy Symptoms

Symptoms of seasonal allergic rhinitis are caused when a person’s immune system mistakenly identifies pollen as an intruder and produces antibodies specific to that allergen. During subsequent exposure and inhalation of the pollen into the nose or lungs, a series of immunologic reactions occur, resulting in the release of histamine and other chemical mediators of inflammation. These mediators are responsible for the inflammatory symptoms of allergy. And so with the change of seasons, both children and adults begin to exhibit symptoms of pollen allergies:

• sneezing
• runny noses
• nasal congestion
• watery eyes
• itchy nose, eyes, ears, and/or throat
• exposure to pollen can also result in seasonal asthma

Which Pollens Cause Allergies?

The particular pollens responsible for seasonal allergy symptoms are the extremely light and airborne weed, tree, and grass pollens. Under ordinary circumstances, gentle breezes carry these microscopic male reproductive cells to female plants during the season of pollination.

The problem begins when these pollens, destined to land on a female plant, are breathed into the nose or lungs, or are exposed to the eyes of a pollen allergic individual. As opposed to the weed, tree, and grass pollens, flowering plants generally do not cause problems for the pollen allergic individual because their pollen grains are too heavy to remain airborne. They depend on insects, not the wind, to carry their heavy, waxy pollen granules from plant to plant.

When Do Plants Pollinate?

Several factors affect the timing and intensity of the pollen season. The time when a given species of plant pollinates is determined by the relative length of the days and nights. In general, the same plant will pollinate earlier in the south and later in the north. Weather conditions, especially rainfall or lack thereof, plays a role in how much pollen a plant produces. This is thought to be the primary determining factor contributing to the wide fluctuation in pollen counts from year to year.

Trees typically begin to pollinate in the late winter or early spring and reach their peak pollen production in early and mid spring. But, as the tree pollen counts moderate and diminish, those with spring allergies usually do not get a much of an allergy break, as the grasses start to pollinate on the heels of the tree pollen season. Grass pollination peaks in late spring and early summer but can continue through the summer season. Ragweed, the main culprit of the weed family in most of the United States, begins to pollinate in mid-August and can continue though October.

Some of the most common trees which pollinate in the early spring to late spring include oak, birch, cedar, cypress, elm, hickory maple, poplar, sycamore, and walnut. From late spring through the summer, the allergenic grasses might include Bermuda, timothy, sweet vernal, orchard, blue, red top, and rye. The most common weeds, whose pollinating season is from late summer to mid autumn, are ragweed, pigweed, cockleweed, Russian thistle, sagebrush, and tumbleweed. However, some trees, grasses, and weeds, are particular to certain geographic area of the United States. For example, in the southwest, western cedar pollen is a major cause of problems, yet this tree and its pollen is not found in New England.

Pollen Counts

Pollen counts can be a valuable tool for allergy sufferers during the pollen season. These counts can help allergy sufferers plan outdoor activities on days and times when pollen is least likely to cause problems and to avoid being outdoors on days when the count is extremely high. Local pollen counts are usually available for most large metropolitan areas.

Pollen Allergy Treatment

A common misconception is the notion that if I or my child is allergic to oak tree pollen and I have oak trees in my yard, it would be helpful to cut them down. Or similarly, if I or my child is allergic to the pollen of bermuda grass and my lawn is bermuda, I need to remove it, or even move. These conclusions are incorrect. It matters not whether the source of the pollen is in your yard or fifty miles away.

The pollen one breathes may have come from anywhere, even a location hundreds of miles away. A sobering statistic: A single ragweed plant can produce approximately a billion pollen grains per season and can travel up to 400 miles from its source!

How to Minimize Pollen Exposure

In your home, keep all windows closed and run your central air conditioning or a window unit for air circulation and filtration. Replace your furnace filters or wash electrostatic filters regularly to help clean pollen out of the air. It can also be helpful to use vent filters on the room vents to catch any pollen which might not have been removed by the furnace filter. Run a HEPA air cleaner in the bedroom to help eliminate the pollen that makes its way into the home.

If possible, try to avoid outdoor activities which will cause the pollen on the ground to become airborne, such as mowing the lawn, or raking or blowing leaves. If you must work outdoors, especially if the pollen count is extremely high, wear a pollen mask. Also, it is a good idea to take a shower when you come inside to remove pollen from your hair and skin. Also, irrigate your nose to remove pollen from your nasal passages.

As with any allergy which cannot be “cured” by total avoidance of the allergen(s), the best treatment option for season pollen allergies is a comprehensive approach, which includes environmental control (minimizing exposure to whatever degree possible), pharmacotherapy (the use of medicine), and possibly immunotherapy ( desensitization to the allergens). Your allergist will play the key role in recommending the best therapy for you or your child with the goal of making the spring and fall glorious seasons once again.

Pet Allergy

According to published studies, between 10-15% of the general population are allergic to cats and dogs. This high incidence of animal allergy, coupled with the fact that approximately 50-70% of homes have a dog or cat living indoors, makes pet allergy a major health consideration. It has been estimated that of the two million people allergic to cats, at least 1/3 of them live with at least one cat in the home. And, to make matters worse for the allergic individual, many homes where there are no indoor pets will still contain enough allergenic pet proteins to cause allergic reactions.

Pet Allergy Causes

Allergy to cats is twice as common as allergy to dogs. Regardless of the animal or species, it is likely that the cause of the allergic reaction is not the hair or fur at all.  One highly allergenic source is the dander or old skin scales of the animal. These particles are deposited wherever the pet goes - on the bed, the couch, and in the carpet. 

Dander allergens are extremely small and easily become airborne, eventually depositing themselves and clinging to furniture, draperies, wall coverings, and even the walls themselves. Because of its stickiness, the allergenic dander can remain in the house for six to twelve months or longer after the animal has been removed from the house.  In cats and dogs, saliva and urine are also potential sources of allergens. They are deposited on the fur through licking and urination. When the hair or fur dries, the microscopic particles flake off, become airborne, and become readily accessible to the airway of the allergic individual.  The major cat allergen is called Fel d 1, and is formed in the sebaceous glands of the skin and is present in saliva. Fel d 1 is deposited on the fur from sebaceous gland secretions and through saliva when cats lick themselves clean. The major dog allergen has been identified as Can f1.

Pet Allergy Symptoms

Some people who are allergic to animals will begin to have symptoms immediately upon entering a home or room where a pet resides. Symptoms might include the acute onset of itchy, watery eyes, itchy nose and throat, sneezing, runny nose, and nasal congestion. Even asthma symptoms, including coughing, wheezing, tightness of the chest, and difficulty breathing can be induced almost immediately upon exposure.

Unfortunately, if one is sensitive enough, it does not take a lot of animal dander to cause an allergic reaction. The allergen is so small and light that it remains airborne for long periods of time, making it readily available to be breathed in and begin causing a problem.On the other hand, many pet allergic individuals will not react acutely when exposed to an animal. Because of constant exposure, they may react, over time, by having daily, chronic symptoms such as persistent nasal congestion, runny nose, itchy eyes, nose, and palate, as well as coughing, wheezing, or shortness of breath.

Are Certain Dogs and Cats “Non-allergenic”?

Unfortunately, there are no known breeds of either cats or dogs that do not produce allergenic dander. It must be remembered that allergies can also be produced by exposure to proteins in pet hair, saliva, and urine. Therefore, every cat or dog has the potential for causing allergies. Patients often comment that “I am allergic to my neighbor’s cat or dog, but I am not allergic to my own”. This may be explained by some species differences, or possibly due to some desensitization which may have taken place with one’s own pet.

Bottom line: If you are allergic to dogs or cats, it is not advisable to own one, even if it is from a species that reportedly produces less allergen.

Pet Allergies in the Home of a Non-pet Owner

Even if you have never had an indoor pet, it is likely that you have detectable pet allergen in your home, and maybe even enough to be causing chronic respiratory symptoms. Since dander is very small, light, and sticky, it can attach itself to your or your child’s clothes and be deposited in your house unknowingly. And if one has outdoor animals, their allergens will inevitably be carried into the home by those who have direct contact with the animal, especially children.

An important fact to remember is that many school classrooms have dog and cat allergens in high enough concentration to cause allergic reactions.  It has also been reported that in some school classrooms, there is as much cat and dog allergen as in homes where cats and dogs reside!

Pet Allergy Treatment

The cornerstone of allergy treatment is to avoid or minimize exposure to known allergens to the maximum degree possible. Therefore, when an allergy specialist confirms the diagnosis of pet induced allergy, the doctor has the difficult task of making it clear that the patient will likely continue to have allergic reactions as long as the pet remains in the home. Recommending that the pet be removed from the home can be a difficult task, as families become emotionally attached to their pets, and the pet is commonly described as “a member of the family”. Most doctors know that family pets often win out and remain in the home, so the doctor can only suggest the best ways to live with the pet.

If the pet does remain in the house, it is not unreasonable for the allergist to insist that the animal never come in the bedroom of the allergic sufferer. This “compromise” can be helpful, although generally not curative. The allergic individual should endeavor to create a totally allergy free zone in his or her bedroom, the room where one spends a great percentage of their life.

Removing Pet Dander From The Home

The bedroom of a pet allergic individual should be cleaned frequently. All hard surfaces in the bedroom should be wiped with a moist cloth to remove the small and sticky animal dander which has likely adhered floors, carpets, walls, furniture, ceiling fans, lamp shades, and even ceilings. In addition, every part of your home, especially the bedroom, should be vacuumed with a HEPA vacuum cleaner. If you have hard surface floors, they should be mopped weekly. In addition, it may be helpful to run a HEPA air cleaner in the bedroom. Pets should be washed or treated with a dander removal product every two weeks. This removes much of the allergenic dander from the fur before it becomes airborne.

Mold Allergy

Mold, also called mildew or fungus, is an organic substance that is often recognized by its musty smell. In most cases, however, we breathe mold spores in our homes, schools, work places, and even outdoors, and are not even aware of their existence. That is, until we begin to have allergic symptoms from inhaling the mold spores.Because mold spores are ubiquitous to most environments, the mold allergic individual can be symptomatic daily, or can exhibit symptoms when spore counts are highest, generally from July to late summer.

The allergenic component of the mold is the reproductive seeds called spores. These spores are extremely unique and their identification can only be differentiated microscopically based on the size, shape, color, and other characteristics. Each spore has the capability of germination and creating millions of new spores. These spores become problematic when they become airborne and are breathed into the nose or lungs of the mold allergic individual. One can inhale up to one-half million more spores per minute without even knowing it!  There are literally thousands of types of molds, but only a few are responsible for the majority of allergic reactions. The major culprits are: Alternaria, Cladosporium (Hormodendrum), Aspergillus, Epicoccum, Helminthosporium, Penicillium, Fusarium, Mucor, Rhizopus, and Aureobasidium (Pullaria).

Where Are Mold Spores Found?

Molds live on a diet of moisture and oxygen and are therefore found in damp areas, both indoors and outdoors. An environment with high humidity, especially indoors in homes and “sick buildings”, sets the stage for mold growth and the potential for adverse health affects. The U.S. Environmental Protection Agency estimates that between one-third and one-half of all buildings in the United States have enough moisture to facilitate mold growth.

In the home, bathrooms (especially shower stalls), damp basements, crawlspaces, and kitchens are the most likely sources of mold spore production. If any part of the home has experienced water damage, it is almost certain that mold can be found in that area. Fungi on house plants and soil can also be a source of exposure, but generally only if the soil is disturbed.

Outdoors, mold and mildew will be found on rotting logs and fallen leaves, especially in shady, moist areas. Compost piles, grain bins, and silos will also contain extremely high levels of mold spores. Some molds attach themselves to grains such as wheat, oats, corn and barley. It is not surprising that farmers, dairymen, loggers, mill workers, greenhouse employees, and bakery and brewery workers are at high risk for developing mold spore allergies.

Mold Allergy Symptoms

The symptoms of mold allergy are generally indistinguishable from those of dust mite allergy or other sources of perennial or year-round allergies, including runny nose, nasal congestion, sinus pain and pressure, post-nasal drainage, sneezing, and itching of the eyes, nose, or throat. A more serious complication which can result from the inhalation of mold spores is chronic fungal sinusitis. When breathed into the lungs, mold spores can result in recurrent or chronic asthma. In rare cases, inhalation of the mold spores of the aspergillus family can result in allergic bronchopulmonary aspergillosis.

There is only weak evidence that the eating of food fungi such as mushrooms or yeast cause symptoms of mold allergy. A more likely explanation for symptoms which result from the ingestion of food fungi are the foods’ direct effect on the blood vessels, such as the effect of histamine which can be produced with the fermentation of red wines. It is important to note that there is no correlation between an allergy to the mold penicillium and the antibiotic, penicillin.

Mold Allergy Treatment

Once the diagnosis of mold allergy is made by your allergist, it is important that all efforts are made to minimize exposure to mold spores, especially in the home.  In practical terms, however, it is impossible to totally rid one’s home or environment of mold, but lessening exposure can go a long way toward allergy relief. It is therefore worthwhile investing the time and effort in trying to make the home as mold free as possible.

Firstly, one should repair any leaks or problems leading to mold growth in your home immediately, and remove all materials that may have been damaged by water, including wood surfaces or flooring, wall paper, and carpet. Keep exterior surfaces of your home properly sealed, and avoid piling wood or leaves near your home, as they collect moisture. Clean showers and tubs at least once a month with bleach, and wash out garbage receptacles frequently. Reducing the number of indoor plants can also reduce the mold spores circulating in the air.

Make sure your home is adequately ventilated. Hidden mold often grows inside HVAC systems. An allergy relief vent filter will trap the mold before it reaches you.

A HEPA air purifier will remove a minimum of 99.97% of all mold spores in your home. Whole house HEPA filters are available for the central HVAC system, or relatively inexpensive portable units are available for the individual rooms. A HEPA filtered vacuum cleaner can be very effective in removing microscopic mold spores deep in carpets and rugs.

It is very helpful to monitor the humidity in the home with a hygrometer, or humidity gauge. Since mold needs high moisture content to grow, keep the indoor humidity between 40 and 50 percent. If the humidity is above 50-55%, use a dehumidifier to remove excess moisture from the air.

Mattress and pillow encasements should be placed on bedding made of polyurethane and rubber foams, as these materials are especially prone to fungus invasion. These encasements also serve as a barrier between the allergic patient and dust mites, another common cause of year-round allergy symptoms.

Mold problems affecting less than 10-square foot areas are generally manageable by homeowners. When the affected area is greater than this, the EPA and other agencies advise seeking professional assessment. If you are concerned with specific items that may have mold infestation, particularly those of sentimental or monetary value, consult a specialist to help you clean these items.

Dust Mite Allergy

Dust mites are microscopic organisms closely related to spiders and ticks. The two house dust mite species found in North America are Dermatophagoides farinae and Dermatophagoides pteronyssinus. Quite appropriately named, dermatophagoides means “skin eater”. These creatures are scavengers that feed primarily on the dead skin that falls off the bodies of humans and animals. Humans shed two to three pounds of skin cells a year, so it is no wonder that mites are found around the places where we spend most of our time, for instance, in our beds.

Dust mites thrive in warm, humid, dark conditions. They live and multiply inside of the fibrous materials that fill our homes: bedding, upholstered furniture, carpets, stuffed toys and old clothing. Depending on the age of a mattress, experts have estimated that it may contain between one million and ten million house dust mites!

Dust Mite Allergy Symptoms

If you or your child awakens each morning with nasal congestion, sneezing, runny nose, or itchy eyes, then dust mites are a likely cause. But, it is not actually the living dust mites that cause the symptoms that plague 20 million Americans. It is their even smaller waste particles. During its 80 day lifespan, one dust mite can produce an estimated 1,000 allergenic fecal waste particles. Everyday activities like walking across the room, turning over in bed, and especially household chores like vacuuming will stir up dust mites’ tiny waste particles causing these highly allergenic particles to become temporarily airborne for us to breathe.

Allergy to dust mites characteristically causes daily and year-round symptoms. These symptoms might include sneezing, runny nose, nasal congestion, as well as itchy eyes, nose, and throat. Inhalation of dust mite allergens can also be the cause of airway inflammation which can lead to asthma symptoms such as coughing, wheezing, and difficulty breathing. It is now recognized that exposure to mites can also exacerbate the skin irritation and inflammation of eczema, especially in young children.

Dust Mite Allergy Treatment

If it has been determined that you and/or your child are allergic to dust mites, then it is imperative that you do everything possible to minimize exposure to dust mites. Recognize, however, that it is impossible to totally avoid exposure to dust mites and it is unreasonable to expect one to “dust proof” an entire house. However, there are some very important things which can and should be done in one’s bedroom to significantly reduce exposure to dust mites and their allergenic waste products. Put all of your efforts into eliminating dust mites in the bedroom of the allergic individual. We all deserve to sleep in a healthy and allergy-free environment.

The following recommendations are a common sense approach to minimizing exposure to dust mites in the bedroom. Even if dust mite allergies have not yet been confirmed by allergy testing, it is prudent to initiate the following:

Preparation

• Empty the bedroom as much as possible.
• Empty and clean all closets and, if possible, store unused contents elsewhere.
• Keep clothing in zippered plastic bags and shoes in boxes off the floor.
• Remove all rugs.
• Remove carpeting, if possible.
• Clean and scrub the woodwork and floors thoroughly to remove all traces of dust.
• Wipe wood, tile, or linoleum floors with water, wax, or oil.
• Keep the doors and windows closed until the dust-sensitive person is ready to use the room.

Maintenance

• Wear a filter mask when cleaning.
• Clean the room thoroughly and completely once a week.
• Clean floors, furniture, tops of doors, window frames and sills, etc., with a damp cloth or mop.
• Carefully vacuum carpet and upholstery regularly.
• Use a special filter in the vacuum or a HEPA vacuum cleaner.
• Wash curtains often at 130 degrees Fahrenheit.
• Air the room thoroughly.

Carpeting and Flooring

• Carpeting makes dust control almost impossible. Although shag carpets are the worst type to have, if you are dust sensitive, all carpets trap dust mites and are potentially problematic. Therefore, your allergist will likely recommend hardwood, tile, linoleum, or any other hard surface floor.
• Treating carpets with a commercially available tannic acid solution can be helpful in eliminating some dust mite allergen. Tannic acid, however, is not as effective as removing the carpet, is irritating to some people, and must be applied repeatedly.

Beds and Bedding

• Encase mattresses and all pillows in zippered, dust-proof or allergen-proof encasements! This will create a natural barrier between the dust mites and the allergic individual.
• Use only washable materials on the bed. Sheets, blankets, and other bedclothes should be washed frequently in water that is at least 130 degrees. Lower temperatures will not kill dust mites.If you set your hot water temperature lower (commonly done to prevent children from scalding themselves), wash items at a laundromat which uses high wash temperatures.
• Use only synthetic pillows and mattress pads.
• Avoid fuzzy wool blankets or feather or wool-stuffed comforters and mattress pads. Hypo-allergenic blankets and comforters are recommended.

Furniture and Furnishings

• Keep furniture and furnishings to a minimum.
• Avoid upholstered furniture and blinds. Use leather furniture, when possible.
• Use only a wooden or metal chair that you can wipe with a wet cloth.
• Use only plain, lightweight, washable curtains on the windows.
• Keep clutter to a minimum.

Air Control

• Although air filters are not directly helpful for dust mites (since they are not airborne), they can reduce the levels of allergens in the bedroom.  Electrostatic and HEPA (high-efficiency particulate absorption) filters can effectively remove many other allergens from the air.
• A dehumidifier may helpful as house mites require high humidity to live and grow. It is recommended that the relative humidity be below 50%.

Children’s Rooms

• Keep toys that will accumulate dust out of the child’s bedroom.
• Minimize the number of washable stuffed animals in the rooms.

Allergic Rhinitis (Hay Fever)

One of the most common presentations of allergies in both children and adults involves the nose and eyes. The clinical condition involving nasal symptoms is called “rhinitis” and we call allergic involvement of the eyes “conjunctivitis”. We all know people who suffer from allergic rhinitis, or “hay fever”. You can spot them from across the room- tissue in hand, sneezing, sniffling, blowing their nose, tearing, and rubbing their eyes. If fortunate, these symptoms are but a minor inconvenience, but, if severe, they can significantly affect one’s quality of life.

Acute Rhinitis and Chronic Rhinitis

Allergies involving the nose and eyes are almost always caused by the contact of an offending allergen to the mucous membrane lining of the nose or eyes. Constant exposure to allergens can cause daily symptoms, resulting in what your physician would diagnose as “persistent, chronic, or perennial allergic rhinitis”.  Allergens responsible for these chronic symptoms may include house dust mites, mold spores, cockroach allergen, feathers, or indoor pets.

Symptoms of allergic rhinitis can also be acute or intermittent, presenting only when one is exposed to a relevant allergen. It is not uncommon for a cat allergic individual to have an acute episode of allergic rhinitis (and even asthma) when they enter into the home where a cat resides. The same might occur when a grass allergic person cuts the grass or enters a barn where they are exposed to hay. Typically, symptoms are short lived in this scenario, but they can be quite severe.

“Seasonal allergic rhinitis”, as its name implies, will manifest itself usually during the pollen seasons, most typically in the spring and fall. Exposure to tree pollens is generally responsible for late winter and springtime symptoms and grass pollens are generally the cause of springtime and early summer symptoms. Flare ups in the fall are typically due to weed pollens and high mold spore exposure.  Symptoms of seasonal allergic rhino-conjunctivitis can be quite intense, and can last for weeks to months, if not treated.

Other Types of Rhinitis

There is another common condition that can present with symptoms quite similar to those of allergic rhinitis, but it is really not an allergy at all. This condition is called Vasomotor (VMR) or Non-Allergic (NAR) Rhinitis, and is frequently misdiagnosed as allergies.

VMR presents most commonly in women, with its onset typically in the second or third decade of life. Even though its cause has not been established, the lining cells of the nose and sinuses become hypersensitive to the inhalation of nonspecific irritants. As opposed to the inhalation of allergens resulting in a classic allergic reaction, the inhalation of nonspecific irritants results in the inflammation of the mucous membranes of the upper respiratory anatomy.

The airborne irritants most likely to produce symptoms are cigarette smoke, perfumes or colognes, other strong fragrances present in aerosols and cleaning solutions, scented candles, potpourri, new carpets or fabrics, and diesel fumes, to name a few. Symptoms can also result from weather conditions, such as changes in temperature, humidity, or barometric pressure.

Allergic Rhinitis Diagnosis

Allergic rhinitis is actually one of the easiest diagnoses for an allergist to make. If the medical history suggests allergic rhinitis, the allergist is likely to perform allergy testing in order to confirm the diagnosis, identify the offending allergen(s), and ascertain the severity of the allergy. The preferable testing method by most allergists is skin testing. This method allows the testing of multiple allergens with the results being available immediately. Alternatively, similar results can be obtained through a blood test called RAST or ImmunoCap.

Allergic Rhinitis Treatment

Once the relevant allergens have been identified, a comprehensive treatment plan will be recommended. Treatment options fall into three categories:

• environmental control
• pharmacotherapy
• immunotherapy

One, two, or all three of these options may be recommended, depending on multiple factors such as the severity and chronicity of symptoms, results of past treatment, and the effect that these symptoms have on one’s quality of life.

Environmental Control
The concept of environmental control is quite simple: one needs to minimize exposure to allergens to which they are sensitive.  As simple as this is conceptually, it may be quite difficult, if not impossible, to implement in many cases. The classic case is the patient who is cat-allergic and lives in a home with a cat. Removing the cat from the home can in some cases be curative, but, in reality, there is often great resistance to the recommendation to remove the cat from the home due to the attachment a family develops with a pet, and the resultant emotional issues that can ensue. And, there are allergens which are impossible to totally eliminate from the home such as house dust mites and mold spores. Fortunately, however, there are effective methods to reduce exposure to these allergens.

Pharmacotherapy
In the arena of pharmacotherapy, there are many medicines available which are quite effective in minimizing or eliminating the symptoms of allergic rhinitis. These generally fall into the categories of antihistamines, steroid nasal sprays, and other non-steroidal blockers of inflammation.

Immunotherapy
As important as environmental control and pharmacotherapy are, neither of these approaches addresses the actual cause of the allergy, i.e., the immune system’s over-response to things (allergens) that it should be able to tolerate without inducing symptoms. The third treatment option, immunotherapy, or desensitization, is the only treatment that addresses the actual cause of the problem.

Once the cause of the rhinitis has been identified, your allergist will recommend a treatment plan designed to minimize or eliminate your rhinitis and/or conjunctivitis symptoms.

Common Stinging Insects

There are a variety of different stinging insects that produce venom and may cause an allergic reaction.  It is not uncommon for one to be allergic to more than one species of hymenoptera, but due to the fact that the chemical composition of the venom produced by these insects is different, one may be allergic to only one of the following, and not to others. If one has had an allergic to a stinging insect, he or she should be tested to all stinging insects by a board certified allergist in order to determine the risk of a future reaction and to consider treatment for this potentially dangerous allergy.

Hornet

Hornets, including yellow and white-faced hornets, build paper-mache type nests in trees and shrubs. These insects may be very aggressive, and a sting may be provoked by a minor disruption in their environment. Some hornets look very much like yellow jackets and can be difficult to distinguish.

Honey Bee

Honey bees are only capable of stinging a person once. The honey bee is the only stinging insect that leaves its stinger and venom sac in the skin of its victim, due to the barbed configuration of the stinger. As the honey bee flies away, it become eviscerated and dies.

Yellow Jacket

Yellow jackets are wasp-like insects that live in mounds built into the ground, They tend to be very aggressive insects, and will often sting without provocation. They are commonly found around garbage cans and picnic areas where food and sugary drinks are abundant.

Wasps

Wasps build honey-comb nests under the eaves of a house, or in a tree, shrub or under patio furniture. They tend to be less aggressive than yellow jackets and hornets, and mostly feed on insects and flower nectar.

Bumblebees

Bumblebees rarely sting people because they are non-aggressive and typically mild mannered. They generally will sting only if provoked. They nest in the ground or in piles of grass clippings or wood.

Fire Ant

Fire Ant bites are generally quite painful. It is not unusual to sustain multiple bites, generally on the feet and hands. The bite of a fire ant characteristically will form into a white pustule within a day or two.  Scratching these pustules can lead to local infection and scars.

Egg Allergy

Egg allergy usually begins early in life and usually presents in infancy as a rash, including eczema or atopic dermatitis, or gastrointestinal symptoms.  Presenting symptoms are usually mild, but, on rare occasions, anaphylaxis can occur in highly sensitized individuals. Symptoms usually decrease over time and may completely disappear by age five to seven years of age. In some cases, the allergy may be life-long.

Egg white, especially raw or poorly cooked, is generally more allergenic than egg yolk, which explains why tasting raw batter, playing with egg shells, or eating egg white icing may induce acute symptoms. Mildly egg allergic children can often eat food prepared with small amounts of egg, such as cakes and muffins, without an immediate reaction. However, these trace quantities may aggravate eczema, and may cause the egg allergy to stay longer. Therefore, unless told otherwise, all eggs should be avoided, even in traces amounts for the first few years of life.

The measles, mumps, and rubella vaccine (MMR) is normally cultured in an egg medium. Severe allergic reactions to the MMR have been reported, but they are extremely rare, even in egg allergic children. In infants who have demonstrated an extreme allergic to eggs, it is often recommended that they be skin tested to the vaccine prior to it being vaccinated. The allergist will then decide if the injection should be given in its entirety or in split doses. Almost all egg allergic children can be safely immunized to the MMR vaccine.

Food Label Ingredients to Avoid for an Egg Free Diet

• albumin
• egg white
• egg yolk
• dried egg
• egg powder
• egg solids
• egg substitutes
• eggnog
• globulin
• livetin
• lysozyme (used in Europe)
• mayonnaise
• meringue
• ovalbumin
• ovomucin
• ovomucoid
• ovovitellin
• Simplesse

Other Possible Egg Products

• A shiny glaze or yellow baked goods may indicate the presence of egg.
• Simplesse is used as a fat substitute and is made from either egg or milk protein.
• Egg white and shells may be used as clarifying agents in soup stocks, consommes, bouillons, and coffees.
• Caution should be used if consuming these products.

Create an Egg substitute

For each egg, one of the following may be substituted in recipes:

• 1 tsp baking powder, 1 Tbsp water, 1 Tbsp vinegar
• 1 tsp yeast dissolved in 1/4 cup warm water
• 1 Tbsp apricot puree
• 1 1/2 Tbsp water, 1 1/2 Tbsp oil, 1 tsp baking powder
• 1 packet gelatin, 2 Tbsp warm water (do not mix until ready to use)

Wheat Allergy

Wheat allergy refers specifically to adverse reactions involving immunoglobulin E (IgE) antibodies to one or more proteins of wheat, including albumin, globulin, gliadin and glutenin (gluten). The majority of true allergic reactions to wheat involve the albumin and globulin fractions. Gliadin and gluten may also, rarely, induce an allergic reaction. Allergic reactions to wheat are most commonly caused by ingestion of wheat-containing foods, although inhalation of flour containing wheat (Baker’s asthma) can induce symptoms.

How Common is Wheat Allergy?

There are no accurate figures for prevalence of wheat allergy. Clinical experience suggests that wheat allergy is relatively uncommon. However, it may be more common in certain subgroups. For example, wheat allergy is responsible for occupational asthma in up to 30% of individuals in the baking industry.

Wheat Allergy Symptoms

An allergic reaction to wheat usually begins within minutes or a few hours after eating or inhaling wheat. The more common symptoms involve the skin (hives, atopic eczema, and swelling), gastrointestinal tract (oral allergy syndrome, abdominal cramps, nausea and vomiting), and the respiratory tract (asthma or allergic rhinitis). Allergic reactions to gliadin or gluten can cause hives and swelling or life-threatening anaphylaxis in association with exercise. Other gluten-containing cereals (rye, oats and barley) may also cause these symptoms due to cross-reactivity of the allergens.

Wheat Allergy Diagnosis

The diagnosis may be easy if a person always has the same reaction after eating wheat-containing food or eats wheat infrequently. But more often the diagnosis is difficult because wheat is such a common food. Diagnosis usually entails clinical evaluation (medical history, family history, food history) supported by appropriate laboratory tests (skin prick-testing or RAST/blood test). Elimination and challenge testing remains the most reliable method of diagnosis.

Wheat Allergy Treatment

Avoidance of wheat and wheat-containing foods is the most important step in the treatment of wheat allergy.  However, because wheat is a common food product, wheat avoidance diets are particularly difficult. Persons on wheat-restricted diets are sometimes severely limited in their selection of foods.

Are Kamut and Spelt Safe Alternatives to Wheat?

Spelt, an ancient wheat, and kamut, a cereal grain, have recently been marketed as safe for wheat-allergic individuals. This claim is untrue, however. Wheat allergic patients can react as readily to spelt and kamut as they do to common wheat.

What is the Difference Between Wheat Allergy and Celiac Disease?

Celiac disease and wheat allergy are two distinct conditions. Allergy to wheat may occur in any individual, unlike celiac disease, which is hereditary. Celiac disease, sometimes called celiac “sprue”, is a permanent intolerance to gluten. Those with celiac disease will not lose their sensitivity to this substance. This disease requires a lifelong restriction of gluten.  The major grains that contain gluten are wheat, rye, oats, and barley. Gluten proteins are extremely resistant to intestinal digestion, despite grinding, cooking, processing and digestion. These grains and their by-products must be strictly avoided by people with celiac disease.

Wheat Avoidance Diet

What items on a food label contain wheat?
Be sure to avoid foods that contain any of the following ingredients:

• bread crumbs
• bran
• cereal extract
• couscous
• cracker meal
• enriched flour
• farina
• gluten
• graham flour
• high gluten flour
• high protein flour
• spelt
• vital gluten
• wheat bran
• wheat germ
• wheat gluten
• wheat malt
• wheat starch
• whole wheat flour

What are other possible sources of wheat or wheat products?
Ingredients that may indicate the presence of wheat protein include the following:

• gelantized starch
• hydrolyzed vegetable protein
• kamut
• modified food starch
• modified starch
• natural flavoring
• soy sauce
• starch vegetable
• gum
• vegetable starch

Wheat Substitutes

1-cup wheat flour equals:

• 1 cup rye meal
• 1 to 1 1/4 cups rye flour
• 1 cup potato flour
• 1 1/3 cups rolled oats or oat flour
• 1/2 cup potato four plus 1/2 cup rye flour
• 5/8 cup potato starch
• 5/8 cup rice flour plus 1/3 cup rye flour

Wheat Avoidance Diet

Food Group:  Beverages
Food Allowed:  Coffee, tea, fruit juices, decaffeinated coffee, carbonated beverages, all milks, cocoa
Food Not Allowed:  Cereal beverages, coffee substitutes.  Beverages made from wheat products: beer, ale, root beer.  Instant chocolate drink mixes

Food Group:  Breads & Cereals
Food Allowed:  Ry-Krisp, rice wafers.  Pure corn, rice, arrowroot, barley, potato, or rye bread made without wheat flour or wheat products.  Cornmeal, cornstarch, soybean, flour, barley flour, oat flour, rice flour, potato starch, arrowroot flour.  Oatmeal, cream of rice, puffed rice, or other cereals made from pure corn, oats, or rice to which no wheat has been added.
Food Not Allowed:  Whole wheat, enriched, or white bread, rolls, or bread crumbs.  Graham or gluten bread.  Donuts, sweet rolls, muffins, french toast, waffles,  pancakes, dumplings, bread stuffing, rusk, povers.  Prepared mixes for pancakes, waffles, biscuits, breads, and rolls.  Cornbread, potato, or soybean bread unless made without wheat flour or wheat products.  Cereals made from farina, wheat, or those with wheat products or malt added.  Pretzels, crackers, Semolina, spelt, or triticale

Food Group:  Desserts
Food Allowed:  Custards, Bavarian creams.  Oatmeal, arrowroot, rice, or rye cookies made without wheat products.  Cornstarch, tapioca, or rice puddings, water or fruit ices, meringues, and gelatin.
Food Not Allowed:  Cakes, pastries, commercial frosting, icing, ice cream, sherbet, ice cream cones.  Cookies, prepared mixes, or packaged pudding containing wheat flour, graham crackers, donuts

Food Group:  Eggs
Food Allowed:  Eggs prepared any way without wheat products
Food Not Allowed:  Souffles or creamed eggs made with wheat products

Food Group:  Fats
Food Allowed:  Butter, margarine, animal, or vegetable fats and oils, cream.  Salad dressings or gravy prepared without wheat flour or products
Food Not Allowed:  Any salad dressing thickened or gravy with wheat flour or products

Food Group:  Fruit
Food Allowed:  All fresh, canned, dried, or frozen fruits and fruit juices
Food Not Allowed:  Strained fruits with added cereals

Food Group:  Meat, Fish, Poultry
Food Allowed:  Baked, broiled, boiled, roasted or fried: beef, veal, pork, ham, chicken, turkey, lamb, or fish.  “All meat” wieners or luncheon meats prepared without wheat flour fillers or wheat products.
Food Not Allowed:  All breaded or floured meats, meats containing filler such as meatloaf, frankfurters, sausage, luncheon meats, bologna, or prepared meat patties

Food Group:  Milk & Milk Products
Food Allowed: Milk, buttermilk, yogurt, cheese, some cottage cheese
Food Not Allowed:  Malted milk, milk drink containing powdered wheat cereal or products.  Cottage cheese with modified starch or other wheat containing ingredients

Food Group:  Potatoes & Substitutes
Food Allowed:  White and sweet potatoes, rice
Food Not Allowed:  Scalloped potatoes, noodles, spaghetti, macaroni, and other pasta products prepared with wheat or semolina flour

Food Group:  Soup
Food Allowed:  Clear bouillon, consommé, or broth.  Homemade soups made without wheat products
Food Not Allowed:  Cream soups unless made without wheat flour.  Soups with noodles, alphabets, dumplings, or spaghetti.  Soup thickened with wheat flour.

Food Group:  Sweets
Food Allowed:  Corn syrup, honey, jams, jellies, molasses, sugar
Food Not Allowed:  Chocolates, chocolate candy containing malt, candy with cereal extract

Food Group:  Vegetables
Food Allowed:  All fresh, frozen, or canned vegetables, and vegetable juices
Food Not Allowed:  Vegetables combined with wheat products, breaded or floured vegetables

Food Group:  Miscellaneous
Food Allowed:  Salt, chili powder, condiments, flavoring extracts, herbs, nuts, olives, pickles, popcorn, peanut butter
Food Not Allowed:  Malt products, Worcestershire sauce, gravies thickened with wheat flour, Monosodium glutamate (MSG), meat tenderizers containing MSG, prepared oriental food seasoned with MSG, soy sauce

A Word of Caution

Always remember to read the ingredient labels for details about every food.

Tree Nut Allergy

It is estimated that 1%-2% of the United States population is allergic to tree nuts, peanuts, or both. In general, tree nut allergy has been considered a lifelong allergy. However, a recent article in The Journal of Allergy & Clinical Immunology suggests that approximately 9% of children with an allergy to tree nuts will outgrow their allergy, including children who have previously experienced a severe allergic reaction.

Tree nuts include cashews, almonds, walnuts, hazelnuts, macadamia nuts, pecans, pistachios, Brazil nut, beechnuts, chestnuts, filbert, and hickory nuts. Pine nuts are edible seeds of pine trees and are not, strictly speaking, tree nuts. However, because of their high allergenic potential, they are included in this discussion.

How to Read a Label for a Tree Nut-free Diet

Be sure to avoid foods that contain any of the following ingredients:

• almonds
• brazil nuts
• cashews
• chestnuts
• filberts
• hazelnuts
• gianduja (a creamy mixture of chocolate and chopped toasted nuts found in premium or imported chocolate)
• hickory nuts
• macadamia nuts
• marzipan/almond paste
• nougat
• Nu-Nuts® artificial nuts
• nut butters, i.e. cashew butter, almond butter
• nut oil
• nut paste, i.e. almond paste
• pecans
• pine nuts (pignolia, pinion)
• pistachios
• walnuts

Helpful Facts About Tree Nuts

• Nu-Nuts® artificial nuts are peanuts that have been de-flavored and re-flavored with a nut like pecan or walnut.
• Filberts are hazelnuts.
• Avoid natural extracts such as pure almond extract, and natural wintergreen extract (for the filbert/hazelnut allergic).
• Use imitation or artificially flavored extracts.
• Ethnic foods, commercially prepared baked goods, and candy can be cross-contaminated with nuts since nuts are frequently used in these types of foods.
• Tree nuts are being added to an increasing variety of foods such as barbecue sauces, cereals, crackers, and ice creams.

Tree nuts may belong to different food families which are unrelated to each other.
Walnut:  walnut, pecan
Mango: pistachio, cashew
Legythis: brazil nut
Beech: beech nut, chestnut
Birch: halzenut, filbert, hickory nut
Plum: almond
Macadamia

Interestingly, tree nuts are not related to peanuts. Therefore, some people who are peanut allergic can eat tree nuts, and tree nut allergic people can sometimes eat peanuts. However, it is important to note that some allergic individuals may be allergic to both peanut and tree nuts. In addition, you can be allergic to some but not all tree nuts. Almonds seem to cause the least problems of all common tree nuts.

What May Contain Tree Nut?

• Chocolate
• Candies
• Cookies
• Desserts
• Sweets
• Almond paste
• Donuts
• Sundaes
• Cereal
• Milkshakes
• Granola bars
• Trail mixes
• Pesto sauce
• European chocolates
• Muesli
• Suntan lotion, shampoo, nut shells, bath oils
• Popcorn and specialty cheese spreads
• Gianduja (chocolate and chopped toasted nuts)
• Specialty coffees, liqueurs
• Small animal food e.g., hamster, gerbil

What Contains Walnut or Pecan?

• Pecan pie, walnut containing muffins
• Crosse & Blackwell Worcestershire sauce
• AIM herbal fiber blend, pesto sauce, pralines, walnut oil, “Turtles” chocolates

What Contains Hazelnut/Filbert?

Nutella, nougat, Toblerone chocolate bars, hazelnut liqueur, Frangelico liqueur, hazelnut coffee

What Contains Pistachio/Cashew?

Cashew butter, pistachio ice cream, chicken with cashews

What Contains Almonds?

Marzipan, almond mocha, almond paste, almond guy ding, trout almandine, pure almond extract (artificial is okay), amaretto

What About Seeds, Tropical Oils, Exotic Nuts?

Foods such as water chestnut, coconut, and nutmeg do not need to be avoided by nut allergic people, unless they are also allergic to these foods. Palm oil and tropical oils do not need to be avoided. Seeds, e.g., sesame, sunflower, poppy, mustard, safflower, canola, do not need to be avoided unless you are allergic to these as well.

Are Nut Oils Safe?

Most tree nut oils probably contain enough allergenic protein to cause allergic reactions. These are cold pressed (unprocessed, extruded or expelled) oils and are not safe for nut allergic people.

Soy Allergy

A soy allergy is an abnormal response of the body to the proteins found in soy. Soybeans are classified as a legume. Other foods in the legume family are navy, kidney, string, black and pinto beans, chickpeas (garbanzo beans), lentils, carob, licorice, and peanuts. Allergy to one legume can often be in association with sensitivity to another legume.

What Items on a Food Label Contain Soybeans?

The following ingredients contain soy and should be avoided:

• Soy sauce
• Soy flour
• Soy Grits
• Soy Nuts
• Soy Milk
• Soy sprouts
• Miso
• Tempeh
• Shoyu sauce
• Textured vegetable protein (TVP)
• Tofu
• Tarmari

Label Ingredients That May Indicate the Presence of Soy Protein

• Hydrolyzed plant protein
• Hydrolyzed soy protein
• Hydrolyzed vegetable protein
• Vegetable broth
• Vegetable starch
• Vegetable gum
• Natural flavoring

Studies show that some soy-allergic individuals may safely eat soy lecithin and soy oil. Soy lecithin is a mix of fatty contents obtained from the processing of soybeans. The majority of soy allergic persons do not have trouble with soy lecithin.

Soy Avoidance Diet

Food Group:  Breads & Starches
Food Allowed:  Breads, crackers, waffles, pancakes and other baked goods not containing soy Commercial cereals not containing soy ingredients.  Potato chips or popcorn cooked in soy oil.  Plain macaroni, soy-free noodles, rice, barley, rye, wheat, oats,  grits, potato, sweet potato
Food Not Allowed:  Breads, crackers, cakes, rolls, or pastries containing peanuts, peanut oil, or soy flour.  Process and “natural “ cereals which contain soy ingredients.  Soy pasta, instant potatoes, canned and dry pizza mixes

Food Group:  Vegetables
Food Allowed:  Fresh, frozen, or canned vegetables (except those listed as not allowed) without sauces or breading containing soy ingredients
Food Not Allowed:  Soy beans, soybean sprouts.  Any vegetables prepared with sauces or breading containing soy products

Food Group:  Fruit
Food Allowed:  All fresh, frozen, or canned fruits and juices process without soy products
Food Not Allowed:  Fruit drink mixed or sauces/toppings for fruit which contain soy ingredients

Food Group:  Beverages
Food Allowed:  Soft drinks, tea, coffee, fruit juice
Food Not Allowed:  Soy-based formulas, coffee substitutes with soy, instant coffee, hot cocoa mixes, malt beverages, fruit drink mixes made with soy ingredients

Food Group:  Meat & Meat Substitutes
Food Allowed:  Any fresh or frozen beef, chicken, lamb, pork, turkey, veal, or fish served without prepackaged sauces, breading, or gravy
Food Not Allowed:  Pork link sausage, deli/luncheon meats made with soy.  Commercially prepared meats where soy is used as a meat extender.  Meat or cheese substitutes which contain soy: tofu/bean curd, natto, miso Textured vegetable protein (TVP)

Food Group:  Milk & Milk Products
Food Allowed:  Milk, cheese, cottage cheese, or yogurt without soy products
Food Not Allowed:  Milk drinks or milk substitutes that contain soy, nondairy creamers

Food Group:  Soups & Combination Foods
Food Allowed:  Homemade soups and commercial soups that do not contain soybeans
Food Not Allowed:  Soy is used in many canned soups, commercial entrees, and combination foods

Food Group:  Desserts & Sweets
Food Allowed:  Ice cream, gelatin, cookies made without soy ingredients
Food Not Allowed:  Baked goods, such as cakes or cookies which contain soy flour.  Soy products may be used in some commercial ice creams and other frozen desserts.  Hard candies, nut candies, fudge, and caramels made with soy flour

Food Group:  Fats & Oils
Food Allowed:  Butter, margarines, shortening
Food Not Allowed:  Margarine and butter substitutes. Some salad dressings, mayonnaise, sauces, or gravies containing soy products.  Roasted soybeans or “soy nuts”

Food Group:  Condiments & Miscellaneous
Food Allowed:  Sugar, honey, molasses, catsup, mustard, jelly, jam, plain sugar candies, syrup, picklesHomemade popcorn popped with corn or canola oil, rice cakes
Food Not Allowed:  Commercial vegetarian products and meat substitutes. Heinz Worcestershire sauce, Lea & Perrins sauce, fermented soybean pastes (miso and natto).  Soy sauce, tamari sauce, granola, or breakfast bars made with soy.  Imitation bacon bits made with soy.

A Word of Caution

Food manufacturers may occasionally change the ingredients in the product without warning. It is a good idea to always read the product label before using it. It is much easier to prevent a food-allergic reaction than to treat one.

Peanut Allergy

It seems hard to believe, but the United States Peanut Council estimates that the average American ingests about 11 pounds of peanut products each year; about 55% as peanut butter and the rest in sweets, baked goods, and table nuts. America ranks third in the world in peanut production, behind only China and India. Interestingly, even though the consumption of peanuts per capita is similar in the United States and China, the prevalence of peanut allergy is much higher in America.

How Common is Peanut Allergy?

It is not surprising that with this high rate of consumption, the prevalence of peanut allergy has increased steadily over the past two decades, especially in the United States and other westernized countries. Medical research has reported that sensitization (positive skin prick test) to peanuts has increased by 55%, while peanute allergy reactions increased by 95% over a 10 year period. Today peanuts are believed to be one of the leading causes of food allergic reactions in the United States and, together with tree nuts, are probably the leading cause of fatal and near fatal anaphylaxis induced by food.

Peanut allergy has been described as being “epidemic” in some countries. Recent surveys of the general population found the prevalence of peanut allergy to be 0.6% in the United States. Peanut is ubiquitous within the US food supply, and a study examining the efficacy of food allergen avoidance found that 80% of all infants had been exposed to peanut products by their first birthday and virtually 100% by their second birthday.

In more than 70% of children with peanut allergy, symptoms develop after the first known exposure. Since these reactions are mediated through the IgE antibody, a prior exposure or sensitization must have occurred. Possible routes of prior sensitization include exposure in-utero as a result of the ingestion of peanuts during pregnancy, or during breast-feeding. Such theories have resulted in recommendations that mothers of babies at high-risk for allergies avoid the ingestion of peanuts during pregnancy and while nursing. A high-risk baby would be one in whom both parents have allergies or the presence of allergies in one parent and a sibling. To date, there is no definitive proof that such recommendations are preventative.

What Other Foods Might The Peanut Allergic Individual Be Allergic To?

The peanut is a member of the legume family and is not considered to be a true nut. It is reassuring to note that most peanut allergic individuals can eat other members of the legume family safely. In those allergic to peanuts, concomitant allergy to beans such as soy, green beans, and peas is generally 5% or less. Lupine, a bean that is processed into flour, may have a higher incidence of cross-reactivity with peanuts than other beans. Clinically more important is the higher incidence of co-allergy to tree nuts in the peanut allergic individual. Between 25 -50% of peanut allergic patients will also be allergic to at least one tree nut, even though tree nuts are from a different botanical family. Care should therefore be taken as the sharing of allergens among the foods can be clinically relevant.

Peanut Allergy Treatment

If one has had a reaction to peanut (or the other tree nuts), they should consult an allergist for testing in order to identify or confirm the offending food allergen. Once identified, the allergist will discuss peanut avoidance and educate the patient on the treatment of an accidental ingestion of peanut allergen.  Peanut allergy resolves spontaneously in only approximately 20% of children by school age.

Currently the only effective treatment for peanut allergy is avoidance. There is promising research on the development of a drug to bind the peanut specific antibody and oral vaccines for peanut allergy, but clinical research trials are still in very early stages. There is also research ongoing which attempts to alter the allergenic proteins in the peanut to make them less allergenic.

Peanut is ubiquitous in our environment. Therefore, allergic individuals are faced with numerous hurdles in avoiding accidental ingestion of peanuts. This can result in very significant quality of life issues for both patients and their families. This is especially challenging during the school age years when children have greater exposures and less supervision.

Patients with a known allergy to peanuts should be prepared at all times to treat an allergic reaction. A written emergency plan outlining the treatment will include the immediate use of a quick acting antihistamine, and the injection of epinephrine using an auto-injector (EpiPen or Twinject) at the first sign of systemic involvement. Patients should be prepared to repeat the injection of epinephrine, if necessary. Any patient having systemic symptoms should call for emergency assistance and should be observed in an emergency facility. It is imperative that patients and their family members know how to recognize the symptoms of an allergic reaction and are prepared to react appropriately
and immediately. Your allergist is prepared to help educate and demonstrate the proper response.

Peanut Avoidance Diet

The key to an allergy avoidance diet is to avoid all foods or products containing the food you are allergic to. In order to avoid foods that contain peanuts, it is important to read food labels carefully. But, as hard as one tries, inadvertent exposure can occur in a variety of circumstances. It can occur as the result of peanut contamination of equipment used in the manufacture of various foods, inadequate food labeling, contamination of foods during cooking in restaurants, and unanticipated exposure such as the inhalation of peanut dust on an airplane. Such inadvertent exposures result in an allergic reaction every three to five years in the average patient with peanut allergy.

Although most peanut allergic individuals instinctively avoid peanut oil, it can be safely consumed in most cases. Since it is the allergen present in the pulp of the peanut to which one reacts, the highly processed, i.e., acid-extracted, heat distilled peanut oil can be safely consumed by such individuals. On the other hand, cold-pressed or extruded peanut oils contain the allergenic protein and may induce an allergic reaction.

How To Read a Label For a Peanut-free Diet

Be sure to avoid foods that contain any of the following ingredients:

• cold pressed, expressed, or expelled peanut oil
• ground nuts
• mixed nuts
• Nu-Nuts® artificial nuts
• peanuts
• peanut butter
• peanut flour

Foods that may indicate the presence of peanut protein include

• African, Chinese, Thai, and other ethnic dishes
• baked goods
• candy
• cereals
• chili, spaghetti sauce
• chocolate (candy, candy bars)
• crackers
• egg rolls
• hydrolyzed plant protein
• hydrolyzed vegetable protein
• ice creams, frozen yogurts, tofutti
• marzipan
• nougat

A Word of Caution

Food manufacturers may occasionally change the ingredients in the product without warning. It is a good idea to always read the product label before using it. It is much easier to prevent a food-allergic reaction than to treat one.

Milk Allergy

A milk allergy, or milk protein allergy, is a reaction to one or more proteins present in the cow’s milk. There are over 20 proteins in cow’s milk that may cause allergic reactions. Casein and whey are the two main components of cow’s milk responsible for the vast majority of reactions. Casein is the curd that forms when milk is left to sour. The watery part which is left after the curd is removed is called whey.
Casein accounts for 80 percent of the protein in milk and is the most important allergen found in cheese. The harder the cheese, the more casein it contains. Whey accounts for the other 20 percent of milk. It consists of two main allergenic proteins, alpha-lactalbumin and beta-lactaglobulin.

How Common is Milk Allergy and Can it Go Away?

Cow’s milk allergy is a common food allergy, especially during the first year of life and can be present in both breastfed and formula-fed children.  Studies show that two to three percent of infants are allergic to milk. Fortunately, most children tend to outgrow it within the first few years. Sixty percent of milk allergic children outgrow it by the age of four and eighty percent by the age of six. Although the majority become allergic as infants, cow’s milk allergy can be acquired later in life.

Even though milk allergy presenting in infancy commonly resolves spontaneously, some children continue to have chronic symptoms from milk. The presenting symptoms such as colic, irritability, spitting, diarrhea, and eczema may disappear, but a new pattern of illness and symptoms may emerge such as nasal and sinus symptoms, recurrent abdominal pain, headaches, generalized lethargy, and dark circles under the eyes. Milk allergy is probably more common in older children, teenagers, and adults than recognized, as its presentation can subtle and difficult to diagnose.

The Forms of Milk Allergy

Allergy to cow’s milk is a well-studied form of food allergy, and there are both immediate and delayed patterns of milk allergy.  Immediate type allergy tends to be obvious, and symptoms can range between mild and severe. Symptoms will result within minutes of ingestion of mild, but can also occur after contact to the skin. The presence of this immediate reaction to milk is easily diagnosed or confirmed by skin or blood tests.

Symptoms of delayed onset milk allergy are not so obvious, and tend to cause less severe, chronic, sometimes nonspecific symptoms. A milk elimination diet can help recognize the presence of delayed allergy to milk.

Are Milk Allergy and Lactose Intolerance the Same Thing?

The terms milk allergy and lactose intolerance are often incorrectly used interchangeably to describe reactions to milk. They are, however, two separate disorders which have absolutely nothing to do with one another. A milk allergy is the immune system’s response to one or more of the proteins found in cow’s milk.

Lactose intolerance, on the other hand, occurs when the intestine lacks a critical enzyme called lactase. Lactase is necessary to break down lactose, the predominant sugar in milk, into two simple sugars, glucose and galactose, so that the sugars can be utilized by the body. When lactose is not broken down in the small intestine, it is passed to the large intestine where it is fermented by bacteria, resulting in various gastrointestinal symptoms such as gas, bloating, and abdominal discomfort, nausea, or diarrhea. It is estimated that 30 to 50 million people suffer from this intolerance.

Milk Avoidance Diet

Important information about avoiding milk and milk products

1. The phrase “non-dairy” on a product label indicates that it does not contain butter, cream, or milk. However, this does not necessarily indicate it does not have other milk-containing ingredients.
2. Any Kosher food labeled “pareve” or “parve” always indicates that the food is free of milk and milk products and can be safely eaten by the milk allergic individual. On the other hand, a “D” on a product label next to the circled K or U indicates the presence of milk protein and should be avoided.
3. All Processed meats, including hot dogs, sausages, and luncheon meats, frequently contain milk or are processed on milk-containing lines.
4. All dairy products contain milk. Many processed foods also contain milk or milk products. To make sure that the foods your child eats do not contain any milk products.

Food manufactures may change the ingredients in the product without warning. Be sure to always read the food label before giving the item to your child to eat. It is easier to prevent a food-allergy reaction than to treat one. If you are not certain that a food is milk-free, check with the manufacturer.  To avoid milk and milk products ask about ingredients at restaurants and others’ homes, read food labels, and become familiar with the technical or scientific terms for milk.

Food Label Items That Contain Milk

• Milk
• Caseinate
• Milk Solids
• Calcium Caseinate
• Non-Fat Milk Solids
• Sodium Caseinate
• Buttermilk Solids
• Lactalbumin
• Chocolate (may contain milk solids)
• Lactoglobulin
• Cream
• Lactose
• Half & Half
• Ghee
• Butter
• Junket
• Curds
• Nougat
• Whey Solids
• Custard
• Whey
• Milk Chocolate
• Casein
• Malted Milk
• Simplesse

Ingredients That Do NOT Contain Milk

• Calcium lactate
• Lactic acid
• Calcium
• Oleoresin
• Cocoa butter
• Sodium lactate
• Cream of tarter
• Sodium stearoyl lactylate

Milk Avoidance Diet

Food Group: Breads and Grains
Foods Allowed: Milk-free breads (wheat, white, rye, challah,corn, graham, gluten, and soy breads made without milk or milk products), some French bread, Graham crackers or rice wafers
Foods Not Allowed: Breads prepared with milk, such as muffins, pancakes, biscuits, french toast

Food Group:  Potatoes and Other Starches
Foods Allowed:  White or Sweet Potatoes, rice or pasta prepared without milk or milk products, plain chips.
Foods Not Allowed: Any potato, rice, or pasta prepared with milk or milk products - au gratin, creamed, and scalloped potatoes, instant potatoes, macaroni and cheese, ranch flavored snacks

Food Group: Vegetables
Foods Allowed:  All vegetables - fresh, frozen, canned. All vegetable juices.
Foods Not Allowed: Any vegetable prepared with milk, cheese or butter - au gratin, creamed, scalloped.

Food Group:  Fruits
Foods Allowed: All fruits- fresh, frozen, canned
Foods Not Allowed: Any fruit prepared with milk, cream or butter

Food Group:  Milk and Milk Products
Foods Allowed:  Soy based infant formulas, calcium fortified soy and rice milk, soy cheese and yogurt, hydrolyzed protein formulas** (**Hydrolyzed protein formulas: Nutramigen, Pregestimil, Alimentum, Neocate, Vivonex Pediatric, Neocate Junior, and Pediatric E028)
Foods Not Allowed:  All cow’s milk, powdered, evaporated, and condensed milk, half and half, cream, ice cream, yogurt, cheese, cottage cheese, goat’s milk, cow’s milk-based infant formulas and supplements

Food Group:  Meat and Meat Substitutes
Foods Allowed:  Beef, poultry, turkey, fish, lamb, pork, beans, lentils, nuts, peanut butter, plain eggs, legumes, tofu
Foods Not Allowed:  Any prepared with milk or milk products such as meatloaf, hot dogs, deli meats, scrambled eggs, egg substitutes

Food Group:  Desserts and Sweets
Foods Allowed:  Hard candy, candies and desserts made without milk or milk products, fruit ices, sorbet, popsicles, juice bars, Jell-O.  Corn syrup, honey, jam, and jelly Granulated, brown, or powdered sugar
Foods Not Allowed:  Candies containing cow’s milk - caramels, milk chocolate, nougats, and fondants.  Desserts prepared with cow’s milk: cakes, pastries, cream pies, ice cream, ice milk, sherbet, frozen dairy products with simplesse, custard, pudding, donuts.

Food Group:  Fats and Oils
Foods Allowed:  Soy oil, corn oil, safflower oil, coconut oil, vegetable oil, olive oil, peanut oil, milk-free margarines, mayonnaise, salad dressing
Foods Not Allowed:  Cream, sour cream, fats prepared with added milk solids - butter, margarine, milk-based gravies, some coffee creamers, artificial butter flavor, butter flavored oil

Food Group:  Seasonings and Condiments
Foods Allowed:  Salt, spices, oil based dressings, ketchup, mustard, relish, herbs
Foods Not Allowed:  Cheese sauces, hollandaise sauce, white sauce, alfredo sauce, butter-flavored syrup, some salad dressings

Food Group:  Miscellaneous
Foods Allowed:  Clear broth, vegetable soup, meat soups, homemade soups without milk, carbonated beverages, tea, coffee, nuts, herbs, chili powder, salt, spices
Foods Not Allowed:  Frozen dinners with cheese sauces, canned spaghetti sauce with cheese, cream soups, chowders, some diet drinks

What Can I Substitute For Milk in My Recipes?

Substitute equal amounts of these items for milk in your recipes:

• Fortified soy milk
• Fortified rice milk
• Water
• Fruit juice such as apple juice to make pancakes

A word of caution

Food manufacturers may occasionally change the ingredients in the product without warning. It is a good idea to always read the product label before using it. It is much easier to prevent a food-allergic reaction than to treat one.

Contact Dermatitis

Contact dermatitis is a raised, red, itchy rash that may also blister. It is caused by a delayed allergic reaction, occurring hours or even days after exposure of the skin to allergenic or chemical sensitizers.

One of the most recognizable forms of contact dermatitis, known to most of us, is the warm weather rash of poison ivy, oak, or sumac. This common rash is caused by direct contact of the skin with urushiol, the oil in the leaves and vines of these plants. Metals, such as nickel and gold, are also common skin sensitizers. The fact is that individuals can develop a contact allergy to almost any substance which contacts the skin. In many cases of contact dermatitis, the exposure to the offending chemical may occur through repeated contact to the allergen in certain jobs, such as a hairdresser who develops contact sensitivity to hair dye.

Contact Dermatitis Allergy Symptoms

A common presentation of contact dermatitis is redness, swelling, and intense itching around the eyes. This inflammatory skin reaction of the upper and lower lids generally occurs in women and can be a recurrent phenomenon. It is thought that the skin of the lids is particularly thin and sensitive and is easily inflamed upon exposure to the many chemicals and sensitizers found in mascara, make-up, hair dyes, shampoos, soaps, and finger nail polish and/or remover, just to name a few.

Contact Dermatitis Allergy Diagnosis

Contact allergy diagnosis often requires patch testing to identify the sensitizing allergen. An allergist or dermatologist will apply small patches containing known skin sensitizers to the back. After several days it will be removed and ones skin response will be measured carefully. Many common contact allergy sensitivities can be confirmed with this test.

Researchers at the Mayo Clinic found the ten most common causes of contact dermatitis diagnosed by patch testing to be:

• Nickel (nickel sulfate hexahydrate). A metal frequently encountered in jewelry and clasps or buttons on clothing.
• Gold (gold sodium thiosulfate). A precious metal often found in jewelry.
• Balsam of Peru (myroxylon pereirae). A fragrance used in perfumes and skin lotions, derived from tree resin.
• Thimerosal. A mercury compound used in local antiseptics and in as a preservative in some vaccines.
• Neomycin sulfate. A topical antibiotic common in first aid creams and ointments, also found occasionally in cosmetics, deodorant, soap, and pet food.
• Fragrance mix. A group of the eight most common fragrance allergens found in foods, cosmetic products, insecticides, antiseptics, soaps, perfumes, and dental products.
• Formaldehyde. A preservative with multiple uses. It is found in paper products, paints, medications, household cleaners, cosmetic products, and fabric finishes.
• Cobalt chloride. Metal found in medical products; hair dye; antiperspirant; objects plated in metal such as snaps, buttons or tools; and in cobalt blue pigment.
• Bacitracin. A topical antibiotic.
• Quaternium 15. A preservative found in cosmetic products such as self-tanners, shampoo, nail polish, and sunscreen or in industrial products such as polishes, paints, and waxes.

In the most difficult cases, a biopsy, performed by a dermatologist, may be helpful to confirm the diagnosis of contact dermatitis.

Contact Dermatitis Treatment

For contact dermatitis, identification and removal of the offending substance is critical for long-term resolution. Topical steroids are the treatment of choice for mild and moderate contact dermatitis. For more severe cases, a short course of an oral or injectable steroid may be recommended by your allergy specialist.

Latex Allergy

Allergy to latex was first described in the late 1970s. Since then, it has been recognized to be a major health concern, especially among health care workers and other high risk groups. It has been estimated that as much as 6% of the adult population may be sensitized to latex and at risk of allergic symptoms upon exposure.  Reactions to the latex allergen can be caused by direct contact or by inhalation of latex particles. Direct contact with proteins in the latex causes sensitization and subsequent allergic reactions.

Latex allergy is a reaction to certain proteins found in natural latex rubber. Latex is the milky fluid derived from the rubber tree (Hevea brasiliensis) found in Africa and Southeast Asia.

Where is latex found?

There are two types of products made from natural latex sources, dipped latex and hardened latex. Dipped latex products are responsible for most allergic reactions to latex due to the fact that they are commonly in contact with the skin. These products are usually stretchy. Common sources are balloons, rubber gloves, rubber bands, and condoms. Hardened rubber, on the other hand, is less commonly a cause of allergic reactions. These products include rubber balls, athletic shoes, soles of shoes, and tires. Products made from synthetic or man made latex, such as latex paints, are unlikely to cause a reaction.

Thousands of consumer products contain latex or rubber, therefore having the potential to cause allergic reactions. Common household products include:

• Rubber Toys
• Baby bottle nipples
• Pacifiers
• Balloons
• Disposable diapers
• Dish-washing gloves
• Elastic waistbands
• Rubber bands
• Erasers
• Swim goggles
• Racket handles
• Bicycle and motorbike hand grips
• Hot water bottles
• Condoms
• Diaphragms
• Sanitary pads
• And, many more

In the health care arena, although much progress has been made in transitioning to non-latex products, latex can still be found in:

• Surgical or disposable gloves
• Blood pressure cuffs
• Intravenous tubing
• Syringes
• Respirators or other ventilation equipment
• Electrode pads
• Surgical masks

Types of Allergic Reactions to Latex

One common reaction is called delayed contact dermatitis. This type of reaction usually occurs 12-36 hours after latex contact and generally results in itching and a rash on the area of the body which came in direct contact with the latex allergen. This reaction is commonly caused by sensitization to chemicals that are added during the manufacturing and processing of the latex rubber. Although extremely irritating, this type of reaction is rarely dangerous and is not life threatening.

As opposed to the delayed allergic reaction, immediate type reactions after exposure to latex can be severe, resulting in itching, generalized redness, swelling, sneezing, and wheezing. In the most severely allergic individuals, exposure can lead to anaphylaxis, characterized by severe difficulty breathing and shock due to loss of blood pressure. It not treated immediately, such reactions can be fatal.

The severity of immediate systemic reactions is dependent on the amount of allergen exposed to and the degree of allergy sensitization in the patient. The greatest danger occurs if a very allergic individual is exposed to latex during an internal exam or during surgery, due to the rapid absorption of allergen into the body.

Highly allergic individuals can also have significant reactions upon inhaling latex proteins. Latex gloves, for example, commonly contain cornstarch powder. The latex proteins adhere to the powder and when it becomes airborne, it is readily breathed into the lungs. Because of the frequent use of these products, intensive care units and surgery suites can contain high concentrations of this highly allergenic powder. Fortunately, the limitation of use of synthetic or non-latex gloves in these high risk areas has greatly diminished the incidence of serious allergic reactions.

Who is at the greatest risk of the Latex Allergy?

The greatest risk are to those who have had repeated exposure to latex. These groups include rubber industry workers, health care workers, and patients who have had numerous medical or surgical procedures. Approximately 50% of individuals with spina bifida (a congenital deformity of the spine) and those with congenital urinary tract problems are at risk. It has been estimated that 10% of dental and other health care workers are also at high risk.

Those with a latex allergy are at higher risk upon ingestion of certain foods that share allergenic proteins with latex. These foods include avocados, kiwi fruit, bananas, passion fruits, and chestnuts.

Latex Allergy Treatment

Although not easy, latex allergic individuals need to avoid exposure to the allergen as much as possible. Fortunately, manufacturers of consumer goods are working to produce alternative products with little or no latex.

Make your physician, dentist, clinic or hospital aware of your or your child’s allergy to latex. And, before any medical or dental procedure, remind your health care professional of the allergy. In addition, consider wearing a bracelet or necklace identifying your specific allergy. For those severely allergic, self-injectable epinephrine should be readily available at all times.

Eczema (Atopic Dermatitis)

Eczema, or atopic dermatitis, is the most common rash presenting during infancy and childhood. Generally red, dry, scaly, and extremely itchy, it often presents with a characteristic distribution on the body. In infants, it usually presents in the first few months of life, and it typically involves the cheeks, the back of the ears, the buttocks, the bends of the arms, and behind the knees. As children grow older, the rash can spread to involve any place on the body that can be rubbed or scratched, but the classic distribution continues to be in the folds of the arms and behind the knees.

Many patients with eczema have a strong family history of allergies, and many go on to develop allergies themselves. When patients with eczema develop allergies, the eczema is also called atopic dermatitis. Recent research has suggested that, in certain individuals, the immune system may become sensitized to allergens because of exposure through the inflamed skin of eczema. Many children who have atopic dermatitis go on to develop nasal allergies and/or asthma, a progression described by the term atopic marchî.

Up to one-third of atopic dermatitis patients have a food allergy trigger, such as egg, milk, wheat, soy, or peanut. Contact with dust mites or other environmental allergens may also worsen the skin. Your doctor may perform allergy testing to determine which if any may be contributing factors. Avoidance of those known allergens will be crucial to help the skin heal.

Because itching in the skin can precede the rash, eczema is sometimes known as the itch that rashes The skin of eczema patients is very sensitive and can be easily irritated. Common irritant triggers for all eczema patients include the physical trauma of scratching, synthetic or wool fibers in clothing, perspiration, and skin infections, especially with Staphylococcal bacteria.

As a general rule, eczema improves during childhood and, in many cases, resolves by the time a child reaches school age. However, some individuals never outgrow their eczema and it may develop into a chronic condition. On rare occasions, atopic dermatitis can present for the first time as an adult.

How eczema diagnosed?

For recurrent or chronic atopic dermatitis, skin testing may be helpful in discovering allergic triggers of the rash. In most cases, the allergist will look for highly allergenic foods such as milk, eggs, soy, wheat, peanuts or nuts, although many other foods and inhalant allergens may be involved. Patients can also be helpful in tracking down the cause by keeping a food diary. This detective work sometimes is very helpful in establishing an important cause and effect relationship.

In certain cases, blood testing (RAST or ImmunoCAP) may be helpful. This form of testing may be preferable if one’s skin rash is too inflamed to perform skin tests, or if the patient is unable to discontinue antihistamine usage five days prior to skin testing. In the case of food allergies, allergy testing may provide useful information about when the food might be safely reintroduced into the diet.

How is Eczema Treated?

Break the Itch-Scratch Cycle
The first, and perhaps most vital step in treatment, involves careful daily skin care designed to keep the skin clean and well hydrated. Research shows that even the unaffected skin of atopic dermatitis patients cannot retain water like normal skin does, so it dries out very quickly, worsening the itchy sensation. To combat this, the eczema patient should follow the soak and sealî technique:

• Bathe every day for at least 15-20 minutes in lukewarm, not hot, water. Showers are acceptable for older children or adults.
• Use a mild cleanser such as Dove, Tone, or Cetaphil. Avoid harsh soaps like Ivory, Dial, or Irish Spring.
• After soaking in the tub, gently pat the skin dry with a towel, taking care not to rub the skin.
• Within 1-2 minutes after the end of the bath, apply generous amounts of a moisturizer to seal in the moisture which the skin has soaked up like a sponge.

Examples of good moisturizers include:

• Eucerin
• Aquaphor
• Vanicream
• Vaseline

Creams and ointments are better than lotions, which contain alcohol and can dry the skin. Ask your doctor which is a good choice for you. Sometimes diligent daily skin care is all that is needed to control mild eczema.

Identify and Eliminate Eczema Triggers
The second step in effective eczema treatment involves identifying and eliminating triggers which can irritate or inflame the skin. Loose-fitting and comfortable clothes, preferably made of cotton, should be worn. Carefully modifying the diet to remove food allergens is also very important.

Eczema Medication
Medications comprise the third step in controlling eczema. In some patients, anti-inflammatory medications, including topical steroids may be added to the soak and seal regimen. Steroid creams and/or ointments will reduce the skin inflammation quickly and effectively. These treatments are commonly prescribed, highly effective, and generally safe, but should be used sparingly and only as prescribed. A short course of antibiotics may be necessary to control infection from Staphylococcal bacteria or fungus on the skin.

Topical steroids are commonly prescribed to control and minimize the skin inflammation of eczema. Minimal strength steroid creams or ointments may be sufficient to maintain control of minor flare-ups, however more potent steroids are commonly required to treat difficult areas of inflammation, or when the inflammation is present on thick skin such as the hands. Oral steroids are also occasionally required for severe exacerbations of atopic dermatitis. You physician will likely prescribe the lowest strength topical or systemic steroid necessary to control symptoms, and for the shortest period of time necessary.

A newer class of topical anti-inflammatory medications is available for atopic dermatitis. These medications, including tacrolimus (Protopic) and pimecrolimus (Elidel), are non-steroidal creams which work by reducing the inflammation in your skin. However, they are currently recommended for children above the age of two, and only for short term due to concerns about possible side effects. Other medications often used for eczema are oral antihistamines which help to reduce the itching and help eczema patients sleep more comfortably.

The treatment of this chronic skin condition can be very difficult and frustrating. Best results are likely to be obtained with a combination of close follow up with your or your child’s physician and a big dose of patience.

Hives

Hives, or Urticaria, appears on the body as raised welts with red coloration either directly on the hive or on its periphery. These lesions can be quite small, about the size of a mosquito bite, or very large, measuring several inches in diameter. Hives will typically come and go, moving from one place on the body to another within minutes or hours. One thing for sure: they are generally intensely itchy!

Hives are caused by release of histamine and other chemicals from special immune cells called mast cells and basophils. When mast cells and basophils are stimulated, release of histamine and other chemicals produces dilation of blood vessels, leakage of fluid, and irritation of nerves. If these events occur only in the superficial layer of the skin, they cause the redness, swelling, and itching of hives. But, when these chemicals are released in large quantities throughout the body, they can also cause anaphylaxis, a serious systemic allergic reaction which can be life threatening.

A related skin manifestation is angioedema. Angioedema is a term used to describe localized swellings which share many characteristics with hives. Angioedema generally presents as one or two areas of localized swelling, while hives usually presents with multiple welts. Angioedema is caused by the release of the same mast cell and basophil chemicals as hives, but involves the deeper tissues, resulting in a large area of swelling.

Causes of Hives and Angioedema

Allergic causes of hives can include foods, food additives, medications, and insect venoms. It is important to remember, though, that mast cells and basophils can be provoked by non-allergic causes. For example, the most common cause of hives in childhood is probably viral infections.

Another important non-allergic cause of hives is autoimmunity, a condition in which the immune system mistakes its own tissues for an invader and attacks that invader. In cases in which hives last for longer than six weeks, an autoimmune attack directed at one’s mast cells and basophils is likely to be the cause. For reasons that are poorly understood, there is sometimes a concomitant autoimmunity against the thyroid gland as well. In most cases, however, no cause can be determined, despite laboratory and allergy testing. Fortunately, most hives and angioedema is self limited and tends to burn itself out over time.

Diagnosis of Hives and Angioedema

It is important to remember that not all cases of hives or angioedema are caused by or exacerbated by allergies. There are many other well described non-allergic (non-IgE mediated) immunologic mechanisms to explain these skin eruptions. Non-allergic causes of angioedema are important to consider, including medications (especially blood pressure drugs called angiotensin-converting enzyme, or ACE inhibitors) and inherited genetic diseases. They are rarely associated with serious systemic diseases. An allergist can be very helpful in distinguishing these causes.  A careful history, physical exam, and laboratory and/or allergy testing can help discern the possible causes of a these conditions.

For recurrent or chronic urticaria or angioedema, skin testing may be helpful in discovering triggers of the rash. In most cases, the allergist will look for highly allergenic foods such as milk, eggs, soy, wheat, peanuts or nuts, although many other foods may be involved. Patients can also be helpful in tracking down the cause by keeping a food diary. This detective work sometimes is very helpful in establishing an important cause and effect relationship.

In certain cases, blood testing (RAST or ImmunoCAP) may be helpful. This form of testing may be preferable if one’s skin rash is too inflamed to perform skin tests, or if the patient is unable to discontinue antihistamine usage five days prior to skin testing. Other blood tests, looking for more unusual, non-allergic causes of urticaria or angioedema, may also be indicated for patients who have had symptoms lasting at least six weeks.

Treatment of Hives

Critical in the treatment for allergic hives and angioedema is avoidance of known triggers. For mild and intermittent outbreaks, over-the-counter or prescription antihistamines, either individually or in combination, usually work well to prevent release of chemical mediators or to block the effects of the histamine once released by mast cells and basophils. For more severe cases, your allergy specialist may use multiple antihistamines, and, when necessary, medications such as oral or injectable steroids for brief durations. Other unusual causes of recurrent swelling or hives may require special medications.