Tag Archives: Allergy

My Sinuses Suck!

Allergy or Irritant--that is the question!
Allergy or Irritant–that is the question!

Sinus pressure can be a real problem during the cold, winter months.  Do I take decongestants or antihistamines?  Sudafed or Zyrtec?  Are my allergies acting up?

Here are some pointers on dealing with sinus infections and sinus pressure with some really cool slides at the end:

  1. Most allergens are gone in December-January, so the statement “my allergies are bothering me” is actually misplaced.  You are meaning to say that sinus pressure is causing congestion and runny nose.  Inflammation and swelling definitely exist in your sinuses, it’s just that your symptoms during the winter are not caused by allergy, but rather sinus infection.
  2. Treatment of a sinus infection is “all or nothing”.  In other words, if you only remove 50% of the infection, it is likely your symptoms will quickly recur.  Your body requires a mucociliary blanket in the sinuses to gradually remove bacteria and excessive snot.  This protective blanket is destroyed during any infection, and won’t grow back until the inflammation subsides.  Often it takes 30 days of antibiotics and prednisone to restore the sinuses back to their original condition. 
  3. One of the pictures in your slide set (slide 3 of 15) shows what normal mucociliary blanket looks like under the microscope.  If this giant vacuum sweeper was operating normally all of the time, you wouldn’t have to use all your medication. 

Here are some suggestions on how to treat your sinuses better:

  1. Make sure you eliminate nasal congestion.  For the short term, use Afrin or similar equivalent (OTC) if you limit to < 1 week per month.  This allows the nasal airflow to drive away the excessive mucous in your nose which would otherwise become a great meal for hungry bacteria.  Sick but true!
  2. Find out if you have allergy!  The winter season gives you a reprieve from outdoor allergens, but during the spring, summer, and fall, tree pollen, Bermuda grass, and ragweed are more than willing to invade your sinuses and cause irreparable damage to your mucous membranes and make you always sick. 
  3. Use your prescribed nasal spray EVERYDAY as prescribed by your doctor.  I know, Americans hate to put anything in their nose (except your finger), but regular use of nasal steroids and antihistamines will reduce the swelling in your sinuses and guess what?  You got it, fewer infections. 
  4. Get smart!  Go through the slides below, and if you don’t learn anything new, I’ll buy your favorite drink at Starbucks. 

http://www.medicinenet.com/sinusitis_pictures_slideshow/article.htm

Contradictory skin test and ImmunoCAP results–which is better?

This question comes up in my office almost everyday….should I do skin testing or blood work?  As you can see from the response of national experts, it depends.  There is NO test that can boast 100% accuracy to predict whether or not you will react to a food.  In fact, the gold standard if you will, is still the oral food challenge.  Here is some food for thought (really, do you have to pun)

  1. Clinical history is very important in determining food allergy.  If you can eat a food without difficulty breathing, rash, or hives, you are most likely not allergic.  You may have a positive test, but that only means you’ve had previous exposure to the food.
  2. I will often obtain both skin testing and ImmunoCap (blood work) to clarify the presence of IgE-mediated allergy. If both tests are negative, you may have an adverse reaction to a food, not the severe life-threatening anaphylaxis.  Very important distinction!
  3. If in doubt, a food challenge is always a procedure to consider.  Here’s why.
  4. Sometimes the food in question just isn’t worth the trouble to challenge.  No one says you have to eat strawberries!
  5. If you challenge peanuts for example, in the doctor’s office and experience anaphylaxis, better there than at home.  Epinephrine is more readily available and in many cases, IV access and full resuscitation is available within minutes of your reaction. 
  6. This is another reason why a single test or treating allergy without experience is not a good idea.  Read the link below and tell me just how complicated things can become!

Contradictory skin test and ImmunoCAP results.

Put This Myth to Rest-(Dirt Jet Pro/SCRUBS hand sanitizer wipes)

Everyday I teach patients the difference between “allergy” and “irritant” reaction.  TV ads are overloaded with allergy advertisements in an attempt to sell antihistamines, so why wouldn’t you think that everyone has allergy of some kind.  The link below is a question about allergy (anaphylaxis in this case) to chemicals.  Consider the following:

  1. Adverse reactions to pollen, food, chemicals can be divided into “allergy” or “intolerance/irritants“.
  2. Allergy is defined as the production of IgE to the substance in question.  This is why you have positive skin tests and blood testing.  Why does this matter?
  3. You can only be “desensitized” to allergens, not chemicals.  IgE can be decreased and if you don’t have IgE to begin with you can’t delete its effect.
  4. The only treatment for irritants is to avoid them, regardless of whether the substance is a food or chemical.
  5. For chemical reactions or food intolerance, there’s not much to say except to stay away.  Click on the link below just to make sure!

Possible anaphylaxis to chemicals contained in cleaning agents (Dirt Jet Pro/SCRUBS hand sanitizer wipes).

Tell Me Which Pain Meds I’m Allergic To!

It’s not unusual for a doctor to refer a patient to our allergy clinic to answer the question, “what pain medications am I allergic to?”  Surgery of any kind is a bit frightening, but add to that an adverse reaction to one of your pain medications and you know what hits the fan!  Reactions can include hives, difficulty breathing, headaches and a whole lot more.  So what can I do if I’m in a car accident or emergency surgery and I receive a pain medication I’m allergic to?  Will it kill me? 

Consider the following:

  1. Most effective pain meds are opioids and release histamine from the body when taken as pain meds.  We can’t skin test to medications in this category, so we rely on previous history.  That works well for the most part, but “there’s a first time for everything”
  2. The one exception to the above rule is fentanyl.  With this medication, skin testing and treatment for tolerance have been published and offer a good alternative.
  3. Often a procedure called “drug provocation testing (DPT)” is necessary to determine what you can and cannot take for pain medication.  Fortunately, most patients can tolerate the standard protocols used by most hospitals, so no need to worry.  If in doubt, DPT will give you VERY small amounts of medication making sure you can tolerate the drug before moving to a higher dose.  With a little patience & a long afternoon in the doctor’s office, we can usually find a medication that will work.
  4. But don’t take my word for it….the American Academy of Allergy Asthma & Immunology has several references on the subject of allergy to pain meds.  Check it out with the link below:

Prevention of allergic reactions in a patient scheduled for knee replacement who has a history of pain medication allergy and possible contact dermatitis to chromium.

How You Can Be an Expert

I want to be an expert.  Always have and always will, but now it’s a little easier than 30 years ago.  In fact, all you need now to become an expert is a little fame, a published book or memoir, and Shazam!  you’re an authority on any subject you want to write on.  So where’s the beef on my book? 

Well, that’s not exactly how an allergist becomes an expert.  I won’t bore you with the details, but doctors are trained by experience in the clinic (office) and reading about the medical conditions you have to treat….over and over again.  Eventually your training ends and what do you do then?  No more residency programs, no more allergy fellowships, and no more mentors.  I have found a valuable resource through the American Academy of Allergy, Asthma, and Immunology (AAAAI) entitled “Ask the Expert” (hey they get paid for content, not the title).  Here’s an example of a conversation about hives.  (click on the link at the end) Patients all hate hives and just from this discussion alone I propose the following take home messages:

1.       Hives are caused by allergy only 20% of the time.  We usually want an easy answer, but if that were the case you would never show up in the allergy office.  It’s important to look for the underlying cause of the hives, but in up to 50% of cases, the hives are due to autoimmunity….more on that later. 

2.       Once hives are identified, change your mindset to 6-12 months of treatment.  Hives can resolve spontaneously, but it doesn’t happen quickly. 

3.       Hives that bruise should be evaluated ASAP….no exceptions.

4.       The usual dose of antihistamines prescribed by your doctor is usually for treating hay fever.  The effective dose for treating hives may be 4 times as high; beware of feeling sleepy for several days, but that side effect will usually improve. 

5.       I try to avoid steroids because of long-term side effects, but sometimes steroids are necessary to get the itching under control.  Limit your use and look for alternative medications.  But I will warn you, it’s not always allergy!

Yes, you too, can become an expert with your health—you’ll spend a lot less time in the doctor’s office if you do!

Acute urticaria resistant to therapy.

A Penny for your Thoughts!

Nickel allergy

Nickel allergy very common

can result in both cutaneous and systemic manifestations, and can range from mild to severe symptoms. A severe form of this allergy is the Systemic nickel allergy syndrome, clinically characterized by cutaneous manifestations (contact dermatitis, pompholyx, hand dermatitis dyshydrosis, urticaria) with a chronic course and systemic symptoms (headache, asthenia, itching, and gastrointestinal disorders related to histopathological alterations of gastrointestinal mucosa, borderline with celiac disease). This review aims to briefly update the reader on past and current therapies for nickel contact allergy.

Nickel is the main sensitizer; its prevalence varies from 4.0 to 13.1% in different countries and is still increasing. Nickel allergy is more common among women than among men (17% and 3%, respectively). This difference is due to different rates of exposure of skin to this substance; such exposure (from jewelry, leathers, etc) is more frequent among women.  Makes sense, can I go shopping now! Continue reading

Shots Aren’t the Only Choice for Treating Your Allergies

Novel Routes for Allergen Immunotherapy

Safety, Efficacy and Mode of Action

Philippe Moingeon; Laurent Mascarell

Immunotherapy. 2012;4(2):201-212. © 2012 Future Medicine Ltd.

I DON’T like shots!  And who does?  But alas, if you have to get shots for your allergies, they better be worth the fuss.  Allergen immunotherapy is the only curative treatment of IgE-mediated type I respiratory allergies. Subcutaneous immunotherapy (SCIT) is used as a reference therapy and has transformed allergic treatments; it improves symptoms (asthma and rhinitis) as well as the quality of life of patients. SCIT requires repetitive administration and carries the risk of severe systemic adverse effects, including anaphylaxis. I have modified the schedule of SCIT by rapidly advancing to MONTHLY shots, which makes a big difference on compliance and convenience.  Continue reading