Do I really want that? Shared decision making and how this applies to allergy.

As #Christmas time approaches, it’s clear that Americans want choice. When I ask patients what they would like for Christmas, “I don’t know” is usually not their answer. Children’s eyes filled with sparkles at Santa’s coming, parents’ smiling at me and thankful I haven’t ruined their stories about Santa dominate our discussions about the holidays. Of course, I’ll always review medications and made sure that #asthma won’t ruin a perfectly good Christmas.

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Ask The Allergista: Is surgical steel nickel-free?

The Allergista


Hi Jennifer! I’m looking for earrings (nickel free). I find I must have an allergy to nickel. Would you happen to have any suggestions? I see some people on Etsy have surgical steel posts, but I’m a bit skeptical to get from individual vs. a company that verifies allergen free.

Also, thanks for listing all of your eczema resources. I have eczema, both my children have eczema and my 4 year old daughter has anaphylaxis to peanut. So, we are always looking for less harsh skin products and clothing. Thanks for sharing your story. You site is AMAZING. Thank you again.


Hi there! And thank you thank you thank you! You are so incredibly welcome.

I would definitely NOT purchase surgical steel. I know it sounds like a good idea to a lot of people, but I’ve had HORRIBLE reactions to surgical steel posts before. ALWAYS buy sterling…

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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

#allergy, #conditions-and-diseases, #contact-dermatitis, #eczema, #health, #puva-therapy, #skin-disorders, #ultraviolet

Wedding Ring allergy

Think you can be allergic to your spouse? Just this week in the clinic, a middle-aged woman presents with a rash found only when she wears her wedding ring.  No other jewellery gives her problems except for the ring when worn > 2-3 days.  Although nickel allergy can cause this scenario, this woman probably has occlusion dermatitis or “wedding ring allergy.”  Any accumulation of soap and water underneath the ring will cause this type of dermatitis in sensitive individuals.  Want to learn more?

#allergies, #allergy, #conditions-and-diseases, #jewellery, #rash, #wedding-ring

Metal implants may cause more problems!

In allergy, I am often asked to evaluate a patient for “metal allergy”. This is from British investigators cautioning against the use of metal implants. They found metal components in the blood stream of patients with implants–this is where the sensitization comes from. Click on the link for the full article. 1

#dental-implant, #hip-replacement, #metal-allergy

The Teen Who Can’t Swallow–What To Do?

The Evaluation of a Patient With Suspected EoE

Our series is on eosinophilic esophagitis (EoE) and I’ve covered how you present with this condition and a little bit about what the heck this condition really is! The website reference is

Patients with suspected EoE should be evaluated by both an allergist and a gastroenterologist.

  • A careful history should include screening for the presence of reflux/GERD, growth delay, feeding/swallowing difficulty, and a past history of allergic disease. 
  • Symptoms of interest include history of weight loss or poor weight gain, dysphagia or odynophagia, multiple emergency department visits for impacted food, altered eating habits such as food aversions, overcutting or overchewing one’s food or eating very deliberately and requiring lots of fluids to wash down each bite.
  • A family history of similar symptoms or atopy can also be a clue.
  • EGD with multilevel biopsy is needed to make the tissue based diagnosis. Careful attention should be paid to gross features when performing the procedure. Dilation may frequently be performed in conjunction with the biopsy.

Allergen testing should be performed only in patients with biopsy proven EoE, because the tests do not have good positive predictive value without established disease.  Unfortunately, skin testing can be positive AND negative in biopsy proven EoE, which leads to much confusion from a diagnostic standpoint. 

Testing is guided by foods reported to cause symptoms, but should include 13 common foods with established predictive values for EoE.   What are those foods? I’m glad you asked.  Milk, egg, soy, wheat, corn, beef, chicken, apple, rice, potato, peanut, oat, barley. This means BOTH skin testing and patch tests to the above list.  Patch testing is a bit different in that I make a “paste” with the food and place it in a Finn chamber on the back for 48 hours.  Keeping it on can be a challenge, but good results.   

Patch test applied to skin

Loading a Finn chamber for patch testing

Inhalants should also be tested given aeroallergy can play a role.  Food atopy patch testing assesses for a cellular-mediated mechanism, and should be placed for food items not positive on initial testing, and read at a minimum of 48 hours after placement. Both prick and patch tests have independent positive and negative predictive values, as well as combined values. Foods positive on either test are generally recommended to be removed from the diet. There is no established role for ImmunoCAP® testing or other allergy blood tests in diagnosing EoE. 

  • So there you have it…find out if EoE is even present before testing for foods.
  • Use both skin tests and patch testing to identify suspected foods that will need to be eliminated.
  • And in case you’re wondering, here’s what a positive patch test looks like…..

    Positive patch test for EoE.

#allergy, #biopsy, #blood-test, #conditions-and-diseases, #eosinophilic-esophagitis, #food, #health, #patch-test

I have a skin rash!

Scratching the Surface on Skin Allergies–Sooo many patients have skin allergy that results in a trip to the allergy office.  How do I know if it’s allergy or something else?  Do I need a dermatologist?  If you’re a physician, please feel free to use the patient information handout here.  If you’re a patient, I’ve included a great video on urticaria or hives that you’ll want to check out. 

What would cause red, bumpy, scaly, itchy, inflamed/blistered or swollen skin? Dry skin, sunburn or an insect bite may be the cause. Or, you may have a skin allergy. The most common skin allergies include eczema, hives/angioedema and contact dermatitis.

Hives and Angioedema

Hives are red, itchy, raised areas which may be triggered by food, latex or drug allergies. Hives can also result from non-allergic sources like rubbing of the skin, cold, heat, physical exertion or exercise, pressure and sunlight. Hives usually go away within a few days. Chronic hives can linger for months to years, and this is the most common reason for allergy evaluation!  Unfortunately, most cases of chronic hives come from the INSIDE, not something you eat or get exposed to outdoors.  Don’t believe me?….check out this 5 minute video  from Dr Meadows explaining chronic hives in detail.  (He is from Alabama and very active with the College of Allergy, Asthma, and Immunology) 

Contact Dermatitis

Contact dermatitis is often more painful than itchy. It is characterized by an itchy, red, blistered reaction from poison ivy, nickel, perfumes, dyes, latex products or cosmetics. Some ingredients in medications can cause a reaction, most commonly neomycin, an ingredient in antibiotic creams.  Patients will often confuse a skin allergy with contact dermatitis & both conditions are very different from each other. 

Allergic contact dermatitis reactions can happen 24 to 48 hours after contact. Once a reaction starts, it takes 14 to 28 days to go away, even with treatment.  Skin allergy may occur within 1 hour after exposure.  Big difference in your history-taking skills.

 Did you know?

Test your IQ

• About 27% of children who have food allergies also have eczema or skin allergies.

• Contact dermatitis leads to approximately 5.7 million doctor visits each year.

• More than 3,700 substances have been identified as contact allergens.