Ok, another study about the dangers of food allergy (yesterday in USA Today). You would think the occurrence of food allergy to KNOWN allergens (peanut & milk) would decrease given all the attention given to accidental ingestion. Evidently, this is not the case. Explanations? Maybe we’re afraid of giving epinephrine. In my personal experience, giving epinephrine is analogous to “waving the white flag.” It doesn’t have to be nor should it be when treating children with suspected food allergy. As I tell my nurses, “give the epi, then call the doctor!”
Conclusion & Future Perspective
The clinical efficacy of SCIT (typical shots) is well established for both rhinitis and asthma. SLIT (sublingual drops) has also been validated in regards to rhinitis and asthma. Two recent meta-analyses in children showed that sublingual delivery of allergen vaccination constitutes a safe and effective alternative to the injectable route to reduce allergic respiratory symptoms and drug intake. Assessment of possible long-term benefits, including long-term disease remissions, suppression of new allergic sensitizations, and reduction of progression from rhinitis to asthma in children, as has been shown for the subcutaneous route, are future requirements for “proof” of benefits for sublingual drops.
The immunological effects of SLIT and how these relate to clinical efficacy are yet incompletely understood. Large-scale trials have confirmed the induction of allergen-specific IgG antibodies to be dose dependent. There is no early suppression of allergen-specific IgE antibodies and a transient early increase in specific IgE antibodies as in SCIT.
Current models of SCIT propose the induction of antigen-specific Tregs (cell type in the body), which then orchestrate the observed antibody and mucosal changes observed during treatment. As of yet there is only scarce evidence that such mechanisms operate during SLIT. Comparative clinical studies of sublingual and subcutaneous treatment yielded heterogeneous results demonstrating efficacy of both modes, but SLIT to be a safer approach.
In conclusion, understanding of the interaction of allergen and antigen-presenting cells within the oral mucosa may allow improved targeting of SLIT vaccines. In the near future the combination of allergen products with adjuvants may improve efficacy of immunotherapy via the sublingual route.
So here’s the bottom line:
- Sublingual drops are not yet approved by the FDA and I can’t bill insurance for the product like allergists now do for subQ shots.
- Why not use Rapid immunotherapy to achieve maintenance in ONE month, followed by MONTHLY shots instead of weekly? With this method, you get the best of both worlds–good, proven benefits at a convenient dosing schedule.
- Sublingual drops have to be given multiple days per week and compliance isn’t all that impressive.
This issue isn’t going away, so stay tuned!
Allergy tests should be used only to confirm a diagnosis that has already been made on the basis of symptoms and medical history, advise 2 leading allergists in an article published in the January issue of Pediatrics.
Scott Sicherer, MD, from Mount Sinai Hospital in New York City, and Robert Wood, MD, from the Johns Hopkins Children’s Center in Baltimore, Maryland, reviewed the benefits and limitations of blood tests and skin-prick tests in the detection of allergic diseases.
Both the skin-prick test (SPT) and sigE test detect a sensitized state. “However, detection of sensitization to an allergen is not equivalent to a clinical diagnosis. In fact, many children with positive tests have no clinical illness when exposed to the allergen,” Dr. Sicherer and Dr. Wood write.
They further point out that testing for allergens that do not make sense (because they would never be encountered in the patient’s environment or because the patient is obviously not allergic to them) could lead to “detrimental actions of unnecessary allergen avoidance.” They also warn against a false-negative on an SPT or sigE test when a child is obviously allergic to a particular trigger.
The allergists identify circumstances in which SPT and sigE are warranted:
- To confirm a suspected allergic trigger after observing a child react
- To monitor the course of a food allergy to detect when it might be waning or outgrown
- To confirm allergy to an insect after an anaphylactic response, and to identify allergies to vaccines (SPT only).
SPT and sigE tests should not be used, Dr. Sicherer and Dr. Wood write, to screen for allergies in nonsymptomatic children or to diagnose food allergies or drug allergies. Food allergies should be assessed with food challenges, they write, and skin and blood tests do not detect antibodies to drugs.
The tests might be useful for identifying the trigger of a respiratory allergy (allergic asthma or seasonal or perennial allergic rhinitis) that is ubiquitous but not obvious in the patient’s environment: for example, SPT or sigE can detect allergy to dust mites, animal dander, cockroaches, molds, or pollen.
You or your child has just been diagnosed with eczema or Atopic Dermatitis and this can be overwhelming. Just what is atopic dermatitis and how is it treated? Atopic dermatitis is a condition of the skin that results from a defect in the normal skin barrier. You can see it’s easy for allergens and toxic substances to penetrate the skin with this protective barrier gone.
The first step in evaluation of eczema/dermatitis is to find out what triggers the condition–is it foods, allergens, irritants, or persistent scratching. After a thorough history, skin testing can reveal many of the contributing factors.
Unfortunately, atopic dermatitis in childhood may progress to hayfever and asthma later on in life. We call this the “allergic march” and you’ll see from this video at National Jewish Center that allergies never completely go away, they just manifest in a different organ. Beach ball effect, if you will!
The most difficult aspect of atopic dermatitis is persistence in treating the skin barrier. Here’s what I recommend:
- Bathing (not showering) hydrates the skin and makes it more difficult for allergens to penetrate. Kids will love the 20 minute bath!
- Do NOT rub the skin dry, but “PAT” dry to avoid trauma to the areas of eczema
- Apply your cream while the skin is still wet. This encourages hydration of the skin which is the most important aspect of eczema care.
- How about using a bleach bath? Yes you heard me….but don’t take it from me–watch this!
As always, I’m here to help you with allergic skin conditions–don’t hesitate to call.
My condolences to the family of the journalist (Anthony Shadid) who died from asthma covering Syria. Several “learning points” for those with asthma:
1. It appears he was exposed to horses and was very allergic to this animal. Unfortunately, allergic asthma can strike at any time, depending on exposure to the allergen. Many children are exposed to a cat or dog at grandma’s house during the holidays and have to go to the emergency department because of sudden asthma.
2. Even if you have your inhalers with you, asthma can be fatal. This is why you take “controller” medication as prevention. Sometimes the immediate rescue inhalers just aren’t enough.
3. Asthma isn’t the same disease in all patients. Sudden death from asthma occurs in two forms–>the type WITH warning and the type WITHOUT warning. If you review asthma death registries, some asthma patients have died from an exacerbation WHILE IN the hospital already.
For the full article, click on the following link. Please call or reply if you have any additional questions.
Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2011. J Allergy Clin Immunol 2012;129:76-85
So what’s new in allergy to foods, drugs, and insects? I promise, I won’t bore you with basic science facts useful only for allergy boards, but here’s some facts for you to digest with the new year:
A US study estimates a food allergy emergency department visit every 3 minutes, on average. This is a very remarkable statistic for a condition that was “trivial” during my allergy fellowship training.
Food allergy health care costs are estimated at $500 million in 2007. Ditto the above–now you know why so much research is focused on a permanent cure for food allergy.
Severity of peanut allergy varies regionally, likely based on the source of sensitization (pollen related vs oral). Not only region variation, but also determined by culture. For instance, infants in Israel who are fed peanut early in life have less allergy than their European counterparts that withhold peanut until age 2 or 3.
Vitamin D deficiency is associated with increased risk for food sensitization (peanut). Is there anything that Vitamin D doesn’t do? Cod liver oil, here we come!
- Freezing fresh fruits for prick-prick testing does not result in a significant loss of potency. Who cares? Well, your doctor may want to test you by pricking a fresh fruit (say peaches) and then testing your skin. Don’t worry about how you’re going to get the fruit to the appointment….just freeze it for later.
Clinical studies of peanut oral and sublingual immunotherapy show promise. Why not eat small amounts of peanut and develop tolerance to it? It works and several studies are beginning in 2012 to find out more information about safety and who are the best candidates for this procedure. Want to be involved in this type of study? Call me for details.
Several studies support the use of Xolair™ for not only asthma, but also food allergy: Milk and peanut to name two. This treatment may also be useful for chronic urticaria refractory to antihistamines–>hives.
During a safety study of a food allergy herbal formula based on traditional Chinese medicine, a trend toward modulation of basophil responses was observed. This means some science exists behind the nutritional and herbal medicine “craze.”
New insights into the use of vitamin D, phototherapy, methotrexate, azathioprine, and immunoadsorption in treating severe AD were shown.
Several studies support the notion that egg content of seasonal influenza vaccines is low, that skin testing is not necessary, and that the vaccine can be safely administered to persons with egg allergy!! See my previous post on egg allergy and Flu vaccine.
A Canadian study shows only 55% with diagnosed food allergy had selfinjectable epinephrine. Folks, this is a life-threatening reaction and only 55% had the lifesaving treatment on hand?
A clinical study of children with delayed urticarial and maculopapular rashes shows a low recurrence rate and efficacy of drug rechallenge. If you’re faced with a rash occurring 4-6 hours after taking a medication, you probably won’t react with the second exposure
Is this enough to absorb in one day? Happy New Year!
It’s time for my allergy shot, but I don’t wanna! If getting shots makes you nervous, watch this girl….a real trooper and funny at that:
Please review the following information on allergy shots…you’ll save some time and learn a lot.
Questions patients ask:
1. How often can I get shots? Once you are at the maintenance dose, you may receive shots every 2-4 weeks. Please adjust your shots based on your allergy symptoms. (ie, shots every 2 weeks during the spring/fall and every 4 weeks during the winter)
2. How long does it take to “build up?” I’m glad you asked that. You can build-up with weekly shots like we’ve always done it and take 4-6 months to reach the maintenance dose–conventional. If you want to reach the maximum benefit earlier, I prefer the “rapid desensitization” which will achieve maintenance in one month. Big difference in convenience!
3. What to do about local reactions? Don’t ignore them. Local swelling doesn’t mean you will develop more severe reactions, but talk to your allergy shot nurse about air lock, application of ice, diluting your serum, just to name a few. I want to know if your arm swells after your shots….the only bad question is–you get the hint.
4. Do shots really work?–I tell patients that after 3-5 years on allergy shots at high dilutions, 70 to 80% of patients don’t have to go back on injections. What this means is that symptoms of allergy go down and need for medication also goes down, leaving you free to enjoy the outdoors!
5. Here’s what allergy serum should look like at the maintenance concentration–if your serum is clear, you may not be receiving the full benefit of shots in the first place. Notice the dark, cola-colored allergy serum…should be your maintenance if tolerated.
Last but not least…..are shots safe long-term? This study published in 2011 is very encouraging. Association of subcutaneous allergen-specific immunotherapy with incidence of autoimmune disease, ischemic heart disease, and mortality. J Allergy Clin Immunol 2011. Subcutaneous allergen-specific immunotherapy (SCIT) is a well-documented treatment of IgE-mediated allergic disease. In this registry-based observational study, receiving SCIT (allergy shots) compared with medications only was associated with lower risk of autoimmune disease and heart disease, as well as decreased all-cause mortality (early death).
Sooo….pull up your sleeve and let’s get you feeling better!
For the last 100 years, the pioneering technique of subcutaneous allergen desensitization first developed by Noon and Freeman has proven quite resilient and, in fact, central to the practice of clinical allergy. It remains the only therapeutic modality by which long-term immune modification can be achieved and has afforded not only symptomatic relief to untold numbers of allergic patients, but also life-saving benefit in the case of venom hypersensitivity. So while we are indebted to generations of scientists and physicians for their outstanding contributions to the understanding of the mechanisms and clinical application of immunotherapy, we embrace the many new technological approaches that hold promise for the treatment of allergic patients and that perhaps one day may give rise to a cure for atopic diseases.