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).

#allergy, #anaphylaxis, #food-intolerance, #immunoglobulin-e

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.

#allergy, #analgesic, #surgery

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.

#allergy, #american-academy-of-allergy-asthma-immunology, #urticaria

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

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

#allergen-immunotherapy, #allergy, #scit

Pork-Cat connection

Pork-cat syndrome a rare (but real!) allergy

By Cari Nierenberg

Allergic to cats? Then beware of pigs — or at least, the meat that comes from these sty-dwelling swine. A small number of people who are sensitive to felines may also get allergic reactions to eating pork.  Continue reading

#allergy, #cat, #food-allergy, #pork

How Can You Resist?

Our environment is so important for treating and controlling allergy.  The holiday season lets many triggers into our homes that normally wouldn’t be allowed.  Does your doctor ever make you mad by suggesting you remove a pet from your home because of allergy?  Granted, it doesn’t matter what clinical research says when your pet is at stake, but this editorial discusses the myth of hypoallergenic pets….by the way, do think the red bow would look good on Scamp for Christmas?

The Journal of Allergy and Clinical Immunology
Volume 130, Issue 4 , Pages 910-911, October 2012  Author: Dr. Richard Lockey.

William Osler, the father of American medicine, said “The practice of medicine is an art based on science.” The article by Vredegoor et al1 entitled “Can f 1 levels in hair and homes of different dog breeds: lack of evidence to describe any dog breed as hypoallergenic” gives credibility to Osler’s admonition. Sound science is fundamental to good medicine, and it is important for physicians and other health care professionals to use this science to provide quality care for their patients and to teach families to better care for themselves, in this case to understand that there is no such animal as a hypoallergenic dog.

What pertinent information can be gleaned from this article? First, the authors compare so-called “hypoallergenic dogs” (labradoodle, poodle, Spanish waterdog, and Airedale terrier) with “nonhypoallergenic” dogs (Labrador retriever and a control group composed of 47 different nonhypoallergenic dog breeds and several crossbreeds). The authors sampled dog hair and coat, settled floor dust, and airborne samples.

The article demonstrates that Can f 1 levels in hair and coat samples are significantly related to the breed, although high variability occurs within individual breeds. Can f 1 levels are significantly higher in hair and coat samples in dog breeds considered hypoallergenic, and they are no less allergenic than any other dogs. Although there is some variation in other characteristics, such as whether the dog was bathed, none of these parameters had significant outcomes on the conclusions of the study. These data are confirmed by another study, published in July 2011, which examined dog allergen levels in homes of hypoallergenic versus nonhypoallergenic dogs. It, too, indicates that there is no evidence for differential shedding of allergens by dogs grouped as hypoallergenic.2

Second, the allergic symptoms of all persons 6 years of age or older living in the homes of dog owners also were elicited. Most owners of hypoallergenic dogs selected them for this alleged characteristic. More than 80% of the allergic owners of hypoallergenic dogs stated that they had less symptoms with these versus other dogs, illustrating that their conclusion is not secondary to less Can f 1 in their home environment.

The United States has the highest number of household pets, with approximately 62% of households having 1 or more domestic animals.3 About 78.2 million dogs and 86.4 million cats occupy homes. The average cost for basic food, supplies, medical care, and training for a dog or a cat is $600 to $900 annually, indicating that if each animal costs $750 annually, up to $123 billion dollars or more are spent on these fur-bearing pets each year, equal to the gross national product of the 57th of the 182 countries of the world.4

Evidence also shows that high levels of Can f 1 are found in settled dust in carpets or soft furnishings, such as couches, pillows, and blankets, in homes. Also, Can f 1 allergen levels are present in classrooms, airplanes, automobiles, day care centers, hospitals, and households without dogs.5 Cat allergens, particularly Fel d 1, the main cat allergen, are also widely dispersed in indoor environments.6 As the prevalence of fur-bearing animals in homes has increased in the United States over the past 60 years, so has the incidence of allergic diseases.7 Is there a cause and effect? In the past, these fur-bearing animals were kept outdoors for a variety of reasons, including the fact that they cause allergic diseases, as well as because they were thought to be dirty, promoted flea infestation, and were associated with cat scratch disease, toxoplasmosis, and other infectious diseases.8 These same risks exist to this day.

Today, animals are considered part of the family and occupy the same territory in homes as the human residents, including beds. In fact, studies show that it is almost impossible to eliminate animals from the home, even when subjects with dog and cat allergy live in the same dwelling.9 A clinical vignette is helpful to illustrate this point. Two children, ages 6 and 8 years, accompanied by their mother were seen by me in the clinic. Both children had a history of multiple hospitalizations for asthma. Five cats lived in the home before the birth of the children and continued to occupy the entire home. Both children were historically allergic to cats and had very positive prick-puncture skin test results to cat extract. When I approached their mother about excluding the cats from the home, she refused and removed her children from my care. This story illustrates sometimes how difficult it is to remove animals from the homes of allergic subjects.

Would 5 smokers be permitted to smoke in the same home? Is chronic allergic inflammation caused by animal dander similar to the detrimental effects of passive smoke or direct smoke for allergic asthmatic patients? Are the persons with asthma who have airway remodeling and irreversible lung disease, possibly caused by continuous allergen exposure, comparable with those who smoke and have chronic obstructive lung disease?

It is a bit ironic that smoking, which has been associated with the onset and worsening of allergic and other respiratory diseases, is universally prohibited in many countries, yet cats and dogs are ubiquitous, even allowed in some restaurants and on planes, resulting in pet allergen contamination of both private and public dwellings and placing persons with dander allergy at risk.

Although there is some evidence that having a cat or dog in the home during the first year of life might prevent allergic disease, including asthma, the evidence remains controversial.10 One article even suggests that dog ownership significantly reduces the risk of eczema at age 4 years among dog-sensitive children, whereas cat ownership combined with cat sensitization significantly increases this risk.11 Many published studies are available about preventing allergic diseases and are summarized in a World Health Organization book devoted to prevention. It calls for the removal of relevant pets from the environment for primary, secondary, and tertiary prevention.12 Similarly, a 2012 review article about preventing allergy in children states that “Acquiring or avoiding a pet cannot be justified as a measure preventing allergy in an infant.”13

Although intelligent conversations about animal removal from a home might have taken place in the past with patients and family members allergic to such animals, today these conversations are often met with immediate resistance and the idea that the treating physician should prescribe a medication or cat and dog allergen immunotherapy, with their considerable cost, inconvenience, and even risk to the patient, to attempt to eliminate dander-associated symptoms.

Physicians and other health care professionals should be knowledgeable about the causes of pet dander allergy so they can educate their patients to help minimize and prevent exacerbations of allergic diseases and asthma. The concept of a hypoallergenic animal, in this case a dog, is not supported by scientific evidence, just as there is no evidence to support the concept of hypoallergenic cats.6 Therefore the implementation of more established practices, such as eliminating animals from the home, remains the treatment of choice.

#allergy, #hypoallergenic, #hypoallergenic-dog-breed

Stay Up to Date with Food Allergy

I always enjoy National Medical Meetings….good food, meeting old friends, and yes, even learning something!  The College of Allergy annual meeting was held in California just one week ago……and what are the hot topics this year? 

Here’s an article and interview from Medscape about this year’s meeting.  Why am I interested? Dr. Portnoy was my mentor (professor) during my fellowship training in allergy.  Way to go Jay! 

Here’s what he had to say–This international food allergy conference features the latest on eosinophilic esophagitis, unusual and “off the beaten track” food allergies, spice allergies, and developments in food immunotherapy.

“Food allergy is always something that people are interested in,” Jay Portnoy, MD, professor of pediatrics at the University of Missouri, Kansas City, and Mercy Children’s Hospital, told Medscape Medical News

Children’s Mercy Hospital entrance

Dr. Portnoy, who chaired this year’s abstract committee, highlighted a few of the presentations on food allergy that he considers particularly noteworthy.

“Researchers at Northwestern University in Chicago have found that kids with egg and milk allergy are more likely to outgrow those allergies than if they have tree nut or shellfish allergy. So when the doctor says your child will probably outgrow their egg or milk allergy, they’re not too far off,” he said.

Another study examines how people who are allergic to hen eggs might be able to tolerate them when they are baked. “It turns out that baking the egg actually denatures or neutralizes the allergen, more so than if you just partially cook it. If you introduce cakes and cookies into your diet, you will be able to most likely broaden your diet and improve the quality of your life,” he said. 

One presentation of definite note is on a newly identified and possibly life-threatening allergic reaction to mammalian meat. Researchers have determined that the lone star tick is the primary reason for meat-induced alpha-gal allergic reactions.

“This new food allergy, alpha-gal, is more common than we thought. There is a high prevalence in some areas of the country, particularly in the central and southern regions of the United States,” Dr. Portnoy explained.

Alpha-gal is a sugar found in red meats such as beef, pork, and lamb. In the study to be presented, positive alpha-gal rates were 32% higher in areas with a lone star tick population than in other areas of the United States.

Symptoms of alpha-gal allergic reactions range from mild hives to potentially life-threatening anaphylaxis.

“The reaction is delayed. A lot of people have experienced this, and now we know what it is. This is why it is so important to come to the annual meeting and learn about these unusual allergic reactions,” he said.

The topic of spice allergies is also on the meeting agenda.

According to a statement issued by the ACAAI, spices are one of the most widely used products, and are found in foods, cosmetics, and dental products. The US Food and Drug Administration does not regulate spices, which means that they are often not noted on food labels.

As a result, they are one of the most difficult allergens to identify and avoid.

“While spice allergy seems to be rare, with the constantly increasing use of spices in the American diet and a variety of cosmetics, we anticipate that more and more Americans will develop this allergy,” said Sami Bahna, MD, DrPH, from the Louisiana State University Health Sciences Center in Shreveport.

“Food allergy is a very important topic for allergists because we need to understand the most current research; recently, the field has seen a lot of changes,” ACAAI President Stanley Fineman, MD, from the Atlanta Allergy and Asthma Clinic in Georgia, told Medscape Medical News.

“There is a lot of new understanding about food allergies, new diagnostic tools, and some potential treatments,” he said. “This is the place to find out the latest information; when you go back to your practice, you [will] be on the cutting edge.”

Back by popular demand is the annual literature review course, where experts present what they feel are the key articles of the year on topics such as immunology, allergic rhinitis, ocular allergies, and immunology. “We have almost 500 people already registered for this program. Some people look forward to this program all year long to catch up on the literature. It’s a very popular feature of the meeting,” Dr. Fineman said.

The slogan for this year’s meeting is “Over the Horizon: Expanding Expertise,” which captures the essence of what the conference is about, he noted.

“The program committee selected this theme to help us see what is going on in the future, to expand our expertise, to make sure that we are able to keep current, and to hone our skills so we can adapt to any changes in healthcare and any new research involved with treating our patients,” Dr. Fineman explained.

“Most allergists go to the meeting to find out what’s new in allergy, to keep their skills up, to interact with colleagues, and to validate what they do. Because, like most allergists and most physicians, if you are in practice and you don’t interact with other physicians, you can start to develop quirky styles of practice that may not be the best practices. It’s really a good idea to touch base with colleagues, interact, and hone your skills,” Dr. Portnoy added.

“At this meeting, allergists will hear about an unusual case and then remember a patient who had the same thing. That’s how advances in our field are made,” he said.

I could say it better.  With all the controversy swirling around health care reform, it’s refreshing to learn about what really matters for taking care of patients….that’s why I keep going to work every day!

#acaai, #allergy, #american-college-of-allergy, #american-college-of-allergy-asthma-immunology, #food-allergy

Have We Lost our CommonSense?

Schools are quite paranoid about giving any medication on their watch.  The liability for giving sunscreen when you don’t need it?  Zero.  This is very similar to the use of epinephrine in a school aged child with food allergy.  You certainly don’t want to withhold epi and risk anaphylaxis or death, when the risk of giving the EpiPen is negligible even if you don’t need the drug.  Maybe our policies in schools will change after a large malpractice case gets media attention for NOT giving epinephrine at the appropriate time for peanut allergy. 


#allergies, #allergy, #epinephrine, #epinephrine-autoinjector, #food, #food-allergy, #health, #new-york-city

Are We Beating a Dead Horse?

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!” 


#allergen, #allergies, #allergy, #epinephrine, #food, #food-allergy, #health, #usa-today