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. 

http://www.usatoday.com/news/health/story/2012-06-27/sunscreen-policies/55877080/1

#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!” 

http://www.usatoday.com/news/health/story/2012-06-25/kids-food-allergies/55797696/1

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

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? 

http://www.medicinenet.com/script/main/art.asp?articlekey=107570

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

Can I Prevent an Allergy Shot Reaction?

Risk Factors for Systemic Reactions to Allergen Immunotherapy

Alfredo Iglesias-Cadarso; Pilar Hernández-Weigand

Purpose of review To update safety information regarding allergen-specific immunotherapy (ASIT) in clinical practice and highlight the risk factors associated with the adverse reactions, product and each dose.
Recent findings Efforts in recent years have focused on increasing our understanding of the efficacy and safety of ASIT, especially the sublingual variety (SLIT), in multicenter studies. Moreover, new Clinical Practice Guidelines (CPGs) and an international consensus concerning ASIT have been published recently. Although no deaths as a result of subcutaneous immunotherapy or SLIT have been reported in the last 2 years, systemic reactions mainly arising from administration errors still appear. Recent studies support the safety of new forms of specific immunotherapy.
Summary An understanding of the risk factors for each patient, product and dose, and the implementation of CPGs are the main factors that could improve the safety of ASIT. The standardization of all procedures for prescribing and administering ASIT, and the systematic collection of standardized safety data in a multicenter database (postmarketing surveillance), may be required to generate new information on the safety of ASIT.

Why Do We Even Care About Safety of Allergy Shots?

Allergen-specific immunotherapy (ASIT), both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), has been shown to be effective for the treatment of allergic respiratory disease in randomized controlled trials and meta-analyses.  Indeed, SCIT is the treatment of choice for preventing anaphylaxis in patients with systemic reactions to hymenoptera (bee stings).

The greatest drawback to the more widespread use of ASIT is the associated risk of severe side-effects, as the dose which has been shown to be well tolerated and effective in a group of patients may not be so for a specific patient. Here again, everyone is different and what may be the best dose for one patient, may cause an adverse reaction for someone else.

Systemic reactions are those which produce symptoms and signs far from the administration site. They may be immediate systemic reaction (ISR), appearing in the first 30 min postadministration, or delayed systemic reaction (DSR), occurring after the first 30 min, with the former tending to be more severe.

The incidence of systemic reactions has been estimated at between 1 and 34% of patients and around 0.2–0.3% of doses, depending on the type of study, patient, diagnosis, extract or treatment scheme.  

Historical reviews of ASIT-related mortalityhighlighted severe or poorly controlled asthma and administration errors as the main causes of fatal systemic reactions. These findings led to the drafting of Clinical Practice Guidelines (CPGs) for ASIT treatment,and their subsequent updates, in the 1990s. Adherence to such guidelines is the main reason behind the reduced frequency and severity of systemic reactions in the past 20 years. The statistics regarding mortality and systemic reactions prior to these CPGs are no longer applicable.

Let’s look at some individual factors that increase your chances of a systemic reaction to an allergy shot!

  • What do you put in my serum? No specific allergen is currently thought to produce higher mortality or a greater chance of a large local reaction.
  • Very few fatal reactions to pure hymenoptera venom immunotherapy (VIT) have been reported. Indeed, several studieshave found a lower incidence of systemic reactions with hymenoptera vaccines, with bee vaccines being tolerated worse than wasp vaccines.
  • Systemic reactions appear to be more frequent when aqueous extracts are used.  This is presumably due to the fact that the allergen is absorbed very quickly after it’s injected.

Dose-related Risk Factors

  • Administration errors are the main identifiable and avoidable cause of ASIT-related systemic reactions, including SLIT. (SLIT is the oral allergy drops)
  • Any delay in the treatment of a systemic reaction increases its severity. This is why I instruct my nurses to give epinephrine first, then call.
  • Although CPGs provide recommendations to avoid such errors, they continue to occur with a greater than expected frequency. 
  • I could write a book on the types of errors that occur with the dose of allergy shots.  Would this be a best-seller or what?
  • Research has shown that a large local reaction does not predict the occurance of a more severe systemic reaction; a concept that can be difficult to grasp for patients.  (see below)

Dosing Scheme

In the case of SCIT with airborne allergens, the use of fast regimens (rush and cluster) has been associated with a higher number of systemic reactions, although more recent studies have shown their safety to be similar to that of conventional schemes. Patients tend to like the rapid schedule because they can avoid the prolonged build-up of conventional treatment. 

Omalizumab (Xolair) has been used to reduce the systemic reaction incidence in patients receiving SCIT with inhaled allergens and VIT (venom shots),  with good results.

It is possible, but not confirmed, that systemic reactions increase during the pollen season, but patients generally do not decrease their dose at this time.

Prior Reactions

Together with poorly controlled asthma, the presence of a prior systemic reaction during AIT is the main risk factor associated with a new systemic reaction. 

There is currently no evidence that the dose adjustments recommended in clinical guidelines reduce recurrent systemic reaction in a patient.

Premedication with antihistamines or omalizumab has been shown to be useful in some studies, although such treatment is not recommended as standard.

Local reactions do not predict the appearance of a systemic reaction, although some studies have suggested them to be a risk factor.  The dose adjustments subsequent to major local reactions recommended in the clinical guidelines do not reduce the frequency of future systemic reactions. For additional information regarding the safety of allergy shots, refer to the reference below:

  • Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127:S1-S55.
    •• Latest and extended update of the Joint Task Force (AAAAI-ACAAI) on Practice Parameters concerning all aspects of allergen-specific immunotherapy.

#adverse-drug-reaction, #allergen-immunotherapy, #allergy, #clinical-trial, #health, #immunotherapy, #scit, #slit, #sublingual-immunotherapy, #symbiosis-centre-for-information-technology

What’s important about Asthma?

If you’re like me, your schedule can’t take another committment–how can you add one more task for asthma?  Don’t neglect treatment for your asthma as proper attention now will save you time & money in the end.  Anyone remember the Fram oil filter commercial….”you can pay me now or pay me later?”  We’ll help you focus on what needs to be done everyday and which tasks are to be used just when needed. 

But first, how does asthma really work and why do I have it?  Review this link for “real time” photos!

 What is my hope for you by using these techniques?

1.  More activity without wheezing, coughing, or becoming short of breath

2.  No unscheduled office visits or Urgent care/emergency room visits for asthma flares

3.  Preserve your lung function for your retirement…we all love being active with our grandkids!

4.  Get you on the cheapest medicines available to prevent asthma.

So what’s most important in treatment of your asthma to avoid the top box?

1.  Get a written Asthma Action Plan…if we don’t bring it up, ask.

2.  Review your inhaler use like you would an oil change–every 3 months.  Which medicines are “everyday” and which ones are just “as needed?”

3.  Peak flow meter.  Use for 1-2 weeks as a baseline and thereafter like a thermometer for your asthma. 

Need extra help:  Click on the link to the American Academy of Allergy (AAAAI)

#allergy, #asthma, #dyspnea, #spirometry