Allergy

Definition
Allergies are overreactions of the immune system to substances that do not
cause reactions in most people.

Types
Allergies are grouped into four types (I, II, III and IV). These classifications
are based on what parts of the immune system are activated and how long it
takes for a reaction to occur. The two types commonly associated with the
term ’allergies’ are type I or ‘immediate’ hypersensitivities, and type IV or
‘delayed’ hypersentivities.

Type I Hypersensitivity
This is when a particular foreign substance or allergen reacts with a specific
type of antibody called immunoglobulin E (IgE). This reaction causes
symptoms to appear within minutes mainly with the respiratory system
(nose, throat, lungs), the gastrointestinal system (stomach, intestines,
bowel) and the skin. They occur most frequently in patients with a family
history of allergies (although not always to the same substance). The first
time a predisposed person is exposed to a potential allergen, they will not
have a major reaction, instead, they will create a specific IgE antibody and
become sensitized. If that person is then exposed to the allergen again, the
specific IgE identifies the allergen, attaches to it, and triggers the release of
chemicals, including histamine, which cause allergic symptoms.

These symptoms start wherever the allergen was introduced (for example in
the skin, eye, mouth or nose).

For skin exposure, the reaction can cause an inflamed, itchy patch of skin
called hives or welts, while in the long term the allergy may cause dry
patches of skin often called atopic dermatitis called eczema.

For lung exposure, the reaction can cause coughing, nasal congestion,
sneezing, throat tightness, and, in the long term, the allergic reaction can
cause asthma.

For eye exposure, the reaction can in the short or long term red itchy eyes.

For intestinal exposure, the reaction can start in the mouth with tingling,
itching, a metallic taste, and swelling of the tongue and throat, followed by
abdominal pain, muscle spasms, vomiting and diarrhea, over time leading to
a variety of gastrointestinal problems.
Any severe acute allergic reaction also has the potential to be life
threatening, causing a reaction that spreads throughout the entire body that
can start with agitation, a 'feeling of impending doom' pale skin (due to low
blood pressure), and/or loss of consciousness (fainting). This type of
reaction is extreme and called anaphylaxis. This severe reaction can be fatal
without the rapid administration of an adrenaline injection.

Type I allergic reactions can be variable in severity, one time causing a rash,
the next time anaphylaxis. Type I allergies can be to just about anything:
foods, plants (pollens, weeds, grasses, etc), insect venoms (for example
wasp or bee stings), animal dander (from the fur of cats and dogs), dust
mites, mould spores, occupational substances (for example latex), and drugs
(such as penicillin). There can also be cross-reactions, where someone
allergic to grass pollen, for instance, may also react to melons and tomatoes.
The most common food-related causes of severe anaphylactic reactions are
peanuts, tree nuts (such as walnuts and hazelnuts), and shellfish.

Type IV Delayed Hypersensitivity

These are most often skin reactions. Common examples include reactions to
metal and jewellery. They occur when an allergen interacts with specific T
lymphocytes. No immune system ’sensitization’ is necessary; patients can
have a type IV reaction with the first exposure. Type IV hypersensitivity is
usually a reaction (redness, swelling, hardening of the skin, rash, dermatitis)
observed at the exposure site hours to days after exposure In type IV
hypersensitivity, the allergen reacts with a specialized type of cell called a T-
lymphocyte. In this case symptoms take hours to days to appear

What is not an allergy?

There are other reactions that can cause allergy-like symptoms but are not
caused by an activation of the immune system. They range from toxic
reactions that affect anyone who has sufficient exposure, such as food
poisoning caused by bacterial toxins, to genetic conditions, such as
intolerances caused by the lack of an enzyme (for example, the inability to
digest milk sugar, resulting in lactose intolerance) and sensitivities to things
like gluten (in coeliac disease). Symptoms can also be caused by
medications such as aspirin and ampicillin, food dyes, MSG (monosodium
glutamate – a food flavour additive), and by some psychological triggers.
While these diseases and conditions may need to be investigated by a
physician, they are not allergies and will not be identified during allergy
testing.

Tests
The diagnosis of an allergy starts with a careful review of the patient’s
symptoms, family history, and personal history, including: the age of onset,
seasonal symptoms, and those that appear after exposure to animals, hay,
or dust, or that develop in specific environments (e.g. home and work).
Other environmental and life style factors such as pollutants, smoking,
exercise, alcohol, drugs, and stress may make the symptoms worse and
should be taken into consideration. Once the list of possible allergens has
been narrowed, specific testing can be done.

Skin prick or scratch tests are usually done in an allergy clinic. Liquid drops
of individual allergen extracts are put onto the skin (often the back) and
then a small needle is used to prick or scratch through the drop into the
skin. A positive test results in a small raised bump about the size of an
insect bite. Reactions usually take place within 20 minutes. Skin prick tests
are often used to detect airborne allergies such as pollens, dust, and moulds.
Because of the potential for a severe reaction, skin prick tests are not
usually used for food allergies.

If the skin prick test is negative, there is a 95% chance that you do not have
an allergy to that substance. Positives are more problematic; only about
50% of those who have a positive result are actually allergic to that
substance. The diagnosis of allergy will depend on whether your symptoms
match up with the allergens you test positive for.

You must not have significant eczema or be taking antihistamines or certain

antidepressants for several days before the skin prick test. The test must be
done by a trained professional.

Allergen specific IgE testing or RAST (RadioAllergoSorbent Test), as it is

known, is a laboratory test that is used to screen for allergen-specific IgE
antibodies. It is often recommended when skin prick testing is not possible
or when a severe allergic reaction might be anticipated. Allergen-specific IgE
antibody testing involves taking a blood sample and checking for each
allergen suspected. Allergens may be selected one at a time or by choosing
panels such as food panels, which contain the most common adult or child
food allergens, and regional weed and grass panels, which contain the most
common airborne allergens in the location where the patient lives. Individual
selections are very specific, for example: bumble bee versus honeybee, or
egg white versus egg yolk.

If a specific IgE test is negative, then chances are that you are not allergic to
that substance, but a positive test must be evaluated alongside your clinical
symptoms. You can have a low level and still have a severe reaction to
actual exposure to the allergen or an elevated level and never experience a
reaction. People who outgrow a food allergy may continue to have positive
IgE test result to the food for many years.
Total IgE testing is sometimes done to look for an ongoing allergic process.
It is a blood test that detects the presence of IgE protein (including allergy
antibodies) but does not identify specific allergens. Conditions besides
allergies can also cause it to rise.

Oral food challenges are considered the 'gold standard' for diagnosing food
allergies. They require close medical supervision because reactions can be
severe (life threatening anaphylaxis). Food challenges involve giving you
small amounts of unmarked potential food allergens (either in a capsule or
injected directly into your bloodstream) and watching for allergic reactions.
Negatives are confirmed with larger meal-sized portions of food.

Elimination is another way to test for food allergies: eliminating all suspected
foods from the diet, then reintroducing them one at a time to find out which
one(s) are causing the problem.

Patch testing. Delayed hypersensitivity patch tests are the easiest methods
of testing for 'delayed' allergies (for example allergies to rubber or nickel). A
concentration of the suspected allergen is applied to the skin under a
nonabsorbent adhesive patch and left for 48 hours. If burning or itching
develops more rapidly, the patch is removed. A positive test consists of
redness with some hardening and swelling of the skin, and, sometimes,
vesicle (blister-like) formation. Some reactions will not appear until after the
patches are removed, so the test sites are also checked at 72 and 96 hours.

Treatments
Prevention. There is some evidence that children who were breast-fed have
fewer type I and type IV hypersensitivities. It is also thought that too
restricted and “hygienic” an environment may play a role in increasing
allergies. Some studies have shown that infants raised on farms tend to
have fewer allergies than those raised in a more allergen-free environment.

Avoidance and Elimination. Once an allergy has developed, the best way to
prevent a reaction is to prevent exposure wherever possible. In the case of
food, this may mean a lifetime elimination of that substance from the diet
and vigilance in watching for hidden ingredients in processed and restaurant
food. For example, a spatula that has touched peanut butter cookies before
touching chocolate chip cookies may be contaminated enough to provoke a
reaction in a peanut-sensitive person.

In the case of insects and animals, avoidance is best. In the case of airborne
pollens, such as regional weeds and grasses, limiting time outside can help
but may not prevent the problem. Some people try moving to another area
to avoid certain local allergens; this may not be effective since people with
allergies often develop new allergies to pollens or grasses in the region they
move to.

Desensitization: Immunotherapy is sometimes recommended if the allergen

cannot be avoided. It includes regular injections of the allergen, given in
increasing doses that may “acclimatize” the body to the allergen. The
injections decrease the amount of IgE antibodies in the blood and cause the
body to make a protective antibody known as IgG. Because it moves across
the placental barrier, IgG is important in producing immunity in an infant
before birth. Immunotherapy injections can cause side effects, like a rash,
and can trigger anaphylaxis. Desensitization is most effective for those with
hay fever symptoms and severe insect sting allergies. Many with hay fever
may have a significant reduction in their symptoms within 12 months, and it
is effective in about two-thirds of those who try it. Patients may continue
their injections for 3 years, then consider stopping. Some will have long-
term relief; others will see their symptoms come back. Immunotherapy is
not recommended for food allergens.

Short-term treatment is used for the relief of symptoms. For example, with
respiratory symptoms it may include antihistamines, topical nasal steroids,
and decongestants.

In the case of anaphylaxis, epinephrine injections are required. Those who

have severe reactions must carry adrenaline with them at all times. Anyone
who has a reaction and uses adrenaline should seek medical treatment, as
follow-up treatment is often needed.