ALLERGIES

A PROTECTIVE MECHANISM OUT OF CONTROL

JERRY M. SHIER, MD
STANLEY I. WOLF, MD

THE ASTHMA & ALLERGY CENTER, LLP

10301 GEORGIA AVENUE 15201 SHADY GROVE ROAD
SILVER SPRING, MD 20902 ROCKVILLE, MD 20850
(301) 681-6055 (301) 869-7820

For appointments call 301-681-6055

 FOREWORD
I have prepared this booklet to supplement your education as we begin Allergy
testing and treatment. I encourage you to read it and refer to it any time you have questions.
I have tried to include most of the basic information you may need. Of course, it is not
intended to replace consultation with either myself or my staff. I recommend that you keep
this booklet with your medical records for future reference.

I look forward to working with you in order to control your allergies.

Jerry M. Shier, MD
 CHAPTER 1

WHAT IS ALLERGY?

Allergy can be described as an abnormal immune tamines. Many people experience drowsiness after
response to substances that do not elicit such adverse taking them, but this is not an allergic reaction: it is
reactions in normal individuals. A susceptible per- an intolerance to the medication. Another example
son who is exposed to these substances (allergens) would be the ingestion of a food that causes a gassy/
has symptoms of the respiratory tract, digestive tract, crampy feeling. This again is an intolerance to the
eyes, or skin. The most common allergic conditions food, rather than an allergy. Understanding whether
are hay fever, asthma, and skin allergies such as any given reaction is allergy or intolerance is what we
eczema, contact rashes or hives. An allergic person are trying to achieve in order to create a treatment
may only have one of these conditions, but it is not plan.
uncommon for one person to have multiple allergic
conditions at the same time. One allergic condition ALLERGENS
may be a problem at one time in your life and a
different allergic condition may be a problem at Antigens are substances that elicit an immune
another time. response. They are proteins that are large enough to
Many times allergic reactions are confused with stimulate the immune system. They may enter the
other adverse reactions that occur to inhaled, in- body by various routes. An antigen producing an
gested, or contacted substances. These reactions are allergic reaction is defined as an allergen.
really known as intolerances and do not have an (See Figure 1)
immune basis. A good example is reaction to antihis-

COMMON ALLERGENS

FOODS: Egg, Milk, Peanut, Wheat, Nuts, Fish, Shellfish, Soy

INHALANT ALLERGENS: Dust Mite, Mold, Cat and Dog Dander, Cockroach, Feathers,
Pollen (from Trees, Grasses, and Weeds, including ragweed)
CONTACT ALLERGENS: Poison Ivy, Poison Oak, Nickel, etc.
DRUGS: Penicillin, Sulfa, Aspirin
INSECT VENOMS: Honey Bee, Wasp, Yellow Jacket, Hornet, Fire Ant
OTHERS: Latex

Figure 1-1
CHAPTER 1 - WHAT IS ALLERGY?

ALLERGIC REACTION DEFINED

The basic mechanism involves four elements: the gestion. If on the skin, hives may occur. In the
allergen, an antibody (a substance made by our gastrointestinal tract, there may be vomiting or diar-
body’s immune system specifically against that al- rhea. Finally, in the respiratory tract, there may be
lergen); cells known as mast cells and basophils, symptoms of shortness of breath, chest tightness,
which produce and release the chemicals that cause wheezing, or coughing.
the symptom of the allergic reaction; and, finally, the The allergic reaction itself is broken down into an
different body organs that react to the chemicals that immediate response after contact with the allergen
are released by the mast cells and basophils. Mast and, secondarily, a late phase reaction that can occur
cells are usually found in the respiratory, gastrointes- anywhere from six to eight hours after the initial
tinal tract and the skin; basophils are found in the contact.
blood. In its most severe form, the immediate reaction
The process begins by the allergen coming in can be life-threatening and is defined as Anaphylaxis.
contact with the body - either through inhalation, Anaphylaxis typically occurs after ingestion of a
ingestion, injection, or skin contact. The body then certain food, ingestion or injection of a drug, or after
processes the allergen and causes white blood cells to being stung by a bee, wasp, yellow jacket, hornet, or
create an antibody known as IgE or antibody E. fire ant. If you have had a life-threatening reaction
These E antibodies find their way to the mast cells secondary to any of the above, please bring this to
and basophils, attach to them, and act as receptors for your physician’s attention.
allergens. As many as 500,000 of these Y shaped IgE
molecules may collect on a single cell. WHO GETS ALLERGIES?
On your first contact with the allergen, there is no
allergic reaction. But, with subsequent contacts, the The tendency to have allergies is inherited. If one
body has now been “primed” or sensitized. The parent or his/her close relatives (parents, grandpar-
allergen attaches to the IgE molecules on the mast ents, aunts, uncles, or siblings) has or had asthma,
cell or basophil and triggers the cell to release many hay fever, or eczema, there is a 40% probability that
chemical substances. The major chemical substance his/her child will develop allergic symptoms. If both
is histamine; this is why antihistamines have been a parents or their family members have or had aller-
mainstay for allergy treatment. There are additional gies, children born to them have a 60-70% likelihood
chemicals e.g. leukotrienes and prostaglandins re- of developing allergies. If there is no family member
leased from the mast cell. These chemicals are as with allergic diseases, there still is a 20% chance that
potent, if not more potent, than histamine. These you may develop allergies.
chemicals then interact with different parts of our Whereas the capacity to develop allergies is ge-
body, creating an allergic reaction. Researchers have netic, the specific manifestations of allergy are not
developed new medications to counteract these other inherited. A parent with hay fever may have a child
chemical substances (e.g. antileukotriene medica- with eczema or asthma. Allergy to a specific allergen
tions) and will be available soon. is also not typically inherited. So, the parent and child
If the allergen attaches to an IgE antibody in the may have hay fever, but the parent is allergic to birch
eye, it results in itchy, watery, red eyes. If this and maple trees; whereas, the child is allergic to oak
reaction should occur in your nose, you have runny and elm trees.
nose, itchiness, sneezing, postnasal drip, and con-
 CHAPTER 1 - WHAT IS ALLERGY?

Allergies can occur at any age, and they may gioedema (swelling); allergic reactions to foods,
change over the years. Symptoms may become worse medications, and bee stings. The amount of re-
or better. Sensitivities to new allergens may develop stricted days and cost to the American public from
while previous ones disappear. A good example is an allergic diseases is mind boggling. Over six billion
infant who has allergic symptoms of eczema from dollars is spent each year for those suffering from
ingesting cow’s milk and eggs. Within two years, asthma and allergic diseases. Individuals with asthma
this problem can disappear. Unfortunately, many of spend 170 million dollars on hospital care, 224
these children go on to have nasal congestion and million dollars for physician services, and 196 mil-
sneezing from exposure to dust, molds, cat dander, lion dollars for medications. Each year, over 25
and pollen; and others go on to have significant million days are spent in bed as a result of asthma.
wheezing, cough, and chest congestion consistent Hay fever sufferers spend 224 million dollars on
with asthma. Although there are exceptions, most physician services and 297 million dollars on medi-
children do not outgrow their allergies. cations. 28 million days of restricted activity, six
A common question that is often asked us is - how million days of bed rest, and five million days of
could I have developed an allergy to my dog or cat work loss are experienced by hay fever sufferers.
after I have been living with it for 10 years without
any symptoms? There are probably three explana- CAN ALLERGIES BE
tions for this. The first is, you may have been having PREVENTED?
subtle symptoms that were not recognizable as al-
lergy. The second explanation may be, it just took As discussed previously, the tendency to have
you that long to become sensitized to that particular allergies is inherited. Unfortunately, we cannot
allergen. Finally, a particular event like a viral infec- choose our parents! A delay in the onset and maybe
tion or excessive exposure to an allergen may have the severity of the symptoms can be done by decreas-
brought out your allergic tendency. The triggering ing exposures to certain allergens early in life.
event many times is not apparent. However, once the Diet is the first way to manipulate the immune
allergic reaction has been triggered, the symptoms system. Newborns should be breast-fed or, if this is
are unlikely to disappear without treatment. not possible, to use a non-allergenic formula
(Nutramigen, Alimentum or Neocate-1). This feed-
HOW COMMON ARE ALLERGIC ing should be given exclusively for the first six
CONDITIONS: months and cow’s milk should not be introduced
until one year of age. No solid foods should be
The National Institute of Allergy and Infectious introduced into the diet until six months of age. Eggs,
Disease estimates that 50 million people are affected fish, nuts, and peanuts should be avoided for two
by asthma and allergic diseases. That is approxi- years. When new foods are added into the diet, it
mately one in four. 30-40 million have allergic should be done every five days, in order to monitor
rhinitis (hay fever), 15-20 million have asthma, and for an adverse or allergic reaction.
11.8 million are affected by one of the following The second way is home environment. This must
allergic conditions: eczema; urticaria (hives); an- be carefully monitored to limit exposure to dust mite,
mold, animal dander, and smoke.
CHAPTER 1 - WHAT IS ALLERGY?

WHAT TYPE OF TESTS ARE Azmacort, Aerobid, Pulmocort or Flovent),

DONE TO DETERMINE WHAT theophylline preparations (Theo-Dur, Slo-Bid, Slo-
Phyllin), and adrenalin-like medications (Alupent,
I AM ALLERGIC TO? Ventolin, Proventil, Maxaire, Terbutaline, Brethine)
do not affect skin testing and may be taken. In fact, if
Skin testing is the best practical method of you are being evaluated for asthma and you presently
detecting allergens you may be sensitive to. There
are on medications, these should not be discontinued.
are two techniques that are used: prick/puncture
(epicutaneous) testing and intradermal testing. We
initially perform prick/puncture tests in order to ARE THERE OTHER TESTS FOR
screen you and to find out how sensitive or allergic
ALLERGIES?
you are. Skin tests by the intradermal method are
often necessary when suspected sensitivities are
Other tests are available to further define your
not revealed by the prick/puncture tests. This form allergies. Blood tests looking at the total amount of
of testing can be performed painlessly if a local
allergic antibody (IgE) and the total number of
anesthetic cream (EMLA) is applied one hour eosinophils (a cell in the bloodstream that is typically
beforehand.
elevated in an allergic sufferer) may be helpful.
With skin testing a small amount of an allergen is Eosinophils can also be discovered if a smear of the
introduced into the skin. Within a few minutes, the
mucus from your nose is looked at under a micro-
allergen has contacted the IgE antibody molecules scope. Finally, there is a test known as the RAST test
on the skin mast cells and chemicals are released
(radio-allergosorbent test) which measures the amount
which cause itching, redness and swelling - the
of IgE antibodies in the blood to specific allergens.
allergic reaction. For the allergy sufferer, there will
Although this test detects specific antibodies, it is not
be a reaction that looks like a bug bite with a raised
as sensitive as skin testing. With RAST testing alone,
area in the center and redness around its outside. If
some allergies may be missed. Other limitations to the
you are not an allergic individual, there will be no IgE
RAST test include the limited number of allergens
antibodies resting on the mast cell; so there will be no
available for testing and the high cost of the test.
reaction whatsoever. Skin tests are available for
pollens, animal danders, dust mite, molds, foods,
HOW ARE ALLERGIES TREATED?
medications, and stinging insect venoms.
It is possible that all of your allergy skin tests
There are generally three approaches to treatment:
could be negative and you are still allergic? This is
1) Avoidance of the allergen, although a sim-
very uncommon, and typically this is due to taking an
plistic idea, is the most effective. Chapter Three
antihistamine before the skin testing. All
will discuss some avoidance measures.
antihistamines should be avoided 48 hours prior to
2) Medication will help alleviate many symp-
testing, and certain antihistamines (like Atarax,
toms caused by allergens. Specific medication
Seldane, Allegra, Zyrtec and Claritin) should be
will be mentioned in subsequent chapters deal-
discontinued for at least seven days. Hismanal, a non-
ing with individual allergic diseases.
sedating antihistamine, should be stopped one month
3) Immunotherapy (allergy injections or
prior to testing. Nasal decongestants taken by mouth
“shots”) is an effective means of reducing one’s
(Sudafed) or topically applied (Afrin or
sensitivity to different allergens. This is dis-
Neosynephrine) do not affect skin tests. Medications
cussed in detail in Chapter Nine.
like steroids (prednisone, Vanceril, Beclovent,
 CHAPTER 2

CRITICAL THRESHOLD

Critical Threshold is the point at which a combi- EMOTIONAL

nation of several factors will produce the symptoms
of an illness. The critical threshold may be viewed as EXERCISE
analogous to placing many blocks on top of each
other until the addition of one more block causes all IRRITANTS
of them to topple. Except for a rare instance in which
a person is highly sensitive to something he has POLLUTANTS
eaten, such as shellfish, or to an insect sting, a critical
threshold usually results from the simultaneous oc- INFECTION
currence of all, or at least a majority, of the factors
listed (see figure 2-1). Thus, a patient with several INHALANTS
factors may feel no distress until one more factor is
added to cause them to wheeze, have shortness of FOODS
breath, or develop other symptoms of allergic illness.
ENVIRONMENT
A second analogy (see figure 2-2) is the bucket
filled with too many allergens. This results in spill- MEDICATIONS
ing over or onset of symptoms.
STRUCTURAL DEFECT
I. Emotional
METABOLIC
Emotional factors must be considered and treated in
any human illness. While emotional factors do not HEREDITARY
cause allergic reactions, including asthma, they cer-
tainly can aggravate the allergic response.

I. Exercise

Many times activities, such as riding a bicycle or

prolonged running, will initiate wheezing and cough. Figure 2-1
CHAPTER 2 - CRITICAL THRESHOLD

III. Irritants VIII. Environment

Tobacco smoke, dust, hair sprays, paint fumes, It is well known that changes in humidity and
and insecticides. Direct cigarette smoke exposure or temperature play an important role in the incidence
passive smoking is responsible for symptoms that of allergies and respiratory conditions. Mites and
mimic allergy. Cigarette smoke is an irritant, which molds thrive at high humidity.
means it does not cause an immune reaction. The
smoke directly changes the lining of your nose, IX. Medications
throat, and lungs. The allergic patient is especially
sensitive to the irritating effects of smoke. More Medications taken for allergy or other conditions
information will be provided if this irritant is playing may have side effects or interactions. (see Chapter 7)
a role in your symptoms.
X. Structural Defect
IV. Pollutants
Included here are disorders of the structures associ-
These are more than just irritants. Many impurities ated with the respiratory system, such as polyps of
aggravate respiratory allergies (e.g. ozone and sulfur the nose, deviated nasal septum, or gastroesoph-
dioxide). Mold contamination of humidifiers in the ageal reflux.
house and at work can cause increased allergic symp-
toms. XI. Metabolic

V. Infection Thyroid dysfunction, dehydration, anemia, exces-

sive fatigue, other illness or debilitating conditions.
This includes infection in the upper respiratory sys-
tem, such as a cold, naso-pharyngitis, sinusitis, otitis, XII. Hereditary
tonsillitis, laryngitis, or infection in the low respira-
tory system, such as bronchitis or pneumonia. Chronic While one does not inherit a specific allergy, one
sinus disease can be associated with persistent asthma. may inherit the tendency to develop allergic reac-
tions in multiple organs throughout a lifetime.
VI. Inhalants

Pollen, dust, animal dander, molds, etc. (See Chapter

Three.)

VII. Foods

Foods, food additives. (See Chapter Five.)

Figure 2-2
 CHAPTER 3

ALLERGIC RHINITIS:
SEASONAL (HAY FEVER) AND PERENNIAL

Hay fever or allergic rhinitis is the most common pollinate from May to early July. There are several
form of allergy. The National Institute of Allergy and weeds that will pollinate in the spring. In the mid-
Infectious Diseases (NIH) reports that 30-40 million summer, there is less pollen in the air, but mold
people are affected by this. The symptoms may spores can be abundant, especially in our high hu-
include any of the following: nasal congestion; sneez- midity area. Late summer and early fall is the weed
ing clear, watery nasal discharge; eye irritation with season. Ragweed is the most abundant weed pollen,
runny, itchy, watery eyes; throat itchiness, irritation, but other weeds include pigweed, sorrel, plantain,
and soreness from postnasal drip; ear pain, pressure, cocklebur, lambs quarters, and mugwort.
popping, or itching; and generalized fatigue, irrita-
bility, and headaches. ANIMAL DANDER
The term “hay fever” is an Olde English term
describing symptoms during hay pitching time. In Dogs, cats, gerbils, rabbits, etc. can all cause non-
the more severe cases, people felt feverish (despite a seasonal allergies. The allergen is in the animal’s
normal temperature) - hence, the term “hay fever”. dander, saliva, or urine. The longer or shorter the
We now know that these symptoms were brought on animal’s hair is NOT a determining factor on how
by airborne pollens and is now referred to as “allergic allergenic the pet may be, as all pets have dander
rhinitis”. (skin). There are no species of dog or cat that are less
Allergic rhinitis can be seasonal, or it may be year allergenic.
round. Typically, seasonal sufferers are affected by
pollen; whereas, year round sufferers are affected by MOLD
dust and its components (dust mite), animal danders,
and molds. Mold is both an indoor and outdoor problem. As
noted in the pollen section, molds are airborne out-
TYPES OF POLLENS AND THE doors and can cause seasonal allergic rhinitis. The
POLLEN SEASON outdoor mold season is from early spring to late fall.
Mold outdoors is no longer a problem after the
Each plant has a period of pollination, which does temperature drops below freezing. The mold grows
not vary from year to year. The amount of pollen in on grasses, dead leaves, and other vegetation.
the air at any one time is affected by the weather. Indoor mold is responsible for year round symp-
Trees pollinate first (March to May), and they cause toms. It is a particular problem in older homes and
early spring hay fever. The major trees in our area are damp rooms like bathrooms and basements. Other
beech, birch, hickory, oak, elm, maple, walnut, ash, sources of mold include house plants, room and car
willow, juniper, mulberry, sycamore, and poplar. air-conditioners, refrigerators, foam pillows and
Grasses (timothy, bermuda, orchard, sweet vernal, mattresses, and stuffed animals. Growth occurs un-
red top, and blue grasses) overlap the tree season and der porches, decks, and in crawl spaces.
CHAPTER 3 - ALLERGIC RHINITIS

DUST MITE get out of the shower, come indoors from a cold
environment, go outdoors on a smoggy foggy day, or
House dust is made of many components. The a rainy, muggy, humid day. Suspect vasomotor
major allergen though is from the dust mite. This rhinitis if you experience allergic-like symptoms
creature is microscopic and lives off of the scales when you are around perfumes, newsprint, paint/
shed by human skin. The waste product particles of gasoline, cleaning solvents or other strong odors.
the mite are the allergen. The greatest source of dust Often, vasomotor rhinitis and allergies occur to-
mite can be found in areas of the home where we sit gether, so allergy should be investigated.
or lay the most. Obviously, the bedroom has the The major difference between treatment of vaso-
highest concentration, particularly in the bedding motor rhinitis and allergic rhinitis is that allergy
and carpeting. injections are not a consideration for vasomotor
Mites tend to thrive in warm, moist atmospheres. rhinitis because the cause is not immunologic in
Their concentration peaks in this area of the country nature. The other means of treatment, however, are
at the end of the summer but persist year round. similar to those for allergic rhinitis. This includes
avoidance of airborne irritants and the use of medi-
ALLERGY OR COLD? cations, either topically to the nose or taken orally.
HOW CAN I TELL THE
DIFFERENCE? TREATMENT OF ALLERGIC
RHINITIS
If symptoms persist for more than several weeks
and there are no other household members with Avoidance, as always, is the first step in therapy.
similar complaints, then you probably have a nasal This is particularly helpful for relief of symptoms
allergy. Symptoms such as sore throat, muscle aches, from dust, mold, and animal dander. It becomes more
and fever suggest a cold or flu. Untreated allergies, difficult to avoid pollens. There are certain areas of
though, may predispose people to recurrent colds. the country that are free of specific pollens. For
These colds are indeed infections, but they tend to example, the desert regions and forests of the Rocky
become more frequent because of the underlying Mountains, Hawaii, Alaska, California, Oregon, and
allergic state. Once the allergy is under control, so is the Caribbean Islands are relatively ragweed free.
the seemingly exaggerated frequency of such infec- However, there is a possibility that escape is not
tions. always the answer; in that, a person can develop an
allergic response to the pollen and mold present in
NON-ALLERGIC (Vasomotor) the new location.
RHINITIS An allergy free room should be the easiest room
in the house to clean. Start allergy proofing in the
Persistent nasal symptoms that are not colds may bedroom because you spend one third to one half of
not always be allergy. The term “vasomotor rhinitis” your life in that room. Then, generalize these changes
refers to allergy-like symptoms that are not caused by to the rest of your home.
allergens but by physical factors such as temperature Pillows, mattresses, box springs, and stuffed ani-
change, air pollution, humidity change, odors, and mals are obvious sources of dust. Pillows should be
emotions. polyester and encased or washed frequently. Mat-
One should suspect vasomotor rhinitis if you tresses and box springs may require special covers.
develop a stuffy, runny nose and sneezing when you Keep only the essential books in the room. Daily
 CHAPTER 3 - ALLERGIC RHINITIS

vacuuming will help, but no carpet is better. Damp overuse can result in a disease called “rhinitis
mop hardwood or linoleum floors weekly. Further medicamentosa”, which causes the nasal passage-
information will be provided by the nurse and physi- ways to swell more than ever and increase the amount
cian on dust proofing. of discharge present.
Mold sensitive patients have exposure both in- Oral decongestants (such as Sudafed) are some-
doors and outdoors. Outdoor molds will grow on times effective in producing symptomatic relief of
most foliage and will accumulate in grass, clippings, nasal congestion. Oral decongestants do not have any
leaves, and mulch. Indoor molds are found in dark, anti-allergy properties. They are often prescribed in
damp areas. The basement particularly can be a combination with antihistamine medications.
problem. Further information will be provided by the New medications over the past 10 years have
nurse and physician on mold and mold prevention. significantly changed our approach to hay fever or
Direct cigarette smoke exposure or passive smok- allergic rhinitis. The topical application of prescrip-
ing is responsible for symptoms that mimic allergy. tion nasal sprays have the distinct property of pre-
Cigarette smoke is an irritant, which means it does venting allergic nasal symptoms. There are also topi-
not cause an immune reaction. The smoke directly cal products for the eyes.
changes the lining of your nose, throat, and lungs. Sodium Cromolyn is available in a nasal spray and
The allergic patient is especially sensitive to the eye drop form. Basically, the medication is designed
irritating effects of smoke. More information will be to stop the hay fever symptoms from occurring by
provided, if this irritant is playing a role in your preventing the release of histamine and other irritat-
symptoms. ing chemicals into the tissues (over the counter).
Antihistamine medications can give temporary Topical nasal steroids (Beconase, Flonase,
relief for up to 12 or more hours in reducing itching, Nasonex, Vancenase, Rhinocort, Nasacort, Dexacort,
sneezing, runny nose, and postnasal drip. Drowsi- etc.) are extremely safe and effective for both the
ness used to be a problem, but now there are non- prevention and relief from allergic nasal symptoms.
sedating or less sedating antihistamines. There are Finally, immunotherapy or allergy injections are
many choices, and more on the horizon (Seldane, very effective means of reducing one’s sensitivities
Hismanal, Claritin, Semprex-D, Zyrtec and Allegra). to the allergens precipitating allergic rhinitis or hay
The most recent advance in anti-histamines is Astelin fever. For more information, please refer to Chapter
nasal sprays. This is the first topically applied anti- Nine.
histamine. It has similar effect to taking the oral
medicine noted above.
Over-the-counter nasal decongestant sprays (such
as Afrin and Neosynephrine) should only be used
under the direct supervision of a physician. Their
 CHAPTER 4

ASTHMA

Dramatic improvements in asthma therapy within age. Children of African-American or Hispanic heri-
the last 10 years have allowed the vast majority of tage living in urban areas also are more affected than
asthma patients to lead fairly normal lives. those in rural areas. Air pollution may be the cause of
this increased incidence.
INCIDENCE Well-known people who suffer or have suffered
from asthma include former Vice President Walter
If you suffer from asthma, you are not alone. 15- Mondale, Theodore Roosevelt, and Joseph Pulitzer.
20 million Americans have this disease. Asthma Others include Christopher Reeve, Carl Reiner, Don
causes approximately 90 million days of restricted Rickles, Jim “Catfish” Hunter, Bob Gibson, Wayne
activity per year, about 25 million of which are spent Newton, Helen Hayes, Liza Minnelli, Elizabeth Tay-
in bed. It is the third leading cause of restricted lor, Rocky Bleier, Art Monk, Chuck Barris, and
activity in patients under 25 years of age and the fifth Olympians Jeanette Bolden, Nancy Hogshead, Jackie
leading cause of all patents. For adults, this results in Joyner Kersee and Dennis Rodman.
five million lost work days/year on an estimated
annual loss of 435 million dollars in earnings. 27 WHAT IS ASTHMA?
million people per year visit a doctor because of
asthma, and millions of dollars a year are spent in Asthma is a non-contagious disease of the bron-
treating this disease. The National Center for Health chial tubes. These tubes carry air from the mouth to
Statistics estimates that children suffering from the air sacs in the lungs. In asthma, these tubes are
asthma and other acute respiratory conditions miss blocked. This blockage is due to:
128 million school days each year, or 61% of all
school days missed per year. Asthma is the most - Swelling of the inside lining of the tubes
common cause of children to be admitted to the (inflammation)
hospital. Four thousand deaths from asthma are re-
ported annually. Thus, asthma is one of the most - Contraction (squeezing down) of the
important and common health problems in the United muscles surrounding the tubes, thus reduc-
States today. ing their diameter
Allergic asthma usually begins before a person
reaches 40. Non-allergic asthma most often occurs after - Excessive mucus production which often
40, although it can strike at any age. Children are more hardens within the tubes producing plugs
affected than adults, but asthma is most prevalent
among boys 14 and under, and men over 45 years of
 CHAPTER 4 - ASTHMA
The airway obstruction results in symptoms of How do I know if I have asthma? A careful
coughing, chest tightness, shortness of breath, and history, physical examination, and breathing test
wheezing. Wheezing is typically heard while breath- (known as spirometry) will help us determine if you
ing out and is a high pitched whistling noise. Symp- have asthma. A spirometer measures the amount of
toms may be subtle. A persistent cough after each air exhaled or blown out to determine the degree of
upper respiratory infection, or shortness of breath airway blockage. A peak flow meter is a smaller
following exertion, may be due to asthma. version of a spirometer, and can be used at home to
The exact cause of asthma is unknown. However, monitor lung function.
we know that a hallmark of the disease is what is
called “hyperreactive bronchial tubes”. That is, the CURRENT TRENDS IN
bronchial tubes react to certain stimuli in a way that TREATMENT
produces these three abnormal processes. We often
say that the bronchial tubes of the asthmatic are After triggers are identified, you will receive
“twitchy”; in that, they overreact to stimuli which are suggestions on controlling the environment to help
usually harmless to the normal person. This state of you avoid the allergens and irritants. Air-condition-
“twitchiness” may fluctuate over the lifetime of a ing reduces the amount of pollen and mold in the
person with asthma, but one does not grow out of it. home. Smoking should not be permitted, and house
Asthma does not lead to emphysema. Asthma, by pets may need to be restricted from certain areas of
definition, is reversible airway obstruction. How- the home or removed permanently. All bedding
ever, if inflammation in the bronchial tubes persists should be a synthetic material. Rooms must be cleaned
for long periods of time, permanent damage to the and vacuumed on a regular basis to prevent the build-
bronchial tubes can occur. up of dust. Ideally, bedrooms should have hardwood,
tile or linoleum flooring and be carpet free. Offend-
WHAT TRIGGERS ASTHMA? ing foods should be avoided.

Asthma can be caused by hypersensitivity to Pharmacological management, in simpler terms,

allergens such as pollens, molds, animal danders, is the practice of using various medications to com-
house dust mite, and foods. It can originate with, or bat the effects of asthma. Some of the more common
be aggravated by respiratory infections. Irritants medications are as follows:
(such as cigarette smoke; harsh odors from paint, Cromolyn sodium (Intal) and Nedocromil (Tilade)
perfumes, and aerosol sprays; and air pollution) may are preventive medications and are not a treatment
trigger asthma. Exercise, especially in cold air, can used when there is a sudden onset of breathing
be a major trigger. Other triggers of asthma include difficulties. These are propelled into the lungs by an
chronic gastrointestinal reflux and chronic sinusitis. inhaler. Intal is also available as a solution that is
Certain medications can trigger asthma like aspirin inhaled using a small machine called a nebulizer.
or ibuprofen (Motrin, Advil, etc.) and Beta-blocker These medications prevent the release of inflamma-
(Inderal etc.). Psychological stress in any form may tory chemicals from the mast cells lining your air-
trigger asthma, as can laughter or crying. Contrary to ways, thus preventing asthma symptoms.
popular belief, asthma is not a psychological prob- Beta-adrenergic or adrenalin-like agents
lem. cause the airways to open and are either given orally,
by nebulizer or metered dose inhaler (“puffer”), or
injection. Albuterol (Ventolin, Proventil)*,
CHAPTER 4- ASTHMA

metaproterenol (Alupent, Metaprel), terbutaline “Anti-Leukotrienes” – a new class of medicine - has

(Brethine or Brethaire), and Pirbuterol (MAXaire) help the ability to act as a Bronchodilator and an anti-
the muscles relax, and are called Bronchodilators. They inflammatory. Accolate, Zyflo, and Singulair are the
are the treatment of choice for an acute attack of asthma three available but there are others being developed.
and are best administered by the inhaled route. Adrenalin This is a maintenance medicine to control daily symp-
or Epinephrine by injection used to be the first line toms and is not meant for immediate relief like the Beta-
treatment in a doctors office or emergency room, but adrenergic medicines.
have been replaced by the inhaled medications. This Theophylline (Theo-Dur, Slo-Bid, Uni-Dur,
class of medications can also be used prior to exercise Uniphyl) is used in the treatment of asthma and is
to prevent exercise-induced asthma. A new agent known as a bronchodilator because it relaxes the bron-
Serevent is available. It is a long acting inhaled Bron- chial muscles. It may be used as a maintenance medica-
chodilator that is recommended as a maintenance medi- tion for people who require daily treatment or who
cation, and should never be used more than twice a day, experience sudden breathing difficulties. Patients who
or in place of Albuterol, Metaproternol, Terbutaline or use theophylline should advise their physician of other
Pirbuteral. medications they are taking, as there are many drug
Corticosteroids are used to prevent and treat ongo- interactions.
ing inflammation of the airways. It is available in the Immunotherapy involves periodic injections of the
inhaled, oral, or injectable form. The inhaled form of the allergic substances (i.e. pollens, molds, dust) that trig-
medication (Vanceril, Vanceril DS, Beclovent, ger asthma symptoms. Injections are not available for
Azmacort, Aerobid, Flovent, Azmanex) allows its use substances a person may be irritated by (i.e. smoke,
on a daily basis without the typical long-term side perfume, or other strong odors). The regular adminis-
effects. A short burst of oral corticosteroids (Medrol, tration of the allergens by injection will create a toler-
Prednisme, Prelone, Pediapred, Azmanex) may be re- ance to the different allergens. The degree of tolerance
quired for an acute asthma attack. The short-term use of that results varies from patient to patient. Our goal is to
the oral form is safe and effective in reducing inflamma- increase your tolerance, thus reducing symptoms. This
tion. The side effects from corticosteroids that you may is further discussed in Chapter Nine.
have heard about are the result of the long-term daily use Space Devices are used to enhance the delivery of
of high dosages of oral medication. These may include inhaled medications (Bronchodilators, Intal, Tilade or
weight gain, high blood pressure, growth delay, cata- Steroids). Inspirease, Aerochamber are just two types
racts, muscle weakness, diabetes, and osteoporosis. If of spacers. Proper delivery of medication is extremely
you are on these medications and contract chicken pox, important. For infants, toddlers, young children and
contact our office ASAP. The infection can be more others who can not use inhaler - Nebulizers can be made
severe than normal. available. Please discuss this with your physician.
In 1999 the FDA required a warning on all inhaled
steriods about possible reduction in growth velocity in OUR CONCERNS
pediatric patients. The FDA stated that “the potential
growth effects of prolonged treatment should be weighed Underestimating the severity of asthma may have
against clinical benefits obtained and the availablity of life-threatening consequences. Studies indicate that
safe and effective non-corticosteriod treatment alterna- those asthma sufferers who delay seeking treatment,
tives. To minimize the systemic effects of orally inhaled self-medicate, or do not comply with prescribed treat-
corticosteroids, including each patient, should be ti- ment plans may be taking their lives in their hands.
trated to his/her lowest effective dose. Education is a key part of our practice. We want you to
Airway inflammation plays a significant role in feel comfortable with your medical problems so please
asthma, so the use of steroids may be the first choice of ask questions.
medication to control daily chronic symptoms, with the
other medications acting as backup or second and third-
line additions.
 CHAPTER 5

FOOD ALLERGY

Hippocrates, an early Greek physician and phi- Food intolerance: An abnormal physical response
losopher, was one of the first to note that cow’s milk to a food or food additive that is eaten and is not
could cause health problems for some people. Al- proved to be immunologic (i.e. milk sugar/lactose
though we do not know if he was referring to a true intolerance, where the individual lacks the enzymes
allergy to cow’s milk protein or an inability to digest to break down the milk sugar for proper digestion).
a milk sugar called lactose, we do know that food Food poisoning: An adverse reaction caused by a
allergy reports began to appear in modern Europe in food or food additive without immune system mecha-
the early 1900’s. Since the 1940’s, food allergy has nisms being involved. Toxins (poisons or bacteria)
been clearly recognized by doctors around the world. may be either contained within the food or released
The true number of people who have food allergy by microorganisms or parasites contaminating food
is unknown (estimates of the incidence of cow’s milk products.
allergy are reported to range from 0.3% to 7.5%). Pharmacologic food reaction: An adverse reac-
The incidence is higher in infants than in adults. tion in which a chemical found in a food or food
Many adverse reactions to foods are not the result additive produces a drug-like (pharmacologic) effect
of true allergic reactions. In some cases, such symp- (i.e. caffeine in coffee causing “the jitters”).
toms have been presumed to be allergic reactions
only because no other cause could be found and/or PROBLEM FOODS
because the patient’s symptoms improved when the
food was removed from the diet. Food allergens, those parts of foods that cause
allergic reactions, are usually proteins. Most of these
DEFINITIONS allergens can still cause reactions, even after they are
cooked or have undergone digestion in the intestines.
Adverse reaction to a food: A general term that is Recent studies conducted in the United States indi-
used to describe any abnormal reaction to a food or cate that the proteins in cow’s milk, egg, peanut, nuts,
food additive that is eaten, whether caused by aller- shellfish, wheat, and soy are the most common food
gic or non-allergic mechanisms. allergens.
Food allergy or hypersensitivity to a food: An Food allergy may make its first appearance at any
abnormal immunologic reaction during which the age, but it is especially likely to occur in infancy.
body’s immune system overreacts to harmless foods, While most early food allergy is “outgrown”, it may
leading to irritating and uncomfortable symptoms. A persist for years, and the symptoms caused by the
severe allergic reaction, that can sometimes be fatal, food may change. For example, milk may cause colic
is known as Anaphylaxis. (See Chapter One.) or eczema in an infant; whereas, later it may cause
CHAPTER 5- FOOD ALLERGY

asthma and hives. If the eczema improved with milk The highest levels of sulfites were previously
elimination in infancy, the mother looks for eczema found in restaurant salad bars. But, in 1986, the Food
when milk is restored to the diet later on. If asthma and Drug Administration banned their use on fruits
occurs instead, she may conclude that the child has and vegetables intended to be sold or served raw
outgrown the milk allergy and that something else is because of the growing rate of sulfite reactions. By
responsible for the asthma. In this case, milk, al- 1987, the FDA also ordered that packaged foods be
though actually the cause, is not suspected, espe- labeled when they contain more than 10 parts per
cially since it may take several weeks after its addi- million of any sulfiting agent, so sulfite-sensitive
tion to the diet before the asthma appears. individuals may identify those packaged foods which
should be avoided. Raw shrimp and uncooked pota-
ORAL ALLERGY SYNDROME toes are still not regulated by the FDA and may
contain sulfites to preserve their freshness.
Certain foods, (primarily fresh fruits and veg-
etables) can cause itchiness within the mouth with- DIAGNOSIS
out causing a more severe allergic reaction. Indi-
viduals are often allergic to seasonal pollens like First, a detailed medical history will be taken,
trees/grasses and weeds. The allergens in the pollens followed by a physical examination. The allergist
are similar to the allergens in the foods resulting in will then inquire about the frequency, seasonality,
this cross reaction. severity, and nature of the symptoms. Your physi-
cian will also ask how much time elapses between
FOOD ADDITIVES the eating of a food and any possible reaction.
A food diary will aid in the discovery of food
FD&C Dyes - The Food, Drug & Cosmetic Act of allergy. A food diary is a detailed record of the foods
1938 gave rise to the term FD&C. It approved a eaten, listing date, time, and any symptoms that
variety of dyes used in foods and beverages. They are occurred after ingestion.
identified on labels by color and number (such as When an allergy to a single food is suspected,
FD&C yellow No. 5 or FD&C red No. 3). elimination of that food will be recommended. If a
FD&C yellow No. 5, or Tartrazine, may infre- period of elimination of a food is to be informative,
quently cause hives in those who are sensitive to the there should be no slips in the diet during that
agent. period. In addition, before the diet is undertaken,
Sulfites - Sulfiting agents (such as sulfur dioxide, there should be a clear definition of just what symp-
sodium or potassium sulfite, bisulfite, and toms it is aimed at controlling. If the symptoms are
metabisulfite) are used to preserve foods and sanitize relieved, the food may be added back into your diet
containers for fermented beverages. They are found to see what happens. When a food allergy is sus-
in canned, frozen, or dehydrated foods (such as dried pected on the basis of frequent or continuous symp-
fruit); in processed grain foods such as cookies or toms, no single food may be identified as the likely
crackers; in shrimp; and in some beverages such as offender, and then a diet in which several suspected
beer, wine, wine coolers, and cider. foods are eliminated may be recommended, or a non-
Sulfites may cause reactions such as chest tight- allergic food substitute might be suggested for a
ness, hives, abdominal cramps, diarrhea, lowered period of time.
blood pressure, light-headedness, weakness, and an Direct allergy skin tests may be helpful in deter-
elevated pulse rate. This has primarily occurred in mining which foods are involved in the allergic
sulfite sensitive persons with asthma. process. Skin tests are not helpful when sensitivity to
 CHAPTER 5- FOOD ALLERGY

dyes, additives or chemicals is suspected. Unfortu- TREATMENT

nately, skin testing with food is not as useful as it is
for diagnosing pollen allergens, as positive tests may Avoidance of specific foods is the best treatment
indicate previous sensitivity and not be relevant at method for food allergy. In children, strict avoidance
this time. Food testing can, however, serve as a guide for a year may result in diminished sensitivity to the
as to which specific foods to include in an elimination food allergen. In adults (and in some children), food
diet. sensitivity may persist forever. Allergy injections for
Blood tests for specific IgE (known as the RAST food are not recommended and may be dangerous.
test) may be helpful for selected patients but are Anaphylactic reactions caused by food allergies
generally not as sensitive a diagnostic tool as elimi- are among the few potentially life-threatening aller-
nation and “challenge” of a suspected food. gic conditions. Persons who have experienced an
If diagnosis of food sensitivity remains in doubt anaphylactic reaction to a food must strictly avoid it,
after the use of diet diaries, elimination diets, and as even the smallest amount can be life-threatening.
allergy tests, the allergist may recommend “blind” Because the sensitive individual may eat the food in
food and/or food-additive “challenges” in the office an unrecognized form (in a restaurant, for instance),
and at times in the hospital under close observation. he/she should carry a kit containing epinephrine
Usually, the suspected food or a neutral food, called (adrenalin) at all times and should know how to inject
a placebo, is fed in opaque colorless capsules or as a himself/herself with the medication in order to be
hypoallergenic slush or pudding (such as tapioca), so prepared for an emergency. The sensitive individual
neither the patient nor the doctor knows whether the should also wear an identification necklace or brace-
suspected food or the placebo is being eaten. This is let which describes the allergy.
called a “double-blind” challenge. When properly A person who is highly allergic to a food must also
performed, these challenges are very helpful in estab- read food labels carefully. Foods that have been
lishing a cause and effect relationship between a food processed may contain amounts of food that need to
and an allergic symptom. be avoided. For example, milk may not be one of the
Food cytotoxic blood tests and sublingual provo- ingredients listed on a label; instead, the label may list
cation food testing are not recommended, since these casein, sodium caseinate, whey, or milk solids.
tests are unproven as procedures to diagnose food Finally, dietary supplements, like Calcium may
allergies. In a March 19, 1985 Compliance Policy be needed. Please discuss this with your physician.
Guide, the Food and Drug Administration deter-
mined that “the cytotoxic test remains, in 1985, as an OTHER SYMPTOMS ATTRIBUTED
unproven diagnostic procedure unsupported by sci- TO FOODS
entific literature of well-controlled studies and clini-
cal trials.” 1. Hyperkinesis or Attention Deficit Syndrome.
In a further development, the Health Care Financ- Dr. Feingold proposed that some children may be-
ing Administration (HCFA) published a notice in the come hyperactive, inattentive, easily distracted, and
June 13, 1985 Federal Register excluding cytotoxic do poorly in school after ingestion of certain foods or
testing for food allergies from Medicare coverage food coloring. This theory has never been proven.
because “available evidence does not show that these 2. Sugar intake and behavior have also been
tests are safe and effective.” linked, but the relationship is unclear and allergy does
not appear to be playing a role.
CHAPTER 5 - FOOD ALLERGY

3. There are a group of patients, both children and BIOGENETIC RELATIONSHIPS

adults, who complain of malaise, fatigue, headaches,
poor or excessive sleep, nausea, diarrhea, indiges- Most foods belong to groups or families of foods
tion, irritability, etc. These patients may have proven which share many characteristics including allergic
allergic rhinitis or food allergy, but these constitu- reactivity in some cases. For example, the peach
tional symptoms are out of proportion to the allergic belongs to the cherry family, comprising all single pit
manifestations. This condition has been referred to fruits such as cherry, peach, plum, nectarine, apricot,
as “Tension-Fatigue Syndrome”. Since these symp- and almond. If a patient is shown to be allergic to
toms are seen in so many other illnesses, both physi- peach, the other foods in the same biogenetic group
cal and emotional, many allergists question whether should be challenged in the diet to determine if he is
this syndrome is an allergic condition. also allergic to them. An individual can be allergic to
4. Controlled scientific studies have shown no only one food in a family; this is frequently the case.
evidence of reaction to candida, a mold which is in
every normal person’s body, or ingestion of mold-
containing foods, as a cause of the generalized symp-
toms mentioned above.

COMMON BIOGENETIC RELATIONSHIPS

1. Citrus Family 4. Potato Family 6. Lily Family 9. Gourd Family

Orange Potato Onion Pumpkin
Grapefruit Tomato Asparagus Squash
Lemon Egg Plant Garlic Cucumber
Tangerine Red Pepper Chive Cantaloupe
Lime Green Pepper Leek Melons
Chili
2. Mustard Family Tobacco
Mustard 7. Parsley Family 10. Miscellaneous
Cabbage Parsley Relationships
Cauliflower 5. Cherry Family Carrot a) Apple - Pears
Broccoli Cherry Celery b) Spinach - Beets
Brussel Sprouts Peach Parsnips c) Cranberry
Turnips Plum -Blueberry
Kale Prune d) Raspberry
Radish Nectarine 8. Legume Family - Blackberry
Apricot Beans of all kinds - Strawberry
3. Chocolate Family Almond Peas
Chocolate Peanuts
Cocoa Licorice
Cocoa Butter Soy
Cola
A more comprehensive list is available in our office.

Figure 5-1
 CHAPTER 6

DRUG ALLERGY

According to the Food and Drug Administration the drug in question is the true offender may be
(FDA), about 37,000 adverse drug reactions are obtained by re-administration at a future time. In
reported per year. A breakdown of the reactions most cases, this procedure is considered far too
showed that 71% involved toxic reactions to “usual hazardous; however, in experienced hands, some
doses of drugs”, 21% involved hospitalization, and drugs will be given cautiously when no other alter-
2% resulted in death. The highest incidences of natives are available.
hospitalization or death were found in those reports
that described “cardiovascular, hematologic, or res- SKIN TESTING FOR DRUG
piratory effects”. Patients over 59 years of age ac- ALLERGY
counted for nearly half of the reported deaths. Drug
reactions occurred within two weeks of initial expo- Attempts to diagnose sensitivity to drugs by
sure in the majority of cases. using the drug itself for skin testing are rarely suc-
cessful and may involve severe risk to the highly
DIAGNOSIS sensitive patient. The most important area in which
skin testing has proven to be of assistance is penicil-
In many instances, a reasonable suspicion that lin sensitivity. In a patient with a history of a previous
drug allergy is present will lead to discontinuance of reaction to penicillin, skin tests with several penicil-
the drug, unless the disease under treatment is seri- lin test reagents should be done prior to further
ous and an adequate substitute is not available. Aller- penicillin administration. If positive skin tests are
gic reactions resulting from drugs usually subside, or obtained, a distinct risk of a severe immediate ana-
begin to improve, within 24 to 48 hours after discon- phylactic or an accelerated allergic reaction exists,
tinuance of the suspected medication. Improvement and penicillin should not be given. If negative skin
of symptoms under these circumstances will strongly tests are obtained, there is no risk of such an imme-
suggest the possibility of drug allergy. Exceptions diate reaction, and penicillin may be administered.
exist in which symptoms continue without change, However, even in the presence of negative skin
or even become worse temporarily, in the week tests, there is still the slight possibility that less
following discontinuance of the drug treatment. When severe delayed reactions may occur.
the allergic reaction to the drug has been severe and Negative skin tests obtained with other antibiot-
has produced extensive tissue damage, recovery may ics are not as reliable as those found on penicillin
be slow and incomplete. If a long-acting drug (such testing. Long-term scientific studies on allergy test-
as an injection of long-acting penicillin) is respon- ing for these drugs have not been established.
sible for symptoms, allergic symptoms may persist
for several weeks or months. Further evidence that
CHAPTER 6 - DRUG ALLERGY
If a person with a history of penicillin allergy future. A patient should be properly informed con-
develops an infection, several steps can be taken to cerning the name of the drug, as well as related drugs,
treat the problem without provoking a serious aller- so that this information can be transmitted to other
gic reaction. Satisfactory alternative antibiotics may physicians who will treat the patient in the future. A
be available. Skin tests may reveal that the allergy no dual responsibility exists here; the patient must give
longer is present, thereby permitting therapy with this information to a new physician, and the physi-
penicillin. If penicillin or a similar drug is needed in cian must inquire about drug allergies prior to pre-
a person who has positive tests for current allergy, a scribing. Patients must be educated concerning the
desensitization procedure can be performed. This presence of the offending drug where it is not obvi-
consists of administering gradually increasing doses ous, especially in non-prescription medications. For
over a period of hours until full therapeutic doses are example, aspirin is present in many anti-cold and
tolerated. headache preparations (such as Anacin, Empirin
Local anesthetic allergy can be diagnosed by skin Compound, Excedrin, Alka-Seltzer, etc.).
testing, although this is usually not required since
alternative, very satisfactory anesthetic drugs are TREATMENT
available. Aspirin sensitivity cannot be diagnosed by
skin testing. The illness that led to the drug being prescribed in
Allergy to immunizations, like the measles, the first place must be considered when treatment of
mumps, and rubella vaccine, and the influenza vac- a drug reaction is planned. In most cases, the drug can
cine can occur in some egg-allergic patients because be withdrawn and replaced with some other form of
the media used to grow these vaccines contain a small therapy. Immediate reactions can be suppressed by
amount of egg protein. If you are egg allergic, skin antihistamines, epinephrine, cortisone-like drugs,
tests are performed to Influenza; if positive, desensi- and other measures. Occasionally, the drug can be
tization procedures are available. continued safely, if suppressive therapy or desensi-
tization is used. In nearly all cases, effective therapy
PREVENTION can be accomplished despite the appearance of drug
allergy.
Once a diagnosis of a drug allergy is made, it is
important that the offending drug be avoided in the
 CHAPTER 7

STINGING INSECT ALLERGY

Insect stings are responsible for inducing severe Hornets and yellow jackets are black with yellow or
allergic reactions in an estimated one to two million white markings - the queens measuring about 3/4 of
people in the United States. An estimated 3% of the an inch long, and the males and workers measuring
population is susceptible. About 50 deaths due to 1/2 inch in length. Polistes are slender, elongated
stinging insect allergy are reported per year. Most wasps about 3/4 to one inch long. They are black,
victims of these serious allergic reactions are over brown, or red and have a few yellow markings.
30. A number of deaths per year go unrecognized as Wasps build open-comb nests or mud structures
being from stinging insect allergy, as there was no under eaves and in carports, behind shutters, and in
witness to the sting. wood piles. Yellow jackets’ nests are usually found
These reactions may occur at any age, regardless in the ground, abandoned burrows of small rodents,
of previous allergic history, striking many who are between the cracks of rock walls, or between the
unaware of their susceptibility to an anaphylactic or walls of frame buildings. Hornets build grey foot-
severe reaction until it occurs. They are caused when ball-shaped hives in shrubs or in trees. Honeybees
a person’s immune system produces too much of an are generally found in commercial hives, and fire
antibody called IgE (Immunoglobulin E) which, in ants usually build colonies in the ground.
combination with the venom, triggers the allergic
reaction. TYPES OF REACTIONS
TYPES OF STINGING INSECTS The usual reaction occurring after an insect sting
is a mild degree of redness and pain, which usually
The common stinging insects belong to the order disappears within one to two hours, but can last for
Hymenoptera and can be divided into two families: 24-48 hours. As a rule, no treatment is required.
the apids, which include honeybee and bumblebees; Sometimes, large local reactions can occur with
and, the vespids, which include yellow jackets, hor- extensive swelling, redness, and itching that peaks
nets, and wasps. There are also several stinging ants at 48-72 hours and may last as long as one week. Red
which can be considered as non-winged Hy- streaks radiating from the sting site, which appear 24
menoptera. The fire ant is a major cause of allergic hours later, may indicate infection and should re-
reaction in the Southern United States, and the har- ceive prompt medical attention. Large local reac-
vester ant is responsible for similar problems in the tions are not predictive of a more serious reaction
Southwestern United States. the next time you are stung.
CHAPTER 7 - STINGING INSECT ALLERGY

A severe allergic reaction (anaphylaxis) can in- contains epinephrine (adrenalin). This medication
volve the entire body, producing symptoms that works within minutes to reverse the allergic reaction.
include dizziness, weakness, and nausea. Stomach Those persons who are susceptible should follow a
cramps and diarrhea may occur, as well as general- physician’s instructions for self-injection in the event
ized hives (urticaria), itching, wheezing, flushing, of an insect sting and then proceed immediately to the
difficulty in breathing, a sharp drop in blood pres- closest emergency room.
sure, shock, and finally, unconsciousness. If medical Individuals who have had generalized reaction
treatment is not obtained immediately, the reaction may be candidates for venom immunotherapy (“al-
may prove to be fatal. lergy shots”). Purified venoms, which are highly
potent, are now available and are given in gradually
PREVENTION AND TREATMENT stronger doses to stimulate the patient’s immune
system until it is able to become more resistant to the
To prevent insect stings: insect sting. Venoms are taken from honeybees, yel-
- When cooking outdoors, keep food covered low jackets, yellow and white-faced hornets, and
until eaten. wasps. Whole-body extracts (rather than purified
- Spray the patio and garbage area with an venoms) are utilized for fire ant hypersensitivity, as
insecticide. fire ant venoms are not yet available.
- Garden cautiously, being careful not to dis- If you are stung, only the honeybee leaves a
turb ant colonies, wasp nests, or bee hives. stinger and an attached venom sac in the skin of its
- Avoid wearing perfume, hair spray, lotions, victim. Removal of the stinger within two to three
or any other types of scented cosmetics which minutes may prevent some harmful effects. Remove
attract insects. the stinger with one quick scrape of the fingernail. Do
- Avoid wearing bright colors, flowery prints, not compress the sac, as this may only serve to inject
and black, which attract insects more than light more venom into the victim.
colors like white, green, tan, and khaki.
- Keep an aerosol pest insecticide in the glove DESTROYING THE SOURCE
compartment of your car, should a stray insect
fly in. To destroy hives, use commercially available sting-
- If you suspect you are hypersensitive, do not ing insect pest aerosols after dark, when insects have
hike, boat, golf, or swim outdoors alone. returned for the night. Take appropriate precautions
by wearing a hat, long sleeve shirt, work gloves, and
Most local reactions can be treated with antihis- boots. Hypersensitive persons should not be allowed
tamines and anti-inflammatory drugs. For those sub- in the vicinity. Burning or flooding the nests will only
ject to severe reactions, a physician may recommend result in angering the insects and is not recommended.
a self-treatment kit (Ana-Kit or an Epi-Pen), which
 CHAPTER 8

SKIN ALLERGIES

Skin is an important organ. It has many functions What causes it?

including heat regulation, being a protective barrier The cause of eczema is unknown. It tends to
for our bodies. It is a sensory organ: it registers cold, occur in allergic families, and children with eczema
heat, pain, touch, and itching. It helps us to adjust to are likely to develop other allergies, particularly
our surroundings. The following is a brief discussion asthma or hay fever. Although allergy, particularly
of those disorders of the skin regarded as allergic in to certain foods, explains a certain percentage of this
origin. childhood type of eczema, there are some cases of
this disease where allergy cannot be found. It may be
ECZEMA OR ATOPIC that some of these cases are still allergic, but that
DERMATITIS (The itch that rashes) additional causes of allergy need to be discovered;
or, the nature of these unclassified eczemas is en-
What is it? tirely different. Only intensive and concerted re-
Eczema is a skin disease which can appear on the search will solve this puzzle.
cheeks and scalps of infants at a very early age. It may
also appear on the wrists, in the bends of the elbows, What makes it worse?
and the folds behind the knees. Individuals with Anything which causes itching will make the
severe cases may have the rash over their entire body. condition worse. Such factors include cold dry
The first symptom is itchiness of the skin. The rash weather, hot weather, sweating, emotional upsets,
appears next and is made worse by scratching and certain types of clothing, and certain washing deter-
rubbing the itchy areas. As a result of all the rubbing gents. Fatigue, nervousness, and emotional upsets
and scratching, the skin becomes thickened and can increase the irritation, although there is no proof
cracked. In other cases, it may become constantly that these conditions by themselves cause eczema.
moist and weep. There may be crusted areas, as the Exposure to foods that have been identified by history,
wet form of eczema dries. This damaged, irritated skin testing or RAST. Exposure to dust mites.
skin may easily become infected.
How do I know if I have eczema?
If it starts in infancy, how long will it last? Your physician will take a detailed history to
In most cases, the eczema either disappears or is determine possible triggers to the development of
less severe by the time the child is two or three years the rash. The history might point to certain foods or
old. In some, the skin condition subsides for several environmental contacts (mites, pets, materials, etc.)
years but returns after the child is older. Those with as possible causes. Skin tests may be required to
a more severe disease may retain their eczema during identify specific contacts or ingestants that make the
their teens and into adulthood. eczema flare.
CHAPTER 8 - SKIN ALLERGIES

What can I do to help my eczema get better? What causes hives?

Itching and scratching are major sources of dam- Hives have many causes. Searching for the cause
age to the skin. An antihistamine is effective in of hives is frustrating detective work for the patient
decreasing the sensation of itching. Keeping finger- and the allergist. In only 10% of the cases is a cause
nails short and clean will prevent damage and pre- ever found; of that 10%, only 1/10 or 1% of these are
vent infection. You may need to place cotton socks caused by allergens. The most common allergic
over the hands of infants and small children to cause is food; and, this can be easily detected by an
prevent scratching. accurate history and skin testing. Other causes of
Avoid skin irritants including wool, silk, and hives from allergy include ingestion of medication,
mohair. Cotton clothing and bedding is best; so, injection of venom from a bee sting, inhalation of
when buying blends, one must find the highest allergens (uncommon), and, finally, contact with
percentage of cotton. Wash the patient’s clothing allergens (e.g. touching pets). Other causes for hives
and bedding separately from the rest of the family’s, may include certain contacts to cold, heat, vibration,
use a mild soap, and do not use bleach, starch, dryer physical pressure, and overheating. Exercise can
sheets, or fabric softeners. You may want to rinse the cause hives. Certain arthritic conditions cause hives.
clothing more than once. Chronic hives may be a sign of an underlying medi-
Avoid getting too hot because this may lead to cal illness.
sweating and itching. Proper humidification of the
home will be helpful, specifically in the wintertime. Is diet important?
Avoid certain foods that have been identified, Food allergy is one of the most frequent causes
either by history, food diary, or by skin testing. Egg of acute hives. Many different foods have been
white, peanut, milk, soy, and wheat are the most responsible for triggering hives but in any one per-
common food allergic triggers. Even minute amounts son there is usually only one or two foods. Food
of a food may cause a flare of eczema. additives are prime suspects. In most cases, they are
Proper skin care is very important. This will be not the absolute cause of the hives rather they act to
discussed in detail by your physician. bring out the hives more frequently. FD&C yellow
dye #5 (tartrazine) and preservatives (like sodium
HIVES AND SWELLING benzoate) are just two examples.
(Urticaria and Angioedema)
What medications cause hives?
“Hives” is the common word for the condition The list of medications is very extensive. The
urticaria, which is characterized by itchy bumps in prime offenders, though, usually are penicillin and
the skin. They vary from pinhead size to welts aspirin. Codeine, Demerol, and morphine many
several inches across. The wheal, a raised area, is times cause hives. It is important to note that, even
pale and is usually surrounded by an area of redness if you are not allergic to aspirin, many individuals
and warmth. who have chronic hives will have worsening with
Hives are usually a short-term problem, lasting ingestion of either aspirin or other non-steroidal
from a few hours to a few days (called “acute” anti-inflammatory medications (Motrin, Naprosyn,
hives). Sometimes, though, they last for several Advil, Nuprin, Anaprox, ibuprofen, etc.).
weeks or months. If they last greater than six weeks,
they are called “chronic”.
 CHAPTER 8 - SKIN ALLERGIES

Are hives a nervous condition? What are the most common causes of contact derma-
Hives are frequently blamed on “nerves”. Emo- titis?
tional upset or trauma can result in a flare of hives. Poison ivy, sumac and oak, other plants, cosmet-
ics, drugs, metals, and chemicals are the most com-
Are hives dangerous? mon causes of contact dermatitis.
By themselves, they are not dangerous. Hives The oil from the poison ivy is found in the plant’s
may be a warning of a more serious generalized sap, which causes the reaction. The response is usu-
allergic reaction. Hives sometimes are associated ally not immediate and can occur 24-72 hours after
with swelling of the lips, tongue, and throat. This the contact. The rash does not spread from one part of
condition is known as “angioedema”. Angioedema the body to another, nor is it contagious. Often times,
of the larynx (voice box) constitutes a medical it will appear at different parts of the body at different
emergency, requiring adrenalin. times - but it is due to how quickly that body part
reacts to the initial poison ivy contact - not due to
Is there a way to test for hives? spreading.
A thorough medical history remains the best The typical metals that cause contact dermatitis
diagnostic tool. Skin testing for food, inhaled aller- include nickel, chrome, and mercury. Nickel can be
gens, drugs, or stinging insects can be done if there found in costume jewelry, belts, buckles, wrist
is something in the patient’s history suggesting these watches, zippers, etc. Since common commercial
agents as a possible cause of the hives. Blood and metals contain nickel, it is likely that contact with an
urine tests and x-rays also may be necessary to rule object that is chrome-plated will also cause a skin
out any type of other underlying disease that may be reaction in a person sensitive to nickel. Contact lens
causing the hives. solutions containing mercury also can cause prob-
lems for some sensitive patients.
Can hives be treated? Cosmetics have many different chemical ingredi-
If the cause can be found, hives can be prevented ents. Permanent hair dyes containing paraphenylene
from recurring by avoiding the cause. In the mean- diamine are the most common offenders. Dyes used
time, the condition can usually be controlled by in clothing can also be irritating. Other products
taking antihistamines. Sometimes, steroids (pred- include perfumes, eye shadows, nail polish, lip sticks,
nisone) may be necessary in order to control hives on and sun screen liquids. Contact dermatitis of the face
a short-term basis. Finally, in the case of acute hives, and eyelids, in most cases, is due to substances on
adrenalin can be used for immediate relief. your hands, like nail polish or hand cream, which
then touch the face.
ALLERGIC CONTACT Drugs, such as neomycin (found in antibiotic
DERMATITIS creams), topical antihistamines, novocain, and
paraben, all can cause contact dermatitis.
This is an allergic reaction affecting areas of the
skin which becomes red, itchy, and inflamed after a Who is affected?
contact with certain substances. Blisters may also In regard to poison ivy, seven of 10 adults could
form on the skin, which later will ooze, thicken, and develop this dermatitis after contact. Adults are af-
crack. This differs from a pure irritant reaction such fected more often than young children. Heredity has
as “dishpan” hands. not yet been shown to play a role in predicting which
family members are more likely to suffer reactions
than others.
CHAPTER 8 - SKIN ALLERGIES

How do you know you have a contact sensitivity? Is contact dermatitis treatable?
In regard to poison ivy, the history is usually The answer is definitely “yes”, with avoidance
pretty clear. The diagnosis of other contact reactions of the suspected material being the first line of
is determined by the appearance of the reaction, the therapy.
location of the reaction, and the history of exposure In regard to poison ivy, wash with soap and water
to the given material. promptly after coming in contact with this plant. If
prompt washing does occur within five minutes,
development of the rash may be avoided. Avoid
Can I be tested for skin contact allergies? excessive scratching of the area, as a secondary
Patch testing is the only known way of testing for infection may develop. Antihistamines are effective
this disorder. This involves taking materials that you to reduce the itching. In more severe cases, steroids
are possibly allergic to and taping them to your skin may be recommended by your physician, either
for 48 hours and then removing the material, looking topically to the skin or larger doses by mouth.
for a similar rash to what you have been experienc- Immunotherapy (allergy injections) administered
ing. over time to increase tolerance have not been
proven effective as a treatment of contact derma-
titis.
 CHAPTER 9

IMMUNOTHERAPY
ALLERGY INJECTIONS

The stimulation of a patient’s immune system by proper manner. If this is the case after 24 months, the
the injection of allergens is called immunotherapy or injections should be discontinued. This decision
hyposensitization. Allergy injections or “shots” de- should be made by your physician and you.
crease a patient’s sensitivity to these allergens. Currently, at least four to five years of injection
Allergy shots contain very tiny amounts of those therapy is recommended. However, the injections
things to which you are allergic (pollens, dust, dust should probably not be discontinued until the pa-
mite, mold, animal dander, and venom). This treats tient has gone for two to three years without serious
the basic cause of the problems you came to us about symptoms.
- ALLERGY. Allergy shots are not a cure. They will Once allergy injections are discontinued, how
increase your resistance to the allergens that bother long the benefits last varies from patient to patient.
you so that, when you are exposed to those things, Some patients remain without symptoms forever;
your symptoms will be less severe. others will have mild symptoms return but will be
Allergy injections are used in patients who have able to control them with medications.
severe symptoms which cannot be relieved by taking For our patients, we will usually have you take
medications or avoiding the allergen. They have your injections once or twice a week until you reach
been used since 1911. Since that time, many studies a maintenance dose. Then, you will progress to
have shown that the vast majority of people who every two weeks, three weeks, and then, finally,
receive injections, as part of a quality program, will once a month.
get better. Remember, even if on allergy injections,
controlling the environment is still the most impor- GETTING YOUR INJECTIONS -
tant way to prevent allergic symptoms. WHAT YOU NEED TO KNOW
It usually takes about six months of being on the
injections before you will notice a decrease in your 1. Are allergy injections dangerous? Generally
symptoms. After the first year, most patients notice a speaking, allergy injections are quite safe. Some-
significant improvement. Over the next several years, times, they can cause reactions. This is because they
they will continue to improve until, eventually, the contain the very things to which you are allergic. A
injections are stopped. A few patients do not get reaction can happen right after you get your shot, or
better with the injections, even though the injections it can occur later on in the evening. If a serious
contain the correct allergens and are given in the reaction is going to take place, it will happen soon
CHAPTER 9 - IMMUNOTHERAPY

after you receive your injection. This is why we ask SYSTEMIC REACTIONS - This type of reac-
you wait in the office for 30 minutes after each tion is rare, but you should know about it in case it
injection and why a physician must always be does happen. As long as you are getting injections
present where you receive your injections. made of something you are allergic to, there is the
chance you could have a systemic, or even life-
2. What usually happens? A small local reaction threatening, reaction. If something severe is going to
is normal and is no cause for alarm. “Local” means happen, it will be right after taking your injection.
that it happens around the site of the injection. This This is why it is so important for you to wait in the
includes redness and itching, much like a mosquito office at least 30 minutes after each injection. We
bite, which lasts no longer than 24 hours. are prepared for this type of emergency. Signs of a
systemic reaction are: itching of the throat, nose,
3. What can happen? There are two types of eyes, palms, or skin; hives, sneezing; runny nose;
reactions to allergy injections that we are concerned shortness of breath, coughing, or wheezing; dizzi-
about. This first is a large local reaction, and the ness or lightheadedness. If you notice any of these
second is a systemic reaction. As stated previously, symptoms, report to the nurse immediately. If they
a local reaction happens just around the area where occur on the way home, take an antihistamine and/or
the shot was given. A systemic reaction can happen anti-wheezing medication at once and return to the
in several different areas of the body. office. If it is after office hours, go to the closest
emergency room.
LARGE LOCAL REACTIONS - The local Most systemic reactions respond to one or two
reaction we are talking about is different from the doses of adrenalin. On occasion oxygen and inhaled
normal local reaction. Your arm may get red, itch, or asthma medication given by nebulization may be
you may have a welt larger than a half-dollar. There needed. On rare occasions an IV line needs to be
may be some pain. If you notice any of these within established to give fluids and other medications.
the first 30 minutes, report at once to the nurse. If you are taking Beta Blocker medications (drugs
These symptoms can usually be relieved quickly. If used to treat high blood pressure, migraine head-
they occur at home, you may want to take an antihis- aches or glaucoma), please notify your physician. Be
tamine, apply ice to the area, and take aspirin. sure to call us at once if Beta Blockers are started by
(Aspirin reduces swelling, whereas Tylenol does another physician after you have begun allergy im-
not. Either can be used for pain). If you ever have a munotherapy. Beta Blockers do not make you more
lot of itching or pain, swelling larger than a half- likely to have an allergic reaction to your allergy
dollar that lasts longer than 24 hours, or an arm that injections. But if a reaction occurs, it can be more
feels feverish to the touch, BE SURE TO REPORT difficult to treat in an individual on Beta Blocker
IT to the nurse before your next shot. Your dose may medications.
need to be lowered. Remember allergy injections in most cases do not
cause problems. But we want you to understand the
potential problems, how they are treated, and why
we are insistent on you being closely monitored after
each allergy injection.
 RESOURCES
Organizations
The American Dietetic Association Asthma and Allergy Network
216 W Jackson Blvd 3554 Chain Bridge Rd
Chicago, IL 60606-6995 Suite 200
(1-800-877-1600) Fairfax, VA 22030
(703) 385-4403
The Food Allergy Network American Lung Association
4744 Holly Ave 11720 Beltsville Dr
Fairfax, VA 22030 3rd Floor
(703) 691-3179 Beltsville, MD 20705
(Publishes Food Allergy News, a (1-800-445-6016 - MD only)
bimonthly newsletter with recipes.
Provides how-to-read-label cards and The American Academy of Pediatrics
pamphlets. Specializes in children’s 141 N.W. Point Blvd
food allergies.) Elk Grove, IL 60007
(1-800-433-9016)
Ener-G Foods
PO Box 84487 The American Academy of Asthma, Allergy
Seattle, WA 98124-5787 and Immunology
(1-800-331-5222) 611 E. Wells St
(A good source of milk-, egg-, and Milwaukee, WI 53202
gluten-free foods and information.) (1-800-822-ASMA)

Eczema Association for Science and Education The American College of Asthma, Allergy and
1221 SW Yamhill #303 Immunology
Portland, OR 97205 1645 Oakton
(Provides free literature.) Des Plaines, IL 60018
(1-800-842-7777)
Medic Alert® Bracelet or Necklace
Medic Alert Foundation National Jewish Hospital in Denver, Colorado
PO Box 1009 1400 Jackson St
Turlock, CA 95381 Denver, CO 80206
(1-800-344-3226) (1-800-222-LUNG)

Immune Deficiency Foundation Asthma & Allergy Foundation of America

25 W. Chesapeake Ave National Office
Suite 206 (1-800-7-ASTHMA)
Towson, MD 21204
(410) 321-6647 Maryland Chapter
(1-800-727-WEED)