When Allergy Season Peaks, Do You Have a Plan? My Tips for Your Worst Patients

With pollen counts skyrocketing, this could be the worst allergy season in years. Be prepared to help your patients.

It’s happening already: TV stations, newspapers and radio are hyping the severe spring pollen season ahead. As we know, long winters with lots of snow are springboards for high pollen counts. Every year when spring arrives my office phone starts ringing and patients can’t wait one day to be seen. My new patients, that is. I’ll explain the difference below. These new patients’ developing allergy “emergency” can be handled effectively with proper management, but more importantly, the crisis can turn into an opportunity to make sure these patients can enjoy spring without interruption next year. Here’s what I’ve learned about allergy peaks over the past 20 years…

They bring a lot of allergic inflammation! Patients come in with their eyes and noses red and swollen. They’ll tell you they feel miserable – like they have a terrible cold. They’ll also tell you they’re tired but can’t sleep at night. Many will complain that their head feels so heavy and their sinuses so painful. These are the ones with the self-diagnosis of “sinusitis.” And they’re right —their sinus passages ARE definitely inflamed. While we know from our training that the inflammatory process is often the result of allergic response, many patients equate sinusitis with infection. And all of them want solutions. So what should you do?

You reach for your prescription pad to put out the fire. But before you do that, it’s critically important that you make a definitive diagnosis. Allergy skin testing is the gold standard for diagnosing IgE mediated allergic disease. When skin test is contraindicated, IgE blood test is an acceptable alternative. Once you know what you’re dealing with, you can begin the management process. Of course, a positive skin or blood test doesn’t rule out infection but if you know there’s an underlying allergic process, you can’t go wrong by attacking it from that angle. Only a sinus tap confirms infection but if you clear up the inflammation, you can bet that this will rarely be necessary.

The medicine that works best in acute inflammatory situations isn’t the antibiotic that the patient often desires. And once your patient sees and feels the results of an allergy test, he/she will understand this concept. Many of us go straight to oral cortisone because it’s effective! However, there’s an art to prescribing oral cortisone so that it works while minimizing side effects and patient concerns. I’ve found Prednisone at a low dose is the key to quick relief. The dosage is weight-dependent but, as a general rule, 20mg is an effective therapeutic dose for adults and children over 60 lbs. You could increase that for patients over 170 kg, but higher doses usually aren’t necessary. Prednisone, like all oral cortisone, should be taken in the morning to synchronize with the patient’s circadian rhythm. It should always be taken with some food to minimize gastrointestinal upset.

One week of Prednisone is usually enough to quell the acute allergic inflammation caused by the eosinophils in the tissue. This gets the ball rolling to reverse patients’ most severe symptoms but you should complement it with topical sustainable medications as well. For nasal congestion, sneezing and rhinorrhea, there is nothing better than topical cortisone nasal spray. Nasacort is the first one of these sprays available over-the-counter. Your patient can use the 24 hour preparation once each morning.

What the patient may not capture from their over-the-counter purchase is the understanding that correct administration technique is vital for effectiveness and safety. It is important that you and your staff demonstrate and educate on the cross-hand technique; show patients how to spray one pump at a time into the lateral aspect of the nostril using the opposite hand.Using opposite hand makes it easier to avoid accidentally spraying medially towards the septum, which diminishes effectiveness, potentially inspires a bloody nose, and ultimately puts the patient at risk for long term septal damage. Nasal steroids are proven superior to antihistamines in terms of both symptom relief and side-effect profile in head-to-head comparison studies.

Many patients don’t like nasal sprays or worry that they’ll “get hooked” on them. My answer: They work. And, no, you don’t get addicted to cortisone nasal sprays as you might after weeks of consecutive use of decongestant sprays like Afrin. That said, decongestant sprays can be incredibly useful for short term treatment of acute inflammation and can sometimes forestall the need for Prednisone.

Eye symptoms such as redness, itching and tearing can be very debilitating. The best short term treatment for acute allergic conjunctivitis is topical antihistamines. I have several favorites in this area, but you need to check with your patient’s insurance coverage. I’ve had patients call up in a panic that the antihistamine eye drop I prescribed cost over $100 for a tiny bottle. I call them “liquid gold” because they’re very effective but the cost is sometimes precious-metal caliber. A nice trick for enhancing relief is storing the eye drops in the refrigerator to ease the burning sensation. Most eye drops should be administered twice each day. Instruct your patients not to use the typical red-out over the counter eye drops. They contain decongestants which may indeed get the red out but also prove quite addicting. Finally, even while using the Prednisone and topical treatments, I recommend my patients take an antihistamine at night. I prefer Allegra(fenofexidine) or Zyrtec (cetirizine) equivalents because they last for 24 hours and are generally more effective and often less sedating than Benedryl (diphenhydramine).

Now that we’ve successfully weathered the initial storm, it’s time for education. This reminds me of an age old saying: “Never waste a good crisis.” In medicine, I take this to mean that when the patient is really suffering, you have an opportunity to explain that they can avoid this same scenario next year with proper diagnosis and treatment! Sometimes it’s necessary to wait for the crisis to pass before definitively diagnosing. This happens when a patient is too symptomatic and miserable to undergo the test. Either way, once we obtain positive results, I explain that allergen immunotherapy — shots or drops — is the only way to minimize or eliminate their regular allergy crises.

No other tools in our bag can actually change the course of the disease. Keep in mind that symptom treatment must continue and even increase in the early weeks of immunotherapy ramp-up, but at the first quarterly visit you’ll discuss tapering meds -for good! For most patients, the choice is simple: a lifetime of meds with side effects and potential interactions vs four years of using elements from the environment to teach the immune system not to overreact to nature. Imagine if we had such a solution for diabetes or hypertension!

In the end, patients relate well to successful results. It brings a smile to my face when I tell the acute patient: “my waiting room used to be filled with sniffles and watery eyes just like yours. Now I have a waiting room mostly full of patients feeling great and just stopping by to pick up their allergy drops.”

– Dr. Dean Mitchell

Exploring the Allergy Roots of Eczema Leads to New Treatment Options

Eczema is a chronic condition that is often associated with allergies. The sharp provider can offer patients several treatment options.

The cold winter months may offer respite for patients with pure pollen allergy, but they are no friend to patients suffering with eczema. Eczema, also known as Atopic Dermatitis, is the classic allergic skin rash. It’s known as “the itch that rashes,” meaning that it is typical for a patient to experience the symptom of itching first and clinical rash next. Atopic dermatitis patients usually have elevated total IgE, which explains why they frequently have comorbid conditions of allergic rhinitis and asthma. The simple treatment for the eczema patient’s symptoms is a prescription for a topical cortisone cream. Cortisone may give the patient temporary relief, but a more comprehensive plan is needed to provide the fundamental disease control that they deserve.

We sometimes forget that the skin is the largest organ in the body.  It covers our entire outer surface. In order to adequately protect that organ, we must provide an emollient that can serve as a barrier to the harsh environment. The good news is these are easy to acquire and they aren’t very expensive. My professor of allergy and dermatology at Columbia Presbyterian Medical Center extolled the benefits of baby oil. Yes, good old fashioned baby oil just after a shower, when the skin pores are wide open, can provide a nice general coating for the skin. In areas of severe dryness or broken skin resulting from the eczema, plain Vaseline or Aquaphor lotion is helpful. Vaseline may be sticky and messy but it’s effective. When we had patients on the dermatology ward with severe rashes, the nurses coated them with Vaseline — it was very soothing and therapeutic.

Cortisone creams are an important element in the treatment regimen, but they should be targeted to the affected areas. It is very important to show the patient how to apply the cream; they must see how to massage it in coin size amounts to the local areas of redness. If they just lightly smear tons of cream over the body, absorption — and therefore effectiveness — is limited. I usually find that a mid-potency steroid cream, such as Mometasone is effective. However, you should use only low potency hydrocortisone (1 or 2.5%) on the face due to the risk of atrophy with the mid-potency preparations. The other important ointment in the treatment spectrum is Muciprin, which contains an antibacterial agent that helps reduce the growth of Staph.aureus on the affected skin areas. Muciprin should be applied to broken skin areas that are oozing with fluid.

The above steps are familiar to most doctors. Now, comes the expert territory. Even dermatologists are a bit lax when pursuing the underlying cause of eczema. Numerous studies show that atopic dermatitis is worse in children with food or environmental allergies — especially to dust mites. It’s important to take a thorough history on these patients and perform an allergy test to see if an allergen exacerbates the condition. Dr. Hugh Sampson, when he was at Johns Hopkins, demonstrated that 50% of children with eczema had food allergies. The studies further showed that eliminating these foods from the children’s diet caused improvement of the eczema. This was ground-breaking information in the late 1990s — now it’s recognized as a standard of care. The AllerVision allergy skin test panel of standard foods is a good place to start your evaluation. AllerVision also offers an additional food panel that allows you to test for 40 individual foods; it’s an excellent way to augment your program.

Exciting new areas of research into eczema treatment indicate that enhancing immunity may provide significant benefit to the patient. The latest studies from Harvard suggest that supplementing with Vitamin D3 can help control patients’ eczema and decrease reliance on topical corticosteroids. As a result, I have recommended supplementation with Vitamin D3 in the ranges of 1,000- 3,000 units daily for all of my eczema patients. I prefer the liquid Vitamin D3 over pills, as the pills can be difficult to swallow. Following your patients’ D3 level along the course of eczema treatment can provide interesting information regarding management.

Finally, it’s worth noting that studies substantiate the value of sublingual allergy immunotherapy (allergy drops) for patients with mild to moderate atopic dermatitis. Specifically data has shown that dust mite allergy, which is associated with aggravating atopic dermatitis, can be treated effectively with sublingual allergy immunotherapy. The same has not been demonstrated with subcutaneous injection immunotherapy.

Once you determine — though medical history and allergy testing — the root of the eczema, you can determine which of these treatments can take the itch out of your patient’s lives.

– Dr. Dean Mitchell