Are You Driving Everyone Crazy at Work?

Constant sneezing and throat-clearing, both symptoms of allergies, can irritate co-workers. There is a solution that will make everyone happy — immunotherapy.

Is there someone in your office who always sneezes, coughs and/or continuously clears their throat? That person may be suffering from allergy symptoms that include post-nasal drip. Co-workers offer a “bless you” once or twice, but the well wishes gradually taper off as thoroughly annoyed office mates secretly wish that person would get their allergies under control and put everyone out of their misery. It’s certainly not your fault but if you’ve been noticing dirty looks, you might be that person.

Similarly, is there a student at your child’s school who just looks miserable — suffering daily with watery eyes, runny nose, lack of energy and fleeting attention? The teacher and fellow students undoubtedly feel bad for that child — at least at first. But when symptoms continue day after day, sympathy turns to frustration and friends find excuses to slink away. That child’s grades are likely to suffer as a result of inattention and/or missed days. For this great, smart kid who isn’t achieving their deserved social or intellectual status, top notch performance seems an impossible dream. Is that your child?

Whether it’s you, your child, or someone who shares your air, there IS a solution that can clear symptoms and restore good relations — immunotherapy. Here are three need-to-know points about it … First, it can resolve reactions to multiple allergens like ragweed, mold and cat dander. Second, it lasts for years. Third, it’s entirely natural — it’s not medication. Immunotherapy exposes your immune system to very small quantities of the allergens, effectively teaching it “see, they’re really not so bad.” Since your system stops trying to fight off these harmless particles, your symptoms subside greatly or disappear altogether.

Allergy drops and shots are both forms of immunotherapy and they’re both effective. One of the major benefits of drops is you can take them at home — or on the road — so there’s no need to miss work or school for weekly doctor appointments, which are required with shots. (Missing work or school may be another strain on relationships with co-workers, friends and teachers.) Drops are affordable and are ideal for everyone from children to seniors. The upside of shots is that, currently, more insurance companies pay for them (co-pay and deductible may apply.)  In the long run, both shots and drops will likely be less expensive than medications — and will almost certainly be more effective.

If you or your child are the ones getting on everyone’s nerves, through no fault of your own, it’s time to put your allergies behind you and patch up those strained relationships. Talk to your doctor about immunotherapy. If it’s someone else, don’t bludgeon them to death — point them to https://www.allervision.com/allergies.

Spring – A Time for Love … and Pollen

A pine tree releases up to five lbs. of pollen, which will be distributed for miles by the wind. February is the start of pollen season. (Image source:Wikipedia)

Whether you’re eagerly anticipating the end of the freeze and the arrival of spring, or dreading it, depends almost entirely on whether you have allergies. If you’re an allergy sufferer, you may already be experiencing those dreaded symptoms; February is the official kickoff of pollen season for trees in many parts of the country.

So what is pollen anyway, and why does it make you feel so miserable? If it didn’t make you feel like sticking your head in the sand until the scorching summer months, the answer would be, if not romantic then at least a little racy. Pollen is a collection of powdery grains made up of microscopic proteins that male tree parts release into their air with the hope of pollinating female tree parts … ideally of a different tree. The wind carries these grains for miles, dispersing them over the terrain to find the perfect mate(s) and increase the chance of successful reproduction. Since this is a very hit or miss delivery technique (slightly more so than an internet dating service), trees — and other plants — release millions of grains of pollen. Put enough pollen out there and, like with internet dating, eventually something good will happen.

With all that pollen circulating in the air looking for companionship, it’s inevitable that sooner or later some will come in contact with your respiratory system. Since the pollen is a normal part of the environment, your body should just be able to ignore it and carry on with little more than an occasional sneeze. However, a pollen-allergic immune system mistakes pollen as a serious invader and immediately summons defenses to fight it off. The result is a wall of mucous and swelling designed to keep the invaders out and a barrage of symptoms that may include runny nose, congestion, sinus headaches, conjunctivitis, skin rashes, coughing, and asthma flare ups; they’re often worse than the symptoms of an internet match gone wrong!

There are a variety of treatment options to quell these symptoms. You can find more details about them in our Which Allergy Treatment is Right For You post. But seeing as it is virtually impossible to avoid these mate-seeking airborne grains, allergic patients should strongly consider the only solution that is actually a “cure” because it teaches your body to ignore pollen season after season: immunotherapy. That’s important considering that at this very moment, pollen from Ash, Alder and Juniper trees, among others, may be swirling around your home. Too bad we can’t offer immunity to bad matches on the internet scene. Welcome to spring!

Does Your Child Have Allergies?… Are You Sure?

Allergies can cause a wide variety of symptoms, many of which you might not expect.

Viruses, bacteria, allergens — there’s any number of small organisms that can make children feel bad. Often the hardest part of treatment is determining the true cause of your child’s illness. For instance, is the latest ear infections the result of a “bug” going around day care or is grass pollen triggering an allergy?

Compounding the situation, allergies manifest themselves in many different ways. Of course, everyone knows that allergies can cause sniffles, watery eyes and sneezing. But here’s a list of other common, though often undiagnosed allergy symptoms in kids:

• Asthma
• Frequent ear infections
• Sinus headaches
• Nasal polyps
• Conjunctivitis (eye irritation)
• Skin rashes and eczema
• Mental problems such as confusion, slow thinking, depression and forgetfulness
• Respiratory effects including endless colds, chronic cough, recurrent bronchitis
• ADHD (Attention Deficit / Hyperactive Disorder)

That’s right,  allergies can even trigger ADHD. So, what do you do? The first step is a full allergy evaluation by a qualified medical provider. An allergy test alone — even a skin test, the gold standard — is not enough; it can show that your child is sensitive to an allergen but not determine if that is causing symptoms. Your provider should conduct a full health history. The results, in conjunction with your answers to when and where your child exhibits symptoms, can help determine if his or her maladies are allergies or something else.

One key to remember is that if your child’s ailments come and go regularly, or if they stay around constantly, there’s a good chance allergies are to blame. If they’re “one and done,” it may be just the cold going around. When in doubt, ask your provider for a full allergy evaluation. To find an AllerVision-affiliated doctor who is qualified to do this, click here.

The Allergy Family History: A Key Component to Diagnosing an Allergic Condition

Family history plays a large role in diagnosing allergies.

Many chronic medical conditions may stem from underlying allergic process: rhinitis, asthma, bronchitis, sinusitis, atopic dermatitis, otitis, conjunctivitis, headache, GI problems and, of course, drug allergies and anaphylaxis. Your physical exam— along with allergy testing — can often help make a specific diagnosis. However the diagnosis begins before you get there. The History is always a key element in the diagnostic process. I have found that, in regards to allergy, the Family History may be the most important component of all.

Allergic diseases have a clear genetic link. While the exact transmission of allergies has not been precisely defined, medical research has demonstrated a strong familial relationship. Allergic parents tend to have allergic children. It makes sense that allergic asthma follows the same pattern. In fact the greatest predictor of childhood asthma is not IgE levels or any other specific allergy skin or blood test; it’s maternal asthma.

IgE-mediated allergic disease can manifest with a variety of presentations. I always ask my patients if anyone in their immediate family — parents, sisters, brothers, aunts, uncles, grandparents, and don’t forget the patient’s own children — has allergies. You sometimes have to give them a nudge by specifically mentioning sinus disease, skin rashes, asthma or allergy to Penicillin. Each of these are indicators of IgE-mediated disease in the family.

I have found the link to be so strong, in fact, that when a patient presents to me with asthma and no family history of allergy, I have doubts. If they had no immediate relatives with allergy, I perform an extra careful search for a non-allergic source for their respiratory symptoms. Of course, I still investigate the allergy angle for the sake of completeness and the possibility that their family members have not been properly diagnosed. But if the family history is truly allergy-free, there is generally another source for the patient’s symptoms, such as Alpha 1 antitrypsin deficiency — an enzyme deficiency that can mimic asthma and bronchitis.

Patients often ask, “My mother (or father) has a specific food or drug allergy, do I need to avoid that product?” The patient has no symptoms but the parent has a terrible reaction to a food or medicine. This is tricky. My advice is to be vigilant! We are not identical replicas of either of our parents but it is wise to be on the alert for any symptoms of allergy to parents’ severe triggers and to avoid the offender at the first hint of a symptom. This recommendation is consistent with my frequently-lectured theme to medical students and patients alike: allergic sensitization occurs after repeated exposure. Sometimes it takes several exposures before the body’s IgE response erupts in a clinical reaction.

We can’t escape our genetics, but we can limit or avoid potential allergen exposures. This holiday season of Christmas, Hanukah and Kwanzaa, when surrounded by family, it might be a good idea to ask around and complete your own Allergy Family History!

Dr. Dean Mitchell

The Allergy Clock is Ticking: Spring Ahead, Don’t Fall Behind in Treatment

Spring usually brings beautiful weather — and lots of allergies.

It’s been a brutal winter throughout most of the country. Once we get even a few consecutive days with weather in the 60’s and sunshine, everyone will rush outside for extra-long lunch breaks. My New York City office is right around the corner from Central Park, which is flooded with fresh-air-seekers of all ages as soon as spring emerges. For individuals who suffer with allergies, excitement for Spring is tempered with the weary anticipation of inevitable symptoms. However, with the right strategy and treatment all of your patients can be enjoying the blossoming of flowers and the sweet smell of Spring.

The first step in helping your Spring allergy patients is identifying them! The best strategy is identifying them before the pollen starts to skyrocket. How can you do this? Run a report of your billing codes for April, May, and June, filtering for the diagnosis of sinusitis, asthma, otitis, dermatitis, bronchitis, conjunctivitis, and, yes, allergic rhinitis. This list will provide you with a valuable group of patients who notoriously wait until their allergy symptoms are severe to seek treatment from your office. Remember, most allergy medications are over-the-counter and patients are taught by their pharmacies and big pharma marketing to take treatment into their own hands. The problem is, most of these medications are not nearly effective enough to provide true relief when the pollen counts are high and patients’ symptoms are at their worst. My recommendation is that you contact these patients – as you would your flu patients before the season – and inspire them to come and get evaluated for a pre-treatment program before it’s too late.

The typical early Spring pollen culprits are the trees. The initial pollen in March comes from the Maple and Elm trees, soon followed in April by Birch and Oak. (The AllerVision Facebook page has featured a full-scale “Field Guide” of allergenic trees. Check it out at facebook.com/allervisionllc.) If your patients suffer with Spring allergies, they need to know these pollens can start early in the season if the weather warms up. The AllerVision screening and skin testing program will help uncover the connection between pollens symptoms, and encourage your patients to prepare.  The worst parts of this allergy season are typically the beginning of Spring and the time between Mother’s Day and Memorial Day. Why does it worsen in the later period? This is usually double-whammy time: tree pollens still float around as grass pollen starts its surge. Again, using the allergy skin test, the gold standard, enables you to set out a plan for your patient to beat the perceived enemy at it’s own game.

Once you identify your tree and grass pollen patients, it’s time to take action; get them started on Nasalcrom immediately. It’s an effective, safe, cromolyn sodium nasal spray designed to stabilize mast cells. The caveat is that it works best if started a few weeks before the pollen counts are high. The other great option, that is now over-the-counter but it is rarely recommended by doctors, is Nasacort.

Of course, there is only ONE disease-modifying treatment for allergic disease: immunotherapy. Your allergy sufferers deserve the option of definitive resolution. And they especially love the fact that immunotherapy, unlike the other options, is not a drug. Your patients will appreciate the natural option that fixes the problem with almost no side effects — who wouldn’t?! Allergy drops or shots are the solution to Spring and your patients’ ticket to the great outdoors!

The clock is ticking: Find those patients before they find your office in a miserable state yet again!

– Dr. Dean Mitchell

Anaphylaxis, The True Allergic Emergency – What You Need to Know

Anaphylaxis, which comes from the Greek term “reverse protection,” is the most

There are many possible signs of anaphylaxis…

dangerous type of allergic reaction. It is described as a type 1 Hypersensitivity reaction that involves release of IgE triggered, most often, by a food, medication or insect sting. Anaphylaxis is a frightening reaction where a patient, who moments before appeared fine and healthy, almost within seconds can be wheezing, hypotensive, and covered with hives.

The foods most commonly associated with anaphylaxis in children are peanuts and tree nuts; in their adult counterparts it’s usually shellfish. The confusing part for patients and clinicians is that a food allergy can develop after eating a particular food on many occasions. However, once that threshold has been crossed, even a minute amount of that food can cause an explosive reaction. If a food is the suspected cause of anaphylaxis, but the specific food unclear, it’s wise to evaluate the patient through several steps.

Initially, I would recommend a panel of food allergy blood tests. ImmunoCap is a common one used by most labs to evaluate IgE reactions to specific foods. The results range from zero to six, with a score of at least two indicating a positive reaction. If there is a positive reaction to peanut, the allergy should be further explored by ordering a UKnow Peanut test which analyzes the proteins Ara h1,2&3, as well as Ara h8. My article in Consultant for Pediatricians, “Pinpointing the Proteins in Peanut Allergy,” explains why these proteins are important to predict the severity of peanut allergy. If, for some reason, the blood test is negative, I would recommend referral to an allergist for skin testing and/or oral challenge in case there is a hidden allergen that requires more extensive testing.

Any medication can cause an anaphylactic reaction however the common culprits are antibiotics and non-steroidal anti-inflammatory drugs. Many antibiotics are mold-based, which may be part of the reason for their allergenicity. In the past, beta-lactam antibiotics such as penicillin and related cephalosporins were the most likely offenders but today we also see anaphylaxis to the widely used category of quinolone antibiotics. To complicate matters, it is not unusual for a patient to have multiple antibiotic sensitivities; there is a genetic component to this reaction. While Pre Pen can be used to diagnose penicillin allergy (talk to your AllerVision representative for more information), there is no such test for most antibiotics, and a drug challenge may be required for conclusive diagnosis.

Non-steroidal medications, such as Advil, Motrin and Alleve, work by blocking the cyclo-oxygenase pathway and trigger release of leukotrienes which are potent mediators of anaphylaxis. In my experience, patients allergic to NSAIDS are usually unaware of the source of reaction until they suffer several episodes of anaphylaxis. Be on high alert for NSAID hypersensitivity when evaluating a patient for anaphylaxis or urticaria. Unfortunately, a drug challenge is the only conclusive test NSAID hypersensitivity.

The clinical diagnosis of anaphylaxis can be complicated. The World Allergy Organization recently came out with new criteria. Essentially, it includes exposure to a possible or known allergen and the finding of two or more clinical signs: urticarial, bronchospasm, gastrointestinal distress and cardiovascular collapse. In case of cardiovascular collapse, no additional signs are needed — call 911 and immediately transport the patient to the hospital.

While anaphylaxis is fairly rare with allergy injections, and exceedingly rare with allergy skin testing, it is important that you and your staff be prepared just in case. When a patient is in your office, the question of whether or not to treat a potential reaction is simplified, and doesn’t include an extensive review of the clinical findings nor consideration about number of signs. If you place an allergenic substance on the patient’s skin, or inject them with a substance you know they are allergic to, and they have a reaction anywhere other than the local site of exposure, TREAT THEM! Common signs to look out for are itching of hands and feet, or clearing of throat that wasn’t happening when the patient came in to the office. If you apply antigen to one area of the body, and the patient has symptoms somewhere else, you have to assume that the reaction has gone systemic and you should treat accordingly.

The initial treatment of anaphylaxis is unambiguous: epinephrine intramuscularly into the lateral thigh. Don’t play around with Benedryl! Don’t give a cortisone shot! Anaphylaxis progresses immediately, and neither antihistamine nor steroid drugs act on the spot to reverse the severe pathophysiological reaction. Deaths resulting from anaphylaxis happen when epinephrine is not administered in under 3o minutes from the onset of symptoms. If you are giving allergy injections in your office, you MUST have the patient wait 20 minutes in the office to make sure they don’t have an immediate allergic reaction. If they develop ANY sign or symptom within that time, administer epinephrine. The EpiPen is convenient for an office because it contains the 0.3 ml of epinephrine with the needle size for an intramuscular injection. It also comes as the EpiPen Jr. for children or infants less than 66 lbs. Once epinephrine has been given, the patient must be monitored for several hours to make sure there isn’t a biphasic reaction; this usually takes place in a hospital.

Anaphylaxis can be the most frightening of clinical reactions. The good news is with quick recognition and prompt treatment with epinephrine, you can be a real hero!

– 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