Common Allergy Topics
Allergy and Asthma Related Links
- The American Academy of Allergy, Asthma and Immunology (AAAAI)
- The American College of Allergy, Asthma and Immunology (ACAAI)
- Seattle Area Pollen Counts (National Allergy Bureau)
- The Food Allergy and Anaphylaxis Network
- Eosinophilic Esophagitis (“EE”, or “EoE”) at the American Partnership for Eosinophilic Disorders
- Immune Deficiency Foundation
- Jeffrey Modell Foundation
- Recurring Infections
- Gastroesophageal Reflux
- Eosinophilic Esophagitis
- Local Anesthetic Allergy
- Penicillin Allergy
- Chronic Hives or Swelling
- Food Allergy
- Sublingual Immunotherapy (“SLIT”)
- Allergy Shots
- Hay Fever & Environmental Allergies
Recurring infections and the immune system
Allergists are also board certified in Clinical Immunology. Clinical Immunologists are trained to detect and treat problems with your body’s response to infections.
What are common warning signs that could mean an immune problem?
– 2 or more serious sinus infections in a single year (especially if there are no allergies)
– 2 or more episodes of pneumonia in a single year
– An infection that requires a hospital stay or IV antibiotics
– An infection of the blood or inner organs
– A family member has been diagnosed with an immune problem
If these or other concerning signs are present, a Clinical Immunologist may order lab testing to look for a problem in your immune system. These lab tests usually include:
– Blood cell counts (including infection-fighting white blood cells)
– Immune globulin levels (aka “antibodies”, whose job is to fight of infections)
– Your body’s ability to respond to common vaccines (e.g. Tetanus, or Pneumovax)
– Important proteins in the immune system called complement
– If necessary, there are many other lab tests available
Sometimes patients have subtle problems fighting infections, but state-of-the-art testing methods cannot detect the problem. Some patients simply have bad luck and get more infections than average. In either case, there may not be a specific test, diagnosis, or treatment for your problem.
You may have heard about over-the-counter supplements or products that claim to “boost” your immune system. Regrettably, these products have not been scientifically proven to improve the immune system.
The Immune Deficiency Foundation is an excellent resource for information about immune deficiency.
Heartburn and Gastroesophageal Reflux Disease (GERD)
Heartburn, or “gastroesophageal reflux” (GER), is a very common problem. GER happens when acidic contents from the stomach enter up the esophagus and cause chronic, aggravating symptoms. Sometimes patients can have GER, even if they don’t feel it! We call this “silent reflux”.
Patients with GER usually complain of :
– Acid (or brackish) taste in the mouth
Sometimes GER happens high in the esophagus, near the voice box. Besides the symptoms above, patients can also experience:
– A hoarse voice
– Frequent throat clearing
– Chronic cough (which can mimic asthma)
– Chronic runny nose or postnasal drip (which can mimic allergies)
– Sensation of something “stuck” in the throat
– Painful swallowing
To treat GER, we usually start with lifestyle modification techniques (below). If these approaches are not helpful, then it is time for medications. Modern medicines like “proton pump inhibitors” (e.g. omeprazole, pantoprazole, etc.) can be effective for patients with GER. The same is true for certain antihistamines (e.g. ranitidine).
It may take at least a month, but treating GER with acid-blocking medicines can reduce symptoms like cough, voice hoarseness, and heartburn.
Tips to avoid GER:
- Avoid spicy, acidic, tomato-based foods like chocolate, tomatoes, citrus fruits, and fruit juices.
- Limit your intake of coffee, tea, alcohol, and colas. Alcohol and caffeine can worsen heartburn.
- Smoking (nicotine) also worsens heartburn.
- Being overweight can cause or aggravate GER.
- Don’t over-eat at meal times. A full stomach is more likely to cause heartburn.
- After eating a meal, avoid exercising for 1-2 hours.
- After eating a meal, avoid going to bed until at least 2-3 hours.
What is Eosinophilic Esophagitis?
Eosinophilic esophagitis (also called “EoE” or “EE”) is an allergic/inflammatory condition of the esophagus (the tube connecting the mouth to the stomach). For unknown reasons, eosinophils accumulate and coat the inner lining of the esophagus causing inflammation, swelling, and other changes. Patients with EoE usually experience painful swallowing and food getting stuck. EoE can resemble GE reflux (aka “heartburn”), but patients with GE reflux tend to have more heartburn, acid taste, and throat clearing. Until recently, EoE was described as “really bad GE reflux”.
Hold on, what is an eosinophil?
Eosinophils (ee-oh-SIN-oh-fills) are a kind of white blood cell and involved in the immune system. They are made in the bone marrow and have several jobs within the immune system. For unknown reasons, eosinophils get involved in allergic and inflammatory reactions. If eosinophils target the wrong areas, it can be harmful to the body itself. We are not sure why, but eosinophils can be drawn to certain organs, like the digestive tract, lungs, and other organs. Eosinophilic esophagitis is one kind of eosinophilic gastrointestinal disorder (EGID). Others EGIDs include eosinophilic gastroenteritis (EGE) and eosinophilic colitis (EC). Among the EGIDs, EoE is the most common.
Diagnosing eosinophilic esophagitis
Before making the diagnosis of EoE, it is helpful to rule out GE reflux. Typically patients will take a trial of an antacid medicine (e.g. ranitidine or omeprazole) for up to 8 weeks. If symptoms do not improve, then a digestive specialist called a gastroenterologist may pass a camera scope into the esophagus and stomach. Sometimes EoE is visible on the inner lining of the esophagus, and sometimes not. During the endoscopy, the gastroenterologist will take small biopsies of the inner lining and send them to a pathologist for further analysis. The diagnosis of EoE can be confirmed if the pathologist sees excessive eosinophils under a microscope.
An Allergist can help with food allergy testing
A majority of patients with EoE have food sensitivity, and should see a board-certified Allergist for testing. Allergists can use traditional skin or blood testing to help see if there are foods to which the patient is allergic. EoE typically improves if a patient can identify and avoid allergy-causing foods. However, food allergy testing is not always 100% accurate. Sometimes patients are sensitive to foods even if the test is “negative”. In this case, we use an elimination diet to see if the patient gets better.
Treatments for EoE: elimination diets and medicines
Research has shown that many EoE patients get better when they avoid 6 common food allergens: dairy, egg, wheat, soy, peanuts/tree nuts, and seafood. Recent research has shown that of these 6 foods, milk may be the most problematic, and should be the first food to eliminate from the diet. If patients feel better after dietary elimination, they may consider slowly re-introducing foods into their diet, watching for their original symptoms to return. Patients should consult with a registered dietician if they plan to eliminate several foods from their diet. The current medication choice is a swallowed topical steroid (e.g. Flovent, Pulmicort). Oddly enough, we normally use these medicines for asthma. Topical steroids are an “off-label” use for EoE, but they are effective at limiting eosinophilic inflammation in the esophagus. It is unclear how long patients will need to use swallowed steroids.
What is the long-term prognosis for EoE?
EoE has only been recognized for about a decade, so we still have a lot to learn. We still do not know if this is a temporary problem, or one that lasts for a long time. We do not know if EoE puts patients at risk for other health problems. Patients with EoE often have food or environmental allergies (e.g. hay fever in the spring). However, Allergists also see EoE patients who appear to have no allergies of any kind.
Allergy to Local Anesthetics
Some patients have experienced reactions to local anesthetics like Novacaine or Carbocaine while at the dentist. After the medication is injected, patients report a variety of symptoms, like increased heart rate, flushing, etc.
Fortunately, very few people are truly allergic to local anesthetics. Instead, many have experienced side effects from the medication, or to additives like epinephrine.
Allergists can use skin tests to help determine if a patient has an allergy to a local anesthetic. If skin testing is negative, patients then receive a “test dose”, usually of Carbocaine (aka mepivacaine) in our office. If the patient does not react, then he or she is not allergic, and it will be safe to receive a local anesthetic at his or her next dental visit.
Penicillin Allergy Testing
Penicillin allergy is the most commonly reported drug allergy. However, studies (1) have suggested that only a small percentage of patients with a reported “Penicillin Allergy” are truly allergic. In some cases, symptoms have been misinterpreted as “allergy”. In other cases, patients may have outgrown a true penicillin allergy.
In other words, many patients (even those with a history of penicillin allergy) may not actually be allergic to penicillin.
Fortunately there is a rapid and generally reliable test for penicillin allergy called Pre-Pen. Pre-Pen is a skin test performed in a single visit at an Allergist’s office. If the test is negative, most patients may start taking penicillin-style antibiotics again. This is good news for patients with multiple drug allergies, for whom it is difficult to choose safe antibiotics.
We offer Pre-Pen penicillin allergy testing at Allergy and Asthma Associates. Call us to schedule an appointment.
1. Simpson M.D., Alyson B., et al. “The Acceptability of a Four-Part Protocol for Penicillin Allergy Testing by Practicing Allergists.” Allergy and Asthma Proceedings. March – April 2009, Vol. 30, No. 2: 192-201
Hives and Swelling
Hives (or “urticaria”) are red, raised, itchy bumps that can appear anywhere on the skin. Patches of hives can pop up, and then disappear just as quickly as they appeared. Hives can last for hours, days, months, or even longer. Hives are very common: nearly 1 in 3 people will have hives at some time in their life.
Hives are often accompanied by swelling (or “angioedema”), such as in the face, lips, hands, feet, etc. Fortunately, most patients with just hives and swelling are not at risk for life-threatening anaphylaxis, and therefore do not need to carry an epinephrine auto-injector.
When hives or swelling last less than 6 weeks, there’s a good chance they are due to an allergy (e.g. food, medication, or something in the environment). These allergies can usually be detected with routine allergy tests. If hives last longer than 6 weeks (also called “chronic urticaria”), then there is less than 5% chance they are due to an allergy.
There are many non-allergic causes of hives or swelling: emotional stress, hot or cold temperatures, pressure on the skin, “autoimmune” diseases, and the list goes on. It can be challenging to locate a specific source of chronic hives. Fortunately there are several treatments for hives, regardless of their source. Many patients respond to daily antihistamine therapy. If not, then an Allergist can recommend stronger medicines. It is difficult to know when chronic hives will stop. It can take weeks, months, or even years. Each patient’s hives are unique, though most hives will eventually go away.
For further reading, the Mayo Clinic has an excellent description of hives:
Eczema is a condition marked by dry, itchy skin. It has been called “the itch that rashes”—patients itch their skin, and later a dry, red rash forms. Sometimes eczema is also called “Atopic Dermatitis”.
Eczema can result from food or environmental allergies. Many patients with eczema have no allergies at all. Allergy testing can help determine whether or not eczema is due to allergies.
Tips to control Eczema
– Humidity in the home should be maintained around 30-40%, especially during winter months.
– Patients with eczema should take at least one bath (or shower) per day. Bathing helps restore moisture in the skin. Gentle cleansers are preferable over soap, which can dry the skin.
– After bathing, apply non-sensitizing moisturizers such as Aquaphor, Aveeno, Cetaphil, Lubriderm, Neutrogena, Nivea, Vanicream, and Vaseline (petrolatum). Vaseline is unique because it acts as a moisture seal.
Medications to help Eczema
– Antihistamines (cetirizine, Benadryl, hydroxyzine) are oral medications that may help limit itching associated with eczema.
– Topical corticosteroid creams should be used as needed for red, inflamed “hot spots” on the skin.
– Non-steroidal creams (e.g. Protopic, Elidel) are safer on the face, but there have been concerns about side-effects.
If eczema skin becomes extra red and warm (especially if it weeps or has yellowish crust), then there may be a skin infection. These infections can be treated with oral or topical antibiotics, depending on the circumstances. This would be a good time to see your Allergist or primary care provider.
What is a Food Allergy?
Food allergy experts define food allergy as an “abnormal response to a food triggered by the immune system.” For reasons we don’t understand, the body makes an antibody called immunoglobulin E (IgE) against a particular food. The next time the person eats that particular food, IgE antibodies bind to food molecules and trigger an immune response. Food allergic reactions usually happen within a few minutes or a few hours after eating an allergenic food.
What are common food allergy symptoms?
Common symptoms include: hives, mouth itch, lip or tongue swelling, vomiting, diarrhea, or stomach cramps. More severe symptoms (also called “anaphylaxis”) may also include trouble breathing, throat tightening, weak pulses, or a drop in blood pressure. Anaphylaxis can be potentially life-threatening, especially without appropriate treatment (i.e. epinephrine injection). Sometimes there can be a second “biphasic” anaphylactic reaction 8-72 hours after the first.
What are other kinds of food reactions?
Some people may be sensitive or intolerant to a particular food. They may describe a wide number of symptoms, ranging from headaches, stomach discomfort, to behavioral changes. While food sensitivity may not work by our classic definition of “food allergy”, patients often feel better while avoiding the trigger food. Currently, there are no tests that can prove or disprove the presence of food sensitivity. A blood test called an “IgG Food Allergy Panel” is available, but it has not been proven scientifically to help make an accurate diagnosis. Patients are encouraged to learn about this test before having it performed. It is common for patients to have several of “positive” IgG tests — even to foods that don’t bother them at all!
A common form of food intolerance is lactose intolerance. Patients with lactose intolerance are missing the enzyme needed to digest milk sugar (called lactose). They experience bloating and gas when they eat dairy. Lactose intolerance is not technically a food allergy, but it’s still a good idea for these patients to avoid dairy products.
How common are food allergies?
Children (under 5 years old): about 1 in 20, or 5%, of children have a diagnosable food allergy.
The most common childhood food allergens are egg, milk, peanut, tree nuts (walnuts, almonds, pecans, etc.), soy, and wheat.
Adults: about 1 in 25, or 4%, of adults have a diagnosable food allergy.
The most common adult food allergens are shellfish (shrimp, lobster, crab), peanut, tree nuts, and finned fish like salmon.
Do food allergies go away?
Most children eventually outgrow allergies to foods like milk, egg, wheat, and soy. Unfortunately, only about 20% of children will ever outgrow a peanut allergy, and only about 10% will outgrow a tree nut allergy. Currently there are no approved treatments for food allergy.
Are food allergies on the rise?
Yes, particularly to peanuts and tree nuts. Food allergy researchers are not sure why there is an increase. One explanation is the “hygiene hypothesis”, which suggests that our lives are too clean — the immune system is not busy fighting infections, so it inappropriately attacks foods and other things. Food allergies usually develop early in life, but can develop at any age. For instance, it is possible for an adult to develop a new food allergy to shrimp, even though he or she has eaten shrimp for decades.
There is also an increase in self-reported food allergy. A recent study1 showed that in children, 90% of foods were being avoided unnecessarily (even with a doctor’s diagnosis!). Other studies suggest that while 30% of adults say they have a food allergy, only about actually 4% do! While there is something real happening, it is probably not a “classic” IgE-style allergy that can be verified with testing.
Can food allergy be prevented?
We still do not know how to prevent food allergies. Recent research suggests that elimination diets (e.g. avoiding milk, egg, peanuts) during pregnancy, breastfeeding, and infancy may not reduce the risk of food allergy. The American Academy of Pediatrics (AAP, 2008) encourages exclusive breast feeding until age 4-6 months of age. At 4-6 months, parents may introduce solids, including milk, egg, soy, wheat, and even peanut, tree nuts, and seafood. These recommendations are a reversal from the AAP’s position in 2000, which suggested avoiding certain foods until certain ages (e.g. “no dairy until age 1″, “no nuts or seafood until age 3”). Many health care providers and internet sources still promote the outdated 2000 recommendations.
What is the best way to diagnose food allergies?
Board certified Allergists are trained to take a detailed clinical history and perform allergy testing. If the patient’s history suggests a food allergy, then testing is indicated. If the history is not consistent with food allergy, then food allergy testing may not be necessary. The reason for this: allergy testing carries the risk of a “false positive” result, where it incorrectly says you have an allergy. Therefore it is important to test only when indicated. Allergists can be particularly helpful when deciding who needs allergy testing, and interpreting the results.
Our current allergy tests have limitations, too. They cannot accurately predict the severity of the next food allergy reaction. They also cannot tell us how long a patient will be allergic to a particular food. A common myth says that “allergic reactions get worse each time”. The truth is that patients can have a potentially life-threatening reaction the very first time they react to a food. Some patients who have a serious reaction to a food may never react again.
Can food allergies be treated?
Currently, there is no treatment that eliminates food allergies. Instead, Allergists recommend strict avoidance of allergenic foods. Patients at risk for serious food allergy reactions (aka anaphylaxis) should carry an epinephrine auto-injector on hand at all times. Unlike simple antihistamines like Benadryl, epinephrine can be a life-saving medication, and should be used whenever there is concern for a serious food allergy reaction.
What is an Oral Food Challenge (OFC)?
If the clinical history and testing suggest the patient does not have a food allergy, this can be confirmed with an oral food challenge (OFC). In a controlled situation, the patient eats a small amount of the food. If there are no symptoms, then the patient is not allergic, and can eat the food. In the small chance there is a reaction, it confirms the diagnosis, and the patient is treated.
What is in store for the future?
Again, there are currently no FDA-approved treatments for food allergy. Food allergy researchers are hard at work, looking for methods to desensitize patients. The goal is to eliminate the allergy, or at a minimum, reduce the risk for serious allergic reactions. A Seattle-area consortium called SeaFAC has been formed to help research food allergy treatments.
Can patients with food allergies receive vaccines (shots)?
New research shows that most patients with egg allergy may receive the seasonal flu vaccine and MMR without special testing or precautions. In previous years we did not give the flu vaccine to patients with egg allergy — this may not be the case. Vaccines for yellow fever and rabies are still unsafe for patients with egg allergy.
The U.S. Food Allergen Labeling and Consumer Protection Act of 2004
This law requires food labels to clearly list the 8 most common food allergens:
milk, egg, peanut, tree nuts, soy, wheat, fish, and crustacean shellfish
Labeling is NOT required if the product “may contain trace amounts”, or is “prepared in the same facility”. These statements are at the discretion of the manufacturer.
What are helpful resources on food allergy?
Food Allergy Research and Education (FARE): www.foodallergy.org
The National Institute of Allergy and Infectious Diseases (NIAID), 2011 food allergy guidelines2.
1 Fleischer MD, and others. “Oral Food Challenges in Children with a Diagnosis of Food Allergy”. Journal of Pediatrics, April 2011.
What is sublingual immunotherapy?
For over 100 years, allergy shots (aka “immunotherapy”) have been a mainstay for allergy treatment. However, recently the FDA approved a new approach to immunotherapy called “sublingual” immunotherapy. Instead of receiving an injection, tablets are placed directly under the tongue.
How is SLIT different than regular allergy shots?
Sublingual immunotherapy, or SLIT, has several advantages over traditional allergy shots. First, there are no shots involved. Children certainly appreciate this part. Second, SLIT has been associated with significantly fewer reactions than traditional allergy shots. Therefore SLIT can be taken at home, work, or even while traveling.
Who is a candidate for SLIT?
Currently, the FDA has only approved SLIT for grass and ragweed pollen allergies. It has not been approved yet for other environmental allergies (pets, dust mite, mold, or tree pollen, etc.), but research is under way. Like with traditional allergy shots, we help patients avoid allergy triggers and maximize allergy medications before considering SLIT.
When can I start?
Typically patients take their first SLIT dose in the office, and are observed for any reactions. If all goes well, patients may then resume taking SLIT at home the next day.
How long do I take SLIT?
Research shows that patients may expect results from “co-seasonal” SLIT use. In other words, patients start treatment 2-3 months before the pollen season starts (e.g. January or February), continue through the pollen season, and then stop in early July. Patients would not require therapy again until the next season. Year-round therapy is also an option. Patients are expected to take SLIT in this way for a total of 4-5 years. Like with traditional allergy shots, missing SLIT doses may decrease the effect of the treatment.
What are common reactions to SLIT?
SLIT has not been associated with as many reactions as traditional allergy shots. The most common reaction to SLIT is tingling or itching under the tongue or in the mouth. In rare cases, patients may experience whole body itching, hives, swelling, or other symptoms. As a precaution in the event of a severe allergic reaction, patients are required to keep an epinephrine auto-injector (e.g. EpiPen, Auvi-Q) on hand while taking SLIT.
Allergy specialists have been providing and perfecting allergy shots — also called “immunotherapy” — for over a century. Allergy shots are usually the most natural and effective long-term treatment for common environmental allergies such as pollens, pets, and dust mites.
How do allergy shots work?
Using information from prick skin testing, each patient receives his or her own allergy shot prescription. Shots may include a combination of tree or grass pollen, pet dander, or dust mites, depending on the patient’s specific allergy profile. Shots start at miniscule doses, and get larger each time. By the time a patient is receiving the top dose — aka “maintenance dose” — the immune system no longer attacks those allergens. In fact, the immune system has been desensitized, or “reprogrammed”. Most patients respond well to shots, especially if there is a tree, grass, or weed pollen allergy. In fact, many patients no longer feel allergy symptoms at all.
How often do I have to come in?
Shots are usually 1-2 times per week at first, then gradually decrease to about 1 time per month. Due to the small risk of a reaction to allergy shots, we ask patients to wait in our office for 20-30 minutes after each injection. We have WiFi in our waiting room, so be sure to bring a laptop or your smart phone!
Do allergy shots work for other kinds of allergies?
Yes! Allergy shots are effective at treating potentially life-threatening allergies to bee stings (honey bees, wasps, and hornets). However, allergy shots have not been approved to treat food or medication allergies.
Hay Fever and Environmental Allergies
Hay fever and environmental allergies are common problems affecting millions of Americans each year. The term “rhinitis” is used to describe irritation or inflammation in the nose. “Conjunctivitis” means similar inflammation in the eyes. Common rhinitis and conjunctivitis symptoms include:
– Clear runny nose
– Nasal congestion
– Post-nasal drip
– Sneezing or Itching
– Red, watery, or swollen eyes
Common Allergy Triggers
In Western Washington, the most common outdoor allergies are to trees (especially alder and birch) and grasses. Trees pollinate from February-April, and grasses pollinate from mid-May to early July. Common indoor allergens include dogs,cats, and dust mites. Due to its cooler climate, Western Washington does not typically have elevated mold levels. If a home or building has excess moisture indoors, then mold and mildew can grow and release irritating chemicals. This problem is usually fixed by cleaning the mold and eliminating leaks or other sources of moisture.
Rhinitis and conjunctivitis can also be triggered by non-allergic factors like dust particles, cigarette smoke, strong odors, pollution, or even temperature changes. While symptoms resemble true allergies, Allergists call this condition “non-allergic rhinitis”.
The most reliable method for allergy testing is the prick skin test. The surface of the skin is lightly scratched or “pricked” with a small amount of a purified allergen, such as pet dander, pollen, or dust mites. Prick testing only takes 10-15 minutes, and gives us a reliable result there on the spot. Studies have shown that prick allergy testing is probably more reliable than blood allergy tests.
Once patients have been allergy tested, we can talk about allergen avoidance. Allergen avoidance means staying away to those things to which a patient is allergic. For example, it might mean keeping a pet out of your bedroom, or keeping a window closed during the pollen season.
If patients are unable to avoid allergens, then we use medications. Oral antihistamines are the most common treatment, followed by prescription nasal sprays and allergy eye drops.
If a patient’s allergies are still not under control, then we talk about allergy shots (aka “immunotherapy”).
Asthma is reported to affect over 20 million Americans. It is also the most common chronic disease of childhood. Asthma can be triggered by a number of factors including allergies, exercise, infections, cold air exposure, smoke exposure, and even stress.
Common Asthma Symptoms
– Coughing at night, cough with exercise, or cough when laughing
– Feeling short of breath
– A tight feeling in the chest
Several treatment options are available for patients with asthma. Our goal is for patients to lead normal, productive lives. Patients with well-controlled asthma should be able to sleep through the night, avoid asthma attacks, and have full participation in athletic activities.
An Allergist is a board-certified specialist trained in the diagnosis of asthma, allergies, and related conditions. An Allergist can take a complete asthma history, perform breathing testing, and even test to see if allergies are contributing to asthma.
When to see an Allergist
Consider seeing an Allergist if you experience any of the following:
– Breathing difficulties that interfere with daily activities
– Breathing problems decrease the quality of your life
– Asthma warning signs:
- shortness of breath
- wheezing or coughing, especially at night or after exercise
- tightness in the chest
- frequent attacks of breathlessness
For further reading about asthma, please visit the American College of Asthma, Allergy and Immunology.