Allergies cause a wide range of symptoms, from the common problems that everyone has heard of such as a runny nose, nasal congestion, sneezing; watery, itchy, red eyes; and itchy ears, to less obvious problems like a tickle in the throat, cough, asthma, wheezing, shortness of breath, hives, eczema, bee sting reactions, and so forth. Fatigue is also common in allergy season. The older antihistamines which cause drowsiness didn't help with fatigue but now the newer antihistamines generally don't cause drowsiness.
People develop allergy problems because of an overactive immune system in which certain gamma globulins are overproduced by the body. Gamma globulins are normally present to fight bacterial infections. In the case of allergies, one of the gamma globulins (called IgE) functions abnormally and views the allergens (e.g. cat dander) as being a foreign bacteria - so the IgE attempts to "kill" it. When IgE attaches to the pollen, a barrage of chemicals including histamine are released into the body from cells called Mast cells, and as a result patients are left with allergic symptoms.
Most people think that allergists only deal with allergy problems, but as you can see from the information contained in this website, we deal with a lot of other problems including sinusitis, asthma, hives, and so forth. Just because you go to see an allergist, it doesn't mean that you necessarily will get treated just for "allergy" problems, especially if you have other kinds of problems that are bothering you, like sinusitis. It also doesn't necessarily mean that you'll get allergy tested. There are many other things that allergists can do to help you in addition to doing allergy testing.
Typically your history of allergy problems is the most important thing that a doctor evaluates in an allergy evaluation, and a good allergist will spend a lot of time going through your history. After doing a careful evaluation, including a physical exam, your allergist will discuss treatment and possibly performing various tests which we'll talk about later. There are a variety of treatments and medications which we can suggest to help you. The most important thing to do in treating allergy problems is avoidance of the allergens that commonly cause problems. First we'll discuss environmental problems.
The most common environmental agents causing problems with allergies include: Dust, dust mites (microscopic bugs that exist in dust), mold, animals, pollen and cockroach.
Dust seems to be everywhere. Dust mites are in dust and reproduce in mattresses, pillows, carpeting and over-stuffed furniture. Mattresses and pillows should be covered with a special fabric which is impervious to the dust mite. Sheets, pillows and blankets should be washed weekly in hot water. There are also some special chemical treatments (Acarosan, Allergex, ADS, etc.) which will kill or denature the dust mite. Masks are helpful with unavoidable exposures to allergens. Stuffed animals and toys can be a problem for kids.
Rooms should be cleaned regularly, preferably not by the patient. Special vacuums are now available which contain HEPA filters (e.g. Nilfisk). These are special filters which are excellent at cleaning the air which comes out of the vacuum cleaner. Rooms should be cleaned with a damp cloth frequently, but remember vacuuming and dusting may raise ambient air dust levels for a period of time, consequently the allergy sufferer may need to avoid being in the room for a period of time. Covering the vents in the bedroom if you have a forced air heating system is often helpful because less dust blows out. Air filters are helpful (HEPA are best, e.g. the Honeywell Enviracaire).
Anyone who is allergic should eliminate carpeting (which traps everything) from the bedroom in order to create what we call an "allergic oasis". The ideal bedroom consists of a wooden or steel bed with a mattress and pillow (non-feather, of course, if you are allergic to feathers) covered with an allergy proof mattress and pillow cover, cotton sheets and a blanket which is washed weekly in hot water, wooden or tile floors, and shades on the windows. Nothing else (no furniture, clothes or knick knacks). Now that you've said NOT, I'll tell you that almost nobody goes that far, but it's important to understand the maximal amount that can be done. It is important to minimize dust catchers such as drapes, pictures, and odds and ends.
Mold (or mildew) smells musty and commonly grows in damp areas including underneath refrigerators, inside air conditioners, in damp (i.e. humidity > 50%) basements, barns, in old books and under piles of leaves. If you can smell it, it is guaranteed to be a problem. Mold is the black stuff that you'll also find in bathrooms near the shower. Mold also grows in damp soil, so house plants can be a problem for allergy sufferers. Fungicides can help with mold control, but it's important to limit the amount of dampness by controlling the humidity and any water source as well as using dehumidifiers and air conditioning when necessary. Occasionally it is necessary to do mold cultures to determine what molds are in your house. These are ideally done by someone familiar with environmental problems around the house.
Older homes are much more of a problem, as there are more likely to be problems with leaky roofs or problems with plumbing. If the basement does not have an adequate vapor barrier, it is often possible for a water to get into the basement, especially when it rains.
Mold requires a food and water source. Sheetrock is fine for them, so in the usual home, they just need a water source to grow. There have recently been an increasing number of problems, some of which are starting to be publicized in the news media. Molds such as Aspergillus or Stachybotris can make people very sick, either from toxins or from allergies. We also think that more exposure to them can cause people to develop sinusitis.
It is very important to carefully resolve any water problems that you have, either at home or at work so that you can avoid future problems. ( Schools are also a major problem.)
Animal dander, (particularly cats and dogs), is an important source of symptoms for many people, but guinea pigs, birds, horses, and cattle as well as down, wool and anything else with hair or fur can be a problem. The best advise for anyone with an animal that they are allergic to is to get rid of it, but most allergists try to be practical: If patients won't get rid of their animals, we can suggest medications and avoidance like keeping animals out of the bedroom if patients refuse to get rid of their animals. Some people have found that washing their cat and/or dog is helpful. Allergy shots have also been shown to be helpful with cat allergies ( See below.)
Pollen is another common allergen usually divided into three categories: Trees, grasses and weeds. Depending on what area of the country you live in, early in the spring, tree pollen comes out, followed by grass pollen later in the spring and early summer, and finally weeds in the late summer and early fall. In some of the warmer areas of the country grass pollen may be present year round.
Pollen counts can be a helpful indicator if you know you have problems with a specific antigen (e.g. trees), but they aren't necessarily reflective of the pollen counts outside your door- pollen counts tend to be highest on dry windy days and early in the morning. Pollen counts drop after it rains because pollen gets washed out of the air-better to go for a run in the park after it rains in the afternoon than on dry windy days early in the morning. Windows should fit tightly and be kept closed in pollen season. Air conditioners and air filters should be left on. In addition during the pollen season animals in the household may get pollen in their fur when outside and bring it inside, so you may need to wash their coat off. You can get pollen counts from 1-800-9-POLLEN (The National Allergy Bureau).
Cockroaches are a major source of allergen in cities, and is a important factor in asthma. The problem with cockroaches is from the roach, and the egg casing, as well as fecal material. It is important to eliminate cockroaches from the environment by using bait or an exterminator - remember though that some people may be sensitive to the chemicals that exterminators use. It is also important to not allow roaches to get into the house. Extermination may kill the roach, but it doesn't get rid of the allergen which is there.
Tobacco smoke and chemicals like perfume, paint fumes, gasoline, insecticides, bleaches, etc. often make allergies worse because they are irritants. People are more commonly sensitive rather than allergic to them. The important thing is that they need to be avoided.
Foods are occasionally a problem, but treatment of food allergies remains controversial. Food allergies tend to occur more commonly in childhood, and tend to lessen as kids get older. They can cause a variety of problems from eczema to asthma; whether they cause problems with hyperactivity is a subject of great debate. There is a group of physicians called clinical ecologists who believe that food and chemicals cause a wide variety of symptoms, from hypersensitivity to depression, whereas most traditional allergists do not believe they cause that many problems. This forum is not one to address the issues other than to say that disagreement occurs.
Other Medical Problems
Occasionally other medical diseases (e.g. pregnancy or thyroid problems) will cause allergy-like symptoms, so its often important for an allergist to be aware of other medical problems which you may have.
There are a variety of different medications available now for treatment of allergy problems. Antihistamines block the action of histamine, which is released when you are exposed to an allergen. The older over the counter antihistamines generally may cause drowsiness or difficulty operating a motor vehicle. It can be analogous to driving under the influence of alcohol.
The newer antihistamines which are now available by prescription generally do not cause drowsiness and include Allegra, Clarinex, and Zyrtec. Claritin also does not cause drowsiness and is now available over the counter. Most are also available combined with a decongestant.
They typically need to be taken once or twice a day. Antihistamines help with most allergy symptoms, but should ideally be taken before symptoms occur, since they work better that way. Although antihistamines block the action of histamine, they do not reduce the amount of histamine produced, so it is very easy for the body to be overwhelmed by exposure to large amounts of allergen.
Another antihistamine, Semprex-D works very quickly but doesn't last long and is more likely to cause drowsiness. It is only available combined with a decongestant. There is also available an antihistamine nasal spray, Astelin. It can be very effective for nasal allergies, but it causes drowsiness in a large percentage of individuals, similar to the older antihistamines. It also tastes terrible to some people, but that problem can be reduced by leaning forward while using it and not sniffing while spraying.
Decongestant nasal sprays are discussed in the section below. Several oral decongestants, e.g. pseudoephedrine (Sudafed) are available which reduce nasal stuffiness. Most are combined with antihistamines, mucus thinners, or in over-the-counter combinations with antiinflamatory drugs such as aspirin. These may be marketed as "sinus" medications.
A variety of nasal sprays are used to treat allergy problems. Over-the-counter nasal sprays such as Neosynephrine and Afrin can be used for short periods of time, but because they work by shrinking the tissues, patients will often have a rebound afterwards and require more frequent usage. They then become more congested. As a result they should not be used for more than several days, and only as frequently as indicated.
Nasalcrom (cromolyn sodium), which is over-the-counter, works by stabilizing Mast cells that release histamine and other chemicals. It is very safe, but often will not be as effective as some of the stronger nasal sprays. In addition, it works much better if used before exposure.
Cortisone nasal sprays (Nasonex, Vancenase, Beconase, Rhinocort, Nasacort, Flonase, Nasalide, and Nasarel) all contain small amounts of cortisone. They come either as a spray (sometimes indicated by an AQ or Aqua after the name) or an aerosol, and must initially be used anywhere from once a day to three times a day. The aerosols are being phased out. After a while, we find that many patients only need to take them a few times per week. In general there are very few side effects from using the cortisone nasal sprays, unlike taking cortisone by mouth which can have severe side effects.
Nasal sprays tend to help with itchy or runny noses. They tend to not work as well by themselves for colored or thick mucus (which often may be due to a sinusitis) or a stuffy nose (which may be due to a deviated septum, polyps or other anatomical problem). A newer nasal spray, Atrovent, is also very helpful for reducing the amount of nasal mucus, including from the common cold, but can cause dryness.
Salt water nasal sprays (Ocean, Ayr, Nasal, Salinex and others) are often helpful for moistening the nose and clearing out the nose.
Eye drops are very helpful in reducing symptoms of itchy, red, burning eyes, but caution does need to be used in treatment with over-the-counter eye drops, as they can stop working and have some side effects like the over the counter nasal sprays. Several eye drops are available by prescription which are very helpful including the antihistamines: Emadine, and Livostin, the cell stabilizers: Alocril, Alomide, Alamast, and Crolom, the dual action medications: Patanol, Optivar, Elestat,and Zaditor and the nonsteroidals: Acular, Profenal and Voltaren. Cortisone eye drops can also be used but should be monitored by an ophthalmologist to check for glaucoma and cataracts.
Oral cortisone (Prednisone, Medrol, and many others) is occasionally given for short periods of time, however, it must be watched carefully as numerous side effects occur. These side effects are unusual with short-term use, but can include ulcers, bone breakdown, infections, psychosis, fatty deposits, fluid retention, etc. Previously, injections of cortisone where given into the nose, but due to potential side effects, they are not usually used now. Occasionally, injections of cortisone may given into the buttocks, which may last for several weeks, but most physicians prefer to give cortisone by mouth in these circumstances.
When patients have allergies which may be due to environmental agents, foods, or several other agents, allergy skin tests can be very helpful in pinpointing the exact cause. Some allergists use blood (RAST) tests instead of skin tests. We won't go into all the reasons but most allergists like me think they are less reliable under most circumstances. There are a few exceptions: in patients with severe allergies, bad skin problems, the very young or old and those who can't stop antihistamines and some other medications, the blood tests may be helpful. (Antihistamines interfere with interpretation of the skin tests.) Blood tests are, however, much more expensive.
Typically patients have skin tests done with a variety of different agents which commonly cause allergies. These may include dust, dust mites, molds, trees, grasses, weeds, animal dander, cockroaches, foods, and the clinical ecologists may test with chemicals (which is controversial). If you have skin tests done, you may need to stop antihistamines and some other medications before your testing is done, because the antihistamines can make you less reactive to allergens.
Skin tests are usually performed by either pricking or scratching the skin with a needle after a small amount of a liquid extract of the agent to be tested has been placed on the skin (these liquid extracts are made by various allergy supply companies). After waiting a short period of time, the allergic reaction can be detected based on the size of the welt and the size of the redness at the site of the prick. This correlates well with respiratory allergies. In addition, intradermal tests may be done in which a small amount of the extract is injected just underneath the skin to form a small welt. The size of the reaction can then be used to determine whether an allergy exists.
Allergy testing for foods is similar to environmental agents, but most allergists do not give allergy shots for foods except on an investigational basis. Clinical ecologists do give food and chemical shots but it raises the hair of traditional allergists - As I discussed above - we'll avoid dealing with it. For the most part, avoidance of foods is suggested by traditional allergists, although some medications can be helpful.
Allergy shots are extremely helpful for reducing symptoms in patients who have continuing symptoms despite medication, fatigue due to allergies, who don't respond to medications or have complications like sinusitis. Allergy shots also are commonly preferred by patients who would rather not use drugs, as the shots are made of an extract of the very things that people are allergic to, e.g. dust mites, pollens, molds, etc. In addition, allergy shots have also been shown to be effective for people with cat allergies, but avoidance is still the best treatment for cat allergies. In addition, allergy shots do not replace the environmental controls discussed above.
If it is decided that allergy shots make sense, patients are given injections of the allergens which cause problems. The shots are less painful than a mosquito bite, and now we have creams that can numb the skin before getting the shot. Most patients can also use ice to numb the skin, if necessary. Believe me, you barely know you've gotten an injection. In general, shots are initially given once or twice a week. Each time the amount injected will be increased slightly until a maximum or maintenance dose is reached. Shots are generally continued with this frequency for anywhere from 3-12 months and then less frequently. Eventually, most patients take their shots only every 3-4 weeks.
In general, allergy shots may take months to a year or two to start working and patients should continue shots for at least 5 years. Because many patients will have a return of symptoms if they stop the shots, some patients will choose to continue them indefinitely. Allergy shots take a long time to work, so if you start on them, BE PATIENT. Most allergists (including me) don't like patients to self administer shots, as serious reactions can occur, so they should be given by a doctor. If you get shots, make sure that you tell the nurse or doctor about any reactions to the shots, any current illnesses and any medications that you're taking. And be sure to wait for 15 - 30 minutes in the office after the shots. Your doctor may also give you adrenalin to self inject in case you have a problem after you leave the office.
Frequently Asked Questions (FAQ's)
I heard about a new shot where people only have to take one or two shots and their allergies are cured?
You may have heard about one of several different things. For a long time, shots of cortisone have been available. These last for about six weeks and reduce allergy symptoms during that period of time. Unfortunately, there are same side effects with injected cortisone as there are if it is taken by mouth - they can be serious. But in addition, unlike oral cortisone, it cannot be stopped since it's already injected. Once it's injected, it is impossible to get rid of it for that same 6 week period.
The other is a potentially new form of allergy shot which is currently under investigation. The individual allergen (e.g. cat) is modified so that when injected, it does not cause an allergic reaction! As a result, more concentrated shots can be given. Typically, with a number of shots given over the course of a few years, the allergy sufferer can get relief of symptoms. These shots are not available yet.
There is also a new medication which is a shot which is called Xolair which blocks the action of IgE. It must be given every few weeks, and shortly after it is stopped, it stops working. It typically costs between $500 - $2000/ month. It was approved by the FDA for use in asthma, but it can also be used to treat allergys of all sorts both allergic rhinitis and food allergies including peanuts. There are special approval processes for this drug because of the expense. It can also be used at the same time as allergy shots. There are very few side effects from the drug, however there was a slight increase in the incidence of cancer in the clinical trials. There was no evidence that it was clearly from the Xolair, however.
Do allergies occur in families?
Allergies in general affect approximately 25% of the population. If one parent is allergic, there is roughly a 50% likelihood that the children of the parent will have allergies. If both parents are allergic, there is almost a 100% likelihood that the children will be allergic. Those symptoms can vary from eczema in childhood to hay fever and asthma later on.
What can be done to reduce the likelihood of a child having allergies?
One of the most important things that can be done is to breast feed for as long a time as possible. It is often said that cow's milk is made for baby cows, not baby humans. The reason is that cow's milk is highly allergenic to infants. The introduction of whole foods early in an infant's life will make the baby more likely to develop allergies later on. Introduction of allergenic whole foods such as milk, orange juice, eggs, etc. should be delayed to approximately one year of age. In addition, it has also been found that exposure to the dust mite early in life will significantly increase the amount of asthma. So much for carpets in kids rooms, which increase the exposure to dust mites! (My wife hates me to remind her of this)
How old do you have to be to get allergy tests or shots?
Although we like to wait until they are older, we will test infants for a limited number of items. We generally like to wait until kindergarten before starting kids on shots, but there are always exceptions.
Are there non-allergic pets?
Despite what you may have read about hairless cats or dogs not causing problems with allergies, because of the fact that the dander is what causes the problems, even hairless animals may be a problem. It is best to have non-mammals for pets.
Where can you go to avoid the pollen?
Try a desert island and make sure it's several hundred miles from civilization-pollen blows a long way.
Air filters are very helpful. We usually suggest a HEPA filter (e.g. Enviracaire by Honeywell) which must remove 99.97% of all particles .0003 mm in size. It is also somewhat helpful with pollutants which are a problem for patients with both allergies and asthma. I used the Enviracaire CPZ filter in my bedroom when painting was being done and could barely smell the paint. Air conditioners are very helpful in reducing dust, pollen and mold, but remember that the filter must be kept clean and dry, because dust and mold can accumulate.
What level should the humidity be?
If mold or dust mites are problems for you, the humidity should be <50%. But if sinusitis is a problem, then you may need a higher humidity. Is this confusing? of course it is, but that's why you need to see an allergist who knows what he or she is doing.
Patients who have serious reactions to stinging insects should have allergy tests done to determine if they are allergic to stinging insects. A small reaction at the site of a sting is not considered a significant reaction, but symptoms such as asthma, difficulty breathing, shortness of breath, or a drop in the blood pressure indicate an increased likelihood of having life threatening reactions with future stings. Hives in adults have also been shown to be a significant potential problem, but not in children.
One important thing to remember when removing a stinger from a bee sting ( honeybees leave their stinger in) is to remove it as soon as possible, as the longer the stinger is left in place, the more venom is injected by the stinger.
Patients who have these kinds of reactions are typically skin tested with stinging insects (which may take several hours). Skin testing is similar to the testing done for environmental agents. If skin testing shows that someone is allergic, they may be started on a series of shots to desensitize them to the various stinging insects to which they are allergic (bees, yellow jackets, white faced hornets, yellow hornets, wasps, and in some areas of the country, fire ants). Most patients need to continue shots for 3-5 years. In addition, they should also carry a special self injecting Adrenalin pen (Epipen or Anakit) for emergencies.
Patients who may be allergic to local anesthetics like Novocaine or Lidocaine can have skin testing done to determine if they are allergic. Most of the time the allergy is not to the local anesthetic but actually to the preservative contained in the anesthetic. It is usually possible to find at least one local anesthetic to which a patient is not allergic. Testing usually takes several hours and is similar to other allergy testing.
Antibiotics can cause a variety of allergic symptoms including rashes, asthma, fever, and hives as well as more severe life threatening reactions. Patients who have reactions to antibiotics may need to have allergy tests to determine if they are allergic.
Allergy testing is only available for a limited number of antibiotics. The tests are similar to environmental testing, but may take several hours. If a patient is allergic, desensitization procedures have been developed which can be used if other appropriate antibiotics are unavailable.
Allergies to latex are becoming increasingly common for reasons that are unclear. Latex allergy was unknown prior to the late 1980's, but it is now estimated that 6% of people may be allergic to latex.