Thursday, September 9, 2010
Smarty Sponsor: Davie Allergy & Asthma Clinic
By Dr. Richard Herring, Davie Allergy & Asthma Clinic
When we think of fall, we think of back to school, football games, spending time outdoors in cool weather, playing in the leaves. But all of this can be interrupted if you or your child is one of over 35 million Americans who suffer from seasonal allergies or asthma. Hay fever symptoms of runny nose, congestion, and itchiness can make one miserable, while asthma can be a significant limiting factor in everyday activities. Before you decide to stay indoors during one the most difficult allergy seasons, there are some important steps you can take to pinpoint specific triggers and minimize discomfort.
The main culprits during the fall are ragweed, other weed pollens, multiple molds, and dust mites (the most common allergy worldwide). Ragweed is a common allergy that usually appears from the time school starts until the first hard frost, or around Thanksgiving. It can be difficult to avoid since pollen grains have been known to be carried well over 300 miles by the wind. Other weeds pollinate during the fall and in late summer. Outdoor molds increase in fallen leaves and vegetation in the fall and can be worse after an especially rainy summer. Dust mites in our homes are typically a year round allergen, but their numbers can peak during the fall in our climate. In a survey of U.S. homes, approximately one-quarter had levels of dust mite allergens present at a level high enough to trigger asthma symptoms. Fortunately for allergy sufferers, dust mite numbers could at least decrease in the winter when the humidity naturally decreases, since they rely on higher humidity to survive. Cat and dog dander can also add to the overall severity of allergies and asthma throughout the year.
Testing for specific allergies is a first step in identifying triggers of asthma and hay fever. About 23 million people, including almost 7 million children, have asthma. About 70-80% of asthmatics also have allergies which can play a role in worsening their lung function. Asthma may present as shortness of breath, difficulty with exertion, or chronic cough which can often worsen at night. These are common signs for kids. Skin testing by an allergist is still the best method of testing since allergy blood tests alone can miss specific allergies. Knowledge of specific triggers allows one to focus on appropriate avoidance measures. One may then consider discussing with their physician whether only seasonal use of allergy and asthma medications would be safe. This can help reduce medication exposure and save money.
Treatment first consists of avoidance. It sounds difficult to avoid pollens but some recommendations include closing your windows on humid and windy days when pollen counts are higher, showering after being outdoors to wash away pollen that has collected on your skin and hair, and wearing a facemask when working outdoors to limit the amount of pollen you inhale. This is also helpful to avoid mold spore exposure. Cats and dogs are common causes of allergies but can also bring in pollen from outdoors. If your pet does not mind getting rinsed off, this might help reduce exposure on high pollen days. Rinsing will also help wash away some of your pet’s natural dander. There are also measures that can be taken to minimize dust mite exposure, especially in areas where we sleep.
Taking non-sedating antihistamines such as Claritin or Zyrtec may help in addition to topical nasal steroid sprays such as Flonase or Nasonex which require a prescription. There are multiple newer medications of these types available. Prescription eye drops can treat itchy eyes. Some asthmatics might benefit from inhaled steroids and other medications such as Singulair, which can also help reduce nasal symptoms. These medications reduce inflammation with minimal to no absorption of steroid.
Another form of therapy is individualized immunotherapy, which is a longer term solution over the course of about 5 years, but is effective for 85% of those who undergo treatment. This involves injections of very small but increasing amounts of the correct allergens over time and it differs for each individual. This approach actually changes the immune system so that allergic reactions become less severe or do not occur at all. One can expect to benefit for more than 10 years after this form of therapy.
Allergies and asthma can have a huge impact on quality of life. Of note, 13 million school days are missed each year due to asthma. So getting tested is beneficial since it allows for avoidance of specific allergy triggers and leads to the most appropriate treatment. It can be the first step to making the most of this fall and also this spring, and to feeling better and living better. 
Dr. Richard Herring is the head doctor at Davie Allergy & Asthma Clinic. The office is located at 108 Dornach Way (Suite 200) in Advance (near Tanglewood Park). Phone: (336) 998-3833. Its Allergy Shot Hours are Monday - Friday from 8:10AM - 4:30PM. Regular Office Hours are Monday - Friday 8:10AM - 12:00PM & 1:00PM - 4:40PM.
Do you have a question for Dr. Herring about allergies? If so, post your question below in the comment section and he'll reply with an answer!
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16 comments:
Both of my children have had runny noses and a cough for the past week, but nothing severe. Is there a secret to telling whether these are colds or allergies?
Is there a certain age when asthma symptoms should already have occured? I am crious because my dauighter is eleven. She has never had problems in the past, but seems to be showing some of these symptoms this season. I can't believe that they would just now show up after 11 years.
I am NOT a doctor, but according to my sis-in-law, who developed venom allergies (bees, not snakes) at age 40, her doctor says you can develop an allergy at any time.
Dear Jeannette,
Your question about colds vs allergies is a very good one, partly because prolonged allergies can feel just like a cold. One main difference is the duration. A cold may last anywhere from 1 to 2 weeks while allergies will last longer if untreated. Unfortunately, there is not a good test to tell the difference right now, but if symptoms persist, then allergies become more likely.
How young is too young to have a child tested for different types of allergies? I think my 5 year old may have both indoor and outdoor allergies, but would love to know specifically what is triggering it.
Catherine,
Thank you for raising such a good question. This often comes up in practice as well. There is no absolute age when you would have expected to see asthma symptoms. Allergies usually become apparent during the first few decades of life so at any point you could develop new allergies and you could develop asthma. There are also some cases where patients do have poor lung function but do not notice it and they never say a word. If it continues, she might benefit from a formal evaluation which would also include a lung function test. Do her symptoms usually occur with exertion?
In response to the comment about bee venom allergies. It is true that you can develop an allergy at any time. This becomes less likely in the elderly though. Regarding your sis-in-law's allergy, bee sting allergy itself responds very well to venom immunotherapy (allergy injections), which decreases the chance of a future severe allergic reaction by 95-97%. I always advise bee sting allergic patients to get tested and get treated since the therapy is so efficacious and can be life saving.
Dear Amy,
This is also a good question regarding how young can you test for allergies. I have allergy tested babies as young as 4 to 5 months, which is usually for food related eczema at that age. It is reasonable to test for inhalant allergens as young as 2 years old since they have had time to be exposed to seasonal allergens more than once. There are times when you can test earlier than this such as when indoor allergens (dust mites, cat, dog, etc.) are the suspected culprits or with eczema or food allergy as mentioned before. So, yes, a five year old can easily be tested, which for children involves skin prick testing. This is a method that does not involve needles, but a simple skin prick with a special device. This test is well tolerated by young children. We see patients of all ages in our clinic and would be happy to help in any way.
The complete picture contains another option to build tolerance is sublingual immunotherapy aka allergy drops. Based on the same science as injections and endorsed by the World Health Organization, they not quite as effective as shots but overall better as shots have an 80% dropout rate because of the pain and hassle. Allergists all over the US over them and they are available otc/online from Canada (full disclosure here) from us. They are Europe's number one treatment for allergies.
Jim,
Thank you for bringing up sublingual allergy treatments. The efficacy and safety of this method has yet to be fully determined. It has been used in the US but is not approved by the FDA and has not been endorsed by the American Academy of Allergy, Asthma, and Immunology. As a result, I am not aware of insurance coverage for this treatment. It is unfortunate that results so far have shown that this is not as effective as injections (Journal of Allergy and Clinical Immunology, 2007: 6: 1466-1468). This same study showed that 38% of studies found no significant benefit from this type of therapy. One concerning note is that there have been allergic reactions to sublingual therapy which raises obvious safety questions when patients are taking this treatment at home. This is something that has been tried in Europe with mixed results. It is thought that it might be more effective when you are allergic to one or two allergens such as just ragweed. Unfortunately, in the US, you are more likely to be allergic to multiple allergens and so this is less likely to be effective. As far as the 80% drop out rate, in my years of clinical practice, I have not observed this and I think this might be related to old data. Hopefully, this treatment method will improve and we can offer it as a very effective treatment for allergies someday, but right now the evidence and data do not support its use on a wide scale due to much lower efficacy and also safety concerns.
Thank you for your answer! I honestly cannot say I have watched these symptoms closely enough since I work full time. I am going to make a point to do so over the next few weeks and we may be calling you for an appointment!
I had severe allergies and was treated with immunotherapy (allergy shots) . It absolutely changed my life. I would not say that it was "painful or a hassle." The pain and inconvenience for me was the chronic sinus infections, sneezing, coughing, etc. from my allergies before the shots. Today, I no longer take shots and barely ever take an otc medication for my allergies. Before you decide (or don't decide) to go with allergy shots, talk with your actual primary care physician or allergist. If you read about "allergy drops" you will see that they are not considered safe, not covered by insurance, and something like less than 40% of people are still using them in Europe. And by the way, if you are looking for a great adult or pediatric allergist, I would recommend Dr. Herring.
Catherine,
We would be happy to see your daughter anytime. We strive to see patients within a week and often same day or next day. We are located about a mile from the entrance to Tanglewood Park in the Davie Dermatology building. Thank you for your questions and comments!
I have been giving my son allergy drops for 1 year and have found them to be very effective. I was skeptical so googled for clinical data of sublingual immunotherapy. There are tonnes of data proving the efficacy and safety of sublingual allergy drops. And the safety profile is good and in some studies, actually better than shots.
http://onlinelibrary.wiley.com/doi/10.1034/j.1398-9995.2001.00181.x/abstract
http://www.aaacr.com/subling.html
http://www.amsl.com.au/products/index.php?divisionid=5&productcategoryid=33&productid=64 My son hates needles so for us it was the best choice. He has now almost completely come off of his inhalers and rarely uses his emergency inhaler (ventolin). Incidentally, it is not FDA approved, but is widely available through ENT doctors who use it 'off label'. In my opinion, it is a matter of time before sublingual becomes the accepted route of choice.
In case anyone is looking for a great allergist, I wanted to give a firsthand recommendation for Dr. Herring. I took my 15 mo daughter to see Dr. Herring and was so pleased by the time he took with us and the help he gave. We had visited a large allergy practice already and were so frustrated by the experience - this was a welcome change! Dr. Herring helped us feel less anxious about my daughter's food allergies, and he gave us coping strategies that have eased our stress significantly. I would highly recommend the practice, even for the youngest patients!
Anonymous (sept 13),
Thank you for your comments. I'm glad your child is better. I wish I had had more space in the original article for this topic, because it can be a long one. The hope is that soon allergists will be offering this as a very effective form of therapy to some patients on a wide scale. It would especially be great for young children, or those with needle phobias. I would rather have this as an option for these patients, even if it has been shown to be less effective than injections overall. Unfortunately, I have met a number of patients who have tried the drops and are coming to me for help.
I am always following this in the literature and with internationally known allergists in the field. What needs to be sorted out soon is an established effective starting and maintenance dose for each allergen as well as multiple other factors. Most success has been in Europe where you are likely to have fewer specific allergies. To date, only one study tried to compare single allergen drops to multiallergen drops and it lacked statistical power, but suggested that multiallergen drops might not be as effective. More studies are obviously needed. Prior to this, there were no studies on using more than 2 allergen mixes (http://www.aaaai.org/patients/jaci/content.asp?contentid=8805). Our climate here is different in that there is exposure to multiple allergens (more than in Europe). Most allergy patients in the US and especially in NC have multiple allergen sensitivities. It seems unlikely based on the data that most people with multiple allergies would have a more favorable response to drops. But stay tuned because this is could change in the coming years.
The safety of drops has recently been brought into question and this will need to be followed. Drops are also not without side effects. There will be reactions that might occur locally in the gut (drops) or the arm (injections), or systemically (both forms). Your first reference from Europe covers this also.
In the end, there are multiple factors to consider. The success of drops is certainly more limited, but that might depend on the climate you live in and each individual's allergy profile. A good reference is www.aaaai.org.
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