May 21st, 2013
The mainstay of respiratory allergy diagnosis is skin prick testing and blood RAST testing for specific IgE to various inhalant allergens including dust mites, pets, pollens and mould spores. Many patients with typical nasal allergy symptoms of nasal itching, congestion, sneezing, profuse mucus production and eye irritation may blood test negative for allergy to common inhalant allergens with no specific IGE and negative skin prick tests. One would then diagnosed this as Non-allergic rhinitis and labelled these patients as having no allergies. However many do still have allergy related Eosinophil cells in their nasal mucus (called Non-allergic rhinitis with eosinophilia syndrome or NARES).
It is now well recognised that 40% of these NARES patients do still produce localised specific IgE in their nasal mucus to common inhalant allergens. This localised IgE produced remains in the nasal mucus and membranes and does not enter the systemic blood steam, so conventional allergy tests on blood and skin remain negative. They do however respond to allergy controlling antihistamines and steroid nasal sprays and may respond to desensitization immunotherapy to the offending allergens.
It should be possible to measure this specific IgE on a sample of nasal mucus, but at present this test is not yet commercially available.
Reference: Rondon C, Canto G, Blanca M. Local allergic rhinitis: A new entity, characterization and further studies. Curr Opin Allergy Clin Immunology 2010: 10 (1); 1-7
May 13th, 2013
The most effective treatment for acute life threatening anaphylaxis is an intra-muscular injection of adrenalin (epinephrine). Research shows that the available auto- injectors are expensive, often under-utilised and more than often, the wrong dose is given. Three products compete are on the UK fixed-dose adrenalin injector market: Epipen, Anapen and Jext.
The market leader being – Epipen 300mcg (for adults) and Epipen 150mcg (for children over 30kg). However, research shows that the adult Epipen may be too weak for an average adult (over 60kg) and the children’s standard auto-injector dose is too strong to give to a child under 15kg (or less than 3 years old).
But there are three versions of Anapen, one contains 500mcg adrenalin for adults over 60kg, a 300mcg for children and adults over 30kg (over 8 years old) and also a 150mg for children weighing 15kg to 30kg (under 6 years old)
The third product that I recently discovered is called Jext, with two formulations: 300mcg for adults and 150mcg for children. The Jext auto-injector has a 24 month shelf-life as opposed to 12 months for Epipen’s and Anapen’s.
So why are most anaphylaxis sufferers prescribed an Epipen (or two)? That’s because old habits die hard!
Reference: Nowak R, Farrar JR, Brenner BE et al, Customizing anaphylaxis guidelines for emergency medicine. J Emergency Med 2013 (13) 102-109.
April 17th, 2013
Isolated Angioedema is quite common in middle aged post-menopausal women and initially presents with facial swelling (eyelid, lip and tongue) and then may progress to affect other soft tissues in the throat, armpits and genital area. Tongue and laryngeal angioedema are potentially life-threatening . Many cases are not associated with urticaria or hives and on testing, no obvious cause is ever found.
A low level complement C4 (less than 12) in the blood is a good screening test for the Hereditary form of Angioedema (where there is usually a family history of facial swelling and deficiency of C1 Esterase Inhibitor in the Complement system). Salicylic acid, aspirin and the non –steroidal anti-inflammatory medications such as ibuprofen and diclofenac are another potential triggers for isolated angioedema as are the first generation ACE inhibitor blood pressure medications such as ramipril, perindopril, enalapril and lisinopril, which cause accumulation of bradykinin pro-inflammatory mediators.
Angioedema can be further be subdivided into “Histaminergic” Angioedema (cases that respond promptly to antihistamines and oral steroids) and “Non –Histaminergic” Angioedema (those reculcitrant cases that do not respond to antihistamine and steroid medication). The Non-Histaminergic patients can be very difficult to treat, and often have to go onto androgenic (male) hormones such as danazol, stranazol but may occasionally respond to pro-clotting Tranexamic acid (also use to treat heavy periods).
A recent published medical study has shown a very impressive response to progestagen hormones such as noresthisterone and even the “progesterone only” oral contraceptive. A single dose of Depo Provera injected every 3 months was effective in controlling angioedema in 82% of study cases – which is a phenomenal response for this troublesome and potentially life-threatening condition.
Reference: Saule C, Boccon-Gibod I, Fain O et al. Benefits of progestin contracepion in non-allergic angioedema. Clinical and Experimental Allergy April 2013
March 18th, 2013
There has been an increase in the diagnosis of Eosionophilic Oesophagitis recently, possibly because we are becoming more aware and biopsying children and young adults with reflux and oesophagitis. This condition presents with difficulty swallowing food, choking and regurgiation often not responding to antacids. In children it is brought on by a delayed hypersensitivity to certain foods such as cows milk protein, wheat , soy and eggs. In young adults it can also be brought on by swallowing grass pollen in the saliva, but confirmation testing is difficult as it seems to be a delayed non-IgE mediated hypersensitivity. The treatment is to use an asthma preventer spray containing the steroid beclomethasone which is then sprayed into the mouth and swallowed into the oesophagus.
February 12th, 2013
Many allergy sufferers note increasing symptoms of eye irritation, nasal comngestion, itchy eczema and even respiratory wheeze when exposed to high levels of chlorine in swimming pools. Although not a recognised allergen, chlorinated water (particularly in indoor swimming pools) may cause allergy-like symptoms when high levels are encountered in the water and surrounding air. Irritant contact eczema and lung irritation may be a delayed Type 4 hypersensitivity. Eye lid and conjunctival symptoms can be exacerbated by rubbing which causes further contact irritation, eczema and conjunctival chemosis. After swimming, wash thoroughly with fresh water, and apply plenty of skin moisturiser after swimming. Public swimming pools should be routinely checked to ensure chlorine in water remain at acceptable levels.
Bernard A. Voisin.c, and Sardella A (2011). Respiratory risks associated with chlorinated swimming pools: a complex pattern of exposure and effects. Am J Respr Crit Care Med 2011
January 15th, 2013
An Australian study by Prof Bardin at Monarsh Medical Centre has brought to light the prospect of applying Botox gel to the inside of the nose to treat hay fever. The application of Botox gel lasts up to 90 days and blocks the nerve supply to the nose. These nerves promote inflammation, sneezing, itching and mucus production which are so problematic in hay fever. Botox temporarily prevents the nerves from causing these distressing effects. Prof Bardin reported that 80% of patients also experienced an improvement in their asthma. This treatment is still undergoing evaluation and is not commercially available yet.
January 15th, 2013
Salbutamol (and salmeterol) reliever inhalers are the corner-stone of acute asthma treatment in children. But recent research in the UK has revealed that 1-in-7 asthmatic children do not respond to their “blue” salbutamol (or Ventolin) asthma-relieving inhalers. This is due to a genetic mutation that prevents them developing a specific receptor in their airways that attaches to the salbutamol molecule to allow it’s life saving bronchodilator action. This results in worstening asthma and frequent hospitalisation. These children do however respond to another asthma treatment in pill-form called Montelukast (or Singulair).
A simple gene test on a sample of saliva taken from the mouth can be be used to check if the gene for this salbutamol receptor is present or whether the mutation causing a lack of this preceptor has occured. This way children can be tested to see if their asthma should be treated with salbutamol and salmeterol inhalers or by the montelukast tablet as an alternative therapy. This genetic mutation is a treatment dilemma in children but unlikely to be a problem in adult-onset asthma.
Reference: Prof Mukhopadhyay Brighton and Sussex Medical School
November 17th, 2012
Clinical trials are underway to assess the effect of Omalizumab (Xolair) in treating Chronic Spontaneous Urticaria otherwise known as Chronic Idiopathic Urticaria. Omalizumab is a recombinant human monoclonal antibody that binds to IgE preventing it from attaching to the surface of airway mast cells and basophils and currently licenced for use in treating allergic asthma. By the same action, if IgE can be prevented from binding to skin mast cells and basophils in chronic urticaria, then these cells are less likely to release pro-inflammatory mediators that trigger the typical wheal and flare reaction so problematic in chronic urticaria.
October 9th, 2012
“Burning Mouth Syndrome” is a chronic debilitating sensation of oral pain (orodynia), described as “a scalded sensation of the mouth” and associated with a bitter taste (dysgeusia) and a sensation of mouth dryness. It may occur in up to 30% of menopausal women, and is now thought to be a neurological condition and not psychological as previously suggested, but may lead to anxiety and depression. Other symptoms may include symptom aggravation by specific foods, a geographical tongue, bad breath, difficulty swallowing, excessive saliva and tongue ulcers. Food allergies don’t usually play a significant role but should be considered (Oral Allergy Syndrome) and the condition can be very difficult to successfully treat. Mangement may include cognitive behaviour therapy and topical treatments such as local anaesthetic oral rinses or gels, topical capsaicin, low-dose amitriptyline, low-dose benzodiazepines, gabapentin and hormone replacement therapy.
Burning Mouth Syndrome reference
October 1st, 2012
The epidemic of childhood allergy has been mirrored in an increasing global predisposition to Vitamin D deficiency. While, specifically childhood asthma has more closely been linked to low levels of Vitamin D in recent medical research. This problem has become increasingly apparent with the advent of routine Vitamin D blood testing. In the UK, the bone disease Rickets, caused by a lack of Vitamin D in children, has started to reappear and this may in part be due to an aversion to sun exposure caused by skin cancer prevention campaigns, an obsession with sun blockers and a more sedentary indoor childhood lifestyle at the helm of the computer games console. These lifestyle changes are a deterent to outdoor sports, school field trips and just enjoying playing outside in the sunshine . Vitamin D can be substituted by taking a weekly dose of calciferol, but somehow good old fashioned sunshine sounds more natural.
September 9th, 2012
Clinical studies suggest that supplementing Omega 3 fatty acids in pregnancy and whilst breastfeeding promote immune development and reduce development of allergies and eczema in infants. A recent study suggests that a window of opportunity exists during pregnancy and in the first 6 months of life, after which omega 3 fatty acid supplementation doesn’t seem to have any positive impact on allergies. Fish oil supplementation and breastfeeding seem to reduce allergic sensitisation, allergy development and eczema in infancy. At this stage it is not clear how much fish oil needs to be supplemented in pregnancy and infancy. Supplementing 650mg daily was used in the study (expressing capsules containing 280mg DHA and 110mg EPA)).
Prescott et al. Fish oil supplementation in early infancy modulates developing infant immune responses. Clinical & Experimemtal Allergy 2012 (42) 1206-1216
September 4th, 2012
Food Protein-Induced Enterocolitis Syndrome (FPIES) is a non-IgE mediated delayed hypersensitivity to food. It presents in infancy usually under 9 months of age and spontaneously resolves within 2 years and is often confused with infantile colic, gastroenteritis or septicaemia. Typical features include vomiting, pallor, lethargy and diarrhoea. These attacks tend to occur about 2 hours after certain feeds. The most common trigger is cow’s milk protein (cows milk protein intolerance CMPI), which is implicated in 65% of all cases, other foods less often implicated include egg, grains, soy, fish and banana. Symptoms are usually reproducible after ingesting the trigger food and diagnosis is made on a positive food challenge test. There are no accurate diagnostic skin or blood tests, but infants with this condition usually have inflammatory eosinophil and neutrophil cells in their stool sample as well as gastric juices during an attack.
Miceli Sopo et al. A multicentre retrospective study of 66 Italian children with food protein-induced enterocolitis syndrome: different management for different phenotypes. Clinical & Experimental Allergy 2012 (42) 1257-1265
September 1st, 2012
Mounting evidence shows that children with eczema do not produce enough essential Fillagrin “glue” that binds the skin Corneocyte cells together in the Stratum Corneum and so prevent irritant chemicals and environmental allergens from penetrating the superficial barrier layers of their skin. Chemical irritants and protein allergens must break through the top layer of the skin to set off an allergic reaction or inflame stable eczema. There is an inherited defect in the skin cells of eczema-prone famiies which reduces the amount of this essential Fillagrin “glue” produced and which is so important for binding skin epithelial cells together and thus preventing infiltration of allergens. Consequently the mainstay of eczema control should be to protect vulnerable skin areas as much as possible with plenty of preservative-free barrier creams, emulsifying ointments and emollients.
August 24th, 2012
Urticaria is a common condition in both adults and also children. The exact cause often remains unclear and antihistamines remain the mainstay of current treatment in most cases. Acute spontaneous urticaria is more common in children, being of short duration (less than 6 weeks) and usually caused by an underlying viral infection and not due to food allergies as is commonly suspected on initial presentation. While chronic spontaneous urticaria (lasting more than 6 weeks) is very often due to an underlying auto-immune condition mediated by functional autoantibodies, these may be difficult to identify on testing. The authors acknowledge the urgent need for more effective treatment for chronic urticaria.
Childhood urticaria. Current Opinion Allergy Clin Immunol. 2012 Jul 20
August 20th, 2012
A small nasal filter (Sanispira) which fits into the nostrils was shown to be very effective in reducing hay fever symptoms during the peak pollen season last year, This was shown in a group of Italian hay fever sufferers confirmed to be grass pollen allergic on both RAST and skin prick test. The nasal filter users required less rescue antihistamine medication and had fewer symptoms during pollen peaks than non-users. These nasal filters may represent an effective therapeutic option for patients, especially those reluctant to take medication.
Nasal filters in prevention of seasonal rhinitis induced by allergenic pollen grains. Open clinical study. European Annals Allergy Clin Immunol 2012 Apr 44(2): 83-85
August 11th, 2012
With the Olympic fever now in full swing in London, there is less thought about hay fever, allergies and asthma. But in discussion with one of the Olympic team medical advisors I was amazed to learn that up to 80% of Olympic athletes suffer with allergies, rhinitis, vocal cord dysfunction and exercise induced asthma induced by their sports. This is in comparison to a 40% incidence for the general population having some form of allergy such as asthma, rhinitis, eczema or food allergy. It has been shown that intensive exercise raises levels of IgE which is the allergy controlling antibody. Heavy endurance exercise and training in unfavourable environments also causes pro-inflammatory changes in athlete’s lungs with 56% footballers showing evidence of exercise induced bronchoconstriction. Sportsmen and women with allergies affected in this way include runners, cyclists, swimmers and skiers.
World Allergy Organisation WAO tells more.
August 8th, 2012
Rupatadine is a new non-sedating antihistamine medication used in allergy management of conditions such as allergic rhinitis and chronic urticaria. As well as primarily blocking the Histamine receptors on cells, Rupatadine has a dual effect of also blocking the action of Platelet Activating Factor (PAF). PAF is one of the most potent allergy provoking mediatoirs released in the body and is associated with more severe allergic reactions such as anaphylaxis. If one can block receptors for PAF then theoretically you can prevent anaphylaxis occuring. Ongoing clinical trials are in progress to assess the efficacy of Rupatadine in preventing and treating allergies and to see if it offers any additional efficacy over common antihistamines such as cetirizine, loratadine and fexofenadine.
Rupatadine in allergic rhinitis and chronic urticaria. Mullol J, Bousquet J et al Allergy:2008;63;suppl 87: 5-28
July 16th, 2012
Some good advice from a patient with Oral Allergy Syndrome to stone fruits and some vegetables which is related to having Silver Birch tree pollen induced hay fever:
“Given the discovery that if I heat the fruits and vegetables, I can consume them without reaction, my life with food has changed. I am now juicing fruits and vegetables, although mostly vegetables and finally feel as though I am attaining my nutrients naturally and without much fuss.
After I juice, I flash heat it in the microwave for 1min so that I can consume the juice without an allergic reaction. I have read in many seemingly reliable sources that microwaving foods very quickly can retain their nutritional value or vitamins. This is more so than boiling or steaming and other means of heating.”
July 5th, 2012
I have been aware of the claims that infra-red and light therapies have had some beneficial effects on hay fever, allergic rhinitis and allergies. Despite this, I have never in 20 years of my allergy practice seen any evidence that this therapy is of any benefit. Ultraviolet light therapy has been shown to be of benefit in dermatology for eczema and psoriasis and this is clinically well documented. There is obviously a marketing opportunity in selling cheap battery operated intranasal light probes and torches to hay fever sufferers with a lot of misinformation. References from reputable medical journals (such as the Journal of Allergy and Clinical Immunology) can be massaged to appear cutting-edge science, but in fact it is very easy to get a letter to the editor of one of these journals published and then used as evidence of scientific acceptance. One only needs to present an anecdotal research paper at a medical congress (without any peer review) and use this as acceptance of a new therapeutic modality. What I am basically trying to say, is that it is very easy to present some superficially convincing evidence of a treatment that is of no basic therapeutic effect. In my final analysis there is no convincing scientific evidence that light therapy has any beneficial effect on allergic diseases and until such evidence is available, I for one could never recommend it.
What’s available? http://www.amazon.com/s?ie=UTF8&rh=n%3A13053141%2Cp_n_location_browse-bin%3A3824271011&page=1
July 1st, 2012
The latest theory on why a generation of allergy sufferers have been born, is the Modified Hygiene Hypothesis, whereby during early childhood, the quality of the germs in your bowel will impact on your immune system and either cause an allergic predisposition to be switched on or off. Infants born by normal vaginal delivery, have their bowel colonised by “good” lactobacilli and bifidobacteria as they pass through the birth canal and are less likely to develop eczema and asthma. This “innoculation” will be missed if you are born by Caesarian section, and the natural bowel colonisation with these germs does not occur instead is colonised by poor quality Clostridium and Staphylococcal bowel germs which as a consequence promote the TH2 allergic prone immune reactivity. However, Probiotic supplements during pregnancy and early childhood will compensate, as will exclusive breastfeeding also help normalise and correct bowel bacteria quality in the newborn. Natural sunlight and vitamin D tend to switch off allergies, and early exposure to animal bacteria also help switch off allergy development. Single children, living in a sterile indoor environment with no snotty germ-infested siblings, and living in an animal-free environment, also born by Caesarian section are at greater risk for developing allergies. Its all about having good quality germs in your childs bowel at birth and early childhood that impacts on the immune system and translates into a tendency not to develop allergies (the allergy phenotype).
Reference: Kukkonen AK, Kuitunen M. Infantile wheeze and maternal gut microbes – is there a connection? Clinical & Experimental Allergy 2012 (42) 814-816