See the next section to learn more about this problem.

Images (above and below from: A Colour Atlas of Allergy, Jackson and Cerio, Wolfe pub.)

Above image shows several hives on the abdomen of a patient.

What illness can creep up on you any time of the day or night, ruin a good day or moment and make you want to scream, but yet you feel no pain?

What medical problem seems to haunt you, not knowing when it may strike?

What disease may drive you to scratch your skin with a hair brush, rub your back against a brick wall or unload a can of Benadryl spray on your body (not recommended)?

What horrendous skin problem gets worse as you scratch, and may be associated with disfiguring facial swelling, which may be quite embarrassing?

The answer is Urticaria and Angioedema (u/a)

(hives and swelling)

I see over 100 hundred new patients each year with u/a and the numbers seem to be increasing. Twenty percent of Americans at some point in their life have experienced hives.

What is Urticaria and Angioedema?

Urticaria means hives and Angioedema means swelling. Hives occur as a result of blood vessels in the superficial layer of skin dilating (widening) and leaking (leaking serum= the liquid portion of blood, without red or white blood cells). Hives (Urticaria) are very distinct in shape (they look like welts) and may be very small (millimeters in diameter or width) or large (giant hives may be several inches wide). Hives are from swelling in the upper layers of skin.

They may be round, linear or oddly shaped. They usually fade with or without treatment over a few to 12 hours (sometimes longer). They may itch terribly, only to become itchier after scratching.

Angioedema (swelling) is not as distinctly shaped as urticaria. The swelling usually covers a larger area of the body (upper and/or lower eye lids, finger, hand, lips, tongue or other body parts). The blood vessels which dilate and leak in this case, are deeper in the skin. The swelling , like hives, tends to fade over hours.

U/A may be acute, going and coming for less than six weeks, or chronic, recurring over six or more weeks. It is usually not life threatening, unless the swelling (angioedema) involves the throat or back of the tongue (medical emergency). Sometimes U/A is part of another medical emergency called anaphylaxis. Anaphylaxis is a potentially life threatening allergic reaction that involves multiple organ systems (skin, cardiovascular system, respiratory system and / or gastrointestinal system).

What causes U/A?

There are many different causes of acute and chronic u/a. Acute u/a is often caused by a food, drug or insect sting. Viral infections may also be a cause of u/a (acute and chronic) especially in children. Chronic u/a is often difficult to figure out. When the trigger is not clear to the patient the doctor must try to extract the possible cause from information taken from a detailed history. Sadly, 80-90% of the time we are not able to define the trigger(s) of chronic u/a.

We know that allergic triggers (such as foods or certain drugs) cause release of histamine and other substances from cells called Mast cells which line the skin and other parts of the body. When histamine is released blood vessels dilate and leak. Nerve endings in the skin respond to histamine leading to itching. Scratching tends to neutralize the itch signal by sending a pain signal through the same nerves involved with the itch.

There are possible food triggers, drug triggers and physical triggers (heat, cold, pressure, vibration, scratching of the skin). People may have multiple triggers (for example cold air and scratching the skin. Emotional stress may worsen or trigger an eruption of hives. As mentioned, triggers may never be identified in the majority of situations.

Are there lab test which may help identify the cause?

Some blood and urine testing may be done for chronic u/a but only seems to help 10% of the time (so we still recommend them). Acute forms of u/a by definition resolve fairly fast, therefore not requiring lab test in most cases. The chronic form is more problematic and frustrating. Allergist generally considers ordering a blood count, thyroid screen and rheumatoid screening test. A urinalysis is also considered. Chest x-rays are considered if there is a smoking history. Other specialty test may also be ordered based on the level of suspicion by your doctor. Years ago numerous lab test and x-rays were ordered in an attempt to find the cause but rarely were they helpful. Instead, patients anxiously awaited the test results only to be disappointed by negative or uncertain results (which usually led to more test). In recent years lab test have been streamlined to avoid such over testing.

What can be done to treat U/A?

Once a thorough history, physical exam and limited lab testing has been done (or ordered) a program of treatment is initiated. This usually involves taking a long-acting, non-drowsy (or low sedating) antihistamine (blocks the effect histamine at the level of the blood vessels and nerve endings) and avoiding high risk drugs (aspirin and ibuprofen or related drugs) and suspected, high risk foods (nuts, peanuts, shellfish etc).

Additional medications are often required for u/a. This may include two different long-acting antihistamines (only to be under doctor’s order) or combinations of long-acting, non-drowsy antihistamines and other drugs. Oral steroid may sometimes be considered for short term treatment in addition to the above medications.

What if these treatments don’t work?

Your doctor should consider having you see an allergy specialist if the treatment has not been effective or not sustained (flare ups keep occurring). I have a number of treatment failures which require adjustments of medications and following food diaries, sometimes modifying the diet for a while. The good news is that more than 80% of the time a formula of treatment will help to relieve the symptoms and suppress the hives and swelling. This takes a significant degree of follow-up with your doctor, initially, follow through on scheduled medications (usually not to be taken just as needed), adherence to avoidance recommendations and patience. Patience is the hardest part at times, understandably.

Most people that have chronic u/a without an identifiable cause (termed Idiopathic Urticaria and Angioedema) will at some point see their problem go away. Chronic u/a may last a few months to several years. Most of my patients, although having this diagnosis for years, have long periods of minimal hives, swelling and itching because of medications and avoidance measures. They are oriented to potential triggers which may perpetuate the hives (such as aspirin and Ibuprofen).

Once a remission period (a time free of signs of the u/a) has been achieved, I gradually reduce medications to the lowest level possible. I urge my adult patients to maintain updated screenings (colon, prostate, breast exams, pelvic exams etc.) annually.

Newer antihistamines have allowed better control of u/a. Steroids are less often required for treatment. Research has uncovered a number of factors which may soon help to better manage this very annoying disorder.

If you have further questions just let me know: AllergyQA@aol.com

Next week: Bee sting allergy: When to call 911 (should you have Epinephrine for self injection?)

Traditional (Prescription) or Herbal Approach?

More than 2/3rds of the world’s population use or have used herbal remedies. It is estimated that 25% of Americans at some point in time have used herbal medication. One published account estimated 8% of eighth-grade students having used herbal supplements.

Why is there an interest in Herbal medications?

Herbal medicine is often used to either supplement the diet to maintain good health or to treat certain diseases as an alternative to traditional, prescribed or over the counter (OC) drugs. Many people think that herbal medications are safer than traditional ones. Herbs also tend to be less expensive and are more accessible (no prescription required).

How safe are herbal medications?

This question for the majority of herbs is unknown. Unlike FDA (Food and Drug Administration) approved drugs, herbal medications are not regulated. This means that safety and efficacy (the overall benefit of the drug) have not been scientifically measured. Most herbs are not standardized, meaning there are no established guidelines for measuring the amount of a particular component of drug in a particular lot. The quality (or potency) of the herbal drug may also be different from one lot to another.

FDA approved drugs have to meet established standards as well as demonstrate doses that may cause harm. Herbal drugs are exempt from reporting potential side effects, long-term risks and possible drug interactions. Some herbs may cause elevated heart rate and blood pressure (Ephedra, Licorice root). Others may interact with medications used for anesthesia, for controlling diabetes, for blood thinning and for asthma control.

Who is at increased risk?

People with the following conditions should exercise extreme caution with herbal drugs:

Asthma and allergy

High blood pressure

Thyroid disease

Heart disease

Blood clotting problems

Seizure disorder

Parkinson’s disease

Glaucoma

Stroke

Enlarged prostate

Why should people with Asthma and Allergy problems be concerned?

Some popular herbal treatments for colds, hayfever and asthma may expose an allergic person to mold spores contaminating the herbal drug. Allergic sensitivity to the mold spore may lead to a severe reaction. Some herbal drugs belong to plant families closely related to ragweed. One example is Echinacea, a compound which is often considered for treatment of upper respiratory problems. There are several reports of allergic reactions and asthma attacks associated with reactions to Echinacea. People hypersensitive to sunflower seeds or melons may also react to this herbal drug.

Herbal teas may contain leaves or pollens which may spell trouble for people with seasonal allergy problems. Chamomile may also be a problem for ragweed allergic people.

Ginkgo biloba, aloe, stinging nettle and evening primrose have been recommended for allergy and asthma treatment. Stomach and intestinal problems have been reported with these herbs.

Understand that allergic people tend to be hypersensitive to organic things (plant pollen, mold spores, animal proteins). They would presumably be more vulnerable to the many organic substances found in several herbal preparations.

Are all herbal supplements bad?

There are probably many herbal remedies that are effective in reducing and preventing certain medical problems. Research by the National Institute of Health, National Center for Complimentary and Alternative Medicine may soon reveal convincing safety and efficacy data on a number of herbal drugs.

They are not all bad. The problem is there are thousands of them, and plant biochemical characteristics are highly variable. This means that comparing the same herbs from different companies may be impossible because of quality differences and the numerous additional ingredients. Even herbs from the same company (different batches of the same drug) have displayed variable quality and quantity levels of ingredients.

Where can I find more information about herbal remedies?

In 1992 the NIH launched a new branch, the National Center for Complimentary and Alternative Medicine: http://nccam.nih.gov

This is a very good source for information on a multitude of herbal supplements.

Here are six Recommendations:

1) Consult your doctor about any herbal supplements you may be considering to take. Inform your doctor(s) about any alternative medication being taken.

2) Try to avoid the herbs reported to be more problematic for allergy sufferers.

3) Avoid taking maximum doses or large quantities of herbal medications.

4) Do your research on any herbal remedies you are considering. Look it up on the above web site.

5) If you are on prescribed drugs, talk to your doctor, specialist and pharmacist about possible drug interactions.

6) Avoid herbs during pregnancy (or if trying to get pregnant).

7) Avoid giving herbs to children.

8) Report adverse effects (side-effects) to your doctor and if serious, to:

                     www.FDA.gov/medwatch

Remember, just because it may be “natural” does not mean it is completely safe.

Herbs in general, lack standardized measurements for safety and effectiveness.

Many prescribed drugs are derivatives of herbs. They are safer because they have standard measures of safety and effectiveness. Additives (in prescribed meds) are identified in complete detail. Package inserts reveal potential adverse effects, risks in pregnancy, risks associated with breast feeding and pediatric experience (most information is available by request and in the PDR- Physician’s Desk Reference).

Comments? Post them here or to: AllergyQA@aol.com

Next Week: Hives (Urticaria) and Swelling (Angioedema)

WEAPONS FOR MASSIVE PREVENTION AND HEALING  - -FOR PEOPLE WITH DRY SKIN--

See the following article on Atopic Dermatitis.

Who gets Atopic Dermatitis?

It is very common in children (approximately 10% of children) and most often starts within the first decade of life. Adults may also have flare-ups of AD, more often involving the hands and feet. People with other allergic problems are at higher risk to develop AD. A family history of AD or other allergic problems (hayfever, asthma, food allergy) increases the risk of developing this problem.

How is AD diagnosed?

There are no specific lab tests for AD. It is a clinical syndrome diagnosed by the history and characteristics of the rash. In young children the rash is often on the scalp, face, elbows and knees. In older children the rash often appears on the inside of the elbows and back of the knees. The rash is itchy and often associated with dry skin. Severe scarring and discoloration of the skin (called lichenification) may accompany AD as a result of scratching. Skin infections may further complicate AD and require oral antibiotics for treatment. Some people have a non-allergic form of eczema.

What triggers flare-ups of AD?

In some people (especially young children) foods may trigger AD. Specific food triggers may be identified by blood test (ImmunoCap) or skin test. Environmental allergy triggers (dust mites, molds, pollens…) have also been reported to trigger AD. Irritant chemicals, soaps, perfumes, wool, sand, heat, dry air, weather changes and emotional stress may be aggravating factors . Non-allergic eczema may be worsened by all of these triggers (excluding food and environmental allergy triggers).

How is AD treated?

The allergist will get a thorough history and do a physical exam, focusing on the skin.

Allergic triggers (food/environmental) are identified by skin testing if possible. Avoidance of triggers is key to successful management. Topical corticosteroids (by prescription) are used to reduce inflammation in the skin (usually twice daily for 7-14 days). Antihistamines are taken (as prescribed by the doctor) in order to reduce itching and scratching. Moisturizers, such as Petroleum Vaseline are used to trap water in the skin (see below).

Antibiotics may be prescribed if there is suspected skin infection. Some people with more severe and frequent flare-ups require oral steroids, special light treatment or other drugs that suppress the immune system.

Will it ever go away?

There is no cure for AD but many people are fortunate enough to have remission periods that last for years. Older children and adults usually have milder flare-ups which may fade out with age.

What can I do to prevent flare-ups?

Here are some recommendations:

1) If you have not seen an allergist or dermatologist consider seeing one in order to confirm the diagnosis and identify allergic triggers (if present). Your family doctor may be able to treat your AD when it is mild to moderate in severity.

2) Avoid harsh soaps, perfumes and many of the available lotions. Dove soap is preferred for body and face. Try to avoid shampooing in the shower or bath. Most shampoos are loaded with chemicals (dyes, fragrances, preservatives) which may worsen skin irritation.

3) Plain Petroleum Vaseline, should be applied to the skin while still damp from the bath or shower (do not rub with the towel, pat once to dry). Most over the counter lotions contain several chemicals and preservatives that may irritate inflamed skin. Aggressive moisturizing of the skin is very important. Vaseline is too thick for the face. Apply Aveeno fragrance free lotion or Eucerin lotion for facial skin moisturizing.

4) Try to wear soft cotton clothing, and pre-wash before the first wear. Avoid wool and nylon clothing.

5) Ask you doctor for an appropriately strong antihistamine to reduce itching, especially over night.

Myths about AD:

People with AD should avoid taking daily baths.

Wrong, as long as you effectively moisturize (as per above), you may take a bath or shower when ever needed or desired.

AD is a childhood disease.

Wrong, most patients with AD are pediatric age but there are many adults with this problem.

AD is an infection and is contagious.

No, it is not an infection although skin infections may complicate this disorder. It is not contagious.

Remember: Dry skin tends to be more itchy and invites a flare-up of AD.

MOISTURIZE!  MOISTURIZE!   MOISTURIZE!     (See step #3 above)

Next Week- Herbals: "Beware if you have allergy problems"

Allergy shots may reduce need for medication

Frequently Asked Questions (FAQs) About Allergy Shots

Patients evaluated in my office go through three phases of examination, followed by a treatment plan. The phases of examination include:

1) A detailed history about their symptoms, level of severity, pattern (seasonal or year round…) other medical problems, environmental triggers (indoor and outdoor, school or work related), family history and medication experience.

2) A physical examination is done.

3) Skin testing and possibly Pulmonary Function Testing is done.

Treatment involves four tiers:

1) There is emphasis on the avoidance of trigger factors (established by skin testing) by implementing environmental controls.

2) Medications are selected to address specific symptoms and control inflammation

3) We provide verbal, written and internet resources to learn more about the first two tiers.

4) We recommend allergy shots for children or adults that fail to respond adequately to medications and environmental controls.

Six FAQs (Frequently Asked Questions) about Allergy Shots (also termed Immunotherapy, Desensitization, Allergy Vaccination)

1) What are allergy shots?

Allergy shots are injections of extracts (materials obtained from specific allergy sources such as trees or grass or other triggers) that have measured amount of protein representing the triggers one has hypersensitivity to. Yes, you are being exposed to the very thing(s) you have been told to avoid in the environment, but in such small amounts, that it should not cause allergy symptoms. The injections, usually one or two, are given in the more fatty part of the upper arm, on a weekly basis (the first 9 to 12 months). The starting doses are over a 100,000 fold weaker than the doses given several months later. The injection doses are gradually increased in potency and amount injected over time. Exactly how allergy shots work is not completely clear but research has identified a number of possible mechanisms. The desired outcome is the establishment of tolerance to specific allergy triggers. This is successful 70-80% of the time.

2) Who should get allergy shots?

Allergy shots are recommended:

- For people that fail to have an adequate response to medications and environmental controls

- When side effects from medications limit the effectiveness of treatment.

- When allergy triggers are unavoidable (outdoor pollens and molds) and lead to moderate to severe symptoms

- When both upper and lower airway allergy symptoms are involved (hayfever and asthma)

- When there is a preference by the patient or family to maximize non-medicinal therapies for allergy control

3) How many years will I be on allergy shots?

If the allergy shots are helpful, they are generally given for five years. Some patients choose to stay on shot therapy longer because of the limited need for medications and overall effectiveness. We encourage our patients that have allergic rhinitis, and asthma to stay on shots more than five years, when the asthma (in addition to the rhinitis) has responded very well. Studies have shown that allergy shots may reduce asthma symptoms and allow for better control.

If the allergy shots are not helpful, they are stopped after 12 to 18 months.

4) Are allergy shots only for older children and adults?

No, children as young as 5 years old may be given allergy shots. Occasionally, a 3 or 4 year old may be started on shots because of the severity of their allergies and/or their intolerance to medications (side effects of medications may limit their use, especially in young children).

We have started patients older than 60 years of age on allergy shots.

5) How safe are allergy shots?

Allergy shots have been given for almost 100 years and have gone through several decades of modifications, based on research. Several years ago people were on shots for thirty or more years. At the time, it was thought that people needed them life long. Reports failed to show problems associated with allergy shots, on a cumulative (build up over time) basis.

Now, any time a shot or shots are given, one is at risk of having a local and/or systemic reaction. Local reactions if they occur are at the site of the injection. They may be small (less than a dime size) or large (several inches in diameter). Redness and swelling, associated with itching and mild burning may be experienced. Treatment includes elevating the arm, applying ice or cold compress, and taking Benadryl (beware of sedation and fatigue with Benadryl).

Systemic reactions are potentially more severe. They are characterized by symptoms, rash or swelling occurring away from the injection site. One may have hives, lip, throat or tongue swelling, difficulty breathing or lightheadedness, although this is very rare. These symptoms, collectively represent an anaphylactic reaction. Such reactions may be fatal if untreated.

Steps are taken, in our office to prevent severe reactions to allergy shots. Some important ones are:

1) Always wait 20-30 mins after allergy shots are given

2) Report to your allergist or nurse, any symptoms or signs of ill feelings associated with a previous allergy shot

3) Come back to the office if any of the above signs of a systemic reaction occur after leaving the office if close by. Otherwise go directly to the nearest emergency department or urgent care, or call 911.

4) If you have a fever, respiratory infection or other illness that is moderate to severe, skip your shots that day or week.

5) Inform the nurse about any new medications and be aware of the class of medications usually avoided when on allergy shots (beta blockers such as Lopressor and Propranolol).

6) Try to avoid rigorous exercising within 2 hours of getting your allergy shot

6) What happens if I become pregnant while on allergy shots?

We continue giving allergy shots during pregnancy unless the obstetrician is against it (which is rare). Allergy shots have been safely given during pregnancy, for years. No increased risk of birth defects has been reported. We actually feel that by controlling allergy problems during pregnancy, mom sleeps better, feels better and has lower risk of requiring more allergy drugs or antibiotics for upper respiratory infections (which often complicate active allergic rhinitis.

We do not start women on allergy shots if they are pregnant, or are trying to get pregnant. Since early on, we are giving increasing doses of extract, there is a higher risk (although small) of having a systemic reaction and therefore requiring a shot of Epinephrine to treat the reaction. The Epinephrine may cause preterm labor (possible early delivery).

If a patient finds out she is pregnant within the first few months of starting shots, we will usually stop them. If she is at or near maintenance doses they will be continued throughout the pregnancy at the same dose (decreasing the likelihood of having a systemic reaction).

Allergy shots represent the most readily available treatment that may be disease modifying (this means have a beneficial impact that lasts long after being stopped) for patients with allergic rhinitis and asthma. On occasion, I have to spend several minutes convincing patients (and parents) that it is time to stop shots. People appreciate feeling more normal, being able to breathe and having less need for medications.

Do you have other questions about allergy shots?

If so, email me at: www.AllergyQA@aol.com

Future topics: Eczema (Atopic Dermatitis) and the best ways to moisturize dry skin

Herbals: “Beware if you have allergy problems”

Hives (Urticaria) and Swelling (Angioedema)

Above illustration from: Atlas of Allergic Diseases, Phillip Lieberman and Michael Blaiss