ALLERGIES

A PROTECTIVE MECHANISM OUT OF CONTROL

JERRY M. SHIER, MD
STANLEY I. WOLF, MD

THE ASTHMA & ALLERGY CENTER, LLP

10301 GEORGIA AVENUE 15201 SHADY GROVE ROAD
SILVER SPRING, MD 20902 ROCKVILLE, MD 20850
(301) 681-6055 (301) 869-7820

For appointments call 301-681-6055

 FOREWORD
I have prepared this booklet to supplement your education as we begin Allergy
testing and treatment. I encourage you to read it and refer to it any time you have questions.
I have tried to include most of the basic information you may need. Of course, it is not
intended to replace consultation with either myself or my staff. I recommend that you keep
this booklet with your medical records for future reference.

I look forward to working with you in order to control your allergies.

Jerry M. Shier, MD
 CHAPTER 1

WHAT IS ALLERGY?

Allergy can be described as an abnormal immune
response to substances that do not elicit such adverse
reactions in normal individuals. A susceptible per-
son who is exposed to these substances (allergens)
has symptoms of the respiratory tract, digestive tract,
eyes, or skin. The most common allergic conditions
are hay fever, asthma, and skin allergies such as
eczema, contact rashes or hives. An allergic person
may only have one of these conditions, but it is not
uncommon for one person to have multiple allergic
conditions at the same time. One allergic condition
may be a problem at one time in your life and a
different allergic condition may be a problem at
another time.
Many times allergic reactions are confused with
other adverse reactions that occur to inhaled, in-
gested, or contacted substances. These reactions are
really known as intolerances and do not have an
immune basis. A good example is reaction to antihis-
tamines. Many people experience drowsiness after
taking them, but this is not an allergic reaction: it is
an intolerance to the medication. Another example
would be the ingestion of a food that causes a gassy/
crampy feeling. This again is an intolerance to the
food, rather than an allergy. Understanding whether
any given reaction is allergy or intolerance is what we
are trying to achieve in order to create a treatment
plan.
ALLERGENS
Antigens are substances that elicit an immune
response. They are proteins that are large enough to
stimulate the immune system. They may enter the
body by various routes. An antigen producing an
allergic reaction is defined as an allergen.
(See Figure 1)

COMMON ALLERGENS

FOODS: Egg, Milk, Peanut, Wheat, Nuts, Fish, Shellfish, Soy

INHALANT ALLERGENS: Dust Mite, Mold, Cat and Dog Dander, Cockroach, Feathers,
Pollen (from Trees, Grasses, and Weeds, including ragweed)
CONTACT ALLERGENS: Poison Ivy, Poison Oak, Nickel, etc.
DRUGS: Penicillin, Sulfa, Aspirin
INSECT VENOMS: Honey Bee, Wasp, Yellow Jacket, Hornet, Fire Ant
OTHERS: Latex

Figure 1-1
CHAPTER 1 - WHAT IS ALLERGY?
ALLERGIC REACTION DEFINED
The basic mechanism involves four elements: the
allergen, an antibody (a substance made by our
body’s immune system specifically against that al-
lergen); cells known as mast cells and basophils,
which produce and release the chemicals that cause
the symptom of the allergic reaction; and, finally, the
different body organs that react to the chemicals that
are released by the mast cells and basophils. Mast
cells are usually found in the respiratory, gastrointes-
tinal tract and the skin; basophils are found in the
blood.
The process begins by the allergen coming in
contact with the body - either through inhalation,
ingestion, injection, or skin contact. The body then
processes the allergen and causes white blood cells to
create an antibody known as IgE or antibody E.
These E antibodies find their way to the mast cells
and basophils, attach to them, and act as receptors for
allergens. As many as 500,000 of these Y shaped IgE
molecules may collect on a single cell.
On your first contact with the allergen, there is no
allergic reaction. But, with subsequent contacts, the
body has now been “primed” or sensitized. The
allergen attaches to the IgE molecules on the mast
cell or basophil and triggers the cell to release many
chemical substances. The major chemical substance
is histamine; this is why antihistamines have been a
mainstay for allergy treatment. There are additional
chemicals e.g. leukotrienes and prostaglandins re-
leased from the mast cell. These chemicals are as
potent, if not more potent, than histamine. These
chemicals then interact with different parts of our
body, creating an allergic reaction. Researchers have
developed new medications to counteract these other
chemical substances (e.g. antileukotriene medica-
tions) and will be available soon.
If the allergen attaches to an IgE antibody in the
eye, it results in itchy, watery, red eyes. If this
reaction should occur in your nose, you have runny
nose, itchiness, sneezing, postnasal drip, and con-
gestion. If on the skin, hives may occur. In the
gastrointestinal tract, there may be vomiting or diar-
rhea. Finally, in the respiratory tract, there may be
symptoms of shortness of breath, chest tightness,
wheezing, or coughing.
The allergic reaction itself is broken down into an
immediate response after contact with the allergen
and, secondarily, a late phase reaction that can occur
anywhere from six to eight hours after the initial
contact.
In its most severe form, the immediate reaction
can be life-threatening and is defined as Anaphylaxis.
Anaphylaxis typically occurs after ingestion of a
certain food, ingestion or injection of a drug, or after
being stung by a bee, wasp, yellow jacket, hornet, or
fire ant. If you have had a life-threatening reaction
secondary to any of the above, please bring this to
your physician’s attention.
WHO GETS ALLERGIES?
The tendency to have allergies is inherited. If one
parent or his/her close relatives (parents, grandpar-
ents, aunts, uncles, or siblings) has or had asthma,
hay fever, or eczema, there is a 40% probability that
his/her child will develop allergic symptoms. If both
parents or their family members have or had aller-
gies, children born to them have a 60-70% likelihood
of developing allergies. If there is no family member
with allergic diseases, there still is a 20% chance that
you may develop allergies.
Whereas the capacity to develop allergies is ge-
netic, the specific manifestations of allergy are not
inherited. A parent with hay fever may have a child
with eczema or asthma. Allergy to a specific allergen
is also not typically inherited. So, the parent and child
may have hay fever, but the parent is allergic to birch
and maple trees; whereas, the child is allergic to oak
and elm trees.

Allergies can occur at any age, and they may
change over the years. Symptoms may become worse
or better. Sensitivities to new allergens may develop
while previous ones disappear. A good example is an
infant who has allergic symptoms of eczema from
ingesting cow’s milk and eggs. Within two years,
this problem can disappear. Unfortunately, many of
these children go on to have nasal congestion and
sneezing from exposure to dust, molds, cat dander,
and pollen; and others go on to have significant
wheezing, cough, and chest congestion consistent
with asthma. Although there are exceptions, most
children do not outgrow their allergies.
A common question that is often asked us is - how
could I have developed an allergy to my dog or cat
after I have been living with it for 10 years without
any symptoms? There are probably three explana-
tions for this. The first is, you may have been having
subtle symptoms that were not recognizable as al-
lergy. The second explanation may be, it just took
you that long to become sensitized to that particular
allergen. Finally, a particular event like a viral infec-
tion or excessive exposure to an allergen may have
brought out your allergic tendency. The triggering
event many times is not apparent. However, once the
allergic reaction has been triggered, the symptoms
are unlikely to disappear without treatment.
HOW COMMON ARE ALLERGIC
CONDITIONS:
The National Institute of Allergy and Infectious
Disease estimates that 50 million people are affected
by asthma and allergic diseases. That is approxi-
mately one in four. 30-40 million have allergic
rhinitis (hay fever), 15-20 million have asthma, and
11.8 million are affected by one of the following
allergic conditions: eczema; urticaria (hives); an-
CHAPTER 1 - WHAT IS ALLERGY?
gioedema (swelling); allergic reactions to foods,
medications, and bee stings. The amount of re-
stricted days and cost to the American public from
allergic diseases is mind boggling. Over six billion
dollars is spent each year for those suffering from
asthma and allergic diseases. Individuals with asthma
spend 170 million dollars on hospital care, 224
million dollars for physician services, and 196 mil-
lion dollars for medications. Each year, over 25
million days are spent in bed as a result of asthma.
Hay fever sufferers spend 224 million dollars on
physician services and 297 million dollars on medi-
cations. 28 million days of restricted activity, six
million days of bed rest, and five million days of
work loss are experienced by hay fever sufferers.
CAN ALLERGIES BE
PREVENTED?
As discussed previously, the tendency to have
allergies is inherited. Unfortunately, we cannot
choose our parents! A delay in the onset and maybe
the severity of the symptoms can be done by decreas-
ing exposures to certain allergens early in life.
Diet is the first way to manipulate the immune
system. Newborns should be breast-fed or, if this is
not possible, to use a non-allergenic formula
(Nutramigen, Alimentum or Neocate-1). This feed-
ing should be given exclusively for the first six
months and cow’s milk should not be introduced
until one year of age. No solid foods should be
introduced into the diet until six months of age. Eggs,
fish, nuts, and peanuts should be avoided for two
years. When new foods are added into the diet, it
should be done every five days, in order to monitor
for an adverse or allergic reaction.
The second way is home environment. This must
be carefully monitored to limit exposure to dust mite,
mold, animal dander, and smoke.
CHAPTER 1 - WHAT IS ALLERGY?

WHAT TYPE OF TESTS ARE Azmacort, Aerobid, Pulmocort or Flovent),

DONE TO DETERMINE WHAT theophylline preparations (Theo-Dur, Slo-Bid, Slo-
Phyllin), and adrenalin-like medications (Alupent,
I AM ALLERGIC TO? Ventolin, Proventil, Maxaire, Terbutaline, Brethine)
do not affect skin testing and may be taken. In fact, if
Skin testing is the best practical method of you are being evaluated for asthma and you presently
detecting allergens you may be sensitive to. There
are on medications, these should not be discontinued.
are two techniques that are used: prick/puncture
(epicutaneous) testing and intradermal testing. We
initially perform prick/puncture tests in order to ARE THERE OTHER TESTS FOR
screen you and to find out how sensitive or allergic
ALLERGIES?
you are. Skin tests by the intradermal method are
often necessary when suspected sensitivities are
Other tests are available to further define your
not revealed by the prick/puncture tests. This form allergies. Blood tests looking at the total amount of
of testing can be performed painlessly if a local
allergic antibody (IgE) and the total number of
anesthetic cream (EMLA) is applied one hour eosinophils (a cell in the bloodstream that is typically
beforehand.
elevated in an allergic sufferer) may be helpful.
With skin testing a small amount of an allergen is Eosinophils can also be discovered if a smear of the
introduced into the skin. Within a few minutes, the
mucus from your nose is looked at under a micro-
allergen has contacted the IgE antibody molecules scope. Finally, there is a test known as the RAST test
on the skin mast cells and chemicals are released
(radio-allergosorbent test) which measures the amount
which cause itching, redness and swelling - the
of IgE antibodies in the blood to specific allergens.
allergic reaction. For the allergy sufferer, there will
Although this test detects specific antibodies, it is not
be a reaction that looks like a bug bite with a raised
as sensitive as skin testing. With RAST testing alone,
area in the center and redness around its outside. If
some allergies may be missed. Other limitations to the
you are not an allergic individual, there will be no IgE
RAST test include the limited number of allergens
antibodies resting on the mast cell; so there will be no
available for testing and the high cost of the test.
reaction whatsoever. Skin tests are available for
pollens, animal danders, dust mite, molds, foods,
HOW ARE ALLERGIES TREATED?
medications, and stinging insect venoms.
It is possible that all of your allergy skin tests
There are generally three approaches to treatment:
could be negative and you are still allergic? This is
1) Avoidance of the allergen, although a sim-
very uncommon, and typically this is due to taking an
plistic idea, is the most effective. Chapter Three
antihistamine before the skin testing. All
will discuss some avoidance measures.
antihistamines should be avoided 48 hours prior to
2) Medication will help alleviate many symp-
testing, and certain antihistamines (like Atarax,
toms caused by allergens. Specific medication
Seldane, Allegra, Zyrtec and Claritin) should be
will be mentioned in subsequent chapters deal-
discontinued for at least seven days. Hismanal, a non-
ing with individual allergic diseases.
sedating antihistamine, should be stopped one month
3) Immunotherapy (allergy injections or
prior to testing. Nasal decongestants taken by mouth
“shots”) is an effective means of reducing one’s
(Sudafed) or topically applied (Afrin or
sensitivity to different allergens. This is dis-
Neosynephrine) do not affect skin tests. Medications
cussed in detail in Chapter Nine.
like steroids (prednisone, Vanceril, Beclovent,
 CHAPTER 2

CRITICAL THRESHOLD

Critical Threshold is the point at which a combi- EMOTIONAL

nation of several factors will produce the symptoms
of an illness. The critical threshold may be viewed as EXERCISE
analogous to placing many blocks on top of each
other until the addition of one more block causes all IRRITANTS
of them to topple. Except for a rare instance in which
a person is highly sensitive to something he has POLLUTANTS
eaten, such as shellfish, or to an insect sting, a critical
threshold usually results from the simultaneous oc- INFECTION
currence of all, or at least a majority, of the factors
listed (see figure 2-1). Thus, a patient with several INHALANTS
factors may feel no distress until one more factor is
added to cause them to wheeze, have shortness of FOODS
breath, or develop other symptoms of allergic illness.
ENVIRONMENT
A second analogy (see figure 2-2) is the bucket
filled with too many allergens. This results in spill- MEDICATIONS
ing over or onset of symptoms.
STRUCTURAL DEFECT
I. Emotional
METABOLIC
Emotional factors must be considered and treated in
any human illness. While emotional factors do not HEREDITARY
cause allergic reactions, including asthma, they cer-
tainly can aggravate the allergic response.

I. Exercise

Many times activities, such as riding a bicycle or

prolonged running, will initiate wheezing and cough. Figure 2-1
CHAPTER 2 - CRITICAL THRESHOLD
III. Irritants
Tobacco smoke, dust, hair sprays, paint fumes,
and insecticides. Direct cigarette smoke exposure or
passive smoking is responsible for symptoms that
mimic allergy. Cigarette smoke is an irritant, which
means it does not cause an immune reaction. The
smoke directly changes the lining of your nose,
throat, and lungs. The allergic patient is especially
sensitive to the irritating effects of smoke. More
information will be provided if this irritant is playing
a role in your symptoms.
IV. Pollutants
These are more than just irritants. Many impurities
aggravate respiratory allergies (e.g. ozone and sulfur
dioxide). Mold contamination of humidifiers in the
house and at work can cause increased allergic symp-
toms.
V. Infection
This includes infection in the upper respiratory sys-
tem, such as a cold, naso-pharyngitis, sinusitis, otitis,
tonsillitis, laryngitis, or infection in the low respira-
tory system, such as bronchitis or pneumonia. Chronic
sinus disease can be associated with persistent asthma.
VI. Inhalants
Pollen, dust, animal dander, molds, etc. (See Chapter
Three.)
VII. Foods
Foods, food additives. (See Chapter Five.)
VIII. Environment
It is well known that changes in humidity and
temperature play an important role in the incidence
of allergies and respiratory conditions. Mites and
molds thrive at high humidity.
IX. Medications
Medications taken for allergy or other conditions
may have side effects or interactions. (see Chapter 7)
X. Structural Defect
Included here are disorders of the structures associ-
ated with the respiratory system, such as polyps of
the nose, deviated nasal septum, or gastroesoph-
ageal reflux.
XI. Metabolic
Thyroid dysfunction, dehydration, anemia, exces-
sive fatigue, other illness or debilitating conditions.
XII. Hereditary
While one does not inherit a specific allergy, one
may inherit the tendency to develop allergic reac-
tions in multiple organs throughout a lifetime.
Figure 2-2
 CHAPTER 3
ALLERGIC RHINITIS:
SEASONAL (HAY FEVER) AND PERENNIAL
Hay fever or allergic rhinitis is the most common
form of allergy. The National Institute of Allergy and
Infectious Diseases (NIH) reports that 30-40 million
people are affected by this. The symptoms may
include any of the following: nasal congestion; sneez-
ing clear, watery nasal discharge; eye irritation with
runny, itchy, watery eyes; throat itchiness, irritation,
and soreness from postnasal drip; ear pain, pressure,
popping, or itching; and generalized fatigue, irrita-
bility, and headaches.
The term “hay fever” is an Olde English term
describing symptoms during hay pitching time. In
the more severe cases, people felt feverish (despite a
normal temperature) - hence, the term “hay fever”.
We now know that these symptoms were brought on
by airborne pollens and is now referred to as “allergic
rhinitis”.
Allergic rhinitis can be seasonal, or it may be year
round. Typically, seasonal sufferers are affected by
pollen; whereas, year round sufferers are affected by
dust and its components (dust mite), animal danders,
and molds.
TYPES OF POLLENS AND THE
POLLEN SEASON
Each plant has a period of pollination, which does
not vary from year to year. The amount of pollen in
the air at any one time is affected by the weather.
Trees pollinate first (March to May), and they cause
early spring hay fever. The major trees in our area are
beech, birch, hickory, oak, elm, maple, walnut, ash,
willow, juniper, mulberry, sycamore, and poplar.
Grasses (timothy, bermuda, orchard, sweet vernal,
red top, and blue grasses) overlap the tree season and
pollinate from May to early July. There are several
weeds that will pollinate in the spring. In the mid-
summer, there is less pollen in the air, but mold
spores can be abundant, especially in our high hu-
midity area. Late summer and early fall is the weed
season. Ragweed is the most abundant weed pollen,
but other weeds include pigweed, sorrel, plantain,
cocklebur, lambs quarters, and mugwort.
ANIMAL DANDER
Dogs, cats, gerbils, rabbits, etc. can all cause non-
seasonal allergies. The allergen is in the animal’s
dander, saliva, or urine. The longer or shorter the
animal’s hair is NOT a determining factor on how
allergenic the pet may be, as all pets have dander
(skin). There are no species of dog or cat that are less
allergenic.
MOLD
Mold is both an indoor and outdoor problem. As
noted in the pollen section, molds are airborne out-
doors and can cause seasonal allergic rhinitis. The
outdoor mold season is from early spring to late fall.
Mold outdoors is no longer a problem after the
temperature drops below freezing. The mold grows
on grasses, dead leaves, and other vegetation.
Indoor mold is responsible for year round symp-
toms. It is a particular problem in older homes and
damp rooms like bathrooms and basements. Other
sources of mold include house plants, room and car
air-conditioners, refrigerators, foam pillows and
mattresses, and stuffed animals. Growth occurs un-
der porches, decks, and in crawl spaces.
CHAPTER 3 - ALLERGIC RHINITIS
DUST MITE
House dust is made of many components. The
major allergen though is from the dust mite. This
creature is microscopic and lives off of the scales
shed by human skin. The waste product particles of
the mite are the allergen. The greatest source of dust
mite can be found in areas of the home where we sit
or lay the most. Obviously, the bedroom has the
highest concentration, particularly in the bedding
and carpeting.
Mites tend to thrive in warm, moist atmospheres.
Their concentration peaks in this area of the country
at the end of the summer but persist year round.
ALLERGY OR COLD?
HOW CAN I TELL THE
DIFFERENCE?
If symptoms persist for more than several weeks
and there are no other household members with
similar complaints, then you probably have a nasal
allergy. Symptoms such as sore throat, muscle aches,
and fever suggest a cold or flu. Untreated allergies,
though, may predispose people to recurrent colds.
These colds are indeed infections, but they tend to
become more frequent because of the underlying
allergic state. Once the allergy is under control, so is
the seemingly exaggerated frequency of such infec-
tions.
NON-ALLERGIC (Vasomotor)
RHINITIS
Persistent nasal symptoms that are not colds may
not always be allergy. The term “vasomotor rhinitis”
refers to allergy-like symptoms that are not caused by
allergens but by physical factors such as temperature
change, air pollution, humidity change, odors, and
emotions.
One should suspect vasomotor rhinitis if you
develop a stuffy, runny nose and sneezing when you
get out of the shower, come indoors from a cold
environment, go outdoors on a smoggy foggy day, or
a rainy, muggy, humid day. Suspect vasomotor
rhinitis if you experience allergic-like symptoms
when you are around perfumes, newsprint, paint/
gasoline, cleaning solvents or other strong odors.
Often, vasomotor rhinitis and allergies occur to-
gether, so allergy should be investigated.
The major difference between treatment of vaso-
motor rhinitis and allergic rhinitis is that allergy
injections are not a consideration for vasomotor
rhinitis because the cause is not immunologic in
nature. The other means of treatment, however, are
similar to those for allergic rhinitis. This includes
avoidance of airborne irritants and the use of medi-
cations, either topically to the nose or taken orally.
TREATMENT OF ALLERGIC
RHINITIS
Avoidance, as always, is the first step in therapy.
This is particularly helpful for relief of symptoms
from dust, mold, and animal dander. It becomes more
difficult to avoid pollens. There are certain areas of
the country that are free of specific pollens. For
example, the desert regions and forests of the Rocky
Mountains, Hawaii, Alaska, California, Oregon, and
the Caribbean Islands are relatively ragweed free.
However, there is a possibility that escape is not
always the answer; in that, a person can develop an
allergic response to the pollen and mold present in
the new location.
An allergy free room should be the easiest room
in the house to clean. Start allergy proofing in the
bedroom because you spend one third to one half of
your life in that room. Then, generalize these changes
to the rest of your home.
Pillows, mattresses, box springs, and stuffed ani-
mals are obvious sources of dust. Pillows should be
polyester and encased or washed frequently. Mat-
tresses and box springs may require special covers.
Keep only the essential books in the room. Daily

vacuuming will help, but no carpet is better. Damp
mop hardwood or linoleum floors weekly. Further
information will be provided by the nurse and physi-
cian on dust proofing.
Mold sensitive patients have exposure both in-
doors and outdoors. Outdoor molds will grow on
most foliage and will accumulate in grass, clippings,
leaves, and mulch. Indoor molds are found in dark,
damp areas. The basement particularly can be a
problem. Further information will be provided by the
nurse and physician on mold and mold prevention.
Direct cigarette smoke exposure or passive smok-
ing is responsible for symptoms that mimic allergy.
Cigarette smoke is an irritant, which means it does
not cause an immune reaction. The smoke directly
changes the lining of your nose, throat, and lungs.
The allergic patient is especially sensitive to the
irritating effects of smoke. More information will be
provided, if this irritant is playing a role in your
symptoms.
Antihistamine medications can give temporary
relief for up to 12 or more hours in reducing itching,
sneezing, runny nose, and postnasal drip. Drowsi-
ness used to be a problem, but now there are non-
sedating or less sedating antihistamines. There are
many choices, and more on the horizon (Seldane,
Hismanal, Claritin, Semprex-D, Zyrtec and Allegra).
The most recent advance in anti-histamines is Astelin
nasal sprays. This is the first topically applied anti-
histamine. It has similar effect to taking the oral
medicine noted above.
Over-the-counter nasal decongestant sprays (such
as Afrin and Neosynephrine) should only be used
under the direct supervision of a physician. Their
CHAPTER 3 - ALLERGIC RHINITIS
overuse can result in a disease called “rhinitis
medicamentosa”, which causes the nasal passage-
ways to swell more than ever and increase the amount
of discharge present.
Oral decongestants (such as Sudafed) are some-
times effective in producing symptomatic relief of
nasal congestion. Oral decongestants do not have any
anti-allergy properties. They are often prescribed in
combination with antihistamine medications.
New medications over the past 10 years have
significantly changed our approach to hay fever or
allergic rhinitis. The topical application of prescrip-
tion nasal sprays have the distinct property of pre-
venting allergic nasal symptoms. There are also topi-
cal products for the eyes.
Sodium Cromolyn is available in a nasal spray and
eye drop form. Basically, the medication is designed
to stop the hay fever symptoms from occurring by
preventing the release of histamine and other irritat-
ing chemicals into the tissues (over the counter).
Topical nasal steroids (Beconase, Flonase,
Nasonex, Vancenase, Rhinocort, Nasacort, Dexacort,
etc.) are extremely safe and effective for both the
prevention and relief from allergic nasal symptoms.
Finally, immunotherapy or allergy injections are
very effective means of reducing one’s sensitivities
to the allergens precipitating allergic rhinitis or hay
fever. For more information, please refer to Chapter
Nine.
 CHAPTER 4
ASTHMA
Dramatic improvements in asthma therapy within
the last 10 years have allowed the vast majority of
asthma patients to lead fairly normal lives.
INCIDENCE
If you suffer from asthma, you are not alone. 15-
20 million Americans have this disease. Asthma
causes approximately 90 million days of restricted
activity per year, about 25 million of which are spent
in bed. It is the third leading cause of restricted
activity in patients under 25 years of age and the fifth
leading cause of all patents. For adults, this results in
five million lost work days/year on an estimated
annual loss of 435 million dollars in earnings. 27
million people per year visit a doctor because of
asthma, and millions of dollars a year are spent in
treating this disease. The National Center for Health
Statistics estimates that children suffering from
asthma and other acute respiratory conditions miss
128 million school days each year, or 61% of all
school days missed per year. Asthma is the most
common cause of children to be admitted to the
hospital. Four thousand deaths from asthma are re-
ported annually. Thus, asthma is one of the most
important and common health problems in the United
States today.
Allergic asthma usually begins before a person
reaches 40. Non-allergic asthma most often occurs after
40, although it can strike at any age. Children are more
affected than adults, but asthma is most prevalent
among boys 14 and under, and men over 45 years of
age. Children of African-American or Hispanic heri-
tage living in urban areas also are more affected than
those in rural areas. Air pollution may be the cause of
this increased incidence.
Well-known people who suffer or have suffered
from asthma include former Vice President Walter
Mondale, Theodore Roosevelt, and Joseph Pulitzer.
Others include Christopher Reeve, Carl Reiner, Don
Rickles, Jim “Catfish” Hunter, Bob Gibson, Wayne
Newton, Helen Hayes, Liza Minnelli, Elizabeth Tay-
lor, Rocky Bleier, Art Monk, Chuck Barris, and
Olympians Jeanette Bolden, Nancy Hogshead, Jackie
Joyner Kersee and Dennis Rodman.
WHAT IS ASTHMA?
Asthma is a non-contagious disease of the bron-
chial tubes. These tubes carry air from the mouth to
the air sacs in the lungs. In asthma, these tubes are
blocked. This blockage is due to:
- Swelling of the inside lining of the tubes
(inflammation)
- Contraction (squeezing down) of the
muscles surrounding the tubes, thus reduc-
ing their diameter
- Excessive mucus production which often
hardens within the tubes producing plugs

The airway obstruction results in symptoms of
coughing, chest tightness, shortness of breath, and
wheezing. Wheezing is typically heard while breath-
ing out and is a high pitched whistling noise. Symp-
toms may be subtle. A persistent cough after each
upper respiratory infection, or shortness of breath
following exertion, may be due to asthma.
The exact cause of asthma is unknown. However,
we know that a hallmark of the disease is what is
called “hyperreactive bronchial tubes”. That is, the
bronchial tubes react to certain stimuli in a way that
produces these three abnormal processes. We often
say that the bronchial tubes of the asthmatic are
“twitchy”; in that, they overreact to stimuli which are
usually harmless to the normal person. This state of
“twitchiness” may fluctuate over the lifetime of a
person with asthma, but one does not grow out of it.
Asthma does not lead to emphysema. Asthma, by
definition, is reversible airway obstruction. How-
ever, if inflammation in the bronchial tubes persists
for long periods of time, permanent damage to the
bronchial tubes can occur.
WHAT TRIGGERS ASTHMA?
Asthma can be caused by hypersensitivity to
allergens such as pollens, molds, animal danders,
house dust mite, and foods. It can originate with, or
be aggravated by respiratory infections. Irritants
(such as cigarette smoke; harsh odors from paint,
perfumes, and aerosol sprays; and air pollution) may
trigger asthma. Exercise, especially in cold air, can
be a major trigger. Other triggers of asthma include
chronic gastrointestinal reflux and chronic sinusitis.
Certain medications can trigger asthma like aspirin
or ibuprofen (Motrin, Advil, etc.) and Beta-blocker
(Inderal etc.). Psychological stress in any form may
trigger asthma, as can laughter or crying. Contrary to
popular belief, asthma is not a psychological prob-
lem.
CHAPTER 4 - ASTHMA
How do I know if I have asthma? A careful
history, physical examination, and breathing test
(known as spirometry) will help us determine if you
have asthma. A spirometer measures the amount of
air exhaled or blown out to determine the degree of
airway blockage. A peak flow meter is a smaller
version of a spirometer, and can be used at home to
monitor lung function.
CURRENT TRENDS IN
TREATMENT
After triggers are identified, you will receive
suggestions on controlling the environment to help
you avoid the allergens and irritants. Air-condition-
ing reduces the amount of pollen and mold in the
home. Smoking should not be permitted, and house
pets may need to be restricted from certain areas of
the home or removed permanently. All bedding
should be a synthetic material. Rooms must be cleaned
and vacuumed on a regular basis to prevent the build-
up of dust. Ideally, bedrooms should have hardwood,
tile or linoleum flooring and be carpet free. Offend-
ing foods should be avoided.
Pharmacological management, in simpler terms,
is the practice of using various medications to com-
bat the effects of asthma. Some of the more common
medications are as follows:
Cromolyn sodium (Intal) and Nedocromil (Tilade)
are preventive medications and are not a treatment
used when there is a sudden onset of breathing
difficulties. These are propelled into the lungs by an
inhaler. Intal is also available as a solution that is
inhaled using a small machine called a nebulizer.
These medications prevent the release of inflamma-
tory chemicals from the mast cells lining your air-
ways, thus preventing asthma symptoms.
Beta-adrenergic or adrenalin-like agents
cause the airways to open and are either given orally,
by nebulizer or metered dose inhaler (“puffer”), or
injection. Albuterol (Ventolin, Proventil)*,
CHAPTER 4- ASTHMA
metaproterenol (Alupent, Metaprel), terbutaline
(Brethine or Brethaire), and Pirbuterol (MAXaire) help
the muscles relax, and are called Bronchodilators. They
are the treatment of choice for an acute attack of asthma
and are best administered by the inhaled route. Adrenalin
or Epinephrine by injection used to be the first line
treatment in a doctors office or emergency room, but
have been replaced by the inhaled medications. This
class of medications can also be used prior to exercise
to prevent exercise-induced asthma. A new agent
Serevent is available. It is a long acting inhaled Bron-
chodilator that is recommended as a maintenance medi-
cation, and should never be used more than twice a day,
or in place of Albuterol, Metaproternol, Terbutaline or
Pirbuteral.
Corticosteroids are used to prevent and treat ongo-
ing inflammation of the airways. It is available in the
inhaled, oral, or injectable form. The inhaled form of the
medication (Vanceril, Vanceril DS, Beclovent,
Azmacort, Aerobid, Flovent, Azmanex) allows its use
on a daily basis without the typical long-term side
effects. A short burst of oral corticosteroids (Medrol,
Prednisme, Prelone, Pediapred, Azmanex) may be re-
quired for an acute asthma attack. The short-term use of
the oral form is safe and effective in reducing inflamma-
tion. The side effects from corticosteroids that you may
have heard about are the result of the long-term daily use
of high dosages of oral medication. These may include
weight gain, high blood pressure, growth delay, cata-
racts, muscle weakness, diabetes, and osteoporosis. If
you are on these medications and contract chicken pox,
contact our office ASAP. The infection can be more
severe than normal.
In 1999 the FDA required a warning on all inhaled
steriods about possible reduction in growth velocity in
pediatric patients. The FDA stated that “the potential
growth effects of prolonged treatment should be weighed
against clinical benefits obtained and the availablity of
safe and effective non-corticosteriod treatment alterna-
tives. To minimize the systemic effects of orally inhaled
corticosteroids, including each patient, should be ti-
trated to his/her lowest effective dose.
Airway inflammation plays a significant role in
asthma, so the use of steroids may be the first choice of
medication to control daily chronic symptoms, with the
other medications acting as backup or second and third-
line additions.
“Anti-Leukotrienes” – a new class of medicine - has
the ability to act as a Bronchodilator and an anti-
inflammatory. Accolate, Zyflo, and Singulair are the
three available but there are others being developed.
This is a maintenance medicine to control daily symp-
toms and is not meant for immediate relief like the Beta-
adrenergic medicines.
Theophylline (Theo-Dur, Slo-Bid, Uni-Dur,
Uniphyl) is used in the treatment of asthma and is
known as a bronchodilator because it relaxes the bron-
chial muscles. It may be used as a maintenance medica-
tion for people who require daily treatment or who
experience sudden breathing difficulties. Patients who
use theophylline should advise their physician of other
medications they are taking, as there are many drug
interactions.
Immunotherapy involves periodic injections of the
allergic substances (i.e. pollens, molds, dust) that trig-
ger asthma symptoms. Injections are not available for
substances a person may be irritated by (i.e. smoke,
perfume, or other strong odors). The regular adminis-
tration of the allergens by injection will create a toler-
ance to the different allergens. The degree of tolerance
that results varies from patient to patient. Our goal is to
increase your tolerance, thus reducing symptoms. This
is further discussed in Chapter Nine.
Space Devices are used to enhance the delivery of
inhaled medications (Bronchodilators, Intal, Tilade or
Steroids). Inspirease, Aerochamber are just two types
of spacers. Proper delivery of medication is extremely
important. For infants, toddlers, young children and
others who can not use inhaler - Nebulizers can be made
available. Please discuss this with your physician.
OUR CONCERNS
Underestimating the severity of asthma may have
life-threatening consequences. Studies indicate that
those asthma sufferers who delay seeking treatment,
self-medicate, or do not comply with prescribed treat-
ment plans may be taking their lives in their hands.
Education is a key part of our practice. We want you to
feel comfortable with your medical problems so please
ask questions.
 CHAPTER 5
FOOD ALLERGY
Hippocrates, an early Greek physician and phi-
losopher, was one of the first to note that cow’s milk
could cause health problems for some people. Al-
though we do not know if he was referring to a true
allergy to cow’s milk protein or an inability to digest
a milk sugar called lactose, we do know that food
allergy reports began to appear in modern Europe in
the early 1900’s. Since the 1940’s, food allergy has
been clearly recognized by doctors around the world.
The true number of people who have food allergy
is unknown (estimates of the incidence of cow’s milk
allergy are reported to range from 0.3% to 7.5%).
The incidence is higher in infants than in adults.
Many adverse reactions to foods are not the result
of true allergic reactions. In some cases, such symp-
toms have been presumed to be allergic reactions
only because no other cause could be found and/or
because the patient’s symptoms improved when the
food was removed from the diet.
DEFINITIONS
Adverse reaction to a food: A general term that is
used to describe any abnormal reaction to a food or
food additive that is eaten, whether caused by aller-
gic or non-allergic mechanisms.
Food allergy or hypersensitivity to a food: An
abnormal immunologic reaction during which the
body’s immune system overreacts to harmless foods,
leading to irritating and uncomfortable symptoms. A
severe allergic reaction, that can sometimes be fatal,
is known as Anaphylaxis. (See Chapter One.)
Food intolerance: An abnormal physical response
to a food or food additive that is eaten and is not
proved to be immunologic (i.e. milk sugar/lactose
intolerance, where the individual lacks the enzymes
to break down the milk sugar for proper digestion).
Food poisoning: An adverse reaction caused by a
food or food additive without immune system mecha-
nisms being involved. Toxins (poisons or bacteria)
may be either contained within the food or released
by microorganisms or parasites contaminating food
products.
Pharmacologic food reaction: An adverse reac-
tion in which a chemical found in a food or food
additive produces a drug-like (pharmacologic) effect
(i.e. caffeine in coffee causing “the jitters”).
PROBLEM FOODS
Food allergens, those parts of foods that cause
allergic reactions, are usually proteins. Most of these
allergens can still cause reactions, even after they are
cooked or have undergone digestion in the intestines.
Recent studies conducted in the United States indi-
cate that the proteins in cow’s milk, egg, peanut, nuts,
shellfish, wheat, and soy are the most common food
allergens.
Food allergy may make its first appearance at any
age, but it is especially likely to occur in infancy.
While most early food allergy is “outgrown”, it may
persist for years, and the symptoms caused by the
food may change. For example, milk may cause colic
or eczema in an infant; whereas, later it may cause
CHAPTER 5- FOOD ALLERGY
asthma and hives. If the eczema improved with milk
elimination in infancy, the mother looks for eczema
when milk is restored to the diet later on. If asthma
occurs instead, she may conclude that the child has
outgrown the milk allergy and that something else is
responsible for the asthma. In this case, milk, al-
though actually the cause, is not suspected, espe-
cially since it may take several weeks after its addi-
tion to the diet before the asthma appears.
ORAL ALLERGY SYNDROME
Certain foods, (primarily fresh fruits and veg-
etables) can cause itchiness within the mouth with-
out causing a more severe allergic reaction. Indi-
viduals are often allergic to seasonal pollens like
trees/grasses and weeds. The allergens in the pollens
are similar to the allergens in the foods resulting in
this cross reaction.
FOOD ADDITIVES
FD&C Dyes - The Food, Drug & Cosmetic Act of
1938 gave rise to the term FD&C. It approved a
variety of dyes used in foods and beverages. They are
identified on labels by color and number (such as
FD&C yellow No. 5 or FD&C red No. 3).
FD&C yellow No. 5, or Tartrazine, may infre-
quently cause hives in those who are sensitive to the
agent.
Sulfites - Sulfiting agents (such as sulfur dioxide,
sodium or potassium sulfite, bisulfite, and
metabisulfite) are used to preserve foods and sanitize
containers for fermented beverages. They are found
in canned, frozen, or dehydrated foods (such as dried
fruit); in processed grain foods such as cookies or
crackers; in shrimp; and in some beverages such as
beer, wine, wine coolers, and cider.
Sulfites may cause reactions such as chest tight-
ness, hives, abdominal cramps, diarrhea, lowered
blood pressure, light-headedness, weakness, and an
elevated pulse rate. This has primarily occurred in
sulfite sensitive persons with asthma.
The highest levels of sulfites were previously
found in restaurant salad bars. But, in 1986, the Food
and Drug Administration banned their use on fruits
and vegetables intended to be sold or served raw
because of the growing rate of sulfite reactions. By
1987, the FDA also ordered that packaged foods be
labeled when they contain more than 10 parts per
million of any sulfiting agent, so sulfite-sensitive
individuals may identify those packaged foods which
should be avoided. Raw shrimp and uncooked pota-
toes are still not regulated by the FDA and may
contain sulfites to preserve their freshness.
DIAGNOSIS
First, a detailed medical history will be taken,
followed by a physical examination. The allergist
will then inquire about the frequency, seasonality,
severity, and nature of the symptoms. Your physi-
cian will also ask how much time elapses between
the eating of a food and any possible reaction.
A food diary will aid in the discovery of food
allergy. A food diary is a detailed record of the foods
eaten, listing date, time, and any symptoms that
occurred after ingestion.
When an allergy to a single food is suspected,
elimination of that food will be recommended. If a
period of elimination of a food is to be informative,
there should be no slips in the diet during that
period. In addition, before the diet is undertaken,
there should be a clear definition of just what symp-
toms it is aimed at controlling. If the symptoms are
relieved, the food may be added back into your diet
to see what happens. When a food allergy is sus-
pected on the basis of frequent or continuous symp-
toms, no single food may be identified as the likely
offender, and then a diet in which several suspected
foods are eliminated may be recommended, or a non-
allergic food substitute might be suggested for a
period of time.
Direct allergy skin tests may be helpful in deter-
mining which foods are involved in the allergic
process. Skin tests are not helpful when sensitivity to

dyes, additives or chemicals is suspected. Unfortu-
nately, skin testing with food is not as useful as it is
for diagnosing pollen allergens, as positive tests may
indicate previous sensitivity and not be relevant at
this time. Food testing can, however, serve as a guide
as to which specific foods to include in an elimination
diet.
Blood tests for specific IgE (known as the RAST
test) may be helpful for selected patients but are
generally not as sensitive a diagnostic tool as elimi-
nation and “challenge” of a suspected food.
If diagnosis of food sensitivity remains in doubt
after the use of diet diaries, elimination diets, and
allergy tests, the allergist may recommend “blind”
food and/or food-additive “challenges” in the office
and at times in the hospital under close observation.
Usually, the suspected food or a neutral food, called
a placebo, is fed in opaque colorless capsules or as a
hypoallergenic slush or pudding (such as tapioca), so
neither the patient nor the doctor knows whether the
suspected food or the placebo is being eaten. This is
called a “double-blind” challenge. When properly
performed, these challenges are very helpful in estab-
lishing a cause and effect relationship between a food
and an allergic symptom.
Food cytotoxic blood tests and sublingual provo-
cation food testing are not recommended, since these
tests are unproven as procedures to diagnose food
allergies. In a March 19, 1985 Compliance Policy
Guide, the Food and Drug Administration deter-
mined that “the cytotoxic test remains, in 1985, as an
unproven diagnostic procedure unsupported by sci-
entific literature of well-controlled studies and clini-
cal trials.”
In a further development, the Health Care Financ-
ing Administration (HCFA) published a notice in the
June 13, 1985 Federal Register excluding cytotoxic
testing for food allergies from Medicare coverage
because “available evidence does not show that these
tests are safe and effective.”
CHAPTER 5- FOOD ALLERGY
TREATMENT
Avoidance of specific foods is the best treatment
method for food allergy. In children, strict avoidance
for a year may result in diminished sensitivity to the
food allergen. In adults (and in some children), food
sensitivity may persist forever. Allergy injections for
food are not recommended and may be dangerous.
Anaphylactic reactions caused by food allergies
are among the few potentially life-threatening aller-
gic conditions. Persons who have experienced an
anaphylactic reaction to a food must strictly avoid it,
as even the smallest amount can be life-threatening.
Because the sensitive individual may eat the food in
an unrecognized form (in a restaurant, for instance),
he/she should carry a kit containing epinephrine
(adrenalin) at all times and should know how to inject
himself/herself with the medication in order to be
prepared for an emergency. The sensitive individual
should also wear an identification necklace or brace-
let which describes the allergy.
A person who is highly allergic to a food must also
read food labels carefully. Foods that have been
processed may contain amounts of food that need to
be avoided. For example, milk may not be one of the
ingredients listed on a label; instead, the label may list
casein, sodium caseinate, whey, or milk solids.
Finally, dietary supplements, like Calcium may
be needed. Please discuss this with your physician.
OTHER SYMPTOMS ATTRIBUTED
TO FOODS
1. Hyperkinesis or Attention Deficit Syndrome.
Dr. Feingold proposed that some children may be-
come hyperactive, inattentive, easily distracted, and
do poorly in school after ingestion of certain foods or
food coloring. This theory has never been proven.
2. Sugar intake and behavior have also been
linked, but the relationship is unclear and allergy does
not appear to be playing a role.
CHAPTER 5 - FOOD ALLERGY

3. There are a group of patients, both children and BIOGENETIC RELATIONSHIPS

adults, who complain of malaise, fatigue, headaches,
poor or excessive sleep, nausea, diarrhea, indiges-
tion, irritability, etc. These patients may have proven
allergic rhinitis or food allergy, but these constitu-
tional symptoms are out of proportion to the allergic
manifestations. This condition has been referred to
as “Tension-Fatigue Syndrome”. Since these symp-
toms are seen in so many other illnesses, both physi-
cal and emotional, many allergists question whether
this syndrome is an allergic condition.
4. Controlled scientific studies have shown no
evidence of reaction to candida, a mold which is in
every normal person’s body, or ingestion of mold-
containing foods, as a cause of the generalized symp-
toms mentioned above.
Most foods belong to groups or families of foods
which share many characteristics including allergic
reactivity in some cases. For example, the peach
belongs to the cherry family, comprising all single pit
fruits such as cherry, peach, plum, nectarine, apricot,
and almond. If a patient is shown to be allergic to
peach, the other foods in the same biogenetic group
should be challenged in the diet to determine if he is
also allergic to them. An individual can be allergic to
only one food in a family; this is frequently the case.

COMMON BIOGENETIC RELATIONSHIPS

1. Citrus Family 4. Potato Family 6. Lily Family 9. Gourd Family

Orange Potato Onion Pumpkin
Grapefruit Tomato Asparagus Squash
Lemon Egg Plant Garlic Cucumber
Tangerine Red Pepper Chive Cantaloupe
Lime Green Pepper Leek Melons
Chili
2. Mustard Family Tobacco
Mustard 7. Parsley Family 10. Miscellaneous
Cabbage Parsley Relationships
Cauliflower 5. Cherry Family Carrot a) Apple - Pears
Broccoli Cherry Celery b) Spinach - Beets
Brussel Sprouts Peach Parsnips c) Cranberry
Turnips Plum -Blueberry
Kale Prune d) Raspberry
Radish Nectarine 8. Legume Family - Blackberry
Apricot Beans of all kinds - Strawberry
3. Chocolate Family Almond Peas
Chocolate Peanuts
Cocoa Licorice
Cocoa Butter Soy
Cola
A more comprehensive list is available in our office.

Figure 5-1
 CHAPTER 6
DRUG ALLERGY
According to the Food and Drug Administration
(FDA), about 37,000 adverse drug reactions are
reported per year. A breakdown of the reactions
showed that 71% involved toxic reactions to “usual
doses of drugs”, 21% involved hospitalization, and
2% resulted in death. The highest incidences of
hospitalization or death were found in those reports
that described “cardiovascular, hematologic, or res-
piratory effects”. Patients over 59 years of age ac-
counted for nearly half of the reported deaths. Drug
reactions occurred within two weeks of initial expo-
sure in the majority of cases.
DIAGNOSIS
In many instances, a reasonable suspicion that
drug allergy is present will lead to discontinuance of
the drug, unless the disease under treatment is seri-
ous and an adequate substitute is not available. Aller-
gic reactions resulting from drugs usually subside, or
begin to improve, within 24 to 48 hours after discon-
tinuance of the suspected medication. Improvement
of symptoms under these circumstances will strongly
suggest the possibility of drug allergy. Exceptions
exist in which symptoms continue without change,
or even become worse temporarily, in the week
following discontinuance of the drug treatment. When
the allergic reaction to the drug has been severe and
has produced extensive tissue damage, recovery may
be slow and incomplete. If a long-acting drug (such
as an injection of long-acting penicillin) is respon-
sible for symptoms, allergic symptoms may persist
for several weeks or months. Further evidence that
the drug in question is the true offender may be
obtained by re-administration at a future time. In
most cases, this procedure is considered far too
hazardous; however, in experienced hands, some
drugs will be given cautiously when no other alter-
natives are available.
SKIN TESTING FOR DRUG
ALLERGY
Attempts to diagnose sensitivity to drugs by
using the drug itself for skin testing are rarely suc-
cessful and may involve severe risk to the highly
sensitive patient. The most important area in which
skin testing has proven to be of assistance is penicil-
lin sensitivity. In a patient with a history of a previous
reaction to penicillin, skin tests with several penicil-
lin test reagents should be done prior to further
penicillin administration. If positive skin tests are
obtained, a distinct risk of a severe immediate ana-
phylactic or an accelerated allergic reaction exists,
and penicillin should not be given. If negative skin
tests are obtained, there is no risk of such an imme-
diate reaction, and penicillin may be administered.
However, even in the presence of negative skin
tests, there is still the slight possibility that less
severe delayed reactions may occur.
Negative skin tests obtained with other antibiot-
ics are not as reliable as those found on penicillin
testing. Long-term scientific studies on allergy test-
ing for these drugs have not been established.
CHAPTER 6 - DRUG ALLERGY
If a person with a history of penicillin allergy
develops an infection, several steps can be taken to
treat the problem without provoking a serious aller-
gic reaction. Satisfactory alternative antibiotics may
be available. Skin tests may reveal that the allergy no
longer is present, thereby permitting therapy with
penicillin. If penicillin or a similar drug is needed in
a person who has positive tests for current allergy, a
desensitization procedure can be performed. This
consists of administering gradually increasing doses
over a period of hours until full therapeutic doses are
tolerated.
Local anesthetic allergy can be diagnosed by skin
testing, although this is usually not required since
alternative, very satisfactory anesthetic drugs are
available. Aspirin sensitivity cannot be diagnosed by
skin testing.
Allergy to immunizations, like the measles,
mumps, and rubella vaccine, and the influenza vac-
cine can occur in some egg-allergic patients because
the media used to grow these vaccines contain a small
amount of egg protein. If you are egg allergic, skin
tests are performed to Influenza; if positive, desensi-
tization procedures are available.
PREVENTION
Once a diagnosis of a drug allergy is made, it is
important that the offending drug be avoided in the
future. A patient should be properly informed con-
cerning the name of the drug, as well as related drugs,
so that this information can be transmitted to other
physicians who will treat the patient in the future. A
dual responsibility exists here; the patient must give
this information to a new physician, and the physi-
cian must inquire about drug allergies prior to pre-
scribing. Patients must be educated concerning the
presence of the offending drug where it is not obvi-
ous, especially in non-prescription medications. For
example, aspirin is present in many anti-cold and
headache preparations (such as Anacin, Empirin
Compound, Excedrin, Alka-Seltzer, etc.).
TREATMENT
The illness that led to the drug being prescribed in
the first place must be considered when treatment of
a drug reaction is planned. In most cases, the drug can
be withdrawn and replaced with some other form of
therapy. Immediate reactions can be suppressed by
antihistamines, epinephrine, cortisone-like drugs,
and other measures. Occasionally, the drug can be
continued safely, if suppressive therapy or desensi-
tization is used. In nearly all cases, effective therapy
can be accomplished despite the appearance of drug
allergy.
 CHAPTER 7
STINGING INSECT ALLERGY
Insect stings are responsible for inducing severe
allergic reactions in an estimated one to two million
people in the United States. An estimated 3% of the
population is susceptible. About 50 deaths due to
stinging insect allergy are reported per year. Most
victims of these serious allergic reactions are over
30. A number of deaths per year go unrecognized as
being from stinging insect allergy, as there was no
witness to the sting.
These reactions may occur at any age, regardless
of previous allergic history, striking many who are
unaware of their susceptibility to an anaphylactic or
severe reaction until it occurs. They are caused when
a person’s immune system produces too much of an
antibody called IgE (Immunoglobulin E) which, in
combination with the venom, triggers the allergic
reaction.
TYPES OF STINGING INSECTS
The common stinging insects belong to the order
Hymenoptera and can be divided into two families:
the apids, which include honeybee and bumblebees;
and, the vespids, which include yellow jackets, hor-
nets, and wasps. There are also several stinging ants
which can be considered as non-winged Hy-
menoptera. The fire ant is a major cause of allergic
reaction in the Southern United States, and the har-
vester ant is responsible for similar problems in the
Southwestern United States.
Hornets and yellow jackets are black with yellow or
white markings - the queens measuring about 3/4 of
an inch long, and the males and workers measuring
1/2 inch in length. Polistes are slender, elongated
wasps about 3/4 to one inch long. They are black,
brown, or red and have a few yellow markings.
Wasps build open-comb nests or mud structures
under eaves and in carports, behind shutters, and in
wood piles. Yellow jackets’ nests are usually found
in the ground, abandoned burrows of small rodents,
between the cracks of rock walls, or between the
walls of frame buildings. Hornets build grey foot-
ball-shaped hives in shrubs or in trees. Honeybees
are generally found in commercial hives, and fire
ants usually build colonies in the ground.
TYPES OF REACTIONS
The usual reaction occurring after an insect sting
is a mild degree of redness and pain, which usually
disappears within one to two hours, but can last for
24-48 hours. As a rule, no treatment is required.
Sometimes, large local reactions can occur with
extensive swelling, redness, and itching that peaks
at 48-72 hours and may last as long as one week. Red
streaks radiating from the sting site, which appear 24
hours later, may indicate infection and should re-
ceive prompt medical attention. Large local reac-
tions are not predictive of a more serious reaction
the next time you are stung.
CHAPTER 7 - STINGING INSECT ALLERGY
A severe allergic reaction (anaphylaxis) can in-
volve the entire body, producing symptoms that
include dizziness, weakness, and nausea. Stomach
cramps and diarrhea may occur, as well as general-
ized hives (urticaria), itching, wheezing, flushing,
difficulty in breathing, a sharp drop in blood pres-
sure, shock, and finally, unconsciousness. If medical
treatment is not obtained immediately, the reaction
may prove to be fatal.
PREVENTION AND TREATMENT
To prevent insect stings:
- When cooking outdoors, keep food covered
until eaten.
- Spray the patio and garbage area with an
insecticide.
- Garden cautiously, being careful not to dis-
turb ant colonies, wasp nests, or bee hives.
- Avoid wearing perfume, hair spray, lotions,
or any other types of scented cosmetics which
attract insects.
- Avoid wearing bright colors, flowery prints,
and black, which attract insects more than light
colors like white, green, tan, and khaki.
- Keep an aerosol pest insecticide in the glove
compartment of your car, should a stray insect
fly in.
- If you suspect you are hypersensitive, do not
hike, boat, golf, or swim outdoors alone.
Most local reactions can be treated with antihis-
tamines and anti-inflammatory drugs. For those sub-
ject to severe reactions, a physician may recommend
a self-treatment kit (Ana-Kit or an Epi-Pen), which
contains epinephrine (adrenalin). This medication
works within minutes to reverse the allergic reaction.
Those persons who are susceptible should follow a
physician’s instructions for self-injection in the event
of an insect sting and then proceed immediately to the
closest emergency room.
Individuals who have had generalized reaction
may be candidates for venom immunotherapy (“al-
lergy shots”). Purified venoms, which are highly
potent, are now available and are given in gradually
stronger doses to stimulate the patient’s immune
system until it is able to become more resistant to the
insect sting. Venoms are taken from honeybees, yel-
low jackets, yellow and white-faced hornets, and
wasps. Whole-body extracts (rather than purified
venoms) are utilized for fire ant hypersensitivity, as
fire ant venoms are not yet available.
If you are stung, only the honeybee leaves a
stinger and an attached venom sac in the skin of its
victim. Removal of the stinger within two to three
minutes may prevent some harmful effects. Remove
the stinger with one quick scrape of the fingernail. Do
not compress the sac, as this may only serve to inject
more venom into the victim.
DESTROYING THE SOURCE
To destroy hives, use commercially available sting-
ing insect pest aerosols after dark, when insects have
returned for the night. Take appropriate precautions
by wearing a hat, long sleeve shirt, work gloves, and
boots. Hypersensitive persons should not be allowed
in the vicinity. Burning or flooding the nests will only
result in angering the insects and is not recommended.
 CHAPTER 8
SKIN ALLERGIES
Skin is an important organ. It has many functions
including heat regulation, being a protective barrier
for our bodies. It is a sensory organ: it registers cold,
heat, pain, touch, and itching. It helps us to adjust to
our surroundings. The following is a brief discussion
of those disorders of the skin regarded as allergic in
origin.
ECZEMA OR ATOPIC
DERMATITIS (The itch that rashes)
What is it?
Eczema is a skin disease which can appear on the
cheeks and scalps of infants at a very early age. It may
also appear on the wrists, in the bends of the elbows,
and the folds behind the knees. Individuals with
severe cases may have the rash over their entire body.
The first symptom is itchiness of the skin. The rash
appears next and is made worse by scratching and
rubbing the itchy areas. As a result of all the rubbing
and scratching, the skin becomes thickened and
cracked. In other cases, it may become constantly
moist and weep. There may be crusted areas, as the
wet form of eczema dries. This damaged, irritated
skin may easily become infected.
If it starts in infancy, how long will it last?
In most cases, the eczema either disappears or is
less severe by the time the child is two or three years
old. In some, the skin condition subsides for several
years but returns after the child is older. Those with
a more severe disease may retain their eczema during
their teens and into adulthood.
What causes it?
The cause of eczema is unknown. It tends to
occur in allergic families, and children with eczema
are likely to develop other allergies, particularly
asthma or hay fever. Although allergy, particularly
to certain foods, explains a certain percentage of this
childhood type of eczema, there are some cases of
this disease where allergy cannot be found. It may be
that some of these cases are still allergic, but that
additional causes of allergy need to be discovered;
or, the nature of these unclassified eczemas is en-
tirely different. Only intensive and concerted re-
search will solve this puzzle.
What makes it worse?
Anything which causes itching will make the
condition worse. Such factors include cold dry
weather, hot weather, sweating, emotional upsets,
certain types of clothing, and certain washing deter-
gents. Fatigue, nervousness, and emotional upsets
can increase the irritation, although there is no proof
that these conditions by themselves cause eczema.
Exposure to foods that have been identified by history,
skin testing or RAST. Exposure to dust mites.
How do I know if I have eczema?
Your physician will take a detailed history to
determine possible triggers to the development of
the rash. The history might point to certain foods or
environmental contacts (mites, pets, materials, etc.)
as possible causes. Skin tests may be required to
identify specific contacts or ingestants that make the
eczema flare.
CHAPTER 8 - SKIN ALLERGIES
What can I do to help my eczema get better?
Itching and scratching are major sources of dam-
age to the skin. An antihistamine is effective in
decreasing the sensation of itching. Keeping finger-
nails short and clean will prevent damage and pre-
vent infection. You may need to place cotton socks
over the hands of infants and small children to
prevent scratching.
Avoid skin irritants including wool, silk, and
mohair. Cotton clothing and bedding is best; so,
when buying blends, one must find the highest
percentage of cotton. Wash the patient’s clothing
and bedding separately from the rest of the family’s,
use a mild soap, and do not use bleach, starch, dryer
sheets, or fabric softeners. You may want to rinse the
clothing more than once.
Avoid getting too hot because this may lead to
sweating and itching. Proper humidification of the
home will be helpful, specifically in the wintertime.
Avoid certain foods that have been identified,
either by history, food diary, or by skin testing. Egg
white, peanut, milk, soy, and wheat are the most
common food allergic triggers. Even minute amounts
of a food may cause a flare of eczema.
Proper skin care is very important. This will be
discussed in detail by your physician.
HIVES AND SWELLING
(Urticaria and Angioedema)
“Hives” is the common word for the condition
urticaria, which is characterized by itchy bumps in
the skin. They vary from pinhead size to welts
several inches across. The wheal, a raised area, is
pale and is usually surrounded by an area of redness
and warmth.
Hives are usually a short-term problem, lasting
from a few hours to a few days (called “acute”
hives). Sometimes, though, they last for several
weeks or months. If they last greater than six weeks,
they are called “chronic”.
What causes hives?
Hives have many causes. Searching for the cause
of hives is frustrating detective work for the patient
and the allergist. In only 10% of the cases is a cause
ever found; of that 10%, only 1/10 or 1% of these are
caused by allergens. The most common allergic
cause is food; and, this can be easily detected by an
accurate history and skin testing. Other causes of
hives from allergy include ingestion of medication,
injection of venom from a bee sting, inhalation of
allergens (uncommon), and, finally, contact with
allergens (e.g. touching pets). Other causes for hives
may include certain contacts to cold, heat, vibration,
physical pressure, and overheating. Exercise can
cause hives. Certain arthritic conditions cause hives.
Chronic hives may be a sign of an underlying medi-
cal illness.
Is diet important?
Food allergy is one of the most frequent causes
of acute hives. Many different foods have been
responsible for triggering hives but in any one per-
son there is usually only one or two foods. Food
additives are prime suspects. In most cases, they are
not the absolute cause of the hives rather they act to
bring out the hives more frequently. FD&C yellow
dye #5 (tartrazine) and preservatives (like sodium
benzoate) are just two examples.
What medications cause hives?
The list of medications is very extensive. The
prime offenders, though, usually are penicillin and
aspirin. Codeine, Demerol, and morphine many
times cause hives. It is important to note that, even
if you are not allergic to aspirin, many individuals
who have chronic hives will have worsening with
ingestion of either aspirin or other non-steroidal
anti-inflammatory medications (Motrin, Naprosyn,
Advil, Nuprin, Anaprox, ibuprofen, etc.).

Are hives a nervous condition?
Hives are frequently blamed on “nerves”. Emo-
tional upset or trauma can result in a flare of hives.
Are hives dangerous?
By themselves, they are not dangerous. Hives
may be a warning of a more serious generalized
allergic reaction. Hives sometimes are associated
with swelling of the lips, tongue, and throat. This
condition is known as “angioedema”. Angioedema
of the larynx (voice box) constitutes a medical
emergency, requiring adrenalin.
Is there a way to test for hives?
A thorough medical history remains the best
diagnostic tool. Skin testing for food, inhaled aller-
gens, drugs, or stinging insects can be done if there
is something in the patient’s history suggesting these
agents as a possible cause of the hives. Blood and
urine tests and x-rays also may be necessary to rule
out any type of other underlying disease that may be
causing the hives.
Can hives be treated?
If the cause can be found, hives can be prevented
from recurring by avoiding the cause. In the mean-
time, the condition can usually be controlled by
taking antihistamines. Sometimes, steroids (pred-
nisone) may be necessary in order to control hives on
a short-term basis. Finally, in the case of acute hives,
adrenalin can be used for immediate relief.
ALLERGIC CONTACT
DERMATITIS
This is an allergic reaction affecting areas of the
skin which becomes red, itchy, and inflamed after a
contact with certain substances. Blisters may also
form on the skin, which later will ooze, thicken, and
crack. This differs from a pure irritant reaction such
as “dishpan” hands.
CHAPTER 8 - SKIN ALLERGIES
What are the most common causes of contact derma-
titis?
Poison ivy, sumac and oak, other plants, cosmet-
ics, drugs, metals, and chemicals are the most com-
mon causes of contact dermatitis.
The oil from the poison ivy is found in the plant’s
sap, which causes the reaction. The response is usu-
ally not immediate and can occur 24-72 hours after
the contact. The rash does not spread from one part of
the body to another, nor is it contagious. Often times,
it will appear at different parts of the body at different
times - but it is due to how quickly that body part
reacts to the initial poison ivy contact - not due to
spreading.
The typical metals that cause contact dermatitis
include nickel, chrome, and mercury. Nickel can be
found in costume jewelry, belts, buckles, wrist
watches, zippers, etc. Since common commercial
metals contain nickel, it is likely that contact with an
object that is chrome-plated will also cause a skin
reaction in a person sensitive to nickel. Contact lens
solutions containing mercury also can cause prob-
lems for some sensitive patients.
Cosmetics have many different chemical ingredi-
ents. Permanent hair dyes containing paraphenylene
diamine are the most common offenders. Dyes used
in clothing can also be irritating. Other products
include perfumes, eye shadows, nail polish, lip sticks,
and sun screen liquids. Contact dermatitis of the face
and eyelids, in most cases, is due to substances on
your hands, like nail polish or hand cream, which
then touch the face.
Drugs, such as neomycin (found in antibiotic
creams), topical antihistamines, novocain, and
paraben, all can cause contact dermatitis.
Who is affected?
In regard to poison ivy, seven of 10 adults could
develop this dermatitis after contact. Adults are af-
fected more often than young children. Heredity has
not yet been shown to play a role in predicting which
family members are more likely to suffer reactions
than others.
CHAPTER 8 - SKIN ALLERGIES
How do you know you have a contact sensitivity?
In regard to poison ivy, the history is usually
pretty clear. The diagnosis of other contact reactions
is determined by the appearance of the reaction, the
location of the reaction, and the history of exposure
to the given material.
Can I be tested for skin contact allergies?
Patch testing is the only known way of testing for
this disorder. This involves taking materials that you
are possibly allergic to and taping them to your skin
for 48 hours and then removing the material, looking
for a similar rash to what you have been experienc-
ing.
Is contact dermatitis treatable?
The answer is definitely “yes”, with avoidance
of the suspected material being the first line of
therapy.
In regard to poison ivy, wash with soap and water
promptly after coming in contact with this plant. If
prompt washing does occur within five minutes,
development of the rash may be avoided. Avoid
excessive scratching of the area, as a secondary
infection may develop. Antihistamines are effective
to reduce the itching. In more severe cases, steroids
may be recommended by your physician, either
topically to the skin or larger doses by mouth.
Immunotherapy (allergy injections) administered
over time to increase tolerance have not been
proven effective as a treatment of contact derma-
titis.
 CHAPTER 9
IMMUNOTHERAPY
ALLERGY INJECTIONS
The stimulation of a patient’s immune system by
the injection of allergens is called immunotherapy or
hyposensitization. Allergy injections or “shots” de-
crease a patient’s sensitivity to these allergens.
Allergy shots contain very tiny amounts of those
things to which you are allergic (pollens, dust, dust
mite, mold, animal dander, and venom). This treats
the basic cause of the problems you came to us about
- ALLERGY. Allergy shots are not a cure. They will
increase your resistance to the allergens that bother
you so that, when you are exposed to those things,
your symptoms will be less severe.
Allergy injections are used in patients who have
severe symptoms which cannot be relieved by taking
medications or avoiding the allergen. They have
been used since 1911. Since that time, many studies
have shown that the vast majority of people who
receive injections, as part of a quality program, will
get better. Remember, even if on allergy injections,
controlling the environment is still the most impor-
tant way to prevent allergic symptoms.
It usually takes about six months of being on the
injections before you will notice a decrease in your
symptoms. After the first year, most patients notice a
significant improvement. Over the next several years,
they will continue to improve until, eventually, the
injections are stopped. A few patients do not get
better with the injections, even though the injections
contain the correct allergens and are given in the
proper manner. If this is the case after 24 months, the
injections should be discontinued. This decision
should be made by your physician and you.
Currently, at least four to five years of injection
therapy is recommended. However, the injections
should probably not be discontinued until the pa-
tient has gone for two to three years without serious
symptoms.
Once allergy injections are discontinued, how
long the benefits last varies from patient to patient.
Some patients remain without symptoms forever;
others will have mild symptoms return but will be
able to control them with medications.
For our patients, we will usually have you take
your injections once or twice a week until you reach
a maintenance dose. Then, you will progress to
every two weeks, three weeks, and then, finally,
once a month.
GETTING YOUR INJECTIONS -
WHAT YOU NEED TO KNOW
1. Are allergy injections dangerous? Generally
speaking, allergy injections are quite safe. Some-
times, they can cause reactions. This is because they
contain the very things to which you are allergic. A
reaction can happen right after you get your shot, or
it can occur later on in the evening. If a serious
reaction is going to take place, it will happen soon
CHAPTER 9 - IMMUNOTHERAPY
after you receive your injection. This is why we ask
you wait in the office for 30 minutes after each
injection and why a physician must always be
present where you receive your injections.
2. What usually happens? A small local reaction
is normal and is no cause for alarm. “Local” means
that it happens around the site of the injection. This
includes redness and itching, much like a mosquito
bite, which lasts no longer than 24 hours.
3. What can happen? There are two types of
reactions to allergy injections that we are concerned
about. This first is a large local reaction, and the
second is a systemic reaction. As stated previously,
a local reaction happens just around the area where
the shot was given. A systemic reaction can happen
in several different areas of the body.
LARGE LOCAL REACTIONS - The local
reaction we are talking about is different from the
normal local reaction. Your arm may get red, itch, or
you may have a welt larger than a half-dollar. There
may be some pain. If you notice any of these within
the first 30 minutes, report at once to the nurse.
These symptoms can usually be relieved quickly. If
they occur at home, you may want to take an antihis-
tamine, apply ice to the area, and take aspirin.
(Aspirin reduces swelling, whereas Tylenol does
not. Either can be used for pain). If you ever have a
lot of itching or pain, swelling larger than a half-
dollar that lasts longer than 24 hours, or an arm that
feels feverish to the touch, BE SURE TO REPORT
IT to the nurse before your next shot. Your dose may
need to be lowered.
SYSTEMIC REACTIONS - This type of reac-
tion is rare, but you should know about it in case it
does happen. As long as you are getting injections
made of something you are allergic to, there is the
chance you could have a systemic, or even life-
threatening, reaction. If something severe is going to
happen, it will be right after taking your injection.
This is why it is so important for you to wait in the
office at least 30 minutes after each injection. We
are prepared for this type of emergency. Signs of a
systemic reaction are: itching of the throat, nose,
eyes, palms, or skin; hives, sneezing; runny nose;
shortness of breath, coughing, or wheezing; dizzi-
ness or lightheadedness. If you notice any of these
symptoms, report to the nurse immediately. If they
occur on the way home, take an antihistamine and/or
anti-wheezing medication at once and return to the
office. If it is after office hours, go to the closest
emergency room.
Most systemic reactions respond to one or two
doses of adrenalin. On occasion oxygen and inhaled
asthma medication given by nebulization may be
needed. On rare occasions an IV line needs to be
established to give fluids and other medications.
If you are taking Beta Blocker medications (drugs
used to treat high blood pressure, migraine head-
aches or glaucoma), please notify your physician. Be
sure to call us at once if Beta Blockers are started by
another physician after you have begun allergy im-
munotherapy. Beta Blockers do not make you more
likely to have an allergic reaction to your allergy
injections. But if a reaction occurs, it can be more
difficult to treat in an individual on Beta Blocker
medications.
Remember allergy injections in most cases do not
cause problems. But we want you to understand the
potential problems, how they are treated, and why
we are insistent on you being closely monitored after
each allergy injection.
 RESOURCES
Organizations
The American Dietetic Association Asthma and Allergy Network
216 W Jackson Blvd 3554 Chain Bridge Rd
Chicago, IL 60606-6995 Suite 200
(1-800-877-1600) Fairfax, VA 22030
(703) 385-4403
The Food Allergy Network American Lung Association
4744 Holly Ave 11720 Beltsville Dr
Fairfax, VA 22030 3rd Floor
(703) 691-3179 Beltsville, MD 20705
(Publishes Food Allergy News, a (1-800-445-6016 - MD only)
bimonthly newsletter with recipes.
Provides how-to-read-label cards and The American Academy of Pediatrics
pamphlets. Specializes in children’s 141 N.W. Point Blvd
food allergies.) Elk Grove, IL 60007
(1-800-433-9016)
Ener-G Foods
PO Box 84487 The American Academy of Asthma, Allergy
Seattle, WA 98124-5787 and Immunology
(1-800-331-5222) 611 E. Wells St
(A good source of milk-, egg-, and Milwaukee, WI 53202
gluten-free foods and information.) (1-800-822-ASMA)

Eczema Association for Science and Education The American College of Asthma, Allergy and
1221 SW Yamhill #303 Immunology
Portland, OR 97205 1645 Oakton
(Provides free literature.) Des Plaines, IL 60018
(1-800-842-7777)
Medic Alert® Bracelet or Necklace
Medic Alert Foundation National Jewish Hospital in Denver, Colorado
PO Box 1009 1400 Jackson St
Turlock, CA 95381 Denver, CO 80206
(1-800-344-3226) (1-800-222-LUNG)

Immune Deficiency Foundation Asthma & Allergy Foundation of America

25 W. Chesapeake Ave National Office
Suite 206 (1-800-7-ASTHMA)
Towson, MD 21204
(410) 321-6647 Maryland Chapter
(1-800-727-WEED)