Eosinophilic esophagitis (EE or EoE) is a relatively newly recognized disease that has been increasingly diagnosed in both adults and children since 2000. It is characterized by a large number of white blood cells called eosinophils that cause inflammation in the esophagus (the tube that connects the mouth and stomach).
This inflammation prevents the esophagus from functioning normally and leads to symptoms. EE commonly occurs in people with other allergic diseases such as allergic rhinitis (hay fever), asthma and/or eczema.
Reflux that does not respond to usual therapy:
- Dysphagia (difficulty swallowing)
- Food impactions (food gets stuck in esophagus)
- Nausea and vomiting
- Failure to thrive (poor growth, malnutrition or weight loss)
- Abdominal or chest pain
- Feeding refusal/intolerance or poor appetite
- Difficulty sleeping
The only way to definitively diagnose EE is through endoscopy with biopsies, usually done by a gastroenterologist. The endoscopy is often performed after treatment with reflux medications have failed to relieve symptoms. During the endoscopy, the gastroenterologist looks at the esophagus, stomach and duodenum (the first part of the small bowel) through an endoscope (small tube inserted through the mouth) and takes multiple biopsies (small tissue samples) which a pathologist reviews under the microscope. A high number of eosinophils (>15 per high power field under the microscope) suggests a diagnosis of EE.
Once EE is confirmed, allergy testing is recommended as many patients with EE have underlying food and possibly environmental allergies that are contributing to the abnormal inflammation seen in the esophagus. The most common type of allergy testing is skin prick testing, but patch testing to certain foods can be useful as well. In patch testing, a small amount of the foods is placed on the skin (usually the back) and covered with tape for 48-72 hours. At that point, the site is assessed for evidence of redness and inflammation indicating food allergy.
At present the two main treatments recommended are dietary management and topical corticosteroids.
Elimination Diets – All “positive” foods on allergy testing are removed from the diet. Often this is the only treatment needed.
Six-food Elimination Diet – Patients eliminate the top 6 most allergenic foods (dairy, eggs, wheat, soy, peanuts/other nuts, fish/shellfish).
Elemental Diets – All sources of protein are eliminated from the diet except for an amino acid (building blocks of protein) formula. These diets are mostly used in young children with EE.
Food Trials – This involves adding back one ingredient at a time to one’s diet to determine specific foods causing a reaction. They begin after symptoms resolve and eosinophils have cleared.
Medications - Medications most commonly include steroids to control inflammation and suppress eosinophils. They can be taken orally (a form of prednisone) or topically (swallowed asthma inhaled steroid such as fluticasone or budesonide).
How We Can Help
The diagnosis and treatment of eosinophilic esophagitis requires a multidisciplinary team approach involving gastroenterologists, allergists, nutritionists. As part of the nation’s largest allergy practice, Allergy Partners’ physicians provide the expertise needed to accurately diagnose underlying allergic triggers to EE. With this information, a personalized and comprehensive treatment plan aimed at alleviating symptoms of EE can be formulated.
November 22-23, 2012 for Thanksgiving
December 24, 2012-January 1, 2013 for Christmas/New Years
The staff and doctors at Allergy Partners of the Midlands wish you and yours a very happy Holiday!
ECZEMA (Atopic Dermatitis)
Atopic dermatitis, also known as eczema (pronounced “EK-zema”), is a skin condition that causes dry, scaly, red, and itchy skin. It can occur at any age, and is more frequent in some families.
Eczema affects 10-20% of children and 1-3% of adults. The cause of atopic dermatitis is unknown, but genetic factors play a strong role. The symptoms are secondary to a dysfunctional outer layer of the skin known as the epidermis. Normally, an intact epidermis keeps out environmental irritants, allergens, and microbes. Because the skin is not working properly, these substances get into the body which lead to inflammation. In children with moderate to severe atopic dermatitis, up to 2/3 of them may have some underlying food allergy.
Most people with atopic dermatitis have symptoms before the age of five. Intense itching of the skin, patches of redness, small bumps, and skin flaking are common symptoms. Scratching can lead to additional inflammation, which causes a cycle of itching and scratching that worsen the disease and can potentially lead to decreased sleep and quality of life. In severe exacerbations, the skin may actually start oozing which can be a sign of infection.
There is no specific test to diagnose atopic dermatitis. The diagnosis is based on clinical information like the patient history and physical examination. Testing done by a well-qualified allergist can identify potential triggers like environmental or food allergens.
SKIN CARE, SKIN CARE, SKIN CARE! Appropriate skin care is the cornerstone of treatment for atopic dermatitis. Aggressive moisturizing with a good quality, hypo-allergenic lotion or cream is the key to preventing skin dryness.
The lotion should be applied at least twice a day and within 3 minutes after bathing. Both intermittent and daily bathing are appropriate, but a fragrance free soap and pat-down drying should be used.
Avoiding known triggers can reduce the intensity of atopic dermatitis. Irritants, stress, heat/sweating, infections, and allergens can all cause exacerbations.
Topical steroids or anti-inflammatory creams should be used as needed on red inflamed areas of skin. Only low potency creams should be used on the face because the skin on this part of the body is thin.
Medications like oral anti-histamines can be prescribed to attempt to control itching, but this is controversial.
Treatments like bleach baths and wet wraps can be used in select cases as determined by your physician.
How We Can Help
An allergist can help identify environmental or dietary triggers and work with patients and their families in creating an effective and practical treatment plan. Skin testing to identify these potential triggers should be performed by a trained professional.
Reactions to food are common, and can be divided into two categories, those caused by food allergy and all other reactions. Food allergies develop when the body's immune system has an abnormal reaction to one or more proteins in a food. Food allergies can lead to serious or even life-threatening allergic reactions. Food allergies can be further divided into “classic” and “non-classic” types. Other food reactions are not caused by the immune system. These reactions cause unpleasant symptoms and are far more common than food allergies. Examples include lactose intolerance, heartburn (gastroesophageal reflux), bacterial food poisoning, and sensitivity to caffeine.
Although 20-30% of people report food allergies, only 6-8% of children and 3-4% of adults have “classic” food allergy. The most common foods causing allergy are cow’s milk, egg, peanuts, soy, wheat, tree nuts, fish, and shellfish.
In people with "classic" food allergies symptoms typically occurs quickly, within minutes to two hours after eating. The most common symptoms of food allergy include:
Skin: Itching, flushing, hives (urticaria), or swelling (angioedema)
Eyes: Itching, tearing, redness, or swelling of the skin around the eyes
Nose and mouth: Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste
Lungs and throat: Difficulty getting air in or out, repeated coughing, chest tightness, wheezing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking
Heart and circulation: Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure
Digestive system: Nausea, vomiting, abdominal cramps, or diarrhea
Nervous system: Anxiety, confusion, or a sense of impending doom
Some individuals suffer from “non- classic” food allergies. The symptoms of this type of food allergy are usually slower to develop and longer lasting than those of classic food allergies. Symptoms commonly include vomiting, diarrhea, abdominal pain, and/or blood in the stool. Food protein-induced enterocolitis and proctitis/proctocolitis are common types of non-classic food allergy that are seen often in infancy.
A complete and detailed medical history is essential for initiating the proper work up for food allergy. Specific skin and blood testing gives providers added information on determining the likelihood of “classic” food allergy. If a person had a reaction after eating peanuts, but has never reacted to wheat or eggs and eats them regularly, it is not necessary to test for allergy to wheat or eggs. The gold standard test for all food allergy is the oral food challenge, where the food is ingested by the patient in a controlled setting (clinic or hospital) to monitor for reaction. It is important to note that neither the size of the skin prick test nor the level on blood tests translate into severity of allergy. These tests only speak to the likelihood of any reaction.
Once a food allergy is certain, the best treatment is to avoid the food. Patients must carefully check ingredient labels for all food products. The most important aspect of the treatment plan is to have emergency medications available at all times in case of an allergic reaction. In the case of a severe allergic reaction, timely administration of self-injectable adrenaline is the cornerstone of treatment.
How We Can Help
Your Allergy Partners board-certified provider can assist in determining whether or not a food allergy exists, what type of food allergy it is, and what treatment plan is appropriate. Your allergist will help you understand the potential testing options as well as directing you to helpful resources like special food allergy cookbooks, patient support groups, and registered dieticians.
With the warmer weather of summer, we are enjoying more time outside. Along with the summer weather comes a dramatic rise in the number of stings from bees and fire ants. For many people these stings are painful and annoying but not dangerous. However, approximately 1 in 100 people has a potentially life-threatening allergy to insect stings. The insects most often responsible for serious allergic reactions are honey bees, wasps, hornets, yellow jackets, and fire ants. Although intimidating by virtue of their size, bumble bees rarely sting.
An allergic reaction can involve the entire body and advance rapidly after the sting. Common symptoms include itching, hives and swelling distant from the site of the sting. Dizziness, asthma symptoms, nausea, vomiting and a drop in blood pressure, shock and unconsciousness may also occur. Severe reactions may be fatal if medical treatment is not obtained immediately.
Once an individual has experienced a severe reaction, they have a 60-70% chance of experiencing a similar or more severe reaction with each future sting. Therefore, anyone who has experienced any of the above symptoms following a sting should carry an EpiPen at all times. However, with insect venom allergy, epinephrine is not enough. Using an EpiPen is critical for treating a severe reaction. However, it cannot prevent future reactions. Anyone with an allergic reaction to a sting should be evaluated by an allergist for testing and consideration of immunotherapy. Allergy shots to stinging insect venom are 98% effective in preventing future stings and are the standard of care treatment for venom allergy.
Stinging insect allergy is potentially fatal. Fortunately, current treatment is very safe and highly effective. Allergy shots to venom can be life-saving. Don’t let the fear of stings keep you indoors this summer. If you have a history of reactions to stings, see us for an evaluation.
Approximately one person in ten has asthma. As we recognize Asthma Awareness Month, help us educate others by sharing your story about how you found out you had asthma on our Facebook page! www.facebook.com/midlands
Understanding Your Asthma
What Is Asthma?
Asthma is a common lung disorder in which the inner lining of the small breathing tubes of the lungs, the bronchioles, becomes inflamed and swollen. At times this leads to spasms or narrowing of these tubes. This may cause wheezing, shortness of breath, and/or tightness in the chest. Cough, especially with exercise or in the middle of the night, is particularly common in asthma. In mild asthma, the only symptom may be cough. Wheezing may not occur, or may only be heard by your doctor listening with a stethoscope.
Who Develops Asthma?
Asthma may develop at any age, but most commonly does so in early childhood, or mid-adulthood. Most cases that occur in childhood improve greatly over time and with appropriate treatment. Many cases that occur in adulthood respond well to treatment, but remain chronic.
Approximately one person in ten has asthma. Many people with mild asthma may not even be aware they have it. The tendency in asthma is often inherited, and is often strongly related to allergies, particularly in childhood. The majority of children with asthma have allergies that cause or significantly aggravate their asthma.
What Causes Asthma?
As with many medical conditions, a combination of heredity and environment plays the biggest role in both causing and aggravating asthma. The most common triggers of asthma are allergies, respiratory infections, exercise, and cigarette smoke.
The allergens that most commonly trigger asthma are inhalants, such as house dust mites, pollens, molds, and animal danders. When the allergens are inhaled into the lungs, they directly provoke asthma by causing swelling of the lining of the bronchioles and mucus production. Asthma is indirectly worsened by allergies for two reasons: first, nasal congestion interferes with the normal filtering and humidification of inspired air; and second, the postnasal drainage from allergies aggravates the cough and wheeze associated with asthma.
Viral respiratory infections commonly cause asthma to flare temporarily, especially in young children, and account for some of the wintertime worsening seen in this age group. Smoldering sinus problems will worsen asthma as well.
Exercise, or any hyperventilation such that occurs with heavy laughing or emotional upset, will cause the bronchioles to tighten. This is because the asthmatic lung is overly sensitive to the sudden cooling and drying of the airway caused by rapid and deep breathing. For this reason, exercise in cooler weather often causes more trouble.
Cigarette smoking, both active and secondhand, is extremely harmful to patients with asthma. Smoke contains numerous toxic gases and particles that further irritate the already inflamed airway of the asthmatic. Cigarette smoking by asthmatics increases the severity of the asthma immediately, and further increases the likelihood of permanent lung damage.
How is Asthma Diagnosed?
Asthma is usually suspected when the characteristic symptoms occur, especially at nighttime, with exercise, with colds or with allergy flare-ups.
Definitive diagnosis and optimal treatment of each individual case requires not only periodic exams, but also measurements of lung function, starting by five or six years of age. This is done by measuring the amount and rate of air flow from your lungs. We often check to see how this changes after using an asthma inhaler. These results, along with your progress since your last visit, allow us to customize and update your treatment plan.
Since allergies are a common trigger in up to 85% of individuals with asthma, we will usually perform allergy testing as part of the initial evaluation in order to optimize your treatment. Chest x-rays, blood work, and other tests are rarely needed for the diagnosis and management of asthma, unless other medical problems are suspected.
How is Asthma Treated?
There are four general areas of asthma treatment. We will often recommend a combination of more than one, or even all, of these depending on your unique situation.
Avoidance of allergens and irritants: Depending on your history and the results of any allergy testing, we may recommend specific measures to reduce your exposure to the substances to which you are allergic. This will help reduce the amount of medication you need to control your asthma.
Treatment of underlying medical conditions: Chronic sinus problems, stomach acid reflux, obesity, and other conditions may cause or aggravate asthma. It is important that these problems be addressed in order to have ideal control of your asthma.
Medications: There are two basic categories of asthma medications- the first are bronchodilators, which temporarily relieve symptoms by relaxing constricted bronchial tubes. These are typically used only when needed. The second are anti-inflammatory medications, which prevent or heal the inflammation inside the bronchial tubes. These are generally used every day, even when you feel well.
Allergy immunotherapy: Allergy injections are the most effective long-term preventative strategy for allergy treatment. In the many cases of asthma where allergies are a significant trigger, injections help decrease asthma symptoms, reducing the amount of medications needed to control asthma.
Your Allergy Partners physician can help determine the cause of your asthma by combining a thorough medical history and physical examination with appropriate diagnostic testing. An allergist is an expert at managing asthma to ensure long-term health and well-being.
Spring allergies are now in full bloom. The spring allergy season kicked off with tree pollen and in some parts of the country this has been joined by grass pollen. Many of you have already experienced that yearly increase in nasal and eye symptoms. While pollen allergies lead to the more obvious symptoms of runny nose, congestion and itchy eyes, allergic reactions to pollen often leads to some less obvious symptoms.
Allergies are one of the leading triggers for asthma. If you experience more coughing, bronchitis, chest tightness, shortness of breath or wheezing during the pollen season, these symptoms may be triggered by your allergies. Allergies also increase the rate of sinus and ear infections. Allergic inflammation can prevent the ears and sinuses from draining properly which in-turn makes you more likely to develop infections. Getting control of your spring allergies will not only provide relief from your nasal and eye symptoms, it often reduces your need for asthma medications and antibiotics.
Minimizing your exposure to spring pollens will reduce your allergy symptoms. Some basic avoidance tips include:
· Keep windows closed to prevent pollens from drifting into your home.
· Minimize early morning activity when pollen is usually emitted — between 5:00 and 10:00 a.m.
· Keep your car windows closed when traveling.
· Stay indoors when the pollen count (which is available from our home page) is reported to be high, and on windy days when pollen may be present in higher amounts in the air.
· Machine dry bedding and clothing. Pollen may collect in laundry if it is hung outside to dry.
Of course, avoidance is not always practical. We want to be outdoors and enjoy the spring weather which means exposing ourselves to pollen. Regular use of your allergy medications such as nasal steroids and antihistamines will help control your allergy symptoms. If medications are not providing complete relief or if you prefer to avoid regular mediation use, consider allergy shots (allergy immunotherapy) to gain better control of your allergies. This non-medication treatment contains natural extracts of allergens and slowly reduces the severity of your allergic reactions. Over and over this has been shown to be the most effective treatment for pollen allergies. Allergy shots are effective for 85% of patients, reduce the need for medication and in the long run are less expensive than medication use.
You do not need to live with allergy symptoms and relief is available. If you are experiencing spring allergies, make an appointment with your local Allergy Partners office.
New Advances in Immunotherapy
Recent and exciting changes to our immunotherapy program include the development of a cluster immunotherapy program that allows patients to reach maintenance immunotherapy in as short as four weeks. Allergy Partners is also excited to offer sublingual immunotherapy to appropriate patients. Compared to traditional immunotherapy, sublingual immunotherapy has a reduced risk of reactions that allows patients to receive immunotherapy at home.
What is Cluster Immunotherapy?
Cluster immunotherapy is an accelerated version of traditional immunotherapy. Our standard immunotherapy build up schedule calls for 27 incremental doses given once or twice a week. In Cluster, this build up period is condensed into 8 ‘sessions’ held once or, ideally, twice a week. At each session, the patient will receive 2-3 doses of immunotherapy separated by a 30 minute waiting period. While sessions may last up to 90 minutes, a patient can reach maintenance dosages in as little as 4 weeks. Such a schedule is very appealing to patients desiring to see results more quickly or whose schedule is better suited to a more intensive initial phase of immunotherapy.
What is Sublingual Immunotherapy?
Sublingual immunotherapy utilizes allergens administered in a liquid or tablet form under the tongue to achieve immune changes as seen in traditional immunotherapy. Sublingual immunotherapy is currently not FDA approved in the United States, but research in both the US and abroad, demonstrate that sublingual immunotherapy can be a safe and effective treatment for allergic rhinitis. Allergy Partners physicians have been deeply involved in sublingual immunotherapy studies and development. After a careful review of all the current available data, Allergy Partners is pleased to announce that we will begin offering this form of immunotherapy to appropriate patients. Patients for whom this treatment may be a good option include those who are needle phobic, those who have not tolerated traditional immunotherapy well, and those with isolated seasonal symptoms. In addition, sublingual immunotherapy appears to be an exciting option for young children.
Talk with your Allergy Partners physician today to determine which method may be best suited for your individual situation.
The Allergy Partners Difference
Allergy Partners is the nation's largest single-specialty practice dedicated to the treatment of allergies, asthma, and allergic diseases. All Allergy Partners’ physicians are board-certified allergists who have years of training and experience in the treatment of allergies and asthma. Working together, our physicians are able to combine their expertise to ensure that each and every patient receives the very best care. Our physicians are dedicated to identifying clinical best practices that will ensure the very best outcomes for each patient. Such collaboration produces what we like to call the Allergy Partners Difference.
One example of the Allergy Partners Difference is our state-of-the-art allergen immunotherapy program and extract lab. To ensure that immunotherapy is as safe and effective as possible, it is imperative that the extract be made with the highest quality raw materials, that the dosage be optimized to ensure effectiveness and safety, and that the extract be individualized for the patient. Working with national organizations and extract manufacturers, Allergy Partners has developed a state-of-the-art immunotherapy program. Our centralized extract lab, located in Asheville, North Carolina, produces the highest quality allergen extract possible. Abiding by national immunotherapy standards, all Allergy Partners extract is designed to provide each patient an individualized vaccine that will provide the utmost clinical effectiveness while maintaining patient safety.
Allergy Partners is also committed to using the latest technology to improve patient outcomes. Allergy Partners has adopted electronic health records to improve patient safety and communication with referring physicians. All Allergy Partners physicians also employ a secure internal e-mail system that allows them to virtually discuss difficult cases with the entire group of allergists. This affords the patient with access to not just his or her allergist, but a network of over 60 board-certified allergists to help solve the problem.
Allergy Partners is dedicated to patient education. Our new website was built and designed by our physicians and contains a wealth of educational material to help families and patients manage their allergies and asthma. You can also find information about upcoming events and news, as well as local allergy and asthma information by ‘Liking’ us on Facebook and ‘Following’ us on Twitter.
We invite you to learn more about Allergy Partners, the conditions we treat, and the services we provide by browsing our website, visiting our social media pages or contacting the practice. Check back often for new updates and the latest information!