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Select ServicesFood Allergy Reaction HotlineFood Allergy 101Allergy ShotsBiologicsClinical ResearchCluster ImmunotherapyDrug AllergyEnvironmentalFood AllergyFood Allergy Risk Reduction (FARR®)Food Oral Immunotherapy (OIT)Insect AllergyMedicationsMetal AllergyPulmonary Function TestsSkin Testing

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  Allergy Shots

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  Allergy shots (also called subcutaneous immunotherapy, or SCIT) is one of the best treatments available for your allergies and asthma. It is one of the few disease-modifying therapies available in medicine and targets the underlying cause of various allergic conditions. SCIT offers the potential of improving asthma control, providing relief from allergy and sinus symptoms, and reducing the need for medicines in the future. In children, allergy shots are particularly helpful as they can reduce the risk of becoming more allergic or developing asthma later in life.

  WHAT ARE ALLERGY SHOTS?

  Allergy shots contain all-natural proteins from allergens found in the environment. Patients are first tested to determine what they are allergic to. Customized allergen extract vials are then produced for each patient based on these results which are injected underneath the skin.

  HOW DO ALLERGY SHOTS WORK?

  By giving increasing doses of allergen proteins in the body, our immune system starts to recognize and become tolerant to these substances. Once tolerance is achieved with a SCIT regimen, we don’t experience allergic inflammatory reactions when exposed to allergens in the environment. Ultimately, this leads to improved symptoms and less reliance on medications. Studies have shown a sustained effect of symptom relief for many years after the completion of a SCIT regimen.

  WHAT’S INVOLVED IN ALLERGY SHOTS?

  Regimens for allergy shots include two phases, the build-up phase and the maintenance phase. Allergy injection build-up is the process of gradual dose increases working up to the target or therapeutic dose. This allows the body time to get used to receiving something it is allergic to. Once the target dose has been achieved, this dose is maintained for a period of 3-5 years in most patients. It is during this maintenance phase that the immune system becomes tolerant and shifts from being allergic to becoming non-allergic. Although allergy shots are not a cure for allergies, it acts on the immune system to prevent the allergic response from even starting, as opposed to just treating symptoms once they occur. Each patient is different and both build-up and maintenance can be customized to meet individual needs.

  WHAT ARE THE RISKS OF ALLERGY SHOTS?

  Most reactions to shots are localized and appear as redness or swelling at the injection site. This typically occurs within a couple of hours of the injection and clears up soon afterwards. Systemic reactions are much less common and can range in severity. Most reactions are mild and include symptoms such as itching, sneezing, congestion, or hives. Rarely, a more serious systemic reaction (or anaphylaxis) can occur that may lead to coughing, wheezing, swelling of the throat, or dizziness. Most systemic reactions occur within the first 30 minutes of the injection, which is why it is important that injections are only administered in a medical facility where patients can be observed during this time.

  WHAT ARE THE BENEFITS OF ALLERGY SHOTS WITH ALLERGY PARTNERS?

  Allergy Partners is the nation’s largest Allergy and Immunology practice, which has allowed us to compile the largest database of SCIT patients in the world. We have worked closely with leading allergen extract manufacturers and the national guideline committee for immunotherapy to develop our state of the art immunotherapy program. At Allergy Partners, we strive to provide the safest and most effective care for our patients.

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  Biologics

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  What is a “biologic?”
  Biologics are injectable medications made from modified antibodies. The antibodies have been altered, and when given, improve control of certain types of allergic diseases. Although considered immune therapy, biologics do not affect the body’s response to infections. These medications are typically used when symptoms are not controlled with other prescribed treatments, and are currently approved for adults as well as children down to age 6 years

  Here are some of the biologics offered at Allergy Partner practices*:

  Xolair was one of the first antibody injections and was introduced in 2003. This antibody actually targets another antibody that is too high in allergic asthma patients (called IgE). It’s helpful for patients with asthma triggered by allergies as well as for those with nasal polyps and chronic hives.

  Fasenra is an antibody injection that targets allergy cells (called eosinophils) that are too high in many patients with severe asthma.

  Nucala targets the survival signal for eosinophils. This treatment can be helpful for asthma sufferers as well as for patients with other diseases of eosinophils – Hypereosinophilic Syndrome (HES) and Eosinophilic granulomatosis with polyangiitis (EGPA, or sometimes called Churg-Strauss Syndrome).

  Dupixent is an antibody injection that targets an intermediate signaling particle in the allergic reaction
  pathway which can lead to improvement in asthma, chronic sinus disease with nasal polyps and eczema
  patients as well.

  When biologics are administered in a medical or office setting, our practices are designed to make the
  process as easy as possible.

  * Please check with your AP provider on which biologics they offer.

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  Clinical Research

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  Want to be on the leading edge of therapeutic programs and diagnostic tests for allergies or immunodeficiency? Select Allergy Partners’ locations offer patients that opportunity through our clinical research studies. Our practice has been selected as one of the few in the nation to conduct FDA approved clinical research studies in our field.

  What are the benefits?

  One immediate benefit is that you are treated in the study at no financial cost to you and without the need of insurance. In addition, if you qualify for the clinical study and decide to participate, you are compensated for your time and travel.

  Why do we offer these research opportunities to patients?

  The clinical studies are in line with our mission to empower patients through education and research. These studies test safety and effectiveness of the latest pharmaceutical agents before and after these new medications reach the general public. Allergy Partners conducts FDA approved clinical research studies from Phases I to IV . These investigative studies are planned for improved treatment of asthma, allergic rhinitis, atopic dermatitis, immunodeficiency and other related problems.

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  Cluster Immunotherapy

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  What is Cluster Immunotherapy?

  Cluster immunotherapy is an accelerated version of traditional immunotherapy. Allergy Partners’ standard immunotherapy build up schedule calls for 26 incremental doses given once or twice a week. In Cluster, this build up period is condensed into 9 ‘sessions’ held once or, ideally, twice a week.

  Why Choose Cluster Immunotherapy?

  At each session, the patient will receive 1-3 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 a little as 4 weeks. Such a schedule may be very appealing to patients desiring to see results quicker or whose schedule is better suited to a more intensive initial phase of immunotherapy.

  What are the Risks?

  With such rapid escalation in dosing, there can be an increase rate of local reactions. There is also an increased risk of anaphylaxis. Allergy Partners recommends pre-medication with a non-sedating antihistamine and a leukotriene modifier for patients undergoing cluster.

  Cluster may not be suited for extremely sensitive patients or those with significant asthma or underlying medical conditions. Some providers may choose a slightly modified schedule based on your history, symptoms, and test results. As always, your Allergy Partners’ physician will discuss the relative risks and merits of Cluster with you to ensure that you receive immunotherapy in the manner best suited to your individual situation.

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  Drug Allergy

  Testing & Treatment

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  If you develop a rash, hives or difficulty breathing after taking certain medications, you may have a drug allergy. As with other allergic reactions, these symptoms can occur when your body’s immune system becomes sensitized to a substance in the medication, perceives it as a foreign invader and releases chemicals to defend against it.

  Symptoms

  While you may not experience allergic symptoms the first time you take a drug, your body could be producing antibodies to it. As a result, the next time you take the drug, your immune system may see it as an invader, and you’ll develop symptoms as your body releases chemicals to defend against it.

  These symptoms may include:

  • Skin rash or hives
  • Itching
  • Wheezing or other breathing problems
  • Swelling
  • Vomiting
  • Feeling dizzy or light-headed

  Anaphylaxis, a potentially life-threatening reaction that can impair breathing and send the body into shock; reactions may simultaneously affect two or more organ systems (for example, when there is both a rash and difficulty breathing)

  Penicillin causes most allergic drug symptoms. Just because you show allergic symptoms after taking penicillin doesn’t mean that you will react to related drugs, such as amoxicillin, but it’s more likely. Also, just because you had a reaction to penicillin (or any other drug) at one time doesn’t mean you will have the same reaction in the future.

  Antibiotics that contain sulfa drugs, such as Septra, Bactrim, and Pediazole, occasionally cause allergic reactions. Non-antibiotic drugs containing sulfa are very low-risk.

  Diagnosing

  Drug allergies can be hard to diagnose. An allergy to penicillin-type drugs is the only one that can be definitively diagnosed through a skin test. Some allergic reactions to drugs particularly rashes, hives and asthma can resemble certain diseases.

  Your allergist will also want to know whether you have had a reaction to any other drug. If you can, bring the suspected drug with you. This will help the allergist recommend alternatives as needed.

  Depending on the drug suspected of causing the reaction, your allergist may suggest a skin test.

  If a drug allergy is suspected, your allergist may also recommend an oral drug challenge, in which you will be supervised by medical staff as you take the drug suspected of triggering a reaction. (If your reaction was severe, a drug challenge may be considered too dangerous.)

  Management and Treatment

  If you have a drug allergy:

  • Make sure all of your doctors are aware of your allergy and the symptoms you experienced.
  • Ask about related drugs that you should avoid.
  • Ask about alternatives to the drug that caused your allergic reaction.
  • Wear an emergency medical alert bracelet or necklace that identifies your allergy.

  Anaphylaxis

  Anaphylaxis is a severe, potentially life-threatening reaction that can simultaneously affect two or more organ systems (for instance, when there is both swelling and difficulty breathing, or vomiting and hives). If this occurs, call 911 and seek emergency medical care immediately.

  If you are caring for someone who appears to be having a severe reaction to a drug, tell the emergency care team what drug was taken, when it was taken and what the dosage was.

  If your allergic reaction to a drug is not life-threatening, your allergist may give you:

  • An antihistamine to counteract the allergic reaction
  • A non-steroidal anti-inflammatory drug, such as ibuprofen or aspirin, or a corticosteroid to reduce inflammation

  Drug desensitization

  If there is no suitable alternative to the antibiotic that you are allergic to, you will need to undergo drug desensitization. This involves taking the drug in increasing amounts until you can tolerate the needed dose with minimal side effects. This will most likely be done in a hospital so immediate medical care is available if problems develop.

  Desensitization can help only if you are taking the drug every day. Once you stop it — for example, when a chemotherapy cycle ends — you will need to go through desensitization a second time if you need the drug again.

  Penicillin Allergy

  Nearly everyone knows someone who says they are allergic to penicillin. Up to 10 percent of people report being allergic to this widely used class of antibiotic, making it the most commonly reported drug allergy. Over time, however, the vast majority of people who once had a severe allergic reaction to penicillin loses sensitivity and can be treated safely with the drug (although 10 percent of individuals will remain allergic).

  Penicillin Allergy Testing and Diagnosis

  An allergist can help you evaluate the safety of taking penicillin.

  In addition to assessing your detailed history about a prior allergic reaction to penicillin, allergists administer skin tests to determine if a person is or remains allergic to the medication. These tests, which are conducted in our office, typically take about two to three hours, including the time needed after testing to watch for reactions.

  When safely and properly administered, skin tests involve pricking the skin, injecting a weakened form of the drug, and observing the patients reaction. People who pass penicillin skin tests by reacting negatively to the injection are seen as at low risk for an immediate acute reaction to the medication. The allergist might then give these individuals a single, full-strength oral dose to confirm the absence of a penicillin allergy.

  Those with positive allergy skin tests should avoid penicillin and be treated with a different antibiotic. If penicillin is recommended, people in some cases can undergo penicillin desensitization to enable them to receive the medication in a controlled manner under the care of an allergist.

  Penicillin Allergy Treatment

  Those who have severe reactions to penicillin should seek emergency care, which may include an epinephrine injection and treatment to maintain blood pressure and normal breathing.

  Individuals who have milder reactions and suspect that an allergy to penicillin is the cause may be treated with antihistamines or, in some cases, oral or injected corticosteroids, depending on the reaction.

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  Environmental

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  Our homes, schools and workplaces contain causes of environmental allergies. These inhaled “causes” can include: dust, animal dander, feathers, mildew and mold spores.

  The best defense is to avoid the allergens that cause your symptoms. This is not always easy to do, especially if the problem is plant pollens, mold, or other substances in the air that are difficult to avoid. Your allergist can provide information that will help decrease your exposure and discuss treatment options that will help reduce your sensitivity to those allergens that affect you.

  Useful tips for the most common environmental triggers:

  Dust mites are tiny bugs that live in bedding, mattresses, upholstered furniture, and carpets. No matter how clean your house is, it’s impossible to completely get rid of dust mites. However, you can limit contact, especially in the bedroom, if you:

  • Put special dust-proof covers on pillows, mattresses and box springs. Remove and clean the covers frequently.
  • Limit the number of stuffed animals kept in bedrooms or put them in plastic containers.

  Grasses, trees and weeds produce pollens that travel through the air and are inhaled. They cause seasonal allergy symptoms and trigger asthma. Pollens from trees are higher in the spring, grasses in the summer and weeds in the fall. The beginning and end of each season may vary depending on weather conditions and where you live. If possible:

  • Keep windows closed during pollen season, especially during the day.
  • Stay inside during mid-day and afternoon hours when pollen counts are highest.
  • Take a shower, wash your hair, and change clothing after working or playing outdoors.
  • Allergic reactions to pets are caused by the animal’s dander. Short-haired pets are not any less likely to cause a reaction than long-haired animals.
  • Keep the pet outdoors or restrict it to a few rooms in the house. At the very least, keep the pet out of the bedroom.
  • Wash hands after petting.
  • Bathe your pet once a week to reduce dander.

  Molds are found in outdoor air and can enter your home any time you open a door or window. Any house can develop a mold problem with the right conditions. Molds like to grow on wallboard, wood, or fabrics, but they will grow any place. They thrive in damp basements and closets, bathrooms (especially showers), places where fresh food is stored, refrigerator drip trays, house plants, air conditioners, humidifiers, garbage pails, mattresses, and upholstered furniture.

  You can control mold in your home if you:

  • Clean bathrooms, kitchens, and basements regularly and keep them well aired.
  • Do not use humidifiers.

  Other irritants that may also trigger your symptoms:

  • Smoke – Avoid tobacco smoke and do not allow anyone to smoke in your home or car. If you smoke, try to quit. Do not use wood burning stoves or fireplaces.
  • Odors – Stay away from strong odors such as perfume, hair spray, paint, cooking exhaust, cleaning products and insecticides. Room air fresheners and electronic air cleaners also can trigger symptoms.
  • Cold air – Cover your nose and mouth with a scarf.
  • Colds and infections – Wash hands frequently.
  • Exhaust – If you have an attached garage, don’t start the car and let it run in there. Fumes can make their way into the home even when the garage door is open.
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  Food Allergy 101

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  The physicians and staff at DFAC are dedicated to the diagnosis and management of food allergies. We understand how the diagnosis of food allergy can be a life changing event with far reaching quality of life implications. The following is a summary of our current understanding of food allergies, including diagnostic methods, management strategies, educational resources and future directions in treatment. We hope that this information will address most frequently asked questions and stimulate additional discussions with our physicians and clinical staff.

  FOOD ALLERGY PREVALENCE IS ON THE RISE

  The prevalence of food allergies in the general population (both children and adults) has clearly increased during the last 20 years. While newly recognized food allergy syndromes, changing definitions and increased availability of commercial allergy testing methods have no doubt contributed to some degree to the rising number of food allergy diagnoses, the incidence of confirmed cases of anaphylactic (life threatening) reactions to common foods has more than doubled during this period, from approximately 1% to 2-3% of the population. Several theories have been proposed to explain the rise in food allergy prevalence, ranging from environmental influences of modern Western society to the ways in which we introduce new foods to infants and young children. However, at this time none of these theories has yielded definitive answers or practical solutions to prevent the development of food allergies.

  OVERVIEW OF FOOD ALLERGY DISORDERS

  PROBLEMS THAT WE EVALUATE AND TREAT
  Although food allergies can present with a variety of different symptoms, the single defining feature of all food allergic disorders is an immunologic mechanism. Immediate allergic reactions (IgE-mediated hypersensitivity reactions), ranging in severity from hives to anaphylactic reactions, are among the most common problems for which patients are referred to our practice. Additional food allergy-related disorders with less clearly defined immunologic mechanisms that we evaluate and treat include atopic dermatitis (eczema), Food Protein-Induced Enterocolitis Syndrome (FPIES), and Eosinophilic Esophagitis (EoE).

  PROBLEMS THAT WE DO NOT EVALUATE OR TREAT
  A notable immunologically mediated food hypersensitivity disorder that we are often asked to evaluate is celiac disease or gluten sensitive enteropathy. We generally refer patients with suspected celiac disease to GI specialists for proper diagnosis and management. In addition, we do not subscribe to the rising common misconception that gluten or casein sensitivities are underlying causes of Autistic Spectrum Disorder.   Additional food sensitivity complaints for which we do not recommend our services include: (1) ADD/ADHD; (2) multiple chemical sensitivities; (3) Chronic Fatigue Syndrome; (4) provocation/neutralization therapy.

  IgE-MEDIATED FOOD ALLERGIES

  The hallmark of these disorders is the potential for life threatening allergic reactions (also known as anaphylaxis) occurring within minutes after ingesting a tiny quantity of the suspect food. Symptoms of anaphylaxis may include any of the following: hives (welts), eye or facial swelling, throat swelling, change in the sound of the voice, cough, wheezing, difficulty breathing, abdominal cramping, nausea, vomiting, dizziness, faintness, sudden quietness, cardiovascular collapse and death. Milk, egg, wheat, soy, peanut, tree nuts, fish and shellfish account for more than 90% of IgE-mediated food allergic reactions. Milk, egg and wheat allergy often begin during the first year of life as these foods are being introduced into the baby’s diet. Allergic sensitivity to these foods often resolves after 5-10 years of avoidance.   By contrast, nut, fish and shellfish allergies are usually lifelong problems.

  DIAGNOSIS OF IgE-MEDIATED FOOD ALLERGIES

  The proper diagnosis of an IgE-mediated food allergy begins with a carefully obtained medical history to determine which food(s) may be responsible for an observed allergic reaction. Because such reactions typically begin within 60 minutes following ingestion, we can usually identify candidate foods for testing by obtaining a detailed history of the events leading up to the reaction. Allergy testing should be limited to the suspected food(s). Appropriate methods for confirming a suspected IgE-mediated food allergy include skin prick testing and serum specific IgE antibody (blood) testing. Each method has advantages and disadvantages highlighted in the table below. Your DFAC allergist will recommend the most appropriate testing method depending on a variety of factors applicable to your specific case. Regardless of the method selected, broad spectrum or “screening” food allergy testing should be avoided because a positive test without a correlating history of an allergic reaction is often a false positive result, leading to unnecessary anxiety and dietary restrictions. Most of the time there is good agreement between skin prick testing and blood testing but, in some patients there are significantly different results. Your DFAC allergist may recommend both forms of testing in some circumstances.

   

  Testing Method Comparisons	Skin Prick Testing	Serum IgE Antibody Testing
  Sensitivity in Confirming a Diagnosis of Food Allergy (With Prior Reaction History)	Excellent (>95%)	Very good (85-90%)
  False Positive Rate as a Screening Test (Without Prior Reaction History)	50%	50%
  False Negative Rate	5%	10-15%
  Location of Testing	Allergist’s Office	Laboratory
  Associated Discomfort	Mild, brief discomfort with application followed by 20-60 minutes of itching	Pain and anxiety typical of any blood draw (venipuncture) procedure
  Stopping Antihistamines Required 7-10 Days Before Testing	Yes	No
  Time Required to Receive Results	30 minutes	5-7 days

   

  Additional specialized testing is sometimes needed to confirm or exclude a suspected food allergy when the patient’s history and/or allergy testing results are not entirely conclusive. Carefully designed and closely supervised graded food challenges represent the “gold standard” of food allergy diagnosis. These procedures are performed only in the Medical City Dallas DFAC office, require special scheduling and staffing assignments, and typically take 4-6 hours to complete. 

  MANAGEMENT OF IgE-MEDIATED FOOD ALLERGIES

  Primary management of IgE-mediated food allergy is known as the Avoidance Management Strategy, which includes identification and avoidance of the offending food(s); having a written Food Allergy Emergency Action Plan; and prompt administration of auto injectable epinephrine to treat allergic reactions. Food allergen identification and avoidance requires careful attention to reading ingredient labels; asking specific questions regarding the ingredients of foods served in restaurants and social settings; and declining offers of foods whose exact ingredients cannot be verified. Because anaphylactic reactions may be triggered by ingesting very small quantities of the offending food, avoidance should also include manufactured foods with “may contain” disclaimers.

  FOOD ALLERGEN AVOIDANCE AT SCHOOL AND OTHER SOCIAL SETTINGS

  School and other social settings where foods are served present unique challenges for children with food allergies. Because young children cannot protect themselves from accidental ingestions of allergenic foods, extra precautions must be taken to keep them safe in these environments. Banning the offending food(s) from the classroom and cafeteria are appropriate safety measures in the preschool setting, as toddlers are notoriously messy eaters and also prone to sharing foods. An acceptable alternative for protecting young food allergic children is to establish a food allergen-free seating arrangement in the cafeteria.  Because protective seating arrangements may stigmatize the food allergic child and lead to social isolation, such restrictions should be discontinued when the child becomes mature enough to read ingredient labels and to resist offers of treats.

  FOOD ALLERGY EMERGENCY ACTION PLANS

  A document with easy-to-follow instructions outlining steps to be taken in the event of an accidental ingestion of an allergenic food is an important component of food allergy safety at school. A Food Allergy Emergency Action Plan form should be requested from the school at the end of every academic year in order to allow ample time for you to schedule a follow-up visit with your DFAC allergist to review your child’s food allergies. DFAC will furnish a Food Allergy Emergency Action Plan form if the school does not provide one.

  FOOD ALLERGY EMERGENCY ACTION PLAN

  PROMPT ADMINISTRATION OF EPINEPHRINE IS CRUCIAL TO SURVIVAL

  Anaphylactic reactions to foods are potentially life-threatening. Even fatal reactions often begin with apparently mild symptoms. Because of this risk, we must maintain a healthy degree of respect for IgE-mediated food allergies, intervening as soon as we become aware of the accidental ingestion of allergenic food. Epinephrine is the only treatment that will reliably prevent the worsening of an anaphylactic reaction in progress. Failure to administer epinephrine early in the course of an allergic reaction (within 20-30 minutes) is one of the major predictors of fatal outcomes consistently cited in published studies. Antihistamines (e.g., Benadryl^™), no matter how quickly they are given or how large the dose, can neither prevent nor treat a serious allergic reaction. Antihistamines and corticosteroids have their place as additional therapy, but only epinephrine treats the basic derangement involved in anaphylaxis. Giving antihistamines such as Benadryl^™ first for treatment of an anaphylactic reaction is a mistake because doing so can mask the progression of more serious symptoms and delay the administration of lifesaving treatment.

  The Food Allergy Emergency Action Plan example below highlights the importance of epinephrine and provides additional steps to be taken in the event of an anaphylactic reaction. Two equally acceptable brands of auto-injectable epinephrine (EpiPen^™ and AuviQ^™) are currently available. Adrenaclick^™ is another auto-injectable epinephrine device offered as a generic substitute for the other products. Because all three devices have different features, training must be specific for the product prescribed. Additional educational materials and hands-on instruction regarding the indications and technique for administering auto-injectable epinephrine are available through DFAC.

  ORAL IMMUNOTHERAPY – AN ALTERNATIVE TO THE AVOIDANCE MANAGEMENT STRATEGY

  Many parents of children with IgE-mediated food allergies express frustration with the burdens associated with the Avoidance Management Strategy and food-allergic children often express sadness due to social isolation and bullying. Validated quality of life surveys of children with food allergies and their parents have shown lower scores than those with other chronic disorders such as diabetes and arthritis. With the goal of improving the quality of life for food allergic children and their parents, oral immunotherapy (OIT) protocols have been developed as an alternative to the traditional Avoidance Management Strategy. OIT involves administering increasing doses of the allergenic food(s) very slowly in order to achieve a state of desensitization, meaning the ability to eat the food on a regular basis with a much lower risk of an allergic reaction. The concept of desensitization is taken from subcutaneous immunotherapy for aeroallergens (“allergy shots”), a treatment that allergists have provided for more than 100 years. OIT must be performed under close supervision by an allergist who is experienced in this procedure. The procedure is demanding and requires careful attention to detail on the part of the physician, medical staff, and parents. However, the anticipated outcome of being able to eat allergenic food without fear of an allergic reaction is very rewarding for food-allergic children and their parents. Dallas Food Allergy Center has been routinely performing OIT procedures for non-resolving anaphylactic sensitivity to milk, egg, wheat, peanut and several tree nuts since 2009. To date, we have conducted more than 220 OIT procedures with an overall success rate of 85%.

  FOOD ALLERGY AND ATOPIC DERMATITIS (ALLERGIC ECZEMA)

  Atopic Dermatitis (A.D.) is a chronic inflammatory skin condition most commonly seen in children with inherited allergic tendencies. The rash typically begins during infancy, often starting on the face and neck and later progressing to the arms and legs. The rash may range in severity from scattered, mild dry patches to severely inflamed, cracked skin. Itching is almost always a problem associated with A.D. In fact, some have referred to this condition as “the itch that rashes” rather than “the rash that itches” because itching leads to scratching, which results in worsening skin irritation with additional itching and scratching. A comprehensive eczema treatment regimen — involving a combination of moisturization, skin barrier protection, topical anti-inflammatory medications, and oral antihistamines — is essential to breaking the vicious “itch-scratch-itch” cycle and controlling this chronic condition. Recognizing the triggers and aggravating factors for A.D. is also important for successful management. The most common aggravating factors include viral respiratory tract infection (“the common cold”), sweating, soaps, perfumes, synthetic fibers, and allergies.

  Food allergy is seen in approximately 30% of children with A.D. Two interrelated problems commonly complicate the diagnosis of food allergy in the setting of A.D. The first is that high levels of allergic antibody (Immunoglobulin E or IgE) produced as a result of immune dysregulation in this condition may result in false positive allergy skin tests or serum IgE test results for multiple foods. A false positive allergy test result means that the patient has had no apparent allergic reactions to a food for which s/he has tested positive. Second, it is often difficult to correlate positive food allergy test results with A.D. because the condition may also be aggravated by a variety of other factors noted above. Because the most common food allergies involved in A.D. include foods of considerable dietary importance (including milk, egg, wheat, soy, sesame and nuts), it is very important to determine the relevance of a positive food allergy test in order to avoid unnecessary dietary restrictions.

  The only way to determine whether or not food allergy may be driving chronic A.D. is to eliminate the food(s) in question for a sufficient period time to observe whether or not eczema improves (at least 14 days), followed by reintroduction of each suspected food individually under careful supervision by a qualified allergist performed in a properly equipped and staffed medical office. Because the reintroduction of an eliminated food may result in a life-threatening allergic reaction, this intervention should never be undertaken without first consulting your DFAC allergist.

  FOOD ALLERGY AND GASTROINTESTINAL DISORDERS

  EOSINOPHILIC ESOPHAGITIS (EoE)

  EoE is an increasingly recognized, chronic disorder that results when eosinophils (a type of white blood cell usually associated with allergic disorders) infiltrate an individual’s esophagus. In young children, EoE often presents with symptoms of persistent abdominal pain, nausea, vomiting and poor appetite, which may result in difficulty gaining weight. Teenagers and adults with this disorder often complain of acid reflux symptoms (“heartburn”, “indigestion”) and solid foods getting stuck in the esophagus. With continued inflammation of the esophagus, individuals may develop strictures, which are bands of tissue that narrow the esophagus and prevent food from passing through easily.

  An individual’s medical history and symptoms are important in suggesting the diagnosis of EoE. Other common gastrointestinal disorders (e.g., gastroesophageal reflux) should be ruled out. A diagnosis of EoE is confirmed with esophageal biopsies obtained by an esophagogastroduodenoscopy (EGD). This procedure, which is performed by a gastroenterologist, involves inserting a flexible scope through the mouth and down the esophagus while the patient is under sedation. The doctor examines the lining of the esophagus, stomach and the first segment of the small intestine for signs of eosinophilic inflammation and takes small pieces of tissue to be examined by a pathologist. The presence of high numbers of eosinophils on esophageal biopsies supports a clinical diagnosis of EoE.

  As is the case with most chronic inflammatory disorders, EoE is more easily diagnosed than treated.   Swallowing an inhaled topical corticosteroid medication (e.g., Flovent^™ or Pulmicort^™) on a daily basis represents the cornerstone of treatment. It may be necessary to take one of these medications for months or even years to keep the inflammation under control. Fortunately, these medications are poorly absorbed from the gastrointestinal tract into the bloodstream, so side effects are minimal with long term use.

  Food allergy may play a role in approximately 50% of individuals with EoE. Foods most commonly implicated in EoE include milk, wheat, soy, egg, peanuts, tree nuts and seafood. Food allergy testing methods used in evaluating EoE include allergy skin prick testing, serum IgE testing, and patch testing. More than one kind of food allergy testing may be needed to identify foods suspected of driving the inflammation. The only way to correlate the results of food allergy testing with EoE is to obtain biopsies of the esophagus before and 2-3 months after eliminating the food(s) in question. Because dietary restrictions may lead to nutritional deficiencies and esophageal biopsies require anesthesia, the potential benefits and risks of such interventions must be considered carefully on a case-by-case basis.

  EoE is a chronic, potentially lifelong condition. With the right treatment plan, however, individuals with this disorder can live full and productive lives.

  
  FOOD PROTEIN-INDUCED ENTEROCOLITIS SYNDROME (FPIES)

  FPIES is a food hypersensitivity disorder of suspected but unproven immunologic cause. Symptoms of FPIES typically begin during early infancy following the introduction of common dietary proteins, chief among these being cow’s milk and soy. Symptoms may range from fussiness and vomiting to chronic diarrhea and failure to gain weight. Stools are sometimes blood-streaked or even bloody. Dietary elimination followed by reintroduction of the offending protein several weeks later (as may occur in babies with multiple formula intolerances) may lead to very severe vomiting and diarrhea, resulting in dehydration and need for intravenous fluids replacement in and even shock in the most extreme cases.

  Unfortunately, there are no available skin tests or blood tests to confirm or exclude a diagnosis of FPIES. The diagnosis is made based on clinical history alone after the exclusion of other possible causes of chronic gastrointestinal symptoms. Observing the resolution of symptoms with dietary avoidance of the offending food(s) and recurrence of symptoms with accidental ingestions is further supportive evidence of the clinical diagnosis. Prolonged dietary avoidance of the offending food is the only available treatment. An average of 5 years of dietary elimination is required for FPIES to resolve. The only way to confirm resolution of FPIES is to reintroduce the food into the child’s diet. Because gastrointestinal symptoms may be severe, food challenges for FPIES should only be performed in the DFAC office.

  Food Allergy Resources

   

  Food Allergy Support Organizations

  Food Allergy, Research & Education (F.A.R.E., formerly FAAN) www.foodallergy.org

  Asthma and Allergy Foundation of America www.aafa.org

  Kids with Food Allergies www.kidswithfoodallergies.org

  American Academy of Allergy, Asthma, & Immunology www.aaaai.org

   

  Managing Food Allergies in School
  
  Safe@School Partners

  Planning for School with Food Allergies

  Getting Started at School

  School Guidelines for Managing Children with Food Allergies

  Healthy Schools

   

  Epinephrine Demonstration Video

  Epipen https://www.epipen.ca/how-to-use-epipen

  Auvi-q https://www.auvi-q.com/about-auvi-q

  Adrenaclick https://www.adrenaclick.com

   

  Food Allergy Cookbooks

  Allergen-Free Baking: Baked Treats for All Occasion Cookbook. By Jill Robbins (2007)

  Allergy-Free Desserts: Gluten-free, Dairy-free, Egg-free, Soy-free, and Nut-free.  By Elizabeth Gordon (2010)

  Complete Allergy-Free Comfort Foods Cookbook: Every Recipe is Free of Gluten, Dairy, Soy, Nuts and Eggs.  By Elizabeth Gordon (2013)

  Bakin’ Without Eggs: Delicious Egg-free Recipes from the Heart and Kitchen of a Food-Allergic Family. By RoseMarie Emro (1999)

  A Taste of Freedom: Recipes for Passover (or Anytime) without Wheat, Dairy, Eggs, Nuts and Fish.  By Tamar Warga (2004)

  What’s to Eat? The Milk-free, Egg-free, Nut-free, Allergy Cookbook.  By Linda Marienhoff Coss (2017)

  The Allergy-Free Family Cookbook: 100 delicious recipes free from dairy, eggs, peanuts, tree nuts, soy, gluten, sesame and shellfish.  By Fiona Heggie (2016)

   

  Specialty Food Manufacturers (DFAC does not endorse any vendor)

  www.amandasown.com

  www.andeandream.com

  www.applegate.com

  www.barneybutter.com

  www.bobsredmill.com

  www.cherrybrookkitchen.com

  www.earthbalancenatural.com

  www.ener-g.com

  www.enjoylifefoods.com

  www.glutenfreepantry.com

  www.iansnaturalfoods.com

  www.namastefoods.com

  https://allcitycandy.com/collections/nut-free-candies

  www.sunbutter.com

  https://reallygreatfood.com/

  www.tinkyada.com

  www.tofutti.com

  www.unrefinedbakery.com/ (a Dallas based company)

  www.vermontnutfree.com

  Food Allergy Travel Translation Cards

  www.allergytranslation.com

  www.selectwisely.com

  www.allergyfreepassport.com

• 

  Food Allergy Reaction Hotline

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  The COVID-19 pandemic has accelerated a change in the approach to food allergy reactions that has been discussed by allergists for the past several years.

  Epinephrine injection is the treatment of choice for anaphylaxis, the most severe form of a food allergy reaction. Patients and parents have been taught to use their epinephrine auto-injector (AUVI-Q, Epi-pen and others) when two body systems are involved in a reaction (e.g. rash [hives] and vomiting) or if there are significant respiratory symptoms (e.g., cough, wheeze, shortness of breath or change in the sound of the voice). Using epinephrine early in a reaction can prevent progression to more severe symptoms and saves lives. Because food allergy reactions are unpredictable and may progress despite a dose of epinephrine, however, the standard recommendation has been to go to the Emergency Department for evaluation and monitoring after every epinephrine use.

  Despite the safety of epinephrine auto-injectors (AUVI-Q, EpiPen and others), parents and patients have often been reluctant to use these devices. Numerous studies have shown that epinephrine has been used as little as 50% of the times when it should have been. In addition to fear of side effects and fear of needles, many patients and parents have wanted to avoid the inconvenience and cost of an Emergency Department visit. This reluctance to use the Emergency Department has been made worse by the fear of being exposed to coronavirus.

  Recently, food allergy experts from Food Allergy Research and Education and two highly regarded food allergy centers proposed a plan for the home management of anaphylaxis. The plan provides guidance on how to deal with food allergy reactions, including the use of epinephrine, at home. The doctors at Allergy Partners of North Texas believe that recommended approach is useful, however, we are concerned that the recommendations place too great a burden for medical judgment on the shoulders of patients and parents.

  Although we at Allergy Partners of North Texas have worked hard to support our patients 24 hours a day through our answering service, sometimes the service is too busy to answer immediately and sometimes, frankly, they make mistakes. Because after hours communications have not been 100% reliable, we have taught the standard recommendation that following epinephrine use, everyone should go to the Emergency Department.

  In an effort to provide the very best care for our patients, the doctors at Allergy Partners of North Texas have changed our recommendation to go to the Emergency Department after epinephrine use. Effective June 15, 2020, Allergy Partners of North Texas maintains a Food Allergy Emergency Hotline, (972) 566-8626 that is answered 24/7/365 by an Allergy Partners of North Texas physician or physician’s assistant experienced in the management of food allergy reactions. This number is exclusively for our established patients, and should be called only in the event of a food allergy reaction involving the use of epinephrine. Patients should not delay the use of epinephrine by calling this number. The number should not be used for mild food allergy related problems or other management questions. Please see the graphic Food Allergy Action Plan below. Contact your Allergy Partners of North Texas physician through the Patient Portal if you have questions.

  

   

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  Food Allergy

  Testing & Treatment

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  If a member of your family has food allergies, it’s imperative that you understand the facts, recognize the symptoms, and know how to respond quickly.

   

  The most common food allergy signs and symptoms include:

  Tingling or itching in the mouth
  Swelling of the lips, tongue and throat or other parts of the body
  Wheezing, nasal congestion or trouble breathing
  Hives, itching or eczema
  Abdominal pain, diarrhea, nausea or vomiting
  Dizziness, lightheadedness or fainting

  What is a food allergy?

  A food allergy is an allergic reaction that occurs when the immune system responds to a food as harmful and causes one or more symptoms. The foods that cause an allergic reaction are called allergens. It takes only a small amount of an allergen to cause an allergic reaction.

  What are the Most Common Food Allergens?

  • Eggs
  • Milk
  • Peanuts
  • Tree nuts, such as walnuts
  • Soy
  • Wheat
  • Sesame
  • Shellfish, such as shrimp, crab and lobster
  • Fish

  Eggs, milk, peanuts, tree nuts, soy and wheat are the most common allergens among infants and small children. Children may outgrow some allergies, such as egg, milk, and soy; but, are less likely to outgrow allergies to peanut, tree nuts, fish, and shellfish

  The adjustments to living with food allergies can be overwhelming. That’s why being informed is the most important action to take.

  Learning how to read labels, what foods to serve, and how to manage dining out are just a few of the steps toward managing food allergies. It’s also critical to know how to respond to a food allergy episode, which means knowing how to recognize the signs and symptoms of anaphylaxis and how to treat it.

  Food Allergy Emergency Care Plan

  Also called an Anaphylaxis Emergency Action Plan, this should be written down legibly and provide steps on what to do in an emergency.

  • Epinephrine is the medicine used to treat an allergic reaction. Learn how to give your child this medicine. It is safe and comes in an auto-injector, which injects a single dose of medicine when pressed against your child’s outer thigh. Your health care professional can show you how to use it.
  • Keep two epinephrine auto-injectors near your child at all times.
    Family or friends who spend time with your child should be shown how to use the auto-injector.
  • A medical alert bracelet can be worn by your child to let others know of their allergy.

  How to Treat Anaphylaxis

  • Epinephrine can save your child’s life, so know how to follow the steps in your child’s emergency care plan and use it immediately.
  • After administering epinephrine, always call 911 or a local ambulance service. Advise them of your child’s allergic reaction, and tell them more may be needed.
  • An ambulance should take your child to the hospital where trained medical staff will monitor them for further reactions and any additional treatment needed.

  Important Food Allergy Health and Safety Reminders

  • Be sure to ask what ingredients are in foods that other people make for your child.
  • Wash your hands and your child’s hands with soap and water before handling food. Prepare and serve foods with clean utensils and other kitchen items and on clean surfaces.
  • Make sure family, friends, and others who will be with your child know about your child’s allergies and how to respond.
  • Be sure to tell your child’s school and anyone responsible for your child about his or her food allergies.
  • Help your child be responsible by teaching them about how to manage their food allergies. Even if they are very young, it is good for them to understand.
  • When old enough, teach your child to read labels and how to use an epinephrine auto-injector.
  • Once diagnosed, keep your focus on what safe foods your child can have, rather than what they cannot have. Start off with simple ingredients and from their look for new recipes together.
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  Food Allergy Risk Reduction (FARR®)

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  Food allergy has become a significant worldwide concern. A food allergy occurs when the immune system mistakenly responds to food as if it was harmful and produces an antibody response, namely IgE. When a food allergen enters the body, it cross-links to IgE bound to special immune cells called mast cells. The mast cells then ‘pop’ and release chemicals such as histamine and tryptase. These chemicals, in turn, cause the classic symptoms of food allergy such as hives, swelling, cough, wheeze and anaphylaxis, in some instances.

  What is FARR®?

  Peanut allergy is an increasingly common and potentially life-threatening condition. Two recent studies indicate that, contrary to previous recommendations, the early introduction of peanut to the diet of at risk children lowers the risk of developing peanut allergy.

  These studies have profound clinical implications in that they offer a strategy to prevent the onset of peanut allergy in high-risk children. Recently, the National Institutes of Allergy and Infectious Disease (NIAID) convened an expert panel to review and revise guidelines for the introduction of peanut into the diets of infants. These new guidelines were published in January, 2017 and can be found at: www.jacionline.org/article/S0091-6749(16)31222-2/fulltext.

  • In summary, the new guidelines emphasize the following:
  • Consider peanut introduction into the diet between 4 and 6 months of age.
  • Risk factors including the presence and severity of eczema as well as the presence of any other food allergy should be taken into account in order to help determine the safest way to introduce peanut.

  These guidelines mark a significant change in the approach to food allergy, with an emphasis on prevention. Yet, there are several outstanding questions that remain, including how to approach children with other food allergies or children with food allergic first degree relatives.

  Given these considerations, Allergy Partners is pleased to offer the Food Allergy Risk Reduction (FARR®) Program. Developed by Richard Wasserman, MD, PhD of Allergy Partners of North Texas, FARR® is aimed at selected infants less than one year of age who might be at increased risk for allergy to foods such as milk, egg, or peanut. The children are skin tested to that food, and, if skin testing is negative or mildly positive, then challenged with the food (milk, egg or peanut). If there is no reaction, the parents are instructed to administer the specified quantity of food at least three times a week.

  Who should be referred for FARR®?

  The LEAP study only enrolled infants who had severe eczema or egg allergy. Such children are those most likely to benefit from FARR®. We know, however, that many children with food allergy do not meet those criteria. In an effort to assist you in counseling parents about the LEAP study and FARR®, we recommend referral of children with the following: Recommendations of the NIAID Expert Panel

  Recommendations of the NIAID Expert Panel

  • Severe eczema, egg allergy, or both

  While these patients are the most likely to develop peanut allergy, prior studies have identified other risk factors for peanut allergy which may increase the risk of at-home introduction of peanut for infants. Infants with the following risk factors for peanut allergy may also benefit from referral for the FARR® Program.

  • Moderate to Severe Eczema
  • Other food allergies
  • 2 or more first degree family members with significant allergic disease
  • Sibling or parent with peanut allergy
  • Sibling or parent with a food allergy other than peanut

  FARR® is not necessary for an infant already eating the food of concern without any adverse reactions. FARR® would rarely be appropriate for a child with no personal or family history of atopy. Children with a strongly positive in vitro (ImmunoCAP) food allergy test are not good candidates for FARR®.

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  Food Oral Immunotherapy (OIT)

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  In the U.S., every three minutes a food allergy reaction sends a person to the E.R. One in 13 children in the U.S. has a food allergy which means it may affect two children in a kindergarten class.

  Food allergies are a reality for over 15 million people in the U.S., yet food allergies are all too often mocked or made light of in real life and in the media. While increased efforts to promote food allergy awareness are more prolific than in years past, there is still a dire need for more focused attention on this profoundly dangerous condition.

  How is the treatment performed?

  Before starting OIT, parent(s) and child attend at least two office visits to be sure that all other allergy-related problems have been identified and controlled. At these visits, OIT is explained and questions answered. All patients must be seen within the month before beginning OIT treatment. They also have the option to speak with or meet other parents of children who have completed the treatment.

  Every child is different, so each treatment is individualized. Children are shown how the doses are mixed and shown big board with photos of OIT graduates to help the children realize that once the treatment is successful they can attend birthday parties, campouts and do more things with their friends without food allergy worries.

  The protocol for treatment starts with a powdered form of food diluted in water mixed with Kool-Aid flavoring that is then administered orally with a syringe. For liquid foods such as milk, no powder is used. The next step is to progress to a powder form of the food and final stage is solid food, such as a whole peanut, egg or organic whole milk.

  Patients are allowed to progress at their own pace, but a minimum of 5 days of twice daily dosing at home is required for each dose increase. The average length of time required for the patient to reach his/her target maintenance dose is 26 weeks. However, some may take longer. If a child experiences allergic symptoms, the dose is reduced by 50% and maintained there until the dose is tolerated.

  Once the target maintenance dose is reached, a full serving of that food is eaten on a daily basis in order to maintain the desensitized state. After three years of maintenance therapy, those patients who have achieved a 95% reduction in food specific IgE antibody from baseline may be eligible for less frequent maintenance dosing.

  More than 80% of our patients who have been treated with OIT can now safely consume foods that once threatened their health.

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  Insect Allergy

  Testing & Treatment

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  Stinging Insect Allergy Testing and Desensitization

  Severe stinging insect allergy affects over 9.5 million Americans including 3% of adults and up to 1% of children. There are 40-100 deaths in the US per year and that number has not changed in the past 30 years. An adult who has experienced anaphylaxis with a sting has a 60-70% chance of having a similar or more severe reaction with the next. Fortunately, venom immunotherapy is 95-98% effective in preventing such reactions and can be lifesaving therapy.

  Stinging Insects

  Stinging insects belong to the order Hymenoptera which include the family Apidae ( Honeybee, Sweatbee, and Bumblebee), the family Vespidae (Yellow Jackets, Yellow Hornets, White-faced Hornets, and Paper Wasps), and the family Formicida (the Fire Ant and Harvester Ant).

  Yellow jackets are the most frequent culprits in North America except along the Gulf coast where wasps are more common. Yellow jackets are scavengers and seek food at picnics and in trashcans, orchards, and dumpsters. They are highly aggressive and sting for no apparent reason especially in autumn while competing for limited food supplies. They tend to nest in the ground or in cracks in buildings or landscaping materials. Hornets are aerial nesters, often building in trees and bushes, and are sensitive to vibration and noise like lawn mowers.

  Paper wasps are found in the eaves or windows of houses and around decks. They have a narrow waist but can be a multitude of colors including black, brown, red, or striped. The Mediterranean wasp is now in the US and has black and yellow stripes, which commonly lead to it being mistaken for a yellow jacket.

  Honeybees are usually docile except for the Africanized hybrids which tend to swarm and be more aggressive. The venom, however, is the same. Most honeybee stings are seen in bee keepers or people who play outdoors without shoes or garden without gloves.

  Fire ants have a true sting apparatus but will bite to anchor to the skin and then pivot to deliver multiple stings. They entered the US through the Gulf in the 1940s but have been found as far north as Maryland. The sting results in a characteristic sterile pustule. In endemic areas like the Florida Gulf, over half of the population is stung every year.

  Reactions

  Sting reactions are classified as local or systemic, and the previous reaction history is the best determinate of future reactions. Prior history of other atopic disease and family history of bee sting allergy do not increase a person’s risk for anaphylaxis.

  Most local reactions are a late-phase IgE dependent reaction that is mild and develops 12-24 hours after the sting. They can be impressive and worrisome with the amount of swelling and can involve an entire limb. Lymphangitic, red streaks can occur. They usually resolve within 5-10 days and are not dangerous except for potential physical compression of the head, neck, tongue, or throat If stung in those areas. These reactions are usually treated with ice, pain control, and antihistamine but early use of steroids within the first hours after a sting can be helpful, especially to stings around the face, head, and neck. Infection is unusual in sting reactions except with yellow jackets. Lymphangitis that develops after 24-48 hours is usually related to the allergic process and not infection.

  Systemic reactions are almost all IgE mediated and cause anaphylaxis. Signs and symptoms of anaphylaxis may affect the skin (hives, angioedema, flushing, itching), the respiratory system (cough, wheeze, stridor, etc.), the circulatory system (dizziness, hypotension, loss of consciousness, etc.) and the GI tract (cramps, diarrhea, nausea, vomiting). The absence of skin symptoms is associated with more severe reactions. Systemic reactions may also be caused by underlying mast cell disorders in 1-2% of cases.

  Evaluation

  Clinical history is the best determinate of risk for future reactions and in deciding who would benefit from testing and therapy. One in five healthy adults has detectable IgE to venom, so testing people without a significant history of anaphylaxis is not recommended. Testing and, if testing is positive, immunotherapy is recommended for: (1)Any adult with more that local reaction including systemic cutaneous (skin) symptoms like hives, and (2) Any child with systemic symptoms not limited to skin only such as respiratory, cardiac, GI, etc. The following table shows relative risk of systemic reaction based on age and previous reaction. Children with only cutaneous symptoms only like hives are at no higher risk than anyone with a large local reaction and shots are not recommended.

  

  Testing is done with an intradermal method skin test with or without blood testing for specific IgE. Skin testing is usually positive for patients with a good history but can be negative especially in the first 4-6 weeks due to a refractory period of anergy. If skin testing is negative, often serum testing is performed, as 10% of patients with a negative skin test will have a positive serum specific IgE. If both are negative, skin testing is often repeated in 3-6 months and a serum tryptase should be checked to screen for mast cell disorders. Why not just do serum testing? Up to 20% of patients with a positive skin test and good history of anaphylaxis will have negative serum testing. Skin testing, therefore, is the initial test of choice in people who have had allergic reactions to stings.

  Treatment

  Treatment of large local reactions, especially around the head and neck, are often treated with a short burst of oral corticosteroid over 5 days. For adults with systemic symptoms and children with systemic symptoms other than skin only should be evaluated for immunotherapy. Venom immunotherapy (VIT) can be 95-100% effective in preventing future reactions to stings and have no higher incidence of adverse reactions than inhalant allergen immunotherapy regardless of the type of schedule is used to build up on therapy. VIT is usually given 1-2 times per week. Bee venom immunotherapy is usually built up over 17 injections and fire ants take longer at 28 or more injections. At Allergy Partners, we prefer a cluster build up which builds up more rapidly providing protection sooner. This involves 1-3 injections in 8 sessions over 4 weeks. Once at full maintenance dose, shots are continued monthly for 12-18 months and then every 4-6 weeks.

  Another concern in patients with anaphylaxis of any kind is the possible interference of other medications. Beta blockers are blood pressure medications that can increase risk for anaphylaxis by interfering with the effects of epinephrine. Selective beta 1 blockers have not been determined to have the same risk yet. Risk analysis shows that stopping Beta blockers in cardiovascular patients creates higher risk than not stopping them during VIT. The question of ACE inhibitors and the increase in risk for anaphylaxis has been less clear with studies showing increase and others showing no correlation with risk of anaphylaxis with their use. It is therefore important for venom allergic patients to review all of their medications with their Allergy Partners physician and notify him or her when any changes have been made.

  Summary

  The risk of repeat severe reactions to stinging insects can accurately be predicted and venom immunotherapy can be lifesaving for these individuals. Given the high risk of repeated severe reactions, adults with any systemic reaction other than localized should be assessed by an allergist and given the option of VIT. Children are at slightly lower risk but should also be evaluated for any reaction that is systemic and not isolated to the skin alone. Venom immunotherapy can lower risk from as high as 70% for future reactions to 2-5%.

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  Medications

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  Allergy Medication

  When you cannot avoid allergens, there are many medications that can help control allergy symptoms. Decongestants and antihistamines are the most common allergy medications. They help to reduce a stuffy nose, runny nose, sneezing and itching. Other medications work by preventing the release of the chemicals that cause allergic reactions. Nasal corticosteroids are effective in treating inflammation in your nose.

  An allergist will work with you to determine which medicines are best for you and how often and how much of them you should take — while eliminating or minimizing any side effects.

  Asthma Medication

  There are many effective medicines to treat asthma. Most people with asthma need two kinds — Quick-relief medicines — taken at the first sign of any asthma symptoms for immediate relief:

  • Short-acting inhaled beta2-agonists
  • Anticholinergics

  Your doctor also may recommend you use these medicines before exercise for treatment of asthma. Quick-relief medicines can stop asthma symptoms, but they do not control airway inflammation that causes the symptoms. If you find that you need your quick-relief medicine to treat asthma symptoms more than twice a week, or two or more nights a month, then your asthma is not well controlled. Be sure to tell you doctor.

  Long-term control medicines — taken every day to prevent symptoms and attacks:

  • Antileukotrienes or leukotriene modifiers
  • Cromolyn sodium and nedocromil
  • Inhaled corticosteroids
  • Long-acting inhaled beta2-agonists (never taken alone)
  • Methylxanthines
  • Oral corticosteroids
  • Immunomodulators

  These medicines are taken every day even if you do not have symptoms. The most effective long-term control medicines reduce airway inflammation and help improve asthma control.

  Your doctor will work with you to find the right medicine, or combination of medicines, to manage your asthma, and will adjust the type and amount based on your symptoms and control. The goal of asthma treatment is to have you feel your best with the least amount of medicine.

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  Metal Allergy

  Testing & Treatment

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  The evaluation and treatment of systemic and cutaneous hypersensitivity reactions of a person to implanted metals can be a bit challenging. Current recommendations suggest that metal hypersensitivity testing can be of great help in the case of patients who were previously suffering from metal hypersensitivity, like nickel.

  Also, testing for metal hypersensitivity can help in pre-operative evaluation of those patients suffering from conditions like multiple drug allergies, autoimmunity (SLE and RA), eczema, fibromyalgia or chemical hypersensitivity. It can also be helpful in those patients who have had a failure of an orthopedic implant.

  Allergy Partners offers full panel testing for bone cement and metal allergy. Testing is carried out in our offices and requires three office visits over 4-5 days. The test involves placing patches across your back with the use of hypoallergenic tape. We will then apply an allergen paste on an area of your skin that is free from rashes. As the test site is read at varying intervals, if a rash similar to that of eczema develops, it can indicate that you have sensitivity to a certain metal.

  After the testing, your results will be given to you and your referring doctor. You as well as your referring doctor can use these results for making a suitable decision for the procedure that you will undergo according to your test results and medical history.

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  Pulmonary Function Tests

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  Lung function tests (also called pulmonary function tests, or PFTs) check how well your lungs work. The tests determine how much air your lungs can hold, how quickly you can move air in and out of your lungs, and how well your lungs put oxygen into and remove carbon dioxide from your blood.

  Spirometry is the first and most commonly performed lung function test. It measures how much and how quickly you can move air out of your lungs. For this test, you breathe into a mouthpiece attached to a recording device (spirometer). The information collected by the spirometer may be printed out on a chart called a spirogram.

  Common lung function values measured with spirometry:

  • Forced vital capacity (FVC). This measures the amount of air you can exhale with force after you inhale as deeply as possible.
  • Forced expiratory volume (FEV). This measures the amount of air you can exhale with force in one breath. The amount of air you exhale may be measured at 1 second (FEV1), 2 seconds (FEV2), or 3 seconds (FEV3). FEV1 divided by FVC can also be determined.
  • Forced expiratory flow 25% to 75%. This measures the air flow halfway through an exhale.
  • Peak expiratory flow (PEF). This measures how much air you can exhale when you try your hardest. It is usually measured at the same time as your forced vital capacity (FVC).
  • Maximum voluntary ventilation (MVV). This measures the greatest amount of air you can breathe in and out during 1 minute.
  • Slow vital capacity (SVC). This measures the amount of air you can slowly exhale after you inhale as deeply as possible.
  • Total lung capacity (TLC). This measures the amount of air in your lungs after you inhale as deeply as possible.
  • Functional residual capacity (FRC). This measures the amount of air in your lungs at the end of a normal exhaled breath.
  • Residual volume (RV). This measures the amount of air in your lungs after you have exhaled completely. It can be done by breathing in helium or nitrogen gas and seeing how much is exhaled.
  • Expiratory reserve volume (ERV). This measures the difference between the amount of air in your lungs after a normal exhale (FRC) and the amount after you exhale with force (RV).
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  Skin Testing

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  What is Allergy Testing?

  When you are allergic, your body is reacting to a particular substance that should not normally bother you. These substances are called allergens. Typical allergens include pollens, dust mites, animal dander, foods, insect stings and even medicines. To determine which substances are triggering your symptoms, your allergist/immunologist will test your skin using tiny amounts of commonly troublesome allergens.

  Allergy testing is generally very safe and effective. Under the guidance of a trained Allergist-Immunologist, allergen skin test is considered the Gold Standard for the diagnosis of allergy.

  Who Should be Tested for Allergies?

  People of all ages with symptoms that suggest they have allergic disease can be tested. These symptoms include:

  Respiratory symptoms: Nasal congestion, runny nose, cough, wheezing, watery eyes, itchy eyes, nose, throat

  Skin symptoms: Eczema, hives, itchiness

  Abdominal symptoms: Abdominal pain and diarrhea after eating certain foods

  Severe life threatening reactions, or anaphylaxis: This typically occurs with ingestions of foods or medication or insect stings (i.e. bees, wasps, fire ants)

  Why is Allergy Testing Important?

  Allergy testing is vital in identifying which substances are causing your allergies, allowing you and your Allergy Partners allergist/immunologist to more effectively manage your symptoms.

  Treatment options can range anywhere from allergen avoidance (i.e. minimizing dust exposure) to allergen immunotherapy (i.e. allergy shots). Allergen immunotherapy helps your body to develop immunity or tolerance to allergens.

  What Types of Allergy Tests are Available?

  There are a few different types of allergy tests. These are the most common:

  Prick technique: A small amount of allergen is introduced into the skin by making a small puncture with a plastic applicator through a drop of the allergen extract.

  Intradermal technique: This test involves injecting a small amount of allergen under the skin with a very small syringe. This form of testing is done if the skin prick tests are negative.

  Blood (Immunocap) tests: This test involves drawing blood to determine if you have allergic, or IgE, antibodies. This type of test is usually only performed if you cannot stop medications that interfere with skin tests, or if you have a diffuse rash, such as eczema or psoriasis.

  The allergen extracts are manufactured commercially and are standardized according to the U.S. Food and Drug Administration (FDA) requirements.

  As with any medical test, the results should be interpreted carefully and be coupled with a person’s history and physical exam. Allergy Partners allergists/immunologists are uniquely trained experts in the interpretation of allergy tests.

  What Will Happen During Allergy Testing?

  During your test, allergic antibodies will activate skin cells, called mast cells. Mast cells release chemicals, such as histamine, that cause swelling and redness, only in the areas where the allergens have touched your skin. This process usually only takes 15 minutes. The hives usually resolve within 30 minutes to one hour.

  Is There Anything I Should Do Prior to Testing?

  There are some medications, such as antihistamines, that interfere with allergy testing. Your doctor will ask you to stop these medications for several days prior to testing. If you are unsure if a medication will interact with the test, you should contact your Allergy Partners physician for guidance.

  Is There Anything I Should Refrain From Doing after Testing?

  There are no real limitations to one’s activity after testing. However, if you take a sedating antihistamine, such as diphenhydramine, you should avoid drinking alcohol or driving, as recommended on the bottle.