Education

These are conditions that have symptoms that may suggest allergy but have a completely different mechanism biologically. Examples would be soy protein intolerance, lactose intolerance and sprue intestinal disease. Food intolerance does not present itself as anaphylaxis. The diagnosis of food intolerance involves understanding the spectrum of food-induced illness and appropriate tests and treatment specific to the condition.

Food allergy often starts in young children but can affect adults as well. Often, there are other allergic conditions in food-allergic patients such as asthma, nasal allergies or atopic dermatitis. Some food allergies can be outgrown, such as milk and egg, where others tend to persist for decades, e.g. peanut, tree nuts and shell fish.

In treating food allergy, objective testing should be done to be clear about the specific cause of symptoms. This leads to avoidance of the offending food, which may require reading labels and being particularly careful about restaurant meals. At some point in the future, there may be treatment available for severe food allergies including the use of a synthetic antibody product that is currently available for asthma.

Subjects who have had significant allergic reactions to foods need to carry adrenaline, such as an Pen® or Twinject®, with them for self-administration. Because these reactions come on very suddenly, adrenaline can reverse the most serious symptoms and allow time to get to an emergency room or call 911. If you are prescribed injectable adrenaline, be sure that you have this with you at all times and understand how to use it confidently.

The Food Allergy Network is an organization with excellent information on all aspects of food allergy. It can be accessed on the internet at www.foodallergy.org.

APPLE FAMILY: Apple, pear and quince.
ASTER FAMILY (composite): Lettuce is most common. Others are: chicory, endive, escarole, artichoke, dandelion, celtruce, sunflower seeds and tarragon.
BEET FAMILY (Goosefoot): Beet, spinach, chard and lamb's quarters.
BLUEBERRY FAMILY (Heath): Blueberry, huckleberry and cranberry.
BUCKWHEAT FAMILY: Buckwheat, rhubarb and garden sorrel.
CASHEW FAMILY: Cashew, pistachio and mango.
CHOCOLATE FAMILY: Chocolate (cocoa) and Cola.
CITRUS FAMILY: Orange, lemon, grapefruit, lime, tangerine, kumquat and citron.
FUNGUS FAMILY: Mushroom and yeast.
GINGER FAMILY: Ginger, cardamom and turmeric.
GOOSEBERRY FAMILY: Currant and gooseberry.
GRAINS (CEREAL OR GRASS) FAMILY: Wheat, corn, rice, oats, barley, rye, wild rice, cane millet, sorghum and bamboo sprouts.
LAUREL FAMILY: Avocado, cinnamon, bay leaves and sassafras.
MALLOW FAMILY: Cottonseed and okra.
MELON (GOURD) FAMILY: Watermelon, cucumber, cantaloupe, pumpkin, squash and other melons.
MINT FAMILY: Mint, peppermint, spearmint, thyme, sage, horehound, majoram, basil, savory, rosemary, balm (melissa) and catnip.
MUSTARD FAMILY: Mustard, turnip, radish, horse radish, watercress and varieties of cabbage (cabbage, kraut, Chinese cabbage, broccoli, brussel sprouts, collards, kale, kohlrabi and rutabaga).
MYRTLE FAMILY: Allspice, quava, clove pimento (not Pimiento).
OLIVE FAMILY: Green olive, Ripe olive, Red, green, bell pepper, Chili, tobasco, Pimento.
ONION FAMILY (Lily): Onion, garlic, asparagus, chives, leeks and sarsparilla.
PALM FAMILY: Coconut and date.
PARSLEY FAMILY: Carrot, parsnip, celery, parsley and celeriac. Also the following spices: anise, dill, fennel, angelica, celery seed, cumin, coriander and caraway.
PEA (LEGUME OR CLOVER) FAMILY: Peanuts, Peas (green, field, black-eyed), Beans (navy, lima, pinto, string, soy, etc.) Less important are licorice, acacia and tragacanth.
PLUM FAMILY: Plum, cherry, peach, apricot, nectarine, wild cherry and almond.
POTATO FAMILY: Potato, tomato, egg plant and peppers. This family includes all food called "pepper" except black and white pepper, such as: green pepper, red pepper, chili pepper, paprika, cayenne and capsicum. (Tabacco, belladonna, stramonium and hyoscyamus belong to this family.)
ROSE FAMILY: Strawberry, raspberry, blackberry, dewberry and such developed berries as loganberry, youngberry, boysenberry, etc.
WALNUT FAMILY: English walnut, black walnut, pecan, hickory nut and butternut.

MOLLUSC FAMILY: Oyster, clam, abalone and mussel.
CRUSTACEAN FAMILY: Crab, lobster and shrimp.
FISH FAMILY: All true fish, either fresh water or salt water such as: salmon, tuna, sardine, catfish, trout, etc.
BIRD FAMILY: All fowl and game birds: chicken, turkey, duck, goose, guinea, pigeon, quail, pheasant, etc.
REPTILE FAMILY: Turtle, rattlesnake and frog.
MAMMAL FAMILY: Beef, pork, lamb, rabbit, squirrel, venison, etc. Cow's milk is of the same animal origin as beef. Most persons allergic to cow's milk cannot take the milk of other animals such as goat.

The following foods are the only members of their botanical family:

Arrowroot, banana, black or white pepper, Brazil nut, capers, chestnut, chicle, coffee, elderberry, fig, grape, hazelnut, filbert, honey, juniper, flaxseed, karaya gum, maple sugar, New Zealand spinach, nutmeg (mace), olive, oregano, papaya, pineapple, persimmon, poppyseed, saffron, sesame seed, sweet potato, tapioca, tea, vanilla and wintergreen.

From this outline you can see there is no such thing as being allergic to all nuts, seafood, fruits, starches, greasy foods, spices, etc.

Notice that these are not related:

• Tuna and shrimp
• White potato and sweet potato
• Wheat and buckwheat
• Black and red pepper
• Crab and clam
• Raisin (grape) and prune (plum)
• Peanut and other nuts
• Almond and other nuts
• Coffee and tea
• Ginger, clove and cinnamon

Notice that these foods are related:

• Apple and pear
• Peach and plum
• Pea, bean, peanut
• Wheat, corn, other grains
• Beet and spinach
• Chocolate and cola drinks
• Onion, garlic, asparagus
• Cucumber and melons
• Walnut and pecan
• Carrot and celery

Dust mites are microscopic creatures that live off tiny flakes of human skin that people shed each day. They require nests to live in, a source of food and sufficient humidity (generally >50%). The major reservoirs of dust mites include mattresses, pillows, bed linens, carpets, stuffed animals and upholstered furniture. Effective avoidance measures may include reducing areas that can harbor nests in the house (e.g. carpet, furniture and drapes) and controlling humidity. Dust mite allergy is sensitivity to waste particles and fragments of the mite that become airborne and are inhaled. Because these fragments are relatively large, they do not stay airborne very long after their source is disturbed. Thus, air filtration plays very little role in controlling exposure to dust mites.

A "dust-free" environment is obviously an unreachable goal. However, there is substantial evidence that rigorous house dust control can reduce allergen exposure symptoms and need for medicines if enforced over a long period of time. We emphasize particular attention to the bedroom to provide an "oasis" from allergens and irritants during several hours of the day spent there.

It is our experience that patients and families who carry out the suggested measures can achieve benefits, manifested by better symptom control and reduced requirement for maintenance and rescue medicine. However, these benefits are seen only with much sustained commitment to allergen control.

In the bedroom:

1. Cover pillows and mattresses with zippered covers which are impermeable to mite and mite allergen. We will give you direction on where these might be obtained.
2. Wash sheets, pillow cases and blankets at 130 degrees Fahrenheit weekly. The blankets should be replaced with those that can be washed.
3. Comforters should be removed, covered or washed. Remove clutter, soft toys and upholstered furniture.
4. Where possible, carpet should be removed or replaced with area rugs that can be cleaned/washed.
5. Use wipeable furniture that can be easily cleaned with a damp cloth on a regular basis.

In the home & air control:

1. When vacuuming or cleaning, the allergic patient should wear a dust mask. The allergic patient should not be in the room for 1-2 hours after cleaning as disturbed dust needs time to settle out of the air. Consider vacuuming using a cleaner with a filtration system (Hepa-type vacuum).
2. Reduce upholstered furniture, particularly old sofas.
3. Ideally, one should replace carpet with polished flooring where possible. Carpets on concrete slabs or over-poorly ventilated crawl spaces should be replaced with polished flooring if possible.
4. Control humidity to less that 50% relative humidity at normal temperatures, i.e. 68-72 degrees.
5. Room humidifiers can be a source of mold and mite growth. Air conditioning can prevent the high heat and humidity which stimulate mite growth.

Air systems for dust mites are not thought to be effective as the particles are airborne for fairly short periods of time and are not "filterable". There is little evidence that cleaning of duct work in home or expensive air filtration systems on central heating and air conditioning systems are of clinical benefit.

There have been chemicals tested that kill or denature mite allergens. Most investigators who have tested chemical treatment of carpets believe that the killing of mites is not possible with currently available chemicals. There may be new products in the future that are more effective.

Patients who are allergic to mites or molds may have some increased exposure and symptoms if living in basements or overly damp housing. Moving from a basement to an upstairs room may be of benefit. Consider use of portable dehumidifiers in the bedroom if these changes are not possible.

4. Press the canister once to release a dose of the medication.
5. Within 1-2 seconds of pressing the canister, take a deep and slow breath in. If you hear a whistling sound, you are breathing too quickly.
6. Hold your breath for about 10 seconds, then breathe out through the mouthpiece.
7. Remove the mouthpiece from your mouth and breathe out.
8. Wait a few seconds before a second dose is taken, and repeat steps 2-8.

1. Remove the cap.
2. Shake the inhaler and insert it into the back of the chamber.
3. Place the mask over the mouth and nose.
4. Encourage the child to breathe in and out slowly. If you hear a whistling sound, encourage slower breathing.
5. Once the breath pattern is well established, press the canister down with the free hand and leave the canister in the same position as the child continues to breathe in and out slowly five more times.
6. Remove the chamber from the child's mouth.
7. For a second dose, wait a few seconds and repeat steps 2-6.

4. Place the orange tip of the auto injector against the outer aspect of the thigh. The injector can be used directly through clothing.
5. With a quick motion, swing and jab the auto injector firmly against your thigh.
6. Hold the injector in place for 10 seconds to allow the medication to be dispensed. Pull away from thigh. Massage injection area for several seconds.
7. Carefully bend the needle back by hitting the needle end against a hard surface and place needle first into the protective case.
8. Call 911 or go directly to the Emergency department after injecting the EpiPen™.
9. Take the auto injector with you to the Emergency department so it can be disposed of properly.

* Check your EpiPen™ expiration date regularly.
* Keep your EpiPen™ at room temperature. Do not store in car or expose to direct sunlight.
* Use can be reviewed at Epipen.com.

4. Fit the inhaler into the InspirEase® mouthpiece.
5. Pull the bag open to its full size.

1. Place fingers on top of canister and thumb underneath mouthpiece.
2. Gently breathe out.
3. Put the mouthpiece in your mouth between your teeth and close your lips around it.
4. Depress the canister once. The medication will be delivered into the bag.
5. Breathe in slowly and deeply through the mouthpiece. If you breathe in too fast, the InspirEase® will whistle. This is a signal to breathe more slowly.
6. Breathe in the entire contents of the bag. You will know when to stop when the bag collapses and you cannot breathe in anymore.
7. Hold your breath for about ten seconds. This allows the medication time to deposit in the airways. Remove lips from the mouthpiece and exhale.
8. Wait a few seconds before a second dose is taken. Repeat steps 1-7.

1. Disconnect and clean the InspirEase® mouthpiece thoroughly with warm, running water. The InspirEase® is NOT dishwasher safe.
2. Shake off excess water.
3. Air dry on a clean towel and wait until it is dry before storing. The InspirEase® should not be stored near heat.
4. Do not clean the collapsible bag. It should be replaced every 4 weeks or as needed.
5. The mouthpiece should be replaced every six months or when it is no longer working properly.

4. Place yourself in an upright position. Breathe out gently.
5. Put the mouthpiece into your mouth. At the start of a slow, deep inspiration (breathe in), press the canister down to release the medication and continue to inhale deeply.
6. Hold your breath for about 10 seconds, or as long as possible, and then breathe out slowly.
7. If the physician has prescribed an additional puff, repeat steps 4-6.
8. Replace the cap.
9. The plastic mouthpiece should be washed, shaken to remove excess water and air dried at least once a week.

4. Gently blow your nose to clear nasal passages.
5. Hold the bottle using one hand to spray into the opposite nostril. This will direct the spray tip away from the midline nasal cartilage, decreasing irritation of this tissue. Think about directing the spray toward the temple.
6. Close unused nostril.
7. Tilt your head slightly down and look towards your feet.
8. Firmly press on the applicator to spray and gently breathe inward from the nose and out through the mouth.
9. Repeat technique into other nostril.

Remove the plastic cap and gently pull up on the nasal applicator to remove from inhaler. Wash the cap and applicator with warm water. Dry and replace nasal applicator and protective cap.

4. Take a deep breath in and place peak flow meter in your mouth (hold horizontally), and close lips. There should be a tight seal around the mouthpiece.
5. Blow out quickly and hard.
6. Note the number indicated by the pointer.
7. Reset the pointer to zero.
8. Repeat twice and obtain three readings.
9. Write down the best out of three readings.
10. To clean the peak flow meter, wash in mild detergent and warm water. Gently shake out the excess water and air dry.

The duration of immunotherapy is generally 3 to 5 years depending on the patient's response to the injections. One of the goals of allergen immunotherapy is to slowly introduce diluted allergen extracts initially on a weekly basis while building up to a maintenance dose that will control the patient's allergy symptoms. After the maintenance dose is reached, the injection interval will be increased to two to four weeks based on reassessment by the physician and patient response to the therapy.

Allergy extracts contain small amounts of allergens that individual patients are allergic to, so there is always the potential for side effects. The majority of patients have no adverse side effects at all, but some do have occasional swelling at the site of the injection, hives, or nasal symptoms. In patients with asthma, there is the potential for triggering asthma symptoms. Because of the possible reactions, we ask that patients remain in the clinic for 30 minutes after their injection to observe for possible serious side effects.

The American Academy of Allergy, Asthma, and Immunology advises against home administration. There is an estimated fatality rate of 1 death per 2 million doses of extract given per year in the United States, and while this fatality rate is extremely low, it is for safety reasons that we only allow injections to be given in a medical facility with the availability of appropriate emergency medical equipment.

Generally, yes. However, we ask that you contact your insurance company before starting allergen immunotherapy to confirm your insurance coverage.

Your physician can discuss with you the benefits and potential complications of immunotherapy as this is dependent upon the patient's own allergy profile. The ideal outcome of allergy injections is the complete disappearance of the patient's allergy symptoms. However, more reasonable goals would be the reduction in the need for allergy medications and better control of symptoms.

• Backing on rugs
• Condoms
• Diaphragms
• Douche bulbs
• Elastic in clothing and disposable diapers
• Erasers
• Eye dropper bulbs
• Hot water bottles
• Koosh balls
• Pacifiers
• Paints
• Rubber hand grips on racquets, bicycles, etc.
• Rubber bands
• Rubber clothing (Rain Coats)
• Rubber toys
• Shoes made with rubber

Latex Item	Non-Latex Solution
Latex Gloves	Vinyl or plastic gloves
Tapes-cloth and adhesive	Plastic, durapore, silk
Red rubber catheters	Plastic Mentor or Silicone
Band-Aids	Silk tape and a cotton ball
Rubber bands	String
Tourniquets	Place over clothing and not directly to skin
Certain toys such as Barbies, rubber or Koosh balls, tempra paint and teething rings	Avoid contact with latex toys
Rubber or latex balloons	Mylar balloons
Nipples and pacifiers	Silicone nipples and pacifiers
Erasers	Cross out errors
Infant NUK toothbrush	Soft bristle brush or cloth
Wheelchair cushions (Roho)	Cover with cloth
Wheelchair tires	Propel with leather gloves

Indoor mold spores grow very well in damp, dark and poorly ventilated areas, particularly if there is excessive moisture. They can be found in bathrooms, laundry rooms, basements, attics, crawl spaces, upholstered furniture, portable air conditioning units and humidifiers. Many of the indoor molds have infiltrated the house through windows and doors and are the same species that grow outside.

Excessive moisture in the home promotes mold growth and this should be controlled as much as possible, e.g., water in basements, wet carpeting or wallpaper. Specific measures to consider would include:

• Prevent infiltration by closing doors and windows.
• Control indoor humidity to 40%-50% by dehumidification/air conditioning.
• Clean washable surfaces with 10% bleach/detergent or approved fungicide.
• Remove contaminated materials - wallpaper and carpet.
• Keep heating and air conditioning systems in good operating order.

When using bleach solutions to remove fungi from washable surfaces, use rubber or vinyl gloves to avoid skin contact and immediately follow treatment with careful rinsing and assure adequate ventilation. If you are the fungal-allergic patient doing the treatment, consider wearing a mask to decrease exposure. Environmental exposure reduction has been demonstrated to improve respiratory symptoms, reduce medication use and reduce irritation of the airway.

Avoid enclosed areas such as barns, buildings for hay storage or grain dust as these organic materials are excellent sources of mold growth and can produce tremendous mold spore exposure. Activity such as raking leaves, mowing grass and gardening are also high mold contact activities. Wearing a particulate mask when handling contaminated materials is helpful.

1. Start by washing your hands.
2. Prepare your nasal wash solution using a clean glass. Either prepare your mixture packet solution or make your own as follows.

Mix:

• ½ teaspoon uniodized salt *
• ¼ teaspoon baking soda
• 8 oz lukewarm tap water

* iodized salt may cause irritation if used over a long period of time

3. For the nasal irrigation you can use an ear bulb syringe, sinus rinse bottle or water pick. Check with your physician as to which method they prefer.
4. Lean forward over a sink with your head down.
5. Fill your irrigation container with your solution. Insert the applicator tip just inside your nostril and start your irrigation. The solution my come out the opposite nostril or mouth. Blow your nose lightly then repeat in other nostril.

For babies you may use a clean eye dropper or a medication syringe. Place 10-20 drops of the solution in your baby's nostril then use a bulb syringe to suction the mucus out of your baby's nose.

For young children you may use a saline nasal spray bottle. Squeeze the solution into your child's nostril and have your child lightly blow his nose.

Clean the bottle, syringe or dropper after each use with hot water and dry/drain completely. A bulb syringe should also be cleaned daily with rubbing alcohol by drawing the rubbing alcohol into the syringe and swish the liquid around and drain completely.

The best way to reduce the exposure is to avoid animal contact by removing the animal from the home. Reptiles and fish are a good option for allergic patients.

Washing the pet can help temporarily remove the allergen from its skin. In addition, it is important to minimize direct contact with the pet. The animal should be kept out of the bedroom at all times. The bedroom doors should be kept closed and the bedroom cleaned aggressively. Some considerations are outlined below:

1. Encase pillows, mattresses and box springs with allergen impermeable covers.
2. Wash blankets and bedding in hot water (at least 130 degrees F) every 2 weeks.
3. Use furniture that can be easily cleaned with a damp cloth several times a week.
4. No carpeting in the bedroom is ideal. Hard flooring is preferable with frequently washed throw rugs.
5. When vacuuming or cleaning, the allergic patient should wear a dust mask, and not be in the room for 2-4 hours after cleaning. Disturbed dust needs time to settle out of the air and 2-4 hours after cleaning is the time of highest exposure.

HEPA (high efficiency particulate arrestor) air filter units can remove animal dander from the air. These are most effectively used in the patient's bedroom on a continuous basis. Vacuums are available with HEPA filters as well.

Rhinitis can be caused from an allergy, irritant or infection.

Allergic rhinitis can be classified as either seasonal or perennial. Seasonal allergies occur in the spring, summer and or fall. Seasonal allergies are caused by sensitivity to pollens from trees, grasses, weeds, or outdoor molds. Perennial allergies occur year around and are caused by a sensitivity to dust mites, mold spores, animal dander, or cockroach debris.

Nonallergic rhinitis is triggered by irritants, structural abnormalities of the airway, hormonal changes and occasionally medications. Irritants can trigger vasomotor rhinitis. Significant nasal irritation can occur from such things as cigarette smoke, strong odors or perfumes, detergents, cleaning solutions, car exhaust fumes and swimming pool chlorine. Some people are sensitive to spices, alcoholic beverages, or weather and temperature changes.

Sinusitis is an infection or inflammation of the sinus cavities. Sinusitis can be caused by a viral or bacterial infection. When the tissue inside the sinuses becomes inflamed it can trap air or bacteria that prevent the sinuses from draining. Symptoms can include headache, sinus tenderness, nasal congestion or "fullness." Treatment can include the use of decongestants, antibiotics, or anti-inflammatory steroids.

There are a variety of potential causes of urticaria and your allergist will take a thorough history to uncover possible causes. However, in approximately 90% of the cases of urticaria, a specific cause is never discovered. This is referred to as Idiopathic Urticaria in that the hives generally are not the result of an allergic reaction and a causative agent cannot be identified.

Depending on your history of when the symptoms started, what you were doing when the reaction developed, and if there were any new medications or change in your diet are among the many questions that will determine if allergy skin testing will be performed.

The initial goal is to make an attempt to identify a potential cause of the urticarial reaction and then avoid the precipitating factor. Oftentimes the underlying cause cannot be identified, so the focus is then upon symptomatic relief. Oral antihistamines are the mainstay of management. Newer antihistamines are frequently used because they have fewer side effects such as sedation. If the hives persist, then other antihistamine medications are added on to gain better control, but can increase the chance of adverse side effects. When there is a poor response to antihistamines, oral steroids may be needed to help control the symptoms.

Generally, urticaria will improve and in many cases will resolve, but as to when that will happen varies greatly. Some patients will have resolution of the hives in a matter of days while some patients can have hives for months to years. Sometimes urticaria can resolve only to reappear after several years of being hive free. The unpredictability of urticaria and angioedema are the hallmark of this skin condition.