Allergies and Related Disorders

Proper treatment of allergic disorders requires accurate diagnosis. It is important to eliminate and treat other disorders that can mimic allergy or coexist with it. Initial evaluation begins with a detailed medical history including an exploration of your home and work environment. A physical examination is performed with special attention to the head, ears, eyes, nose, throat, chest and skin. If the information from your medical history and examination suggests an allergic cause for your problems, diagnostic testing is indicated to find the specific cause for your symptoms. This allows a customized treatment plan that is tailored to  your allergies.

Problems We Treat at Allergy and Asthma Associates

Asthma is a condition of the lungs characterized by shortness of breath, a whistling sound from the chest known as a wheeze, and variable degrees of coughing. The hallmark of asthma is inflammation of the airways, which leads to reversible airway obstruction. Airway obstruction is most pronounced with expiration. This means that air can enter the lungs, but it becomes trapped as the airways narrow with expiration. Expiring against blocked airways produces the wheezing sound of asthma. Inflammation in the lungs is similar to inflammation elsewhere in the body and is characterized by swelling of tissue lining the airways, loss of function, increased production of mucus,  irritability of the airways with constriction of surrounding muscle. The net effect of this process that causes is that the airways become obstructed when trying to exhale. This expiration against an obstruction produces a wheeze or whistling sound in the chest and causes shortness of breath.  Asthma is caused by allergic triggers in the majority of people. Non-allergic factors that can also trigger asthma are acid reflux otherwise known as GERD, and substances that are irritants, such a pollutants, strong odors and cigarette smoke. Physical factors that can precipitate asthma are cold air, exercise and emotional events. If the asthma occurs primarily from airborne allergens, it is called extrinsic. When no allergic cause is found for asthma, it is called intrinsic. Removing the offending allergens is the cornerstone of treatment. Medications to relieve asthma are classified as either rescue or controlling. The type you need depends on the severity and triggers of your asthma. All controlling medications are anti-inflammatory, which reverse the underlying process producing asthma.

Exercise Induced Asthma (EIA) is a variant of asthma that causes wheezing, shortness of breath and sometimes cough, only during exercise. It is strongly associated with environmental allergies, especially sensitivity to perennial, indoor allergens such as dust mites, molds or animal danders.  Most people with EIA suffer with ocular and nasal allergies. Asthma may occur because the same process that is affecting the nose and eyes is smoldering in the lungs. The lungs produce excess mucous and become hyperirritable. Cooling of the airways with hyperventilation is thought to stimulate the airways and many people with EIA also have cold induced asthma. EIA can be controlled with albuterol before exercise. More persistent symptoms require inhaled steroids to reverse the inflammation in the lungs.

Chronic Sinus Infection is sometimes difficult to distinguish from nasal allergy. Symptoms include nasal congestion, headache, loss of sense of smell, pressure or discomfort around the nose, cheeks or eyes and nasal discharge or drainage. The sinuses are hollow bony cavities in the skull that are connected to the nose. Paranasal sinuses produce a watery liquid that drains into the nose and is similar to the mucous produced by the nose. If the sinuses become blocked, and mucous does not drain, a chronic bacterial infection can establish itself in the sinuses. Nasal allergies are a risk factor for sinus infections because nasal swelling blocks the tiny sinus openings and prevents the sinuses from draining normally. Other causes of sinus infection include anatomical problems, cold viruses, deficiencies of infection-fighting antibodies and genetic disorders including cystic fibrosis and immotile cilia. Cilia are microscopic hairs on the surface of cells that line the nose and sinuses. They rhythmically move and beat to sweep mucous out of the sinuses and nose. Immotile cilia are unable to mechanically remove secretions that accumulate in the nose and respiratory tract. It occurs with varying degrees of severity. Mild cases can have chronic sinus infections that are difficult  to eradicate. More severe cases of immotile can be associated with recurrent pneumonias that lead to collapse of the breathing tubes and damage to lung alveoli. Infertility in men  is also associated  with immotile cilia because the sperm are unable to swim with abnormal cilia. Diagnosis usually is made by examining tissue with an electron microscope that can magnify tissue tens of thousand times. Cystic fibrosis is caused by an inherited abnormality of mucous production that results in a very thick or viscous mucous that cannot be cleared from the respiratory tract, nasal passages or sinuses. This tenacious mucous prevents normal drainage of the sinuses and lungs. The end result is chronic lung and sinus infections that can be destructive over the long term. Fortunately, new antibiotics and other treatment are improving the prognosis of cystic fibrosis.

Whatever the cause, proper treatment requires identification of the underlying cause of the infection. Antibiotics are usually required for up to eight weeks. Long term treatment may involve aggressive control of underlying allergy with desensitization or allergen immunotherapy.

Atopic Dermatitis (AD) is a chronic, itchy, inflammatory condition of the skin in people with environmental or food allergies. It usually occurs in childhood, but occasionally persists into adulthood. In adults, it most commonly affects the folds of the elbows and behind the knees. At times  it involves the eyelids but can be generalized to almost any area of skin. Rarely, it is associated with eczema around the nipples. Because breast cancer can also cause nipple eczema, this must be excluded, especially if only one breast is involved. In children, atopic eczema can be very extensive, affecting almost  the entire skin. Most commonly,  involvement in children is less severe and affects the cheeks, knees and elbows. AD is also associated with a skin disorder known as keratosis pilaris. It is usually found on the outer surface of the upper arms and looks like "chicken skin". It is caused by abnormal shedding of sloughed skin, which then plugs hair follicles. Long standing AD is also associated with cataracts, and a cone shaped deformity of the clear part of the eye (cornea) known as keratoconus.

The exact role of allergy in the cause of atopic dermatitis is debated. New evidence indicates that a defect in the barrier properties of the skin caused by a mutated or absent skin protein (fillagrin) may be the primary cause of atopic dermatitis and the allergen sensitization occurs secondarily increased permeability of the skin to allergens. Mutations in fillagrin have been found  in almost half of an Irish population studied. Acquired deficiencies of fillagrin have been demonstrated in vitro by a research group in Denver Colorado.

Treatment of AD requires identification of allergic triggers, topical steroids, non-steroid anti-inflammatory creams and antibiotics. The most common environmental allergen associated with atopic dermatitis is dust mite, and the most common foods are eggs, milk, wheat, soy and peanut. Most children with atopic dermatitis have a  least one parent with allergies. In the first year of life, food allergies are quite commonly linked to atopic dermatitis.  Atopic dermatitis has a similar appearance to allergic contact dermatitis and irritant dermatitis, and usually can only distinguished by it location. Allergic contact dermatitis is a rash caused by substances in contact with the skin. When there are atypical features of the rash such as its location or persistence, allergy to the steroid creams used to treat the rash should be excluded by performing a patch test. Atopic dermatitis usually precedes the development of nasal allergies, asthma and ocular allergies in young children.

Contact Dermatitis or eczema is a chronic inflammatory and itchy skin condition that occurs from a hypersensitivity reaction to substances in contact with the skin. It may occur anywhere on the body, but hands, eyelids, face and neck are the most common sites. The rash has a different appearance depending upon it duration. In the early stages, it appears red, swollen, sometime oozing with small blisters. As the rash becomes more chronic, the redness fades, the skin becomes darker and thickened and develops white, flaky scales. At all stages, the rash itches.  Substances causing contact dermatitis include fragrance, metals, preservatives, hair colorings and formaldehyde releasing substances in personal care products. Offending substances can be identified with a simple patch test. Treatment usually requires topical steroids and in severe cases, oral steroids. Some cases of contact dermatitis do not respond to treatment because of allergy to the topical steroid. This can also be determined by the patch test. Allergic contact dermatitis cannot be distinguished from irritant dermatitis by examination alone. Irritants are chemicals that are toxic to the skin and will damage the skin in all normal individuals if a significant exposure occurs. Allergens, in contrast, affect only a small percentage of people, and those people who are not allergic can have unlimited exposure without adverse effects. Only a patch test can determine if there is a hypersensitivity or allergy to a substance. Eyelid dermatitis is usually caused by a substance transferred from the hands to the face. Common substances include acrylic in nail polishes and artificial nails, fragrances from soaps, sunscreens, preservative and occasionally metals found in cosmetics. People with environmental allergies can also develop eyelid eczema for unclear reasons. Click here for common contact allergens

Find out if a patch test can help you find the cause of your chronic eczema. 203-459-8712

Persistent cough has multiple causes in many people. Cough is considered chronic when it lasts longer than six weeks. In a non-smoking adult or child, a non-productive cough is caused by chronic sinus infection, cough variant allergic asthma, or "silent" laryngopharyngeal acid reflux. Evaluation often requires allergy testing, tests of air flow in the lungs and lung volumes using a spirometer, and an endoscopic examination of the throat. A chest radiograph is indicated if cough does not respond to conventional treatment or is present is a smoker. A productive cough usually indicates a different problem such as chronic bronchitis, bronchiectasis, lung infection and sometimes malignancy. Post-nasal drip is associated with chronic cough and is more likley to be related to acid reflux than allergies or chronic sinus infection.

Immunodeficiency should be suspected when infections occur with unusual organisms, do not clear completely with antibiotics, or are recurrent. Immunodeficiency can present in infancy, or it can be acquired in adulthood. Adult immunodeficiency is commonly caused  by the Human Immunodeficiency Virus (HIV) but can also be caused by medications used to treat autoimmune and malignant disease. Another common immunodeficiency known as common-variable hypogammaglobulinemia occurs in adults as part of a generalized loss of ability to produce infection-fighting antibodies.  The exact cause of this acquired immune disorder is unknown. The most common immunodeficiency in adults and children is deficiency of IgA, which occurs in about one in five hundred people and is a relatively mild disorder. IgA is an infection fighting antibody that occurs on the surface of body tissues in contact with the inside and outside worlds This includes the lining of the nose, mouth, lungs, intestinal tract and urinary tract.  It usually becomes apparent when chronic infections affect the ears, sinuses and lung. Many  people are without symptoms, and it is usually discovered incidentally during evaluation for other problems. Common variable antibody deficiency can be treated with intravenous gamma globulin, which replaces the missing antibodies the immune system is unable to produce. IgA deficiency cannot be restored with transfusions of antibodies because of the risk of severe allergic reactions.

Hives or Urticaria are recognizable as itchy, irregular shaped, raised, red wheals that appear in different places over time. When the same process occurs in  deep tissue, it is called angioedema. Hives and angioedema can be precipitated by food or drug allergy or viral infections. Some people with angioedema have inherited the inability to produce a protein known as C1 esterase inhibitor. These patients usually have an affected parent. There are other diseases, such as tumors of the immune system, that can lead to acquired deficiencies of C1 esterase inhibitor. Chronic hives, defined as lasting longer than six weeks, are frequently related to an autoimmune disorder. This means that your immune system, whose purpose is to fight infection, mistakenly attacks the skin as if it were a foreign invader. Hives that are related to autoimmunity are frequently associated with thyroid problems.  Diagnosis may require testing for food or environmental allergies as well as examination of the blood for autoantibodies against the thyroid gland. No commercially available tests are able to measure the antibodies that cause hives. Treatment begins with a combination of antihistamines, but may also require other types of medications as well . New information indicates some types of hives can be considered to be an auto-inflammatory disorder.

Call today to  find out if your hives are caused by autoimmunity or allergy.

Food Allergy is most common in children but also occurs in adults. Typical symptoms of food allergy include vomiting, swelling of the lips, tongue, throat and eyelids as well as hives. Reactions can be life-threatening in some people.  Symptoms usually appear within thirty minutes after eating the offending food. Delayed  symptoms, and the fact that foods are rarely eaten alone can cause difficulty identifying the responsible food. Some people with food allergy have only symptoms of a digestive disturbance such as cramps or diarrhea. The foods most responsible for food allergy include peanuts, tree nuts, soy, milk eggs and shell fish. Many reactions to foods are not caused by allergy. Symptoms of abdominal pain, diarrhea, and bloating can be caused by the inability to digest lactose, a sugar in milk products. Diarrhea and weight loss can by caused by inability to digest and absorb gluten, a protein found in various grains. More abrupt and violent reactions to foods can be caused by bacterial contamination and toxins due to improper handling or inadequate refrigeration. Testing for food allergy should not be performed except to confirm a suspected allergy. Blood tests such as RAST give many false positive reactions, especially in people with atopic dermatitis. Skin testing gives more accurate and clinically significant results. The "gold standard"  for diagnosis is a food challenge, but the physician must be prepared for a severe allergic reaction. IgG has not been shown to play a role in food allergy. IgG antibodies are present in normal people without digestive disease and  is of unknown significance. The Oral Allergy Syndrome or Pollen-Food Allergy syndrome is a type of food allergy  of short duration, with symptoms limited only to the mouth and lips upon contact with certain fruits, tree nuts and vegetables. It occurs in people who are allergic to various types of pollens, especially birch and mugwort. These mild oral reactions occur because substances in the pollen are distantly related and widely distributed  to proteins in many foods. The mouth develops a weak allergic reaction as if it were in contact with pollen. Raw foods are more likely to cause these symptoms than cooked foods. Fortunately, this type of food allergy is more annoying than a serious health threat. Preservatives and food colorings have been blamed but rarely proven to cause allergic reactions. Children with atopic dermatitis are frequently found to have unsuspected food allergies that have the potential to worsen the rash.

Anaphylaxis is the most dramatic and severe of all allergic reactions. Within minutes of ingestion of a food, drug or insect sting, swelling in the airway causes obstruction of ventilation and shortness of breath. This is also accompanied by loss or blood pressure and collapse. The combination of respiratory and circulatory failure can cause death if not immediately recognized. Fortunately, epinephrine, self or physician administered at the onset of symptoms is effective in aborting the attack in most people. Some people, rarely, may experience anaphylaxis for no apparent reason or cause.

Stinging Insects that cause severe allergic reactions include wasps, honey bees, hornets and yellow jackets. Honey bee is the only stinging insect that leaves a stinger. Allergic reactions usually begin within minutes and include anaphylaxis, respiratory distress, hives and deep tissue swelling. It is not unusual for a large amount of swelling to occur around the site of a sting, and this does not indicate risk for a future, severe allergic reaction. This large, local reaction is the result of tissue destruction and digestion by strong chemicals in the injected venom.