By Gailen Marshall, Jr.
WebMD Live Events Transcript
The first warm days, the first runny nose; the first blooming buds, the first red eyes. If springtime means sneeze time for you, review our WebMD Live discussion about finding relief. Our guest was allergy expert Gailen D. Marshall Jr., MD, PhD.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Hello Dr. Marshall. Welcome back to WebMD Live. What is so special about spring allergies? Why are so many bothered at this time of year?
Marshall: Well, first of all, the major problem with allergies in general is that it is such a widespread problem. Up to 30% of all Americans have some difficulty with allergies. This time of year is particularly bad because of the blooming trees and grasses throughout the country and other parts of the world.
Member: How do I know if I am being plagued with seasonal allergies, a cold, or the flu?
Marshall: That's really an excellent question. Many people are unsure of whether their symptoms are the cause of a cold or an allergic reaction. The basic difference is the presence or absence of fever.
In allergic rhinitis (also known as hay fever), there is no fever. Fever indicates some sort of infection. Also, hay fever typically causes symptoms that are limited to the nose, throat, and perhaps ears and eyes. In contrast, a cold or the flu makes a person feel bad all over, such as achy muscles and joints, and even difficulty moving about.
Member: I seem to go through a period of time only in the spring when I feel exhausted and get headaches. Is this some sort of allergy?
Marshall: It is possible that you may have a seasonal allergic disease, if your symptoms of headache are accompanied by nasal congestion (stopped-up nose) or sneezing and drainage. If it is only a headache and fatigue, other diagnoses should be sought.
Member: I have heard that some people with pollen allergies may also be allergic to tree fruits. Is this true? I was wondering what symptoms are associated with a fruit allergy.
Marshall: Some people do have pollen allergies and cross-react with certain food. Two prime examples are watermelon and ragweed (a fall pollen) and apples and birch tree pollen. The most difficult presentation is someone's nasal symptoms in season who consumes the offending food (i.e., eating an apple after exposure to birch pollen.) As the food is eaten, the patient develops oral symptoms, such as itching and perhaps some lip swelling. This is called the oral allergy syndrome. Out of season, the patient can eat apples and have no symptoms at all. So it is not a true allergy, but there is clearly a relationship.
Member: My allergies are significantly less bothersome at the age of 36 than they were at age 10 or so. (Cats, grass, mold, etc.) Is that typical, and can I expect them to get better as time goes on? And why is it that being near a cat would nearly kill me when I was a child, but now they hardly bother me?
Marshall: There are two major parts to the answer of the question. First, if you had asked this question 10 years ago, I would tell you that you could look forward to decreasing symptoms as you age. However, in the last 10 years (particularly in urban areas) the prolongation of symptoms into the 30s, 40s, and even 50s is becoming increasingly common. So it is possible you may develop worsening symptoms in the future, particularly if you live in certain polluted areas.
The same information holds true for allergies to animal danders as it does to allergies to pollen. Thus, we do see patients who have child cat allergies "redevelop" the sensitivity to cat later in adult life. Why this happens is unclear.
The second part of your question is even more concerning. There is an alarming increase in the rate of adults developing new allergy symptoms after losing them in childhood, into their 30s, 40s, and even 50s. So someone who had hay fever as a 10-year-old that was gone by the time they were 15, they now expect to see new symptoms when they reach 35, 45, or 55. We believe this is because of the rapid change in our environment, and is a reason to be concerned about preserving our environment.
Member: I am allergic to tree and grass pollen as well as animals. I also have severe asthma. An allergist suggested that allergy shots may help me control my asthma but my primary care physician refused to give the shots for fear that I have a severe reaction. He said I could die. Is this overreacting? Could the shots help me?
Marshall: Well, actually both of your physicians are correct. The allergist is correct, in that there is clear evidence that in the appropriate patient (one who has controlled asthma and rhinitis who defined allergens that you mentioned) and get significant improvement in both nasal and chest symptoms with allergy shots. However, your primary care doctor is certainly appropriate about your risk to adverse reaction to an allergy shot.
Being an asthma patient, a severe reaction could well be more dangerous. Fortunately, when shots are given in a carefully prescribed manner under direct supervision of a physician, these severe reactions are extremely rare.
Moderator: Spring can be particularly troublesome for the 10 million Americans who suffer from allergic asthma, according to the American Academy of Allergy, Asthma and Immunology (AAAAI). Can you explain why? And what should those individuals do to manage their disease?
Marshall: The seasonal allergic asthma comes from the same mechanism that causes seasonal allergic rhinitis; that is, when exposed to pollens, the susceptible individual manufactures a specific antibody (called IgE) that will bind a particular post defense cell, called a mast cell. There are mast cells in the nose, chest, and in other parts of the body. The patient with allergic asthma activates their mast cells when exposed to the pollen. It is the mast cell contents that is largely responsible for the acute asthma attacks in the allergic individual.
The same holds true for nasal symptoms in allergic rhinitis. Most allergic asthma patients also have allergic rhinitis. We physicians often say, "As the nose goes, so goes the chest." Thus, the very things you do to control nasal symptoms during spring allergy season would also help for allergic asthma symptoms.
Member: Where in the country are seasonal allergies less problematic?
Marshall: In our country, probably northern Alaska is a good place to go if you have seasonal allergic rhinitis (particularly spring season) because everything is still pretty much frozen. In the old days doctors would send patients to the desert for their allergy symptoms. However, some of my best friends are allergists in places such as Phoenix, Las Vegas, and Albuquerque.
Moderator: For many people, spring means spring cleaning. For those with allergies, what are the pluses and minuses of this annual ritual?
Marshall: Particularly in the parts of the country that get warm relatively earlier (April or early May) spring season represents time for spring cleaning. For my grandmother, that always meant opening all the windows in the house, hanging all the sheets on the clothes line, and even dragging the mattresses outside to "air out." The major problem with this for allergic patients is that pollens can attach themselves very nicely to sheets, mattresses, and get inside the house through the open windows.
Spring cleaning also means major dusting activities. Many, if not most, with seasonal allergies, also have sensitivities to other allergens, such as dust mites, mold spores, and animal dander. Heavy cleaning and dusting can stir the airborne amounts of these allergens greatly, resulting in new and/or worsening symptoms. This can relatively easily be dealt with by doing dusting with a cloth that has an agent sprayed on it that will collect the dust and a vacuum cleaner that has a HEPA filter attached to it. Many, if not most, modern vacuums already have this attachment.
Finally, if the susceptible individual is doing the spring cleaning or is inside while it is being done, use of a pollen mask (available for a buck or more at the drugstore) can be very beneficial.
Member: Are you aware of any cases where the use of central vacuums systems in the home can significantly reduce allergy symptoms? I read a clinical study done at the University of California, Davis that showed the use of a central vacuum relieving allergy symptoms in patients with rhinitis.
Marshall: I am not aware that the central vacuum itself offers any superior effectiveness compared to other devices. The study that you reference, I believe was not a comparison study. Rather, it showed that the use of a central vacuum was effective. This may be the cause of the relative ease in using a device such as a central vacuum cleaner, compared to lugging the vacuum to room to room.
Member: What medication can cover allergy skin rash and hay fever (runny nose and eyes)? I've been given Allegra but it doesn't work on the hay fever part of it. And the VA clinic says that they can give me nasal spray and eye droplets. But isn't there just one medication that can do both?
Marshall: Unfortunately, the answer is no for many patients. Some individual patients who take a single medication, such as Allegra, can do fine for both skin and symptoms. However, many patients require multiple medications. Unfortunately, you may be one of the patients.
Moderator: Should you purchase over-the-counter medications for spring allergies or is it important to see your doctor first?
Marshall: That's a very good question. The correct answer, in my opinion, relates to the severity and duration of the symptoms. If a person has allergy symptoms (sneezing, itching, runny nose or drainage and congestion) that last for weeks at a time, that patient likely needs a physician. However, if someone only sneezes and itches during March when they play golf, but otherwise do well, there are over-the-counter medications (such as the newly released non-sedating antihistamines such as Claritin) that may control symptoms just fine.
Member: I have been diagnosed with sarcoidosis and subsequently asthma after 40 years of upper respiratory problems. I'm trying different medications, since the insurance changed policy with the over-the-counter release of Claritin product. I am currently taking Singulair (after having the doctor get it pre-authorized, since I'm over 17), Advair, and was taking Allegra-D, but since insurance changes I have to try the Claritin-D. My symptoms seem worse at work, (I work in the office of a textile manufacturer), but I have never been tested for allergies. My question: Should I be tested to narrow down the allergens, or just keep trying to treat everything? Doctor doesn't recommend the testing.
Marshall: It would seem to me, based upon your story, that allergy testing would be the appropriate thing to do. I say this because you have different symptoms based on exposure. That is reasonable for validating the need for allergy testing.
Member: What tests are available for seasonal allergies?
Marshall: The testing that is done for seasonal allergies really depends on whose office you go to. In a classically trained allergist's office, skin testing is commonly done. This involves placing small amounts of extracts from pollens, dust, molds, and other allergens on the skin of the patient (usually the forearms or back). The skin is then pricked in the area where the extract is to "activate" the skin test. If the individual has an allergy to the specific extract placed on his or her skin, they will develop a small wheal and flare reaction, which looks a lot like a mosquito bite. This only takes approximately 20 minutes to develop. Thus, a complete evaluation can be accomplished in less than one hour.
Other physicians may take a blood test (called RAST), which looks for the presence of specific IgE in the blood. While this is more convenient for the patient, it typically takes up to one week to get an answer about the allergic status, and is considerably more expensive than skin testing, and is usually less sensitive than allergy skin testing (a higher false negative rate).
All in all, allergy skin testing performed by experts is the standard used to establish allergic sensitivity.
Member: I have a 4-year-old and she has really dark circles under her eyes all the time. My mother-in-law calls them "allergy shiners." Could this really be what they are?
Marshall: Assuming that your 4-year-old has other symptoms of allergies (particularly nasal congestion), the allergic shiners that you describe are fairly typical in small children. If she also has a runny nose that strongly adds to the suspicion. I would recommend, in that case, considering taking her to an allergist.
Moderator: So many people enjoy gardening or golf or just getting out to enjoy the season. What can we do to minimize the effects of spring allergies and still enjoy the great outdoors?
Marshall: That's really a very important question, in that it addresses the idea of living with allergic disease, rather than the succumbing to it. Several facts will allow a person to tailor their activities during allergy season. A few points:
- Pollens are typically at their highest level very early in the morning. Thus, during allergies, a later tee time can be very helpful in reducing symptoms.
- Exposure to pollens (and perhaps mold spores in dirt) during gardening exercises can often be managed with the use of a pollen mask while gardening.
- In the spirit of "an ounce of prevention is a pound of cure," a patient with known allergic disease could use their allergy medications before they develop symptoms.
Moderator: What is the impact of seasonal allergies on our daily lives? What is the economic impact?
Marshall: Many individuals do not consider allergic rhinitis a critical allergic condition. In my mind, these individuals either do not have allergies, or do not know anyone who has allergies, and almost certainly do not take care of patients with allergies. Allergic disease affects up to 30% of the American population. The estimated cause of treating allergic rhinitis in the year 2000 was in excess of $8 billion. This does not include the cost of 3 million lost work days, 2 million school days, and over 28 million days of what is described as decreased productivity by students and workers, either by the symptoms of allergic rhinitis (sneezing, itching, drainage, congestion) or side effects of the medications to treatment.
Additionally, the impact of allergic rhinitis on cognitive (clear thinking) facilities of patients has been well documented. Indeed, it had been suggested at one time that children with severe allergic rhinitis might actually be mentally retarded, since they clearly had learning difficulties. More recent studies have shown that such children improve learning and academic performance when their allergic rhinitis is adequately treated.
Finally, the presence of allergic rhinitis is associated with risk for other diseases, such as asthma, cardiovascular disease, and perhaps certain forms of cancer. Thus, recognition and proper treatment of allergic rhinitis has both short and long-term benefits.
Moderator: Dr. Marshall, we are almost out of time. Before we wrap up for today, do you have any final comments for us?
Marshall: I would simply say once more to heed the advice my grandmother used to give me. That is, control your allergen exposure as much as possible. Taking your medications regularly will translate into much better control of your symptoms this season and the next.
Moderator: Our thanks to Gailen D. Marshall, MD, for being our guest.
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