Allergy refers to a
medical condition where the body's immune system is reacting to a
foreign substance (antigen) which should be regarded as harmless to the
body. There are six major types of allergic reactions. Of these, three
are common and will be discussed in the text below:
Search PubMed for Allergic Rhinitis
An allergic crease or salute
formed from constant rubbing
of the nose
(click to enlarge)
first type of allergic reaction is a Type I reaction. This reaction is caused
when an antigen attaches to an IgE antibody which then stimulates a "Mast
Cell" to release histamine along with a number of other chemical mediators
of allergy. (Note: This is why drugs which treat this type of allergy are called
This type of reaction causes sneezing, itching,
hives, welts, wheezing (asthma) and a runny nose. Usually, an allergy does not
cause the individual to feel sick all over and does not cause a fever. More
severe cases can cause nasal obstruction, facial pressure and facial pain. This
type of allergy commonly causes nose and sinus symptoms along with asthma. Some
food allergies, such as allergy to shell fish, are mediated by IgE. The symptoms
include itching, hives, wheezing and rarely death.
Shown in the
picture to the right is a nose with chronic allergic rhinitis. The lining of the nose (mucosa) is white and the secretions are sticky.
The second type of allergy is a Type III reaction
it is mediated by IgG and occurs many days after exposure to the foreign
substance. Some "Food Allergies" are thought to be this type of
The third type of allergy is a Type IV delayed
hypersensitivity reaction. It is mediated by white blood cells (lymphocytes) and
occurs 2 to 5 days after exposure and lasts for up to 21 days. There is a skin
rash with deep blisters and intense itching. Poison ivy is a common cause of a
delayed hypersensitivity reaction.
Diagnosis of Type I Reactions
to Inhalation Allergies
Today almost all the prescription
"Allergy" drugs available to doctors 5 years ago are now over-the-counter and directly available to the patient. There are many brands of
medications with many trade names. Most are marketed as Allergy, Cold and or
Pollens often trigger Type I
Inhalational Allergy. These allergy are usually seasonal with tree and
grass pollen in the spring and weed pollens in the fall. To find out your
areas current pollen count and five day projection go to
Testing - Inhalation Allergy
(click here for food allergy)
main types of allergy testing are skin testing and blood or laboratory testing, or RAST. The goal of skin testing is to lower the circulating IgE level and increase the
circulating blocking antibody (IgG4) which will prevent IgE’s interaction with
the "Mast Cell".
Both types of tests measure IgE. These tests are
not as accurate in evaluating for food allergies. Food allergy can be a severe IgE reaction, in which case allergy testing may be
contraindicated or food allergy can be a IgG reaction in which case you may not be
testing for the proper antibody. Also, foods are digested by the body and there
is little knowledge about the end product that the patient is reacting to.
There are two types of skin testing, prick and intradermal. A useful technique is
to use prick testing to determine which antigens cause an allergic reaction and
then titrate the positive allergens using intradermal testing to obtain an accurate starting level for
desensitization. This titration method is called skin end point titration -- see right hand picture. If only prick testing is done,
the patient usually starts on a lower dosage of antigen and shots are sometimes
given multiple times per week to shorten the time it takes to reach maintenance
dosage. The combination of prick and skin end-point titration (intradermal
testing) is less
expensive, more accurate, and will
allow the patient to start at a higher antigen level for desensitization than a RAST blood test. Thus, one will reach maintenance dosage sooner. However,
skin testing has more discomfort and rarely a patient can develop a serious reaction.
RAST testing is useful in children, patients
that are at risk for developing a severe reaction, such as asthmatics or
patients on Beta Blockers. However, since you start desensitization at a lower
dose than skin testing (RAST minus 1) it will take 10 weeks longer to reach a
maintenance dose. Because of the difficulty in treating anaphylaxis,
allergy desensitization should be used with caution in patients taking Beta Blockers.
Once the maintenance dose is reached, allergy
shots are often given for 3 to 5 years. They can then be stopped. After being
off of the shots for several
years, many patients will experience a recurrence of their symptoms. If this
happens, allergy testing should be repeated and allergy shots restarted.
Some allergists will keep patients on allergy shots for a longer period of time
but administer the shots less and less frequently, until the shots are given
only once or twice a month.
Interaction of drugs
which may interfere with allergy testing:
Beta Blockers - many consider this a contraindication
Alpha Blockers - many consider this a contraindication
Ace Inhibitors, Angiotensin II receptor blockers
ADAD May make worse
Medications which are
which are compatible with allergy testing:
Corticosteroids - Can be taken prior to allergy testing.
Allergies & Nasal Infections Most cases of nasal allergies start with swelling
and fluid production from the main nasal passages only. A patient with an
allergy has clear nasal secretions, no fever, pain and does not feel sick.
Often the patient will have itchy watery eyes, sneezing and a scratchy
throat. If the swelling becomes
severe, the sinuses can also be blocked, producing pressure and discomfort. Blocked sinuses can become chronically infected. Thus, a patient can have a nasal
allergy and a bacterial sinusitis at the same time. This is not an uncommon
situation and a chronic or long standing infection may develop. In this case, a doctor may also elect to treat with an antibiotic usually for as long
as three weeks. It is always best to consult a doctor to obtain a correct
#1. Antihistamine: These medications relieve
symptoms of allergy such as sneezing, itchy-watery eyes and nasal drainage.
However, they also dry secretions in the mouth and lungs and can can cause
drowsiness. Other side effects are urinary retention, especially in patients
with prostate hypertrophy, and worsening of glaucoma, and rarely impotence.
Because of their drying effect, antihistamines are not indicated in
"Colds" and may cause worsening of asthma. New longer acting
antihistamines are available from your doctor which will not cause as much
sedation or drying, and also have less complication. Of the over-the-counter
antihistamines, Diphenhydramine (Benedryl) is the most likely to cause
drowsiness, Chlor-Trimeton (Chlorpheniramine) causes less drowsiness and
(Claritin) the least. If drowsiness
occurs, one should not operate motor vehicles when taking antihistamines.
Antihistamines are broken down in the liver.
Over time a patient will become resistant to the drug, as the liver increases
its ability to metabolize the drug. Rotating antihistamines or different
classes may help to prevent this. (Benedryl Allergy & Travist-1 are in the
same class and can be rotated with Chlor-Trimeton Allergy.)
#2 Nasalcrom. This medication takes a long time
to work and prevents the "Mast Cell" from releasing mediators when
stimulated by IgE. This medication takes a long time to work and usually has
to be applied four to six times a day for up to 4 weeks before an improvement
#3 Decongestants. Decongestant Nose Sprays Should Seldom Be Used
To Treat Allergies.Allergies are
usually a long term condition and will not be helped by a three day course of
a nose spray. Longer periods of use, will cause addiction and worsening of
Cold & Sinus Section.
#4 Pain Medications. These
rarely need to be used. Most pain attributed to sinus disease is
actually caused by other conditions such as neuromuscular headaches.
Cold & Sinus Section.
If you have a heart condition, high blood
pressure or diabetes, or are taking MAO
inhibitors or Anti-Parkinson Medications:
There are only a few
over-the-counter medications you can take for an allergy, since almost all
medications contain decongestants. Decongestants may include
phenylephrine, or pseudoephedrine. Pseudoephedrine is a
methamphetamine precursor and this had lead to its restricted sale in some
regions of the USA. A third decongestant, phenylpropanolamine has
been taken off the market by the FDA.
FDA states that cold and
sinus medications containing
one or more of
the following ingredients: decongestants, expectorants,
antihistamines and antitussives were found not to be effective in children
under the age of 6 years and the safety of there use in
this age group had not been established. See Fox
The FDA also recommends NOT using cold and sinus medications in children
under the age of two:
Listed below are five
over-the-counter medications that contain an antihistamine and NOT a
decongestant which your doctor may approve for use with a heart condition or
high blood pressure:
In addition, Nasalcrom nose spray can also be
used since it is not a decongestant and is not addictive. A prescription
(montelukast) can also be used.
If you have glaucoma or
prostate problems over-the-counter antihistamines should not be used.
The have an anticholenergic effect which can worsen these conditions.
One over prescription antihistamine, Allegra, has little or no
anticholenergic effect and may be approved by your doctor for use.
The following is a partial list of
Allergy Medications Many of these drug combinations are also
available for children in the form of an elixir. Always read the directions
carefully and consult your doctor regarding dosage and indications for usage. Many "Cold" & "Sinus"
medications contain acetaminophen. If used together, liver damage can occur from
an over dosage.
* Denotes Elixir or Liquid Medication
** Note: This drug combination should be used
carefully since you will probably not want to take a cough medication if you
have an allergy and you will probably not want the drying effect of an
antihistamine if you have a "Cold".
little systemic effects as compared to oral steroids, some approved down to age
6 years. Prolonged use can sometimes cause nose bleeding and thinning of the
lining of the nose. Patients taking these medications should be checked by a
physician every few months. The picture on the right shows a through
and through area of necrotic nasal septum in a patient who had been using nasal
steroid sprays for over one year.
Intranasal Steroids in Children with Allergic Rhinitis
L. Buck, Pharm.D., FCCP
(Note: The viewer must register for
Search PubMed for Nasal Steroids
Three medications are in this
drugs-- Loratadine (Claritin), Fexofenadine (Allegra) and Cetirizine (Zyrtec). These
are now available over-the-counter, with the exception of Fexofenadine. These medications have less
sedative effects, less drying and less complications of urinary retention and
impotence. Some doctors are even starting to use some of these drugs in
asthmatic patients. Cetirizine has been shown to have a significant bronchodilatory effect (opens the lung passages) in patients with mild to moderate asthma.1,4
Fexofenadine is an antihistamine said to have little or no anti-cholinergic
effects and should have less problems with drying, urinary retention and
impotence. Fexofenadine has the shortest half-life and is administered
to adults in
either a 60 mg bid dosage or in a 180 mg qd dosage. The Medical Letter has
indicated that Loratadine
may have decrease effectiveness2 and it may
be more appropriated to give this drug in a 10 mg bid dosage.3
Antihistamine Nose Spray--
HCL) -- This medication is effective in the treatment of both allergic
View Abstract View Abstractand vaso-motor (non-allergic) rhinitis
View Abstract. Because the medication is applied topically it
systemic complications and increased nasal symptom relief. It has less
complications than topical steroid nose sprays. The major drawback to
asteline nasal spray is that many patients complain of a bad taste and it must
be used twice a day.
Search PubMed for azelastine
Oral Leukotriene Inhibitors. Singulair
(montelukast) is a once daily medication which has been shown to reduce symptoms
of allergic rhinitis
View Abstractby inhibiting leukotriene
receptors in the airway. Stimulation of leukotriene receptors has been
shown to cause edema, inflammation and smooth muscle constriction.
Singulair is a well tolerated drug with a low incidence of complications.
(or injectable) steroids should only be taken to suppress severe symptoms and
only for a short period of time. Steroids have many complications including
elevation of blood pressure, worsening of diabetes, elevation of cholesterol.
Prolonged use may even be a precipitating factor for strokes, heart attacks, and
the formation of blood clots. ONLY USE UNDER THE GUIDANCE OF A DOCTOR.
A combination of oral and intranasal
steroids has been shown to be an effective treatment for nasal polyps.
This is reserved as a last resort and is usually performed to relieve sinus
blockage or increase nasal airway. Removal of nasal polyps (shown being removed
in the picture on the left) is a common indication for surgery. If the
patient is allergic to bacteria or fungi in the sinuses, the operation may
result in marked improvement. However, the surgery will often only relieve the
symptoms associated with the blocked sinus and not improve the underlining
allergy. Thus, after surgery the patient may be improved but will still have to
take sinus medications or shots Surgery for "sinus headaches" is
debated and results cannot be guaranteed. Shields has shown that there was
no correlation between the severity of pain and the severity of sinus symptoms.
This brings into question whether sinus disease is causing the symptoms at all.
One explanation is that most of this pain is caused by tension headaches and
migraines. The patients just assume the pain is from sinus disease because
of the mass marketing of sinus medications they see on television.
View AbstractRamadan reported that children under the age of
six have more surgical revisions and less benefit from sinus surgery.
Children exposed to second hand smoke from their parents
also have less successful surgical outcomes.
Nasal Surgery Videos
Video May Not Be Suitable For All Viewers
Sinus surgery is often performed with scopes
through the nose and is usually done in an outpatient surgery center
("in-and-out surgery"). Because the sinuses are fixed and the operated
tissue does not move, post- operative pain is usually minimal. Surgery is not
without risks, injury to the eye and lining of the brain can occur. However,
these structures can also be damaged by untreated sinus disease.
#1 Grant JA, Nicodemus CF, Findlay SR, Glovsky MM, Grossman J, Kaiser
H, Meltzer EO, Mitchell DQ, Pearlman D,
Selner J, et
al. Cetirizine in patients
with seasonal rhinitis and concomitant asthma: prospective,
placebo-controlled trial. J Allergy Clin Immunol. 1995 May;95(5 Pt 1):923-32.
#2. Medical Letter (Issue 1103) Vol 43 April 30, 2001.
#3. Roman IJ, Kassem N, Gural RP, Herron J. Suppression of
histamine-induced wheal response by loratadine
29851) over 28 days in man.
Ann Allergy 1986 Oct;57(4):253-6
#4. Spector SL, Nicodemus CF, Corren
J, Schanker HM, Rachelefsky GS, Katz RM, Siegel SC. Comparison of the
bronchodilatory effects of cetirizine, albuterol, and both together versus
placebo in patients with mild-to-moderate asthma. J Allergy Clin Immunol.
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