Allergies

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- Does it seem like many people you know are struggling with allergies?

We hear sometimes allergies are bad this year or this area has terrible allergies, but what exactly does that mean?

We wanna know all about allergies, particularly seasonal.

What's happening in your body when you get a reaction?

And how can you live with allergies?

Especially this time of year.

Talking about allergies on this episode of "Call the Doctor."

Hello and welcome.

We are so glad you're with us for this season and this episode of "Call the Doctor."

We're gonna get right to tonight's panelists, 'cause this is a topic that I think a lot of people are talking about right now.

Welcome to all three of you.

I would love if you could introduce yourself and let people know who you are and where they can find you.

- Sure, my name is Puneet Bajaj.

I'm an allergy and immunology specialist.

My office is in Forty Fort.

I work with Geisinger, and I'm the Director for Allergy Division for Geisinger.

- Great, welcome.

- Thank you.

- How about you, sir?

- And I'm Mohammad Elmusa.

I'm a family medicine specialty, and I work for Lehigh Valley Medical Group, currently practicing in Hazleton.

- Welcome, we're glad you're here.

- Thank you.

- How about you?

- I'm Joel Laury, board certified in allergy immunology.

I'm practicing in Dunmore, right over the border from Scranton.

- All right, great.

So glad to have all three of you here tonight.

- [Panelist] Thank you.

- We will get to different types of allergies, of course, in a minute.

'Cause I know that there's a lot of things that one could be allergic to in theory.

But let's start with seasonal allergies, and we talked a little bit earlier, I mean this is the question we'll get to, and I know that this is not your area, but why is this area so rife with allergies?

It seems as though everyone we know is dealing with seasonal allergies, or just about.

Why?

Do we know?

- So you're right, Julie.

I think this area is particularly known for severe allergies.

I think it's always ranked in the top 10 in the country for the pollen allergies.

I think because of all the trees and all the vegetation we have and how the valley is.

I think a lot of pollen kind of gets accumulated in this season.

And also when it warms up, sometimes when it warms up very quickly, all the pollen kind of is released together.

So we see a surge of pollen happening very quickly.

So that's why I think, especially towards the end of April and May, it can be very high pollen in our area, and that's probably the reason why people get a lot of allergy symptoms at this time of the year.

- So this is the time?

- Yes, absolutely.

And the office, we already started to see a lot of patients come in with many symptoms, and I think also this year we didn't have a long or a bad winter.

We didn't have a long time of freeze.

So a little bit earlier maybe we see a lot of patients coming to the office with symptoms of seasonal allergies.

- Yeah, what are you seeing, doctor?

- Well what happens is that over the years the allergy counts have been going higher and higher and they're starting earlier and earlier.

And tree season, usually February, March, April, May, grass season, which is the most common allergen, is May and June.

So everybody's miserable in May.

'Cause everything's there at the same time.

- [Julie] All at once.

- And the thinking is maybe because of the higher levels of carbon dioxide the trees are producing or the plants are producing more pollen.

There's theories, but there's no question that that number of, the amount of pollen in the air has been going up over the years.

- We'll stick with you for a second.

What's actually happening in your body when you're having an allergic reaction?

What is it that's happening?

- So the way an allergy works is you have an antibody called IgE, and it's attached to a special kind of cell called a mast cell.

So think about it like a floating World War II mine.

It's just sitting there doing nothing.

When it gets exposed to something that it's allergic to, it says, oh, warning, danger, and it sends a signal to the mast cell and explodes and releases histamine and many other chemicals.

It's not just histamine.

And that's what make people miserable.

They may itch.

Depending where the histamine is released and how much it makes a difference.

If it's in your eyes, you may have watery, itchy eyes.

If it's in the nose, you may sneeze, have an itchy nose, stuffy nose, runny nose.

If you have enough histamine released through the whole body, that could be anaphylaxis, meaning the entire body is having an allergic reaction.

Usually not from pollen, though I've seen it.

I had a girl years ago, and she was driving a convertible through a big field, and she ended up going to the ER for anaphylaxis she had so much exposure.

- Wow.

So do people think they have allergies sometimes when it's really something else going on?

How are we to tell?

Especially in the age of COVID now, and there's other, I mean we're out of flu season, or at least we should be, but how do people know whether that's allergies or something else happening?

What would you tell your patients?

- So I think it's- - Either or, go ahead.

- So I think it's very common to confuse allergies with the common cold.

I mean, that's a question we get asked all the time.

Is it truly an allergies going on?

Or is it a sickness or a cold going on?

So a a cold is a viral infection.

So it's kind of when you get a viral upper respiratory tract infection, you get runny nose, water, nasal discharge.

So you can easily confuse it with allergies, and sometimes it can be hard to tell.

But I think some of the main differences would be with allergies you get itching, which is not very common with common cold.

With common cold you get scratchy throat or maybe sometimes sore throat, fevers, body aches.

So those things are very unique to kind of when you have these common cold or viral infections.

Whereas when you get allergies, as I said, it's itchy eyes, itchy nose, runny nose.

You can have itchy throat, itchy ears.

If you have asthma, you start to get asthma symptoms like coughing, wheezing.

You can also get headaches.

It may affect your sleep and you get very irritable.

And those symptoms are more prolonged.

And allergy symptoms can last for the whole season.

So if you're allergic for tree pollen, you may be having this pattern of symptoms at every spring season.

You kind of have these symptoms lasting for two months.

So that's how I would kind of differentiate between allergies versus something like a cold.

- [Julie] There are differences in ways to tell.

- Yes.

- Yeah.

Also, for older population or people who have allergies for some time, and the talk is about seasonal allergies, you'll find those symptoms happen always around the same time of the year.

So this is another way to kind of differentiate between seasonal allergies and something else that's going on.

The timing is very important here.

So a good history when we see the patient and good intake that will always help differentiate between the two, allergies and something else that's going on.

- Do you still use the, and I have no idea what it's called, but, all the little pin pricks on your- - Oh, absolutely, absolutely.

- Is that still the standard of testing for what kind of allergy you might have?

- Yeah, 'cause there's blood tests, but it's not as good.

It may miss things.

So the scratch test actually is the best test we have right now.

And it's very good.

You have to get a good history first and find out what's going on.

But it definitely is the best test we have.

That is still used.

- Yeah, and so it's, but even with the testing, sometimes I'll tell people, if people are not allergic to dust mites, I'll still explain to them how to avoid dust mites anyway.

For example, for a few reasons.

First of all, dust is a mixture, house dust, even though we're talking about seasonal, it's also perennial, house dust is a mixture of human skin, animal dander.

Even if you've never had a cat or dog in the house, there's enough cat and dog dander in your house dust, enough to cause allergies.

They've done some fascinating studies with school children, and the more classmates have cats, these other kids who don't have any cats have higher levels of cat dander.

It's on their clothes, it goes in the air, it comes, they bring it home.

So house dust is also full of mold.

And also there's something called endotoxin, which is produced by germs.

So people can still have a problem anyway, even if they're not allergic.

- Ah.

So, yes, there are antihistamines, of course.

We'll stick on this track just for a second here and talk about ways that you might help a patient who comes in with allergies.

I think it was you, doctor, who talked about the steps that you take when it comes to figuring out how someone can live with allergies this time of year.

- I usually say there's three steps to treating allergies.

Step one is finding out what they're allergic to, try and decrease their exposure the best we can.

And I always say, "I know no one gets rid of the cat and dog."

I know that, I've been doing it long enough.

But whatever's reasonable, try and decrease the exposure the best we can.

In terms of the grass and tree pollen, which is out now, usually the best we can do is keep the windows closed, maybe run an air conditioner set on recirculate so you're not getting the fresh air in.

So the worst thing you could do is open the windows wide open and get all the pollen.

And a lotta people say, "Oh, I go to sleep at night, "I'm great."

Well, the problem is the pollen count is usually highest around 6 a.m. so when they wake up, they're miserable.

So step one is environmental control, and there's no side effects.

That's the only thing in medicine I can say there's no side effects.

Second step is the medicines.

And again, histamine is part of the problem.

It's not the entire problem.

So antihistamines do help, but it's not the be all and end all.

And I've been hearing...

I'm not that old, but I was told when Benadryl first came out in 1948, they said that's the end of allergy.

You don't need any allergists anymore.

We're finished.

(people laughing) Not true.

- Not so much.

- And then the last step is the allergy shots.

So the allergy shots do change the person so they're no longer allergic.

And it's not like you get one shot and then you're cured, but it's a whole series, so eventually your body learns to ignore what you're allergic to.

- And shots are something that you'll need lifelong?

- Typically we do shots for at least three to five years if a patient can do it.

The way the shots are done is typically we start on a weekly schedule, and we build up the allergen level in your body, and after that we transition to a monthly schedule.

So if it's working for you, then we do recommend patients to stay on shots for at least three to five years.

Because sometimes patients stop their shots and they want to go back on it.

And that would involve going back on the weekly shots to build it up.

- You have to go back to the very beginning- - Yes.

- And get that first hit in there.

- Usually what I tell my patients is that shots don't work for everybody, but for the majority of people they feel much better.

But in theory, one third of people are cured for life.

If they have their shots, they're finished, they're good.

- Really?

- In theory, one third of people do great for 10 or 20 years after stopping their shots.

And you have those one third, as soon as you stop, within a couple of months, everything comes back.

And those people I'm not in any rush to stop.

- From what I see in from patients, the length of the use of the shots, actually, the longer they've used it, I think the longer they go without symptoms after that.

So they stop, maybe if they use it for 10, 12 years, I think they do better for longer time than someone who used them for like three, five years.

- You're right.

I mean we see that patients who have stopped shots and their symptoms have come back, when they restart shots, they typically stay on it for as long as they can.

- If an allergy is an immune system reaction, is there anything to helping your immune system out?

Or is this something that... You see what I'm getting at here?

Why isn't, helping your immune system, why won't that help an allergy?

- So, immune system is designed to work against or protect us against infections or bugs or organisms, right?

But when the same immune system starts to act against harmless kind of substances, that's an allergy.

So when we talk about allergens, we are talking about, pollen or environmental allergens or food allergens or drug allergies or bee sting allergies.

So these are all kind of otherwise harmless substances, but it's the immune system that starts to think of this as a bad thing and starts to react to it.

And then it starts to produce these allergy antibodies, which when reacts with these allergens causes the allergic reaction.

So it's not like the immune system is kind of, it's kind of, you can say, more of a strong response of immune system to some things.

Why it happens?

I think it's a genetic thing as well.

So, some people are more predisposed to getting allergies than others.

Over time the prevalence of allergies have been going up.

We don't know for sure why, but we feel that less people are getting infections these days.

So their immune system is kind of, instead of fighting off infections, it's kind of getting into allergies or autoimmune diseases.

So that's why we are seeing more and more allergies happening these days.

Yeah, you had a- - So I agree.

If anything, the immune system is too good, and some fascinating data is suggesting people with a lot of allergies may have lower rates of cancer, because their immune system is good.

So the last thing- - It's fightin' it.

- You wanna do is rev up their immune system even more.

- Interesting.

- So a lot of the strongest medicines for allergies are actually gonna weaken the immune response, like steroids and so on.

- What about the allergies shots themselves?

- That's a good- - I mean, we can look at it as they do, the allergy shots do modify the immune system in a way- - So if you look at how- - That you're responding, actually, differently to the allergens you've been allergic to for a while, so yeah, I would say- - I see what you're saying.

Yeah, the allergy shots are- - So what shots do is basically tone down your immune system.

So because the immune system is already very strongly reacting to all these allergens, so it's basically we are tricking the immune system into believing that these allergens are not harmful, that they're harmless.

So we build up kind of a, we slowly introduce the allergens in their system, and we build up to a certain level, and as we keep doing it, the body gets it every month and it gets used to it.

So when the actual allergen is high around you, your body doesn't perceive it as as a risk and it stops kind of reacting or overreacting to it.

And that's how they work.

- Any idea why sometimes you can grow out of an allergy or someone who's never had seasonal allergies suddenly all of a sudden has issues?

What's happening?

I'll let you take that one doctor.

What's happening?

- Yeah, that's probably a question for- (people laughing) - You're like, no I don't want it.

(laughing) - I was glad not to answer that one.

(Julie laughing) - So I think the natural history of allergies varies.

We don't understand it completely.

This question gets asked to us, like am I gonna grow out of allergies?

And we don't know the answer for that question for sure.

Your allergies, you can outgrow your allergies, they can stay the same, or they can even worsen.

I think the only way to be sure about growing out is actually, as Dr Laury said, is allergy shots.

That's one way that we've seen that.

That is one modality that people can outgrow their allergies with.

But other than that it's kind of how your genetics is.

So, why our body suddenly becomes allergic to a certain allergen?

Like, for example, sometimes you can get allergic reaction to a shellfish and you may be eating that shellfish all your life without any problems, but suddenly you may throw a big reaction to it.

So those things, we don't understand it completely, but that's how the allergies are.

So sometimes, as I said, the immune system starts to recognize that thing as a threat and starts to react to it.

And that's an allergy.

- I'd like to talk through some misconceptions about allergies and about ways to treat allergies.

What are some of the common misconceptions that you hear?

Are people often confused about what an allergy is or is not?

Or how they can treat it?

- Oh, absolutely.

And a lotta people... For example, let's talk about food for a second.

- Sure.

- So if someone drinks milk and they get diarrhea, stomach cramping, they may say, "I'm allergic."

Well a lotta times they're not.

They may be missing an enzyme called lactase that breaks down the milk sugar.

That's lactose intolerance.

They're not allergic.

You can give them the enzyme, you could replace it, called lactate, and they could drink all the milk they want.

There's some fascinating diseases out there.

You never wanna have a fascinating disease.

- I know.

(everyone laughing) - Where people, it's called favism.

They're missing an enzyme and they eat fava beans and they have this, the blood starts, they break down their blood, they get homolysis.

- Oh my word.

- I'm sure maybe you've seen more of it in the Middle East.

- Yeah, in the Middle East.

Yeah, that's very popular there.

- It's more common there.

So people think that anything that they can't tolerate is an allergen, but it's not.

We mentioned also about aspirin.

If you take aspirin, you get stomachache or you get bleeding.

That's not an allergy.

That's what it's supposed to do.

That's what it does.

But an allergy, a very specific immune response, that's abnormal.

I always mentioned, if anything, it's like friendly fire.

Your body thinks it's attacking something foreign, but it's not.

- Trying to do you a favor.

- Mm-hm.

- Yes.

- Right.

- What were you, were you going to say something there?

Yeah, I was thinking about something.

It's not so much a misconception, but we see a lot of patients with allergies and symptoms and they don't, a lot of people consider it as it's okay.

I don't think they realize how much it's affecting their daily routine and their daily life.

And one thing is they get used to it.

You get used to to wake up in the morning and have stuffy nose and keep goin', not breathing good all day, and keep going.

So I think they won't know until...

If we educate them, if we try to treat them, if we offer them more information, and they see the difference, this is it's something that's important to get the message to.

- That's a very good point that, as you said, I think, again, having allergies means that they can affect your quality of life, and sometimes people kind of get used to it, but the consequences can be kind of not good for you.

For example, if you're a child or if you're a student and you have allergies and that's affecting your sleep, your performance at school, and if you ignore it, that's gonna keep going.

You may be missing work, you may be missing school.

If you have asthma, you may be getting multiple asthma attacks.

So I think it's one of those things that the awareness will create a better quality of life, and that's gonna make you more productive.

- What about, we talked a little bit about food, but you can be allergic, of course, to food and medications, makeup, contact, as you said.

What are some of the other of the other allergies that you see that are not seasonal allergy related?

- I think one of the common allergy questions that we get asked is bee sting allergies.

- Bee stings?

- Yes, so people think that if they get stung by a bee they will immediately have a bad allergic reaction.

They may die from it.

So that's a common kind of question we get asked.

But, again, people wanna be tested for bee stings sometimes when they have never had a reaction to bee stings.

They would want to have a screening test done to see if they will ever have a reaction if they get stung again.

But, again, that's not something we recommend, because these allergy testings can come false positive a lot.

So just because the test comes positive when we test you doesn't mean that you have a true allergy.

So we always recommend that if you have a reaction to a bee sting... And when I say a reaction, we're talking about an anaphylactic reaction or a severe allergic reaction, and such reactions would typically present with four type of symptoms.

So they can involve your skin, which will present with hives and swelling.

- Like a rash or?

- Yes, or the second thing would be your breathing.

So that would present with throat tightness, chest tightness, coughing, wheezing.

Number three is your abdomen or your belly, and you would have cramping and vomiting.

And number four is your heart, which can present with lightheadedness, drop in blood pressure, or loss of consciousness.

- Wow.

- So if you've had a reaction which is on those lines, that you got stung and you had hives and you had trouble breathing or you vomited, then we recommend getting tested for it and to see if you need an EpiPen or some kind of shots for bee stings.

But otherwise, if you get stung and you get swelling on your hand, well that is expected.

So that's something that we do not recommend testing for.

- You've talked about the EpiPen, too, and I thought that was interesting.

Do you think people aren't really educated as to what goes on with an EpiPen?

- Yeah, I think that epinephrine, is adrenaline, same exact word, and it saves lives.

So usually if there's a question I say, "Use it right away."

The adrenaline's gonna make your heart race, it's gonna make you jittery and nervous, and that's okay.

It saves your life.

So if there's a real question, you're much better off using it too soon.

Any studies of anybody who died from peanut allergies and so on, the one thing they all had in common is they all waited more than an hour.

So you really wanna use it early, and if you need to, you could repeat it again in 10 minutes.

Don't wait.

And we were discussing earlier that just because you used the epinephrine doesn't mean you have to go to the ER.

Means you need to use the epinephrine.

Now if you used it twice and you're not feeling better, I would definitely go to the emergency room.

But the vast majority of people who use the epinephrine autoinjectors don't need anything special afterwards.

They're cured.

And Benadryl and steroids are really much lower on the list.

- Like they're waiting for the big one or something.

- I think that's a good point you brought.

So I think if you specially talk about food allergies in the same context, so many times if you know that you have a food allergy, you know you've had a reaction in the past and your testing is positive to that food, then we prescribe EpiPens to these families and patients, and we tell them to always keep it accessible, and if there's any accidental exposure that happens that leads to an allergic reaction, they should immediately use the EpiPen.

But sometimes people wait it out, and they're not sure if they should be using an EpiPen or should they give more time.

So I think it's important to use it early on.

So if you have hives or any kind of breathing symptoms, or even if you're not sure, you won't go wrong with using an EpiPen.

So that will be a lifesaving measure to do if you have any concerns for allergic reaction.

- So there, is is there a risk with the EpiPen?

- [Puneet] Generally not.

- For most people, no.

For people who have heart disease, it's not an ideal situation.

And in some people taking some certain medicines called beta blockers, it may not even work as well.

So there's a work around.

There's a second medicine called glucagon we could use if we need to, if the epinephrine doesn't work.

But I think people need to understand it's gonna be right through the clothes.

You're still fully dressed.

You're just jabbing in the outside, upper outer thigh, and leaving it there for a few seconds.

And that's another thing.

It's fascinating, it's one of my favorite studies.

They took pieces of meat, they weighed how heavy it was, then they put the EpiPen on it, and they weighed how much the increase in weight there was over time, and almost all the increase in weight was in the first one second.

So the EpiPen goes in very quickly.

You don't have to leave it there for five or 10 seconds.

- [Julie] Interesting.

- 'Cause a lotta people will just do it and then they wanna take it out 'cause it hurts or what have you.

But you were talking before about things, I wanted to mention about unusual kind of allergies.

So in terms of hives, the fancy word is urticaria for hives, people can be allergic to water.

I've seen people- - Water?

- I've seen sunlight urticaria, solar urticaria.

- Wow.

- I've seen people, well some people are allergic to themselves.

Some people when it's too hot or too cold they'll break out.

Or when they exercise.

- Yes.

- So there's all sorts of fascinating things.

As I mentioned before, you don't wanna be a fascinating patient.

- Is that uncommon?

Or just things that we don't typically hear about?

- It's fairly common actually.

As Dr. Laury said, cold-induced urticaria, we see that a lot in our region.

So in the colder times of the year, you can get hives or swelling on the exposed parts of your body.

So it's like an allergy to cold.

And sometimes the way we test it is that we actually put ice cubes on their forearms and we let it sit for five to 10 minutes.

And when we take it off, it just forms a big swelling there.

- [Julie] Oh my goodness.

- And the biggest danger for these people is jumping into a swimming pool, because if they have a big allergic reaction, all the blood flow goes to the skin, they could lose consciousness.

- [Julie] Oh my goodness.

- Other things in that regard, I mean we see a lot of patients sometimes for the first time they have some allergic reaction.

By the symptoms and the exam you can say this is a really allergic reaction.

And a lot of times you cannot find out what they were allergic to.

- What they were allergic to.

- You treat and then it never comes back.

- And what about asthma?

Didn't you bring up asthma a little bit earlier, too?

What's asthma's role or connection here?

- Well, asthma has an allergic component to it as well.

So anytime we have patients with asthma, and the season they have their allergies high, we try to educate them to maintain their medications for asthma as well as stress on the importance of use of the medications for allergy this time of the year.

So if they're using nasal sprays or loratadine, they should be starting those medications a week or two, I tell my patients, usually, before the season starts, because you wanna prevent any asthma attack.

You wanna prevent emergency room visit, hospitalizations, and long-term effect on the lungs from that.

- We were talking- - Yeah, it is important to prevent those things.

- We were talking before about how important it is to treat allergies, and you had definitely mentioned that kids don't do as well in school and people at work don't do as well, it also increases the risk of having asthma, increases the risk of having ear infections, and other problems like that.

So, a lot of times by treating the allergies very aggressively, then you may prevent that.

There's some fascinating studies where they gave very young children cetirizine at age 12 months for a long time and those people had a lot less asthma.

People who are at higher risk for developing asthma.

- So asthma is when your air tubes close up on you, when the trigger comes, and the triggers could vary.

But allergies are a very common triggers for asthma.

You could have cold air as a trigger or activity as a trigger or respiratory infection as a trigger.

But when the allergies are high, and that's your main trigger, especially in this season, if you don't take the allergy medicines, it not just flares up your allergies in your nose and sinuses, it can very well lead to an asthma attack, and that's gonna put you in a bad situation.

So that may lead to ER visits or need for steroids, and that can cause a lot of concern, or sometimes admissions in the hospital, too.

- It seems as though it's usual to treat allergies as in you take a small amount of sort of a maintenance, a little bit throughout the entire season.

At least I've heard that anecdotally, of course.

Are there situations where, so you have your over-the-counter type medications and the shots.

IS there anything else that I'm missing?

Any other way that you would treat allergies?

- So I think, as Dr. Laury said, the first thing is avoiding the allergen.

The second thing is the medicines.

So there are a couple of options that we have out there.

So we have antihistamines.

The standard antihistamine that a lot of people use is Benadryl, which unfortunately is not the best, because it's only active for four hours in your system.

We do recommend using something long-acting like Zyrtec, or sorry, cetirizine or loratadine or fexofenadine.

They stay in your system for 24 hours.

The other thing is steroid nose sprays like fluticasone, so you can use them every day.

Now most people would try to use them as needed, but that doesn't work as good if you have seasonal allergies.

So if you know that you're allergic for the spring pollen and that's gonna be out for two months, it's better to use it every day instead of just using it when your symptoms are flaring up.

In fact, we tell our patients who have spring allergies to start using their medicines mid-March, and go throughout the season so that their body's kind of prepared to handle the allergens.

- [Julie] Are we almost through it?

- No.

- No.

- I mentioned- - Tree season is up 'til May, but grass season, which is usually the worst, is May and June.

- May and June, so in two.

- And it's been my theory, I haven't read any studies, but I like my theory.

(people laughing) There's so much tree pollen in May that even people without allergies a lotta times have itchy, watery eyes, and you could test 'em and nothing shows up, but you still have to treat them.

- But it's still, right, yeah.

I wish we could continue on, but we have reached the end of the episode.

Thank you.

I know I told you it'd go fast, right?

Thank you all of you for your expertise.

We do appreciate it.

That's gonna do it for this episode of "Call the Doctor."

We are very glad you've joined us.

If there's something that you've missed or you want to take a listen to again, you can find the whole show at our website, wvia.org.

For all of us here at WVIA, I'm Julie Sidoni, thanks for joining us.

We'll see you next time.

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