Birch & Fruit Connection

The tree pollen counts have been extremely high this past week according to local pollen reports. One particular tree pollen, Birch, not only causes nasal, eye and chest symptoms like other pollen, but this pollen causes food allergies if a person eats certain fruits.

How so?

The boy who wanted to ” scratch the back of his throat” mentioned this happened whenever he was eating an apple. He didn’t understand because if he ate an apple in the winter this didn’t happen. Another girl loved to eat cherries, as well as peaches and plums–these foods also made her throat itch, but nothing worse than that seem to occur. The parents of these children were concerned because they had always heard that food allergies could be quite dangerous, but fruits are so healthy for kids. Should they avoid them just because of some itching?

The Oral Allergy Syndrome

These children all had what is termed The Oral Allergy Syndrome. It is a type of food allergy (often quite mild) that is related to a person’s pollen allergy. Children and adults who are allergic to Birch pollen can have this allergy to fruits that have a genetic linkage to the Birch pollen. These fruits include apples, cherries, kiwis, plums and peaches–the so called pitted or stone fruits. Also, vegetables such as carrots and celery are also included in this cross-reactive food allergy. Hazelnuts and soy products have been associated with Birch pollen allergy too. The proteins in these foods, specifically termed Betv1, is what causes the allergic reaction.

What You Can Do…

Although patients are disappointed they can’t eat these foods without symptoms, I do tell them that they can get away with eating these fruits or vegetables cooked. For example, most of the patients can eat an apple or cherry pie without a problem. The cooking process breaks down this protein easily and the protein is no longer allergenic. It is important to differentiate the Oral Allergy Syndrome from a more severe type of allergy. I can do this in my office by ordering a special new allergy component test that breaks down the different proteins to see which are the dangerous and safer ones.

Another interesting cross-reaction, but this time to grass pollen, is wheat. Again, this pollen and this food share some homologous (genetic) proteins that can make someone react to eating wheat products, such as rye bread, during the grass pollen season. Peanuts also cross-react with grass pollen, but many times this shows up more frequently on allergy testing than in real life. I mention this because sometimes I have patients come to me with their parents who are told their child is allergic to peanut, but they have consumed peanut without a reaction. Certain proteins in the grass pollen also cross-react with the peanut proteins and in essence gives a false positive. This can be very important to differentiate, as a child doesn’t want to be under all the restrictions of a true peanut allergy patient. Again, special allergy testing can identify the true peanut allergic patients from the less dangerous reactions.

I want to wish all the mothers out there a wonderful Mother’s Day. And if you do have The Oral Allergy Syndrome, you can tell your family Dr. Mitchell said you can have the apple pie — a la mode for Mother’s Day!

The Worst Allergy Season Ever!

I was curious if he was just going to make his viewers aware that pollen allergies can be severe this year, or whether he was going to introduce a new remedy. I watched with amazement as he asked the allergist on the show, “what about all this talk on Allergy Drops?” My colleague, Dr. Bassett, mentioned that he was aware that allergy drops are now being used to help children and adults with all types of airborne allergies. I was so excited to see this happen on national television. Finally, Allergy Drops are getting the attention they deserve!

Our practice has been using Allergy Drops for 15 years! I wrote the book: Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006) which discusses my serendipity in discovering a physician who introduced me to this new treatment, and how it radically changed our way of practicing medicine.  The premise of the treatment is that by building up the body’s natural immune system to counteract the allergies, you can develop life-long immunity and be free of medications. Our practice has treated thousands of patients over this 15 year period, and the majority of patients has achieved significant relief.

One of my favorite stories that aired on Fox News several years ago was about a young boy Mark who suffered with terrible spring allergies and asthma (you can see it on YouTube). He loved playing baseball, but during the Little League season his sneezing and wheezing were so bad he had to come out of the game. We treated Mark with allergy drops to tree and grass pollen and he did a complete turn around. Dr. Steve Salvatore was shown having a catch with Mark in Central Park during the height of the spring pollen season. Mark didn’t miss a throw!

4 Reasons We Practice Allergy Drops:

• EASY: The beautiful thing about Allergy Drops is that, unlike allergy injections, there is NO Shot!
• CONVENIENT: The other big factor is that you do the drops at home, or wherever you are travelling. There is no need to go to the doctor’s office.
• SAFE: Another key factor is safety. Allergy drops have been reported in medical literature to be much safer than shots.
• EFFECTIVE: And finally, they work….enough said.

The key to this treatment is to get on a regimen before your symptoms are severe.  Using Allergy Drops is like working out with weights: you have to put some time in to see results.

I didn’t get invited to The Dr. Oz Show yet, but if he does give me a call next year I’m going to insist the title of the show be: The Best Allergy Season Ever…on Allergy Drops!

“When you make an appointment with one of us, you are actually getting 2 doctors thinking about your case.”

Even when you’re not here, we are thinking about you. You see, we always confer on cases as a team, and this collaboration gives us more successful outcomes.

What’s new?

We have made the natural next step by combining our practices. Ricki Mitchell MD, and Dean Mitchell MD, Allergy Drops, are now Mitchell Medical Group, Integrative Medicine, which combines the best of Western Medicine with the best of Holistic medicine.

Who Are We?

We have been in private practice in New York for over 20 years, and we have cared for thousands of patients. We are dedicated to teaching our patients how to make informed decisions to improve their health and maintain that level of health.

We have the expertise and credentials, unlike chiropractors or nutritionists, to do diagnostic testing (laboratory work, radiology films). These tests ensure that your illness may be treated through a proven treatment. We also believe that enhancing the body’s immunity through vitamin therapy or immunotherapy (to allergens) can have lasting results.

Why a Newsletter?

We are dedicated to bringing you the latest medical information, both research and clinical, to empower you be in charge of your wellness, and to help you make better decisions regarding your healthcare.

When we see patients they often say, “I’ve read about this…or…I saw this on TV.” We are on top of it. We read the information from popular media, separate the sensationalistic from the sound advice, and offer you our expertise and point of view. This newsletter lets us share these potential benefits with you.

Because even when you’re not in our office, we are thinking about you.

We welcome your comments and questions. Email us at care@mitchellmedicalgroup.com

Sign up for our newsletter, Doctors Thinking About You, HERE.

The Worst Allergy Season Ever 

The difference has to do with timing: tree pollen allergies tend to start earlier, usually once the weather warms up in early April. As we all put away our winter coats and enjoy the first few days of warmth and sunshine, the tree pollen starts floating off the budding trees. The symptoms typically begin with itchy eyes and some mild sneezing. People who wear contact lenses might notice their eyes are suddenly becoming uncomfortable. We’ve all seen allergy sufferers carrying around boxes of tissues for the constant nasal drip. Of course, the initial response is that you are coming down with a cold, except you don’t have fever or chills. Then you turn on the TV or radio and are reminded that the tree pollen counts are going through the roof.

The people who suffer from grass pollen allergy have a reprieve usually until May, but then they get a blast of the pollen which can make Mother’s Day to Memorial Day quite unpleasant. Typically, the park or the golf course is where the heavy duty grass pollen exposure forces you to run to the closest Starbuck’s for a latte and some indoor safety.

Allergy Self-Defense is Available–with or without your doctor’s help.

Over-the-Counter Remedies to try:

1. Nasalcrom is one of the best preventive nasal sprays you can possibly use. It used to be a prescription, so it is proven effective yet safe. It is actually based on the Egyptian herb Khaillen, but the key to its effectiveness is to start using it at least 2 weeks before the pollen gets too intense.
2. Antihistamines are now available without a prescription. The good news these medications are relatively non-sedating compared to the older antihistamines, such as Benedryl. Good choices: Claritin, Allegra and Zyrtec. They are all available as generics as well. These medications are best used when you start experiencing symptoms, not ahead of time like Nasalcrom. However, timing can be important: use these antihistamines at night so their action peaks into the next morning when you leave the house. Pollen counts tends to be highest between 8am and noon.

Prescription Medications:

1. Cortisone is the medication of choice once allergy symptoms become severe. The nasal cortisones are safe and effective, but your doctor will have to write a script for you. If your symptoms are very severe, your doctor may have to prescribe a short course of oral cortisone to bring down the allergic inflammation.
2. Pataday or Optivar, prescription allergy eye drops, are superior to over-the-counter eye drops for several reasons. They are more potent, longer-acting, and don’t have the decongestant component that many non-prescription eye drops contain which can cause “rebound red eye,” which is when you use non-prescription eye drops for a prolonged period of time, then stop, making your eyes red again.

Sublingual Immunotherapy( Allergy drops)

If  you suffer season after season, year after year, then you may want to consider doing sublingual immunotherapy, also called allergy drops. This is a proven treatment that uses the natural pollens in nature to build up your immunity so you can permanently reverse your allergies. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution, I discuss at length how patients can use this treatment and conquer their on-going misery with allergies.

Follow my recommendations for preventing and reversing your allergies, so next time you hear: “The Worst Allergy Season Ever!” – you can turn to another channel and let someone else get nervous.

The concept of desensitization or now more commonly referred to as immunotherapy is to give small amounts of the allergen to a patient and slowly build up there immune tolerance. I do this commonly for patients allergic to environmental allergens, such as animals (pets mainly), pollen, dust and mold. The results are usually very gratifying: patients can visit relatives with cats and dogs, and in many cases even live with a pet they couldn’t tolerate being around before. Also, many patients, children and adults suffer terribly when the tree or grass pollen counts are high. Again, immunotherapy can make a tremendous difference.

Immunotherapy to foods has been a different story: doctors and researchers had several stumbling blocks to advance this area of medicine. One, it has been difficult to conduct research trials in healthy children aside from their food allergies and expose them to risk in being food challenged or treated with the allergen they are allergic to. Second, is money (always, an issue.) Not many pharmaceutical companies are interested in desensitization or immunotherapy treatments due to the fact that they are not patentable, that profits will not benefit their company. Dr. Nadeau mentioned that she went without a salary for 3 years while doing these studies because funding for the research was minimal compared to typical drug company-sponsored research.

The two types of food allegy immunotherapy being closely looked at: oral and sublingual.

What’s the difference?

Oral immunotherapy to foods, such as peanut, involve giving a child miniscule doses of peanut in a flour base mixed with apple sauce. Every two weeks, the dose is increased until over 6 months the child is getting the equivalent to about 8 peanuts. So for example, the child at the end of the program is asked to eat 8 peanuts a day to maintain immune protection from the allergy.

Oral immunotherapy seems to work very well, the down side is that during the protocol the children do get reactions similar to peanut allergy at times–and at the end adherence to having to eat that food daily can be an obstacle in children and adolescents especially. The sublingual protocol in my opinion is preferable. This involves a solution of peanut diluted also to a low level and given in drop form under the tongue (sublingual). As I mentioned, I have done this for years with environmental allergens and found it safe and effective.

The research studies also have found the sublingual approach to peanut allergy to be safer than oral therapy but slightly less effective. The goal with sublingual immunotherapy is not for the child to ultimately eat the food, but rather be protected from accidental exposure to the food allergen. One of the children mentioned in the article (the author’s son) stated, ” I’m tired of being Epipenned”– meaning, he was tired of using the self-injectable adrenaline whenever he had a food allergy reaction.

Families call my office and ask if I treat peanut or other food allergies–I regretfully say, “not yet.” I think the sublingual can be done in private practice settings, not just research facilities. But it is difficult when prominent researchers voice their disapproval of doing this treatment in private practice. But that’s why I love Kari Nadeau’s saying: ” Failure is not an option!” This inspires me to get ready to take the next step.

The story behind this new device is right out of a scene from the popular show “Shark Tank” on ABC. The invention came from 2 brothers, twins Eric and Evan Edwards from Virginia, who grew up with severe food allergies. The two boys and their parents worried constantly that they were going to have a life-threatening reaction when eating out in places where possible foof allergies were lurking. The boys made a promise to themselves that when they got older they would invent something to help others deal with the fear of  food allergies and not succumb to these fears.

Eric and Evan went off to separate colleges but kept their main goal in site: to develop a device to help others cope with food allergies. Evan chose an engineering major to learn the technical aspects of creating a device, and Eric studied pharmacy to learn the therapeutic use of an allergy treatment. The key breakthrough the young entrepeneurs made was to improve the current injectable epinephrine device, which is used to treat anaphylaxis for a food or insect allergy. They accomplished this by adding a voice activated system to this small instrument so that anyone can follow the simple instructions during an allergic emergency. I watched the video demonstration on www.Auvi-Q.com and it is very user-friendly, especially for children. As a food allergy specialist in NYC,  I will strongly advise my patients who currently need injectible adrenaline to purchase an Auvi-Q. Interestingly, it’s very similar to the voice activated automatic defribillators that are in all the schools and airports now–the voice activation gives you simple instructions to get you through those chaotic emergencies.

These are really exciting times in treatment and prevention of food allergies–especially in regard to peanuts. In my NYC allergy specialist practice, we have been testing patients with the new blood test for peanut allergy called the UKnow Peanut test, which measures the specific proteins in the peanut that help determine if a patient has the particular proteins that put them at greater risk for a severe allergic reaction to peanut. This new test shows promise in decreasing the need to do food challenges to determine whether a patient’s food allergy to peanut has changed.

Eric and Evan Edwards, inventors of Auvi-Q

I was also very excited to see in January’s issue of The Journal of Allergy and Clinical Immunology 2013, that a group of medical centers have shown that children with peanut allergy could be successfully desenstized to peanut through sublingual allergy immunotherapy. This is the second major article that has proved this concept–the first was from Duke University in the November 2011 issue of  the same journal. I was very pleased because in my book, Dr. Dean Mitchell’s Allergy and Asthma Solution(Marlowe 2006), I predicted that sublingual allergy drops could someday aide food allergy patients and change their lives. I currently use sublingual allergy drops to help my patients with environmental allergies to cats, dogs, pollens, dust and mold; however, I can see in the near future using allergy drops to block a  severe food allergy to peanut or any other food.

I am very optimistic that in the next few years we are going to make huge advances in helping food allergy patients live better lives.

Kudos to the Edwards brothers–when you want a problem solved don’t wait for the next guy, just do it yourself!

To Your Good Health,

Dr. Dean

The overwhelming majority of patients that don’t get a flu shot say: “I don’t want to get the flu from the shot itself”. This really doesn’t make sense, because the flu vaccine contains a purified protein from the virus, which has been weakened or killed. When it comes into contact with your immune system, it will then begin to make antibodies to patrol the bloodstream for a future real influenza encounter. The antibodies typically take about 2 weeks to reach protective levels, and should remain protective for several months.

I say all this from personal experience. When I was a doctor in training, we weren’t offered the flu vaccine, unfortunately. I was working long hours in the Emergency room and must have come in contact with a patient that had early flu-like symptoms and became infected. I was sick for almost 3 weeks with high fevers, a painful cough and generalized body aches. I was in my 20′s but I felt 90. I swore to myself to never go unvaccinated again.

The places where flu can spread are numerous: buses, subways, airports…anywhere and everywhere. Yes, washing your hands frequently can help…so can disinfectant. The only real way you can have some mental comfort is to get the flu vaccine. Dr. Mitchell’s orders!

This time of year I get lots of calls and forms to fill out from parents

Last Saturday, (September 8, 2012) The Business Section of The New York Times ran a lead article entitled: “Tiny Lifesaver for a Growing Worry.”  The article focused how many states (not New York) had passed a law that an EpiPen can be used in a school without a prescription by a school nurse to treat a child in danger of anaphylaxis (the most severe form of allergy). The article showed a picture how EpiPens would be mounted in the nurse’s office just like a defibrillator unit (to reverse cardiac arrest) to call attention to the use of this life-saving medication.  This medical issue unfortunately only got national attention when a year ago, Amarrria Johnson, who had a known peanut allergy was given a peanut by another child and went into respiratory arrest due to the allergic reaction. The nurse did not have a documented prescription to give epinephrine and it was not given in time to prevent Amarria’s death. Law-makers and Health officials using common sense are now putting laws into place to allow a qualified health professional to administer the Epipen, regardless if a prescription is in place. This is important because a child may develop a severe allergic reaction for the first time in their elementary school years and they may not have had the need for a prescription. A study in Massachussets found that 25% of children that received epinephrine never knew they had an allergy.

Food allergy is on the rise. Today 1 in 13 children have a food allergy- and 40% are found to have a severe reaction to the food. Peanut allergy is notorious for causing severe food allergy reactions. Today 1 in 70 children are allergic to peanuts- back in 1997 1 in 250 children had peanut allergy. The good news is that testing is getting better and safer. When I have a concern that a child has a peanut allergy I order the UKnowPeanut test (PIRL labs); this test can quite accurately detect if a child is at risk for a severe allergic reaction to peanut. These tests are more specific than a skin test- and safer because the child gets no exposure to the actual peanut, it’s all through the blood. I’ve also been fortunate to advise parents who were concerned their child might have a peanut allergy that in fact they were not allergic to peanut from the test. I can also order other food allergy tests in the blood or do skin tests if I think it is necessary.

So, once again, if your child has a food allergy please make sure the school has an updated prescription to use epinephrine from your doctor, and the same goes for asthma medications.

Allergy drops have been and found effective for many people tested for egg allergies.

The New England Journal of Medicine published an article this week titled “Oral Immunotherapy for Treatment of Egg Allergy in Children“. The lead author was Dr. Wesley Burks, president of the Academy of Allergy, Asthma and Immunology.  The significant finding is that oral immunotherapy can desensitize a high proportion of children with egg allergy. In the long run, oral immunotherapy can induce long-standing protection against egg sensitivity so that children can continue to eat eggs after the treatment is stopped.

The excitement in this new field of oral immunotherapy is that previous studies have shown that this treatment is effective for peanut allergy, and now the same has been shown for egg allergy. Parents should be warned that this is not an overnight treatment success. Results take time.

• At 10 months of therapy about 55% of  the children treated with oral immunotherapy passed an egg food challenge.
• Even better– at 22 months 75% of the treated children were desensitized
• At 36 months all (100%) the children that had passed the challenge at 24 months passed that time.

lgG4, called the “blocking antibody” can be a marker of immune intolerance.

I’ll take those scores any day of the week! However, a few children did drop out of the study because of allergic reactions. Interestingly, one of the markers that seems to correlate with the children’s inability to pass the challenge is an elevated IgG4 level. This is the so-called “blocking antibody” which seems to be a marker of immune intolerance.

Some of the researchers of the article have been quoted in seminars as saying that this type of treatment is still under clinical investigation and is not ready for use in routine practice. That may hold some validity, but with parents clamoring for a safe and effective treatment for potentially life-threatening food allergies, a more rapid evaluation of how to bring this treatment into the mainstream is most needed.

My own experience with an egg-allergic patient was unforgettable. It was my first year in private practice and my patient said he wanted to be tested to see if he was still egg-allergic. He was diagnosed in his twenties with severe egg allergy after having allergic shock (anaphylaxis) after eating a plate of eggs in a diner. He had to avoid restaurants because even a miniscule amount of egg in a pancake would cause a severe reaction. After 20 years, he came to see me. I initially did a blood test called the RAST on him and it was negative. Today, blood testing is much more accurate with the ImmunoCap and ISAC testing by Thermofisher. However, the patient couldn’t believe, nor could I that he was really ok to eat eggs. I decided to test further, and performed a prick skin test to see his allergenicity. That was an unfortgettable moment. The patient immediately broke out in hives and had trouble breathing, I had to give him 2 shots of adrenaline (epinephrine) to calm down the reaction. Needless to say, he stayed on his egg-free diet.

I believe we are at an exciting time in the treatment for food allergy. My message to children, adults and parents: “Hang on– a cure is in sight.”

An Olympic athlete needs all the oxygen they can get to perform at their peak.

It’s very exciting with the Olympics just a few weeks away to watch these incredible athletes, who have devoted their lives to this moment, get a chance to perform their exercise genius. I also find it interesting to hear the different stories from these Olympians and the challenges they have had to overcome to reach their goals. One of the most difficult challenges for any Olympian has to be a medical condition that interferes with their endurance. A breathing disorder, like asthma, is an incredible challenge physically and mentally to any athlete.

With asthma, the lungs constrict and the person feels like they are breathing through a tiny straw. Now, picture an Olympic athlete  either running at full speed or swimming and experiencing this condition. Interestingly, Olympians have to be specially screened who are taking asthma medications to get an exemption from the anti-doping rules set up by the Olympics so that an athlete doesn’t get a special advantage by  taking these medications.

Some studies have shown that an athlete, when given a diagnosis of exercise-induced asthma, didn’t actually have asthma in 3 to 15% of the cases. In these cases, the diagnosis of vocal cord dysfunction was the actual cause of the difficulty breathing. You may ask, ” What’s the difference, does it matter?”. The answer is a resounding, “Yes!”. Patients with vocal cord dysfunction typically don’t respond well to bronchodilator inhalers, such as Proventil, Ventolin or albuterol- even in a nebulizer. The reason is that the problem isn’t in the bronchioles of the lung, but the vocal cords are moving in a “paradoxical motion”- that is in the opposite direction of how they should be opening when you are breathing in. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution(Marlowe 2006) I devote a whole chapter to conditions that mimic asthma.

Some athletes have been diagnosed with Asthma, when the real problem lies elsewhere.

The diagnosis of vocal cord dysfunction can be very tricky. You need to observe a person in a breathing attack to do the proper testing. One test that can help make a diagnosis is a Pulmonary Function test that looks at the Flow-Volume loop on inspiration. This part of the loop will appear ” flattened” instead of the normal pattern of a semicircle. Ask your doctor to pay special attention to this component of the breathing test and show you himself. The other test, which is considered the “Gold-Standard” to diagnose vocal cord dysfunction is a laryngoscopy, where the physician looks at the vocal cord movements.

The symptoms of vocal cord dysfunction can mimic asthma but there are warning signs that can point your physician to make the correct diagnosis:

• Shortness of Breath, especially in the throat, but also in the chest
• Chest pain
• No wheezing on expiration (Breathing out)
• Your asthma medications don’t give relief within 5 to 10 minutes

For some unknown reason, young women are more prone to this condition than men. One theory is women are reaching puberty with fluctuating hormones, and especially ones that are found in stressful situations or high achievers.

The treatment of vocal cord dysfunction is very different than asthma: no medications are necessary. The key treatment is special breathing techniques that stretch the diaphragm and prevent the vocal cords from adducting (coming together) when they should be abducting (opening apart). A good speech pathologist can help a patient develop this proper breathing technique.

So, whether you are headed to London as an athlete, or just to your local gym to get exercise if your “asthma” has not been well-controlled, ask your doctor to work with you to re-evaluate your diagnosis.

Go Team U.S.A!!!

Asthma by the Numbers

But what can be done to prevent the rise of asthma? In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006) I dedicate a full chapter as to what can be done to prevent and reverse asthma. The special ingredient in my program is sublingual allergy immunotherapy, also known as allergy drops. Studies have clearly shown that for allergic asthmatics, which account for about 70% of the asthmatic population, you can identify and eliminate all key allergens from their environment or you can treat them with allergy immunotherapy, which can reverse the process and significantly decrease or eliminate the need for medication. I have treated children and adults for over 15 years with sublingual allergy drops, and my experience is that this can be done safely, conveniently (at home, it doesn’t get better than that) and effectively.

I used to get a lot of questions from patients, and some doctors, who, when I mentioned this treatment would say, “I never heard of that.”  I think the genie is going to come out of the bottle very soon – sublingual allergy drops are ready for prime time and it will make a huge impact on patients with asthma all over the country. By treating the underlying cause that triggers the bronchospasm (closing of the bronchioles), you decrease the amount of allergic inflammation that is the hallmark of chronic asthma. The other gratifying aspect of allergy drops is that after a few years of treatment a patient is finished – it’s not a life-long relationship.

My biggest concern for all Americans is that because of the trend to do less in healthcare, the opportunity to prevent and reverse many disease processes will be missed. None of us should be thought of as a number, and when it comes to our own or our children’s health, we have to advocate for the best possible care available.

Eosinophilic Esophagitis is a fairly new disease entity that is often recognized in patients who have been told that they suffer from heartburn despite not responding successfully to medications designed to decrease acid production. EE is diagnosed when a gastroenterologist does an upper endoscopy biopsy and finds more than 15 eosinophils. The eosinophil is a type of white blood cell that is found in the bloodstream in small amounts but that rarely occurs in the body’s tissues. Eosinophils are typically associated with allergic reactions or parasitic infestations in under-developed countries.

Up until recently, doctors had no clue as to what caused this disease and what made it worse. Now evidence is emerging that shows the prominent role food allergies play in triggering Eosinophic Esophagits. Eliminating the problem foods can actually reverse the growth of the disease without medication! A study published in Gastroenterology (June 2012) showed that when patients eliminated milk, soy, egg, wheat, peanuts/tree nuts, and shellfish from their diet, the eosinophils decreased to less than 10 in 78% of the patients – impressive! The most common food triggers were wheat (60%) followed by milk (50%), soy (10%), nuts, and eggs. Remarkably, none of the participants were aware of any food allergies or intolerances prior to the study.

Unfortunately, prick skin allergy testing only helped predict the causative food in 13% of cases. I think the reason for this is the immune mechanism: prick skin testing, where the skin is lighlty punctured with a plastic toothpick-type instrument, helps detect when IgE immediate allergy is involved. I am aware from other studies, particularly Dr. Jonathan Spergel’s at The Children’s Hospital at University of Pennsylvania, that allergy patch skin tests have a much higher accuracy for diagnosing these food allergies, which implies that T-cells are likely involved in directing eosinophils.

I ran into Dr. Spergel at the American Academy Allergy meeting in Orlando this spring and, in a brief conversation, he mentioned to me he has seen dramatic improvement in many children diagnosed with Eosinophilic Esophagitis by eliminating the aforementioned 6 key foods. Failing to eliminate the problem foods resulted in a progression of the disease process with pathological changes in the esophagus, requiring inhaled or oral steroids to try and control the disease. The message is clear: work with your doctor to figure out if you have this condition and try and find the food or foods that need to be eliminated.

While we’re on the topic, I’d like to mention a book that discusses a more common type of heartburn – Gastroesophageal Reflux. Dropping Acid, by Dr. Jamie Kaufman, is a wonderful collection of recipes for the patient that suffers from Reflux and needs to know what foods are high in acidity. I recently met with Dr. Kaufman and we had a chance to discuss the importance of helping patients better understand why they get Reflux. Dr. Kaufman gave me a quick pearl: “Green is good, yellow-orange is bad,” meaning that the color of food can be a clue as to what may give you trouble.

A wonderful nutritionist I know for several years, Wilma August, always reminds me that “food is meant to be energy for the body.” Choose what you put in your mouth wisely and your body will thank you for it.

Celiac disease, the most severe type of gluten-sensitivity, is more common than most people realize. It affects 1 in 133 people in the U.S.A – a little over 1%. The ratio among men and women is nearly equal, although women tend to get diagnosed at an earlier age than men because women are more likely to attend to their medical needs promptly.

The symptoms for Celiac disease and gluten-sensitivity are different from those taught to most doctors, including myself, in medical school. Celiac disease was mainly taught in Pediatrics as a malabsorption syndrome, a disease where the intestine cannot absorb proper nutrients. Classic Celiac patients were shown as having rail-thin arms and legs and protruding bellies, but this is rarely seen anymore. Although diarrhea and abdominal pain account for 9% and 20%, respectively, of patients’ symptoms, the scope of its symptoms is much broader.

My wife, Dr. Ricki Mitchell, a chronic fatigue specialist, has diagnosed numerous cases of Celiac disease in patients who for years were told that they were hopeless and needed psychiatric help. Fatigue and anemia (having a low blood count of Hemoglobin) are common symptoms of Celiac disease in adults. Because the intestine is not absorbing nutrients properly, these patients become iron and B12 deficient. In this case, replacement therapy isn’t the answer because it wouldn’t address the underlying problem.

Women, especially those already diagnosed with Osteoporosis, should be checked for Celiac disease because taking a medicine to strengthen the bones will only be a temporary fix if the real issue is po0r intestinal absorption of nutrients. Dr. Green also made the point that undetected Celiac disease can lead to an increase in malignancies, such as Intestinal Lymphoma, if left untreated. Low cholesterol and a low HDL can also be associated with Celiac disease – sometimes even a good thing, like a low cholesterol, is too good to be true.

There are many different ways to diagnose Celiac disease. The gold standard for diagnosis is a biopsy of the small intestine. This is done in order to detect the absence of microvilli, the finger-like projections that help increase surface area to absorb nutrients. However, before you even have to think about being “scoped”, there are blood tests available that indicate if you are a likely candidate for this procedure.  The Tissue Transglutamanase IgA blood test is an excellent screening test to determine if a patient may have Celiac disease. A second blood test, called Endomyosomal antibody, will tell if a biopsy is needed. Another way to test for Celiac’s is through genetic testing. For this test, all the doctor has to do is swab the inside of your cheek and send it to the lab for analysis. If you have the genome HLA DQ2 or DQ8, you are at risk.

The good news is that a gluten-free diet will cure you – no meds needed. Ah, but the cure is worse than the disease, you say. No more pasta or pizza, what could be worse! Well, restaurants hear your pain and many of them now offer gluten-free pasta and pizza and supermarkets often have special sections for their gluten-free products.

Quinoa is a wheat alternative that can satisfy your craving for grains while being tasty!

Oh, and I almost forgot to mention the best part of this diet, weight loss! Dr. William Davis, cardiologist, wrote a book called, “Wheat Belly: Lose the Wheat, Lose the Weight”. He explains that wheat, even whole wheat has a high glycemic index – meaning that your blood sugar soars after eating wheat bread, which causes weight gain. The reason this happens – and has nothing to do with gluten sensitivity – is because modern wheat has high levels of amylopectin A, which converts to glucose faster than any other carbohydrate. If you like grains like I do look into the following products: millet, quinoa, and amaranth. They make good granola and rice-like dishes and actually taste good.

A number of celebrity A-listers have gone gluten-free: Steve Nash, the Phoenix Sun’s star, Novak Djokovic, the number 1 Tennis player in the world, and talk show host, Elizabeth Hasselback. I think there might be room on this list for me, if I jump on the gluten-free bandwagon before Dr. Oz!

The article mentions a patient that was diagnosed online with an upper respiratory infection and given a prescription for an antibiotic. This “doctor visit” only cost 45 dollars. The fee may be a bargain, but not when the patient is being short-changed. I truly cannot think of one time that I have gone to the doctor and thought for a second my ailment could have been treated over the phone… or worse, the Internet.

My medical training has taught me to assess a patient’s condition from their facial appearance and gait. A physical exam for asthma or bronchitis patients is critical in deciding if a chest X-Ray, antibiotics, or no medicine at all is needed to heal the patient.

The other issue is, of course, how well your doctor knows you. I feel confident advising one of my patients that I know well and have examined in the past over the phone, but many times if they continue to feel unwell, I strongly advise them to come in for a visit. I’ll never forget the patient who called me and said she had broken out in hives and the itching was terrible. She pleaded with me to call in some cortisone because it had worked when this happened in the past. However, she also had a fever and the combination worried me. I asked that she come into the office the next day. Her diagnosis wasn’t hives… it was the Chickenpox! She had caught it from her daughter – she had never had Chickenpox as a child. If I had prescribed oral cortisone it could have been disasterous!

My feeling is that “Virtual Care” can be a virtual nightmare. The insurance companies have a vested interest in this type of care – cost containment. If you don’t go to a doctor’s office you will probably get less care, and they, in turn, save money.  And to think things couldn’t get any worse – RiteAid Pharmacies are testing out these NowClinics in their stores to replace their current clinics, which are staffed with doctors and nurses. Yikes!

There is one area of medicine where I think Telemedicine may have some benefit and that is with skin rashes. I frequently ask patients to take photos of their rashes and send them to me so I can evaluate their condition as quickly as possible as rashes can frequently change.

I teach at The Touro College of Osteopathic Medicine in New York City. I enjoy training these doctors in using their minds and their hands – they are specially trained in physical manipulation to relieve certain medical conditions. I would hate to see these young doctors who will have much to offer their patients reduced to a 17 inch monitor where they cannot use the skills they have learned and that medicine needs so desperately… now more than ever.

Today,  MRSA has become more prevalent in office settings due to the overuse of antibiotics. MRSA infections are important to detect because they are usually resistent to the first-line antibiotics used to treat sinus infections, such as Amoxacillin, Cephalsporin, Erythromycin, and Tetracycline. MRSA infections can be treated if the lab finds they are sensitive to Quinolones (ex. Levaquin) or Vancomycin.

My main concern is that patients with chronic sinus infections are using products to rinse their sinuses, such as bulb syringes or Neilmed products, and are not properly disinfecting them between uses. It is quite easy for these products to become contaminated if the proper procedures are not followed. The same thing probably goes for the Neti pot, which is quite popular with patients that suffer from chronic sinusitis.

I can attest that treating patients with chronic sinusitis is extremely difficult – as a physician you are always debating whether or not to use anitbiotics. In many of the cases, the chronic inflammation is not due to bacteria and antibiotics are of no benefit; on the other hand, these recent cases make me suspect culturing the nose may be important.

My pearl of advice: Remember to disinfect any equipment you use repeatedly in your nose – it’s one of the main ways you can prevent infection.

It wasn’t a medical breakthrough, but, instead, a computer breakthrough. Allergy Apps, which can be downloaded onto your smartphone, can give you helpful allergy information. I was reminded of the time Bill Gates was asked, “Why don’t you give out free computers in developing nations to help them advance?” His clear answer was that these countries didn’t need a computer – they needed safe food and water and vaccines. In that same line of thought, a phone won’t cure your allergies, but it can get you some useful information.

What followed was a demonstration of the app’s features. The app downloads the pollen count in your area from pollen.com, which can help you connect your symptoms to what’s going on outside. It can also help you locate a pharmacy in your area, if you need immediate relief.

This story caught my attention, but seemed a little disappointing. I was a little more impressed with a different app that I hear about the old-fashioned way – through the regular mail. Allergy Eats! offers an app that can help people with food allergies find restaurants that are safe and enjoyable to eat at. Users of the app can rate more than 600,000 restaurants quickly and easily by answering three simple questions about their dining experience. This is the real power of the online experience!

Let’s get specific: Tree pollens are hitting peak levels and grass pollen will soon follow. Pollen levels tend to peak around 11am – 2pm, after which they subside through the evening. Our adrenal system, the gland that sits on top of your kidneys, produces cortisol, which is a hormone that affects metabolism and the immune system. The best way to use allergy medications is to time them so they are working optimally with your immune system to blunt the affects of pollen when they are at their height. I typically recommend taking an antihistamine such as Claritin, Allegra or Zyrtec, the night before. These are long-acting antihistamines, unlike Benedryl which is short-acting, and these medications will have saturated the maximal amount of cells by midday the following morning. The same is true for eye drops, such as Pataday or Elestat – both long-acting.

On the other hand, if you need immediate relief from sneezing and congestion I would use a nasal cortisone spray such as Flonase, Nasonex or Rhinocort. These sprays mainly work locally in the nose. Because cortisol peaks in our bodies in the early morning, I would recommend using these sprays in the early morning. They are fast-acting and should provide protection within 1 hour and it’s good to coordinate the cortisone dosing with our bodies natural cortisol production. This is especially true if your allergies are very severe and your doctor determines you need oral cortisone to control nasal and sinus pain or asthma.

A few other interesting facts regarding “the rhythm of life”: Your brain is most alert around 10 a.m. to get all those great ideas flowing and your muscle and cardiovascular system are at their peak around 5 p.m., the optimal time for you to work-out.

The best way to avoid your springtime allergies in the future is to speak to your doctor about a prevention program, either through medications or immunotherapy. The exciting part about immunotherapy is that in our office we can do it with under-the-tongue allergy drops to build up protective antibodies to minimize or eliminate allergy symptoms. But again- timing is everything! You have to start several months ahead of time, otherwise you miss the boat again!

My tips to reduce spring allergy symptoms:

1. Go to your drug store and find the nasal spray called Nasalcrom. Nasalcrom is now over-the-counter, but it used to be a prescription. It is very safe and can be very effective… if you start ahead of time. It mainly works as a preventive spray to decrease nasal sneezing and congestion. If you wait until the pollen gets bad, you won’t get as much benefit. Nasalcrom is not a steroid spray, it is based on the Egyptian herb Khellin, and can be used at least twice a day.
2. Ask your doctor for a prescription eye drop the moment you begin to experience eye irritation. I like Elestat and Pataday. They are both effective and well-tolerated; however, Pataday can be pricey so I’d recommend trying Elestat first.
3. Keep your antihistamine ready. They are all now over-the-counter. They are all effective, but I have some additional thoughts. My experience is that Claritin is the lightest in the sense that it will help for mild allergies, but not severe ones. Allergra (fenofexitidine) and Zyrtec (Cetirizine) are more powerful; however, Zyrtec has a sedative effect on many patients so Allegra would be my optimal choice. Be sure to check with your pharmacist since Allegra can interact with other medications or if you have heart arrythmias.

If you wait too long and are already getting hammered by the pollen your allergist can prescribe you a short course of oral cortisone to get you well enough to return to work and your responsibilities. However, we now have Allergy Drops (sublingual allergy immunotherapy), which can help you to build resistance and tolerance to the pollen allergies permanently. I’ve been pleased to see how well my patients, who have been using the allergy drops for several months, are doing. The studies being done at Stanford Medical Center and Johns Hopkins are showing that sublingual allergy treatment can be an effective way of changing an allergic patient’s immune system to a non-allergic state.

At the American Academy of Allergy meeting that I attended recently, I was excited to see the data presented from around the world, showing that sublingual allergy immunotherapy is achieving the results every allergy patient has been waiting for: a safe, convenient, effective therapy that lasts!

There are several US-based companies that market “hypoallergenic pets”. These companies include: Midneelyn Siberian Cats, Siberian Cat Breeder, Allerca Lifestyle Pets, and Kitails Siberian Cattery. However, only 1 company has boldy stated that it has produced, “the world’s first scientifically-proven hypoallergenic cat, followed by a true hypoallergenic dog.” This company, Allerca Lifestyle Pets, based out of San Diego, California began to market these animals in 2004. The company doesn’t guarantee a 100% success rate, but their price-tag would make you think otherwise: the price for a hypoallergenic dog is 7,950 dollars and the cats can vary from 6,950 to 22,950 dollars per cat. The company claims that by breeding their cats and dogs with animals that have gene mutations (genetic defects) that stop the animal from producing the potent allergens that trigger symptoms in their owners. This claim, to the best of my knowledge, in reviewing the article is not well supported.

Feld 1 is the major allergen produced by cats and it comes form the feline salivary, sebaceous (skin), and perianal glands. These allergens make their way to the cats epidermis and fur through self-grooming. Because this allergen is very small and light, it can embed itself in bedding, furniture, and carpets, and is easily transferred from one person to another through their clothing. In one study, cat dander that was found in the homes of children who did not have pets could be traced back to the childrens’ classmates at school who did.  Significant levels of Feld 1 have been found in cinemas, cars, planes, and even hospitals!

The dog issue is a bit trickier, due to a lot of anecdotal evidence for one dog being more or less hypoallergenic than another. Dogs are basically divided up into “low dander” types and “high dander” types. Low dander dogs include: American Hairless Terriers, Chinese Cresteds, Peruvian Inca Orchids, and the Mexican Hairless. Other allergy-friendly breeds include the Bolognese, Havanese, and Lowchen. Unfortunately, the high dander dogs are the more familiar, family-friendly dogs: the Irish setter, German Shepard, Cocker Spaniel, and the West Highland White Terrier. The dog allergen proteins, Can f1 and 2, are derived from the salivary glands and the saliva, dander, and fur are where the allergens reside. If you start to itch or get a red welts after a nice lick on the face by a dog, you can be sure you are allergic.

If you are allergic to cats or dogs but are determined to have one in your life, there a few things you can do to minimize your symptoms.

• Try to keep your pets out of your bedroom. If animal allergen build up in your bedroom, you will be inhaling the allergen all night while you sleep. While you sleep you don’t clear your secretions and the allergic inflammation can intensify.
• Purchase an air-filtration device to remove these air-borne particles on a daily basis. Medical studies have shown these to be beneficial. A company called Rabbit Air makes some beautiful models that are very effective.
• Consider sublingual allergy immunotherapy, also called allergy drops. I have been doing this for 15 years and have successfully desensitized many patients that previously couldn’t stand to be around a dog or cat for even 15 minutes. I even have a cat and dog allergic patient married to a veterinarian, and after a year of allergy drops he is feeling well, even around animals. I have to admit that it’s hard to live without these lovable critters.

Infection

I’ve developed severe viral infections after flying on long flights. Four days into my trip to Europe last year  I came down with the worst sinus infection I ever had and I know I got it from the plane ride. My tips to protect yourself in the air:

• Wear gloves when you go to the bathroom. Bathrooms, and bathroom doorknobs, are prime areas for germs to spread.
• Bring hand-sanitizer and use it generously.
• Purchase First Defense nasal strips. They look a litte like band-aids for the nose and they work to prevent bacteria and viruses from entering the nostrils. They look a little funny, but who cares if they allow you to have a wonderful, relaxing, and disease-free vacation.

Allergies

The upholstery, seats, and carpeting on planes are full of dust mites. Dust mites are powerful airborne allergens that can trigger the nasal congestion and mucus that can lead to a sinus infection. Dust mites can also trigger allergic asthma which may require use of an asthma inhaler. What’s the antidote?

• Use Nasalcrom spray a few days before the flight – usually twice a day. It is extremely safe and now available over-the-counter, without a prescription.
• First Defense nasal strips may also be a good addition to prevent inhalation of these dust mites while in the cabin.

Swelling and Clots

The reduced cabin pressure and oxygen content on flights can make you more susceptible to joint swelling and clot formation. NBA player Amourie Stoudemire recently had his ankle swell up on the flight back from a game due to an injury. If you remained seated for several hours during a long flight you can also be more prone to clot formation in the legs, which can travel to the lungs.

• Take an aspirin the morning of the flight. The aspirin prevents platelets from aggregating and can lessen the risk of a clot.
• Get up from your seat every hour on the plane and take a walk.
• Massage your calves. A good solution for those of us stuck in the middle seat!

Finally, once you arrive at your destiny take a nice shower or, even better, a bath. This will reduce your stress level and get your vacation off to a great start.

Angioedema from food allergies

The location of the swelling should help your doctor determine if the cause of your angioedema is allergic, or due to another medical condition. For example, swelling of the lips, face or eyelids in many cases is due to an allergic trigger. One of the most common causes of angioedema in these locations is a food allergy. Typically, I hear that a patient has eaten at a restaurant, many times an Asian restaurant where the food is served with many sauces, and within an hour the allergic reaction has affected the lips or tongue, and maybe also the face or eyelids – think of Will Smith after he ate peanuts in the movie Hitch. If the allergic reaction is not so obvious, a blood test or a simple, non-invasive skin test can reveal the cause.

Angioedema from contact dermatitis allergies

Another common cause of swelling in these areas can be from a contact dermatitis allergy. This is where a person touches a substance that gets transfered from the fingers to the face and can trigger intense swelling. Recently in our office, I was visited by  a woman who started coloring her hair. She applied the hair color on Friday and by Sunday her eyelids were swollen so badly she could hardly see! This is an example of what we call a delayed allergic reaction – meaning, the allergic swelling doesn’t take full effect until 48 hours after the application. My office does skin patch testing which is a safe way to determine which chemical in the product caused the reaction.

Angioedema from medications

The other main cause of angioedema can be medications themselves. I have seen several cases where common drugs like Aspirin or Advil have caused the reaction. Another well-known cause of facial or neck angioedema can be from the a specific type of blood pressure medications called ACE-inhibitors, which includes popular medications such as Diovan.

Hereditary angioedema

Angioedema is not only caused by allergic reactions, it can also be hereditary. Hereditary Angioedema can involve a dangerous, recurring swelling of the respiratory tract that can cause asphyxiation. It is often confused with Irritable Bowel Syndrome or Appendicitis, because of the severe stomach pains it can cause.There are specific blood tests that can be ordered called complement proteins which can reveal if you have this disorder. The good news is that there is a replacement medication to prevent these attacks today. Non-allergic causes of swelling can be infectious and require antibiotics or autoimmune medications, such as in inflammatory arthritis.

The answer

So if Benedryl isn’t a good treatment for allergic swelling, what is? The answer is oral cortisone. The short term use of oral cortisone can quickly reverse the deep swelling and make you look normal again. The next step is to visit your allergist for a complete medical evaluation to determine the cause. I hope if Will Smith reads this article he will remember not to drink Benedryl but to call his doctor for some cortisone!

One of my patients came to me with a story that is all too common: she was having a salad, with multiple toppings, and suddenly experienced severe diarrhea. Most of us would associate diarrhea with a stomach or intestinal upset from spoiled food but many patients and doctors don’t realize that diarrhea or vomiting can be the initial sign of a severe food allergy reaction. My patient also described further alarming symptoms: a hot, flush feeling running through her body and blurry vision.  These are also classic signs of anaphylaxis, as histamine and other chemicals begin to flood the body. She was stumbling in the street until a taxi cab picked her up and brought her to the door step of the hospital.

Because she came by taxi, emergency staff didn’t recognize the seriousness of her condition. She was observed for several hours until the allergic reaction finally subsided on its own. In many cases, patients with severe allergic reactions are given an injection of Benedryl, which is unfortunately not the appropriate first line treatment for anaphylaxis.

The patient had had this kind of reaction before, but a previous visit to an allergist hadn’t yielded any results. Currently, I am running tests to figure out if she is allergic to nuts, legumes, or any vegetables that could have been in her salad. The key thing I have emphasized to her is that this could occur again, and that she needs to have an EpiPen to self-treat if she is not near medical help. An EpiPen looks like a big pen, but it contains epinephrine (adrenalin) in an injectable form, which can reverse a severe allergic reaction within minutes. A patient that uses an EpiPen should dial 911 for medical attention and be properly evaluated. The great news is that studies have shown that early, appropriate use saves lives!

This holiday season there will be lots of parties and delicious tantalizing treats – if you have a food allergy, especially a severe one, please be sure to have an EpiPen and know how to properly use it. The boy scout motto, “Be prepared” can save your life.

First, resolved component testing (aka the UKnow Peanut Test), a technique developed by PIRL laboratory in Michigan, a division of Thermofisher Diagnostics, allows for a more precise way to test for the allergy. The UKnow Peanut Test is a blood test, as opposed to a skin test, that isolates specific proteins in the peanut in order to find out which proteins are dangerous for a person to have and which are most likely cross-reactions to another allergen protein, such as pollen. A study published in The Journal of Allergy and Clinical Immunology by Nicholau et al., showed that patients suspected of having a peanut allergy were more likely to have a severe allergic reaction to peanuts if their blood count was elevated for the proteins Ara h1, Ara h2 and Ara h3. The Ara h2, in particular, was linked to severe peanut allergy. I now routinely order this test on patients that are concerned about peanut allergy.

Next, what might be the most exciting news in the allergy field in over 25 years – the successful oral desensitization to peanuts! USA Today profiled a young girl, Kirsten Mahoney, who participated in clinical trials in Iowa for oral desensitization to peanuts. Kirsten completed the study and is now eating the equivalent of 12 peanuts twice a day with no allergic reaction! Kirsten and other peanut allergic children “microdose” with peanut flour, which is added to a food or drink. They start at an extremely low dose under the supervision of their doctor and then continue at home with the same dose. This program takes about 5 months to complete.

Kirsten’s story is truly awe-inspiring. She went from having a potentially fatal peanut allergy to eating peanut M&M’s every day to maintain her tolerance. A great commercial for Hershey’s?

If you have any questions about resolved component testing for peanuts or other foods, please don’t hesitate to contact us on Facebook or Twitter.

This past week the American Academy of Allergy, Asthma and Immunology had their annual meeting in Boston. The Academy estimates that 40 to 50 million Americans suffer from asthma or allergic diseases. Asthma rates alone have more than tripled in 25 years, now affecting 22 million people. A recent article USA Today article titled, “Allergies triggered by ‘things we love’ are rising,” suggests that pets may be having an increased effect on our allergies. It is estimated that 90% of homes have significant levels of dog and cat hair – even in those homes that don’t have a pet! How can that be? Pet dander is easily transfered from pet owner’s clothing to other places they visit. Studies done in Scandinavia and here in the USA have shown that school children without pets still had a measurable amount of pet dander in their home, transferred to them at school from classmates with pets at home.

Allergists that see patients with allergies and asthma caused by their family pet typically recommend removing the pet from the home – this is sensible, but sometimes emotionally very difficult. Dr. Dana Wallace, the president of the American Academy of Allergy, Asthma and Immunology admits that, “in 30 years of practice, I can count on one hand the number who have willingly given up a pet.” I can confirm her experience, but I disagree with Dr. Wallace, who says that allergy shots are the only alternative. I typically see patients that either have a cat or dog that one of the family members is allergic to, or I see patients that are in a relationship with someone that has a pet that is causing tension. For these patients, I feel comfortable offering them the choice of sublingual allergy immunotherapy, more commonly known as Allergy drops. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution, I describe how children and adults can reverse their allergies by using allergy drops safely at home. A study published in the journal Allergy in 2007 by Alvarez-Cuesta showed how sublingual immunotherapy to cat dander extract reduced nose, eye, and asthma symptoms.

A man in his 30′s once came to see me because his fiancée had 3 cats and every time he went to her apartment he started wheezing and needed to use an inhaler to control his symptoms. His fiancée was also a patient of mine and I knew that it would be difficult for her to give up the three cats she had had for some many years. He tested positive for cat allergens, I treated him with allergy drops, and his symptoms abated. The couple got married and now, even with his increased his exposure to cats, his symptoms are minimal and getting better with time. He did the full course of the allergy drops treatment for 3 years and he was able to stop using any medications to control his allergies. Several years went by after he had finished his treatment and, by chance, I ran into him outside my office one day. We exchanged pleasantries and I asked him how he was doing. He responded, “Good and bad.” The bad news was that he and his wife had divorced, but the good news was that he got to keep the cats… “That’s the good news?”, I asked.  He responded, “Yes, now that I’m no longer allergic to them I didn’t want to lose them…”

I can’t always guarantee results, but I have had a lot of nice outcomes like the one I described above!

Cat and dog allergies don’t have to end badly… Allergy drops can help!

CBS News ran a story today about problems children have with food allergies, particularly tree nuts and peanuts, when they go trick-or-treating on Halloween, and how to take precautions against a reaction.

In our NYC Allergy practice, I see a lot of kids with food allergies, but I have not found a case where a child couldn’t participate in this fun Halloween event if some reasonable ground rules are set before the fun of collecting candy begins.
The key ground-rule for Halloween is that while all candy can be collected:

• No candy is eaten until the  child comes home
• Parents must carefully go through the Halloween candy and make sure they don’t contain any nuts
• If the candy is home-made or there is no visible label, then the candy goes into the garbage – no arguments there
• If your child is very young — go with them so they are not tempted to “cheat”

Set firm ground rules for collecting the candy

If a family is throwing a Halloween party and they know that some of the children may have food allergies to nuts, a great place to order nut-free candies and desserts is from Divvies, who specialize in nut-free, great tasting treats. I personally met the owner, Laurie, and her son, who were on The Martha Stewart Show last spring when I appeared.

As a NYC and LI allergist, I have seen numerous children with peanut and tree nut allergies. Peanut and tree nut allergies can cause the most explosive type of allergic reaction - anaphylaxis - if an allergic child ingests a particular nut. It is possible, but unusual, for a child to have a severe reaction by simply coming in contact with the allergenic food. It is possible the child may get a rash in the area of contact with the nut allergen, but that usually does not lead to a more severe reaction.

Exciting breakthrough news in food allergies is that there is now a blood test that can measure which proteins in the peanuts and other foods, such as eggs, soy and wheat, that can help determine how severe a specific food reaction is to that food. The peanut test is called component testing and is done at one particular lab in this country called PIRL labs in Michigan. I send my patient’s blood with concerns about unclear severity to these foods and help determine what foods must be avoided and what can more safely be in their diet.

Happy Halloween!

Dean Mitchell, MD

Twenty years ago, I was a fellow in allergy and immunology at the St.Lukes-Roosevelt Hospital, affiliated with Columbia University. When I wasn’t working in the allergy clinic, I “moon-lighted” in the Ambulatory Walk-In Clinic at the hospital for extra money. I’ll never forget the time that I treated several patients for high fevers and found myself, several days later, with the same high fever and a couch that lasted 3 weeks. I barely dragged myself to work! After that, I vowed never to make the mistake again of not getting my flu shot. Over 2 years ago, I also had the misfortune of getting the “Swine-flu” in June, right before I was to have ankle surgery. That caught me off-guard; it wasn’t flu season. In either case, good nutrition and proper vaccination is your best defense. I especially implore my asthmatic patients, anyone with an immune condition, and the elderly to get their flu shot!

Yesterday’s USA Today helped de-bunk the 4 myths why people sometimes avoid a flu shot:

1. The flu is just a bad cold: Wrong! The flu kills up to 49,000 people a year! 200,000 are hospitalized, according to the CDC. If you have a high fever and generalized body aches get tested immediately for the Influenza virus by your doctor – they can do an instant nasal smear and decide if you need anti-viral medication.

2. The flu shot causes the flu: Wrong again! The injectable flu shot is treated so it’s not live and can’t transmit the flu to you. The nasal mist has a weakened live virus given to teenagers and adults under 55 without certain contraindications – on occasion, this can cause a runny nose.

3. Only sick people need a flu shot:  Not true. Any person that is around a lot of other people can contract the flu and spread it to co-workers, family members, or fellow subway or bus riders. “Healthy” people tend to try and fight through an infection, but in the case of the flu you are just adding to your misery, and possibly spreading that misery to others.

4. Flu shots contain Mercury: Partially wrong, partially true. The single dose flu injections that we give in our office at Ocean Allergy and Asthma are thimerosal, preservative free. The FluMist nasal spray given by many pediatricians is also without thimerosal. Only the flu injections from multi-dose vials – check your with your pharmacist if you get your flu shot there – can contain thimerosal but it has not been linked to any specific disease.

Please don’t be one  of the 42% of consumers surveyed that they plan to skip the flu shot – there are some things in medicine we get right, and getting a flu shot is one of them.

I’ve noticed that everyone lately is complaining about Mosquito bites. It seems Hurricane Irene brought with her more than just damaging floods. The excess water everywhere is a breeding ground for mosquitoes. Normally, mosquitoes wouldn’t be a major topic of discussion, but with West Nile virus being reported in our area, and some unusually severe reactions that I have seen in my New York city allergy practice, I think it’s worth being aware of some facts:

1. Mosquitoes come out more in the evening, so if you are taking an after dinner stroll wear long sleeve shirts, pants and socks—don’t give the mosquitoes much skin exposure. Using citronella candles or mosquito coils can help a little to repel the insects.

2. If you are going into a grassy outdoor area like a park, be sure to use insect repellent. The most proven effective repellent is DEET in concentrations of 10-30% and can be used safely in children older than 2 months.

What to use and not use:

If you get some very itchy bites Don’t use Benedryl spray or cream! You are much better off using over-the-counter cortisone cream and applying ice to the area so there is less swelling. You can take an oral antihistamine like Claritin, Allegra or Zyrtec to decrease the itching, and even Ibuprofen (Advil or Motrin) can stop some of the swelling and itching.

Another over-the-counter remedy is to use After Bite. If you use it immediately, it greatly reduces itching and swelling.

Reactions can sometimes be severe

There is allergy testing for Mosquitoes, but it is rarely necessary because most bites aren’t severe and resolve with the above treatments. However, this past year I had 2 cases of severe allergic reactions to mosquito bites. One was in a small child, his mother brought in photos how severe the swelling was in the boy’s leg after the mosquito bite. He couldn’t walk for a few days afterwards. Another strong reaction occurred in a college student who was bitten behind her knee. Her knee swelled up so much she also had difficulty walking. In both of these cases, if I had spoken to the patient early enough (they were both new patients I had not yet seen) I would have prescribed oral prednisone to make sure the swelling didn’t become severe enough to cause inflammation in the deeper tissue. If someone’s job put them in increased exposure to mosquito bites and these kind of reactions, I would consider desensitization with mosquito extract.

And lastly, if you do get several mosquito bites and develop a fever, Call your doctor immediately to be tested for West Nile virus!

The good news: Fall is on the way and the mosquitoes will be leaving town soon!

Dean Mitchell,M.D.

The Allergy Detective

Mold is a type of fungus that grows wherever water and moisture is present along with warm temperatures. As an allergist in New York and Long Island, I have seen many patients over the years suffer from medical problems related to chronic mold exposure. The type of problems range from:

• Respiratory symptoms such as coughing, wheezing or shortness of breath
• Common nasal symptoms such as sinus pressure or pain
• Headaches
• Fatigue

In some cases I’ve seen patients develop rashes from airborne mold. Mold can be very dangerous for a person that is immune compromised, such as after a round of chemotherapy when a patient’s white blood cell count may be low. Mold can be invasive, get into the bloodstream and cause a deadly infection. More commonly, in patients with allergies, mold causes the symptoms described above, along with fatigue.

The most common molds are Alternaria, Cladysporium, Penicillium (similar but not the same as Penicillin) and Aspergillus. As an allergist, I can test for these molds through skin or blood tests to see if a person is allergic. In my experience, mold allergies are sometimes difficult to treat with just antihistamines. My best results seem to occur in patients treated with sublingual allergy immunotherapy (allergy drops). Sublingual allergy immunotherapy builds a person’s natural resistance to specific molds and can usually decrease a persons need for medications.

Meanwhile, I hope all of you are safe back in your own home, and that the electricity is working! The best thing you can do to prevent molds from growing is to clear out the water, use dehumidifiers to suck out the moisture in the air, and check for any unusual green or black spots where water damage occurred.

Dean Mitchell, M.D.

The Allergy Detective

It has been shown in medical articles that even if patients were allergic to Penicillin as a child, this allergy can disappear after many  years of non-exposure. The question I’m sure you are now asking is: Is there a way to find out if I’m allergic to Penicillin? The answer is yes!  There are simple skin tests that as an allergist I can do in the office in one session that will predict with over 90% accuracy if you are allergic to Penicillin and if it is safe to use. This allergy testing in NYC is convenient, has important medical implications and, most importantly, gives peace of mind to my patients.

Today, there are many antibiotics that can be used by a physician to treat infections anywhere in the body, in contrast to 50 years ago when Sulphur compounds and Penicillin were the only game in town. Penicillin was so valuable that in the early days of its use in hospitals, the doctors would collect the urine of patients given Penicillin and boil it down to extract the Penicillin and use it for other patients—it sounds horrific, but it did save lives. We are in a much better place today with antibiotics widely available in our country and many choices. However, the new antibiotics are very powerful – sometimes too powerful – and have side effects that are not widely known.

With Quinolones for example, you may recognize the names Cipro or Levaquin, which are new, potent antibiotics that treat a wide array of infections. A side effect not commonly appreciated is that these antibiotics have an enzyme that can cause tears in your tendons. Podiatrists and Orthopedic surgeons are acutely aware of the Quinolones causing these problems – especially Achilles tendon rupture. Another common antibiotic, Zithromax is good for mild respiratory infections, but it doesn’t kill bacteria (the medical term is bacteriocidal) it just slows it down (bacteriostatic). Zithromax is not good enough against the bacteria called anaerobes – the type found in your mouth and gut. Penicillin, as I learned in medical school, has the special properties of killing bacteria’s cell wall and thoroughly clearing an infection. In truth, when Penicillin was used for many years some resistence developed to its use and derivatives of Penicillin were made to add to its potency. The medications like Amoxacillin, Ampicillin and Cephalosphorins took over the place of just giving the original. These medications work very well and have a long history of safe use. If someone is allergic to Penicillin they also may be allergic to these medications, but again allergy testing will help determine if these are safe to use.

The question, “Does it matter if I am Allergic to Penicillin?”, the answer is yes. There are many situations where use of antibiotics are needed prophylactically (before the surgical procedure) and penicillin is still one of the best choices. For example, a patient that has a heart murmur should be treated with antibiotics before dental surgery. The bacteria in the mouth can enter the bloodstream and if heavy enough can lodge on a heart valve that is compromised – this causes a condition called Endocarditis which can be fatal. Another common situation is anyone that has “hardware” in their body – artificial hips, knees, etc. These replacement parts can become infected after a “dirty” procedure like dental work or surgery in another location involving the bowel. Penicillin and Cephalosporins are excellent antibiotic coverage to keep the bloodstream clean.

There is an appropriate place for some of the new antibiotics that are very powerful – especially in the hospital where bacterial resistant infections are more common. However, good ol’ Penicillin still has its place in the doctor’s black bag (I still have one) and knowing if you are allergic can make a difference in your care. Contact one of our allergists of New York today for more information or to be tested.

Here are a few key points:

• Sunscreen products that pass FDA’s test for protection against UVA/UVB rays will be labeled as Broad Spectrum.
• Products with SPF values of 15 or higher may state they reduce the risk of skin cancer and early skin aging when used with other sun protection measures, and when used as directed.
• Products with SPF values between 2 and 14 may be labeled as Broad Spectrum if they meet the requirements, but can only say they help prevent sunburn.
• Sunscreen products that do not meet the Broad Spectrum guidelines, or have an SPF of 2 to 14 must include a warning that the product has not been shown to help prevent skin cancer or early skin aging.
• The terms waterproof, sweat-proof and sunblock are not permitted on packaging.
• Labels may state a sunscreen product is water-resistant, but it must include the amount of time before reapplication (40 or 80 minutes).
• All sunscreens must have a Drug Facts section on the back and/or side of the package that includes Active Ingredients and Use Claims.

These changes will take place over the next 12 months, and you can call the FDA (800) 299-4786 for more info.

Generally, an SPF rating over 30 will block 97% of UVB radiation. However, UVA  radiation, which is not currently labeled in sunscreens, may be the reason for the increase in skin cancers, especially melanoma. Prolonged exposure to the sun, even if the person doesn’t burn, can still cause photo damage to the skin that has lasting consequences. The new Food and Drug Administration guidelines will take into account the sunscreen’s ability to protect against UVA radiation.

Sunscreen allergies and the effect of medications

Many patients come to my office because they developed a severe rash after being in the sun. Some patients develop a rash or itching almost immediately after even a few minutes of sun exposure. My job as a NYC Allergist is to determine if the patient has a sunscreen allergy to chemicals in the product, such as PABA, or if the patient has an underlying medical problem that is causing a photo-sensitive reaction. In some cases a patient may be taking a common medication that can be causing a photosensitive reaction. You would be surprised at some of the medications on that list: non-steroidal anti-inflammatory drugs like Motrin or Advil, thiazide diuretics used in many blood pressure pills and even antibiotics, such as tetracycline and ciprofloxacin have been associated with severe reactions.

Additionally, certain foods, if handled in the sun, can cause a contact photosensitivity. This happened to me several years ago: I was on vacation in Florida and it was very hot. I was drinking bottled water and squeezing lemons in the water for flavor. A few days later I came back to New York and I discovered this creeping red rash on my right forearm. It was strange – it didn’t itch but it looked terrible. Despite being an NYC Allergy Doctor, I sought out another medical professional who astutely figured out that the rash was do to my using the lemons in the sun. Lemons contain psoralen and this natural photosensitizing chemical can cause ugly rashes. This can also occur with celery, so watch out if you are drinking those Bloody Marys at the beach!

The Effect of Perfume

Another area of contact photosensitivity can be from perfumes or colognes. These products can contain parabens and other chemicals that when exposed to sunlight cause rashes. I would strongly advise against putting anything but sunscreen on your skin when going into the sun for several hours. Unfortunately, the sunscreen itself can be another culprit for a photosensitive reaction. The higher the SPF the more likely the more chemicals in the sunscreen. The common chemicals that can cause allergic reactions are: PABA, oxybenzone and cinnoxate. In my opinion, the ideal sunscreen with the least allergic potential and the best sun protection are products containing only zinc and titanium dioxide. Many companies make skin tone products with zinc and titanium dioxide and they can match your skin color. My key caveat is to wear old clothing when you use this sunblock because it is messy and I have stained many white shorts with tan-colored sunblock.

Detective work

My final job as the Allergy Detective is to make sure my patients don’t have an underlying medical problem that is making them sun-sensitive. These conditions may include vitamin deficiencies, such B6, which can cause skin rashes. Certain liver diseases allow for the accumulation of toxins in the blood and these will be more pronounced after sun exposure.  Auto-immune conditions should be checked in anyone with chronic rashes after even mild sun exposure.

The good news is that some sun exposure can be a good thing. Vitamin D deficient patients are recommended to get 20 minutes of sun on their arms and legs without sunscreen to boost their levels of this important vitamin.

I wish you all a wonderful, fun and rash free summer!

The Allergy Detective

The mystery about rashes, especially hives, is that the answer is below the surface of the skin. Chronic hives can be due to a food allergen the patient is consuming on a daily basis and not even be aware that it is aggravating the condition. As a food allergy specialist, I order specific tests to identify which foods might be triggering an allergic reaction. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006), I wrote about a person who ate hot dogs and sauerkraut, and it took her months before she realized she was allergic to sulfites, an ingredient found in high quantity in sauerkraut.

The thyroid is  an internal organ that has been linked to chronic hives. It’s not well understood, but when the thyroid is over or under active the dysfunction can manifest itself with skin rashes, such as hives. I order special antibody tests for the thyroid to determine if there is a connection between the hives and the thyroid. If the tests are positive, I will then order a thyroid Ultrasound to see if any nodules are present. This a simple, painless test that only takes a few minutes, but offers clues to the condition.

I read some interesting reports linking Celiac Disease and chronic urticaria. I have seen several Celiac disease cases in my career as an allergist. Patients present with stomach problems and think it is a food allergy. Instead, after careful testing, I discover there are no specific food allergies, but the patient have an immune reaction to gluten products. Celiac disease today is even more common than we realize: 1 in 300 people suffer with this condition. The most deceptive part of this disease today is that many patients don’t have any gastrointestinal symptoms, and instead present with sinus disease, arthritis, anemia and rashes. I am an avid tennis fan, and I suspect Novak Djokovitz, the number 2 player in the world, may have Celiac disease. He mentioned in  Sports Illustrated that he now eats a gluten-free diet and feels his energy is much better. The gluten-free diet is not an easy diet to follow in our society, but there are many supermarkets that now have an array of gluten-free products which offer many new options.

Going back to the flat, red rashes,  good allergy medical detective work is needed. I recently treated a patient with severe redness on his face and all over his hands. Allergy Patch testing (without needles) was done and revealed he was allergic to his hair dye. Another patient developed a painful rash on her legs. A painful rash is usually not allergic – it turns out she had a cellulitis (an infection with bacteria of the skin).

The summer is upon us – with a lot more skin exposure. My advice to all: get 45 minutes of sun exposure to raise your Vitamin D levels, wear sunscreen after that and especially on your face. If you do get a rash which persists more than a day or two, make sure to see a physician.

USA Today, using data collected from Quest Diagnostics, reported the worst cities for ragweed pollen (the late summer pollen usually referred to as “hay fever”) are:

1. Phoenix

2. Las Vegas

3. Kansas City

4. Riverside, CA

5. Dallas

6. Chicago

7. Sacramento

8. Philadelphia

9. Denver

10. Washington and Minneapolis (tie)

The report published in AllergyCapitals 2011, in cooperation with the Asthma and Allergy Foundation of America, had a very different list:

1. Knoxville

2. Louisville

3. Charlotte

4. Jackson

5. Chattanooga

6. Birmingham

7. Dayton

8. Richmond

9. McAllen, TX

10. Madison, WI

Clearly these reports are not compatible. This is easily explained by the different ways they assessed being allergic. The USA Today report measured the results of allergy blood tests that were reported positive. This requires careful insight: to have the blood tests the patients had to see a doctor to order the tests, and it’s assumed because these tests were positive these individuals had allergies – this is not always correct. They did notice over the 4 year study that Sensitization (antibodies showing allergic potential) did increase 5.8% during the study period. Again, the drawback of this study is that patients had to have the finances to see a doctor and have the blood testing done. I think that many patients with allergies unfortunately have never even see a doctor and rely on over-the-counter medicines.

AllergyCapitals 2011 took a different approach: They did measure the pollen counts in the different cities (very important), and measured prescription medication use, another important variable. But of course many allergy meds don’t need a prescription anymore, and the number of Board Certified Allergists in the populated area. I tend to give more credence to this report because of the multiple factors evaluated, compared to the 1st report which just used blood studies.

Interestingly, the USA Today report seems to be dominated by Western cities and the AllergyCapitals 2011 report seems to favor the Southeast. The Southeast, with its longer periods of hot, humid weather is a prime breeding ground for heavy pollen and mold counts, and is more likely to have more allergens. I have had patients fly up to see me in my office from Washington to Chattanooga who have found this year’s allergy season unbearable.

The local good news: in the realm of allergies NYC ranked 23rd! I don’t know how much relief that gives to many patients I saw this past month with severe allergies from tree pollen. The most challenging place to live with allergies is wherever you are and the pollen is making you miserable. The best advice I can give you is as an allergy doctor in NY: find out what specific pollens you are allergic to and get treated ahead of the season! Contact us today for an evaluation.

Dean Mitchell, M.D.

“The Allergy Detective”

Transfusion reactions are rare, and are usually avoided with careful screening of ABO blood compatibility. The mother made the keen observation that the only time her son had a similar reaction was at age 1 when he ate some peanuts, and the family had since been very careful to avoid any peanut ingestion by their son. The physicians were astute in locating the multiple blood donors of the platelets (blood clotting  particles) in this case.

With careful questioning the donors did recall eating peanuts the night before they gave their blood! How could this affect the young boy with Leukemia? It turns out peanut proteins can stay in the blood for 24 hours after ingested. The blood donated by these individuals was measured and found to have circulating peanut proteins. The young boy’s blood was tested and showed he had high levels of IgE (the allergy) antibody to peanut protein. This is the first time a reaction like this has ever been reported and linked to a food allergen.

The take home message: Peanut allergy is clearly on the rise, and to anyone generous enough to donate blood to help save another person, please avoid eating peanuts for at least a week before the donation.

As an NY allergist, I know that peanut allergic parents don’t need one more thing to worry about, but I think this information is useful and if there is a concern, they may want to ask donors, family and friends if they have avoided peanuts before donating blood. Contact us with any questions you may have, or to have a food allergy treatment in NY.

Now a company, Pure Solutions, is doing something about this problem. I called the CEO, Brian Brault, because I wanted to find out what their company was doing that protected allergy sufferers from the common airborne allergens encountered in many hotel rooms. These are the steps his company takes to make the air in hotel rooms more amenable to allergy patients.

• Tea tree oil enzyme tablets are placed on the coils of the beds to prevent bacterial build up
• Ozone treatments are done in the rooms to remove viruses and bacteria
• A air quality check is done to make sure once the room is treated there is no ozone detected in the air.
• Air Purifies are installed to circulate and clean the air of over 90% of mold and viruses.

The bottom line: the Pure Rooms have 90% less particle counts than comparable hotel rooms. This is impressive.. even to an allergy doctor of NY. Inside the rooms, they use fragrance and chemical free products certified by Green Seal. They also have fragrance-free soaps, shampoos and lotions on request. At this point, you are probably thinking, why don’t hotels do this to all the rooms – the answer, cost. However, the cost to the consumer is not exorbitant. for an extra twenty-five dollars you can get a hypoallergenic room, and hopefully sleep with more confidence and more comfortably. There are now 5,000 rooms in 200 hotels worldwide including the Hyatt, Hilton and several other chain hotels.

Next on my wish list: Allergy Safe Airplanes. I’ll have to talk to Mr. Brault if they can expand into this market.

So, if you are concerned about the hygiene in your room, ask if they have Pure rooms available.

The prescription eye drops are helpful, but when the tree pollen counts are super high even these eye medications are not enough. Children and adult patients also complain of the annoying symptoms of an itchy throat during this time. This can be a very tough symptom to treat. I sometimes recommend that children, as well as adults swish in the back of their throat an oral antihistamine liquid: e.g. benedryl, claritin or zyrtec. This swish, gargle and spit method can provide some temporary relief.

The other cause for oral itching in the spring for tree pollen allergy sufferers can be foods. There are several fruits and nuts that cross-react with specific tree pollen and by eating these fruits you can worsen the oral itching. The foods that cross-react with Birch pollen include: apples, cherries, kiwi, soybean products, almonds, carrots and celery. These foods when consumed raw can trigger the intense oral itching. I have some patients that can’t even peel an apple or carrots during this time of year. Interestingly, many of these foods can be consumed if they are cooked, so you can have your apple pie for dessert. There are now special tests that can be done to differentiate these milder food allergies from the serious food allergies that can cause anaphylaxis (allergic shock). As an NY allergist,  I use Component Testing which is the newest and most specific blood testing to evaluate the proteins causing the food allergy.

My patient’s rightfully complain: “This is unfair – I love these fruits and vegetables and they are supposed to be healthy for you, right?” It is unfair, but the good news is that they are not the severe type of food allergy in most cases. For now, I can use the allergy drops (sublingual allergy immunotherapy) to desensitize patients to the tree pollen allergy and make their eyes, nose and chest symptoms less severe. I believe this has a big advantage over allergy shots, in which the doses have to be decreased in the season to avoid an allergic reaction from the allergy shots themselves. I have been pleased so far this season that my patients that are on maintenance levels of allergy drops have had much less intense symptoms than the new patients I’m seeing these past few weeks.

If food allergy treatment in NY is something you’re considering, be assured that our experts are there to help.

Fight back! Photo from LHJ

I just picked up the May issue of Ladies Home Journal off the newsstand. The title of the article on page 152: Allergies Suck! The picture shows a woman vacuuming in a bright orange Hazmat suit…

My response: Fight back with proper treatment!

The writer, Laurie Tarkin, interviewed me a few weeks before about why so many people suffer with allergies despite all the readily available over-the-counter treatments. My gut reaction: allergy sufferers that take medications like Claritin, Allergra or Zyrtec can expect mild to moderate relief, but finding the cause of your allergies is the key to staying healthier and being symptom-free. The only way to find this out is to get tested!

Testing is not as onerous as it used to be. In our office, we typically do a simple blood test called the ImmunoCap and send it to the lab. Usually within a week or two we get the results and I can advise my patient as to the specific allergens that may be causing symptoms. If the blood test doesn’t show a clear cut answer, we can do painless prick tests (similar to a plastic tooth pick) to get additional information. This time of year the tree pollen is on the rise and I’m seeing new patients who have nasal congestion, eye itching and throat itching. By the time May rolls around both the tree and the grass pollen are packing a one-two punch making allergy sufferers miserable.

The article quotes myself and several other prominent allergists: Linda Cox, Gary Rachelefsky and Mark Dyskewicz, and discusses the range of symptoms that a patient with allergies can have. Surprisingly, not all allergy symptoms are the classic ones, such as sneezing and runny nose, itchy eyes and asthma. Symptoms that sometimes get overlooked are: headaches, sinus pressure and, more recently, stomach pains. Allergy patients are 14 times more likely to have migraines.

My interview focused on one of my patients who was having a combination of stomach pains and throat tightening. She saw a gastroenterologist who diagnosed that her stomach pain wasn’t the typical acid reflux, but the acid was due to allergy cells called eosinophils. The eosinophils are activated by airborne or food allergies. A food allergy can cause an acute severe reaction, such as difficulty breathing or a dangerous drop in blood pressure. However, a relatively new condition called Eosinophilic esophagitis or gastritis, has been found to cause acid reflux that doesn’t respond well to even the strongest acid blockers.

The key allergy testing and treatment for some of these patients is to test them for food allergies and if a positive test is found, try and eliminate this food from the diet. In this case, it was interesting that my patient was worried that she had Celiac disease, a condition where you are immunologically intolerant  to wheat. My testing showed that she wasn’t allergic to wheat, but to barley, which is used in many wraps and sandwiches today. She was also allergic to mustard which surprised both of us. Her symptoms have improved greatly since she has avoided these foods.

Fortunately, as an allergist in NYC, I have yet to recommend a Hazmat suit for any of my patients. I have a better weapon for the outdoor and indoor allergens – Allergy drops. The last page of the article mentions: Try The New Drops. Although it mentions only 6% of the allergy doctors are prescribing it, I have been doing it for 13 years and have seen incredible results. If you want to read further about allergy drops, you can find my book: Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006) on Amazon.com or through Barnes and Noble’s e-reader.

If you see anyone walking around New York on a sunny, spring day when the pollen is high, and they are wearing a bright, orange Hazmut suit – I know you won’t find my business card in their pocket.

There may be a brighter future for peanut allergy sufferers

I received my allergy medical journal a little late this month, but it has a special surprise: a great article showing that sublingual allergy drops can protect children from peanut allergy. This is major headline news, and yet I didn’t hear anything in the lay press newspapers about this exciting breakthrough. Sublingual allergy drops have been successfully done for hazelnut and kiwi, but to protect against peanut allergy is a tremendous accomplishment.

The article appears in The Journal of Allergy and Clinical Immunology, March 2011. The research was conducted at Duke’s Department of Pediatric Allergy and at the Food Allergy Center at Massachusetts General Hospital- two highly reputable centers. The study was done on 18 children, ages 1 to 11, who had a diagnosed peanut allergy. It was a double-blind placebo controlled study — the highest quality. 11 children received sublingual allergy drops and the other 7 children received placebo drops. The study had a 6 month build-up phase and a 6 month maintenance phase.

The key results: the group treated with the peanut allergy drops were able to ingest 20 times more peanuts (equivalent to 6-7 peanuts) than the control group (who tolerated less than 1 peanut at the end of the year study). The exciting part to me as a physician is that not only was the desensitization successful, but in the process of the treatment no patients required epinephrine (adrenalin) to reverse a severe allergic reactions — indicating the treatment can be done safely!

Unfortunately, I don’t think the treatment will be available in the next few months, but I would hope in the next year or two this treatment will be approved and available to help protect all those children and adults who fear an anaphylactic (severe allergic) reaction to ingesting peanuts. I wrote in my book, Dr. Dean Mitchell’s Allergy and Asthma Solution, that I hoped in the future sublingual allergy drops would make a difference in reversing food allergy—The time has come sooner than I expected.

Meanwhile, if you suspect your child or you have a peanut or other food allergy, it is imperative to get tested and know the emergency treatments available. Contact us today for an evaluation.

Dr Mitchell on Martha Stewart—click here to view the video

Two weeks ago I was in a whirlwind of activity. My office was moving to its new location on 57 West 57th street and I was contacted by The Martha Stewart Show to come and discuss the problem of indoor allergens. I was excited at the opportunity to be on the show, however with the move and all that it entails, I wasn’t sure if I was juggling to many balls in the air.

I was impressed that Barbara, the producer at The Martha Stewart Show, was very intent on the quality of the material being interesting and factual – no hype -  just the real deal. She spent the entire week getting me ready with my material and her assistant Sara was busy tracking down good pictures to use for the television audience. The preparation for the show was a good review for me: I worked with Allergy Control Products, a company that specializes in products for the home to decrease indoor allergens. All the facts mentioned on the show to reduce dust mites are well-documented in the medical literature: use of encasements for mattress and pillow covers, using HEPA vacuum cleaners and keeping humidity in the home under 50%. The Martha Stewart line of bedding : Allergy Wise bedding at Macy’s was new to me, but it was made from comfortable materials and hypoallergenic synthetic fabrics – and affordably priced.

I was excited that the show started with a zoom in of my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006).  Then I was sitting next to Martha – live on the air getting ready to take her questions. I will admit I was nervous for a half-hour before I was to go on the air, but I was lucky that the guests for the day - Joan and Melissa Rivers - got me laughing minutes before I went on the air.

Joan took a question from a young female audience member just before I was to go on. The question was from a 20 year old female: “Mrs. Rivers, if you were my age, what would you recommend I do with my life? Joans answer: “Honey, my advice is to get married, make sure he’s rich – and very old and in need of a a pacemaker.”  Joan Rivers, like Don Rickles, is still on top of her game.

Finally, the spotlight was on me and I knew I had to remember all the facts floating in my head. Martha asked me “Why are allergies are so common today?” My answer was the same as I wrote in an earlier blog: New studies are confirming that city children are more likely than rural children to develop allergies. The findings are pointing to the early exposure to bacteria found on farms with animals that strengthen a child’s immunity to allergies and asthma. The key seems to be exposure in the first year in life, when the immune system is very influenced by external surroundings. A prior study showed similarly that children exposed to dogs in the first year of life were less likely to develop animal allergies to dogs.

Joan Rivers—still on top of her game

When I was in the dressing room I had the pleasure to meet Lori Sandler and her son Benjamin. Lori is the owner and founder of Divvies, a company that makes desserts and other treats for allergic children and adults. I spoke with Lori and said there is a great need for these products. I’ve seen so many parents try hard to make sure their child with a peanut or a tree nut allergy finds desirable and safe treats for birthday parties and other events. Even an everyday chocolate bar can be dangerous to some of these children if contaminated at the processing plant with nuts.

Well, my fifteen minutes of fame (actually it was nine minutes) is over, and I’m glad to be back at my regular job as an NYC allergist helping my patients with allergies and asthma.

Our new Manhattan, NYC address, starting on Tuesday, March 8th

57 West 57^th St
Suite 601
NYC NY 10019

But don’t think for a minute that farm life is all that easy. The take home message from the European researchers who conducted this study was that while growing up on farms, children were exposed to multiple different bacteria and fungi (molds) that actually stimulated their immune system in a good way to prevent later development of asthma. This news is not actually new: in my book, Dr. Dean Mitchell’s Allergy Solution (Marlowe 2006), I have a chapter devoted to, ” Why Allergies are so Prevalent Today”.

The best explanation for the lower incidence of asthma and allergies in rural and 3rd world countries vs. urban and Western countries is called ” The Hygiene Hypothesis“.  The Hygiene Hypothesis makes the case that our  ”cleaner”, more antiseptic environment makes the immune system tilt in favor of  developing allergic inflammation. The hypothesis attributes vaccines, antibiotics and our diets to causing allergic diseases. There has been great discourse as to whether frequent use of antibiotics and multiple vaccines are more harmful than beneficial to infants – and the debate will probably not be answered for quite some time. Meanwhile, what can we do to prevent childhood asthma, which has doubled in the past 30 years?

My answer for those of us who are not ready to ” buy the farm”, is to go back to nature. We are all in agreement that processed foods are not as healthy for us as fresh grown foods. This is common sense. The same thing applies to the air our infants breathe. Even an infant is much better off getting several hours a day of fresh air at a park or schoolyard than being stuck indoors watching videos and breathing in forced air – hot or cold – and breathing in dust mites from the carpeting. The studies continually show that in the first year of life, an infant’s immune system is highly influenced by its environment. I have read several studies by asthma doctors showing that an infant exposed to a cat or dog in their first year of life was less likely to become allergic to these animals.

Well, we can’t turn back time, but we still have some good options. For future parents with a history of allergies or asthma, make sure your infant gets lots of fresh air and exposure to animals – take him frequently to a petting zoo. For the grown-ups, the other good option is sublingual allergy immunotherapy  (allergy drops). I have been able to help so many patients with nasal, eye  allergies and asthma by using the home program of allergy drops and restore the immune balance…that not growing up on a farm lacks.

Oh, one last thing: our new NC office at 57 West 57th street and the corner of 6th avenue is just 2 blocks from Central Park – in the nice weather I expect to see all of you getting some fresh air on your way to the office.

1) use a scarf to cover your mouth when outside: breathing in cold air through your mouth can immediately trigger an asthma attack; your nose is supposed to be doing the breathing , because it warms and humidifies the air before it gets to your lungs.

2) if  you are going to be walking outside many blocks or for an extended time use your inhaler at least an hour before you go outside to open the airways and give you extra protection.

3) Make sure you know how to use your inhaler (s) correctly.

My nurse, Mildred, is an avid sports fan. She was watching the Australian Tennis Open on TV, and she happen to see Venus Williams struggling to breathe. She saw Venus use an asthma inhaler on the change-over to help her breathing. However, Mildred, who has worked with me for many years and knows how to use an asthma inhaler correctly, quickly told me: she was shocked that Venus Williams appeared to be using her asthma inhaler incorrectly! Venus is not alone. I frequently see patients that have asthma, who before coming to my office were never shown the correct way to use an inhaler. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006), a chapter called, ” The Asthma Action Plan“, discusses and illustrates the correct way to use an asthma inhaler.

“The Asthma Action Plan” shows you the proper technique and strongly encourages anyone using a rescue inhaler, like Ventolin or ProAir, to use a spacer device. A spacer device is essentially a holding chamber so that the aerosolized medicated particles can be inhaled deeply into the small air tubules where the spasm is taking place. There are studies that show a spacer device is as good or even better than the nebulizer machine many asthma patients rely on. I also discuss in this chapter the common mistakes patients make when using their inhalers. One important tip: Wait a few minutes if possible between puffs of your inhaler. Many patients rush to get it done. By waiting a few minutes (2-3) between puffs, you are allowing the larger bronchioles to more fully open, and then the 2nd puff can go deeper to open the small bronchi where the blockage is occurring.

In the meantime, Stay Warm! Spring is only a month away.

I just read a great article in The New Yorker magazine by one of my favorite science writers, Dr. Jerome Groopman. The February 7th issue, is titled: The Peanut Puzzle. The article discusses what has baffled Food Allergy researchers for the past twenty years: Why are food allergies, particularly peanut allergies, on the rise when more and more mothers aware of this problem are taking specific precautions to try and decrease the risk that their child will have a food allergy? For years, mothers were told to breast feed their child, and avoid peanuts during pregnancy and breast feeding. None of this now seems to make a difference. And in fact, in the future the opposite advice might be given. Why?

The first theory  – Play with dirt

There are a few interesting and plausible theories now circulating that may explain this conundrum: First, The Hygiene Hypothesis, which I discuss in my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006). The hypothesis makes the case that with advances in medical practice, such as vaccinations and increased use of antibiotics in the first year or two of an infant’s life, that we are re-directing the immune system away from the infection fighting mode and resetting it to battle against allergies. Their data shows that children growing up on farms, surrounded by dirt and animal manure, seemed to have less allergies. It was part of the “play with dirt” theory of exposing children to certain endotoxins that may actually strengthen the immune system.

The second theory – The sunshine vitamin

The 2nd and newer theory revolves around the “Sunshine Vitamin”, Vitamin D. Researchers are finding that geographical areas – typically in the U.S. below Atlanta on the east coast and out west in Arizona and Southern California that allergies are less prevalent. Studies have shown that Epinephrine, the injectable medication for a severe allergy attack, (anaphylaxis) is more commonly written in these areas of the country. Vitamin D is also being found to help decrease allergic dermatitis, specifically atopic dermatitis (eczema) because it blocks certain proteins in the skin that cause the inflammation. I am now routinely recommending Vitamin D to my patients with eczema.

The third theory – Give babies peanuts

The 3rd and final new theory is fascinating because it goes against everything we think is logical. An infant at risk for food allergies, specifically peanut allergy, should be given peanuts early in life. Dr. Gideon Lack, a pediatric allergist at St. Mary’s Hospital in London, has published letters in British medical journals drawing attention to the disparity between peanut allergy in the U.K. and U.S.A vs. Israel. He found that the risk in the U.K. among Jewish children was 11X higher than the Jewish children in Israel – this was astonishing. I know families in my New York practice that have children with peanut allergy and have cousins in Israel without any food allergies. One interesting, but not proven theory, is that Israeli infants are given Bamba, a peanut concoction early in life, which may cause the immune system to build an early tolerance from the exposure.

Hopefully, over the next few years we physicians will better understand the causes of peanut and other food allergies. In the meantime, our best options are careful avoidance through education, being prepared with an EpiPen and awaiting new desensitization treatments.

I read a disturbing story in Newsday last week about a teenage boy playing basketball in Long Beach, N.Y. (my hometown) who collapsed and died while playing a basketball game with his friends. The details are scant at this time as to the exact cause of death, but he did have a known history of asthma. The article said that he had been diagnosed with asthma in the past, but wasn’t on any current medications because he hadn’t had an asthma attack in a while. It is unusual for a teenager or adult to get a sudden asthma attack without some prodrome (early warning signs) such as shortness of breath, wheezing, or constant coughing, unless it’s from a food allergy, which triggers anaphylaxis (the most dangerous type of food allergic reaction).

Keep your inhaler fresh and ready

As a NYC asthma doctor, my main concern in this case is to remind all patients with a history of asthma to carry an updated rescue inhaler, like Ventolin or ProAir, to have on hand if you develop any acute symptoms that may be related to asthma. I often find a patient who is doing well is doing well has an inhaler that is expired. Asthma can be brought on by many factors: cold air (like the frigid weather we have now), exercise (it may happen a few minutes or even an hour after finishing a vigorous workout), emotions (nothing like a nasty argument to cause tension and bronchospasm), and of course, air-borne allergies like cat or dog dander, dust, mold or pollen (in the spring or fall). Periodic checkups to measure your breathing status with a peak flow meter or a spirometry (lung function test in the office) is good way to keep tabs on how strong your breathing really is.

Rethinking a diagnosis

The other important point in cases like this is for the physician who takes care of any patient diagnosed with asthma to occasionally re-think the diagnosis. I discuss this in my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006) that other conditions can masquerade as asthma, and require a totally different treatment. In young teens or adults, a condition called Hypertrophic Cardiomyopathy can exist that can cause episodes of shortness of breath, because the heart is too thick and can cause irregular heart beats and rhythms. This can lead to fatal arrythmias (irregular heart rhythms). A doctor needs a high suspicion because a heart murmur is not always heard, and an ECHO cardiogram is needed to help make the diagnosis. As a New York Asthma Specialist, I use a detailed history to guide me whether a person’s asthma is authentic. I also find allergy tests help support the diagnosis of asthma, since 70% of asthmatics tend to have a positive allergy test.

The key is with a proper diagnosis and proper education on which inhalers to use and when to use them, any patient with asthma should feel confident to reverse and control his symptoms.

Do antibiotics make allergy symptoms worse?

Antibiotics and Asthma

There is a growing body of literature supporting the concept that the overuse of antibiotics among children is related to the increase in allergic asthma. Frequently, a medical research article seems to contradict everything that is logical about medical care. It is important to not let one or even several articles change your mind about medicines or vitamins.

A New Theory

A theory called “The Hygeine Hypothesis” is mentioned in my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006). The gist of The Hygeine Hypothesis is that frequent doses of antibiotics in children can alter the immune system away from fighting infections, and direct the immune system to go in the direction of allergic inflammation.

This can result in a greater incidence of allergic conditions, such as asthma, skin allergies and nasal diseases. In the American Journal of Epidemiology on December 29th, 2010, researchers at the Yale Public School of Health studied 1401 children between the years 2003 and 2007. They found that children with early antibiotic exposure had an increased risk for asthma – even in children where there was no family history of asthma.

The main recommendation of the researchers is a more “judicious use of antibiotics in infants, especially the broader spectrum antibiotics.” This makes sense. Of course, all parents are distraught when their child is sick, especially with ear infections that can be extremely painful. However, in many cases, the cause is viral and the antibiotics are not truly effective. The mainstay is supportive care and careful observation.

This winter many children will experience runny noses, coughing and sometimes more painful sore throats and ear infections. Please see your doctor for a careful examination – don’t just call up and ask for antibiotics, even if you are the patient.

An infection or something else?

And please remember, if your child is constantly coughing, it may not be recurrent infections, but more likely bronchospasm. Bronchospasm is an early sign of asthma and is treated totally different than a cold. In fact, I just had a patient that has asthma and self-treated with an over-the-counter cough medicine for colds and got worse: the medicine had an expectorant component, which actually makes you cough more. This is the worst thing for someone with bronchospasm or asthma. As an Asthma specialist, I devote a whole chapter in my book on the two components of asthma: bronchospasm and inflammation – and how they should be treated.

My last key point, if you or your child has repeated colds or coughing, is to see a specialist. In my office we do allergy testing to make sure a common allergen, such as dust or your pet, is not the cause of your asthma. The good news with allergies is that they are reversible in many cases. There are certain environmental controls that can be applied: air purifiers, encasing mattresses and pillows in hypoallergenic covers… and for those allergic children or adults who suffer, we use allergy drops, instead of shots, to build up your immune system to be more resistant to developing chronic symptoms.

Call us for more information.

Allergy testing can confirm a diagnosis, not make one

They mention that skin prick tests and blood tests can be misleading. I do agree any test can be misinterpreted if the reviewer is not experienced in diagnosing the medical condition in question, and that testing should clarify or confirm a diagnosis - not make a diagnosis. However, I’m also concerned that the report didn’t address issues I mentioned in my prior post on the dangers of not adequately preparing for a serious food allergy.

Making the connection with meals

My experience has been that patients who suspect they have food allergies as the cause of their symptoms need a very careful history: noting when the possible food reaction occurs in relation to meals, what is the exact reaction (skin, respiratory or, most likely, gastrointestinal) and what foods are safe to eat. There are many patients that have food related reactions that can be labeled adverse reactions because they don’t always cause the same problem, but patients who are aware can see a pattern.

The most common food intolerance

The classic food intolerance is lactose intolerance, which is the result of lacking adequate enzymes to digest milk products. This can develop after many years of drinking milk. We can lose the amount of enzyme in our bodies that we once produced. The other classic intolerance is to wheat, but is more serious in those patients with a diagnosis of Celiac disease. This is an autoimmune disease triggered by the ingestion of wheat products. The danger with Celiac disease from patients I have seen is that they don’t always recognize that wheat products like bread are making them sick. They just don’t feel well and many times can be anemic or have rashes or arthritis. There are blood tests available that can help establish the diagnosis. A blood test called anti-tissue transglutaminase IgA and anti-endomyosomal IgA antibodies are the non-invasive tests to ask for.

The most important question you have to ask yourself, or as a parent regarding your child is: does there seem to be a relationship between the symptoms and eating meals. Patients without food allergies have symptoms even when they don’t eat. A food allergy in most cases occurs within minutes or up to an hour after eating the allergic food. I strongly believe that if your symptoms have a temporal relationship to your meals or snacks then  food allergy testing can be beneficial. The studies cite that only a few foods cause most of the food allergies: milk, eggs, peanuts, tree nuts, soy, shellfish and regular fish. In reality, there are many foods that can cause a serious food allergy. I’ve had a patient that is allergic to chocolate- she can’t even go into a room where someone has been eating a chocolate candy bar. I have a patient that is also so allergic to tuna that she couldn’t go into a restaurant because the smell of tuna gave her an asthma attack. These are the real food allergies - and testing and educating my patients how to be prepared to treat a reaction is my job!

Component testing

For serious food allergies, you don’t need to challenge the patient with the food – that could be dangerous. There are new blood tests that measure the specific proteins a person may be allergic to which is helpful in assessing how serious the food allergy is, and if it must be avoided. It’s called Component testing and right now it is the best test to assess the potential danger in a peanut allergic patient. The peanut has 9 different proteins that can be tested, and one of them has been identified with severe peanut reactions called Ara h 2. This test can be specially ordered by your doctor from PIRL labs in Michigan.

The future is promising

The treatment for food allergies right now is frustrating – just avoid eating the food. However, in my book, Dr. Dean Mitchell’s Allergy and Asthma Solution, I devote a whole chapter to food allergies and mention the different treatments being evaluated in clinical trials now. The future does look promising, but for now, if you think you have a food allergy, please see an allergist. If you have a food allergy, always have your EpiPen on hand.

Be prepared

As a NYC allergist, my concern is two-fold: that children and adults be properly evaluated and diagnosed for a true food allergy, and if they do have a food allergy that they be prepared to treat the unexpected emergency situation. The Food Allergy News (a newsletter from The Food Allergy & Anaphylaxis Network) in December 2010 had a lead article on a survey done at the University of Michigan to try and categorize the scope of the problem of food allergies on its undergraduate student population. Specifically, they were most interested in the food allergy preparedness of the student and the campus health facilities. 513 students responded to the survey and 293 reported they had a known food allergy. Almost 48% said they had emergency medication with them in case of a food allergy reaction. However, in most cases(41%) it was Benedryl, not the more powerful and effective self-injectable epinephrine (just 21%).

What’s baffling is that 24% of the students that had a life-threatening allergic reaction (anaphylaxis) had never been prescribed epinephrine. This problem is close to my heart as both an doctor and a parent. My alma mater, Brown University, had a tragedy occur a few years after I attended. A young man with a known peanut allergy had a bowl of chili at a restaurant, not knowing it was made in a peanut base; he went into anaphylaxis and died. I don’t know if he had an injectable epinephrine device, but I do know that studies done at Mount Sinai have shown that patients that use the epinephrine injectable device within minutes have much better outcomes – and a much lower risk of death. I try to teach my patients with severe food allergies to not only carry their EpiPen with them at all times, but to know how to use it properly, so they are ready and not afraid if the situation arises.

If someone has a severe allergic reaction, especially if it requires emergency room attention, I believe it is critical to see an allergy specialist to be tested to see which specific food caused the reaction – and to make sure there are no other related foods that may trigger a future reaction. The testing is highly accurate and safe. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution, I have a whole chapter on this topic and discuss some of the therapies that are being investigated.

Along with many travelers this holiday season, I passed through busy airports. There was no shortage of  Kleenex packets being bought at the convenient shops, and many travelers had their stash of cough drops. In my opinion, the “cough drop” is one of the least effective treatments for a chronic cough. Yet why are so many millions of these products sold?

Chicken soup: A better alternative

The Pharmacies have done a good job in making us believe that cough drops are a safe and effective remedy for a cough. Of course, for a simple viral illness, like the common cold, a cough drop with Eucalyptus will make you feel better. It will soothe some of the throat irritation which can trigger a cough or throat clearing mechanism. A good bowl of homemade chicken soup is a better alternative. The warm water combined with salt is even more soothing on the throat, and the chicken stock has been shown in some studies to improve white blood cells in fighting off infections. I see too many individuals who are “popping” cough drops like breath mints – they are doing it for survival. They don’t want to create a spectacle in a public place where a loud, hacking cough brings stares of disdain or worse – isolation.

Getting to the root of the problem

As an allergist, I see many patients that have battled with a chronic cough for years. It can be debilitating and frustrating. I focus on the underlying cause, which I have mentioned in prior posts, that can come from different sources: the nose, the chest or the stomach. In each case, the chronic cough will be alleviated much faster if the primary cause is treated.

Using an Inhaler

To wean a patient off cough drops I have to give them some confidence in an alternative treatment that will do the job. I usually start with an inhaler. Inhaler’s by definition are bronchodilators, which open up the airways which are spasming – that’s why you are coughing. An inhaler that combines a bronchodilator with a corticosteroid is even better, because the mild cortisone component is a ” mucus buster”, much more effective at breaking up mucus than over-the-counter decongestants, which essentially dry the mucus but don’t remove it.

Survival tips to get relief from a chronic cough:

If you can’t get to your doctor immediately:

1. Drink a caffeinated beverage. Coffee or tea will give you some bronchodilation – but use it in moderation.

2. Use saline or just a few days of Afrin to make sure your nose is opened and mucus doesn’t build up, causing post-nasal drip.

3. Old medical trick: if the coughing is non-stop, place a small piece of paper just between your lips – just for a minute or two – this is just enough time to break the cough reflex, and sometimes gives temporary relief.

These are temporary solutions… the real key is to seek medical attention and not be your own doctor. The cost in the long run is well worth the relief.

Christmas and New Year’s Day are literally  around the corner…. I’ve spoken to many of you who are excited to get out of town and visit friends and family. One concern many of my patients have expressed to me is: How can I avoid getting sick, from either my allergies or infections, on my trip? I’ve done some research over the years and I think have come up with some good tips to ensure a healthier travel experience.

Tip #1:

If you are traveling to a friend or family that has a pet, cat or dog, and you are allergic, there are some sensible things to do. First, if you are on allergy drops, continue to take them while on your trip to maintain protection – unless you get very sick. Second, make sure to take preventive medications a few days before you travel. Topical medications  like nasal sprays (ex. Flonase, Nasonex), eye drops (Elestat or Pataday) or inhalers (Advair, Flovent) are the best way to add extra protection before you get the exposure.

Also, if possible ask your host if they can make sure the room where you are sleeping is off-limits to the pet- this is critical: the worst reactions I see is when a person sleeps in a room where the pet has been staying for long periods of time- even if it’s not when they are sleeping there. The cat dander especially stays airborne for up to 4 months! If you develop symptoms while you are there, you should use antihistamines, such as Zyrtec or Claritin (both are over-the-counter) which will give added relief. Try to get out of the house during the day to get some periods of fresh air.

Tip#2:

If you are staying at a hotel, dust mites – and possibly mold – are the allergens to be concerned about. This is especially true if you are travelling to a warm, humid climate (Florida or the Caribbean). What can you do realistically? You can tell the hotel management that you are allergic to dust and mold, and would appreciate a thorough cleaning of the room – especially the headboard area. This area gets overlooked in cleaning and is literally right by your head, where you are breathing in all that dust. This may sound obvious, but ask them to make sure the sheets were changed from the prior guests and if possible washed in hot water (over 135 degrees) which kills the dust mites. If you want to be fanatical (but to me not unreasonable) bring your dust mite covers, at least for your pillows- and see what a difference this can make. If you smell mold in your room, pump up the AC. Mold spores don’t like cold temperatures.

Tip#3:

This one’s simple but overlooked: ask for a smoke-free room. You probably think most people don’t smoke anymore, but there are many European travellers to the U.S. with the weak dollar and they are smokers. The chemicals in the smoke last in the room for days. The hotel staff will try to spray air-freshener all over the room, but the smoke fumes linger and are damaging to your sinuses and respiratiory tract- making you more prone to an infection.

Tip#4:

Don’t use the bathrooms on the plane! Of course, unless you have to. The bathrooms on the plane are germ infested! I have gotten sick several times before I read an article explaining what is going on in these bathrooms. My advice is to put on rubber gloves. I do this all the time. I have my lavender or blue latex-free gloves in my carrying-on bag and if the urge to go to bathroom gets too much, I put on my gloves and take my chances. So far, over the last 8 years I haven’t gotten sick on a trip. If you forget a pair of  rubber gloves, no problem- the TSA security has plenty of those gloves as they examine your bags: ask politely if you can have a pair or two.

Tip#5:

Get some sun if you are going to a warm climate. Do it safely and try not to burn on your first day or two. In the Northeast, all of us get a paucity of Vitamin D during the cold, dark winter months. There is no substitute for good old sunshine. Start out with at least an hour a day, and slowly build up an extra half-an hour on top of that. It is good idea to use sunscreen on your face, but let your arms and legs go sunscreen free to soak up the Vitamin D. Many of the new studies clearly show Vitamin D stengthens our immune system- and many new allergy articles show it helps decrease allergies- it’s also great to clear up your eczema.

I hope these tips make your holiday allergy and infection-free. Have a great time!

The studies keep pouring in: at the American College of Allergy, Asthma and Immunology meeting in Phoenix, researchers presented data showing that sublingual allergy tablets to grass pollen was safe and effective in children. This was the first study done in North America. Prior studies were done in England and Europe. The exciting part is that the therapy appears to work within 16 weeks and gave significant protection against grass pollen allergy compared to placebo (water tablet). It is also easy for kids to use.

I’ve been using the sublingual method to treat my patients for the past decade and have seen the dramatic improvement in children and adults. Dr. Blaiss, a former president of the Allergy society, mentioned that the great thing about this therapy is that it changes the immune system to protect against the allergen, unlike drugs which can only try and mask symptoms. I wrote in my book, The Allergy and Asthma Solution, that this unique therapy which has been around for over twenty years in Europe can change the lives of millions of allergy and asthma sufferers.

Mike’s Story

I had a patient I’ll call Mike, who couldn’t go outside during the months of May and June, because his grass allergy was so bad. He was an avid golfer, but was getting ready to sell his clubs because the misery just wasn’t worth it. Mike was a great patient: he stayed on the program and within a year he felt much better but still needed some medications. The following year he got through the spring season without any medications, just using his drops. It has been over 5 years since Mike finished the program, and I know how great he is doing by the many friends and family he has referred to our office to become allergy-free.

Journal of Allergy Study

One more important recent study: in the The Journal of Allergy, Asthma and Immunology in November this year, a team of top Italian allergy researchers showed that if patients continued their allergy drops for the proper maintenance period of 3 years, they kept their protection for over 8 years and beyond. This again goes to prove that immunotherapy is an immune changing treatment that can give long-lasting protection. The most striking other fact is that patients receiving the drops developed no new allergies during the therapy, whereas the control group (just meds, no drops) had a 24% increase in developing new allergies.

Allergy Drops: A no-brainer

It’s really a no-brainer anymore: for environmental allergens (cats and dogs, tree and grass pollens, dust mites and molds) allergy drops are the way to go. I just can’t wait until the food allergy studies that are currently underway come out. Allergists and their food allergic patients so desperately need a safe treatment option.