I'm Dr. Robert Bocian, MD, PHD, FAAAAI. I'm an Allergist-Immunologist and Co-Founder at Allermi. I'm here to answer your questions about allergic disease. AMA.

Hello,

I noticed immediate relief thank you. Obviously, the medicine says not safe for consumption, but it drips down the back of my throat resulting in that bitter taste. The taste not a big deal, but obviously I am consuming it if I swallow by accident. Is this unsafe?

Hello, I am glad to hear that Allermi is starting to work well for you. It is not unsafe to swallow tiny amounts of your nasal spray that drip down the back of the throat. However, this does potentially increase the likelihood of developing certain side-effects such as nausea. It also suggests that you may not be using the correct technique when taking your nasal spray - as we say, if you taste it, you waste it! We need the nasal spray medication to stay in the nose where it belongs.

So, please make sure you're doing the following every time when taking your Super Spray to get the best results:
-Shake your Super Spray bottle well
-While seated on the edge of your bed or chair, lean forward and look down straight towards your toes in the nose-to-toes position, so that your chin touches your chest
-Insert the nozzle as deep as comfortable, ideally about 1/2 an inch into the nose, straight up into the nose
-Press the opposite nostril closed
-Pump your nasal spray with a short, firm pump and sniff up once
-Immediately begin 15 seconds of short, rapid little "bunny" sniffs after each spray, breathing out through the mouth when needed - not big, high-suction sniffs - to bring the medication up into the nose
-Keep your head pointed down, in the nose-to-toes position, the whole time!
-Repeat for the other side
-Don't lift your head up until you're fully done with your treatment on both sides!
-Avoid tilting your head back or lying down for a full 30 minutes after taking your Super Spray.
Please pay special attention to these instructions and let us know how you do!

Here is a short video I made demonstrating the proper technique.

Thank you, that explains my random nausea, that I was starting to get worried about. Enlarged Turbinates, and now nausea. Hopefully, proper application remedies this.

I'm glad this was helpful. Please keep the Allermi team updated in case a formula change is warranted, if this persists after very careful attention to technique.

I have "inappropriate tachycardia" sometimes after eating, a pulse above 145, just sitting there. Sometimes it will last for hours, leaving me exhausted and feeling horrible. I've had endless tests trying to determine a cause. None has been found, going back two years now.

The only food I have definitively shown to trigger this is canola oil. If it eat any canola, I'll get tachycardia, sometimes a short spell, others interminably long. I do get it eating other foods. I have a suspicion that bananas, dark chocolate, avocados, and walnuts might also be causes.

My wife believes that it could be tied to acid reflux, but it sometimes happens eating foods that wouldn't cause acid reflux. She also thinks it could be associated with IBS. I'm not sure about anything other than I'd love to learn what to avoid so that it doesn't happen as often as it does (about once a week, on average).

Have you ever run across someone with my same symptoms/complaints? If so, how did you approach their case, as an allergist/immunologist?

Thank you for your professional time.

Hello and thank you for your question. I'm sorry to hear you have been experiencing this.

Isolated tachycardia is highly unlikely to have an allergic cause. Other than foods that contain identifiable cardiac stimulants, such as foods that contain caffeine or theobromine - which is present in cacao/dark chocolate - there is no clear biochemical connection that I can think of between ingestion of the food and cardiac stimulation.

Pure canola oil, which should be 100% lipid, should be completely non-allergenic.

With respect to acid reflux, "silent" acid-reflux conditions, which may not be associated with acid indigestion, heartburn or regurgitation, might still cause a tachycardic response. Thus, bringing the symptoms that you described to the attention of your gastroenterologist could be quite helpful.

Continued follow-up with your cardiologist would also be recommended.

I hope this is helpful.

What do you think of SLIT Therapy for curing allergies?

I've been battling post-nasal drip my entire life and cycled between zyrtec, claritin, allegra, etc with not much luck and Ive developed acid reflux in more recent years due to work/life stress. The combination has been destroying my vocal cords. I went to an ENT back in April for a checkup/diagnosis for more serious options and they examined my vocal cords - they said they were enflamed and my throat was "cobbled" and suggested a combo of Flonase, any common anti-allergy pill, and SLIT therapy after running an allergy test (surprise surprise, I'm allergic to just about every common environmental allergen at a 9 out of 10 severity).

I've been diligently taking the drops for about two months now and am kinda bummed that this will take a few years to really see any progress.

I am sorry to hear about this constellation of symptoms but do believe there is good help that can be given.

First, with respect to acid reflux, the general approach is to use a good acid-inhibiting medication. For this, I generally turn to the proton-pump inhibitors (PPIs), some of which work better than others and thus a trial of more than one member of the PPI category might be necessary. Response to treatment with PPI therapy can vary from days to weeks.

This is joined by other lifestyle measures to limit acid reflux, including dietary modifications, refraining from eating in the 2-3 hours before bedtime, and sleeping on a gentle incline of 3-6 inches of elevation of the head of the bed frame, using bed-risers.

Turning to allergic symptoms, post-nasal drainage and mouth-breathing due to congestion can combine to irritate the vocal cords and the membranes around the vocal cords, in a way that can add to the irritative effect of acid reflux, whereby acid can contact these areas, particularly during the night's sleep.

Antihistamines are good at targeting the 3 cardinal symptoms of allergy: sneeze, itch and runny nose. However, they will neither decongest nor control allergic inflammation, the latter being the fundamental issue in allergic disease and the cause of post-nasal drip.

A good topical nasal spray approach can be highly effective in calming nasal inflammation and in doing so, diminishing or eliminating the symptoms it causes, namely congestion, post-nasal drip runny nose, sneeze and itch. Specifically with respect to the use of Flonase, we disfavor the use of fluticasone propionate since this medication requires an alcohol solvent, which could irritate the entire airway including the throat in several ways. At Allermi, we combine multiple nasal spray medications into one, alcohol-free formula to comprehensively address all of these symptoms with one nasal spray.

From the immunotherapeutic standpoint, my group and I have not favored sublingual immunotherapy for a number of reasons, including reduced effectiveness in comparison with traditional subcutaneous immunotherapy, i.e., allergy shots. The potential for irritative and allergic side-effects, and perhaps an increased risk of esophageal inflammation in the form of eosinophilic esophagitis, which could be contributing to your acid reflux.

I hope this information is helpful.

Do you think your group may be biased and disfavor SLIT because it is a home-based treatment that does not reimburse nearly as well as office-based SCIT (i.e. allergy shots)?

No. Monetary bias does not play a role in our preference for SCIT over SLIT. We have many reasons for favoring SCIT over SLIT, among them our observations that SCIT provides greater efficacy for a broader array of allergens. In addition, SLIT is not devoid of potential side-effects or complications such as pruritus of the oral airway, stomach upset and the risk of eosinophilic esophagitis. That said, we do have a small number of patients for whom we do prescribe SLIT, who either have a great deal of difficulty with transportation to and from the allergy clinic, or who have a tremendous aversion for injections. For such patients, we limit our prescribing to the FDA-approved SLIT products, for dust mite, timothy and related grasses, and ragweed. This is our view, and undoubtedly a number of other allergy practitioners are more favorably disposed to SLIT.

Slightly off topic, but are you glad you did your PhD? I am applying to medical school (would love to go to Stanford, but their acceptance statistics are some of the highest in the country) and am very interested in research. I have a decent amount of research experience and was considering going MD-PhD, but I am not really interested in running my own lab and wasn't sure if the extra few years was worth it.

Hello and thank you for your question. Whether to pursue a PhD might depend on what you envision to be the nature of your involvement in medicine and biomedical research - whether it is in private practice, a university setting or in the biotechnology sector. From a purely educational standpoint, pursuing a PhD tends to sharpen one's ability to analyze scientific research, the merit of new scientific discoveries and in general, refines the ability to analyze raw data and determine its potential clinical, and not solely its statistical, significance. I personally am quite grateful to have devoted time and effort toward a PhD and have found that doing so has enabled me in perpetuity to bring a higher level of scientific accuracy to the care of my patients, and to be able to formulate more-informed patients' many questions regarding diagnostic testing and pharmacotherapy. Wishing you continued success in your educational and professional endeavors!

You are an excellent writer.

…though I remain skeptical of your handwriting ability. :P

Ha! My handwriting indeed leaves much to be desired. Thank you for the kind compliment.

I’m allergic to cats but live with two of them. My allergies usually present themselves in my lungs (mild whizzing is the worst that it gets). What are the long term health impact for me if I continue to live with the source of my allergies? Medication seems to help only slightly, so I basically am forced to use albuterol sulfate inhaler to clear my air ways before going to bed at night if I’ve been home most of the day. I’ve also lived in multiple places but I always have exhibited the same symptoms so I’ve ruled out other potential triggers for my whizzing.

Hello, and thank you for your question. Albuterol is used as a "rescue" medication to relax the muscles surrounding your bronchial passages so that the effort of breathing is reduced and that chest-tightness, wheeze and/or cough are controlled.

However, continued exposure to inflammatory agents - whether it be allergens, irritants, viruses, etc. - is likely to continue to promote inflammation of the lining of your bronchial passages, which runs the chance of making asthma progressively worse.

Thus, particularly when a significant source of allergen, such as your cats, continues in your presence, it is important to also be taking an anti-inflammatory medication for your lower airways, for sustained, daily use. For this purpose, please consult your primary care physician, allergist or pulmonologist.

Examples of inhaled medications that include helpful anti-inflammatory medication are Flovent, QVar, Arnuity, Pulmicort, Symbicort, Dulera, Breo, Trelegy, Advair, Wixela and Breztri.

An allergy immunotherapy program, properly known as allergy shots, can also reduce and control airway inflammation over time, but such immunotherapy programs involve a lengthy commitment, generally a minimum of 5 years of monthly injections.

I hope this information is helpful.

Thanks for doing this Dr. Bocian!

My question is; can one really cure allergies? For context, I had allergy shots for 2 years back when I was a teenager and barely had any symptoms (coughing, throat feeling tight, itchy eyes) for a long time afterwards. I thought that was the cure and the end of it. Eventually symptoms started coming back slowly and in various different forms than before. I know have (contact?) dermatitis, chronic rhinitis and sneezing as well yay :(

Also is Allermi going to be available in the EU? Would love to try!

Hello and thank you for your question. With respect to allergies, we speak not of cure, but of varying degrees of control.

The 3 main pillars on which allergy treatment stands are environmental-allergen control (i.e., reducing exposure), which can be informed by allergy testing; allergy medications that address the fundamental issue, which is allergic inflammation, and allergy medications that provide acute symptom relief; and, allergy immunotherapy, addresses allergy at the most fundamental level, which is at the point at which the allergic response is generated by the immune system in the bone marrow and lymph nodes.

At times, immunotherapy either has to be revised according to updated allergy testing, or needs to be continued either long-term or in perpetuity, in order to achieve consistent control of symptoms.

Allermi is currently only available in 40 US states and we don't have current plans to expand into the EU, unfortunately. Best wishes to you!

I'm 17 . I have been suffering from skin allergies since I was 12 years old. But something new is happening these days. My eyes swell up and down again for no reason. I have been in severe pain for days. And it lasts for days. Is it related to allergies?

Hello, I am sorry to hear you're experiencing this. Your history of allergy does make you more likely to develop new allergic reactions in the future, so it is possible that your eye swelling is related to allergy. I would recommend you contact your primary care doctor or allergist, or visit urgent care as soon as you can.

In the meantime, what I would recommend to my own patient that would be generally safe would be to try a non-sedating oral anti-histamine. For this, we would recommend generic, non-prescription Allegra (fexofenadine), 180-mg, twice-daily. I would also recommend Pataday Extra-Strength (olopatadine) 0.7% antihistamine eye drop, one drop per eye once daily. And, lastly, ice-pack treatment of your eyes using ice covered by a thin towel for 5-10 minutes at a time, several times a day.

I hope this is helpful.

I am one week into trying Allermi and it has been working fairly well. My formula has oxymetazoline in it. I know this isn’t safe for long term use but Allermi uses a micro dose. What is the traditional percentage of oxymetazoline found in Afrin type sprays?

Hello and thank you for your question. I am glad to hear your Allermi is starting to work and hope you continue to see progress with more time.

The Afrin dosage written on the package is 3 sprays per nostril, with a 300µL spray volume of 0.05% oxymetazoline, equivalent to 0.45mg.

Allermi is prescribed at a dosage of 1 spray per nostril with a 100µL spray volume of 0.003125%-0.0125% oxymetazoline, equivalent to 0.003125mg-0.0125mg.

Therefor, the dosage of oxymetazoline in Allermi effectively ranges from 1/36th-1/144th the dosage of standard, over-the-counter decongestant sprays.

Is this ok for people with hypertension since it's a microdose?

Thanks for asking this. I’ve also been wondering

Yes, we have not seen instances of aggrevation of hypertension owing to the micro-dose of oxymetazoline that we use at Allermi.

Yes, we have not seen instances of aggrevation of hypertension owing to the micro-dose of oxymetazoline that we use at Allermi.

Why do you hide the price of the medicine on a FAQ page only accessible from the footer, separate from the FAQ on the main page?

Your medication is $35 a month plus five bucks for shipping. That's remarkably affordable, so I don't see a motivating factor behind hiding that.

Hello and thank you for your question. We are not hiding our pricing intentionally, as we need to pre-qualify prospective patients first. We also offer different pricing options, such as the one-time purchase. That said, I will pass this feedback along to our marketing team and appreciate your opinion here.

I have suffered from severe grass pollen allergies since I was 8 years old and rely on oral antihistamines daily for the 3 months of the year when grass is pollinating. As I get older the physical side effects of taking the medication seem to be getting worse. Lethargy, brain fog, depression and body aches. I cycle between claratyne, telfast and zyrtec every couple of years because I find my body adjusts to them and they lose effectiveness. Does your therapy work for severe allergies? I react on skin contact (hives) eyes (mucus membrane contact) and nose (sneezing and flu like attacks)

Hello, I am sorry to hear that you are experiencing side-effects to your oral allergy medications. You may be able to lessen your need for oral antihistamine use by introducing a nasal spray program and an eye drop to your routine. I am surmising that you are not in the United States, so Allermi would not be available to you. I would instead recommend considering an anti-inflammatory nasal spray and an antihistamine nasal spray, along with an antihistamine eye drop. That said, nasal spray nor eye drop medications will treat hives, and for that a non-sedating oral antihistamine is the mainstay initial treatment.

Last year I randomly got hives on my face, around my mouth, so I was referred to an allergist. We did the prick tests for environmental allergies, as I have no known food allergies, and one known med allergy (sulfa). They all came back negative, and the hives never returned.

I do suffer from allergy symptoms regularly, such as sneezing, congestion, runny nose. The allergist suggested rhinitis, but I haven't really done anything about it. Is it worth investigating further? It's annoying, but not debilitating, except for a couple times a year I get worse symptons that resolve on their own after a couple days of rest.

Not all patients with classic allergic symptoms affecting the upper-airway have identifiable allergen reactivities on allergy testing. We do recommend that even mild, transient symptoms of rhinitis be addressed, since rhinitic symptoms can have adverse consequences on sleep quality; sense of smell/taste; and many aspects of daytime comfort that can be improved with better nasal airflow, absence of nasal discharge/sneeze/itching. If left untreated, rhinitis can potentially worsen.

If you had immunoglobulin g deficiency could this lead to issues with allergies or is that one of the other immunoglobulins? Just found it I have this and I’m not getting much feedback from the docs.

Hello and thank you for your question. IgG deficiency is independent of allergy. Allergic reactions are mediated by a different immunoglobulin, IgE.

I would like to mention that many instances of total-IgG deficiency, or deficiency of one or more of the IgG subclasses 1-4, are not clinically consequential. It depends on why the IgG lab study was obtained - for example, recurrent respiratory infection.

I'd also like to mention that in many instances of total-IgG or IgG-subclass deficiency, the production of specific IgG antibodies (for example, IgG antibody to tetanus toxoid, diphtheria toxoid, and the pneumococcal-polysaccharide antigens) is intact. Meaning, immune defenses might be quite normal despite a subnormal total antibody level. I would suggest that these specific antibody measurements be made to illuminate the total picture, if not done already.

I would recommend that you consult with an allergist-immunologist, immunologist or infectious-disease specialist to gain more insight into the meaning of the lab results that you have received.

I hope this is helpful.

Hello Dr Bocian. I've been doing gel nails (UV-cured nail polish)at home for 5 years, I'm not a trained nail technician. A year ago, I developed an allergy for all permanent type of nail polish (acrylic, gel etc). After doing some research I realised it may be self induced, by repeat incorrect application at home. I also realise more and more women get this allergy due to these products becoming more accessible. My mother also has this allergy. The symptoms include severe itching around nail bed, blisters and nails lifting. My question: will I ever be able to have beautiful nails again or is this a permanent thing? :(

Unfortunately I do not know a lot about this. I would recommend consulting a dermatologist who can do patch-testing with the products that are used in manicuring. Based on the results, it is often the case that specific products can be included or avoided, so that local reactivity does not take place.

Are there tests that can determine if you are allergic to a particular food item?

Yes, the selection of particular allergens to test, as well as the testing modality (skin test, blood test and/or supervised oral-ingestion food challenge) is best guided by your specific medical history. Meaning, your allergist will need to interview you and determine what the pattern of symptoms has been in relation to the ingestion of specific foods. We would recommend against "food sensitivity" tests, which are available from many online sources and which usually are based on a scientifically-invalid premise.

Blood tests aren’t really accurate though

Blood tests have varying degree of sensitivity and specificity, depending on the allergen in question. For many allergens, skin testing is superior and for others, blood testing and skin testing are considered to be on a close par with one another.

(To clarify, when we refer to blood testing, we are not referring to home-based tests involving a finger-prick source of blood, but a formal laboratory test method that is FDA- and CLIA-approved.)

How does one suddenly become allergic to something as an adult? A few years ago we went to dinner and my brother ordered crab legs and his whole mouth swelled up, he was 35yrs at the time and had never had that happen before.

We do not know yet how an allergy can suddenly surface. But what we do know is that before the symptoms became outwardly manifest, a length of time passed during which "silent" allergic sensitization was taking place in the body, from earlier exposures to crustaceans. It is quite common that shellfish allergy can arise in adulthood, and often the realization that such allergy has come to the picture is sudden. When one discovers an allergy to crab, one must be equally cautious with respect to consumption of shrimp, lobster and crayfish, since the crustaceans share the major allergen protein. Allergy testing should be done as soon as feasible, either by skin-testing or a blood test.

It is usually important to also test the mollusk category of shellfish (mussel, oyster, scallop, clam, squid, octopus), since there is a higher incidence of allergy to the mollusks when one has allergy to the crustaceans. Likewise, it is important to ascertain if allergy to finned fish could also be present.

Such allergy is not necessarily permanent once it is established, and can often disappear after a period of complete avoidance of the relevant seafood category - the length of time during which reversal of the allergy might take place is very difficult to predict.

Finally, if a food allergy is established, it is important to have a prescription for an epinephrine auto-injector such as the EpiPen in the even that inadvertent or accidental injection of the food allergen triggers moderate to severe reactivity in the oral airway. I would recommend consulting with an allergist about this as soon as feasible.

I hope this information is helpful.

What is the simplest chemical to which someone has shown an allergic reaction?

This is an interesting question. One could be allergic to a relatively small molecule such as penicillin, provided it has attached itself to a protein, such that the penicillin complex is recognized by the immune system. Otherwise, classical allergens are large glycoproteins. Some very small molecules, such as sulfite, can directly elicit histamine release from mast cells, but this process short-circuits the formal allergic mechanism and is really a pharmacologic effect.

M’y tongue gets itchy when I eat certain fruits like melons and peaches and no one every believed me. It’ll even itch in my oesophagus if that makes sense. But it’s never serious enough for it to cause worse symptoms. Allergy tests didn’t look at fruit so I’ve never been diagnosed. What could this be?

I definitely believe that your symptoms are quite real, and in fact, represent a common syndrome called oral-allergy syndrome or pollen-food hypersensitivity syndrome. This phenomenon often occurs when one has become allergically sensitized to certain pollens of trees and/or weeds, whereby there is cross-sensitization to highly similar or identical peptides or proteins present in fresh fruits. These fruit allergens are generally quite sensitize to heat and thus, people who have the symptoms you described with the fresh forms of the fruit generally do not have those symptoms when the food has been heated. The ideal way to confirm fruit allergy is with skin testing, using the actual fresh fruits as sources of skin test material. Commercial extracts of fruits that are used in standard allergy testing often lack the protein allergens that are in higher concentration in the fresh fruits. Your allergist should request that your provide fresh, whole forms of the fruits in question for use in what is termed direct skin-testing, where a skin-test instrument will be used to collect a small amount (a few nanoliters) of the fresh fruit and apply it directly to your skin. In addition to the testing of fruits, it is often helpful to test a variety of airborne allergens to determine if there is pollen-food cross-reactivity. A classic example is apple hypersensitivity in the setting of birch-pollen hypersensitivity. There are many additional examples. In many instances, receiving allergy immunotherapy injections for the airborne pollens has the effect of diminishing or eliminating the allergic reactivity to the corresponding fruit allergens. Very mild oral-allergy symptoms, such as tingling or itching, limited to the mucous membranes of the mouth but not extending to create swelling of the tongue or sensation of restriction of breathing, swallowing or speaking at the level of the throat, can often be prevented by the taking of a non-sedating oral antihistamine, 1.5-2 hours before eating the fruit. For this purpose, I recommend to my patients to take Allegra/fexofenadine (180-mg tablet) 1-2 tablets, 1.5-2 hours before eating. We also provide our patients who have this syndrome an epinephrine auto-injector, such as the EpiPen, in the unlikely but not impossible event of an upsurge in the level of allergic reactivity of the oral airway in response to food. For this, I would recommend that you consult with your allergist as soon as feasible.

I had MIST sinus surgery about 8 years ago due to recurrent sinus infections. Within a year after the surgery, I also had 2 minor procedures using radiofrequency to shrink the "nasal swell body." I've had a reduction in sinusitis episodes, but over the past several years have been dealing with increased congestion issue. The primary symptom is when I am lying down at night, within minutes of turning onto my side, that side of my nose becomes completely congested (while the other nostril is still clear). If I flip sides, within 5 minutes it will flip and the other nostril will become congested. It leads me to have trouble sleeping and breathe through my mouth all night.

About a year ago, I had Radiofrequency turbinate reduction performed. Symptoms improved for about a month but quickly returned. I had a second Radiofrequency turbinate reduction performed with no improvement in symptoms.

Afrin works absolute wonders, but I don't want to use it due to rhinitis medicamentosa. I use Flonase daily before bed and it has a mild benefit, but I still get swelling in my turbinates on the side that I lay on when sleeping. It is very frustrating and leads me to breathing primarily through my mouth.

I am intrigued by Allermi and the concept of microdosing oxymetazoline along with the nasal steroid. Do you think that a microdose will still be effective enough to keep my turbinate swelling down when I lay on my side at night? Do you feel that long-term use of oxymetazoline in low dosages is safe and won't cause reliance or rebound? And lastly, do you recommend that I consider a more invasive turbinate reduction microdebrider submucosal resection to treat my issue or is a nasal spray a suitable alternative? Thank you!

Hello, thank you very much for your question and the detailed overview of your history.

Increased nasal congestion at night is common, since the nasal passages are posture-sensitive, and the horizontal sleeping position causes the nasal blood vessels to carry more blood flow. This in turn causes swelling of the nasal lining, which narrows the nasal passages and reduces the airflow, which we perceive as congestion. When one is one the side, the lower nasal passage (closest to the bed), also termed the dependent side, tends to become further narrowed.

The micro-dosed-oxymetazoline-plus-anti-inflammatory-steroid combination we offer at Allermi may very well be sufficient at relieving your nasal congestion when lying down, based on our experience with similar instances in our practice.

I believe it would be worthwhile to give Allermi a try for several weeks before considering a more invasive surgical procedure, to see if this topical-medication approach suffices. Compared with Flonase, Allermi will be far more effective at relieving congestion.

At the micro-dose level, and certainly when combined with anti-inflammatory medication, we have not seen instances of rebound congestion, even with sustained, twice-daily, long-term use.

I hope this information is helpful.

Every time my seasonal allergies flare up I also get systemic joint pains, fingers, feet, elbows, knees, shoulders, hips.. do you know what mechanism might cause this?

Generally speaking, allergic reactions to environmental allergens do not cause joint pain or joint swelling. Thus, I would recommend that you please consult a rheumatologist for the joint-related symptoms that you describe. I hope this is helpful.

Can you take a regular Claritin and a Claritin D at the same time?

We would not advise doing this. In fact, we would advise using Claritin-D at all, due to the side-effect potential and risk of pseudoephedrine present in Claritin-D, which can include elevated heart rate, elevated blood pressure, sleep disruption, irritability, dryness of the mucus membranes of the eyes, nose and mouth, urinary-tract obstruction in men, and a host of other side-effects. The class of decongestant in which pseudoephedrine is a member has also been linked with an elevated risk of stroke.

Claritin (loratadine) by itself is a very mild but generally side-effect-free antihistamine. Antihistamines such as Claritin best target 3 classical allergic symptoms: sneeze, itchiness and runny nose. Congestion will generally not be reversed or improved by Claritin alone, which is why pseudoephedrine is added to Claritin, making it Claritin-D. We place paramount value on maintaining un-congested nasal passages, but we never advocate the use of oral decongestants to do so. Instead, we at Allermi use micro-dosed topical decongestant medication to achieve a superior decongestant effect, with essentially no risk of side-effects or danger.

I've been taking Afrin for the last few years and a bunch of other OTC medication, how can I get off of it and not be dependent on it?

Go cold turkey.

While a sudden withdrawal of all oxymetazoline might eventually re-set the nasal lining to a non-rebound state, doing so is likely to be extremely uncomfortable due to the high degree of congestion that is likely to take place. We favor usage of a micro-dose of oxymetazoline, which should be effective in controlling congestion and at the very same time, employing topical anti-inflammatory medications that are intended to control inflammation of the nasal lining, which is the fundamental cause of congestion in the first place.

What are factors that contribute to post nasal drip? What are the best ways to get rid of it? I love my Allermi spray, I’m just noticing with the season change that my post nasal drip is getting worse. It’s been the worst symptom of my allergies for as long as I can remember and ends up contributing to a chronic cough when it gets bad enough.

Hello, thank you for your question. I am very pleased to hear you love your Allermi spray.

Post-nasal drip is a symptom if inflammation. When nasal mucosal tissue becomes inflamed, it produces an excess of mucus, as a defense mechanism against what the body perceives as invaders, i.e., allergens or viruses.

To help improve your post-nasal drip, please stay consistent with your Allermi Super Spray as prescribed to reduce inflammation. If your post-nasal drip continues to get worse, your Allermi care team can adjust your formula to either increase the anti-inflammatory component, or add/increase a medication called ipratropium that targets excess mucus.

Please also increase your Salinity Spray use. This helps excess mucus thin and drain. To do so:
-Insert the Salinity Spray nozzle as deep as comfortable
-Leaning over the sink, sniff up 5 sprays of Salinity Spray in each nostril
-Then gently blow your nose
-Repeat this saline-then-nose-blowing cycle several times
-Then use Super Spray

Since your post-nasal drip is causing cough, you may benefit from sleeping on an incline using bed risers to elevate just the head of your bed or a wedge pillow. Both of these items are available online. (We don't advise using pillows to prop you up instead, as this can worsen symptoms - you want a gradual, smooth incline). This helps nighttime post-nasal drip drain more easily and can help reduce cough.
I hope this information was helpful.

are we nearing the end of allergy season or do you expect it to continue or get worse into summer/fall? also do you have any recommended places to vacation this summer for people who want to avoid any sort of allergens? thank you!

Hello, thank you for your question. It depends on where you are writing from. Allergy seasons depend a great deal on geographical location. Many areas in the US have a fairly well-defined allergy season that occupies portions of the spring and fall months. Other regions have a perennial (i.e., year-round) allergy season that can, from the allergy standpoint, render all four seasons allergy season.

It's difficult to predict locations that have a complete absence of allergen. In general, we recommend coastal vacations or vacations at the higher elevations, typically 6000 feet or higher. A number of desert settings also can feature minimal allergen exposure. Tropical islands also tend to be minimally allergenic. Cold-climate locations such as Alaska are minimally allergenic. Ocean cruises are likely to be the least allergenic.

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The various subtypes of MCAS warrant a careful and thorough diagnostic evaluation, which includes a detailed history, and specific tests. One of the most important tests is to determine a baseline serum tryptase-level, which is one of the biomarkers of mast-cell activation. However, it must be said, that many suspected cases of MCAS do not pan out as such.

How likely are you to be in an anaphylactic shock with pollen allergies?

In principle, possible, but extraordinarily unlikely.

Hello, I get a reaction from having water from the nearby lake and river entering my nose. About 7 hours later I start to sneeze, then my nose starts to run which leadsI to a sleepless night because of it. Things get back to normal the next morning. It doesn't happen in swimming pools, at the sea or in other lakes that are further away. I can put my head under water if I block my nose with my fibgers so it's not too bad but I can't do water sports because of thus reaction. Have you heard of others having a similar problem, is there a name for it and is there somethings I can do about it? Thank you

Hello, thank you for your question. This may be explained by suspecting that the lake contains a great deal of surface allergen in the form of pollens of grasses, trees and weeds, possibly also the spores of dry, outdoor molds, and possibly also animal-dander allergens. Thankfully, it is unlikely to be the water itself triggering this reaction. We would recommend considering using nose-plugs. If these are not used, rinsing your nasal passages with a nasal saline spray after exposure to the lake should offer some help. You can also consider a non-sedating oral antihistamine tablet, ideally taken 1-2 hours before exposure to the lake to offer prevention and relief.

How does one manage or approach cholinergic urticaria? Does significantly elevated IgE contribute to the condition?

Cholinergic urticaria is quite common and is generally responsive to non-sedating oral antihistamine, which for my patients I often prescribe at elevated, off-label dosages. For example, Allegra/fexofenadine, 180-mg tablet, from 1 tablet once daily, dosing upwards in stepwise fashion to as many as 2 tablets twice a day. Other non-sedating antihistamines used for this purpose include Zyrtec/cetirizine, Xyzal/levocetirizine, Claritine/loratadine and Clarinex/desloratadine. We prefer non-sedating antihistamines to avoid interfering with daytime activities and concentration.

At times, Singular/montelukast is added to antihistamine treatment for cholingeric urticaria.

When the response to the above medications in insufficient, or if side-effects to the above medications occur, Xolair/omalizumab is often prescribed - this injectable monoclonal antibody, a "biologic" was FDA-approved for chronic urticaria, including of the cholinergic type in 2014.

Depending on the severity, more powerful immunomodulating medications are used.

Keeping the skin cool and avoiding excessive perspiration and overheating of the skin in hot weather and during exercise can be helpful in mitigating the occurance and intensity of cholinergic urticaria.

Cholinergic urticaria is usually independent of IgE levels.

I hope this is helpful information.

Hello Dr. Bociam

Thank you for taking the time to do this AMA.

My question is focused on eczema, specifically in children. Do you happen to know of any research that is looking into what causes eczema and any potential cures for it?

We are currently at the stage where we control the eczema as much as possible and keep an eye out for flare ups. But there doesn't seem to be anything that causes the flare up or anything to prevent it. And the flare ups change locations, it could be hands, arms, legs, feet etc. Its like we are constantly chasing the eczema away. Do you have any recommendations on how to prolong the periods between flare ups?

We see this very frequently in our practice. Most eczema in children is atopic or allergic dermatitis, which tends to be outgrown in later childhood or early adolescence. Genetics is largely responsible for creating this condition with contributory genes in both the realm of allergic response and the constitution of the skin barrier.

In approximately 30% of infants with eczema, one or more food allergies is thought to be responsible, based on specific allergy testing. The environmental allergen that has been conclusively linked to aggravation of eczema in children who are allergic to it is the dust mite, and thus indoor-allergen control measures directed primarily to reducing dust-mite indoors are helpful.

Our initial approach to eczema treatment consists of (1) thorough hydration of the skin; (2) sealing in the hydration layer with an ointment - either medicated for active rash or non-medicated to maintain the susceptible area of skin in a rash-free state; (3) avoidance of thermal irritation of the skin by not using bath water that is hot or too warm and by not over-insulating the skin, particularly on hot or humid days; (4) avoiding chemical irritation of the skin by avoiding the use of standard soaps and cleansers, in favor of dermatologic-grade cleansers such as those made by CeraVe, Aveeno, Cetaphil, Vanicream or Eucerin, and rinsing away the cleanser film thoroughly; (5) avoiding lotions since they are too thin to hold in the hydration layer and invariably contain irritating preservatives such as alcohols; (6) avoiding mechanical irritation from fabrics other than 100% cotton; and (7) minimizing the itch-scratch inflammation cycle by reducing inflammation.

Our fundamental pharmacologic approach involves the careful use of topical steroid anti-inflammatories of tapering strength and application frequency, the use, where necessary of non-steroid topical anti-inflammatories, and the use, when necessary, of topical antibiotic to reduce or eliminate colonization of the skin by staph bacteria, which harbor chemicals that stimulate the allergic T-cell response of the skin that worsens eczema.

We would recommend arranging a visit with a pediatric allergist as soon as feasible to discuss prescription topical medications.

If the above treatment program is insufficient, consideration can be given to use of one of the "biologicals" that have been FDA-approved for use in pediatric eczema.

Testing for food allergy and dust-mite allergy can be additionally helpful in guiding dietary choices and environmental-allergen control measures.

I hope this is helpful information.

I came here to ask a MCAS question, so thank you for your response on the other question about it.

So, I guess I do have a somewhat related question. We have coined the term "histamine bucket" as a way to explain the threshold between symptoms changing from managable and unmanagable. We have switched to a mainly low histamine diet, referencing the 23 page pdf by the Swede science team AND around the clock antihistamines. Much of our time has been identitying the leeway for foods that aren't bread or rice; Plainly, the response to a spoonful of vinegar may be equal to a pound of strawberries. But we can't only eat strawberries!

On to the question: Does the average person (without a disorder like MCAS) also have a "max capacity" for histamine, and would an overflow more or less be a targeted response (like a more susceptible body system, i.e. hives or rhinitis) versus a more generalized diffuse systemic response?

Thank you!

Hello, and thank you for your question. A sufficiently high dosage of histamine will trigger a response resembling allergic symptoms in any human being, although the dosage that elicits such a response will vary among individuals. The extent to which histamine intake from dietary sources can trigger or aggravate allergic symptoms in one or more organ systems is controversial in the medical literature, although what has been termed a "low-histamine diet" makes sense, provided whether the diet embodies all of the proper food groups that one needs for nutritional health.

Hey Doc,

I am in the midst of a long and frustrating battle to understand what's going on inside my body. I've been diagnosed with eosinophilic esophagitis (and my biopsy shows evidence of reflux), and i've had all sorted of rhino-sinus issues over the years and CT Scans show significant mucosal thickening. My biggest complaint is that my whole face (tracing my sinus passages) feels sore, puffy, and inflamed - including & especially around my eyes. The best I've felt in the last 10 years was after a 10d course of prednisone. All allergy tests have been negative and anti-histamines have never seemed to help, although i do keep optimistically reveerting back. Beyond this, my jaw (TMJ) often hurts, my lymphnodes feel quite tender, and my face is puffy.

It seems increasingly likely this is an inflammation issue and likely all related. Working with an Immunologist and trying to start Dupixent but it's proving to be a challenge in my country (Australia).

Beyond Dupixent, I'm really struggling to figure out what to do and how to manage symptoms.

Do you have any suggestions on what to pursue next? i am geting desperate :(

PS: congrats on the launch of Allermi! I am using Ryaltris right now and not very sure if it's helping.

Dupixent treatment should be considered, since it should not only benefit the eosinophilic esophagitis, but should also benefit your upper-respiratory tract.

TMJ syndromes should be separately addressed by a dental clinic skilled in this condition or by a TMJ clinic in a university medical center, or by both.

Of note, however, is the published finding that nasal congestion, particularly nocturnal congestion during sleep, can activate the TMJ-related musculature to contract, further aggravating the TMJ condition. Thus, improving your upper-airway function can improve your TMJ condition. In addition, a perfectly-fitting bite guard can be key to ameliorating TMJ-related symptoms.

I just wanted to thank you. Your product was one of the first nasal sprays I found relief with. I also learned the bunny sniff method which I had never been taught before.

My question is why did I never find relief before from what doctors prescribe (Like Flonase or Nasonex)? An allergy test revealed I was allergic to almost everything, are those tests accurate?

Hello, I am very pleased to hear you are doing well with Allermi! There are many possible reasons that Allermi works in superior fashion to Flonase or Nasonex alone. To name just two, Allermi contains a micro-dosage of decongestant, that, with regular use, progressively improves the access of the anti-inflammatory and antihistamine components of your formula to the higher and deeper reaches of the nasal passages. Secondly, Flonase, which remains very popular in the American market, contains a preservative and solvent alcohol, that I have found to be irritating to the nasal passages in several ways.

To your question about allergy testing, a great deal rides on which entities were tested, how they were tested, and how the skin test responses were interpreted. Allergy testing tends to have a non-trivial false positive rate and generally a lesser false-negative rate. The interpretation of the testing and what is done with the data is both art and science. There are many patients who indeed have bonafide allergy to every allergen that is tested on a testing panel, and there are others for whom the results might be over-interpreted or might be false positives.

why do my allergies flare up in the summer? isn't allergy season mainly in the spring?

Hello, thank you for your question. While spring is often associated with allergies due the abundance of tree pollen, allergies can occur at any time of the year, depending on the specific allergens one is sensitive to. If one is allergic to to grasses, which primarily bloom and pollinate in the summer, allergic symptoms in the summer can be quite severe. One who is allergic to mold spores might experience symptoms during the summer if he or she lives in a more humid area. You may benefit from allergy testing to identify your allergic triggers. I hope this information is helpful.

What are your thoughts on the theory that rosacea is caused by skin mite allergy?

Any tips for alleviating rosacea symptoms ?

Dermatologists are skilled at rosacea treatment, which has been evolving in a good direction over the past several years. The relationship of the presence of skin-mites such as Demodex species to the development or aggravation of rosacea is an area of active research. The latest theories and research on this subject are featured in a helpful article published online by the National Rosacea Society, which you can review on www.rosacea.org.

Is there any link between dysautonomia and being allergic to a lot of things, that you know of? For example, I'm allergic to eight medications, with three of them having caused anaphylaxis. And with a different three of them, I took them from a week- a month before l the allergic reactions happened. I'm also allergic to titanium- I found that out after having jaw surgery and my body rejected all the titanium plates 😅 (never had any piercings or anything so I didn't know). I've been diagnosed with dysautonomia (IST and vasovagal syncope that has many triggers) since I was a young girl, my grandmother had it too.

Hello, I am sorry to hear you have experienced these symptoms. Allergy does not have a direct relationship to autonomic dysfunction, to my knowledge. Allergy to metals such as titanium occurs by a different immune response than does most allergy to medications, foods or environmental allergens.

Has any progress been made on the use of parasitic worms to reduce allergy responses? I remember this being researched years ago

Fascinating question! The hypothesis was based on the observation that in countries where parasite infestations are commonplace within the population, the prevalence of classical allergy is low. This suggests that the arm of the immune system that is responsible for manifestations of allergy is either diverted to controlling the parasite infestation or that parasite infestation suppresses allergic immune/inflammatory responses. Research has been ongoing in this area for at least the past dozen years. Some of the more recent thinking on this subject postulates that a non-pathogenic nematode that can be harbored in the human intestinal tract might be able to function to suppress the classic allergic immune response, and with this, classic hay-fever symptoms. This is by no means standard of care and the potential downsides and hazards of this kind of therapeutic approach have not been fully elucidated as of yet. Please visit the following link for more information: hjf.org/technology-using-worms-treat-allergies

Is there a treatment for allergic reaction to nonselective NSAIDs? I know there are treatments for environmental allergies like pollen, and food allergies, but being allergic to many over the counter medications sucks.

Why does it seem like everybody I know that moves to the Bay area develops allergies?

Other than aspirin desensitization, which is one of the available treatments for aspirin-exacerbated respiratory disease (also known as Samter Syndrome or Samter Triad), the only treatment for hypersensitivity to the non-selective NSAIDs is avoidance. However, the vast majority of people with hypersensitivity to the non-selective NSAIDs as a group can be tolerant to a selective NSAID such as celecoxib. In order to determine if such tolerance to a selective NSAID exists, we favor formal, supervised, graded-dosage challenge in an Allergy department.

I hope this is helpful.

Any chance that the Allermi trial can be extended to Canadians?

Unfortunately, not at this time, although perhaps one day in the future.

Can you offer any insight to relief for oral-allergy syndrome? I suffer from ragweed and can’t eat Mellon, banana, cucumber, zucchini, etc. without cooking them first.

Oral-allergy syndrome or pollen-food hypersensitivity syndrome often occurs when one has become allergically sensitized to certain pollens of trees and/or weeds, whereby there is cross-sensitization to highly similar or identical peptides or proteins present in fresh fruits. These fruit allergens are generally quite sensitize to heat and thus, people who have the symptoms you described with the fresh forms of the fruit generally do not have those symptoms when the food has been heated. The ideal way to confirm fruit allergy is with skin testing, using the actual fresh fruits as sources of skin test material. Commercial extracts of fruits that are used in standard allergy testing often lack the protein allergens that are in higher concentration in the fresh fruits. Your allergist should request that your provide fresh, whole forms of the fruits in question for use in what is termed direct skin-testing, where a skin-test instrument will be used to collect a small amount (a few nanoliters) of the fresh fruit and apply it directly to your skin. In addition to the testing of fruits, it is often helpful to test a variety of airborne allergens to determine if there is pollen-food cross-reactivity. A classic example is apple hypersensitivity in the setting of birch-pollen hypersensitivity. There are many additional examples. In many instances, receiving allergy immunotherapy injections for the airborne pollens has the effect of diminishing or eliminating the allergic reactivity to the corresponding fruit allergens. Very mild oral-allergy symptoms, such as tingling or itching, limited to the mucous membranes of the mouth but not extending to create swelling of the tongue or sensation of restriction of breathing, swallowing or speaking at the level of the throat, can often be prevented by the taking of a non-sedating oral antihistamine, 1.5-2 hours before eating the fruit. For this purpose, I recommend to my patients to take Allegra/fexofenadine (180-mg tablet) 1-2 tablets, 1.5-2 hours before eating. We also provide our patients who have this syndrome an epinephrine auto-injector, such as the EpiPen, in the unlikely but not impossible event of an upsurge in the level of allergic reactivity of the oral airway in response to food. For this, I would recommend that you consult with your allergist as soon as feasible.

Thanks for the AMA! Do you have any information about the cause or treatments for delayed pressure urticaria? I've talked to several doctors and tried a variety of standard allergy meds. But it's been 10+ years and no one seems to have any answers. It's affecting my life and limiting my activities, but I don't know what else to try at this point.

If delayed pressure urticaria cannot be brought under complete control with a combination, high-dosage, antihistamine regimen, or if such a regimen produces side effects, then please ask your allergist to apply to your insurance for treatment with the biologic, Xolair/omalizumab, given as a once-monthly subcutaneous injection, which can even be self-administered at home.

Xolair has been specially FDA-approved for this purpose since 2014, and has been prescribed by us very frequently for urticaria, as well as for asthma and for chronic sinusitis with nasal polyps.

Hello doctor. My mom suffers from chronic sinusitis with nasal polyps. She has trouble sleeping, breathing, tasting, and smelling. She's had it for... 5 years? At least two surgeries have provided only temporary relief, but the polyps grow right back. She's tried just about every medication and seen some great doctors but nothing has worked. Sprays, pills, rinses, woo, none of that works very well at all. She's quite miserable from it all.

Could you recommend anything? Any new drugs worth trying?

I am so sorry to hear of your mother's longstanding nasal and sinus symptoms.

If surgery has not yielded sustained and satisfactory results, and if nasal polyps continue to be the primary issue, then an application to insurance for "biologic" treatment should be considered.

The biologics that are FDA-approved for chronic sinusitis with nasal polyposis are Dupixent, Nucala, and Xolair. In the meantime, a well-formulated nasal-spray program containing optimal dosages of decongestant and anti-inflammatory medications should provide some measure of relief while insurance processes your physician's application.

There are other approaches to the condition that you describe, but in our view, a good nasal-spray regimen plus treatment with an approved biologic should yield the best results.

Hi thanks for doing this. What's your take on eating local honey?

Hello, thank you for your question. Honey is a wonder-product, but given that whatever local pollen might be contained in honey, the pollens are from plants that are not very allergenic, if at all, to human beings. Plants that require insect pollination tend to be colorful and fragrant, and carry heavier pollens that do not stay buoyant in the air and travel in the wind, to pollinate other vegetation. In contrast, pollens from trees, grasses and weeds, that require wind and not insects for pollination, are much smaller particles that can enter and stick to the human nasal tract, lower airway, eyes and skin, and present themselves as allergenic. These pollens will not be present in honey, since bees are not required for pollination. All that is say, local honey is not anticipated to provide any form of allergen immunotherapy, and would not be an advantage over any other honey produced elsewhere.

What's with all the A's in that acronym?

Great question. That acronym stands for "Fellow of the American Academy of Allergy, Asthma and Immunology."

Thank you the AmA, very informative.

My question is regarding wasp stings. I have an unjustified phobia of wasps, It all started a few years ago for absolutely no reason whatsoever. But I'm very anxious around them and sometimes it stops me from enjoying my time outside.

How likely would someone develop a nasty allergic reaction to their stings, am I overreacting?

Thanks

Anaphylactic reactions can occur to stinging-insect envenomations, and so your concern is completely rational and understandable. Thankfully, such reactivity is rare, and fatal reactions are extremely rare.

The following is recommended for you:

1) Arranging definitive allergy testing to the venom proteins---this is very commonly and routinely performed by Allergy clinics. Occasionally, both a blood-test panel and a skin-test panel are done. Sometimes, a serum tryptase level is drawn to screen for rare mast-cell disorders, wherein mast cells are triggered to release histamine at the time of an insect sting.

If venom-protein allergy is determined, allergy immunotherapy is available, and greatly reduced the chance of a severe sting reaction.

2) Carrying an epinephrine autoinjector kit, such as the Auvi-Q or EpiPen when outdoors.

3) Pre-dosing with a non-sedating oral antihistamine before going outdoors. We commonly recommend fexofenadine (Allegra or generic, 180-mg tablet, 1 tablet once to twice daily).

4) Carrying Benadryl/diphenhydramine with you as a "first-aid" antihistamine. This can be safely taken in addition to Allegra/fexofenadine.

5) Taking anti-sting precautions when outdoors, including not wearing fragranced products; wearing khaki or green colors as opposed to other bright colors, pastels, etc. (basically, "not to look like or smell like a flower"); taking oral-hygiene measures after eating (since stinging insects are attracted to food aromas); wearing closed shoes; and steering clear of thick, grassy ground cover, trash cans in picnic areas, abandoned structures, etc., where wasps, hornets and yellow jackets prefer to congregate.

Can you make it illegal for EMRs to list allergies to steroids and benedryl? Thanks

Ha! It is true that the "allergies" section of the EMR invites the listing of multiple entities that do not cause bonafide allergic reactions, but cause any of a variety of non-allergic adverse reactions, whether real or perceived.

A rare person will develop allergic reactivity to diphenhydramine (I've seen two cases in the past few decades of acute urticaria after an oral dose of diphenhydramine) and allergy to the steroid salts (e.g., triamcinolone acetonide) can cause immediate hypersensitivity reactions. There is also a contact dermatitis to topical steroids, outside of the accompanying active ingredients such as propylene glycol, that is not uncommon.

Therefore, there is some merit in retaining the ability to list steroids and Benadryl under the rubric of allergies even though the use of the term "allergies" in this sense is, unfortunately, overly inclusive.

Few questions —

1. Could you list the different types of medications you have available to use at Allermi to create the unique nasal spray?
2. Debilitating allergic rhinitis unresponsive to treatment (all traditional medical therapy, 2 years + of immunotherapy [started on RUSH]), what would your next steps be?

At Allermi, we prescribe custom combinations and doses of up to 4 of the following active ingredients, compounded into one nasal spray formula:

-Oxymetazoline (decongestant) for congestion and stuffy nose (Note: we only use micro-doses of this ingredient to prevent rebound congestion) -Azelastine (antihistamine) for sneeze, itch, runny nose and allergic inflammation -Ipratropium (antisecretory) for excess mucus, runny nose and post-nasal drip -Triamcinolone (anti-inflammatory) for inflammation

I am so sorry to hear of those persistent symptoms. Even having tried all nasal sprays previously, Allermi is a new approach and might be worth trying for you.

A highly detailed and complete review of all aspects of your allergy diagnosis and treatment should be done by your allergist --- we see quite a number of allergy sufferers with history similar to yours for whom surprisingly small changes in medication, dosage, frequency and/or technique make all the difference.

At other times, substantial shifts in medication are needed, and many an immunotherapy program needs significant revision in terms of content and dosage.

In sum, my sense is that you should be able to have your entire allergy-symptom situation improved considerably, safely, in relatively short order, and on a sustained basis if the right approach is taken with the right allergist.

Do covid shots (I had Pfizer) cause rashes in the long run? I don't mean immediate rash after injection, but perhaps it might change the immune system? Because I have itchy rashes on my body since a year ago, but I've never had any known allergies or skin issues in my life. And anecdotally a nurse who saw my rashes told me that she has those too and has been seeing it on many people since the pandemic.

I'm not even sure if it is eczema because mine are less severe than the google images I saw. Mine have no pus, no oozing of any kind. They are a bit red, dry and itchy on the base of my neck (left, right and back), on my elbowpits and armpits. The back of neck patch looks dry with dead skin flakes sometimes when it is very itchy. Any idea what I'm having? I've been googling and none fits the bill.

We have observed instances of reactivation of past dermatitis (most commonly, eczema), or dermatitis arising de novo, after COVID vaccination.

At present, the association is correlational and has not yet been shown to be causative, since a precise mechanism - presumably an immuno-inflammatory one - has not yet been elucidated.

COVID vaccination, as with many cases of COVID disease, elicits a marked inflammatory response that appears to have the potential in some people to activate allergic-type processes.

I would surmise that much can be done to alleviate the dermatitis - which sounds most like eczema - that you now have.

An evaluation by your dermatologist would be the recommended next step --- a relatively short period of good topical treatment might be sufficient to resolve the dermatitis, or at least to keep it at bay with only periodic topical medications.

I hope this is helpful.

Hello, Thanks for the AMA - If you're still here for it, I was wondering why there doesn't seem to be much knowledge among primary care doctors/GPs with regards to allergens affecting the bladder with mast cell degranulation and histamine releases causing things like interstitial cystitis and general nerve irritation in the urinary tract - Is there any over the counter medication you or others provide for this? It only seems to be hydroxyzine that is recommended and this has to be prescribed unlike other anti-histamines

These symptoms remain medically enigmatic, which might explain the fact that many different medications and treatment approaches have been forwarded for these urinary-tract conditions. Among the medications used are:

-Nonsteroidal anti-inflammatory drugs;

-Tricyclic antidepressants, such as amitriptyline or imipramine (which, interestingly, have some antihistamine properties);

-Antihistamines;

-Pentosan polysulfate sodium (Elmiron), which must be prescribed by a physician with experience with this medication.

Im allergic to cats and dogs but I want a cat. Ive had cats in the past, and... yes, Im allergic.

Having spent the last 3 years without a cat has been great for me - no itching, sneezing, etc. But, I REALLY want a cat.

What do you recommend?

One of the key aims of our Allergy practice is to help people obtain - and healthfully keep - their desired pets.

In our view, by far the most effective prevention and treatment for animal-dander allergy is traditional subcutaneous immunotherapy---allergy injections.

The formulation for allergy injection treatment can be well-enriched for cat-dander allergen.

Moreover, if you have environmental allergies aside from cat-dander allergy, it is important, in our view, that these be included in your immunotherapy formulation, since doing so will serve to lessen your overall allergic reactivity.

Since an allergy immunotherapy injection program entails a long-term commitment, and since the dosage-escalation phase does not yet bring the full measure of relief that is anticipated with the passage of time on the monthly-maintenance injection program, an allergy medication program that includes carefully selected and properly dosed anti-inflammatory and antihistamine components can be quite helpful. If you are based in the US, you may want to consider Allermi.

Additional benefit comes from continually running one or more HEPA-type air purifiers in your home, and from carefully wiping down the fur of your cat (in the direction that the fur grows) with a damp, disposable paper towel at least once daily.

I hope this is helpful.

I have been battling with allergy rhinitis and my work did renovation and moving, and it causes me to have nausea , dizziness. I also have tightness of throat 6 hours later which led my dr suggest epipen. However I checked that serious inhalant allergies are rare and not sure what to think of it? My parent did have rare allergies that cause anaphylaxis and I am not sure whether I am overreacting (for different allergen)

Second question is I have been offered SLIT, however the mites only covered two of the mites I am mildly/ moderate allergy and not the mites I have trouble with(Blomia) . Two of my doctors have conflicting conclusion, one ask me to use it so I only need to manage blomia , the other ask not to since it doesn’t address blomia mites

Inhalant allergies certainly can be severe, and are rare causes of anaphylaxis.

In general, maximal attention should be given first to allergen avoidance/environmental control.

Second, a carefully selected, properly dosed allergy medication program is key, and should feature one or more safe anti-inflammatory components as well as one or more antihistamine components.

Third is immunotherapy---we continue to favor traditional subcutaneous injection immunotherapy (SCIT, also known as allergy shots) over sublingual immunotherapy (SLIT) for a number of medical reasons, yet we do prescribe SLIT in limited instances.

I hope this is helpful.

How safe would it be for me to try sushi? As a kid i only had fish once (Tilapia) and i ended up covered with hives and was always told I was allergic. I’ve been told by people around me that it’s something common with kids and goes away. I want to know if there’s any precautions i can take while trying sushi and other seafoods.

Side note, while in highschool (15/16 y/o) I would also get really bad hives with 0 explanation and they just suddenly went away despite me keeping the same diet and habits, would could that have been?

Caution is key. Food allergies often do resolve with time, but this should never be assumed in the absence of Allergy consultation and definitive allergy testing.

As a general statement, allergy to fish, shellfish, peanut and tree-nuts, more so than allergy to other foods, tends to last longer, and in some people, is present permanently---this is why properly performed, "preemptive" food-allergy testing and Allergy consultation are important.

Of note, the major allergen protein of fish is shared among all members of the finned-fish category.

Crustaceans share their own distinct major-allergen protein, and mollusks likewise.

Thus, being allergic to one type of fish could mean being allergic to all fish.

At times, one is allergic to a genus- or species-specific protein and not to the shared, major protein allergen.

Proper allergy testing should help you discern among these possibilities, and then you can much more safely move forward.

I've got known allergies to dust mites, mold, and oak pollen-- probably more but those are the ones that were tested. Have them fairly under control with daily dose of Zyrtec, nasocort, and allergy eye drops.

My question is, is it possible to be allergic to fabric softener, dryer sheets and fragranced detergents? As I have eczema and psoriasis, I do not ever use these myself, but I'm in a condo and my neighbors sometimes do. The ducts in our building are all connected. When they do their laundry, I not only feel ill from the smell, I break out all over in hives.

The irritative and allergenic properties of fragraces are well established and generally testable by patch-testing in Dermatology clinics. Patch-testing, however, might not answer the reactions that occur on inhalation of those fragrance molecules. Of note, many products that claim to be "fragrance-free" actually contain "competing" fragrance chemicals that mutually cancel the perceived fragrance, but which nevertheless are present in the product and thus are available to cause reactivity. Fabric-softener liquids and dryer sheets are common culprits.

What are your thoughts on the existence of iodine allergies ? My mom developed a sudden seafood allergy after going in for an MRI and having a reaction to the iodine-based contrast they used; iodized salt also causes a similar reaction, as well.

But, since the human body requires iodine for certain functions, wouldn't she have a constant reaction if the iodine is what she was allergic to ? I've done some reading about it online, but haven't found any studies/articles/what-have-you that have a definitive answer in one direction or the other. If it has any bearing on anything, my mom has also had a latex/banana allergy for most if not all of her life.

Contrast agents used in CT scans contain iodine, whereas MRI contrast agents do not contain iodine and rarely cause allergic reactions.

Yet, such reactions can and do occur and, thankfully, diagnostic imaging facilities have judicious contrast-selection approaches and excellent pre-medication protocols to greatly reduce the likelihood of contrast reactions and the intensity thereof.

You are quite correct that allergy to iodine per se does not exist, and that iodine is an innate component of thyroid hormone.

Allergic-type reactions to iodinated contrast used to be thought to be due to reactivity to the iodine itself, but this is now known to be untrue. Under the old, false assumption of iodine allergy, a further incorrect assumption used to be made that, if one were shellfish-allergic, such allergy would portend a greater risk of iodinated-contrast allergy. The triple irony here is that (1) shellfish allergy is caused by allergic reactivity to shellfish protein allergens, and not to shellfish iodine; (2) allergy to iodine is impossible; and (3) many foods (egg, dairy, legumes) contain high levels of iodine, and yet reactivity to those foods was not questioned.

Hey Doc!

But late to the party, but I wondered if there is anything interesting happening in the field of Chronic Urticaria?

I've had an extended bout for around 2 years of quite severe Chronic Urticaria as a teenager, often needing to resort to long term steroids, then went without symptoms for 15 years.

I've recently started having severe symptoms again and at it's worst, maximum dosages of either Fexofenidine or Ceterizine don't cover it.

I really hope I don't have to resort to long term steroids again, so I wanted to check in and see if there are any interesting studies happening at the moment. Will an apple a day keep the doctor away?

Thank you for answering questions!

Chronic (defined as 6 weeks or longer) urticaria is very common.

Most people with chronic urticaria have the "idiopathic" (medicine's term for "cause unknown"), or "spontaneous", type.

When a combination, high-dosage, non-sedating, oral-antihistamine treatment program is insufficient, or if it incurs the patient side effects, trying Xolair (omalizumab) treatment is very often highly successful and is generally very safe.

Xolair is a bioengineered monoclonal antibody that is taken by simple subcutaneous injection once-monthly. Many people self-administer the injection at home.

The vast majority of our patients receiving Xolair for chronic urticaria have no side effects and have achieved complete control of urticaria without the need for further oral antihistamine.

Xolair was originally FDA-approved for allergic asthma in 2003 and continues in this role.

Xolair received further FDA approval in 2014 for chronic urticaria.

(For the record, Xolair was granted further FDA approval in 2020 for treatment of chronic sinusitis with nasal polyps.)

Please consider asking your allergist about Xolair. I hope this is helpful.

Hello!

I have gotten eczema later on (it started around 13 years old) and it has been spreading as I've gotten older. I'm now 34 and it's moved from under my nose to the corners of my eyes, my scalp, and the side of my hand (itchy bumps filled with a chest liquid). In winter I get bumps on the back of my hands and they were there during the pandemic when I had to sanitizer my hands often for work.

My allergies also seem to be growing and I'm reacting to new things couple of years. Metals, scented products like perfume and even shampoo (menstrual pads!), some raw fruits and vegetables that have been rinsed (they must be peeled or cooked), etc. Metal started around 13 also but many of my other allergies appeared well into adulthood and my metal allergies have heightened. Other allergies, like a cat allergy, seem to have significantly lessened.

Is there any way I can curb this growth? I'm afraid that it will eventually start to limit my life. Thank you!

A great deal can be done to diagnose, treat and help prevent the dermatologic symptoms that you describe.

At least two different allergy-testing modalities might be needed: inhalant - and possibly also food - allergy testing (more likely by blood-testing, since skin-testing in the setting of active dermatitis is generally not recommended), as well as patch-testing for possible contact dermatitis, which is the probable cause of the metal sensitivity that you describe. Patch-testing is best done by a dermatologist, although many Allergy clinics offer this. In addition, in some instances, a tiny skin biopsy is done to further characterize the dermatitis at the cellular level.

On the basis of the results of the above tests, specific allergen-avoidance measures are prescribed---some allergens are easier to avoid than others, to be sure.

For most allergic-eczematous conditions, excellent treatment is available that includes properly selected topical medications and, if needed, injectable (even self-injectable at home) "biologic" treatments that have essentially revolutionized the treatment of allergic eczema.

Topical medications work best with proper application technique, whereby the medication (ointment forms are generally least irritating and also constitute the best barriers against evaporative water loss from the skin) is applied right after hydration of the skin (e.g., from soaking in the bath or shower) and rubbed in very well into small areas at a time. This is often underemphasized in skin-treatment programs.

A number of nonpharmacologic skin-care measures are also important to implement, including maintaining proper skin hydration at all times; avoidance of exposure to harsh chemicals, such as standard soaps and cleansers, and the alcohols in many lotions; avoidance of exposure to skin allergens, usually identified by appropriate testing; avoidance of thermal injury of the skin by avoidance of hot water; and avoidance of mechanical injury of the skin by, for example, rough fabrics, and by scratching (which can only reasonably be avoided when itching is controlled by the other measures above).

A team approach, consisting of you, your allergist, and your dermatologist, should be very helpful to you.

Hi! I had pretty bad asthma as a kid and now as an adult, I have a hard time staying healthy. When I was in school I would get sick about 6 weeks into each semester, then again in the summer, almost always resulting in bronchial irritation and persistant cough. As a professional, and now that society is returning to normal post peak pandemic, I am using nearly all my sick leave with bronchitis-like symptoms three or four times a year. X-rays never show pneumonia or bronchitis despite wheezing and the persistant and deep painful cough. I rarely am prescribed antibiotics. I don’t smoke, though doctors ask me several times because they have a hard time believing that I get so sick so frequently without smoking. Do you have suggestions on what I can do to improve my lung health and support my immune system, seek a consult with an immunologist, or seek daily medication (I only use symbicort and ventolin when sick)? Am I missing a key piece to give my lungs the best chance at staying strong despite normal germs or should I be self-advocating for investigation into potential autoimmune issues?

I believe that a good deal can be done to both diagnose, treat and help prevent the symptoms that you describe.

It is recommended that this be done in consultation with an allergist-immunologist.

After a thorough medical history and examination, diagnostic testing of several types might need to be considered, including environmental-allergy testing (by skin-testing, blood-testing, or both); testing of basic immune defenses (general and specific levels of defense antibodies; the level of immune responsiveness to vaccinations, most importantly the Pneumovax vaccine; assessment of cellular immunity with at least one of several available lymphocyte analyses); pulmonary-function testing; and perhaps other tests specific to your detailed medical history, including possible environmental-exposure risks, etc.

At times, certain immunodeficiencies are discovered to underlie recurrent or difficult respiratory infections, and the treatment of these is best sought from immunology or allergy-immunology consultation.

In many instances of lower-respiratory-tract conditions, it is crucial to give simultaneous attention to the health of the upper-respiratory tract (nasal passages and sinuses) --- this is all-too-often overlooked in situations in which the dominant symptoms are those of the chest.

A judiciously selected and properly dosed (including careful attention to such factors as optimal inhaler and nasal-spray administration technique) medication regimen can be key, and it is most likely that the greatest benefit will be derived from a year-around, maintenance-medication program, on top of which additional medication can be taken at the very first sign or symptom of any new respiratory infection.

Depending on the specifics of your medical history, diagnostic testing, and response to medications, treatment with one of the newer "biologics" might be suggested---these have virtually revolutionized the care of respiratory conditions such as asthma, which is essentially a form of chronic bronchitis.

An allergy immunotherapy program might also be offered, depending on your specific allergy history and the results of allergy testing.

I hope this is helpful.

How much does the treatment you recommend cost per year? Is it covered by insurance Medicare and Medicaid?

Thank you for your question. The first month of Allermi is free (just cover the cost of shipping at $4.90) and subsequent months are $35.00 + shipping. Allermi is not covered by insurance.

Is there any reason why you decided to use triamcinolone as the corticosteroid in allermi instead of fluticasone or mometasone? Triamcinolone seems to have a lower binding affinity and higher systemic absorption. I prefer the idea of using fluticasone or mometasone which should have decreased risk of long term side effects due to having lower bioavailability.

Thank you for this question.

While you are correct that there are sizable differences in measured transnasal absorption bioavailability among the topical nasal corticosteroid sprays, even at the higher end of bioavailability, the clinical significance is thankfully minimal. Thus, factors including bulk availability, solubility, pH optimum, tonicity, stability, medication compatibility and of course, cost, have needed to be taken into account when creating customized, multi-ingredient, compounded nasal sprays.

[As a side point that you might find of interest, the pro-drug, ciclesonide, has by far the least transnasal bioavailability (of its active metabolite, desisobutyryl-ciclesonide), but we have observed that not everyone harbors sufficient levels of the requisite esterase for local conversion to the active steroid, and thus the nasal spray can seem essentially ineffective.]

Hello. I hope you'll still see this this.

My wife has been tested for allergies several times and the tests have been negative for everything, every time.

But: Every year, when pollen-season starts, her eyes starts to itch and tearing up, her throat starts hurting, her nose fills up and she sneezes constantly.

It helps for her to take off-the-shelf allergy medicine, but on the worst days, even that is not enough.

How can it be, that all the tests are negative when all the symptoms are there, every year?

What you describe is actually a not-uncommon observation in the practice of clinical allergy---it can be quite confounding, particularly if one hopes to identify and avoid a particular allergen, or if one wishes to have specific-allergen immunotherapy injections.

Possible reasons for negative skin-testing or blood-testing for environmental allergens are (1) there are allergens, both known and as-yet unknown, to which one might be allergic, bur that are not included in the test panels; (2) the tests might not have been done with a suitable level of sensitivity; (3) medications in one's system at the time of allergy skin-testing might interfere with the production of a significantly positive test; and (4) the skin and/or blood might not contain the immunologic "information" that is harbored in the lining of the nose and/or eyes to produce, respectively, a positive skin- or blood test. On the last point, direct nasal or conjunctival allergy "provocation" tests can be done to confirm the concept of isolated allergic systems localized to the nose and/or eyes, in which case standard allergy skin-testing or blood-testing can effectively miss one's allergies.

Thankfully, a properly selected and dosed allergy medication program can be highly effective even in the absence of having identified the particular allergen(s) responsible for the allergic symptoms. If you and she are in the US, she may benefit from trying Allermi.

I hope this is helpful.

I live in MA and suffer from horrible seasonal allergies. The only thing that ever worked for me was Seldane, which is no longer available. Should I try allergy shots? I am so tired of suffering 9 months of every year. Spring time is the absolute worst, from March to July. I get literally sick and NOTHING HELPS.

Thankfully, much can be done to alleviate your allergy symptoms.

To address the antihistamine modality first, Seldane (terfenadine) is metabolized by the body to its active compound, Allegra (fexofenadine), which has been available in place of Seldane since 1996. Fexofenadine does not carry the cardiac risk that, in rare cases, was attributed to terfenadine.

Proper selection and dosing of antihistamine can go a long way toward preventing and ameliorating allergic symptoms.

And yet, antihistamines are limited in terms of the anti-allergy effects they can provide.

Allergic symptoms are rooted in allergic inflammation, which in hay fever (allergic rhinoconjunctivitis) pervades the mucous-membrane linings of the nasal passages and eyes. Antihistamines have minimal to no anti-inflammatory activity.

Therefore, topical medications that lessen and control, or eliminate, allergic inflammation constitute by far the most effective pharmacotherapeutic means of dealing with allergy. You may benefit from trying Allermi. We are available in MA.

Antihistamines are thus usually occupying a secondary - though still useful - role in effective allergy treatment, with topical anti-inflammatory treatment, often including safe, topical decongestant treatment, occupying a primary role.

Allergy-immunotherapy injections have been a highly effective allergy treatment for over a century in the U.S., but the effectiveness of this treatment modality needs to be weighed against the many injection visits required over a lengthy period of time. The specifics of an allergy-immunotherapy program and the injection schedule that it entails can be discussed with the prescribing allergist.

I hope this is helpful.

Nut allergies. Are there any ways to get rid of them?

Peanut and tree-nut allergy is very common, especially among children of the current generation, but also across the entire age spectrum. We take an admittedly conservative approach - namely, to recommend complete avoidance of the culprit nut(s), along with annual or biannual allergy testing (by skin- or blood-testing) in order to gauge the level of allergic sensitization over time, looking for opportunities to be able to confirm tolerance to the nut(s) in question (usually by formal, supervised, graded-dosage oral-ingestion challenge). Oral immunotherapy (OIT) for peanut and tree-nut allergy is practiced by many allergists, and an FDA-approved, calibrated peanut-powder treatment exists for this purpose, but our view is that OIT, while successful in certain instances, is sufficiently fraught with risk and uncertainty on several fronts as to give us considerable pause before recommending it.

I hope this is helpful.

Has your work ever sparked any thoughts on migraines and whether they could be allergic responses?

Migraine-type pain can be triggered or aggravated by allergic-inflammatory processes in the upper-airway. Rhinologic/rhinopathic headache has features of migraine pain, since similar neurovascular/neurosensory pathways are activated to produce the pain characteristic of migraine in nasal-inflammatory conditions. A specific example, that of rhinogenic contact-point headache, which is triggered by structurally anomalous contact points within the nasal passages, can resemble a migraine-headache experience. True migraine and pain of nasal-allergic-inflammatory origin may be challenging to distinguish, unless the migraine headache has classic prodromal features, such as an aura. In our experience, particularly when migraine is accompanied by nasal congestion, improving nasal function by addressing both congestion and inflammation improves migraine symptoms. If you are US-based, Allermi may be a good option for you.

I hope this is helpful.

I’m pretty certain I have alpha gal syndrome. They don’t test for it on the west coast (I’m originally from east) because the lone star tick isn’t really out here. Do you know anything about testing or anything related to the allergy that isn’t common knowledge?

Quest Diagnostics, an example of a highly reputable clinical commercial laboratory, has an alpha-gal blood-test panel that includes Beef IgE, Lamb IgE, Pork IgE, and Galactose-Alpha-1,3-Galactose (Alpha-Gal) IgE. Your physician should readily be able to order this test for you. Whichever blood-drawing facility collects the sample from you can also mail the sample to Quest.

I hope this is helpful.

Hi,

Is there any plans to ship Allermi internationally? I'm in Australia and have been battling rhinitis/sleep apnea for about 20 years with no relief. Have tried pretty much every treatment available (multiple surgeries, CPAP, multiple medications) with no luck. Thanks!

Hello, thank you for your question. Unfortunately we are limited to the US at this time. I wish we could be of more help to you.

My children suffer from seasonal allergies and food allergies (milk and soy). Their paternal grandmother developed OAS and MCAS in her 40s and I’m terrified they will go down this same road. She did not grow up with allergies. Are these hereditary? Should I be worried and is there anything I can do to prevent?

Thankfully, the vast majority of children outgrow milk and soy allergy, and most such children will not necessarily develop food allergies later in life.

Oral allergy syndrome symptoms exist on a spectrum of severity. The condition is often transient, and in many instances - with allergy testing and discussion with your allergist - the symptoms can be prevented by pre-dosing with oral antihistamine before eating the culprit food (usually a fruit). (Antihistamines alone cannot be depended upon to prevent anaphylaxis, and thus consumption of the culprit foods in the setting of OAS, with or without antihistamine pretreatment, should not be undertaken outside of consultation with an allergist.) There are also instances of OAS that are attenuated or eliminated by allergy immunotherapy (allergy injections) for allergic hypersensitivity to the pollens whose protein-allergen structure is cross-reactive to that of the culprit fruit. Allergy to raw apple and birch-pollen allergy is a classic example.

An MCAS diagnosis would need to be probed very carefully, as many such diagnoses are made on tenuous grounds, and treatments strategies range quite widely. The degree and extent of genetic inheritance is still vague for the broad span of mast-cell-related conditions.

Seasonal allergy, most often to pollens of grasses, trees and/weeds, and often to outdoor, dry molds, does carry genetic predisposition, but modern-day diagnostic and therapeutic modalites are safe, convenient and effective for the majority of those with seasonal allergy. The fundamental approaches include environmental-allergen control measures, pharmacotherapy with judiciously prescribed anti-inflammatory, decongestant and antihistamine medications, and allergy immunotherapy.

I hope this is helpful.