Dust Mite Avoidance

broomOne in four Americans are sensitive to dust mites. If we include other components of house dust (pollens, animal danders, cockroaches and molds), the number is even higher. Dust mites are arachnids, like spiders and ticks. They thrive in warm, humid climates; temperatures above 70 degrees Fahrenheit and humidity over 70%. Mites live off water in the air and ingest particles of human skin and animal dander. This is why the concentrations are so high in your mattress and bedding. However, dust mites are not bed bugs, they do not bite nor carry disease. Mites are only harmful to those people who are allergic. Dust mite allergy can result in several allergic conditions: 1. Allergic rhinitis: runny nose, congestion, sneezing and itching. 2. Asthma: cough, wheezing, shortness of breath. 3. Atopic dermatitis: eczema, itching. People who are allergic to dust mites react to proteins within the bodies and feces of the mites. These particles are found mostly in pillow, mattresses, carpeting and upholstered furniture. They float in the air when anyone vacuums, walks on a carpet or disturbs bedding, but settle out of the air soon after the disturbance is over. Research has confirmed that targeted avoidance (environmental control aimed at relevant triggers) can be as effective as medications in reducing symptoms. Here are some tips: • Focus on reducing dust mite levels in the bedroom. Keep indoor humidity below 50%. This may require a dehumidifier. Do not use vaporizers or humidifiers. Use ventilation fans in bathrooms and kitchen. Use a vacuum with a HEPA filter. If you are allergic, wear a N95 filter mask while dusting, sweeping or vacuuming. Even better, find someone else to clean when you are not at home. ◦ Encase mattresses and pillow with ‘mite-proof’ covers. ◦ Wash all bed linens weekly using hot water ( > 130°). ◦ Remove wall-to-wall carpets. ◦ Remove plants, soft toys, cushions and upholstered furniture. ◦ Treat stuffed animals with fire and ice: Dust mites die at freezing temperatures. Put pillows and children’s stuffed animals in plastic bags and put them in the freezer for 24 hours. Alternatively, put toys in a fabric bag and place them in the dryer for 10 minutes. Remember to take off anything that could melt. • Acaracidal sprays (i.e. tannic acid) can temporarily reduce mite levels in airborne, furniture and carpet dust. Application of liquid nitrogen to the mattress and carpets is slightly more effective and much more dangerous. • Install a high efficiency media filter with a MERV rating of 11 or 12 in the furnace and air-conditioning unit. Change the filter at least every three months (with the change of the seasons). • Portable HEPA filter air-cleaners are less effective at reducing dust mite levels. This intervention may be worthwhile for pet allergy (esp. cats). There are more than 30 trials demonstrating the effectiveness of bed encasings for asthma. Financially, the one time cost is significantly less than a monthly copay. Unfortunately, the clinical benefit of covers alone was small. A complete program, including acaricides and extensive bedroom based environmental control is necessary. Benefits include decreased allergy and asthma symptoms, less medications and more savings.

Discovery Channel presents “An Emerging Epidemic: Food Allergies in America.”

FARE FARE (Food Allergy Research & Eductation) has teamed up with The Discovery Channel to produce a new documentary about food allergies called “An Emerging Epidemic: Food Allergies in America.” The hour-long documentary, narrated by Steve Carell, explores what it is like to live with life-threatening food allergies, how families and individuals managing food allergies are working to raise awareness in their communities, and the vital research underway to find effective treatments and a cure. Watch the full documentary online> The documentary debuted on Saturday, September 7 and will air again on Saturday, September 21 at 8 a.m. ET/PT. The documentary will also be available for viewing online at www.discoverychannelpatienteducation.com and available for download on iTunes.

Egg Allergy & 2013-14 Influenza Vaccination

flukidThe CDC recently published vaccine recommendations for the 2013-4 influenza season (http://www.cdc.gov/flu/about/season/index.htm). Special attention is given to those patients with a history of egg allergy. Influenza vaccine is grown in embryonated chicken eggs and contains residual amounts of ovalbumin, a major egg allergen. For patients with egg allergy, even small amounts of this protein can trigger an allergic reaction. This risk must be considered before vaccination . On the other hand, Influenza infection poses a significant risk itself. There are approximately 300,000 hospitalizations annually, including more than 20,000 in children younger than 5. Children with asthma are most vulnerable. This is concerning given the increased incidence of asthma in children with egg allergy. Due to fear of allergic reaction, flu shots were previously withheld from all children with egg allergy. In order to assess risk, allergists began skin testing children with the influenza vaccination.  In 1977 physicians began immunizing those egg allergic children with a negative influenza skin test. About ten years later another group pushed further. This time, children with a positive skin test were successfully vaccinated using a multi-step protocol. The most recent studies (including those with H1N1 vaccine) have found the real risk of reaction to be exceptionally low. One recent study, vaccinated 143 children with documented severe egg allergy. No children had a significant allergic reaction take place. This data is prompting change. Beginning with the 2011-2012 season, the AAP, CDC/ACIP, and NIAID specifically recommend that patients with egg allergy receive the trivalent inactivated influenza vaccine (TIV) with some precautions. Here is a quick summary of the most recent CDC recommendations: 1. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. – Vaccine should be administered by a healthcare provider who is familiar with the potential manifestations of egg allergy; and – Vaccine recipients should be observed for at least 30 minutes for signs of a reaction after administration of each vaccine dose . 2. Persons who report having had reactions to egg involving such symptoms as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention may receive egg-free vaccines, if aged 18 through 49 years and there are no other contraindications. If egg-free vaccines are not available or the the receipient is not within the indicated age range, such persons should be referred to a physician with expertise in the management of allergic conditions for further risk assessment before recipient of vaccine. – All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available. 3. For individuals who have no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of previously performed allergy testing, consultation with a physician with expertise in the management of allergic conditions should be obtained prior to vaccination. 4. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to future receipt of the vaccine. Beyond the recommendations: – Egg-free vaccines may be used for persons aged 18-49 years who have no other contraindications.  In 2012, the FDA approved Flucelvax, the first influenza vaccine produced without egg. A second vaccine, FluBlok, was approved in 2013. – Skin testing is NO longer routinely necessary for patients with egg allergy. However, skin testing with the vaccine IS still appropriate when evaluating a patient with a history of reaction to the influenza vaccine itself, as opposed to a history of reaction to egg. – Studies have shown ovalbumin (egg) content up to 1.2 ug/ml to be well tolerated. Most available vaccines have significantly less. – Although intranasal vaccine (FluMist) contains one of the lowest absolute amounts of ovalbumin per dose, there are no data on its administration to patients with egg allergy. Thus, injectable vaccine only should be used for patients with egg allergy.  

Eczema: To Bathe Or Not To Bathe

duckEczema is a common skin problem, affecting 10-20% of children. Dry, scaly patches and intense itching result in unhappy children and parents. Complications include bacterial infections, viral infections, bleeding and most importantly, sleep disturbance. Often allergic eczema (atopic dermatitis, AD) is the precursor to several allergic conditions; food allergy, asthma and allergic rhinitis. Before getting wet let’s look at the causes of eczema. Genetic mutations and environmental factors combine to produce a skin-barrier defect. This ‘leaky’ skin barrier allows for excessive water loss. Additionally, local immune dysfunction, allergy and infection produce inflammation of the skin. Inflammation leads  to itching. Itching leads to scratching. Scratching leads to further inflammation. Treatment must restore health to the skin and break the itch-scratch-cycle. There are a staggering number of treatment choices; oils, lotions, creams, soaps and ointments. Some are natural and some contain potent steroids. An effective treatment regimen should include a combination of medicines, specific for the individual patient. Rehydrating the skin is essential for healing the skin and preventing recurrence. Doctors advise frequent moisturizer use and bathing on a regular schedule.  Recommendations range from bathing twice daily to twice weekly. The frequency is likely based on physician training and experience.  There is little consensus and even less evidence which is best. It is commonly accepted that bathing dries out the skin. Water not only washes away dirt but also natural oils. Use of soap and harsh detergents, such as sodium lauryl sufate (SLS), has been shown to remove protective skin lipids and natural moisturizing factors. Bar soaps are often highly alkaline and can result in further drying. They may have chemical additives (i.e. perfumes) that can act as irritants or allergens causing inflammation. Hot and very hot water contribute to inflammation as well. The problems don’t end when the bath is over. Aggressive drying creates friction and skin damage. On the other hand, bathing has important benefits. Soaking in water may help to rehydrate skin cells. Cleaning bacteria from the skin reduces the risk of infection. The intermittent addition of bleach is effective in lowering the amount of bacteria living on the skin. My conclusion, bathing can dry out the skin UNLESS done properly. Here are some tips for effective bathing and hydration: • Keep water at a lukewarm temperature. • The bath should last approximately 15-20 minutes. • Avoid harsh soaps, bubble bath and hand washes. Instead use emollient washing products. • Be gentle. Try not to rub your body too strongly with your towel. • Apply moisturizer to slightly damp skin within three minutes of getting out. • Intermittent use of antiseptic bath oils and dilute bleach can reduce flares. • Other additives may be helpful, for example magnesium salts and natural colloidal oatmeal. • Use LOTS of moisturizer following the bath and throughout the day. Emollients (moisturizers) and steroids should be applied in a 10:1 ratio. Application should be separated by 30 minutes, 1 hour for tacrolimus. Remember not to insert hands or fingers directly into emollients, in order to avoid microbial contamination of the contents.
Food dish

Can Diet Cure Chronic Hives?

Food dishFat, Sick and Nearly Dead is a 2010 documentary which follows the journey of Australian Joe Cross (http://www.fatsickandnearlydead.com). Joe traveled the country during a 60 day juice fast. Nothing but liquid nutrition. His purpose; cure disease, reduce dependence on medications and lose weight. Joe has chronic hives (urticaria). He relies on multiple medications, including oral steroids, to control symptoms. Throughout the trip he undergoes a miraculous transformation. The number of pills and pounds continue to drop. Should everyone expect these results? Probably not. A documentary film is not sound medical evidence. In this film, there is only one subject. There is no comparison group. Most importantly, hives frequently come and go on their own without reason. A German study published in 2010 investigated diet manipulation for the treatment of chronic hives. Patients eliminated all processed foods, artificial substances, food additives, dyes, antibiotics, preservatives, phenols and natural foods rich in aromatic compounds such as tomatoes. What is most interesting, patients avoided the majority of Joe’s diet – NO fruit. The results were mixed; 34% benefited from the diet and 24% deteriorated while on the diet. Responders took on average 3 or more weeks to respond. These doctors believe that artificial preservatives and dyes in modern processed foods (and aromatic compounds in some natural foods) act as pseudoallergens, substances causing allergy symptoms via non-allergic mechanisms. These foods trigger the release of histamine and subsequent hives without an allergic immune response. This suggests another possible link, those foods with high levels of histamine (http://chronichives.com/useful-information/histamine-restricted-diet). An Italian group put patients on an oligo-antigenic and histamine-free diet for 21 days. They excluded foods with artificial coloring (esp. tartrazine), fermented foods, benzoates, Butylated hydroxyanisole (BHA) and butylated hydoxytoluene (BHT). Patients in this study had a significant improvement in symptoms. However, there were only 10 patients. Additionally, patients in a similar study out of Canada showed less substantial improvement. Other foods under investigation for chronic urticaria include; MSG, parabens and aspartame. Alcohol and spices both can cause vasodilation (widening of the blood vessels) and hives in  patients with chronic urticaria. Unfortunately, hives continue to occur after elimination. Overall, there is little scientific evidence to support elimination diets for the treatment of hives. We do not routinely advise patients to adopt a pseudoallergen free diet. However, there are patients who do not respond well to medications, who require multiple medications or are experiencing significant side effects. For this group, there is little risk in trying an elimination diet. Patients should be motivated. Patients should eliminate a large group of foods; although foods can be added one at a time (after hives have resolved), it is unlikely to help if they are removed one at a time. Most important, prolonged diet changes require the supervision of a doctor or nutritionist.