The Doctor's Corner

ALLERGY AND CONDITIONS THAT SIMULATE ALLERGY OR CONTRIBUTE TO THE SYMPTOMS

by Robert W. Boxer, MD


Introduction
This time my "Doctor's Corner" will deal with conventional allergy and a somewhat expanded broader concept of allergy along with some conditions that we have treated in the office for a number of years that are related to allergy either because they mimic allergy or because they contribute to symptomotology of allergy.

[Here we] deal with conventional allergy and a somewhat expanded broader concept of allergy along with some conditions that we have treated in the office for a number of years that are related to allergy . . .

For those who are not familiar with me, I'm a Board Certified Allergist who has been practicing for some 40 years in the Old Orchard Professional Building in Skokie.

I am a Fellow of the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the American Academy of Environmental Medicine. I have been on the NOHA Professional Advisory Board for some 30 years and have contributed a number of prior Doctor's Corners. I am on the active medical staff at Rush North Shore Medical Center and am on the emeritus staff at Lutheran General Hospital after 40 years on the active staff.

Much of conventional allergy deals with asthma, hay fever, conjunctivitis, sinusitis, eczema, urticaria (hives), and angiodema, which is swelling and is somewhat related to hives.

In most allergic conditions, the antigen or allergen, as we will call it, is something that is harmless for most people and it may be a genetic error that some people will make antibodies to fight off a harmless substance, whether it be something breathed or eaten, or otherwise contacted.

The allergic reaction involves an antibody, which the body makes in response to prior exposure to the antigen. In most allergic conditions, the antigen or allergen, as we will call it, is something that is harmless for most people and it may be a genetic error that some people will make antibodies to fight off a harmless substance, whether it be something breathed or eaten, or otherwise contacted. This allergic reaction is mediated by the production of the IgE antibody and can be demonstrated by skin tests and blood tests. The combination of the IgE antibody and the allergen causes sensitized mast cells to liberate histamine and other chemical mediators. The chemical mediators, again prominently histamine, will cause dilatation of capillaries leading to swelling and hives, excess production of mucus leading to hay fever, inflammatory irritation, and bronchospasm leading to asthma. It's uncertain what causes the itching of some allergic conditions, but histamine is suspect.

Four Basic Classes of Allergens
There are four classes of allergens that we usually consider. The first are the inhalants and these can be divided into seasonal and perennial. Seasonal inhalants include tree, grass, ragweed, and other weed pollens, as well as mold spores. Each of these generally has a somewhat predictable seasonal appearance such as trees in the earlier spring, grass in later spring and early summer, and ragweed and other weed pollens in the summer and fall. Mold may occur mostly in the fall but also frequently occurs at other times as well, especially when it is damp. There is of course some overlap and variation from season to season depending upon weather changes and climatic conditions.

Seasonal inhalants include tree, grass, ragweed, and other weed pollens . . . Perennial inhalants include house dust, house dust mites, animal dander, mold spores, feathers, and in some instances can also include chemical pollutants.

Perennial inhalants include house dust, house dust mites, animal dander, mold spores, feathers, and in some instances can also include chemical pollutants. The chemical pollutants may also be the result of occupational exposure.

The second class of allergens are the ingestants, food being the primary one. Other ingestants are food additives, preservatives, sweeteners, dyes, and other excipients. All one has to do is read the ingredients on a box or even a can or bottle to see that generally there is an extensive list of ingredients in addition to the primary ingestant or food. Incidentally, we will sometimes advise people to go on a diet where they eat nothing with a list of ingredients, thereby eliminating a certain class of potential allergens. Foods can contain residues of pesticides, chemical fertilizers, herbicides, hormones, antibiotics, and various chemicals and it is for this reason we strongly recommend organic foods.

. . . we will sometimes advise people to go on a diet where they eat nothing with a list of ingredients, thereby eliminating a certain class of potential allergens. Foods can contain residues of pesticides, chemical fertilizers, herbicides, hormones, antibiotics, and various chemicals and it is for this reason we strongly recommend organic foods.

A third classification of allergens includes contactants, such as poison ivy. The actual immune mechanism is somewhat different, in that rather than appearing as antibodies in the serum, there are sensitized lymphocytes (white blood cells) that cause the reaction. The reaction is often delayed by one to three days and testing is often by patch testing. There are some contact sensitivities, however, which are mediated by IgE and can appear rather immediately. Recently there has been some interest in delayed hypersensitivity reactions to foods and actually there are some clinicians who will patch test to foods as well as do more routine epicutaneous (scratch or puncture prick) and intradermal skin testing to foods. In other words there may be several mechanisms operative in any given patient, with any given condition.

The fourth classification of allergens are the injectants and these can be medications such as penicillin injections, tetanus antitoxin or even tetanus toxoid, or any other injected medication, and can also include bee stings and the stings of the imported fire ant, which can be highly antigenic or allergenic, and IgE antibody can often be shown in these conditions.

Individual Dietary and Environmental Histories
There are a number of reactions to foods that are the result of intolerance, often because of enzyme insufficiency unrelated to allergy. Lactose intolerance, which can also be referred to as lactase deficiency, is one example.

The diagnosis of allergic conditions rests upon a very detailed history. . . . [which involves] what happens, where it happens, under what circumstances, what relieves it, now long does it last, what season is it, what time of day is it, and just about every other question one could possibly think of.

The diagnosis of allergic conditions rests upon a very detailed history. I was trained by an internationally renowned allergist at the University of Illinois, Dr. Max Samter, who emphasized the necessity of a careful history involving what happens, where it happens, under what circumstances, what relieves it, now long does it last, what season is it, what time of day is it, and just about every other question one could possibly think of. In other words, the diagnosis of allergy involves three aspects: "History, History, History." The history also includes a comprehensive medical history involving dietary and social history, past illnesses, medication, occupational exposure, and environment. Then, there are confirmatory aspects of the physical examination such as wheezing in asthma, pale inflamed swollen nasal mucosa in hay fever, reddened conjunctivae in conjunctivitis, typical eczema, and of course urticaria or hives as well as angiodema, which can be obvious on physical examination.

There are some other aspects of physical examination that may be helpful, such as the so-called allergic salute, which is a crease in the nose caused by constantly rubbing it or pushing up on it, also, the so called "allergic shiners" or dark circles under the eyes.

Different Tests for the Presence of Allergy
There are tests to confirm the presence of allergy and generally speaking skin tests are the most accurate and the most sensitive. These are divided into epicutaneous, which can be scratch tests or puncture prick tests involving the most superficial or outer part of the skin, and intradermal tests where the suspect allergen is injected with a small needle between the layers of the skin. Generally in our office, the epicutaneous tests are done as screening tests, but if they are positive, sometimes that is all that is necessary. When those are negative, intradermal testing is important. For highly sensitive patients, i.e. by history, the intradermal test, and even the epicutaneous test at times, can be diluted for safety's sake. With skin testing, there is always the possibility of an adverse reaction including anaphylaxis but this is exceedingly rare in the hands of skilled practitioners.

[Allergy tests] are divided into epicutaneous, which can be scratch tests or puncture prick tests, and intradermal tests where the suspect allergen is injected with a small needle between the layers of the skin.

Blood tests are available for IgE antibodies and they have been available for the past 25 years. They are not as accurate or as sensitive as skin tests but they are useful in small children or others, who can not cooperate fully with skin testing, and with patients who have conditions that are so fragile or labile that skin testing might be dangerous, including patients who are on beta blockers. This might involve adults with concomitant heart disease or those with severe asthma. The other use of the blood test is in those patients who can't come off of medication, which would interfere with skin tests, long enough. This would primarily mean antihistamines. The blood tests are not interfered with by the usual medications given in allergy.

There is also a blood test for IgG antibody, which is a controversial antibody. There is also a somewhat indirect measure, called the Food Intolerance Test and we have had extensive experience with this for the past 30 years and it seems to be especially useful in patients with delayed reactions, particularly inflammatory bowel syndromes, musculoskeletal syndromes including arthritis, and frequently neurologic syndromes including migraine and at times depression.

Different Allergy Treatments
Treatment of allergic conditions involves several modalities. Environmental control means trying to separate the patient from the allergen and can include diet as well, which is often very useful in food allergy. There are a number of medications that can be used: including antihistamines; short and long acting bronchodilators; cromolyn sodium; corticosteroids, both topically and systemically; leukotriene inhibitors such as Singulair; Atrovent, which is in a different class; and Xolair, which is an anti-IgE injection. Each medication has its own indication and its own potential side effects. The art of medicine involves carefully weighing both and picking the most likely, and least harmful, medication to help the patient.

[Besides] Environmental control [which] means trying to separate the patient from the allergen and can include diet as well . . . a number of medications [are] used . . .

For those patients who still have unacceptable symptoms after environmental control, including diet, and medications, then desensitization is an option. This involves injecting small amounts of the offending allergen, and in many instances gradually increasing the amount and concentration (in some instances patients respond better by keeping the amount small and consistent) up to a maximum tolerated dose. Desensitization is probably indicated in between 10 to 20% of allergic patients that many allergists see. Our philosophy has generally been to try diet, environmental control, and reasonable medication, and if necessary to go further, to desensitize.

The Patient's Environment
Coming back to the environment, the first thing we usually do is think about the location of the home and work place in terms of traffic and proximity to factories, airports, and golf courses. Golf courses often have spraying of insecticides and herbicides and can be problems especially for chemically sensitive patients. Also proximity to forest preserves, ravines and other areas where there might be increased exposure to pollen and mold should be ascertained.

. . . the first thing we usually do is think about the location of the home and work place in terms of traffic and proximity to factories, airports, and golf courses [as well as] proximity to forest preserves, ravines and other areas where there might be increased exposure to pollen and mold . . . sewage disposal plants, drainage ponds, electromagnetic fields, due to transformers or high-tension wires and some electrical appliances, and on-going construction sites . . .

It is important to determine the type of house, i.e., is it a two-story house or is it a split-level, or a ranch style home? Does the patient walk up to get to the first floor? Do they live often in the sub-grades areas, i.e. a half basement or full basement, where dust and mold seem to be a suspect problem? It is felt that patients who live sub-grade have more problems than those who live up higher. Anything else in terms of proximity, such as sewage disposal plants, drainage ponds, electromagnetic fields due to transformers or high-tension wires and some electrical appliances, and on-going construction sites should be noted.

The bedroom and the bathroom are key places because the patient usually spends at least eight hours in those areas. We are concerned about carpeting and any carpeting or even area rugs will harbor dust and dust mites, and it is best to have tile or wood floors. It's often helpful to avoid fabric softeners, especially the scented sheets that go in the dryer. We recommend detergents that are free of dyes and scent. It's often important to use hypoallergenic soaps, cosmetics, and cleaning agents, and to avoid aerosols. Avoidance of smoking and passive (second hand) tobacco smoke is vital.

We are always interested in the type of heat that the house has, i.e., is it gas or oil, or electric? If it is gas, is it forced air, radiant, or baseboard, or hot water radiator? Are there space heaters? If it is centrally heated, have the furnace ducts ever been cleaned and if yes, when was the last time cleaned? We usually ask for our patients not to have SaniSeal sprayed in after the duct cleaning because that tends to bother patients, especially chemically sensitive patients. We do recommend duct cleaning every five years or after any construction.

The bedroom and the bathroom are key places because the patient usually spends at least eight hours in those areas.

Are there any central electronic air cleaners, or even portable electronic air cleaners? We used to recommend these, but about 30 years ago we stopped because we recognized that the ozone produced by some of them was causing problems in some patients, particularly cough and asthma and headaches.

We do recommend that central, H.E.P.A. like, media type filters be installed in the plenum of the furnace. Portable H.E.P.A. filters are also useful in situations were central filters can not be used. We again try to avoid anything that produces ozone, since some patients are sensitive to even very small amounts.

We are interested in the humidifier, i.e. is it a central flow-through humidifier, such as Aprilaire, which tends not to accumulate mold? If it is a portable humidifier are chemicals added since sometimes these can be a problem. Portable humidifiers need to be cleaned fairly often, again without the use of chemicals.

We do want to know if there is a basement, and whether it is full or partial, and whether it is finished or unfinished, and whether it is dry or damp.

We are interested in whether the garage is attached, since that is a source for not only chemical fumes but potentially even carbon monoxide. We do want to know where the door to the garage is, i.e. does it open into the laundry room or into the kitchen where a patient might spend a considerable amount of time? We also want to know if the patient's room is over the garage, or which room, if any, is over the garage? We do point out that most of the fumes coming from a car are put out in the first 30 minutes after driving and after the car is parked. Sometimes patients with an attached garage will park their car outside for a half hour; then pull it into the garage. Obviously there are safety and convenience considerations to be taken into account. Ideally there would be an exhaust fan that would exhaust the air from the garage to the outside. Some patients are able to leave the garage door open for a while after they pull the car in, but again safety can be an issue.

We do want to know if there is a basement, and whether it is full or partial, and whether it is finished or unfinished, and whether it is dry or damp. Damp basements tend to be a source of mold, and it could be seepage or actual flooding and we do ask if the basement has ever flooded and if so what was done afterwards. We also want to know if a dehumidifier is used in the basement since in this area, during the summer, that is usually very important. We need to know how much time is spent in the basement.

We are interested in whether the garage is attached, since that is a source for not only chemical fumes but potentially even carbon monoxide.

We want to know if there is a crawl space and which rooms is it under and is it cemented, and is it damp or dry? Has it every flooded? Crawl spaces generally are not as good for allergic patients as full basements, but when there are crawl spaces, if the floor can not be cemented, then at least they should be dehumidified and cross ventilation should be provided.

We need to know if there are potted plants in the house, particularly in the patient's bedroom. Potted plants, because of the soil and also the fact that mold can grow on the stems and leaves as well, can aggravate allergic conditions. Rarely there would actually be pollen coming from the plant that would bother the patient. Ideally we think potted plants should be outside of the house.

We need to know if there are potted plants in the house, particularly in the patient's bedroom. Potted plants, because of the soil and also the fact that mold can grow on the stems and leaves as well, can aggravate allergic conditions.

We do ask about clothes coming from the cleaners in terms of:

Of course, we need to know about pets, particularly cats, dogs, birds, and to a lesser extent fish. Do the pets come into the patient's bedroom, and do they sleep in the patient's bed? In which room is the bird and/or fish kept? Does the bird fly around the house?

The type of carpeting and the type of pad are occasionally of importance although it seems the very presence of carpeting seems to be more important. Bedrooms without carpeting are far healthier from an allergy point of view, but in many two story or high-rise situations, particularly in apartments or condos, this is not permitted. Oriental carpets are generally not chemically treated and are pretty safe. However none of them are as good as having a tile or wood floor. Low pile, continuous weave, wool or synthetics, such as Burberry or some type of industrial carpet might be OK in areas where carpeting is absolutely essential. Synthetics generally will have formaldehyde released for a number of months. We do ask that Stainmaster be avoided with carpets, because we have seen patients have difficulty with that. Sometimes the type of padding is important and occasionally patients are sensitive to blends or jute and it seems that foam rubber or some type of synthetic pad is more often tolerated. In the past, there were horsehair pads, which frequently caused difficulties, but we usually don't see that anymore.

. . . the very presence of carpeting [is] important. Bedrooms without carpeting are far healthier from an allergy point of view. . .

We are interested in whether there is a shower door or curtain and whether it gets moldy easily.

A bedroom closet door should ideally be solid rather than louvered, although sometimes the louvering is important to allow circulation of fresh air. It is also important to know what else besides clothes is/are stored in the closet and if so, what. We do ask if there is a cedar closet or cedar chest, since those occasionally can cause problems.

Generally we discourage down comforters, although Dacron is usually fine.

For allergic patients we usually recommend total enclosure zippered hypoallergenic covers. Often these are of vinyl plastic, and at least for the box springs that's least expensive. Whenever they are used, we recommend that they be aired out for about a week away from the patient, so that they lose their vinyl odor. While these covers also would work on the mattress, some patients find plastic somewhat uncomfortable even if there is an intervening cotton or Dacron filled mattress pad. In that case, we would recommend one of the vinyl clad percale covers which are available through allergy supply houses, or three or four hundred count percale total-enclosure zippered covers that can often be purchased at stores such as Macy's, Bed, Bath and Beyond, Linens Plus, etc. There are also other sources available through our office and other allergists' offices as well. We always inquire regarding the pillow and we prefer that allergic patients not sleep on either feather or foam rubber. Ordinarily we prefer Dacron or polyester. Some patients, who are highly chemically sensitive, do better with cotton, or even a cotton towel folded up. Patients who are sensitive to feathers can sometimes use a hypoallergenic zippered total enclosure pillow cover.

For allergic patients we usually recommend total enclosure zippered hypoallergenic covers.

Generally we discourage down comforters, although Dacron is usually fine. If down comforters are used, a 300 or 400 count duvay cover, which is zippered, is available but they are fairly expensive. We like cotton or synthetic blankets and for some patients wool is tolerated, but it is often an irritant and sometimes an allergen. Chemically sensitive patients usually do better with natural fibers rather than synthetics.

Ideally the bedspread would be removed at night.

Stuffed toys, book cases, book case headboards, shelves, desks, dolls, canopy beds, bunk beds are all sources of dust in the bedroom for patients who are allergic. If bunk beds are used, the patients would be better off, from an allergy point of view, sleeping on the top bunk. We inquire regarding the bedroom window covers and we prefer unlined washable drapes or curtains, rather than heavy lined drapes, which have to be dry cleaned periodically. We do recommend that the washable curtains be washed fairly often. Venetian blinds, particularly if they are enclosed so that they do not become dusty, are satisfactory, and even pull-shades are fairly good.

Stuffed toys, book cases, book case headboards, shelves, desks, dolls, canopy beds, bunk beds are all sources of dust in the bedroom for patients who are allergic.

We prefer paint to wallpaper, but we recommend low VOC which means low volatile organic compound paint and there are several brands that your paint store dealer can help you select.

If wallpaper is used, we would recommend avoiding wheat paste, which is seldom used these days anyway. We also suggest that the paper be smooth and ideally washable, or at least wipable rather than a texture that may accumulate dust.

Sometimes it is important not to have the head of the bed near a heating duct, or if it is, close the duct or cover it with filters that are available at allergy equipment stores.

Frequent use of a fireplace does expose patients to a number of chemicals and logs that are stored in the house also expose patients to mold. With fireplaces, we strongly recommend that a good draft be ensured. We do point out that scented candles, potpourri, pest strips, dried flowers, and plants, and room deodorizers can all bother allergic patients. Scented candles will out-gas even if never lit and are a potent and frequent source of allergic problems, as are, to a lesser extent, the other items mentioned.

We prefer paint to wallpaper, but we recommend low VOC which means low volatile organic compound paint. . .

We highly recommend H.E.P.A. filtered vacuum cleaners and we are against bagless vacuum cleaners unless the person who empties them is not the patient and is non-allergic and will empty the vacuum outside. Our preference is bagged H.E.P.A. filtered vacuum cleaners.

We always inquire regarding exposure at work or school to open windows, plants, tobacco, aquariums, lab animals, formaldehyde, chalk, chemicals, fumes, mold, and any other potentially irritating or allergenic substances. Again, we are always interested in the specific duties of any occupation. We also want to know if the school or work place is air conditioned and how long the patient has been working at the site.

Our preference is bagged H.E.P.A. filtered vacuum cleaners.

It is important to know how much time is spent in other rooms, such as a TV room, or family room, or recreational rooms, and how much time is spent in other homes where there are exposures such as pets, dust catchers, etc. We also like to know about the hobbies and habits that the patient has, particularly in terms of exposure to chemicals, dust, or fumes. People who do woodworking in their basement create a tremendous amount of dust and some mold and they need good exhaust and filtration. Artists who work with oil paints can have difficulty and can cause problems for other members of the family.

We are interested in vacations: the locations, the dates, and the effect on symptoms. We are interested in whether the patient has problems in a particular car. We also want to know if insecticide has ever been sprayed inside the house and if so, what was used and when. We also ask about lawn services, which use chemicals monthly during spring, summer and fall, and our advice is to limit or avoid such services.

We recommend that with central forced air systems, the fan should be running at all times even when not heating or cooling. This is sometimes called "continuous fan." This can also be true for room air conditioners. Stale air seems to be the enemy of the allergic patient.

If the patient is a child, we always ask if either parent's occupation exposes the child to any toxic substances, either fumes, liquids, or solids. Incidentally in any patient that has neurological symptoms, if they haven't had careful screening for lead, and sometimes for mercury, and other potential toxics, this should be done.

We recommend that with central forced air systems, the fan should be running at all times even when not heating or cooling. This is sometimes called "continuous fan." This can also be true for room air conditioners. Stale air seems to be the enemy of the allergic patient.

In regard to house dust mites, we remind patients that overstuffed furniture, carpeting, pillows and mattresses, and other such items are the main source. Leather or vinyl upholstered furniture seems to be most easily cleaned, and porous fabrics least easily cleaned. We do recommend that the top and bottom sheet and the pillow cases be washed in hot water on a weekly basis, and we recommend that the mattress pad be washed, ideally on a weekly basis but probably more realistically on an every other week basis. While the mattress pad is off, the exposed portion of the mattress and box spring covers should be wiped with a damp cloth if they are wipable plastic, and if not, they should be vacuumed with a H.E.P.A. vacuum cleaner.

In regard to house dust mites, we remind patients that overstuffed furniture, carpeting, pillows and mattresses, and other such items are the main source.

It is important not to have too much humidity in the house because that will foster the growth of house dust mites, but it is also important to have sufficient humidity and we usually recommend between 40 to 50% relative humidity.

Allergy Medications
In regard to medication, there are antihistamine decongestant combinations, but we have never been totally happy with the amount of pseudo-ephedrine present. Generally for a 24-hour antihistamine, there is 240 mg. of Sudafed and this will frequently cause nervousness and insomnia and may aggravate hypertension. 12-hour pills will usually contain 120 mg. and some patients will tolerate those in the morning and the regular12-hour antihistamine without the decongestant at night. For most patients, we have recommended over the counter, or now behind the counter, Sudafed tablets 30 mg., usually one in the morning and one at 2:00 or 3:00 in the afternoon and we find that this is sufficient as a decongestant for most patients.

There are a number of combinations, particularly employing long-acting bronchodilators, such as Serevent, and a corticosteroid. There is a slight risk in using long-acting bronchodilators, which is minimized by combining them with an anti-inflammatory such as a corticosteroid. These medications can be highly effective for asthma, and of course if a patient begins to experience increased problems, they should let their physician know promptly.

With asthma, we always recommend daily peak flow readings. This is simple and inexpensive and can be done in a minute or two once daily . . .

With asthma, we always recommend daily peak flow readings. This is simple and inexpensive and can be done in a minute or two once daily and is very helpful for both the patient and the physician in managing asthma.

We do use Guaifenesin as an expectorant and we usually recommend Mucinex. We tell adult patients to take two 600 mg tablets of Mucinex twice daily, so this equals 2400 mg daily. Robitussin is generally 100 mg per teaspoon and it has other ingredients that may not be desirable. Cromolyn sodium is available as Intal for use in asthma and is also available over the counter for nasal use as Nasalcrom and also as crolom eye drops. It is also available for oral use, although not approved by the F.D.A. for treating food allergy in this country. In almost all other countries it is approved for treating food allergies. While Cromolyn sodium is not as effective as steroids generally, in some patients it is even more effective, and the potential side effects are considerably less.

Diets for Allergy
In terms of diet, we stress rotation, which means that instead of eating the same food day in and day out, you might have a particular food once or twice in one day, and then not repeat it for three or four days and have other foods on those intervening days. Rotating the other foods is also important. It is hard to keep track of a four or five day rotation since a week is seven days. As a compromise, if the patient is not highly food sensitive, we will suggest that they have a twice a week rotation such as Monday-Thursday, Tuesday-Friday, Wednesday-Saturday, Thursday-Sunday, etc. and this seems to work out pretty well for the majority of patients. There are exceptions where people need to carefully rotate every four to five days and keep track.

. . . we stress rotation, which means that instead of eating the same food day in and day out, you might have a particular food once or twice in one day, and then not repeat it for three or four days and have other foods on those intervening days.

Often patients need assistance from a competent experienced nutritionist in this regard.

Rotation has preventative, diagnostic, and even therapeutic advantages.

Of course, the other side of the coin in terms of diet is complete avoidance. If someone is highly allergic to wheat, milk, peanuts, shell fish, or any other identified allergen, then usually complete avoidance is important. Unless the patient has anaphylactic reactions, avoidance is not necessarily forever and even not necessarily forever in case of anaphylactic reactions although one has to have guidance in that regard. As an example, patients who are allergic to wheat and milk, but not anaphylactically sensitive, after avoiding those foods for six months, they might try reintroducing the foods one at a time with at least a two week interval between the introduction of each food; and rotating the introduced foods. If a food is not tolerated, then of course it can be taken out. The problem with reintroducing foods is that it could take several months to become sensitized again and by then the patient may have reintroduced three or four foods and it may be confusing to figure out which food is causing symptoms.

There is also the so-called Caveman diet, where the patient does not eat any foods that have a list of ingredients. In other words, the patient will have fruits and vegetables, meat and poultry and fish, and maybe seeds and nuts. Although milk, grains, and eggs are common allergens, sometimes they can be included in the so-called cave man diet. There is also the rare and exotic diet where patients eat only foods seldom encountered before. Exotic meats not eaten before are preferable and are available in the area. Often there are necessary modifications and compromises in every diet.

the so-called Caveman diet [is] where the patient does not eat any foods that have a list of ingredients. . . . We recommend organic food where possible since exposure to chemicals can have an adverse effect in many patients.

We recommend organic food where possible since exposure to chemicals can have an adverse effect in many patients. The availability of organic foods, and the desirability, including appearance and taste, has greatly improved in the last few years.

Some years ago, the late Dr. Emanuel Cheraskin wrote a book called Psychodietetics and also gave a number of talks or lectures, which I attended. He had a PhD, a Dental degree, plus a MD degree and he had shown in laboratory animals how sugar particularly would interfere with the body's white blood cells' ability to engulf and destroy bacteria. At that time, other books were appearing, other speakers were talking about the problems with sugar, and we began to ask our patients to cut back on sugar. Dr. Benjamin Feingold from Miami wrote and spoke extensively about hyperactive children and the problems with salicylates, preservatives, dyes, flavorings, and sugars. I had the opportunity to have lunch or dinner with him on three occasions and I had pointed out that other specific foods and even inhalants could cause the same problems. He was well aware of that but chose to concentrate on a more narrow area so as to gain acceptance and compliance.

. . . avoid so-called junk foods, i.e. foods with an abundance of artificial coloring and flavoring, chemical additives and preservatives, and natural and artificial sweeteners.

We have long given general advice to patients to avoid so-called junk foods, i.e. foods with an abundance of artificial coloring and flavoring, chemical additives and preservatives, and natural and artificial sweeteners. Particularly we try to get patients off the usual soft drinks. There are some soft drinks that are available through the health foods stores that seem to be less problematic.

Other Allergy Treatments
When patients have not responded adequately to environmental control including diet and reasonable and safe medication, and when they are sensitive to seasonal and perennial inhalants, then desensitization or hyposensitization (allergy shots) as it may be called, is sometimes advised. Depending upon individual practices, allergists probably recommend this for anywhere from 10 to 50% of the patients that they see. The immunologic basis of desensitization is fairly well understood, although not completely.

Desensitization in experienced hands is probably 85% effective, perhaps more consistently with pollen, but, in our experience, also with dust, mold, animal dander, and other allergens.

Patients who are allergic to certain allergens will have high IgE antibody levels towards that particular antigen. They have low levels of IgG, which is a blocking (protective) antibody toward that antigen. By giving allergy injections in small amounts, often gradually increasing to the maximum tolerated dose (at times patients do better on a smaller consistent maintenance dose), patients will increase the level of IgG antibody. It is speculated that the increased level of IgG antibody combines with the allergen but does not cause an allergic reaction, thereby decreasing the exposure of the immune system to the allergen, and eventually the IgE is decreased. So the low IgG is elevated and the high IgE level is decreased and eventually you have a situation where you have much more IgG than you have IgE and the patient is either without symptoms or less symptomatic. Desensitization in experienced hands is probably 85% effective, perhaps more consistently with pollen, but, in our experience, also with dust, mold, animal dander, and other allergens. Desensitization is usually given weekly for a matter of months or even years, and eventually the interval is widened and the frequency is decreased and after two to three years, in many patients, it can be discontinued. Some patients seem to be better if they have some type of maintenance program of desensitization, which could last for many years even if the interval is as wide as four or even up to 12 weeks. We don't understand all of this biologic individuality but we certainly have seen it in over 40 years of practice.

An Expanded Allergy Perception
So that pretty well covers the more conventional approach to allergy and now I'd like to talk a little bit about an expanded perception. This expanded perception was pioneered by one of the founders of NOHA and for many years a member of the Professional Advisory Board, the late Theron Randolph, MD. Dr. Randolph, early in his career, recognized that patients were having problems from foods and chemicals and that their symptoms were not necessarily just the typical allergic symptoms but could be symptoms involving any system or organ in the body. Sometimes arthritis, colitis, and even syndromes affecting the nervous system such as depression and even psychosis were found to be caused or aggravated by allergies, especially to food but sometimes even to chemicals and inhalants. He went about testing patients by hospitalizing them, fasting them for five days, then giving them one food at a time. That technique is called an open challenge, as opposed to single blind or double blind challenge that is most often done these days. He helped enormous numbers of otherwise desperate patients to reconnect with their lives. He also influenced a number of physicians to think in broader terms regarding intolerance and allergy.

. . . the late Theron Randolph, MD . . . recognized that patients were having problems from foods and chemicals and that their symptoms were not necessarily just the typical allergic symptoms but could be symptoms involving any system or organ in the body.

Basically, my perception, and that of a number of other physicians, is that any allergen can cause any symptoms, and any organ can be involved. This means that even inhalants, such as ragweed pollen or cat or dog dander could cause symptoms away from the respiratory tract, not just involving the skin, but even at times involving the central nervous system and other areas. It also means that food would not necessarily cause just gastrointestinal symptoms, but could also be responsible for the whole gamut of typical allergic type symptoms, plus arthritis and other symptoms involving other organs.

Taking it from the top to the bottom, in a sense, foods, chemicals and inhalants can actually cause scalp problems, eye problems, skin problems anywhere on the body, nasal problems, mouth and throat problems, esophageal problems, bronchitis, asthma, gastrointestinal problems, arthritic problems, muscular pain, neurological symptoms including depression and migraine and at times even influence ADD and ADHD as well as autism. Other systemic manifestations include fatigue and weakness. Obviously, consideration of other causes and conditions is important.

The expanded perception concept involves the conventional approach, which is testing, but seems to lean more toward provocation and neutralization rather than progressively building up doses of antigen. In other words, the concentration of the antigen might be increased until symptoms or a significant skin reaction occurs, and then it might be decreased or at times even increased to try to quickly neutralize the symptoms. We have seen this in the office hundreds of times. We don't have an explanation for the neutralization, although we probably understand the provocation. It could be that a certain concentration of allergen gives a signal to the immune system to be tolerant of this antigen and to consider it as not a threat.

This expanded perception includes recognition that odors and in fact chemicals in general can cause sensitivities, including difficulty in concentrating. Diagnosis can be made through provocation neutralization which can be done by skin or sublingually, i.e. under the tongue, or by open challenge as mentioned earlier. Also, there are certain blood tests that measure either IgG or IgG4 or the equivalent and have been very useful in many of these systemic manifestations of intolerance.

The expanded perception concept involves the conventional approach, which is testing, but seems to lean more toward provocation and neutralization rather than progressively building up doses of antigen.

There are a number of conditions that may cause symptoms that can appear similar to allergic symptoms and sometimes these conditions may complicate or compound allergic symptoms. Hypothyroidism, Vitamin B12 deficiency, iron deficiency, and yeast imbalance may all contribute to the patient's general condition as well as increase the allergic problem. Space does not permit detailed discussion of these conditions in this Doctor's Corner but some of this was discussed in the last Doctor's Corner that I contributed ("Fatigue," NOHA NEWS, Summer 2003). These conditions may also contribute to impaired immunity, fatigue, difficulty in concentrating and learning, and even depression at times. They may not always be picked up on some of the routine laboratory tests that are often ordered and sometimes special tests are needed.

There are a number of alternative approaches to allergy that have been helpful in certain patients and again space does not allow for detailed discussion at this particular time. Sleep disorders are increasingly being recognized as another important cause of fatigue and impaired functioning. The relationship of dental health to general health can often be exceedingly important. Celiac disease or gluten intolerance is increasingly being recognized as a cause for symptoms that may be outside the gastrointestinal tract as well. There has been much recent emphasis on supplements including possibly the need for increased Vitamin D in many situations, particularly in Northern climates, and its important role in general health.

Of encouragement to NOHA is the fact that the Wall Street Journal on October 4, 2006, had an article on "Hospitals Go Green To Decrease Toxin Exposure For Patients," noting that this also helped hospital staff as well.

There is much interest in genetic studies and their usefulness. Anyone who reads NOHA NEWS and has come to the meetings is familiar with the metabolic syndrome and this again comes back to diet and nutrition emphasized at NOHA. The Alkaline Way, described by NOHA Honorary Member Russell M. Jaffe, MD, PhD, seems to have merit also. We are becoming increasingly aware of the role that hormonal factors may play in many allergic and systemic conditions, and also there seems to be an increased interest in plant based steroids, rather than synthetic steroids.

As NOHA members know, a healthy mental attitude, appropriate exercise, careful driving, and avoiding tobacco smoke exposure are among numerous other aspects tied into general health. Finally, I hope all NOHA members and friends are greatly appreciative of the fantastic job that Marjorie Fisher and Andrew Fisher have done in collaboration with Lynn Lawson in writing and editing the NOHA NEWS.

Yours for Optimal Health,

Robert W. Boxer, MD