Conditions

The following are conditions that I specialize in and would love to help you manage. In this section, I will take you “under the car hood” so to speak whereas a specialist, I detail how I approach each to work with you for positive results and peace of mind.

Common Themes:

 

1. Your History is the Most Important Part
* Your medical history of the symptoms you experience and all the factors surrounding those symptoms is by far the most important part of every evaluation. Every detail (positive and negative) is key. They give us an idea of what your triggers or allergies are and guide what to test for and perhaps what not to test for.

2. We need to be on the same page about treatment goals
* I need to know what you hope to get out of our partnership and how I can support you to achieve your goals. We need something objective to strive for. And although I am an extreme optimist by nature, if your goals are not realistic at that moment, I will let you know and not lead you on.

3. A positive test does NOT mean you are allergic.
* This is very hard for most to understand and I get it. Unfortunately, allergy testing is full of false positives. As a result, testing should be as focused as possible to prevent these false positives which typically lead to confusion and anxiety. Thus, your history is key. If history is limited or unclear, the results of testing should be interpreted with caution.

4. You are not a number or a positive or negative result, you are a patient
* I do not treat test results, I treat patients. Especially in the allergy and asthma world, the results of a test are important but mean very little to me without getting a good history from you or knowing where you are at in your treatment journey. Just treating numbers or results can cause severe harm and I’ve seen it happen many times. An improvement in test results is not significant if your condition has not improved. On the contrary, if you are feeling better, we may not need new testing to provide us validation. We should not seek after a “normal” result on paper. Our goal is always an improvement in your condition and quality of life.

5. Negative testing means there’s approximately a 99% chance you are not allergic, but NOT 100%
* Again, this is where we rely on our history. If there is a strong history of a likely allergen but the test result is negative, you should continue to avoid the allergen until a challenge (typically under medical supervision) is done.

6. There must be a “WHY” for any testing done. Testing should be not done if it will have an impact on your management plan
* If the outcome of a test will not change or have any impact on how we manage your condition to achieve your goals (i.e we have NO WHY), we should not perform that particular test. Said another way, we should know how to put into action any test result we get.

7. We need to have an open dialogue with respect to treatment options
* It is becoming far more common for me to encounter patients that want nothing to do with conventional medications. I truly respect that and want to learn more about your reasoning. You will not get a judgment from me. That being said, if I feel there is a role for them in your situation and the benefits outweigh the risks I need you to keep an open mind and reconsider. Some of my patients need help seeing the big picture that in some situations, avoiding medications and delaying treatment is much more harmful to you

8. Accounting for all factors, you should be on the least and safest medications necessary
* In general, I dislike medication. It’s a bandaid, it’s often expensive and even if safe, how it will affect you individually, and the long term side effects, are unknown. That being said, medications can save your life and improve your quality of life. It is my job to help you analyze your situation at that moment in time to determine if medication is right for you.

9. Your medications should be re-evaluated frequently
* Piggybacking on the statement above, in order to get you on the least medication possible, the need for them needs to be re-evaluated often. A common theme I encounter is that I can stop or significantly decrease one’s need for medication during certain times of the year. On the contrary, while we may need to ramp them up or add medications during others.

Allergic Rhinitis and Allergic Conjunctivitis

Rhinitis and conjunctivitis are fancy medical words meaning inflammation of the nose and the eyes respectively. You may experience this allergy driven inflammation in many forms including:
1. itching and/or burning sensation
2. increased mucus production (i.e watery eyes or runny nose)
3. increased swelling and congestion (dark circles and swelling under eyes; plugged, stuffy nose)
4. Sneezing
5. Throat clearing from postnasal drainage

Although these conditions sound benign they can severely impact your sleep, school or work performance and productivity as well as your overall quality of life. They can also make other conditions such as asthma worse.

Evaluation

History

I want to know every aspect of your symptoms including but definitely not limited to:
* What exactly you experience: runny, stuffy, sneezy, itchy, changes in taste or smell, etc – help confirm the diagnosis and can help guide treatment
* What environments and exposures seem to trigger them: time of year, time of day, inside, outside, animal exposure, mold exposure
* How you perceive your symptoms to affect your quality of life
* Previous Testing (if any)
* Medication Usage (if any) – what have you tried, what works and doesn’t work

Testing

Since nose and eye symptoms are mainly the result of exposure to airborne microscopic allergens we may not always have an accurate history of what culprit allergens are triggering those symptoms. Thus, we may need to cast a larger net testing for all your likely airborne indoor and outdoor environmental exposures including pollens, molds, animals, and dust mites.

Treatment (3 Pillars – Avoidance, Medication, Immunotherapy)

Avoidance

* Your history and testing results will allow us to take a deep dive into avoidance strategies that can substantially improve your symptoms and quality of life. Obviously, you can’t live in a bubble and avoid all of your allergens 100% of the time. But, the more you can avoid your identified allergens the fewer symptoms you will have. Handouts are great but in my experience, are not sufficient. I need to communicate to you the most important and highest yield avoidance techniques to employ for your specific situation.

Medication

* There are great medications and techniques to control nose and eye symptoms. Thankfully most are available over the counter and accessible without a doctor’s prescription. However, it is often that I encounter patients who are using the wrong over-the-counter medications, the wrong way. A thorough understanding of what medications will work best for your situation will not only improve your symptoms but limit side effects.

Immunotherapy

* Immunotherapy is another fancy medical term for a treatment whose goal is to make you “immune” to your allergies. Your body is exposed to small amounts consistently over time to build immunity. If you are immune, your body will not react and produce symptoms. Immunotherapy takes time and diligence on your part but can lead to severe improvement and possible cure of your allergies where your requirement for medications is drastically reduced. Immunotherapy can be done a few different ways and there are pros/cons and risks/benefits to the different forms that I can break down for you. Since this does require time and often a financial investment, it will be extremely important for you to know what you are getting into to increase your chance of success.

Anaphylaxis

Anaphylaxis is the medical term for a life-threatening allergic reaction. Once exposed to the allergen, the reaction typically causes immediate swelling which can lead to difficulty breathing and low blood pressure. Delayed reactions can also occur several hours later. If not promptly and adequately treated, the end result can be a lifelong debilitation from a stroke or even death.

Most typically think of anaphylaxis as caused by severe food allergies. It can also occur from insects (bees, hornets, wasps, ants, etc), medications, exercise, or a combination of factors causing the body to react violently. One example of the latter is food-dependent exercise-induced anaphylaxis, where after a person ingests an allergen, the severe reaction will only occur in a setting of exercise typically within a few hours of ingestion. In place of exercise, other cofactors can trigger the reaction such as NSAIDs (non-steroidal anti-inflammatory drugs) and alcohol. There are also many cases that are declared “idiopathic” or caused by an unknown trigger.

Evaluation

History

The importance of history in the setting of anaphylaxis can not be understated. It can be the difference between life and death. Thus, it needs to be exhaustive and include:

* A timeline of all the events several hours surrounding the reaction including but not limited to the following questions:
* How were you feeling prior?
* What were you doing?
* What were your surroundings?
* What were you exposed to?
* Is there any chance you may have been bitten or stung by an insect?
* What did you consume including foods, supplements, and any medications (with ingredient labels)?
* What exactly were the symptoms of your reaction?
* What is the time relation from exposure, consumption, or activity to your reaction?
* Have you ever had this happen before?
* How were you treated (i.e was epinephrine or other medications used)?
* Any reactions after the initial reaction (delayed reactions)?

Testing

Focused testing should be done to exposures surrounding the anaphylactic episode and if positive can confirm the culprit. However if lots of tests are done and there are a lot of positives, we have to be aware of the potential for false positives especially if the story surrounding the episode doesn’t completely indict the positive allergen. Consideration of an oral challenge is an option to confirm or refute this result, especially if avoidance is difficult. On the contrary, an oral challenge is NOT optional and must be done following negative results to allergens having a high probability of being the culprit. Although not common, false negatives occur and I have encountered this in clinical practice several times.

Blood testing looking for markers such as tryptase associated with the reaction should also be done. An elevated baseline (when not having anaphylaxis) tryptase level can indicate you have a mast cell disorder making you more likely to have anaphylactic episodes in the future. In some instances, when the diagnosis of anaphylaxis is not clear, a tryptase level drawn in the setting of the reaction can confirm or refute an anaphylactic response.

Treatment

Avoidance

Obviously, if a trigger is identified avoidance is of utmost importance to prevent future episodes that have the potential to be more severe.

Medication

In almost all scenarios, a person with a history of anaphylaxis should have an epinephrine device on them at all times and ideally 2. More important than having an epinephrine device is knowing how and when to use it. Having an anaphylaxis action plan is crucial as it can not only remind you or others what actions need to be taken in the event of a severe reaction. Med alert bracelets and other allergy identifiers are also important as they can help the medical response team identify the issue if you are unconscious or not able to communicate what is going on.
The points can be life-saving and require a special discussion with you and your physician.

Other medications such as antihistamines, steroids, and more investigational treatments have the potential to help limit or possibly even prevent a reaction. A discussion should be had regarding these especially if anaphylaxis is recurrent or unknown. However, in the immediate setting, epinephrine is the only life-saving option and other treatment options should be considered secondarily.

Immunotherapy

Immunotherapy (IT) can be an option if the trigger is known. The modality of immunotherapy differs depending on the trigger. For example, patients with anaphylactic reactions to insects typically receive IT via subcutaneous (SC) injection or SCIT. Patients with food anaphylaxis can receive oral (OIT) or sublingual immunotherapy (SLIT). All options, including pros and cons, should be presented. It should be clarified that the goal of immunotherapy is not to cure but to greatly decrease the chance of anaphylaxis in the event of accidental exposure. Thus, having epinephrine on hand is still essential.

Asthma

Asthma is a reversible inflammatory condition of the lungs that is up to 80% of patients is triggered by allergies. Patients often have multiple triggers which can include changes in temperature, respiratory infections, chemical inhalation, and exercise among others. I like my patients to think of asthma as a smoldering fire and the triggers as lighter fluid. If the fire is active, a little lighter fluid can set it ablaze. If the fire is barely burning, it will take more than just lighter fluid to get it going. Patients typically present with asthma by wheezing, coughing, experiencing chest tightness, or shortness of breath. If uncontrolled, asthma can dramatically worsen one’s quality of life. It can also be deadly.

I like to point out to my asthma patients that if their asthma is controlled, it should never limit them exceptionally. Furthermore, if they are competitive athletes, getting their asthma under control can dramatically improve their performance and I’ve seen it happen many times.

History

Asthma is a clinical diagnosis in most especially younger kids who cannot sufficiently perform objective measures of lung function like Spirometry (see below). Even then, lung testing alone does not confirm the diagnosis.
Patients will often present with chest tightness, wheeze, cough, or shortness of breath which is often worse at night or with exertion. However, some patients have a harder time realizing they have symptoms. They may avoid exertional activities altogether due to experiencing these uncomfortable respiratory symptoms in the past and may not be aware of the condition is treatable.

In kids, I often hear parents say they frequently cough with exertion or cannot keep up with the other kids. The family history is also important as one of the most common risk factors for asthma in a child is asthma in a parent.

Key pieces of history include:
* Respiratory symptoms experienced (i.e chest tightness, shortness of breath, cough or wheeze)
* Setting in which these symptoms occur such as night, early morning, indoor, outdoor, exertional, seasonal, etc
* Potential triggers including infections, chemical exposures (i.e vehicle exhaust or cleaning solutions), animals, molds, dust, pollens, temperatures, etc
* Have you ever used albuterol for respiratory symptoms and
* If yes, did it work?
* If yes and it did not help, do you feel you are using the inhaler correctly?
* Have you ever needed an oral or injectable steroid for respiratory symptoms?
* if so, did it help and how often have you needed these steroids
* Have you ever taken daily medication for asthma or respiratory symptoms?
* if yes, did it help?
* If yes and it did not help, do you feel you were using the medication correctly?
* Have you ever been hospitalized for asthma or respiratory symptoms?
* Have you ever had any lung testing done? (i.e Spirometry, Exhaled Nitric Oxide)
* Do you have a family history of asthma or other respiratory condition

Testing

As discussed previously, testing is not essential to make the diagnosis but can help greatly. Spirometry can compare your lung volumes and function with people who have similar characteristics such as age, height, weight, race, and race. It can also give us something to follow over time in response to treatment. Fractional excretion of Nitric Oxide (aka FeNO or NiOx) can give us the degree of allergic (eosinophilic) inflammation present in your airway and can guide treatment. Both of these tests as well as others including home testing with peak flow meters require careful interpretation.

Allergy testing can be very helpful as the vast majority of asthmatics have one or more allergic triggers. As per allergic rhinitis above, testing for indoor and outdoor airborne allergens can guide our discussion of likely successful treatment options.

Targeted blood testing for IgE and eosinophils may also be done as the presence of these allergic markers can further expand treatment options.

Treatment

Asthma treatment is still one of the most commonly misunderstood concepts I encounter among patients and for the most part, I feel that physicians such as myself are to blame.

There are 2 types of medications: rescue medications and controller medications.

Rescue medications work within minutes are meant to “rescue” you from asthma symptoms such as shortness of breath, wheeze, cough or chest tightness. Albuterol or levalbuterol are the 2 main rescue medication options as they work within minutes but only last a few hours. If you are using these “rescue” medications too often, typically defined as more than twice in 1 week excluding prior to exertion, your asthma is not in good control. Not in good control means that not only is your quality of life likely suffering due to limitations from your asthma but you are also at a higher risk for other complications including asthma exacerbations requiring the need for oral or systemic steroids (which have their own nasty side effects), hospitalizations and even death. Thus, you may need to start or adjust your controller medications in order to achieve better control.

Controller medications “control” the inflammation in your chest in order to limit your need for rescue medications. Less need for rescue medications implies that your symptoms are better controlled, your risk of an asthma exacerbation is reduced and your quality of life has improved.
Controller medications include an oral tablet called Montelukast (Singular) along with a wide variety of inhalers. Injectable biologic medications have also been game-changing for patients with various forms of asthma such as eosinophilic asthma. These target specific inflammatory components and have been safe treatment options for many of my patients.

Medical therapy is not a life sentence and should be re-evaluated often. As noted in common theme #8 above, you should be on the least amount of medication needed to control your symptoms. Your body’s requirement for medication to control asthma changes relatively frequently and we should change along with it.

As per allergic rhinitis above, if allergens are identified, avoidance strategies can be extremely helpful. Immunotherapy can also change your body’s immune response to your allergic triggers and improve your asthma greatly. In young kids, immunotherapy has even been shown to prevent asthma.

Atopic Dermatitis

Atopic Dermatitis aka eczema is allergy-driven inflammation of the skin that causes itching which results in an endless cycle of scratching, rashing and more itching. It is a chronic condition that often improves and worsens periodically. This issue is complex but one of the major highlights is an impaired skin barrier causing your skin to lose water and moisture and exposing it to allergens, irritants, and microbes triggering and enhancing the itch and inflammation.
It is mainly diagnosed in children and about 50% will have the condition persist into adulthood. It can be extremely debilitating to patients as well as caregivers. If not controlled the patient for a rash that can spread and worsen like wildfire leading to skin infections and unpleasant changes in skin pigmentation and texture. There is also concern that more allergies can be developed over this impaired skin barrier. It is also strongly associated with sleep disturbance and a variety of mental health disorders including anxiety, depression, and suicidality.

Evaluation

History

Again, far and away the most important piece of the patient encounter. Open-ended questions by your physician are key and the typical questions I like to ask include:

* Does it itch?
* If it does not itch, it’s likely not eczema
* Is the affected area, dry, scaly and flaky
* Where is it occurring?
* Different ages tend to have different areas of involvement
* Any bleeding, scabbing, open wounds, blistering or pus?
* Could an infection or contact dermatitis be complicating or mimicking eczema?
* How long have you been dealing with these symptoms?
* Do the symptoms come and go, relapse or remit?
* Or does severity change?
* What triggers make it worse?
* Temperature
* Time of year
* foods/preservatives
* meds/supplements
* Specific exposures such as clothing, certain topically applied medications or moisturizers, animals, sweating, etc
* What makes it better?
* What is your skincare regimen?
* What is done in the morning, day or night?
* Any bathing? Any if so, is anything applied to the bath?
* Any topical moisturizers or medications applied to the skin
* Any other treatments? (i.e antihistamines, home remedies
* Have you seen or discussed eczema with your doctor?
* Was any blood testing done?

Testing

If you have not reviewed the Common Themes section please do, especially #s 3-6 as they are incredibly important for this condition. Atopic dermatitis is a clinical diagnosis and thus testing will not confirm our diagnosis but will help us identify triggers that we will want to control.

As a result of your impaired skin barrier due to eczema, you are far more likely to be sensitized to allergens. Sensitized is different from allergic. Sensitized means that blood testing shows you have allergy antibodies to an allergen but does not mean you will have an allergic reaction to that allergen (i.e you are allergic). Thus, you can be sensitized and not allergic (false positive allergy test) but it is very uncommon for you to be unsensitized and not allergic (false negative allergy test).

False positives (sensitivities) are confusing and anxiety-provoking but they occur. Thus, to limit them we need a reason for every allergy test we order. We need to also have a plan for whatever result we obtain whether it was something we anticipated or did not.

When we acknowledge the limitations of our testing and are on the same page with reasons and plans in place for the tests we are ordering, we can feel good about any result that is obtained.

Testing typically involves environmental allergens and select foods, especially if there is a history of a reaction. Consideration should also be given to testing any possible contact allergens such as ingredients in topical moisturizers and medications that may be worsening eczema (i.e contact dermatitis).

Treatment

Treatment should be focused on supporting the impaired skin barrier and controlling itch.
I like to go in-depth through a skincare regimen with my patients that can make all the difference in the world, especially when dealing with an eczema flare. It starts with key aspects of bathing and applying medicated and non-medicated topical treatments. All treatment options will be discussed including the pros and cons of each. It will also be important to highlight the consequences of deciding not to aggressively treat. Often, I have patients that are so concerned about the side effects of medications that they do not take into consideration the cost of continued suffering and worsening of an uncontrolled condition.

As per allergic rhinitis and asthma above, if allergens are identified, avoidance strategies can be extremely helpful. Immunotherapy can change your body’s immune response to your allergic triggers, decreasing itch, and improving eczema greatly. Although I have seen IT help many of my patients, it needs to be done carefully as I have also seen it trigger eczema flares, especially when starting out.

 

Drug Allergy

Drug allergies are often misunderstood and misdiagnosed. Drug allergies are inflammatory reactions your body has to a drug that may result in a variety of symptoms including itching, swelling, rash, trouble breathing or even dizziness, weakness and passing out. They can even result in death. They are not common and should be distinctly differentiated from drug side effects which are far more common. Drug side effects are undesirable effects that are known to be produced from certain medications especially at higher doses. Again, although not ideal, side effects are typically not life-threatening.

Drug allergies are important to identify and avoid as your reaction will often get worse with subsequent exposures to the drug. However, misclassifying a drug allergy due to experiencing a side effect or some other non-allergic reaction can also be a major problem. It can lead to the avoidance of medications that are in actuality harmless with minimal side effects and cause exposure to more dangerous medications with more potential to do harm.
Evaluation

History

Again, the history is the most critical piece of the evaluation that helps me determine the chances that you experienced a true allergic reaction to the drug versus a non-allergic reaction or side effect. Unfortunately, it is common that a patient will not know the details of the reaction as it may have occurred when they were a child or so long ago that they cannot recall. If you are able to provide a history of the reaction, details that are helpful include:

* Why were you taking the drug?
* What are the symptoms you experienced from the drug?
* Did your symptoms cease when you stopped the drug?
* Did you take any medications in response to the symptoms?
* Were your symptoms severe enough to lead to an ED or hospital visit?
* What was the time relation from medication exposure to experiencing symptoms? Minutes, hours, days?
* Was this the first time you had been exposed to the medication? If not how long had you been on it prior to the reaction? Days, weeks, months?
* Was this your first exposure to the medication or have you taken it before?
* If you have taken it before, do you remember experiencing any prior symptoms?
* Have you taken any related medications?

 

Testing

The only medication for which there is a standardized test, is the antibiotic Penicillin. Otherwise, all other drug testing performed is not standardized, which means there is not an agreed upon way to interpret it and as a result it’s accuracy is in question. That doesn’t mean that non-standardized testing such as skin prick testing to a drug should not be performed as it may provide a safe knowledge point prior to advancing to the only way to truly determine if you have a drug allergy or not: oral challenge testing.

Oral challenge testing is typically done in a graded fashion starting with small doses and increasing up your standard daily dose. It is done in a physician’s office where the response can be closely monitored and appropriate medical care can be given in the case of a reaction. Although time consuming, this testing can open the door for safe medical alternatives in the future that can be life-saving.

Treatment

Treatment is obvious, avoiding the drug or drugs you are allergic to. However, in critical situations where you need the drug you are allergic to, the allergist is typically called in to help perform what is called a desensitization. This is where small incremental doses of the drug are given under close observation (anticipating you will have a reaction) until your goal dose is achieved. Through this repetitive dosing your body becomes temporarily immune to your drug allergy. However, this drug exposure has to be maintained. If you miss dosing prior to your treatment course ending and resume the medication you run the risk of having a severe allergic reaction due to your body losing it’s immunity. Desensitization can be a complex process with a great deal of risk and should only be employed as a last resort option.

Eosinophilic Esophagitis (EoE)

Eosinophilic esophagitis or EoE is a relatively newly described condition in which your esophagus is inflamed and becomes narrow due to an abundance of eosinophils which are cells typically produced in response to allergies. As a result, it has a strong association with other classically allergic conditions including food allergies, allergic rhinitis, asthma and atopic dermatitis. Common symptoms experienced by EoE patients include trouble swallowing, food getting stuck or impacted, vomiting, heartburn not responsive to antacid medications, and upper abdominal pain.

Evaluation

History

Unlike other allergic conditions where the diagnosis is made almost entirely by history, with EoE the history you give triggers my suspicion leading to either a trial of treatment and/or referral to a gastrointestinal specialist who can perform an upper endoscopy and confirm the diagnosis.

If you have one or more allergic conditions such as food allergy, atopic dermatitis, allergic rhinitis or asthma and give a history of any of the following,I strongly consider EoE as a diagnosis:
* Trouble swallowing (dysphagia) solid foods (more common in adults)
* Food getting stuck or impacted upon swallowing (more common in adults)
* Pain with swallowing (odynophagia)
* Heartburn, chest or abdominal pain (more common in kids)
* Vomiting or food regurgitation (more common in kids)
* Food avoidance (more common in kids)

I also like to ask about various food coping mechanisms you can develop (particularly in kids) that can support an EoE diagnosis:
* Preference for only liquid or soft foods
* Avoidance of solid foods previously eaten
* Prolonged meal times due to eating slowly or excessive chewing
* Drinking lots of fluids with meals

Often, I find that EoE patients will have a family history of EoE or one of the common symptoms above such as trouble swallowing.

Since food and environmental allergens are likely to play a strong role as well, it will also be important to ask focused allergy questions that will help guide testing and treatment strategies.

Testing

Allergy testing is important in all EoE patients and should consist of possible food and environmental triggers.

Although food allergies play a major role in EoE, classic IgE food allergy testing is not done for the main purpose of identifying triggers. It is mainly performed to identify foods that may trigger an allergic reaction when eliminated foods are restarted during treatment. Said another way, since food elimination is a mainstay of EoE treatment (see below), testing will help us identify those foods that we should re-introduce with caution after being eliminated. Food allergy testing to identify triggers of EoE is for the most part unreliable with many false positives. However, a negative test can essentially rule out a trigger in most cases with a few exceptions (i.e milk).

Testing for environmental allergens is important to control other allergic conditions you may have that are likely to contribute to an eosinophilic response and hence EoE. You should be tested for relevant regional pollen (trees, grasses, weeds), molds, animals including cats and dogs, and dust mites.

While allergy testing supports our treatment plan, upper endoscopy and biopsies of the esophagus that show eosinophils and rule out other causes, confirm the diagnosis. I refer every patient whom I suspect has EoE to a gastrointestinal (GI) specialist to assist in diagnosis and management. Since an upper endoscopy is minimally invasive and requires anesthesia, if your symptoms are relatively mild or already responsive to treatment, the GI doctor may be okay with following you without endoscopy. However, if the symptoms are severe or the diagnosis is in question, an upper endoscopy should be done ASAP and is then often followed to assess the response to treatment.

Treatment

There are several ways to approach treatment and I like to give you a few options as well as have a GI specialist on our team to provide their input and perform endoscopies if necessary.

The four cornerstones of therapy are:
* Food elimination
* Acid Suppressing Medications (i.e proton pump inhibitors or PPIs)
* Topical steroids (i.e. steroid inhaler medications that are swallowed instead of inhaled)
* Esophageal expansion (dilatation) – only if absolutely necessary
Taking into account many factors including the severity of symptoms, the stress of dietary restriction, medication concerns, and possible complications, we will formulate a plan that works best for you. The plan may include one or a few of the modalities listed above in order to get a response that dramatically improves your EoE symptoms and maintains this improvement using the safest measures possible. To do this effectively, constant re-evaluation is necessary to ensure the benefits of your management plan are always outweighing the risks of treatment (i.e side effects) and EoE complications.

Food Allergy/Intolerance

An allergist’s definition of a food allergy is an immediate, potentially life-threatening reaction occurring after exposure to a food. Immediate is defined as within minutes to hours and the symptoms experienced may include itching, rash, swelling, vomiting or shortness of breath. This type of reaction is the result of your body having an IgE antibody response to a particular food and this antibody can be tested via skin or blood testing.

Food intolerances are generally defined as non-life-threatening reactions you may have to a food that does not involve IgE. Since they do not involve IgE, they are also called non-IgE mediated food allergies. They are rarely life-threatening but can still cause a lot of debilitating symptoms including nausea, vomiting, abdominal pain, diarrhea, malnutrition and weight loss. These reactions are primarily made by your history of symptoms as testing although helpful at times can be difficult to interpret.

Evaluation

History

In a perfect world, your history of symptoms wouldn’t matter. You’d be able to consult with any medical provider, have testing and the testing would tell you exactly what you’re allergic to and thus what you can and cannot eat. Unfortunately, it’s far more complicated than that. Food allergy testing is full of false positives. Without a strong history of a particular food causing symptoms, the test result may be inaccurate. Thus, as in the previously described conditions, your history of symptoms is critical.

Key information I’d like to know about your condition includes:

* A list of specific foods you are concerned are causing symptoms
* Symptoms suspected to be caused by each food
* Time course from exposure to symptom onset for each food
* Health at the time of the reaction: feeling good or ill, any other symptoms present?
* Were you taking any medications at the time including prescription medications, over-the-counter medications, vitamins or supplements.
* Any physical activity before or after exposure to the food and subsequent symptoms
* Did you take any medications for your symptoms such as antihistamines or epinephrine?
* If so, did these medications improve or resolve your symptoms?
* Did you need to seek emergency medical care for the symptoms?
* If so, what was done in the ER? IV fluids, epinephrine, Benadryl, steroids, other meds?
* Were you hospitalized?
* If so, for how long? Did you need to go to the intensive care unit (ICU) or be intubated?
* Have you ever eaten this food before?
* If so, how many times?
* Did you have reactions with prior consumption?
* Have you ever consulted with a doctor about similar food reactions?
* If so did you have testing?
* Are you currently strictly avoiding all forms of this food including raw, cooked, baked, trace amounts, etc.

If your history of a reaction to a specific food is not clear, testing can still be done but it should be interpreted with caution.

Testing

If you describe symptoms that clearly implicate a particular food and testing is positive, you are likely allergic. If there is still any doubt, even after a positive test, a food challenge can be considered. Food challenges, where food is given under observation are the gold standard to confirm or refute a suspected allergy.

If you describe symptoms that are not as clear for a suspected food, a negative test can be very powerful since it almost eliminates that food as an allergy. On the contrary, a positive test may be a false positive. It can be avoided or a food challenge can be discussed if the implicated food would like to be reintroduced to the diet if possible.

Treatment

Avoidance is the mainstay for food allergies and although it’s the most important part of the treatment strategy, there are other parts to the treatment plan that are essential.

If you have a history of an IgE-mediated allergy to a food, you must have an epinephrine device (i.e EpiPen or AuviQ) on you at all times as well as an action plan. The action plan will help remind you how and when to use the device and to call 911 or go to the ED immediately after epinephrine is given. It will also contain the dosing of adjunctive medications that can be given as well as when to repeat epinephrine if needed.

Immunotherapy

Immunotherapy is now becoming more common as there is now an FDA approved oral immunotherapy (OIT) option for peanut allergy. Sublingual immunotherapy (SLIT), allergy drops placed under the tongue which is not FDA approved, is also an option starting to get used by more allergists and epicutaneous immunotherapy (EPIT) an allergy patch may be available in the near future.

Despite these exciting treatment options, it is important to know that they are not cures and have risks and limitations. Their goal is to build a level of tolerance to the food, such that in the event of accidental exposure, a life-threatening allergic reaction does not occur. The goal is not to freely eat the food without concern which would be a cure. It’s possible that a cure could happen along the way but that likely occurs irrespective of what type of immunotherapy is prescribed.

Of the currently available options, OIT and SLIT, the risk-reward ratio is proportional for each type of immunotherapy. OIT has the most risk (i.e is most likely to trigger anaphylaxis or other adverse effects) and is most likely to produce side effects while it also has the greatest reward (i.e the ability to tolerate the greatest amount of food and thus provide the greatest protection). SLIT is much safer and less likely to produce side effects but does not provide the degree of protection that OIT can.

A very thorough discussion of all aspects of these therapies including risks, benefits, time course, and goals should be had with your physician prior to embarking on any IT treatment plan.

 

 

Urticaria (Hives)/Angioedema

Urticaria aka hives are red, raised itchy patches that come and go on various areas of your body. Angioedema is essentially an exaggerated hive or swelling occurring in deeper layers of skin (subcutaneous) or mucous membranes and often involves the lips, eyes, and extremities such as the hands and feet. There are rare forms of angioedema that are often hereditary and associated with more severe symptoms including abdominal pain, vomiting, diarrhea, and even airway swelling that can be life-threatening.

Most cases of urticaria and angioedema are short-lived or “acute.” However, when they are ongoing for longer than 6 weeks they are termed “chronic.” They are extremely debilitating from the intense itch and sometimes pain associated but also the physical disfigurement to your outward appearance that can shatter your confidence and self-esteem. Another disturbing aspect is that flares often occur without warning and you may never know when one can occur and ruin your day. Chronic causes can persist for several months or several years before completely resolving or going into a “remission” like state where they may not show up again for several years.

Evaluation

History

The first part of history involves confirming the diagnosis. Hives typically come and go on various aspects of your body for several days. However, the thing that distinguishes hives from other skin conditions is that one hive on your body (i.e on your arm) will not last longer than 24 hours and most likely only a few hours. And, it will completely resolve like it was not even there without leaving a bruise or blemish in the skin. Sure, other hives may come and go all around it, but that one particular hive will resolve. If it does not, other skin conditions should strongly be considered.

Angioedema may last up to a few days and is typically associated with more pain than hives which are predominantly characterized by itch.

Key aspects that I’d like to know about your condition include:

* Description of symptoms: area of the body involved, characteristics such as redness, swelling, itching, or pain
* When did the symptoms start and how long did they last, including for a typical individual area (i.e one hive)
* Upon resolution, are the hives completely gone or do you see skin changes such as bruising?
* Upon first noticing the hives or swelling, how were you feeling on that day or the days prior? Any recent illnesses or symptoms prior to your hives or swelling?
* Any symptoms associated with the hives or swelling such as shortness of breath, wheeze, nausea, vomiting, diarrhea, abdominal pain, trouble swallowing, voice changes?
* What were you exposed to in the hours before and after noticing the symptoms: foods, medications, vitamins/supplements, changes in your environment (i.e animal exposure, damp basement exposure)?
* Any exercise or exertion before or after symptoms?
* Any changes in body temperature before or after symptoms?
* What medications (prescription or over the counter), vitamins, or supplements do you take?
* Did you take anything for your symptoms such as antihistamines or epinephrine?
* If so, did they help your symptoms?
* Have you ever had similar symptoms before?
* If so, have you ever seen a doctor before or had a work-up for these symptoms?
* Has anyone in your family ever had similar symptoms?
* Are you under any new or worsening stressors: physical or emotional/psychological

Testing

The vast majority of urticaria and angioedema cases are idiopathic which means “unknown.” Or to keep things light, I often state that it means, “the doctor is an idiot and can’t figure it out.” As a result, unless there is suspicion for a certain trigger such as a specific allergen or underlying medical condition, testing is discouraged as it is usually not helpful and expensive.

However, there obviously is a cause and I truly believe that in some scenarios it is a combination of factors causing the cells in your body to release chemicals leading to itching and swelling. Thus, I am not entirely opposed to testing and will consider the following:

* Allergens – Something I will likely not test for these conditions specifically unless there is a strong history of specific food or environmental trigger or another reason to test. Without another reason to test, allergy testing will be extremely limited and focused and we must have a plan in place for each test, whether positive or negative

* Medical Conditions: Although rare, I have seen a few underlying medical conditions present as hives. If your symptoms are chronic, medical causes have not been investigated, and/or you have symptoms to support further testing I often consider ordering the following among others:
* A complete blood count (CBC) – looking for evidence of infection, possible allergy/drug reaction, or overall blood abnormality such as low or high levels of blood cells that could make us think of other conditions
* Complete Metabolic Panel – electrolytes, kidney function, and liver enzymes which can help us evaluate a whole host of conditions primarily liver and kidney abnormality
* Thyroid testing: I have seen thyroid conditions cause hives a few times so this is always something to consider
* Inflammatory Markers ESR and CRP – if there is a concern for an autoimmune condition or the hives or swelling are not typical this maybe something to look into. Strongly elevated results may trigger a deeper dive into specific conditions and more testing
* Complement levels (particularly C4): The complement system is a component of our body that keeps inflammation and specifically swelling in check. If you have a family history of swelling, angioedema without hives, or other key components of the history, this may be investigated
* Tryptase level: Tryptase is an enzyme released by mast cells and if elevated could indicate a mast cell condition as the cause of your symptoms. This is another test that has to be interpreted with caution and tested only when symptoms are supportive
* Vitamin D: I like to check Vitamin D levels as there have been some associations of Vitamin D deficiency and uncontrolled hives and swelling. And if deficient, it is an important Vitamin to replace as it serves many essential purposes in our body, namely bone health

Treatment

If an underlying cause is identified, obviously we will focus on that. However, as discussed since most causes are not known, there is a recommended algorithm that helps that vast majority. It centers around higher than normal dosing of selective or non-sedating antihistamines to get the hives and swelling under control and if that doesn’t work, there are many other medications that can be added. However, if antihistamines do not work, I am quick to have patients evaluated for Omalizumab (Xolair) which is an injectable medication typically given monthly at a doctor’s office. This medication has changed the lives of more patients of mine than I can count and thankfully is extremely safe. However, as with any medication it is not without the potential for side effects and can be costly so that needs to be considered as well. When this hasn’t worked I have used more potentially toxic medications if the benefits outweigh the risks. If your quality of life is dramatically impacted and no other safer medications are working, these should definitely be discussed. Thankfully, it appears that many other new medications for treatment are on the horizon that may be options in the near future.

If there is a chance that stress is a contributor, I often advocate for working on ways to decrease that stress. Taking more time for yourself, exercising, making dietary changes, and possibly even seeing a counselor or psychologist to assist are just a few of many examples. I can’t tell you how many times a person has told me that once they were relieved of a particular stressor or started down a more healthy lifestyle, their symptoms improved or even resolved.