Allergies

What are typical environmental allergy symptoms?


Environmental allergy symptoms can include some or all of the following symptoms: episodes of sneezing, runny nose, nasal congestion, watery eyes, itchy eyes, nose or mouth, post nasal drip, cough, hives or fatigue.


What are common environmental allergies?


Symptoms may either be year-round (perennial) or seasonal depending on the particular allergen hypersensitivity.  For example, if a person is allergic to ragweed then this person may develop allergy symptoms during ragweed season (late summer and early fall). In contrast, if a person is allergic to dust, they may experience allergy symptoms year-round.


The most common environmental allergens include dust, molds, trees, weeds, pets and pollens.


Other types of allergies include allergies to food, medications, insect venoms and various metals/chemicals.  These types of allergies may cause different reactions beyond what a person may typically see with an environmental allergen.


How do I treat my allergies?


Environmental allergies can be treated with over the counter medications, avoidance techniques and environmental controls, prescription medications and/or immunotherapy.  The following sections will go into more detailed descriptions of each treatment strategy. Your doctor can help you decide what is right for you.

Over the Counter Medications


There are many over the counter medications to treat environmental allergy symptoms.  What works best for you may not be what works best for your friends and family.  Typically a regimen of an oral antihistamine, a steroid nasal spray and regular salt water irrigations of your nose work well.  There are other additional medications listed below which may be helpful when allergy symptoms are particularly bad.  You will need to experiment with a regimen to see what is right for you.  Your doctor can help you make a plan and decide what is the best personalized regimen for you.

  • Antihistamines: non-drowsy medications include Claritin (Loratidine), Allegra (Fexofenidine), Zyrtec (Citerizine), Xyzal (Levociterizine).  All available as generics listed.  Usually taken once daily but can be repeated in 12 hours if allergy symptoms are persistent (sneezing, itchy nose/eyes, runny nose/eyes)

  • Salt water nasal irrigation.  This is one of the most effective treatments for allergy and if done properly can only help. See more under the Avoidance techniques section.

  • Oral Decongestants: these medications constrict vessels in the nose and airways to diminish swollen tissues.  They are often sold as combinations with antihistamines and other medications usually designated as medication-D (ex Claritin-D).  A word of caution:  if used for more than 5 days (especially in combination with antihistamines), this can lead to thick mucus, dry nose and throat and worse nasal obstruction due to mucus plugging causing facial pressure and pain and ear fullness.  You can also experience rebound congestion as your body develops a tolerance to this medication.  If this occurs you may no longer experience benefit from the decongestant yet you experience worsening nasal congestion if you try to stop taking the decongestant. Decongestants can also hinder sleep, increase blood pressure and cause other side effects.

  • Nasal Spray Decongestants (Afrin, Dristan, 4-Way, Neosynepherine).  Similar to oral decongestants in that they constrict vessels in the nose.  Can be very effective for a few days but tend to start causing rebound swelling after a few days that can lead to dependency and even harmful to nasal mucus membranes.  Limit to 4 or fewer days of use if at all.

  • Steroid (anti-inflammatory) Nasal Sprays- Flonase (Fluticasone), Nasacort (triamcinolone), Rhinocort (Budesonide), Beconase (Beclomethasone), Nasalide (Flunisolide).  Best used after rinsing and/or gently blowing the nose to get mucous cleared out then apply by aiming away from the nasal septum (wall dividing the 2 sides of the nose).  Try aiming toward the ear on the same side as the nostril.  No need to sniff back as the nose will drive the medication back by itself.  We recommend using two puffs in each nostril twice daily.  It will take a week or two to start working, when the nose is more open start to taper the dose and maintain if nasal congestion continues through the season.  Can try to back off of medication when the environmental situation changes.  Go up and down on dosing/frequency to needs.  Do not exceed total of 4 puffs a day.

  • Anti-allergy (antihistamine) eye drops (for itchy, red, tearing eyes and eyelid swelling).  Examples include Ketoifen (Alaway, Zaditor), Olopatadine (Pataday, Patanol, Pazeo), Pheniramine and naphazoline (Visine, Opcon-A).

  • NasalCrom Spray: to be used specifically to avoid nasal allergy symptoms if you know you are going to an environment or task that will cause nasal allergy symptoms (like cutting the grass for some folks).  Apply to nose 30 minutes or so prior to the activity.  Don’t bother to use after the nasal allergy symptoms have started, as it likely will not help at this point.

  • Mucinex (Guaifenesin) can be used to thin out thick secretions to help clear chest or sinonasal thick mucus.  Note:  it doesn’t prevent mucus it only thins it.  It must be taken with lots of water to be effective.   This medicine comes in many different brands and combinations, be careful to read what is in the mixture.  See below

  • A word of caution on the wide variety of OTC allergy and cold medications: there are many, many to choose from and they are often in combinations and have very confusing names and claims on the bottles.  Remember that combination medications have multiple effects and interactions that are difficult to separate and can even make things worse (we see it frequently).  Many OTC medications can also interact with other medications you may be taking and even with certain foods.  Ask the pharmacist but remember we are here to help you sort it out and the pharmacist doesn’t see and treat patients with chronic ear, nose, sinus and throat issues; we do!  If in doubt, contact us for guidance.

Avoidance Techniques and Environmental Controls


The best way to stop allergy symptoms is to not come into contact with the allergen.  Unfortunately, this is nearly impossible given the amount of allergens in the air and in our environment.  The next best thing is to try to decrease your exposure.  Below are tips you can try to decrease this exposure.  We recommend attempting to make these changes in your own life within reason and not at the expense of your quality of life.  Likely most patients will require other treatment in addition to avoidance techniques for good control of allergy symptoms.

  • If you will be outside and “your” pollens and/or mold spores are prevalent, pretreat with a non-drowsy antihistamine or NasalCrom spray (see above section for recommendations)

  • When you finish outside time or a dusty job that increased your exposure to particulates, change clothes, shower, rinse your hair and irrigate your nose with a salt water solution using a nasal rinse bottle, Neti-Pot or if you prefer a powered (WaterPik, Nauvage) irrigator (more expensive but some patients prefer these). Take a look at NeilMed.com website: They have an excellent patient education section that shows videos and animations on how to do this effectively and without feeling like you are drowning yourself or getting fluid into your ears.

  • Change your furnace filter and replace every 3 months.  We recommend an electrostatic type such as those made by “Filtrete”.  Not necessary to use HEPA filters on the furnace especially since it likely shortens the life of your compressor, but the plain fiberglass ones are ineffective.   Be sure to change out regularly (more often if very high particulate counts to filter or if you are having work done in your home that generates more particulates)

  • Consider getting your vents cleaned out by a professional every 5-10 years or so, or after any major remodeling to your home

  • If you or a family member are pet dander sensitive please try to keep the pets out/off of the spaces/places where you spend more time like the bedroom or the sofa or easy chair.  Have a non-allergic family member do the grooming or change out bedding or litter for the pet or use mask if you do it.   Refer to the guidance for getting rid of particulates under the second bullet point above

  • Use a vacuum that has HEPA filter bags or cyclonic so you are minimizing how much dust you blow back into the room when you perform this task

  • If you are dust mite sensitive, use mattress and pillow covers and wash all bedclothes in HOT water (at least 140 degrees) weekly.  This includes blankets, comforters, etc.  Sleep in the bed not the upholstered chair or sofa that may be full of dust mites!

  • Look around the house for water leaks around pipes, drains or basements to minimize mold issues especially if you are sensitive.  If there is a mold problem there are companies and lots of information online for mitigating it in and around your home.  Consider de-humidifier in high moisture basement, check with humidity gauge.

  • Consider alternatives to organic mulch in landscaping under windows close to house that tend to hold moisture and grow molds

  • While the heat is on, consider using a humidifier to try to keep humidity in the bedroom or the room(s) you inhabit during the day.  Ideal humidity is around 40%.  Avoid much below 30% or above 50%.  A cool mist room air humidifier will cost around $30 and a humidity gauge can cost under $10 to monitor the levels.

  • Did you know that dry air causes thickening of mucus and can hinder nasal and sinus function as well as increase the likelihood of viral infection?!  Another reason why we like saline nasal irrigation (not just saline mist)

  • HEPA room air filters for indoor particulates can be purchased for well under $100 for a large room.  (Sometimes around $60!).  This is different than humidifiers, these devices filter out particulates like pet dander, dust and other allergens (not as effective for viruses and bacteria)

  • Don’t forget cross reacting foods for when your pollens are in-season.  These are the foods that might trigger throat or other allergy symptoms when eaten during times when you are also exposed to pollens or molds that you are sensitive to.  This occurs due to a quirk in the immune system that “fools” the body into releasing allergy chemicals like Histamine that can cause the symptoms.  If you have had allergy testing done you can get a list of potentially cross reacting foods to watch out for.  You can also find more information on potentially cross reacting foods for your allergens online.

  • Try to keep doors and windows closed on the days when pollens or mold spores you or your family member(s) are sensitive to are prevalent (check on the air quality).  This is difficult on one of our rare nice days this time of year!

  • Don’t forget the cabin filters and windows in the vehicles too.  Look at your owner’s manual for how to change filters or have the folks at the auto parts store, car wash, oil change place, service station or dealership help.


Prescribed medications


Most commonly an oral antihistamine, intranasal topical steroid sprays (as discussed in the over the counter medication section) and salt water nasal irrigations will control your allergy symptoms.  You can also talk to your doctor about the following medications:

  • Antihistamine nasal sprays (Azelastine, Olopatadine) – this medication is useful if you cannot tolerate the side effects (such as fatigue) of oral antihistamines

  • Singulair (generic Montelukast) which is another type of anti-inflammatory medication.  It is usually prescribed in patients with asthma or difficult to treat allergic rhinitis. A word of caution: the FDA recently added a boxed warning for this medication which states this medication can exacerbate neuropsychiatric conditions such as depression, anxiety, agitation, sleeping problems and suicidal thoughts and actions.

  • Oral steroids (ex. prednisone, Medrol Dose pack) – these medications may be used in severe allergy or allergic reaction.  There are many side effects of steroids including, but not limited to exacerbation of mood disorders, elevated blood sugars, severe hip pain caused by avascular necrosis, osteoporosis and GI upset. Your doctor will go over these risks if you are prescribed this medication.

  • Biologics – this is a relatively new class of medications which target a specific immune system signaling molecule.  They are typically given as injections and are used when you have uncontrolled allergy symptoms despite adequate therapy or uncontrolled comorbidities such as asthma or eczema.


Immunotherapy


This is a process where you are given a medication which contains the specific allergens you are allergic to in order to slowly desensitize you to that particular allergen. Immunotherapy can be given via shots, called SCIT (subcutaneous immunotherapy), or via drops or tablets placed under your tongue, called SLIT (sublingual immunotherapy).  Patients undergoing immunotherapy are often on this treatment for three to five years.


Subcutaneous immunotherapy (SCIT)


This type of immunotherapy is given as a weekly injection. As you begin to undergo desensitization, the shots can get spread out over time so that you are coming into the doctor’s office less frequently. If you have an allergy to multiple things, these allergens can be combined at your doctor’s office to make up your allergy shot which is personalized for you. Most insurance companies cover SCIT therapy.


Sublingual immunotherapy (SLIT)


This type of immunotherapy can be given either as a tablet or as drops which are placed under your tongue. The first dose of SLIT is often given at the doctor’s office to monitor for reactions and then if this goes okay, the patient can generally take the medication home to administer at home.


There are currently four FDA approved tablets for use in the United States including two tablets which treat grass allergies, one for ragweed and one for dust mites.  These tablets are manufactured by pharmaceutical companies and made to treat only one type of allergen.  Because you cannot combine allergens, these tablets are usually given to people who are only allergic to one thing (grasses, ragweed or dust) or given to people whose allergy response is dominated by one of these specific allergens (grasses, ragweed or dust). The tablets may be   covered by insurance.


Another method for delivering SLIT therapy is via drops placed under the tongue.  Different allergens can be added to the drops depending on the particular allergen hypersensitivity of the patient. Like SCIT, this can be personalized at your doctor’s office.  This type of therapy unfortunately is not covered by insurance and is typically paid as an out-of-pocket expense by the patient.


How do I get tested for allergies?


Talk to your doctor about getting tested for allergies.  Typically, we recommend getting tested for allergies if either (1) your allergy medications (oral antihistamine and nasal steroid spray) are not controlling your allergy symptoms, (2) you want to get desensitized with immunotherapy in order to potentially stop taking your allergy medications or (3) your comorbidities such as sinus disease or asthma are not in control and your doctor wants to understand if allergies are making these comorbidities worse.


There are two mechanisms for allergy testing – either skin testing or a blood test.  For most people, we recommend starting with a skin test.  The most common skin test is a “skin prick test” where a doctor will place substances you may be allergic to on your skin and make a tiny prick to see if a reaction occurs. This reaction will appear as an itchy red bump if you are allergic to the substance.  If a bump does not occur for a particular substance, but you and your doctor still have a strong suspicion that you are allergic to that substance, you may undergo a more sensitive skin test called an “intradermal” test. During an intradermal test, a small amount of the substance being tested will be injected just under your skin. Before you are skin tested, you will have to stop certain medications including antihistamines and beta-blockers.  Talk to your doctor regarding if skin testing is right for you.


A blood test for allergies may be helpful in patients who have a history of anaphylaxis, severe reaction to allergies in the past, poorly controlled asthma, skin conditions such as dermographism, urticarial or mastocytosis or in patients who cannot come off of certain medications. There are downsides to the blood tests for allergy.  The blood tests take time for the results to come back and are often costlier than the skin testing. The blood tests for allergies are also less specific and therefore a positive blood test to an allergen is not a confirmed allergy until a patient exhibits allergy symptoms to that particular allergen. For example, even if a blood test shows an allergy to cats (ex elevated IgE to cat dander), if a patient has a cat and does not show allergy symptoms when around the cat – the patient does not have a true cat allergy. Talk to your doctor about what testing is right for you.