Posts Tagged ‘asthma attacks’

Controversy abounds in medicine, especially when it comes to alternative forms of treatment, but there is one thing that almost everyone agrees on: feeling calmer and more

relaxed is good for your health. There are many ways in which a person’s mental and emotional state can affect their allergies or other sensitivity reactions (see pp. 232-7),

and these help to explain the beneficial effects of relaxation.
There are several different types of approach that can help in the quest for a calmer state of mind and a more relaxed state of body:
• Straightforward relaxation techniques which you learn and then practise for yourself, either on a daily basis, or whenever you need them, or both. Examples include

relaxation exercises of various kinds, biofeedback, autogenic training and self-hypnosis.
• Relaxation techniques that are rooted in spiritual practice, such as meditation, yoga, t’ai chi or chi kung (ql gong). Some other martial arts, in addition to t’ai chi,

also have a strong element of spiritual practice.
• Treatment techniques such as massage, aromatherapy, reflexology and short courses of hypnotherapy, that are intended to help you feel more relaxed. Acupuncture (see p.

214) can also have this effect. Some therapists providing this type of treatment will also teach you simple relaxation exercises to use at home.
• Investigative approaches that look into the fundamental causes of tension, and attempt to deal with deep-seated emotional problems: psychotherapy (in its many different

forms), psychoanalysis, long-term hypnotherapy when this has psychotherapeutic aims, and biodynamic massage.
In the long run, approaches that make you dependent on another person (an aromatherapist or reflexologist, for example), in order to feel relaxed, are usually less helpful than

those that give you an active role. If you are learning and practising a technique, as with relaxation exercises or yoga, this puts you in charge of your state of mind.
The techniques that are rooted in spiritual practice, especially meditation and yoga, are particularly helpful because they invite you to take a very broad view of the problems

that face you, and the situations that cause you stress. Firstly, rather than focusing very narrowly on your own tense muscles and recurring difficulties, they look at the human

situation as a whole – at the basic causes of tension and unhappiness in human beings. Secondly, rather than trying to graft a relaxed viewpoint onto a horribly unrelaxed daily

existence (which is what most of us now endure) a regular meditation practice can result in a fundamental and long-lasting change in outlook, with a greater sense of wholeness,

direction and stability. This is something that happens naturally within the stillness of meditation practice, and it should be very much an individual process of change, not

something imposed from outside. At a purely practical level, a spiritual practice tends to improve relationships with other people, and since a great deal of our stress is

caused by the people around us, any improvement in our social interactions can reduce stress enormously.
Some kind of psychotherapeutic approach may be the best choice for those who have tried and failed with other techniques, or achieved only a temporary reduction in stress

levels. By tackling the problems at a deeper level, it is often possible to achieve a more profound and long-lasting solution.
Many people discover that, whenever they try to relax or to meditate, they feel even more agitated and anxious. Others begin to cry, or show other signs of distress. Not

surprisingly, people who react in this way quickly give up their attempts to unwind, because their responses are so disturbing. Underlying these reactions to relaxation

exercises there may be deep-seated problems, usually going back to childhood, that can only be held at arm’s length with the help of a tense and always-busy approach to life.
Constant mental activity is part of this defensive strategy, which is why relaxing or meditating is such a frightening experience. Although it is tempting to run away from the

problem, by plunging back into a life of frenetic activity, mental and physical, this is ultimately no solution. Some form of psychotherapy is usually needed to deal with these

long-standing problems.
Whatever you decide to try, make sure that the teacher or therapist seems a calm and relaxed person. You should also look for someone who is sympathetic and supportive about

your illness. Avoid like the plague those who attribute all allergies and other physical symptoms to mental or emotional problems. Such people can cause immense psychological

damage – if you don’t get 100% better it will, of course, be your fault.
Hypnotherapy
Hypnosis has a distinctly shady reputation, because of its use – or misuse – in stage and television performances. If hypnosis were not so valuable medically, it would probably

be rejected entirely by conventional medicine, on the strength of this reputation. The fact that hypnotherapy is used by some entirely mainstream doctors, as a legitimate

treatment for conditions such as atopic eczema, is a great testament to its effectiveness.
Hypnosis is certainly a mysterious phenomenon, and it is difficult to say exactly what happens when a person is hypnotised. Dr Ruth Lever, a qualified doctor who combines

hypnotherapy with conventional medical practice, describes the hypnotic state as ‘not a form of unconsciousness but rather an altered form of consciousness, in which the patient

is more open to suggestion than he would normally be, and in which a corridor is opened between the conscious and the subconscious mind’.
It is certainly not true that the hypnotised person is under the control of the hypnotist or hypnotherapist. Autonomy is retained, and no one under hypnosis can be forced to do

anything that is really against his or her will. While the person may experience a different state of mind, he or she remains aware of what is going on in the room and anything

that is said.
The exact change in mental state during hypnosis varies greatly from one person to another. Some people respond far more readily than others, and go into a deeper hypnotic

state. (These same people are more susceptible to placebo effect, a psychological response to drugs or other forms of treatment –see p. 233.)
At one time, it was thought that only adults could be hypnotised. Children seemed to be immune to hypnosis, but in fact they are just immune to the particular hypnotic

techniques used for adults. With the right techniques, children can also be hypnotised.
Hypnotherapy treatment can be quite brief, taking only a few sessions. This approach relies on suggestions from the therapist to achieve relaxation, a change in perceptions

(e.g. that the skin feels cool and smooth, for someone with atopic eczema) and a change in habits (e.g. stopping scratching).
Another approach is to use hypnosis as a means towards achieving personal insight into emotional problems by accessing suppressed memories. This is a long-term treatment, which

has much in common with psychotherapy. It should only be practised by those who have full psychotherapy training.
Scientific studies show that hypnotherapy can be of benefit in both asthma and atopic eczema. Make sure you get a really well-qualified hypnotherapist –preferably someone who

also has conventional medical training, or psychotherapy training, and plenty of experience.
You may be given exercises in self-hypnosis to do at home, or tapes, possibly music tapes to be played at bedtime for children with eczema. These can be very useful in

reinforcing the messages from the hypnotherapy sessions about sleeping deeply and not scratching,Relaxation exercises
Acquiring the knack of relaxing is a very personal thing – what works for one person will be useless for another. You may have to try several different techniques before you

find one that is right for you.
Guided imagery is often an effective method, and increasingly popular with the widespread availability of relaxation tapes. The tape will ask you to sit in an armchair, or lie

down, and picture the scenes described (’waves are lapping gently on the golden sand…’ etc.). If you are able to visualise the scene, this should induce a more relaxed state

of mind – rather like the relaxation you get from watching a good film.
There are also tapes of special music, or music combined with natural sounds (waves, seagulls etc.) that are intended to produce a relaxed state of mind. Much of this music is

incredibly banal, and it may irritate you more than relax you! However, there are also some excellent tapes available, so shop around.
One time-honoured method of relaxing is to sequentially contract, and then release, muscles in each part of the body, beginning with the hands or feet. This is known as

Jacobsonian systematic relaxation training or progressive muscle relaxation. A study of children suffering from asthma found that this training increased the peak flow by an

impressive 32% for some children, although others did not do quite so well.
Autogenic training
Based loosely on self-hypnosis, autogenic training is a very down-to-earth approach to relaxation which may be useful for anyone who is wary of things esoteric. You are taught

to concentrate on different parts of your body in turn and imagine them growing warm and heavy. Beginning with ‘my right arm is heavy and warm…’ (repeated three times, either

out loud or in your head) you work your way through the rest of the body: ‘my left arm…’ , ‘both my arms…’ , ‘my right leg…’ etc.
You could, in theory, teach autogenic training to yourself, using a book, but it is helpful to have to go to a class. The teacher can encourage you to persist when you feel

discouraged by your slow progress, and can help with any problems that arise.
Teachers of autogenic training often add more specific lines at the end of the exercise, such as ‘my breathing is calm and regular’ for asthmatics, or ‘my skin is soft and cool’

for someone with eczema. A study of asthmatics found that they performed better in basic lung-function tests after eight months of regular autogenic training.
Autogenic training can sometimes evoke strong reactions if there are long-standing problems or suppressed feelings and memories. In these situations, the training sessions may

need to incorporate some elements of psychotherapy. Teachers vary in the extent to which they can offer this.
Yoga
Yoga, in its original form, provides a complex religious philosophy of life. If followed with dedication, it affects the whole person –physical, mental, emotional and spiritual.

Those who have practised yoga seriously for many years achieve a great deal of mental focus and calmness, plus a surprising level of control over bodily functions such as blood

pressure and heart rate. These profound changes are achieved through a combination of breathing exercises (pranayama), yoga postures (asanas), meditation, cleansing practices

and careful attention to diet and way of life.
Yoga has now been practised in the West for over a century, and during that time it has been watered down and very thoroughly Westernised. There are now forms of ‘yoga’ that

consist of little more than stretching and relaxation.
For the greatest benefits from yoga, look for classes with a more rigorous approach. If the particular kind of yoga is specified, e.g. Hatha yoga or Kundallni yoga, the chances

are that you’ll be getting something more authentic,
lyengar yoga is the most common form taught in the West, but it is rather narrow, concentrating almost entirely on postures. A form of yoga that includes breathing exercises is

probably more useful, especially if you have asthma.
Before you sign up for a class, talk to the teacher and find out what it includes. If you are asthmatic, make sure the teacher is really experienced in working with asthmatics.

It is all too easy to get the yoga breathing exercises wrong, making the breaths too deep. This can turn into a form of hyperventilation (see p. 226).
Approaching the breathing exercises with a ‘got to get this right’ attitude is another pitfall for Westerners doing yoga. Most of us have the unfortunate habit – acquired in

early childhood – of tensing up and ‘really trying’ when we are taught anything. This is a major obstacle to doing yoga breathing correctly. Eastern attitudes are much more

easy-going and this helps asthmatics much more, because relaxing as you breathe is the key to it all.
Meditation
Basic meditation involves stilling the mind – either emptying it of all thoughts, or focusing it on one very simple object. This is fantastically difficult for most people at

first, but with time, and regular daily meditation, it gradually becomes easier.
Many different forms of meditation exist. Most are part of a spiritual tradition such as Hinduism, Sri Lankan Buddhism, Tibetan Buddhism, Zen Buddhism, or Taoism (Daoism).

Meditation also forms part of yoga, and it is a cornerstone of most martial arts, though this tends to be played down when these are taught in the West. In each case, meditation

takes a slightly different form and has different psychological effects.
A practice known as transcendental meditation (TM), is one of the most widely available – the teaching is arranged by a large international organisation, and can prove

expensive. It is cheaper, and probably better in the long run, to go to classes in a local Buddhist centre or consult one of the many books and tapes on this subject. ect.
Biofeedback
This is the most thoroughly scientific, rational and high-tech of alternative treatments. Biofeedback uses technology to measure the state of some part of your body – a part

that is usually under automatic control, such as the electrical activity in your brain –and relays this information back to you (hence bio-feedback) .
The feedback is shown by means of swinging needles on dials, flashing lights or bleeping sounds. The idea is that you gradually learn to influence the signal, by noticing that

it has changed very slightly in the desired direction, and then re-running (in your head) the thoughts or feelings which apparently led to that change.
In quite a short space of time, you can, with this method, alter bodily states that are beyond voluntary control in most people. Scientific studies show that biofeedback can

teach people to regulate their heartbeat, for example, or reduce the amount of acid produced by the stomach. Although yoga practitioners have long claimed to be able to

influence such bodily functions. it was only with the invention of biofeedback that scientists accepted this was possible.
Biofeedback can also teach asthmatics to relax tight airway muscles, something that has been demonstrated convincingly in scientific trials. Unfortunately, the specialised

equipment needed for this particular form of training is not generally available.
If you sign up for biofeedback, you will probably be trained with equipment that measures the electrical resistance of the skin (this varies with how tense you are) or the

electrical activity of the brain. This kind of equipment can help you learn to relax at will.
Massage and aromatherapy
There are many different varieties of massage, and most are relaxing to some extent. Regular massage treatments may improve your general sense of calmness and your ability to

cope with life’s stresses and problems. In the case of long-standing asthma,
massage may also help with tension in the muscles of the chest, back and neck, which frequently develop during asthma attacks.
Aromatherapy is really a form of massage, with the use of scented oils. Bear in mind that the strong smell of some oils can provoke asthma attacks (see p. 39), while other oils

can irritate the skin of people with atopic eczema or contact dermatitis.
Biodynamic massage involves a much more subtle touch than other forms of massage and it has different aims. The central objective is to identify bodily tensions that are a

result of repressed memories or blocked impulses, and to rebalance the energies of the body. Think of this more as psychotherapy than as massage. It can be very helpful.
Reflexology and zero balancing
Reflexology is based on the belief that specific zones on the soles of the feet correspond to particular parts of the body, and that stimulating those zones on the feet (by

gentle pressure) can induce a healing process at distant points in the body. It may or may not be true – certainly, having your feet massaged is immensely pleasurable and can

induce a profound relaxation.
Zero balancing is a sequence of static touch, gentle holding and light pressure, applied to specific parts of the body. It can induce a state of great well-being and calmness.
Psychotherapy
The basic tenet of psychotherapy is that it is much more painful and exhausting to keep on repressing bad memories than it is to bring them out into the open, in a safe

therapeutic situation, which allows you to process them and move on. Dealing with deep-seated problems lets you relax and live life more fully. In some cases it may help with

physical symptoms, such as allergies.
There is a bewildering choice here, with so many different varieties of therapy on offer. Fortunately, according to recent research, they a// work to about the same extent, as

long as you have a good rapport with the therapist. But if you don’t click, the therapy usually doesn’t work, however expert the therapist might be. So make sure you have an

introductory meeting before committing yourself to a course of therapy, and don’t be afraid to say ‘no’ and try someone else, if you don’t feel quite right with the therapist.
Counselling can also be valuable, and again you will do much better with someone you feel at home with, but who is not afraid to challenge you when necessary.

Air Pollution and Allergy

Air pollution plays a variety of roles in allergic reactions. Some pollutants irritate the nose and airways (and sometimes the skin) making them more sensitive to allergens. These pollutants can worsen existing allergic symptoms and may promote the development of allergies in children, by making the airway membranes more permeable. Other chemical pollutants may affect the immune system directly, increasing any existing tendency to allergic reactions.
Indoor pollution
For many of us, the air in our houses is much more polluted than any outdoor air. Several of the indoor pollutants irritate the nose and airways, and some can trigger asthma attacks. A few of the pollutants found indoors can also make allergies and asthma more likely to develop in young children.
Background pollution
One of the worst irritants in indoor air is tobacco smoke. Other people’s cigarette or pipe smoke can trigger asthma attacks in the short term, and makes asthmatics generally worse in the long run. Passive smoking might also affect the immune system making allergies more likely to develop, though this is not proven. Do whatever you can to eliminate tobacco smoke from your home.
Everyone is different
This article considers air pollution from the point of view of someone with classical allergies (e.g. hayfever or asthma). Those with chemical intolerance (see p. 84) may well be more severely affected by air pollution.
If you smoke yourself, there are many good reasons for giving up:
• If individuals from atopic families (see p. smoke, they have a far greater chance of developing allergies and/or asthma when exposed to an allergen in the air.
• For those who had asthma as children and have since grown out of it, cigarette smoking doubles the chance of it coming back.
• Parents of asthmatic children who smoke indoors make their children’s asthma worse. Teenagers can be just as badly affected by passive smoking as young children.
• Smoking during pregnancy significantly increases the risk of a woman’s baby developing allergies and asthma. (Smoking also leads to more prematurity, still-births and cot deaths.)
If possible, have an electric cooking stove rather than a gas one –or fit a powerful extractor fan. Cooking with a gas stove generates a lot of nitrogen dioxide, a gas that you can’t smell or see but which affects the airways. This same gas also comes from motor traffic, but peak levels of nitrogen dioxide in kitchens with gas cookers are often ten times the average level on city streets, and frequently exceed standards for outdoor air set by the world Health Organisation. Other sources of nitrogen dioxide include cigarettes, gas fires and kerosene-burning stoves.
For some people with allergies, nitrogen dioxide enhances their response to the allergen. So if you inhale dust-mite allergen together with nitrogen dioxide, it may have more effect than the Smoke screen
Smoke particles from coal or wood do not seem to make allergies more likely to develop - in fact, quite the reverse. In rural areas of Germany, researchers have found that children with coal or wood stoves in their homes were less likely to have allergies or asthma. An Australian study made a similar finding. Bronchitis and pneumonia are more common in those children with wood and coal stoves and these infections may stimulate the immune system in such a way that allergies are less likely to develop later. However, wood smoke may be a cause when asthma begins in an adult.
allergen alone. Breathing sulphur dioxide (see below) and nitrogen dioxide together boosts the reaction to allergen more powerfully than either gas alone.
Nitrogen dioxide might also make asthma attacks more likely, but the evidence on this is conflicting.
For young children, a high level of nitrogen dioxide at home may make the development of allergic reactions more likely. A recent Canadian study showed that children exposed to high levels of nitrogen dioxide in the home - usually from gas cookers - were ten times as likely to develop asthma as those breathing low levels of nitrogen dioxide. If a dog, cat or other furry pet was kept, and there were high nitrogen dioxide levels, the risk of developing asthma shot up even higher, to 25 times that of children with low nitrogen dioxide and no pets. (Other studies have not produced the same spectacular results, but their methods of measuring nitrogen dioxide exposure were less precise.)
Try to eliminate materials that produce formaldehyde fumes, or seal the items with a good coat of paint. Formaldehyde is given off by chipboard and to a lesser extent by MDF (medium-density fibreboard). Injected cavity wall insulation can also produce persistent formaldehyde fumes, and is very difficult to get rid of -moving out is often the only option. A recent study from Australia showed that children exposed to formaldehyde, especially in the bedroom, were more likely to develop allergic reactions: the higher the level of formaldehyde exposure, the more severe the child’s allergic sensitisation.
Those with asthma have more frequent symptoms if exposed to high formaldehyde levels. A recent study from Finland shows that easy-to-clean plastic wall-covering and flooring increases the risk of asthma in children.
A Canadian study found that children whose first home was less than 20-30 years old were 50% more likely to develop asthma than children living in older houses. One possible explanation for this lies with the materials used in the construction and fitting of new houses, especially the plastics, wood preservatives and insulation materials. Solvents, and chemicals such as formaldehyde, are still being given off by these materials some years later.
Air fresheners provoke asthma attacks in some people. For a few individuals they can cause general symptoms of ill-health that are similar to those described for mild chemical intolerance (see p. 84). Those affected generally don’t realise that the air freshener is the source of the trouble. This malign effect is not entirely surprising, since air fresheners work by giving off a chemical that targets part of the brain - the part involved in processing sensory input from your nose. The chemical ‘freshens the air’ by partially disabling your sense of smell. Better to open a window.
Cleaning products, furniture polish and deodorant were never intended to go into the nose and airways, but that’s what happens when they are sprayed from an aerosol, and they can trigger asthma attacks. Steer clear of aerosols as much as possible - there are usually alternatives.
Pollution peaks
Read the instructions and ingredients lists on all products carefully. It is not just a question of what’s in them, but also what gases they might give off when used. One asthmatic died within minutes when the de-rusting agent she was using on her dishwasher produced a large amount of sulphur dioxide gas: her airways tightened up so much that she couldn’t even use an inhaler to save herself. ‘Sulphuric’, ’sulphate’ or ’sulphite’ in the list of ingredients should ring warning bells if you have asthma: sulphur dioxide gas could be given off by this product.
Bleach, and other chlorine-based cleaning products, such as toilet cleaner and scouring powder, should be used sparingly, and with plenty of ventilation. These products release chlorine gas which, in large amounts, can irritate the airways of asthmatics. Never allow bleach or toilet cleaner to become mixed with any other product. Take care with any product containing hypechlorte, chloramine, ammonia, acids or morpholine and with the chemicals used for swimming pool water. All these can trigger asthma attacks.
If doing repairs or DIY work about the house, take special care. Always ventilate the work area well, and wear a dust mask if sawing or drilling.
The smell of paint is due to solvents, and these can act as irritants to the nose and airways. When decorating, ventilate well, and use low-odour water-based paint. Some of the best low-odour paints, tested and shown to be safe for paint-sensitive asthmatics, are only available by mall order: see p. 255.
‘Instant foam’ kits sold for DIY insulation can provoke asthma in those who were not asthmatic previously. Two different substances are mixed to create the polyurethane foam, and during the mixing process, isocyanate is released – this is one of the most powerful asthmagens known (see box on p. 132). The level of isocyanate can breach the safety limit set for factories.
Avoid using fly spray or other insecticides: look for other methods of pest control. A study from Ethiopia showed that people using an insecticide in their houses were twice as likely to develop allergies. A study of Canadian farmers suggested that asthma might be linked to the use of carbamate insecticides (e.g. carbofuran). The sprays used for cockroaches can act as irritants for those with allergic rhinitis or chronic sinusitis.
If advised that your house needs spraying with insecticide, for woodworm or other wood-boring pests, ask for more information before you go ahead. Is the spraying really necessary? What will happen if the house isn’t sprayed? How quickly will it happen? Is there any other method of eradicating the pest? Spraying is often done when it is not really essential – houses remain standing even with woodworm holes all over them. Unless you have a heavy infestation that is threatening the structure of the house, you are probably better off not having the house sprayed. The heavy and ongoing exposure to insecticide that spraying of a house involves is something you and your family should avoid if at all possible. All the sprays used are toxic to some extent – don’t believe those who tell you otherwise. A heavy exposure to pesticides can sometimes make allergic symptoms worse or precipitate chemical intolerance (see p. 85).
The garage, workshop or garden shed can also be very polluted. Petrol, kerosene and paraffin can affect some people with rhinitis or asthma, and can bring on their symptoms. These fuels should always be kept in airtight containers. Paints sold for cars often contain isocyanates, among the most common causes
of work-related asthma (see box on p. 132). If using such paint, wear a mask with an activated carbon filter and make sure the area is well ventilated. Avoid prolonged or repeated exposure.
Outdoor pollution
Some of the pollutants in outdoor air can make allergic reactions worse and can trigger asthma attacks in people who are already asthmatic. A study of hospital admissions in London, Paris. Barcelona and Helsinki found that high levels of pollution increased hospital admissions for asthma by about 3%.
The pollutants that matter to those with allergies are:
• ozone, which soars to high levels on sunny days, mainly in country areas that are near large cities. The reason for this is a chemical reaction which occurs when car exhaust fumes are exposed to sunlight, producing ozone, a highly reactive form of oxygen. Further chemical reactions, involving another ingredient of exhaust fumes, then break the ozone down again. Thanks to this second reaction, there is usually little ozone in city air. But in a relatively rural area 20 miles or so upwind of the city, the pollutants are too dispersed for the second reaction to occur, and the ozone from the urban traffic can accumulate.
Ozone levels in the air tend to peak in the late afternoon and early evening – but it takes 4-24 hours for ozone to produce its effects on the airways. Indoors, ozone breaks down very quickly because of contact with other gases inside the house.
Ozone can increase the effects of allergens, such as pollen, on the nose and airways.
In addition, ozone makes the airway muscles contract, even for people without asthma. Healthy people tend not to notice these effects, whereas some asthmatics may have more symptoms, and may need more drugs, on days when ozone levels are unusually high.
• diesel particulates, which can become a problem in town centres, and close to main roads used by vans and lorries. Unlike ordinary petrol, diesel fuel contains oil, so when it burns it produces tiny black particles. These consist of flakes of carbon (soot), coated with complex chemicals that are produced by the
But what about the ozone layer…?
Is ozone good for us or bad for us? People often get confused about this, because of all the discussion about
‘the destruction of the ozone layer’. But that ozone layer (which screens us from harmful ultraviolet light) is a natural phenomenon and it is thousands of feet up, well away from our lungs. At ground level, in the air we breathe, ozone is unnatural and potentially damaging .
The size of the particles
Diesel particles are 1-10 microns in size, with most smaller than 2.5 microns. Tobacco smoke, coal smoke, fumes from oil-burning boilers, and the smoke from frying food all contain very much smaller particles, down to a hundredth of a micron (.01 microns) in size. (A micron is a thousandth of a millimetre.)
In pollution reports, counts for particles in the air (mostly diesel particles these days, except in heavily industrialised areas) will often appear as ‘PM1 0′, meaning ‘Particulate Matter less than 10 microns in diameter’. This particle size is chosen because larger particles tend to settle in the nose and throat, and not reach the airways of the lungs. The term ‘Small Particles’ is sometimes used to mean PM10.
To deal with air pollution, you need a really good mask with two filters: a dust filter that can take out very small particles and an activated carbon filter that absorbs irritant fumes and gases. Note that while activated carbon filters remove most pollutants, they do not take out nitrogen dioxide unless they have been specially treated.
partial combustion of the oil. It is probably these surface chemicals, rather than the soot particles themselves, that have such bad effects on the nose and airways.
Some research suggests that diesel particulates might increase the risk of allergies developing – to pollen for example. Additionally, when levels of diesel particulates are high, asthmatics tend to have more symptoms. If levels rise above 50 micrograms per cubic metre there is a sharp increase in asthma attacks – and a recent study in Birmingham showed that such levels are regularly reached at roadsides.
• sulphur dioxide, which often reaches high levels in areas of heavy industry, particularly near coal-fired power stations and coking plants. It acts as an irritant to the airways and can trigger attacks in asthmatics, who are far more sensitive to sulphur dioxide than healthy people (see box on p. 207). However, at the sort of concentrations normally encountered, even in quite polluted air, sulphur dioxide does not have any effect on most asthmatics.
• nitrogen dioxide, which is produced by all types of vehicles, and by power stations and some factories. In towns and cities with heavy traffic, nitrogen dioxide can build up to high levels. This gas is also found indoors (see p, 128) – often at far higher levels.
Oil refineries and cement works
In addition to these widespread pollutants, there are localised areas of air pollution, around industrial sites, that are frequently accused of causing health problems, including high rates of asthma. The kinds of industrial sites regularly mentioned include:
• oil refineries and oil-burning power stations
• cement works that use waste solvents for fuel
• dock areas where oil is loaded into tankers.
None of these accusations has been investigated in any detail, so it is impossible to say if there is a real link with asthma.
Avoiding outdoor air pollution
If you live in the kind of area that experiences high levels of ozone (see p. 130), plan your outdoor activities, especially jogging or playing sport, to avoid summer afternoons and early evenings.
Those who live very close to a main road, with a lot of lorries going past, would probably improve their own health, and reduce the chance of their children developing allergies and asthma, by fitting air conditioning or high-quality HEPA air filters – or by moving house. However, the benefits, in terms of decreased risk, are not enormous, and it is important to take other preventive measures as well (see Chapter 8).
When driving, if you stop behind a lorry or bus, keep your distance, close the window and turn off the fan. Diesel vehicles often emit a thick cloud of particles as they set off, and this can come straight into your car, setting off severe attacks for some asthmatics.
A car with air conditioning will reduce your exposure to diesel particulates while driving. When buying a new car, you can make a contribution to air quality by choosing a non-diesel vehicle, preferably one with a catalytic converter fitted. Alternatively, buy a diesel vehicle with a particle filter on the exhaust (now fitted as standard in Germany).
In Britain, the Vehicles Inspectorate of the Department of Transport encourages the public to report lorries and buses seen pumping out black smoke (look in the phone book for the number).
If you are asthmatic, breathing through your nose may help as this can filter out some damaging pollutants before they reach the airways in your lungs. (If your nose is usually blocked, try the exercises on pp. 230-31).
When levels of ozone or sulphur dioxide are high, taking a supplement of Vitamin C and eating plenty of foods that contain Vitamin E and beta-carotene (see p. 207) can protect your airways.

Many countries have special schools for children with severe asthma and other allergies. Italian children are sent to one in the Italian Alps, where there is no trace of pollen, house-dust mite, or animal allergens. After nine months these children are a great deal healthier and more active - all their lung function tests are vastly improved. Blood tests show that they are actually less allergic to common allergens than before.
You may not be able to do quite this well at home, but all allergens and irritants can be avoided to some extent. Even if you can’t eliminate them completely, you can certainly reduce your exposure.
Before you start, it is important to be clear about exactly what affects you, otherwise you will be wasting a lot of effort. For example, people who are allergic to dust mite often think that a dusty house will necessarily be worse for them than an apparently clean house, but this is not so (see p. 115). Or they may say ‘Oh, I got asthma on holiday, because the roads were so dusty and I’m allergic to dust,’ forgetting that only house dust contains dust mites. The road dust may have acted as an irritant, and helped to spark the asthma attacks, or it may have contained pollen or mould spores - but it does not contain dust mites or their allergens. Blaming the wrong thing for the asthma attack means that the real culprit is not identified.
If you are not absolutely sure what causes your allergies, skin-prick tests (see p. 91) can identify the allergen. These are especially recommended if your reactions to the presumed allergen are inconsistent, or you don’t respond to the anti-allergen programmes described here. For example, a few people who react to house dust are not allergic to dust mites, but to something else in the dust such as wool fibres or mould spores, or particles from cockroaches, house
flies, carpet beetles or a long-departed cat. Even pollen that has accumulated in house dust can provoke allergic reactions - if you are not an over-keen duster, it can still be there long after the pollen season.
If you have hayfever, knowing which pollens cause your symptoms (and learning to recognise the plants concerned) is useful. You will probably need skin-prick tests to be sure. ‘Hayfever’ can even be a seasonal mould allergy in some people (see p. 27).
Tackling allergens is now big business. There are a lot of people out there competing for your money and false claims are common, especially for anti-mite products. Only a few manufacturers are deliberately misleading, and most false claims probably stem from ignorance or wishful thinking, but be very sure you know the facts about your allergen before you buy.
Air cleaners are a good example. A really good quality air cleaner (which uses a HEPA filter - a High Efficiency Particulate Air filter) is an expensive purchase and, as the advertising tells you, it takes out very small particles with staggering efficiency. But this is entirely irrelevant if the source of those particles is no distance at all from your nose - your mite-infested pillow, for example, or the cat on your lap.
Something else that advertisements for air cleaners rarely mention is that unless you reduce allergen production - tackling mould growth in the house, for example, or keeping the dog outside - the filter can’t help much. In short, air cleaners do have their uses for some allergens, but they can’t work miracles.
The products mentioned here, if not available in your locality, can be bought mail-order from specialist suppliers of anti-allergy products (see p. 255). Note that some offer both very good products and distinctly doubtful products, so judge each item on its individual merits. Ask to see scientific evidence that it works.
Don’t be taken in by vague statements such as anti-allergenic’ - get the facts. This label is often used on pillows with synthetic filling, for example, and people assume that it refers to dust-mite allergy, whereas it simply means that the pillow does not contain feathers. But unless you are allergic to feathers, there is no reason to avoid feather pillows. (In fact, if not covered with mite-proof covers, synthetic pillows collect more dust-mites than feather pillows, because the fabric used for the cover is less tightly woven and the mites and skin particles get in more easily.)
Bad advice is also a hazard. Some of it just wastes your time and effort, but some could actually increase your exposure to the allergen. Advice to vacuum floors daily, or to vacuum beds, is commonplace but this achieves little and it means breathing much more allergen unless you have the right kind of vacuum cleaner. One health magazine even advised its readers with dust-mite allergy to ‘air mattresses by regularly turning them’. This will not affect mite numbers at all, but it will shoot massive amounts of mite allergen out of the mattress and into the nose and lungs.
Ridding your house of allergens and irritants is, in itself, a hazardous procedure because more of the offending substances will be released into the air during the work. If you take up carpets or remove mattresses, dust-mite allergens and mould spores will be churned up in their millions. Just bundling up a duvet will produce invisible clouds of dust mite allergen - and cat allergen, if your pet once slept on the bed.
Ideally, the allergic individual should not do the work, nor be in the house until it is 100% complete and the house has been very thoroughly aired. This is particularly important for those with chronic sinusitis and mould growth in the house, because of the risk of fungal infections in the sinuses (see p. 32).
If you are an allergy sufferer and have absolutely no choice but to do the work yourself, or to be present, then you should get a good quality dust mask and wear it throughout - only take it off when you go outdoors. Those with atopic eczema and sensitivity to airborne allergens should cover their skin carefully -with clothing, not barrier cream.
An ordinary hardware-shop dust mask is not adequate for most allergens - it only takes out really big particles and lets through all the common airborne allergens except pollen. You need a more serious sort of mask, designed for workplace use and conforming to official standards. Before buying one, ask what is the smallest size of particle that it filters out (at 90% efficiency, or better). Compare this with the particle size of your allergen (given in the articles that follow).
You must be able to breathe well through the mask when physically active, and it must fit tightly against your face, forming a seal at all edges. Beards and moustaches tend to prevent this - as does stubble.
Masks that combine an activated carbon filter with a dust filter will take out gases and chemical vapours as well as particles. Cycle shops now sell such masks -or try an industrial supplier. Such a mask can be useful if you are affected by traffic exhaust or industrial pollution as well as an allergen, for example, or if you are exposed temporarily to wet paint or other fumes at home. Activated carbon masks should also filter out the irritant substances from oil-seed rape plants.
Some people who try the anti-allergen programmes feel much better quite fast. But generally these are long-term strategies - you may not reap any benefits for a few weeks, and the improvement may be small at first. Sometimes it takes several months for the full effects to be felt, so be persistent.

Moulds and Other Fungi

The air around us is full of bits and pieces that are mostly too small to be seen without a microscope - pollen grains, mould spores, fragments from plants, fibres from clothing, specks of ash from smoke, skin flakes and diesel particles. Of these, mould spores are by far the most abundant.
Except in very dry climates, there are more mould spores in the air than anything else. In Britain the record count is over 160,000 spores per cubic metre of air, compared to a record pollen count of only 2800 grains per cubic metre. Luckily, mould spores are not particularly allergenic or even more people would be suffering as a result of inhaling such huge quantities of them.
Spores are produced by moulds and other fungi, and they are to the fungus what seeds are to a plant – they can grow into new fungi. Doctors generally speak just of ‘mould allergy’ because moulds are the most common offenders, but larger fungi – mushrooms and toadstools – also produce allergenic spores. For example, a bracket fungus called Ganoderma, that infests dead trees and produces spores prolifically in mid-June, has been found to affect 16% of asthmatics in one part of New Zealand. Bracket fungi occur all over the world, but until recently no one had suspected them of causing allergic reactions, so the extent to which they cause allergies has not been investigated. The same is true of other large fungi.
Yeasts (single-celled fungi) are also found in the air, and it is possible –though this has not been investigated – that people with an allergy to yeast in food would also react to inhaled yeasts.
Indoors and out
Mould spores are a particular nuisance because they can be produced both indoors and out. There are different species of mould in different places, and you may be lucky and only react to one or two uncommon species. But many moulds grow in a very wide range of situations, both indoors and outdoors. There are also cross-reactions (see p. 14) between some of the moulds, unfortunately, which means that people generally react to a great number of different moulds. You will probably need to reduce mould growth inside your home as well as avoiding mould-rich places outside. Changes to your garden that eliminate havens for moulds, such as leaf piles, may also be helpful.
Moulds may only be growing in one part of a house – the cellar perhaps – but can be carried all around the house on air currents.
The size of the allergen particles
Most mould spores are between 2 and 10 microns in size. A few species have spores that are smaller than 2 microns.
(A micron is one thousandth of a millimetre.) Some people with mould allergy may be protected by an ordinary dust mask (see p. 109), but most will probably need a better-quality mask.
Avoiding outdoor moulds
Moulds live in the soil, and grow on any decaying plant matter, such as dead leaves, dying plants, fallen trees, hay and straw. Spore counts are highest in the autumn. A thick covering of snow reduces the numbers of mould spores in the air dramatically. Once the snow melts in spring, moulds flourish on the plants killed by the cold, so spore counts soon rise again.
The effect of the weather on spore release is very complex. Some moulds like to release their spores when it is dry and windy, but others favour fog, mist or dew. Rainfall washes a lot of spores out of the air, but it stimulates the release of some small spores.
A few pollen information services also give current mould-spore counts, but predicting spore counts for the following day is well-nigh impossible.
Drastic avoidance measures, for those who are severely sensitive, include moving to a desert or semi-arid area where there are far fewer mould spores in the air.
Listed below are the mould-rich situations and activities which could provoke your allergy symptoms. If they do, you should avoid them, or wear a mask that will prevent the spores being inhaled (see box on p. 120).
Places
• Near fields of cereal crops in late summer, because of moulds growing on the cereal leaves. Symptoms are likely at harvest time, when combine harvesters disperse the spores.
• In forests and old orchards, in gardens with compost heaps or piles of dead leaves, and in greenhouses.
• Near springs, waterfalls, and other damp, shady places.
Times
• During late summer and autumn, when moulds flourish outdoors on fallen leaves and fruit.
• Following the first frost of autumn, which triggers spore release by fungi in the soil.
Activities
• Disturbing compost heaps, damp straw or hay, piles of grass clippings or heaps of fallen leaves, all of which are absolutely full of moulds.
• Collecting up fallen leaves or fruit.
• Watering the garden because mould spores are released when water hits the dry soil.
• Mowing grass, if the clippings were not cleared up after the last mowing. Unless the weather is very dry, the clippings tend to go mouldy.
• Removing dead leaves or flowers from plants.
A dangerous mould allergy
Anyone with asthma who also has allergy to the mould Alternaria should –with their doctor’s agreement – increase their dose of preventer inhaler (e.g. steroid or cromoglycate) during the spore-producing season. Research shows that severe near-fatal asthma attacks often occur during the Alternaria spore season among those allergic to this mould.
Spore release by Alternaria usually occurs in the summer or autumn, but the timing varies from one part of the world to another, so check with your doctor or a local pollen/spore monitoring service. Alternaria can live outdoors in soil, and on seeds and plants. Indoors, it is a denizen of window frames, carpets and textiles.
Indoor moulds
These are the indoor situations that can be difficult for mould-sensitive people. You should either avoid these, wear a mask, or tackle the problem at source – for example, by reducing dampness (see p. 119).
Places
• Buildings that are damp, because moisture encourages mould growth. Never sleep in a room which has mould growing on the walls or window-panes. In addition to damp houses – now very common – you may encounter moulds in old churches and church halls.
• Buildings that are near lakes, rivers or the sea, because of the dampness of the air. Rooms with humidifiers.
• Bathrooms and shower rooms, unless well ventilated, owing to the steam and condensation.
• Rooms that are generally left unheated, and are therefore colder than the rest of the house, as these tend to suffer from condensation.
• Buildings with dry rot or wet rot. Not all mould-sensitive people react to the spores of these dreaded timber-rotting fungi, but some do.
• Buildings where old timbers are being removed, as this stirs up huge numbers of spores.
• Buildings where central heating has recently been installed, as the warmer temperatures in the building stimulates the existing moulds to release their spores.
• Buildings with lots of indoor plants. There are moulds you cannot see growing on the surface of the soil around a potted plant.
• Cellars and basements. Conservatories can also be full of moulds if not well maintained.
• Antique shops, farms, mills, holiday cottages.
On the first day of Christmas…
Christmas trees usually have moulds (which you can’t see) growing on the needles. When the tree is brought indoors, the warmth encourages these moulds to shed their spores.
Times
• During the winter, when there are usually more moulds growing indoors due to condensation.
Activities
• Handling clothes, curtains or furnishings that smell mildewy: they may be dry now but they will still be full of mould spores.
• Handling vegetables or fruit that have been stored a long
time, or in damp conditions (e.g. in plastic wrapping). Note
that this can include mushrooms – they often have white
moulds growing on them, which can be quite inconspicuous. If looking around your house for moulds, bear in mind that they vary a great deal in colour. Bread, vegetables, cheese and other foods that are past their best grow green, grey or white moulds, often furry, and these are the ones most people are familiar with. But the black stuff on the walls of bathrooms and in the door seals of refrigerators is also mould. In some situations it takes a practised eye to spot this type of mould – around window frames for example, or in the patterns of bathroom-window glass, it can easily be mistaken for ordinary dirt. On shower curtains and cubicles you may find pinkish-red moulds as well as these black kinds. Garden plants and crops can have bright orange moulds (called ‘rusts’) on their leaves, as well as the more familiar grey or black kinds.
Combating indoor moulds
The crucial task here is to reduce dampness and condensation in the house – see p. 119 for the details – as this encourages mould growth on all kinds of surfaces, including walls, ceilings, windows, bathroom tiles, shower curtains, and even carpets. Once you have reduced the humidity, then you can have a big clean-up and remove the spores that have been left by moulds.
If your allergy symptoms are very bad, and you need some immediate relief, then you could get someone to clean away the mould growth and spores first, then tackle the damp problem, then repeat the cleaning operation. Obviously, this is less efficient, but it may be the best approach if you are severely affected.
Note that the cleaning will, in itself, stir up a massive but unseen cloud of spores, so the allergy sufferer should not be at home during this work (see p. 109).
Cleaning away moulds and stopping regrowth
There are two aspects to this task:
• a one-off effort to clear the accumulation of mould growth and old mould spores – trillions of them are probably lying around your house – since these spores are the cause of the allergic reaction
• an ongoing effort to prevent the regrowth of moulds in problem areas such as the bathroom.
Get rid of any furniture that smells ‘mildewy’: it is packed with old mould spores. Fabric items that have this smell should be washed thoroughly. Old clothing, books and newspapers may also be a source of mould spores.
Any carpets or other porous materials (e.g. ceiling tiles, wall panels) that have ever been soaked by flood or storm waters should be disposed of now – and, unless everything can be dried within 24 hours, this should be always be done if there is water penetration in the future. Research shows that such materials quickly become infested with moulds. Check above the flood line, as water can seep upwards through the walls or panelling.
On fridges and freezers, clean out the rubber seals around the doors, going into all the crevices to get out the black mould that lives there. Also clean out the drip-pans of fridges, freezers and dehumidifiers. Keep shower heads and air conditioning equipment (including the filters) very clean. This all needs to be done regularly from now on.
Clean off all the mould growing around windows, or on walls and ceilings, tiles or other surfaces. Alcohol (e.g, white spirit or surgical spirit) kills it very effectively, without the use of water, and it takes a long time to grow back again. You could, alternatively, wash down the walls with a mix of one part bleach to two parts water. (But note that chlorine fumes may be irritating to the airways of those with rhinitis or asthma.) Special anti-mould sprays are also available, but try them out cautiously as they too may be irritants. Do not brush mould growth off with a dry cloth, as this simply disperses the spores. In the future, keep an eye out for new mould growth, and remove it promptly.
Buy a new shower curtain and replace it regularly, or clean it thoroughly with an anti-mould spray.
Can foods and mould spores cross-react?
Some people with mould allergy appear to be affected by eating mushrooms, or foods that contain yeasts or other fungi, e.g. certain well-ripened cheeses, dried fruit, soy sauce and vinegar. There has been little scientific investigation of these claims.
No cause for concern
The drug penicillin – which can cause severe allergic reactions – comes from the Penicillium mould. Fortunately, there appears to be no cross-reaction between the drug and the spores of Penicillium.
Cut down on the number of houseplants, and find a new home for any that need constant moisture. With the remaining plants, take off dying leaves and flowers promptly, and remove the top layer of soil occasionally, replacing it with fresh soil or – even better – sand or grit. Pot-pourri should also be evicted, as it can be full of mould spores.
Use vegetables and fruit promptly, and do not allow bread to go stale, or jam to go mouldy.
What to do if these measures fail
Where there is an invincible damp problem, a really powerful dehumidifier used during the day in bedrooms, and at night in the sitting room, will kill off most moulds and defeat their efforts to regrow. Close all the doors and windows in the room where the dehumidifier is operating, and shut off air vents. Note that air conditioning will also reduce the humidity of the air, but not as much.
Keeping mould spores out of the airways
Ordinary house dust can contain a lot of mould spores. The allergic individual should not dust, vacuum clean, sweep floors or make beds until the anti-mould measures have begun to bite. Ideally the allergic person should go out while housework is done, and the house should be thoroughly aired before their return. If this is impossible, then wearing a good mask all the time is essential. A special vacuum cleaner that retains allergens, or vents them outside. may be helpful in addition to the mask.
Even though you have cut down on moisture and condensation, and tackled mould growth, there could still be a lot of mould spores around, especially in an old house, one that has been very damp in the past, or one that is close to water. If symptoms persist, then think about hiring or buying a high-quality HEPA air filter (see p. 108) to take mould spores out of the air.
Do not use fans or fan heaters, as these churn up mould spores from the floor and other surfaces.
Beating athlete’s foot
Allergenic fungi can grow on your body, as well as in your house (see pp. 16-17). If athlete’s foot is playing a part in your allergies, it is vital to treat the infection thoroughly with drugs, because the fungus grows deep into the skin and can quickly stage a come-back if not completely destroyed. You should also be careful not to reinfect yourself:
• always dry your feet very thoroughly, especially between the toes; kitchen roll does a better job than towels, and can be discarded, reducing the risk of re-infection
• wear cotton socks and shoes made of leather or canvas, which allow sweat to evaporate; only wear trainers or gumboots, or any other footwear that makes your feet feel sweaty, when you really need to
• when your feet get wet, change your socks and shoes promptly
• launder all towels and bath mats at high temperatures when you start the course of anti-fungal drugs, and again when you complete it
• never share towels, bath mats, socks, sandals or shoes
• wear flip-flops at the swimming pool or sauna, and in changing rooms; if any other member of the household has athlete’s foot, take the same precautions in the bathroom at home – and make sure they seek treatment.
Occasionally athlete’s foot is a misdiagnosis for atopic eczema of the feet, which is a common problem among allergy-prone children (see box on p. 45). If the skin between the toes is not affected, it’s unlikely to be athlete’s foot and more likely to be eczema.

Using inhalers
The value of using an inhaler rather than taking tablets or syrup is explained on p. 141 for steroids. The same principle applies to all drugs.
The oldest type of inhaler is the ‘puffer’ or aerosol inhaler, properly called a ‘pressurised metered-dose inhaler’ or MDI. It delivers the drug as a fine, moist, spray. In addition, there are now many devices that deliver drugs in dry-powder form.
If you or your child find the aerosol inhalers difficult, you may do better with a dry-powder inhaler. Your doctor should have several different inhalers available for you to try out, to see which one suits you best.
When you are given an inhaler you must be shown how to use it by a doctor or asthma nurse. A great many asthma patients have a ‘poor inhaler technique’, and get too little of the drug as a result. This often leads to their asthma getting out of control. The advice given here for using inhalers is no substitute for proper training, and should only be used to supplement what your doctor or asthma nurse has told you.
When using an aerosol inhaler or MDI, remember to shake the inhaler well or you will not get the right dose. Your in-breath must coincide exactly with pressing the canister down: this is the part that many people find difficult. You must breathe in slowly and deeply, otherwise you do not get much of the drug into your airways.
Many asthmatics stop inhaling the moment the
spray from the aerosol inhaler hits the back of the
throat. The spray contains a propellant, which
makes it very cold, and there is a natural reflex
response to this cold liquid which stops inhalation.
This response may be impossible to control. If so,
you need a dry-powder inhaler (see right), or a
spacer to use with your aerosol inhaler (see p. 162).
Breath-operated aerosol inhalers such as the
Autohaler can be useful for those who find ordinary
aerosol inhalers too hard to use. With these devices, you do not have to push the canister down because your in-breath triggers the release of the drug. Take care not to block the air-intake holes with your hands and don’t stop breathing when you hear the inhaler click. (If there is no click, start again and breathe in more forcefully this time.)
One hazard with aerosol inhalers is that, when almost empty, they produce no drug – just the propellant. Although they still ‘puff’ normally, they are not effective. It may be hard to tell when your inhaler is running low. Ask your doctor or asthma nurse for advice about this.
Many asthmatics find dry-powder inhalers such as the Spinhaler, Rotahaler, Diskhaler, Accuhaler, Clickhaler and Turbohaler are the easiest to use. They have no aerosol device, so none of the problems associated with the coldness of the propellant.
On the other hand, nothing pushes the drug into your mouth and lungs with a dry-powder inhaler: you have to do all the work yourself. This means you have to breathe in quite hard and fast. During a severe asthma attack you may not be able to breathe in hard enough to get a good dose of the drug. Some asthmatics have an aerosol inhaler as well, often combined with a spacer (see p. 162), for use during severe attacks.
For the parents of asthmatics, who want to keep an eye on how much of a drug is being used, most of the dry-powder inhalers allow you to do so.
Arthritis and inhalers
Those who suffer from arthritis in their hands often find inhalers difficult to use. There are several aids now available to help with this problem – ask your doctor or asthma nurse about these.
Do hold your breath
Whichever type of inhaler you use, it is important to give the drugs a chance to do their work. After inhaling, and when your lungs are full, you should hold your breath for at least ten seconds. Then breathe out, but wait at least another 30 seconds before breathing in again.
Side effects from non-drug ingredients
There are other ingredients in inhalers, besides the drug, and they occasionally cause side effects.
Aerosol inhalers are the worst offenders. They can contain up to five non-drug ingredients, such as propellants and surfactants. Some asthmatics are sensitive to one of these, and respond with coughing or bronchospasm when they inhale them.
If inhaled in large amounts, the propellants in aerosol inhalers can give a mild ‘high’, and asthmatic teenagers and their friends may - very rarely - begin abusing inhaled beta-2 relievers. Parents should be alert for the possibility of such problems, but not worry unduly.
Dry-powder inhalers do not need propellants or surfactants, so they are suitable for anyone who develops a sensitivity to these. However, they may contain lactose, or milk sugar, in addition to the drug. Enough lactose is deposited in the mouth and swallowed to provoke symptoms, such as diarrhoea and wind, in people who suffer from severe lactose intolerance (see box on p. 79). Trace amounts of milk proteins in the lactose may be a problem for people with severe milk allergy.
CFCs and inhalers
Aerosol inhalers have long contained CFCs, which are very inert gases (at ground level) and perfectly safe to inhale. Unfortunately, they cause serious damage when they reach the ozone layer high above the earth, so they are being phased out in asthma inhalers, as they are in all aerosols. Other propellants, called hydrofluoroalkanes (HFAs), are being introduced to take their place. The spray from an HFA inhaler may taste and feel different, but it should do exactly the same job as a CFC inhaler: the drug it contains remains the same. Research suggests that these new propellants are very safe, but tell your doctor if your reaction to your inhaler seems to change suddenly.
These new propellants deliver medication more efficiently into the lungs, so that usually only half the previous dose is required. Unlike CFC-type inhalers, they will deliver a constant dose until empty. In addition, they are not affected as much by below-freezing temperatures.
Inhale - then clean your teeth
Asthmatic children are more prone to dental decay than other children, and inhalers are suspected of causing the problem. No one knows, as yet, exactly which ingredient of the inhalers is the culprit - it could be a drug, or a non-drug additive such as a propellant. Alternatively, the fact that the spray from some inhalers is slightly acidic could explain this side effect. Brushing the teeth after using the inhaler, or just rinsing out the mouth with water, is recommended as a preventive measure.
Using spacers
A spacer is a large empty chamber that can be fitted to an aerosol inhaler (a puffer or MIDI). to make it more effective and easier to use. The aerosol spray goes into one end of the spacer, and the asthmatic breathes it in from the other end.
When using a spacer, you can breathe normally: you don’t have to take all the drug in at once. or hold your breath after you’ve inhaled. But you should try to breathe as deeply as possible, and hold your breath for up to ten seconds if you can.
Note that spacers are for use with aerosol inhalers only. Spacers allow the aerosol propellant (see p. 161) to evaporate, leaving tiny airborne droplets of the drug to be inhaled. Once the propellant has evaporated, these droplets are no longer cold, so the reflex response that stops inhalation is avoided.
During an asthma attack, spacers are immensely valuable because they allow you to get some of the drug into your airways even though you are unable to take a deep breath. There is a collapsible spacer, called the E-Z Spacer, which folds up into a plastic case small enough to be slipped into a pocket. In a severe asthma attack, having such a spacer could save your life.
In an emergency, if no spacer is available, you can improvise one (see p. 100).
Babies and small children, who cannot yet coordinate the in-breath with pushing the aerosol canister down, need spacers for everyday use. There are spacers designed for children under two years, with masks that fit over the nose and mouth.
When using a spacer, shake the inhaler and then spray it into the spacer once only. Inhale within five seconds. During an asthma attack, you can add another dose from the inhaler every ten seconds, until the attack begins to subside, but keep a count of how many puffs you use (see p. 100).
For a young child, shake the inhaler well, and fit it to the spacer. Put the mouthpiece into the child’s mouth, or put the mask on. Tell the child to breathe in and out steadily. Listen for the clicking of the valve on the spacer - this shows that it is opening and closing. When the child’s breathing is regular, puff a single dose into the spacer. The child should breathe in and out 5-8 times.
Priming a spacer
Prime a new spacer, or one that has been washed, by firing the inhaler into it about five times. Do this before you actually need to use the spacer.
The drug will coat the spacer walls, due to an electrostatic charge on the plastic. You won’t be able to see the drug as it forms a very thin coating.
When you come to use the spacer, no more of the drug will stick to the spacer walls, because they are already coated, so the full dose will be available for you or your child to inhale.
Priming new spacers is particularly important when the asthmatic is a young child, because there may be some delay between firing the inhaler and the child actually getting a proper lungful of the drug. The longer the delay, the more chance the drug has to stick to the unprimed spacer walls.
A spacer can be used on a baby while it is asleep, which may make life easier for you both. If you need to use the spacer while the baby or toddler is awake, stroke the mask against the child’s cheek first. Keep smiling and talking so that the situation doesn’t seem so frightening. If the baby does start to cry, keep the mask in place: crying will bring on a deep in-breath which is just what is needed.
For an older child, decorating the spacer with coloured stickers can make it appear less daunting. Try to make using the spacer seem like a game. If this fails, don’t get into a battle with the child – leave it a while and try again later.
Playing with the spacer when feeling well will help the child to see it as something familiar, not as a frightening piece of equipment associated with asthma attacks.
Nebulisers
A nebuliser delivers high doses of asthma drugs in an easily inhaled form. It is generally used for severe asthma only, or in an emergency to relieve asthma attacks.
A nebuliser can be attached to an oxygen cylinder, which enriches the air–drug mixture with oxygen. This is useful in severe asthma.
The only people who need to have a nebuliser at home for emergencies are those with brittle asthma, whose condition can deteriorate very suddenly and sharply.
For routine use, only a very small minority of asthmatics require a nebuliser. They include:
• Those with such severe asthma that they depend on large doses of drugs to control their symptoms
• Very small children or elderly people with severe asthma, who have difficulty using inhalers. For them, a nebuliser may be the easiest way to take their drugs.
The fact that the hospital’s nebuliser is so effective in an emergency gives it a special mystique for many people, who assume that nebulisers are a magical cure for asthma. Nebulisers are widely advertised in specialist publications for asthmatics and, while they are expensive, they can look like the answer to a prayer. Many asthmatics, or their parents, mistakenly believe that owning a nebuliser would be the answer to all their problems. In fact the nebuliser only works so well because it delivers a much higher dose of the reliever drug – a dose which also carries a higher risk of side effects. This high-dose treatment should not be used on a regular basis unless it is absolutely essential. No one should buy a nebuliser without first discussing the matter with their doctor.
Asthmatics who own a nebuliser should have detailed written instructions from a doctor about when and how to use it, and how much of the drug to put in. One hazard of owning a nebuliser is that it may give you a false sense of security during emergencies, and delay you from getting expert medical help when you need it. If the nebuliser is for emergency use you should be told the exact signs that indicate a need to use it and – no less important – the signs that show the attack is out of control and needs hospital treatment.
Take care, when using a nebuliser, not to allow the mist to escape and settle on the face or eyes. Regular exposure to steroid mist can cause cataracts in the eyes, and thinning of the skin on the face. Anti-cholinergics (see p. 156) can cause glaucoma if they come into contact with the eye. The mask must fit very tightly. As an additional precaution, place a scarf around the upper edge of the mask to cover any gaps. Wash the face after using the nebuliser for steroids.
Keep off the cough mixture
Coughing can be a useful reaction in asthma, evicting mucus from the lungs. But in some asthmatics the cough does not produce mucus and seems to be no more than a reflex reaction to the airway inflammation. This type of cough can be debilitating, but it is not a good idea to treat it with cough mixture which has no benefit and may mask the seriousness of the asthma. Tackling the airway inflammation with preventer drugs such as steroids is the best course. Simple expectorants, which loosen mucus, may be of value – ask your pharmacist about these.

Steroid inhalers
Most asthmatics nowadays are given a steroid inhaler at some point, as part of their asthma treatment (see p. 160). It will probably be a low-dose inhaler, and the risks of side effects from this are very small. Even at higher doses, inhaled steroids are relatively safe. Many people are unnecessarily afraid of inhaled steroids and refuse to use them until their asthma becomes really incapacitating. It is important not to delay using an inhaled steroid for too long, as this could cause permanent damage to the airways: inflammation eventually thickens the airway wall, leaving it less flexible and therefore less capable of widening.
For side effects of inhaled steroids see p. 145, and for common brand names see p. 147.
Steroid tablets
These are usually a treatment of last resort. But when you need them you need them – and if your asthma has got badly out of control, they can, quite literally, be a life-saver. On the other hand, if there are any other means by which you can tackle your asthma, so that you do not need steroid tablets again in the future –avoiding allergens and irritants, for example, or using other preventer treatments – those means should definitely be taken.
For side effects of steroid tablets see pp. 141-3, and for common brand names see p. 147.
Cromoglycate-type drugs
For asthma, these drugs are taken by inhalation only. They work by blocking the allergic reaction (see p. 148), and are therefore a type of preventer drug.
Cromoglycate-type drugs are usually inhaled four times a day, although your doctor may recommend more frequent inhalations to begin with. Once your asthma is well controlled, you may be able to reduce the dosing regime to three times a day, or possibly twice a day: ask your doctor’s advice about this.
Should you decide to stop taking these drugs at some point, talk to your doctor first. It is generally best to reduce the dose gradually, over a period of 7-10 days. Some asthmatics need to introduce (or reintroduce) steroids at this time, to maintain control of the airway inflammation.
Side effects
When inhaled, cromoglycate-type drugs can produce short-lived irritation in the throat, which may lead to coughing. This sometimes develops into temporary bronchospasm, causing you to wheeze, but this is really only a minor side effect – it does not indicate that the drug is making your asthma worse.
Asthmatics are sometimes advised to use a short-acting
beta-2 reliever (such as Ventolin) before their cromoglycate inhaler, to overcome this problem. However, this would involve using the beta-2 reliever four times a day, which is no longer considered a good idea (see pp. 153-4). Talk to your doctor again if you have been given this advice.
Inhalers that combine sodium cromoglycate with a short-acting beta-2 reliever (e.g. Aerocrom) are not recommended for the same reason.
A better way around the problem of throat irritation may be to switch to an aerosol inhaler, because the irritation is much less than with dry-powder inhalers. Using a spacer along with the aerosol inhaler (see p. 162) will help even more.
Serious side effects of these drugs are very rare (see p. 149). For common brand names, see p. 148.

Few drugs create quite so much alarm as corticosteroids. To some extent, this alarm is justified — if

over-used, they have dangerous side effects. But rejecting them entirely is a great mistake, because

they are safe at the right dose, and immensely useful for a variety of allergic symptoms. With the

information given here, you can use steroids as safely and effectively as possible.
Although their proper name is corticosteroids, these drugs are commonly — and rather inaccurately —

called steroids. This name adds to their doubtful reputation by confusing them with the notorious

anabolic steroids (see box on p. 142). However, the term ’steroids’ is used for corticosteroids in this

book, simply because that is the name most people recognise.
Steroids do not deal with the allergic reaction itself, unlike antihistamines (see p. 138) or

cromoglycate (see p. 148). Instead, they tackle the consequences of the allergic reaction,

inflammation.
What exactly is inflammation? The visible features of this phenomenon – for example, if it occurs in

the skin, around a scratch or cut – are redness and slight swelling. There is also soreness, and some

warmth. All these effects are produced by an influx of immune cells, intent on protecting the broken

skin from infection. These immune cells generate messenger chemicals (see box on p. 10) which boost the

inflammation, as well as attracting yet more immune cells to the area. When inflammation affects

delicate membranes, as when you suffer a sore throat for example, there can be a great deal more

swelling and discomfort.
The inflammation that follows allergic reactions is very similar to that provoked by infection,

although the balance of immune cells and messenger chemicals is slightly different. Eosinophils (see p.

19) play a particularly important role in sustaining the inflammation produced by allergies.
This influx of eosinophils and other immune cells, which lights the fires of inflammation, occurs some

hours after the allergic response itself. It is known as the Late Phase Reaction (see p. 13). Steroids

work well for allergies because they curtail the Late Phase Reaction and have a calming effect on

various immune cells, especially the eosinophils.
Steroid phobia
So many patients have a profound objection to taking steroids that doctors call it, half-jokingly,

’steroid phobia’. One of the hazards of giving information about potential side effects – as in this

book – is that it may encourage ’steroid phobia’. That would be a tragedy, because steroids really are

useful drugs that can do you a lot of good and very little harm, if used correctly. The risks are very

small when the steroids are used at low to medium doses, and targeted directly onto the inflammation.

Even with high doses, the serious side effects can generally be avoided. Please don’t use the

information here to scare yourself – instead, use it to protect yourself while getting the most from

steroid treatment.
A few effects on other body processes remain, even with the new steroids:
•    Raised blood pressure – this can occur even with short-term use of steroids.
•    Children may stop growing, or grow more slowly. Usually they make up for this later.
•    Quite commonly, there is increased hunger (though you don’t actually need more food, and will

put on weight if you eat more than usual). Insomnia and an agitated, edgy feeling during the day may

occur. These are minor side effects, and no cause for concern.
•    Side effects in the eye can occur: there is an increased risk of glaucoma and, with prolonged

use, cataracts.
•    Long-term use can also result in loss of minerals from the bones, leading to thinning and

fragility (osteoporosis).
•    Psychological changes may occur. Some people experi- ece euphoria or greatly increased energy

levels – with the opposite effects occurring when the course of steroids ends. At worst, steroids can

trigger paranoia or severe depression and suicidal feelings. (These effects are more likely to occur in

those with a history of mental illness. If you are concerned about this aspect, discuss the possible

risks with your doctor before taking steroid tablets.)
•    Epileptics may suffer more frequent or more severe seizures.
•    Very rarely, stomach ulcers develop, or other side effects in the digestive system.
•    The skin may become thin, and the small blood vessels beneath it more fragile, leading to easy

bruising and stretch marks (striae). This is also a potential problem with steroid creams (see p. 146).

Elderly patients are much more susceptible to this side effect.
•    Some diabetics need more insulin. in addition, anyone with the potential to develop diabetes is

more likely to do so, but only if taking steroid tablets long term. The diabetes usually goes when the

steroids are stopped.
•    A few men suffer impotence, but only with long-term use of tablets. This can be treated, so see

your doctor. Women may have irregular periods.
•    Damage to the hip bones may rarely occur, usually with excessive doses of steroid tablets. This

is called avascular necrosis and may require hip replacement.
In addition to these effects on other body processes, there are also some side effects that arise from

the steroids’ suppression of the inflammation. These can occur even with short courses. Again, however,

these problems can almost always be prevented, or treated, or reversed if detected at an early stage.
•    Skin wounds may be slow to heal, and are more likely to become infected because of reduced

immunity. This is not a serious problem – just keep all cuts as clean as possible.
•    Infections by viruses and fungi (e.g. Candida – see box on p. 83), may occur more readily.
•    Some infections may be masked initially because fever is suppressed by the steroids.
•    Chickenpox and measles can be far more serious – even fatal – if steroid tablets are being

taken, or have been taken for more than three weeks within the last three months. This is something to

be very careful about (see item 15 on p. 143).
•    Prolonged use can increase the risk of chest infections.
•    Vaccination with live vaccines can cause problems.
•    Older people who once suffered from tuberculosis (TB) may find it comes back.
•    Steroids can lead to pregnancy if using an IUD, because IUDs work by inducing mild inflammation

in the womb.
The most insidious effect of steroids – and remember again that this is only a hazard of prolonged

high-dose treatment – is adrenal suppression. When steroid tablets are taken for more than three weeks,

the adrenal glands’ own ability to produce cortisol (see p. 141) starts to be slightly suppressed. The

longer the course of steroids, the greater the effect. Stopping the steroids abruptly leaves the body

without enough cortisol to protect itself, which, in the very worst cases, can lead to collapse. Less

obviously, there may be greater vulnerability to the effects of accidents, serious illnesses, surgery

or childbirth – demanding events that would normally stimulate a rise in cortisol production to help

the body cope with the stress.
If you take a short course of steroid tablets during this period, there is more risk of side effects

than normal. Adrenal suppression can last for 6-12 months after steroid treatment ends. It may be two

years before the body can cope with surgery unaided and you will need low doses of steroids to get you

through stress of this kind.
Will I look like a weight-lifter?
Absolutely not. The steroids taken by unscrupulous athletes to pump up their muscles artificially are

anabolic steroids. They are entirely different from the corticosteroids used to treat allergies.
Mimicking nature
All corticosteroids are chemically very similar to a substance known as cortisol that is produced

naturally by the body. Cortisol – which is a hormone made in the adrenal glands, located near the

kidneys – has a great number of different effects, apart from damping down inflammation. It regulates

the action of the kidneys, moves proteins out of the muscles and bones, and alters the pattern of fat

distribution.
Like other hormones and chemical messengers that the body produces, cortisol achieves its effects by

binding to receptors on target cells (e.g. immune cells, muscle cells and the cells that make up the

kidneys). These receptors vary a little, which gives researchers scope for making a synthetic version

of the hormone, cunningly modified so that it binds well to one kind of receptor (the one on the immune

cells, for example) but not so well to another (the one on the kidneys).
Hydrocortisone, the original steroid drug, is identical to cortisol, but the newer steroids have been

modified chemically to have the maximum effect on inflammation and minimal effects on other body

processes. While hydrocortisone can only be used for allergies at very low doses (as in

non-prescription hydrocortisone cream), the modified steroids can be used at higher doses.
The side effects of steroid drugs are of two basic kinds:
•    those due to suppression of inflammation (the desired effect of the drugs) because this

partially reduces immunity to disease
•    those due to the effects of steroids on other body processes – undesirable effects which have,

as far as possible, been designed out of the modern drugs.
These different side effects are discussed in more detail on p. 142. First, it is important to look at

the crucial difference between taking steroids in tablet form and applying them directly to the

affected area. Much unnecessary anxiety can be avoided by understanding this difference.
Targeting steroids
The risks of steroids fall dramatically if, instead of taking them in tablet form, you put them exactly

where they are needed: that means drops for the nose or eyes, inhalers to get the drug into the

airways, or creams and ointments to target the skin.
The medical term for this is topical application, and it is infinitely preferable to taking steroid

tablets. When a drug is swallowed, it does its job by being absorbed through the stomach lining into

the bloodstream, and then being carried around the body in the blood. This is called systemic treatment

because it reaches the whole body-system via the blood.
The areas that need the drug – the itchy skin or inflamed airways – get their dose, but so does every

other part of the body. In order to get a useful amount to the afflicted parts, a fairly large total

dose has to be taken which inevitably affects the rest of the body, making the drug far more hazardous.
When a drug is targeted precisely, in sprays, drops, creams or inhalers, the dose used can be very much

smaller. Some of the drug does get into the bloodstream, by penetrating the skin or the membranes of

the nose or airways, and entering the tiny blood vessels that lie just below. But the amount reaching

the bloodstream is usually minuscule compared with the amount in the blood when you take steroid

tablets. Systemic side effects –those due to the drug going round in the blood (see below) – are

usually avoided, although there may be some local side effects, where the drug is applied.
Only with very powerful doses – as in the steroid inhalers used for severe asthma, or high-potency

creams for eczema – do topical steroids reach the bloodstream in sufficient amounts to cause systemic

side effects. You have to be on these treatments for a long time, or be overdoing the dose (a possible

hazard with creams for eczema), to run the risk of systemic side effects.
Steroid tablets
Short courses of steroid tablets – which means three weeks or less – are pretty safe. They are usually

sufficient to get the inflammation under control, and can be taken three or four times a year without

creating any problems.
Even if you have no choice but to take steroid tablets on a long-term basis, remember that the serious

side effects can usually be avoided, or reversed if caught early (see p. 143).
Side effects
Apart from changes that may (rarely) occur in the stomach lining, the side effects of steroid tablets

are all systemic side effects.
In the early days of steroid use, a set of side effects that resemble a disease known as Cushing’s

Syndrome were frequently seen. The side effects included deposits of fat on the shoulders and abdomen,

and around the face, producing a ,moon face’, water retention resulting in puffiness, weakening of the

bones, easy bruising, acne and muscle wasting. All these changes are due to the unwanted effects of

steroids on other body processes, not to any effect on inflammation.
With the new and improved steroids (see left), plus a much more watchful approach by doctors, these

severe side effects have become very rare, but they can still occur in those on high-dose steroid

tablets. As long as they are noticed in good time (see p. 143) the problem can be reversed.
Using steroid tablets safely
Those taking steroid tablets for more than three weeks, or taking a lot of short courses, can protect

themselves from serious side effects in the following ways:
1. Weigh yourself every day. Should your weight suddenly start to rise, despite eating normally,

consult your doctor: this may be a sign of water retention.
2. If you develop hip pain, swollen ankles, muscle weakness or acne tell your doctor.
3. Get your blood pressure checked regularly by the doctor.
4. Get your eyes checked regularly by an optician, who can detect any problems before there is

irreversible damage.
5. In the case of children, make sure the child’s growth is being monitored carefully by the doctor.
6. Stay as active as possible, with plenty of vigorous exercise, to protect against osteoporosis. Avoid

getting too thin, as this is also a risk factor for osteoporosis. Reduce your salt intake and don’t

drink too much alcohol. Ask your doctor to order a bone-density measurement periodically. Following the

menopause, women on steroid tablets should consider taking hormone replacement therapy (HRT) as this

protects against osteoporosis.
7. Persistent unexplained back pain must be reported to your doctor: this can be a sign of

osteoporosis. If you fracture your wrist in a fall (a Colles’ fracture) make sure your doctor knows

about this, and prescribes urgent drug treatment for osteoporosis.
8. See your doctor if you are over-tired, thirsty, or need to pass urine much more frequently – these

can sometimes be signs of diabetes.
9. Take your tablets after food to protect the stomach. See your doctor if you have persistent

indigestion: coated forms of the tablets may help.
10. If you ever produce black, tarry stools, call your doctor immediately. This is generally a sign of

bleeding from the digestive tract.
11. With your doctor’s permission, take all your daily steroids as a single dose in the morning. The

long gap between one dose and the next stimulates the body to maintain its own steroid-making abilities

and so reduces the risk of adrenal suppression. It can also protect against growth problems in

children. Even greater protection comes from taking steroids on alternate days – one day on, one day

off – although not everyone can keep their symptoms under control with this regime. Obviously, you must

consult your doctor before you try. Your dose may need adjusting.
12. Adrenal suppression puts you at risk during any medical procedure. Tell your doctor, dentist, and

anyone treating you in an emergency – even if you stopped taking steroids up to two years earlier. You

should also carry a Steroid Card at all times, in case you are unconscious. These cards are available

from your doctor.
13. Ask the doctor what you should do if you develop any kind of infection or suffer an accident. It is

often necessary to increase the dose of steroid tablets.
14. Tell your doctor if you have ever had tuberculosis, as this can recur.
15. If you or your child have not had measles or chickenpox, avoid contact with anyone suffering from

these diseases – or from shingles (herpes zoster) which is caused by the chickenpox virus. See your

doctor promptly if there is any contact with someone infected. Emergency treatment to combat the virus

must be started promptly.
16. When being vaccinated, remind the doctor or nurse that you are taking steroid tablets.
17. Never stop taking steroid tablets abruptly if you have been taking them for more than three weeks,

as some degree of adrenal suppression may already have begun. Your body needs time to recover its

natural level of activity, so reduce the dosage gradually. Get precise instructions from your doctor

about how to do this.
18. If you are asthmatic, at the end of any course of steroid tablets lasting more than three weeks, be

extra careful about exposure to allergens and asthma triggers. You may be more vulnerable to severe

asthma attacks for as much as a year after long-term steroid tablets are stopped, or the dosage

reduced.
Watch out for adrenal suppression
If you develop any of the following symptoms after stopping steroids,
or while reducing the dose, call your doctor as soon as possible:
•    muscle weakness; muscle and joint pain
•    feeling ‘under the weather’
•    mental changes
•    scaly or flaking skin
•    breathlessness
•    lack of appetite; or nausea and vomiting
•    fever and weight loss
•    painful itchy lumps on the skin.
Note that, very rarely, withdrawal of steroid tablets, or lowering the dose, can unmask a disease

called Churg-Strauss Syndrome (see p. 160).
Steroid nose drops and sprays
Most steroid nose drops and nasal sprays contain very low doses of the drug, and produce no significant

side effects when used for short periods of time. The safety of these preparations is such that several

are available without prescription.
Steroid drops and sprays for the nose are a very effective way of treating hayfever and perennial

allergic rhinitis. They can be used after the symptoms have begun, or in advance of encountering the

allergen.
Steroid nose drops are also useful in reducing the size of nasal polyps (see p. 30) but only if the

drops are inserted correctly. Kneel down and, bending your neck forward as much as possible, put the

crown of your head on the floor. Now put the drops in and stay in this position for several minutes

while the drops reach their target. Once the polyps have shrunk, the drops can be replaced by a steroid

spray which will keep them under control.
Always stick to the stated dose, as with any drugs – don’t use the drops or spray more often than you

should. If you have a cold or other infection in the nose, stop using steroid drops and sprays until it

is better. Following surgical operations on the nose, ask your doctor’s advice before using steroid

drops or sprays.
Side effects
Minor short-term side effects may include dryness and irritation in the nose and throat, and

disturbances of smell and taste. Nosebleeds might occur and should be reported to your doctor. When

inserting the drops, try to keep them away from the central partition of the nose (the septum), as this

is
the part most vulnerable to bleeding. If you are a long-term user of steroid nose drops, your doctor

should check the membranes in your nose regularly, to be sure that they are not becoming thinned. Eye

checks may also be advisable with long-term use, as glaucoma can occur.
Allergic reactions to the steroid are possible, and they can cause bronchospasm (contraction of the

airway muscles) though this is unusual. You should obviously stop using the drops and see your doctor

if this occurs.
With very high doses of steroids in the nose, or prolonged treatment, some systemic side effects might

occur. The main cause for concern is children’s growth (see box on p. 145) – their height should be

checked regularly.
Steroid eye drops
Steroid eye drops are sometimes given for severe inflammation of the eye during the hayfever season.

However, the eye is vulnerable to infections if treated with steroid drops, and such treatment requires

close medical supervision.
Side effects
Be extremely careful about infections – don’t rub your eyes with your fingers, for example, or dry

around your eyes with a towel unless it is absolutely clean. Follow your doctor’s instructions very

carefully, and go back immediately if your eyes become more uncomfortable, if redness increases, or if

you have any other cause for concern.
Steroid eye drops are rarely used for more than a few weeks. With prolonged use, there is a risk of two

serious side effects, glaucoma and cataract.
Using two lots of steroid
Allergy sufferers who need steroid nose drops or a nasal spray, as well as a steroid inhaler, often

worry that they are getting too much steroid overall.
In fact there is no cause for concern, unless you are taking very high doses of inhaled steroid, in

which case talk the matter over with your doctor. The amount in most nose drops and sprays is quite

small and the same is true of steroid eye drops. In all cases, relatively little gets into the

bloodstream.
If you have allergies in the nose, this may well be making your asthma worse, and using steroid nose

drops can be very helpful for the asthma symptoms (see p. 39).
Inhaled steroids and children’s growth
If an asthmatic child inhales relatively high doses of steroids for many years, his or her growth can

be stunted. However, only a small number of children need these high doses, and with low to moderate

doses most children’s growth is unaffected. They may experience a short-term slow-down in growth, but

their eventual height should be normal.
Unfortunately, there are a few children whose growth is stunted even by relatively low doses of inhaled

steroids - and it is impossible to predict which children will respond in this way. However, if it is

noticed in good time, and if the steroids can be withdrawn safely, the child’s growth rate will almost

certainly recover.
Your GP or paediatrician should be monitoring your child’s growth. You can also measure this yourself,

and go back to the doctor if you are concerned. Keep the risks in perspective - uncontrolled severe

asthma also stunts children’s growth, as well as endangering the child in far more serious ways, so

don’t stop using the steroid inhaler.
Steroid inhalers
Inhaled steroids are a key part of the modern treatment of asthma (see p. 157). As with other topical

treatments, inhaled steroids are a great deal safer than steroid tablets. However, some of the drug

does get into the bloodstream, and with high-dose inhaled steroids taken for several years, the levels

can be high enough to cause systemic side effects such as osteoporosis (see p. 142).
The dose is the crucial factor here. The packaging or information leaflet that comes with your inhaler

will tell you how much of the drug is delivered with each inhalation. To interpret the information

about side effects correctly, you need to know your total daily consumption of inhaled steroid, and

whether this corresponds to a low, medium or high dose:
•    For budesonide or beclomethasone, two of the more common steroids, less than 400mcg

(micrograms) per day counts as a low dose for adults and children over the age of five. A moderate dose

is 500-800mcg per day, and more than 800mcg a day is a high dose.
•    For fluticasone (Flixotide), halve these figures (i.e. more than 400mcg a day is a high dose).
•    In the case of children under five, all these figures should be halved (e.g. a high dose of

beclomethasone is more than 400mcg a day).
•    For other steroids, check with your pharmacist.
Anyone taking a low or moderate dose has very little to worry about as regards systemic side effects.

Only those inhaling high-dose steroids for many years need feel concerned.
If you may be at risk of systemic side effects, follow the protective measures described for steroid

tablets on p. 143. Apart from growth suppression in children (see box above) the most likely effects

are osteoporosis, adrenal suppression, and a recurrence of tuberculosis.
You can minimise the risk of systemic side effects from
steroid inhalers by swallowing as little as possible of the steroid. Always rinse out your mouth,

gargle, and spit out the water after using your inhaler. Using your steroid inhaler morning and

evening, just before brushing your teeth, will make it much easier to remember to do this.
Bear in mind that inhaling steroids regularly will help you avoid the need for steroid tablets.

Asthmatics who are worried about side effects sometimes skip doses of their inhaled steroids, then find

their asthma is much worse and that they need a course of steroid tablets. Frequent courses of tablets

increase the risk of serious side effects.
Minor local side effects of inhaled steroids include hoarseness and short-lived coughing due to direct

irritation of the throat. These are no cause for concern.
If you are regularly inhaling steroids from a nebuliser, make sure the mask fits really well (see p.

163).
Because steroids reduce the immune defences a little, one common side effect of inhaling them is a

throat infection by Candida (see upper box on p. 83). Oesophageal infections with Candida can also

happen but these are rare; the symptoms are heartburn and indigestion. Gargling with warm water after

each inhalation will help prevent Candida infections. There are also anti-fungal lozenges, if you are

still having trouble.
Keep inhaled steroids away from your lips if you suffer from cold sores (herpes infections around the

mouth). These can be made worse with steroids.
Fortunately, other infections are no more common when using inhaled steroids. This includes chest

infections.
Recent research has found other side effects in children using high doses of inhaled steroids. Cough

and thirst are common, while hoarseness and loss of voice affect quite a few. Behavioural problems also

occur, including hyperactivity, mood swings, excitability, sleep disturbances, depression, and even

hallucinations.
Steroid creams and ointments
Steroid creams and ointments are used for both atopic eczema and contact dermatitis. By delivering the

drug to the place where it is needed, they reduce the dose required to an absolute minimum and, if used

correctly, are very safe. Dr Ernst Epstein, a dermatologist at the University of California, observes

‘All too often I encounter children who are miserable with uncontrolled atopic dermatitis because of

their parents’ unjustified fears of steroid side effects. It is cruel to the child and the family to

forgo topical medication.’
It is very important to use a steroid cream of the right strength. For example, applying a 1%

hydrocortisone cream (available without prescription) to severe atopic eczema will be of no value.

Similarly, only applying a prescribed cream occasionally, or only once a day when the doctor said three

times a day, will mean that the rash never really succumbs to the treatment.
Keeping old tubes of steroid cream in the bathroom cabinet, and using these rather than the newly

prescribed cream, is another frequent mistake. If the earlier prescription was for a weaker steroid

cream, that is not quite up to the job, you won’t get the symptoms under control.
Inadequate treatment means that the rash goes on longer, so you probably apply more steroid in the long

run – which exposes you to a greater risk of local side effects. It is far better to use a moderately

strong steroid cream for a short period of time and get the inflammation fully under control.
Remember that steroid creams are absorbed far more effectively immediately after a bath or shower, so

this is a good time to apply them (see p. 48).
Don’t stop using steroid creams too soon. The skin looks healthy and happy long before it is completely

healed underneath. You must continue until the ‘hidden healing’ has occurred. As a rough guide, the

point when the skin looks good is just the halfway point: so the steroid creams should be continued for

the same length of time again. If it took three weeks to get to the point where the skin looks fine,

then you should go on applying the steroid creams for another three weeks after that.
Generally speaking, it is a good idea to phase out steroid creams slowly, especially after using them

for a long period of time. Stopping abruptly may cause the rash to flare up again –this is called a

rebound effect.
Once you have atopic eczema under good control, you will still need some steroid cream at home for

dealing with relapses. As soon as you notice any rough, itchy skin, apply the cream twice daily for

three days, then once daily for another three days. This should be enough to curb the outbreak of

eczema before it really gets going.
Side effects
To assess the risk of side effects from your steroid cream or oirtment, you need to know how strong it

is. Four grades are recognised: mild (corresponding to non-prescription hydrocortisone cream),

moderately potent, potent and very potent. Ask your doctor or pharmacist which grade corresponds to

your cream, so that you can make sense of the information given below.
Unfortunately, if steroid creams are not used correctly, there are some quite serious local side

effects. Any steroid cream that is strong enough to work is also strong enough to produce side effects

if over-used, so this is a delicate balancing act. The main local side effects are thinning of the skin

and striae (stretch marks). Teenagers and pregnant women are particularly susceptible to stretch marks

if using steroid creams.
It is important to take care because these side effects can be irreversible. The stretch marks, for

example, may fade in time but never entirely disappear. Sustained over-use of steroid creams can

produce permanent thinning of the skin. Thinning of the ski on the face may produce redness, with small

blood vessels shoving through. The fingertips may develop painful cracks.
Note that these side effects can come on very gradually.. Some may be mistaken for symptoms of the

disease itself.
Other local side effects may include an outbreak of spots that look rather like acne. Increased

hairiness or change in skin colour are also possible. Fortunately these effects are reversible.
To avoid side effects, follow the instructions for using steroid creams carefully, and don’t apply too

much or too often. If you have not been given clear instructions by your doctor on the quantity to use,

go back and ask for more information. Ideally, you should actually be shown the correct amount of the

cream to use each time. Remember to wash your fingers after applying steroid creams
If potent or very potent steroid creams are slapped on W& abandon, enough is absorbed into the

bloodstream to produce systemic side effects, comparable to those that can occur with steroid tablets

(see p. 142).
With very potent steroid creams, used for a long period of time, there is some risk of slight systemic

side effects even though the instructions for use are carefully followed. Young children more

susceptible. Bear in mind that covering the skin with cages after applying the cream increases the

amount absorbed into the bloodstream. The degree of adrenal suppression caused by using the cream (see

p. 142) is probably going to remain unnoticed in everyday life, but a major illness, accident,

childbirth or a surgical operation might reveal the problem – so tell medical what you have been using.
Different areas of the body respond differently to steroids creams. The skin of the face, and within

skin folds.
sensitive and generally requires a lower-strength cream, while the palms of the hands and the soles of

the feet require a higher strength. The genitals and the area around the anus are particularly

sensitive, and can become permanently damaged (and then a source of intense discomfort) by strong

steroid creams: some dermatologists recommend using nothing stronger than 1 % hydrocortisone.
Make sure you see your doctor regularly when using steroid creams continuously, especially if:
•    you are using very potent steroid cream
•    you are applying potent or moderately potent steroid cream over more than 20% of your body for

more than a month
•    you are applying potent steroid cream to a baby or young child.
The vehicle – the cream or ointment base in which the steroid is carried – is important because

sensitivity reactions can occur to certain of its ingredients (see p. 45). Eczema sufferers can even

become sensitised to the steroid itself, and this problem is difficult to diagnose because patch tests

with steroids often give false negatives (see box on p. 91). If you are not getting better, ask the

doctor if this could be the explanation. (If a rash gets worse and starts to spread when you begin

using steroid creams, go back and see the doctor very promptly – you may have an infection called

tinea, or ringworm, which flourishes all the more when steroid creams are applied.)
Tacrolimus and pimecrolimus
These are new treatments for atopic eczema. They are not steroids, but are covered here because they

are an alternative to steroid creams and ointments, and if you are comparing the two treatments it may

help to have the information on them side-by-side.
Tacrolimus ointment (brand name Protopic) is for the treatment of moderate to severe atopic eczema, and

pimecrolimus ointment (brand name Elidel) is for milder atopic eczema, especially in children.
These drugs are immunomodulatory rather than immune-suppressive – they adjust the balance of immune

reactions in the
skin. Unlike with steroid creams, there is no risk of thinning the skin, so they can be used on

delicate areas like the face and eyelids.
These treatments are generally used for patients who are not getting better with moisturisers and

steroid creams. Because they cost so much more (about ten times as much as topical steroid treatment),

and since much of the fear of steroid creams is unfounded, doctors are reluctant to prescribe

tacrolimus ointment ,on demand’. With time, the cost of these treatments may fall.
One important advantage of tacrolimus and pimecrolimus ointments is that they may have good effects

that persist after you have stopped using them. And the benefits are cumulative: in one trial where

babies with atopic eczema were treated with pimecrolimus ointment on an as-needed basis, most had fewer

and fewer flare-ups as the months went by. This was not true of babies being treated with steroid

cream.
As with topical steroids, the effect of tacrolimus and pimecrolimus on infections such as

Staphylococcus aureus is surprisingly beneficial: the enormous improvement in the surface structure of

the skin keeps bacteria out. But heavily infected skin should be thoroughly treated with antibiotics

before you start. While using the ointment, watch out for any signs of infection, especially herpes

(see p. 44), and see your doctor immediately.
Minimise your exposure to UV light – in sunlight and sunlamps – because of the tendency of UV to

provoke skin cancers. With the dampening effect that tacrolimus has on the immune system, the risk of

skin cancers may be a little higher.
Don’t apply anything else to the skin (not even moisturisers) within two hours of putting on the

tacrolimus ointment – they dilute the treatment too much. And don’t apply tacrolimus ointment

underneath bandages or other dressings.
Side effects
A few patients find that, while using tacrolimus ointment, skin in areas not being treated actually

gets worse. Talk to your doctor if this happens. Other possible side effects include stinging and

burning when applied, or redness. These are nothing to worry about, and usually lessen with time.
Some common brand names
Common brand names of steroids include:
nose drops – Betnesol, Vista-Methasone
nasal sprays – Beclometasone, Beconase, Flixonase, Nasacort, Nasonex, Rhinocort Aqua, Syntaris eye

drops – Betnesol, Cloburate, Maxidex, Predsol, Vista-Methasone
inhalers – Aerobec, Becloforte, Beclometasone, Becotide, Flixotide, Pulmicort
tablets – Betnesol, Cortisyl, Dexamethasone, Medrone, Prednesol, Prednisolone,
creams – Adcortyl, Betnovate, Dermovate, Fucibet, Synalar