Posts Tagged ‘Atopic’

Over-the-Counter Remedies Vitamin E
Vitamin E, once considered a potential super-nutrient, has fallen out of favor as a preventive for heart disease or cancer viagra comercial with vcr . But back when it still looked ever so promising, a group of Italian dermatologists conducted a study to see if vitamin E could improve symptoms of eczema ecstacy lexapro . 295 It was single-blind; that is, the patients did not know who was getting the active treatment, but the doctors did sources side effects zoloft . The patients ranged in age Vita
This fat-soluble vitamin has been disappointing in studies of cancer or heart disease prevention stopped procardia labor . The natural form of vitamin E used in this study (alpha-tocopherol at 400 IU daily) was surprisingly effective in reducing the lesions and itching of eczema ibuprofen urticaria .
Side effects: Minor digestive upset is possible, but unlikely prescription plans that will cover valtrex . Downside: There has been only one study of this therapy for eczema biaxin pack description . Although vitamin E is inexpensive and relatively nontoxic, more studies to substantiate the benefit would be desirable does lipitor cause skin rash .
Cost: Approximately $3 to $8 a month
from 10 to 60 years old, and all had itching that had not been well controlled by their previous therapies how does naproxen sodium work .
The study lasted 8 months, and over the course of that time, the skin of fewer than 10 percent of the people taking vitamin E (400 IU daily) got worse pseudoephedrine hci 60mg . The skin of more than three-fourths of those on placebo had worsened antabuse breath odor . Conversely, almost half of the patients on vitamin E had excellent improvement, compared to only 1 (of 46) of those on placebo baby cannot keep prednisolone down . The investigators noted that the patients who had good results clinically also had marked reduction in the IgE levels that indicate allergic arousal of the immune system wat is lithium . They concluded that vitamin E might prove to be an excellent therapy for atopic dermatitis sie affects of drug diovan . Unfortunately, there are no other studies to confirm or refute these findings de effects of norvasc .
Topical Creams
Over the years, we have learned of a number of surprising remedies for itchy eczema facts and comparison of zyrtec . One is the old-fashioned moisturizing cleanser Noxzema west palm beach lasix center . Many people have written to say they had success easing the itching and even clearing up the rash after applying Noxzema to their eczema cellcept batten disease . Of course, nothing works for eczema all the time separating codeine from promethazine . But Noxzema is relatively low risk remeron tab . We suspect the herbal oils it contains may contribute to its effect clinical trial exelon . According to the manufacturer, camphor, menthol, and eucalyptus have given Noxzema “its redolent signature since 1914 buy accutane online .”
O fosinopril sodiun . I just had to let you know the success I’ve had with your suggestion to use Noxzema for eczema will lasix help with blood test . My 3year-old son has suffered with this skin condition on his legs and feet for 2 years caffeine gum addiction .
We treated it successfully with the prescription drug Elidel, but after learning of safety concerns, we checked with his doctor and stopped using it metronidazole for catas .
I tried many moisturizing creams to soothe his skin, but he cried and said they hurt levothyroxine purchasing . I started using Noxzema the day I read your article, and there were no tears 5 how sildenafil works .
His skin responded quickly and after 3 weeks almost aft traces of eczema are gone viagra vs kamagra . This advice has changed my young son’s life clozapine adverse event reporting post marketing .
A zoloft memory loss . We are certainly pleased to learn of your success toradol breastfeeding side effects . Lore has it that the name Noxzema was given after the product helped an early customer “knock” her eczema wellbutrin anger .
• 0 •
The mainstay of eczema treatment is a topical corticosteroid order tadalafil no prescription . In most cases, the doctor will prescribe a mild cream for
*** Noxzema
The brand now includes a number of different cleansers, but the one you want is the original, in the blue jar viagra paperweight . Apply it to the affected areas like you would a moisturizing cream olmesartan medoxomil . The herbal ingredients, camphor, menthol, and eucalyptus, may be helpful against itch, and the base cream is a good moisturizer allergic reaction to levaquin levaquin medication .
Side effects: Uncommon mucinex with clonidine . Discontinue use if it irritates the skin evista comprimidos .
Downside: There’s no scientific proof that this product will help eczema buy clonidine without prescription .
Cost: Approximately $4 to $6 for 14 ounces
Topical Hydrocortisone I Percent
Topical corticosteroid lotions, creams, and ointments are the mainstay of eczema treatment any difference between methocarbamol flexeril . This is the one that is available without a prescription, because it is less potent than prescription products carisoprodol china production . clozapine vs clozaril . It probably will help mild eczema sertraline hcl 100mg side effects . It may not be strong enough for moderate or severe conditions tetracycline 500mg strength .
The best way to use thislotion or cream is to apply it conscientiously for 3 to 7 days at a time rechargable aa lithium ion . Then take a break for several days amiodarone thyroid australia .
Side effects: Uncommon, but burning, itching, irritation, or dryness could occur where the product is applied does aygestin stop your period . Downside: Long-term use could lead to thinning of the skin novo levofloxacin side effects . This is a small -risk with the over-the-counter creams, but it should be kept in mind ibuprofen slow release r .
Cost: Approximately $3 to for a 1-ounce tube
use on the face and a more potent one for use elsewhere on the body carbatrol versus lamictal . Hydrocortisone 1 percent is available without a prescription and can be used for eczema cis diagnosis lipitor . We don’t suggest longterm use without checking in with the doctor, though lawsuits lithium heart failure valve damage . Even though the nonprescription cream is not very strong, it could still cause some thinning of the skin if it were used for many months flagyl use in cats .
Those who would prefer to avoid hydrocortisone cream may want to check out a product called CamoCare Soothing Cream order ivermectin merck online . It contains extract of chamomile flowers in an emollient base and has been helpful against eczema in one stud y gatifloxacin ophthalmic solution .296 Apparently, it has an effect comparable to low-dose hydrocortisone cream (0 effects side zyrtec .25 to 0 prednisone indications for use .5 percent), although it does not contain any steroid armada 4100 4200 lithium battery .
Another nonprescription ointment that has been put through a clinical trial is a homemade mixture of honey, beeswax, and olive Oil diamox hearing loss .297 This study was not as rigorous as we would like—not by a long shot how much caffeine in go fast . And honey, beeswax, and olive oil might just be too messy to be practical naltrexone and sertraline . But the Dubai dermatologist who ran the trial found that it had benefit for about 80 percent of the patients with eczema soma cruz genya arikado yaoi . That is almost the same as the percentage who respond well to topical steroid creams compazine box . So if you are in the mood for an experiment, get Soothing Cream
CamoCare his cream apparently was developed in Germany and is better known in Europe than in the United States natural sources of penicillin . German chamomile (Matricaria chamomille) contains an lithium grease plastic lubricant .oil called bisabolol that has been shown to have powerfulanti-inflam-matory action, comparable to that of the drug indomethacin imipramine 150 mg . That might explain its improvement of skin irritation drug recall china methotrexate .
Side effects: Some people are allergic to chamomile precose 50mg . Since individuals with atopic dermatitis may be especially susceptible to developing allergies, discontinue use immediately if the rash gets worse common side effects of paxil .
Downside: We know of only one study of CamoCare for eczema prevacid and children . In addition, it is relatively expensive is hydrochlorothiazide .
Cost: Approximately $10 to $14 for a 1-ounce tube lexapro withdrawal migrains .
out the blender and mix together equal amounts of honey, beeswax, and olive oil maximum dose topiramate 1600mg per day . Then see what it does for you psms and spironolactone . It should have no side effects, other than being sticky president ceo tricor systems inc . And it should not be overly expensive what is piroxicam .
Prescription Options
Doctors are most likely to prescribe some form of corticosteroid (cortisone-like) cream or ointment for eczema bipolar zyprexa . That’s because around 80 percent of patients with atopic dermatitis seem to respond well to these prescription creams pseudoephedrine extraction method . Fewer than 40 percent of those patients improve on a placebo cream or ointment 298 That’s why topical corticosteroids are so widely used avapro high blood pressure medicine .
If your doctor has given you a prescription fora corticosteroid, be sure to get the details on how to use it ivax pharm prozac . Using too strong a preparation on the face can have negative consequences zoloft theraputic level . The skin may become thin and tear or bruise easily, and blood vessels may become prominent guidelines for warfarin therapy . In fact, some people with eczema need two different formulations—a fairly strong one for hard-to-treat areas like the hands and a relatively mild one for eczema on the face fentanyl interaction with ultram . Keep in mind, too, that overuse of topical corticosteroids can thin the skin goldline enteric asprin 81mg .
People sometimes worry about steroid side effects from such creams jshua and abilify . It’s not impossible that side effects typically as-
**** Topical Steroids
One or more topical steroid preparations—a cream or an ointment—will probably be the dermatologist’s first choice to control eczema ld50 asprin . It helps significantly in most cases manufacturer information on prednisone .
Follow the directions carefully soma heightened climax . The cream may need to be applied two or three times daily diclofenac sodium 75mg 3ml injection . Do not put a strong steroid on the face, or any steroid cream near the eyes is kamagra illegal uk . Ask your doctor about “pulsing” the use of cream—applying it for 3 to 7 consecutive days and then stopping for several days 17 b estradiol . Adults may be able to use such products for just a few days a week levaquin and colstridium .
Side effects: Stinging, burning, irritation, itching, peeling Downside: Long-term use or application over a large part of the body, especially under a close covering, could thin the skin, lead to marks on the skin, or (most serious) result in side effects similar to those from oral prednisone lithium 450 mg 900 mg .
Cost: Depends upon the specific steroid the doctor selects cephalexin dose for dogs . These drugs can be expensive lamisil and exacerbation of psoriasis . Inquire about a generic version, which may cost much less amoxicillin and indications and uses .
sociated with steroid use might occur, but it is very unlikely unless the area treated is large and has been covered with some kind of bandage or “occlusive dressing withdrawel from zoloft .” Be very careful in applying this kind of treatment barringer wc and minocycline . It may indeed help the skin, but it must not be overdone prevacid for oral suspension ingredients .
Atopiclair
In 2005, the FDA approved a nonsteroidal cream for eczema excellent results taking effexor . Atopiclair is a prescription product that contains a number of botanical extracts in an emollient base taylor lithium scale . Like CamoCare, it contains bisabolol, but Atopiclair also contains a vitamin E—like compound, a licorice root derivative, and an extract of grapeseed, along with shea nut butter celecoxib evaluation . A gel containing licorice extract had earlier shown promise for treating atopic dermatitiS testosterone mesterelone .299
Elidel and Protopic
The frustration of trying to control eczema, a condition that may not respond to the usual anti-inflammatory treatments, has led doctors to explore other treatment options cholesterol pravachol . The de-Clair
This nonsteroidal cream is significantly better than a simple moisturizer at alleviating itch and reducing rash gabapentin and erection problems . It should be applied two or three times a day shell shrimp cytoxan .
Side effects: Local irritation
Downside: People allergic to any of the ingredients, including nuts, should avoid Atopiclair does citalopram .
Cost: Approximately $85 to $95 for lMgram tube
velopment of immune-modulating treatments to prevent the rejection of transplants led some dermatologists to think about modulating the immune reaction at the level of the skin carisoprodol 2444 imprint . After all, eczema does seem to be linked to an immune reaction gone a bit haywire, comparable to hay fever allegra versace 2007 . It turns out that there are two compounds that can be applied topically to dampen the immune response allegra of ri . They are Elidel (pimecrolimus) and Protopic (tacrolimus) seroquel xr versus seroquel .
Parents of children with eczema were very pleased to have these effective treatments made available so they would not have to rely so heavily on potent corticosteroid creams to keep their youngsters comfortable meloxicam taken with tylenol . They were alarmed, however, when the FDA issued a warning that these immune-suppressing drugs might increase the risk of children developing cancer, especially lymphoma order tadalafil ups online . Such cancers are rare in kids, so it will probably be years before it is possible to assess how serious this potential risk really is no prescription german pharmacy prednisone . But weighing red, itchy skin against a potentially lethal disease suggests that these drugs should be used only when other treatments have not worked bupropion high .
Another topical cream for treating eczema is called MimyX cream diflucan used to treat tenia capitas . It is available by prescription, but does not contain a steroid homotaurine campral gabapentin . Clinical trials showed that it can reduce the size of areas affected by eczema and extend the period between flare-ups seroquel too sedating for bipolar . Side effects appear to be local, such as irritation or itching viagra lawsuit . The manufacturer, Stiefel Laboratories, suggests that MimyX could be used on a regular basis without danger prednisone for t12 to l2 fracture . Because it was approved relatively recently, however, there are no good long-term safety data hydroxyzine withdrawl .
This immune-suppressing cream is significantly better than a simple moisturizer asprin 110mg . It is approved for use in adults and in children older than age 2 gabapentin and migraine .
Side effects: Local irritation, burning, stinging, itching, infections, seizures
Downside: Long-term use is discouraged because there is a possibility that it increases the risk of cancer cheap no prescription tramadol . When application of the cream is discontinued, however, a high proportion of patients regress to pretreatment condition,
Cost: Approximately $65 to $80 for a 30-gram tube of 0 phytosterol testosterone .03 percent ointment, the only strength approved for use in children
Other Approaches
A number of other possible treatments may have some benefit for people suffering from atopic dermatitis generic ultram tramadol 50 mg . Some of them are pretty straightforward and well accepted, whereas others are on the wacky side find how to use viagra . Here’s a brief summary:
1 terbutaline ol1 inhalation compounding pharmacy . Heliotherapy can you take zoloft with lorpressor . This means: Get some sunshine on your skin tramadol ultram hci . Sunburn is bad, of course, but a couple of weeks of moderate sun exposure seems to make eczema better combivir indications . 300 This almost sounds like a prescription for a tropical vacation! Be forewarned, though, that some of the medicines used to treat eczema could make skin more sensitive to sunburn clomid and ovulating pain twin . This is a worry particularly with Elidel and Pro-topic paxil cr 125 mg .
2 trazodone and insomnia . Ultraviolet light therapy carisoprodol b carisoprodol . This probably explains why sunshine is beneficial jeffery m allegra . Exposure to ultraviolet A in the dermatologist’s office can help alleviate eczema symptoms treatment rheumatoid arthritis sulfasalazine . Stubborn cases may improve with the addition of a psoralen gel or bath before the light exposure generic drugs atorvastatin . This is similar to a standard treatment for psoriasis buy cheap kamagra . The dermatologist will probably recommend it if she thinks it will be helpful caverta side effect . Although it is usually administered in the office or hospital, a portable unit used at home can be equally effective concerta adhd caffeine adhd theadhdspecialist com .- 301
3 dilantin and lasiz . Balneotherapy digoxin and elderly . Immersion in salts derived from the Dead Sea, followed by exposure to ultraviolet B, can be helpful, especially if eczema is chronic and widespread interactions of imitrex and celexa . This effect was first observed in people actually bathing in the Dead Sea, but it is no longer necessary to go there lithium cr123a . Some dermatologists offer this type of therapy in their treatment suites clindamycin doxycycline bordatella . One big drawback is that it takes a lot of time zoloft seroxat side effects .302,303
4 order sumatriptan mail . Hypnotherapy claritin acrylic coffee cup price . Both hypnosis and self-hypnosis can help 3 people cope with eczema, especially with its terrible itch excessive testosterone acne .
5 ditropan $4 . Music bioidentical testosterone cream for women . Listening to Mozart—but, oddly enough, not to Beethoven—reduced the size of a wheal that rose on the skin in response to a specific allergen challenge in people with eczema and latex allergy allegra’s window songs . 305 This is probably the most peculiar of the therapies we have come across, but the study used quite objective measures (IgE production, size of wheal) that presumably are not easily manipulated availability of viagra in new zealand .
Conclusions
Eczema, or more precisely atopic dermatitis, is an itchy skin condition that is often chronic testosterone and vaginal cancer . Besides the itch, skin affected by eczema may develop a rash with liquid-filled bumps cymbalta lower dosages . Skin-fold areas, such as the back of the knees, seem to be especially susceptible to the rash ct angiogram lopressor san antonio . Eczema is often accompanied by generalized dry skin, and the patient may also have asthma or hay fever domperidone in infants .
There’s no cure for eczema, although sometimes it does go away for a period of time levothroid interactions . No treatment works all the time or for everyone, so people are understandably on the lookout for something that might work better than what they have already tried 18 v lithium ion . Eczema is quite common in young children, and parents need to be especially vigilant in weighing the benefits against the risks of various therapies they might use for their kids nexium and polyps .
• Avoid prolonged exposure to water or any irritating chemicals, including soap or detergent caffeine birth defect . After washing hands or bathing, apply a moisturizer within 3 minutes of patting the skin dry acomplia price .
• A person with a documented food allergy that makes eczema worse should avoid that food paxil vs effexor . Eggs may be a culprit for young children what’s anastrozole .
• Probiotics can help in some instances 1967 neonatal exposure to depo provera . Look for a high-quality supplement with viable organisms price cefpodoxime compare . Lactobacillus GG and L pravastatin 20mg . fermentum have done well in studies aleve competitor .
• Fatty acid supplements providing gamma-linolenic acid (such as evening primrose oil, borage oil, or black currant seed oil) help some individuals, but have not performed well in clinical trials insomnia paxil cr . One exception is hemp seed oil, although the data on it are limited to one study topamax and glaucoma . It might be worth a try effect of ibuprofen on blood pressure .
• Cut table sugar and simple starches out of your diet vasotec blood pressure medicine . A low-glycemic-index approach might be worth trying, though will
there is no scientific evidence that it wicontrol eczema female zantac de .
• According to anecdotal reports, eating salsa may ease eczema symptoms increase of depression with zoloft . If you like spicy foods, go for it can lamictal help depression .
• Drinking 4 cups of oolong tea daily was shown in one study to help eczema that wasn’t responding to other treatments albuterol and nebulizer . It is easy and nontoxic, so it would be worth a try woman on viagra .
• Vitamin E capsules did very well in one study of people with atopic dermatitis caffeine levels pop . Check with your doctor first if you are a smoker or at high risk of heart disease; some large studies suggest vitamin E might increase your risk of serious complications claritin dose . For others, there is very little risk in a short-term personal trial to see if it helps your skin tobacco and depakote .
• Apply Noxzema—the original formula in the blue jar—to the affected areas clomid use after laproscopy . The herbal ingredients, camphor, menthol, and eucalyptol, may soothe itching what is citalopram hydrobromide . Be alert for increased irritation, though avandia image .
• Over-the-counter hydrocortisone cream (0 promethazine hcl suppository .5 or 1 percent) may help if the eczema is mild lithium etek .
• CamoCare Soothing Cream is available without a prescription and may ease itching, redness, and inflammation toradol opiod .
• Blend up a batch of honey, beeswax, and olive oil for a homemade salve that may help celexa anxiety depression . It sounds sticky, though yaz spironolactone .
• Use prescription steroid creams according to the physician’s instructions effects of gabapentin and alchohol . Don’t use a potent steroid on the face, or for too long a time health and wellness caffeine health product . “Pulsing” the dose—applying the cream for 3 to 7 days straight, then not using it for a time—may help zyrtec over the counter patenet . Ask your doctor azithromycin pharmacy .
• Drugs such as Protopic (tacrolimus) or Elidel (pimecrolimus) may be helpful as back-up treatment if the steroid creams stop working or don’t work well enough long term use of carisoprodol .

Diet to Protect against Asthma
There is growing evidence that several aspects of the modern Western diet make asthma more likely to develop. Parts of this evidence are very convincing, while other findings are less conclusive as yet. Some people might argue that, until all the facts about diet and asthma are firmly established, no dietary changes should be recommended. However, all the dietary changes that might protect against asthma are also very valuable for general health.
This diet is potentially useful for:
0Atopic families who wish to reduce the chance of their chil- dren developing asthma. Other preventive measures, such as allergen avoidance and exercise (see Chapter 8), are obviously important as well.
•    Anyone who already suffers from asthma – with this diet, their symptoms may diminish.
The main elements of the anti-asthma diet are:
•    A high intake of fresh fruit. Researchers in Britain and the Netherlands have shown that people who eat more fruit have better lung function, and are less likely to develop asthma or bronchitis. Apples have a particularly good effect on the airways, according to one recent study. Many other studies show a link between Vitamin C – the major vitamin in fruit – and asthma prevention. This makes sense because Vitamin C is an antioxidant which inactivates the pro-inflammatory substances (called oxidants) that are found in cigarette smoke and other polluted air. In addition to Vitamin C, many fruits contain beta-carotene (see below) – mangoes and apricots are the richest sources.
•    Regular helpings of carrots, which contain the orange pigment beta-carotene. This is another antioxidant that can help prevent inflammation in the airways. It should be obtained from food, not supplements (see p. 207).
•    A high intake of fresh green vegetables, especially broccoli, spring greens, dark green cabbage, peas, parsley and courgettes. One Australian study has shown that children who eat fewer vegetables are more likely to wheeze. The benefits of vegetables may be partly due to the fact that they contain beta-carotene and (if eaten raw or only lightly cooked) Vitamin C. Dark green vegetables are also a good source of magnesium, and researchers find that people with a higher magnesium intake have healthier airways. Magnesium is believed to protect against asthma by helping the muscles of the airways to relax.
•    Plenty of tomatoes and tomato products, such as tomato juice, tomato sauce, ketchup and paste. The special protective effect of tomatoes is not entirely explained by their Vitamin C or beta-carotene content – another antioxidant, called lycopene, may be the crucial ingredient here. Good news for fast-food fans – the benefits of tomato paste are even seen among pizza eaters who are significantly less vulnerable to asthma.
•    Daily intake of sunflower seeds, or sunflower oil and margarine. These are by far the best natural source of Vitamin E, another antioxidant (see left) which helps to reduce the risk of becoming asthmatic. Vitamin E taken in supplements seems to have much less beneficial effect than natural Vitamin E from food.
•    A good intake of the minerals zinc, manganese and selenium, as well as magnesium (see p. 206). Shortage of any of these minerals may be linked with asthma. It is important not to eat too much wheat bran or unyeasted wholemeal bread, especially with main meals, as these block the absorption of several minerals.
Good sources of zinc include meat, shrimps, clams and oysters, with smaller amounts in cheese and egg yolks. Nuts, lentils and beans are fairly good sources of zinc, while soya protein blocks its absorption.
As well as being found in dark green vegetables, magnesium is plentiful in sardines, peanuts, hazelnuts, walnuts and lentils. Other fish, lean meat, milk, cheese and bananas contain smaller amounts.
Manganese is found in eggs and milk, and though the amounts are small, these are good sources because the mineral in them can be absorbed easily. While green leafy vegetables, whole grains and tea apparently contain more manganese – and are frequently recommended as a source of this mineral – in fact very little can be absorbed from those foods. Lentils are a moderately good source of manganese.
Selenium is most plentiful in fish and meat. It may be scarce in home-grown plant foods in areas of the world (notably Finland and parts of New Zealand) where selenium is lacking in the soil.
•    A limited intake of meat, especially red meat, plus a com-
-    plete avoidance of kidney, liver and other offal meats. An entirely vegetarian diet incurs a risk of mineral deficiencies however (see above). On balance, it is probably best to eat meat once a week or less.
•    A low intake of salt. Researchers in Kenya found that children eating a high salt diet (which equals the average salt intake in Britain and other parts of the developed world) were at greater risk of becoming asthmatic. For existing asthmatics, increasing the amount of salt eaten can make asthma worse, while reducing salt can lessen symptoms. Male asthmatics seem to be more vulnerable than females. Salt probably affects the muscles of the airways, making them more likely to contract.
The role of supplements
You should try to get all the nutrients you need from food rather than supplements. However, there are times when a supplement can be useful. Any asthmatic who has to cope with the effects of high air pollution, especially ozone and sulphur dioxide (see pp. 130-31), may find a supplement of Vitamin C beneficial. However, you should avoid very high doses of Vitamin C (e.g. I g/day) as they can cause disturbed sleep. Use natural sources for Vitamin E (see p. 206) if you can, but taking a supplement is better than nothing.
Vegans should think about taking a multi-mineral supplement, given the difficulties of ensuring an adequate intake of zinc, manganese and selenium from vegetable food (see left). Vegetarians may also benefit from a mineral supplement.
Some supplements, in certain circumstances, can do more harm than good. Omega-3 oils (also called w-3 oils, concentrated fish oils, or EPA and DHA) may make asthma worse for some people (see box on p. 221). Beta-carotene (sold alone and as part of mixed antioxidant supplements) may, according to some studies, promote cancer at the high doses used in many supplements. It should only be obtained from food.
Foods and drinks that bring on asthma attacks
The anti-asthma diet tackles the inflammation of the airways and the underlying tendency of the airway muscles to go into spasm – in other words, it is concerned with the long-term treatment or prevention of asthma. In addition, you should obviously avoid any foods which aggravate asthma in the short term. Various foods and drinks can bring on an asthma attack:
•    Foods and drinks containing sulphur-based preservatives tend to give off the irritant gas sulphur dioxide while being chewed or swallowed. Some asthmatics are more sensitive to sulphur dioxide than others. The foods that most commonly cause problems are dried apricots and other dried fruit (except those labelled ‘unsulphured’), shellfish, french fries, ready-made salads and fruit salads. Sulphur-based preservatives are used widely in the catering industry. On packaged food, look for ’sulphite’ and’metabisulphil or E numbers 220-227. Soft drinks, wine, beer and cider almost always contain sulphur-based preservatives.
•    Foods that cause heartburn (GER – see p.38) can aggravate asthma for some people.
•    Alcoholic drinks may make the airways contract for some asthmatics (see box on p. 160).
•    Some asthmatics need to avoid foods containing histamine (see box on p. 67).
•    A few asthmatics respond badly to the smell of food cooking. The most severely affected can suffer an asthma attack from anyfood aroma. Cromog lycate -type drugs (see p. 148) or anti -choli nerg ics (see p. 156) may block this reaction.
Needless to say, if you have a sensitivity reaction to any food listed for the anti-asthma diet you should not eat this food.

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.

Tony had suffered from hayfever since childhood but rarely took any medicines. Outside the grass-pollen season, he was fine, free of allergies and very fit. Then, when he was 35 he bought a run-down cottage in the country. The cottage was very damp and dirty.
The previous owner of the cottage, an elderly man, had died, and everything was much as he had left it. Tony moved in with his wife in late summer, and they began pulling out all the old carpets and furniture. Many of the windows would not open and there were dank musty cupboards and attics to be cleared. Dust filled the air – and Tony’s nose. He began to sneeze a little and within a few days he had a strange and unfamiliar feeling of tightness in his chest. During the following weeks, harvesting began in the surrounding fields, with several huge combine-harvesters working away all day and night. Tony noticed that, when out of doors, his eyes began to stream and the tightness in his chest became more noticeable. A few more days passed, and Tony found it harder to breathe, so he reluctantly went to see the doctor. The diagnosis was asthma. Skin-prick tests showed that Tony had allergic reactions to house-dust mite and moulds.
Tony’s case shows how someone who is already sensitised to an allergen – pollen in this case – may be vulnerable to developing new sensitivities, and new symptoms. It was almost certainly the dust mite and mould spores in the cottage that sparked off the trouble, followed by the mould spores from the cereal leaves, dispersed during harvesting.
For people with a tendency to allergies, the dangers of heavy exposure to potential allergens are something to bear in mind. It is surprising how many people with asthma had their first major attack while away from home, sleeping on an old sofa or in a friend’s dusty spare room. The dose of dust-mite allergen that you get from an ancient mattress or eiderdown can be massive.
Managing your allergy symptoms
As well as avoiding the development of new allergies, you need to manage your existing symptoms, and make sure that they interfere with your life as little as possible. For this you need good information and advice, support from your doctor, optimal drug treatment, and careful avoidance of your allergens.
Quite often people have all the information and drug treatment they need, but they still don’t stay on top of their health problems. There can be two distinct reasons for this: either they are not wholehearted about wanting to be well (ambivalence) – or they have never really accepted that they are ill (denial).
Ambivalence
Sometimes being ill has certain benefits – or being entirely well has certain disadvantages. Our state of health determines how people treat us, especially within the family, and the expectations people have of us. It may be comforting to be ill because others are more supportive then, or it may be less risky, because we are not forced to try things (such as sports or other physical activities) at which we might fail or look foolish. Being ill as a child often sets up a pattern for how we interact with the world, which revolves around caution, the comforts of familiarity, and holding back from new situations.
These habitual patterns can survive in the mind long after any real advantages have evaporated. Many people become stuck with a way of thinking and living where ill-health is a cornerstone of their existence. Doctors at the Chelsea and Westminster Hospital in London, who have developed a radical programme for treating atopic eczema (see pp. 46-8), have noticed this in their patients. ‘Old habits die hard and living with a little bit of eczema is a very tempting prospect for many patients, rather than clearing the skin completely…. As atopic skin disease begins for many in the first year of life, causing sometimes understandable alarm and despondency in the parents, the child learns how relevant their condition can be in their relationship with the external world, and with their parents in particular. Before they are able to speak, they have a powerful means of gaining parental attention which can have long-standing effects in the development of their personality. For some, to live without eczema is understandably a daunting prospect. This can be consciously appreciated and spontaneous-y referred to by some patients, while for others the issue will be buried from view, deep in their unconscious.’
If any of this rings bells with you, try to tackle the problem at source. Such mental blocks are not immovable. Indeed, simply recognising that the block is there can start to change things for some people.
Others may need professional help to overcome these longstanding habits of mind. Counselling or cognitive therapy can be very valuable, and your doctor may be able to help in locating a suitably qualified person for this.
Denial
At the opposite end of the spectrum are those who want to deny that they have any kind of health problem. Often these people cannot quite accept that they have a long-term disease, such as eczema or asthma, so they forget to take their drugs, apply creams to their skin, or carry their inhalers. Ironically, these people frequently wind up having far more trouble with their allergies than they need to, and a very poor quality of life, simply because they neglect preventive treatments.
To be really well, you first have to admit that you do have allergies, and then sort out your conflicting feelings about what this means. Again, counselling, cognitive therapy or some other kind of psychotherapy can be helpful.
Dealing with doctors
The decisions that your doctor makes about your treatment are ones in which you should be fully involved. Quite a few allergy patients don’t feel happy about their doctor’s treatment plan, but they never say so to the doctor’s face.
The usual pattern is to accept what the doctor prescribes without any argument, but then halve the dose of tablets, or only put the cream on once a day instead of twice, or not use the Inhaler at all. Some people stop and start their drugs in a random way because they never quite make up their minds about whether drugs are a good thing or not.
This approach to allergies invariably leads to worsening symptoms. The risks are greatest with complex problems such as
atopic eczema or chronic sinusitis, where a vicious circle can easily be set up if the disease is not brought under control, and for those with a life-threatening condition such as asthma. In the case of asthma, neglecting preventative treatment can be fatal.
It is far better to say what you think in the surgery, and discuss any misgivings you may have about drugs with the doctor. That way you can agree on a treatment regime that you are prepared to stick to – which may or may not involve drugs. Most doctors would far prefer a little plain speaking at the outset to having a patient who is half-hearted about following the treatment plan and never really improves.
A more serious form of communication breakdown occurs when a doctor stops believing what a particular patient says. This usually occurs because the doctor has decided that some or all of a patient’s symptoms are due to psychological rather than physical causes. (This is far more likely to happen to those with intolerance or unusual forms of allergic reaction than to those with classical allergic diseases.) Sometimes doctors say what they think, but often they don’t – they just start treating the symptoms in a different way, or acting impatiently, or saying rather puzzling things that leave the patient trying to guess what is going on.
If you find yourself in such a situation, the main thing to do is stay very calm and be very rational. Getting upset, or challenging the doctor’s opinion in a manner that seems at all aggressive, instantly confirms the ‘psychological’ diagnosis. Unfortunately, insisting firmly that the symptoms are not psychological also confirms the diagnosis as far as many doctors are concerned (see p. 237) which can be extremely frustrating. To begin with, deal with the situation by informing yourself about your illness. Be tactful and patient but persistent with the doctor, trying all the time to keep the relationship pleasant and the channels of communication open. If, after giving it a fair try for some weeks or months, this approach isn’t working, you should look into the possibility of changing doctors (see p. 88).
Emergency alerts
An emergency alert bracelet or pendant should be worn by anyone who:
• is allergic to latex rubber, or to drugs such as penicillin
• has a severe allergy to insect stings
• suffers from exercise-induced anaphylaxis, or anaphylactic shock as a result of food allergy
• has very severe asthma attacks.
Key information is engraved on the bracelet, along with a telephone number which gives medical staff access to a computer database containing vital medical data about you. This valuable service is provided by a non-profit-making company called Medic Alert.
As everyone knows, a little knowledge is a dangerous thing. You can use the information in this book to help yourself, but it’s important to remember that there is no substitute for the comprehensive understanding of the human body that your doctor gained during many long years at medical school. Always check with your doctor before changing your diet, stopping your drugs, practising breathing exercises, taking a non-prescription medicine or trying any other experimental treatment.
The information about disease, diagnosis and treatment in this book falls into four categories:
• basic information about the disease that no doctor would disagree with
• the findings of new research, or research that has not become widely known, but which falls within the accepted medical model of the disease concerned. Your doctor may not know about some of this research (there is a terrifying amount of new information bombarding doctors every week, and no one can keep up with it all) but he or she won’t find it unbelievable.
• evidence from research that is entirely valid, but which is widely ignored or dismissed because it falls outside the accepted medical model of the disease concerned (see pp. 86-7)
• information based on the repeated observations of doctors, or of patients – this does not amount to scientifically valid evidence, but it’s included here if it seems plausible and if it could be useful to some readers.
You should be able to tell, from the context in which it is presented, which category any item of information falls into. When talking to your doctor about items that belong in the last two categories above, be prepared for a certain amount of scepticism or possibly outright dismissal.
The important thing to ask the doctor is if there is good reason why you should not try the suggested measures, in addition to your usual treatment – is there any risk involved, given your particular state of health? Make it clear that you want to try the additional treatment with an open mind and will drop it if it is not helping. Ask for the doctor’s help in assessing the effects of the treatment objectively.
Managing asthma
Of all the diseases described in this book, asthma is among the most difficult to live with, especially severe asthma. Learn to recognise asthma symptoms before they get out of hand, and take immediate action.
Studies of patients who die from asthma attacks find that the deaths could, in almost all cases, have been prevented. Factors contributing to fatal attacks include:
• heavy exposure to allergens just before the asthma attack
• cigarette smoking
• failure to use preventer drugs
• repeat prescriptions for inhalers being given without the patient seeing a doctor
• delays in seeing an asthma specialist
• depression in the asthmatic leading to neglect of treatment.
For the day-to-day management of asthma, you should have a written management plan prepared by your doctor or asthma nurse.
This should tell you how often to take your drugs under normal circumstances, and what to do if your symptoms change or you develop a cold or chest infection. The actual brand names of your drugs (or the colour of the inhaler) should be included on the management plan. Assuming you have a peak-flow meter – and you really should have one –specific peak-flow values should be included on your management plan, with instructions for how to respond if your peak flow falls to these levels.
Your plan should tell you how to recognise a severe attack coming on, and what to do at the various stages of the attack. (This personal management plan is specifically geared to you or your child. Although pp. 100-101 give generalised advice, your own plan is invaluable.)
Be sure that you know exactly how the advice in the plan relates to the sort of real-life situations you experience. No matter how good your plan, real life can sometimes be far more complex than anyone anticipates, so there may be times when it is difficult to know what to do. When this occurs, make a note of the situation, and the reasons why you are unsure how to implement the plan. Call your doctor immediately if your asthma is getting worse, and get the asthma attack under control. Save your notes and, at the next opportunity, check with the doctor what you should have done in those circumstances. This will help you to build up your detailed knowledge of how to manage your asthma, or that of your child.
Research shows that asthmatics can, with training, develop a greater awareness of how narrow their airways are – this helps you to detect worsening asthma before things get too serious. You can train yourself in this art by guessing what your peak flow will be and writing your guess down before you use your peak-flow meter (see right) each day. Over a period of weeks, you should find your guesses getting closer to the true value.
A key part of asthma control is having everything with you that you need in case of an attack. It’s tedious, but you have to do it. You should take your reliever inhaler with you wherever you go. Those with severe asthma can also benefit from carrying a collapsible spacer (ask your pharmacist or see p. 255 for contact details of suppliers).
For a long day out, or a stay away from home, check that you also have:
• your management plan
• your peak-flow meter
• your preventer inhaler
• steroid tablets, if you sometimes need these
• your doctor’s phone number.
A little lateral thinking may be needed regarding the problem of carrying all this kit around. One asthmatic friend of mine carries his inhalers in a trendy-looking camera bag that goes everywhere with him. Mothers of asthmatic children have solved the problem by making an ‘inhaler pouch’ from a sunglasses case and attaching it to a favourite belt or by enlarging the pocket in a teenager’s jacket to accommodate inhalers.
Anyone with severe allergies to food or insect stings should take similar steps, so that carrying their auto-injector everywhere is a simple matter.
Peak-flow meters
A peak-flow meter can detect narrowing of your airways – the beginnings of an asthma attack – before there are any obvious symptoms. It measures the maximum speed at which you can force air out of your lungs. The signs of worsening asthma include:
• a morning reading which is less than 75% of the evening reading
• average readings less than 75% of your best-ever reading. (If they get to less than 50% of your best reading, this is a severe and possibly life-threatening attack.)
To use a peak-flow meter:
• push the pointer to zero and hold the meter horizontally
• keep your fingers away from the scale and the pointer
• breathe normally before you start
• stand up and take a deep breath, but don’t puff your cheeks out and don’t hold your breath before you blow
• seal your lips tightly around the mouthpiece
• blow hard into the meter, as if blowing out candles on a birthday cake; don’t move your tongue while doing this
• repeat three times, and record the highest reading of the three.
You must learn how to use a peak-flow meter from your doctor or asthma nurse, who should also check your technique regularly – it is very easy to get into bad habits.

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.

Allergy and Your Immune System
`The summer used to be such a miserable time for me because I’m allergic to grass pollen. For most of

my life I have had dreadful hayfever, and my asthma would get worse during the summer as well.

Antihistamines knocked me for six, and although there were nose drops that helped a little, they

certainly did not resolve the problem completely. Exam time was always a nightmare when I was a student

- then, as now, it coincided exactly with the pollen season.’
‘Getting a job in Chicago was a turning point in my health. My colleagues were amazed to see me

snuffling through the summer and just accepting that nothing could be done to improve matters. The

whole approach to treating allergies is different there. Eventually someone marched me off to see her

allergist, who said that I should have “allergy shots” and that my health insurance would cover it. The

process was very time-consuming at first, and it took a while to work, but the change is remarkable.

I’ve never regretted having the treatment. Summer is a time I can actually enjoy now.’
Not everyone responds this well to immunotherapy, but for those allergy sufferers who do benefit, this

is an excellent treatment. It tackles allergies right at their source, by teaching the immune system to

react differently to the allergen.
Also known as Specific Immunotherapy (SIT), Incremental Immunotherapy (11T) or simply as

hyposensitisation, this form of treatment was devised by two English medical researchers, Leonard Noon

and John Freeman, who reported their successes with hayfever patients in 1911. Ironically, their

treatment is now less readily available in Britain than in any other industrialised nation. Only a

small minority of British allergy patients receive immunotherapy. The cause of this strange situation

is a ruling made in 1986 by the Committee on the Safety of Medicines (CSM). This states that

immunotherapy must only be given where there is resuscitation equipment available, and that all

patients must wait for an hour after each injection, in case of
side effects. In addition, immunotherapy cannot be used for severe asthma.
The requirement for resuscitation equipment rules out most GP surgeries, and this effectively puts

immunotherapy beyond the reach of many allergic individuals in Britain, owing to the extreme shortage

of allergists and hospital allergy clinics (see p. 89). (In the past, the lack of allergy specialists

meant that most immunotherapy in Britain was given by GPs.)
The CSM ruling was triggered by a number of deaths due to immunotherapy: there were eleven fatalities

between 1980 and 1986, with five of these in the eighteen months just before the report. But almost all

these deaths were due to very basic errors in the way the injections were given – tragic as the deaths

were, the official response to them was inappropriate. Fatal reactions to immunotherapy can be avoided

with close attention to ordinary safeguards (see p. 166-7).
Allergen immunotherapy is still freely available elsewhere in the world, and is regarded as a key part

of allergy treatment. Britain is now out of step with all other developed countries, and most doctors

feel that British restrictions are far too strict.
There are hopes that this situation may change within the next few years, and that more allergy

sufferers may be able to take advantage of this valuable treatment. This could be achieved, in part, by

investing more National Health Service money in allergy clinics and allergy specialists. In addition,

there should be a relaxation of the regulations, so that properly trained GPs can give immunotherapy to

patients who are not at high risk of a fatal reaction. For people whose lives are affected by

allergies, the reintroduction of this treatment (with appropriate safeguards) would be a huge boon.
The uses of immunotherapy
Immunotherapy is mainly used for airborne allergens such as pollen, house-dust mite and mould spores.

Allergies to animals can also be treated with immunotherapy, but the treatment cannot work miracles –

if a cat-allergic person decides to keep the cat, the high dose of allergen inhaled every day limits

the impact of immunotherapy treatment.
People with straightforward allergic reactions affecting the nose and eyes (allergic rhinitis and

conjunctivitis) respond well to immunotherapy. In patients with hayfever, for example, the success rate

(patients showing some degree of improvement) is about 80-90%. When nasal allergies are complicated by

chronic sinusitis or nasal polyps, the chance of success is a little lower.
Some studies of the long-term effects of immunotherapy suggest that, if it is given to children with

hayfever or perennial rhinitis, those children are less likely to develop asthma.
The benefits of using immunotherapy to treat established asthma are less certain. Asthma is a more

complex disease than hayfever, and allergies are only one factor among many (see p. 36), which may

limit the impact that immunotherapy can make. Experience suggests that immunotherapy can be a great

help for an asthmatic with a strong allergic reaction to a single airborne allergen, such as grass

pollen or house-dust mite, but not for other asthmatics. Asthmatics with aspirin sensitivity or chronic

sinusitis are unlikely to benefit.
The value of immunotherapy to children with asthma is a subject of great debate among doctors in the

United States. Some studies suggest that it is of little real benefit, while others are more positive.

One interesting study, that followed asthmatic children for 15 years or more, found that if they were

given a full five-year course of immunotherapy when young, they tended to have fewer asthma symptoms

and need less medication in their late teens and early twenties.
Chronic urticaria (nettle rash) is occasionally due to airborne allergens, in which case immunotherapy

may help. However, immunotherapy is not recommended for atopic eczema. When people with both eczema and

rhinitis try immunotherapy for their nasal allergies, some find that their eczema gets worse.
Insect-sting allergy is a prime candidate for immunotherapy (see pp. 167-8) but food allergy is a

different matter, and is not treated with immunotherapy at present (see p. 168).
Who can get immunotherapy?
As a result of the CSM ruling (see p. 164) remarkably few allergy sufferers in Britain receive

immunotherapy.
Those with insect-sting allergy, who have suffered anaphylaxis (see p. 58), are the most likely to be

offered this treatment. However, even with this frightening and life-threatening problem, which can be

treated with almost 100% success by immunotherapy (see p. 167-8), such treatment is not automatically

available.
A few people with severe hayfever that does not respond well to drug treatment may also be given

immunotherapy. It is worth asking your doctor about such treatment if you feel you would benefit.
How immunotherapy works
Immunotherapy consists of a series of small injections, just under the skin. The liquid that is

injected contains an extract of the offending allergen, for example house-dust mite. The injections are

given at regular intervals, usually once a week, although other schedules are possible (see p. 167-8).
At the outset, a very dilute version of the allergen extract is used, way below the threshold for an

allergic reaction. People who seem highly sensitive, on the basis of their skin tests, start on an

extract that is even more dilute.
For the next injection, a slightly higher concentration of the allergen extract is used, and the

concentration goes on increasing with each successive injection. The idea is to habituate the immune

system to the offending allergen, by very gradually raising the dose. Eventually, when the dose reaches

a level which generally gives beneficial effects, no further increases are made.
If an allergy sufferer reacts badly to immunotherapy injections (see p. 166) on several successive

occasions, the dose may be levelled off before the ideal maximum dose is reached. However, a good

allergist will persist for some time in trying to increase the dose because stopping at a lower level

often results in the treatment being ineffective.
The first stage of immunotherapy, when the concentration of allergen is being increased week by week,

is referred to as the build-up stage. The second stage, when the dose is being kept at the same level,

is called maintenance therapy, and the dose used is the maintenance dose.
There is sometimes an obvious improvement by the time the build-up stage is complete, but not always.

The benefits of the treatment generally appear within six months of reaching the maintenance dose, but

some people have to wait a year or even two before things improve. As the immunotherapy begins to take

effect, symptoms decline and there is often less need for drugs.
A great deal of research effort has gone into finding out what lies behind these changes – in other

words, what is actually happening to the immune system when immunotherapy is effective. The answer is

that a surprising number of different changes may occur and no two allergy sufferers react to

immunotherapy in quite the same way. Frequently there is a shift in the kinds of antibodies the body

produces against the offending allergen. Levels of IgG antibodies (which help to block the allergic

reaction) go up, while levels of the allergy antibody, IgE, tend to stabilise and eventually go down.

The numbers of mast cells (see box on p. 12) may also decline, and they can become less responsive to

the allergen. The balance of power between Th1 cells and Th2 cells may also shift, with the pro-allergy

Th2 cells (see p. 11) becoming less influential.
What can go wrong
The secret of safe immunotherapy is to go at exactly the right speed for the immune system of the

individual being treated. The doctor should look for feedback from the immune system – signs that show

how well it is coping with the steadily increasing dose of allergen – and use these to pace the

immunotherapy schedule.
Going too fast – getting ahead of the immune system’s ability to cope – is hazardous. A major allergic

reaction, called anaphylaxis (see p. 58), can occur, and this is the cause of deaths during

immunotherapy. However, as long as there is injectable adrenaline (see p. 150) and resuscitation

equipment available, even such an extreme crisis can be dealt with safely.
Serious reactions to immunotherapy usually occur:
•    during the initial build-up phase; maintenance therapy is much safer
•    during the pollen season, for those with pollen allergy
•    when a new vial of allergen extract is first being used, because of variations in concentration

(see p. 168-9).
Those most vulnerable to severe reactions are:
•    people with asthma, especially severe or unstable asthma
•    those who have experienced systemic allergic reactions in the past
•    anyone who appears to be extremely allergic, on the basis of skin tests
•    anyone taking beta-Mockers (see box on p. 150).
With care, these fatalities can be avoided. Patients who are given immunotherapy can ensure their own

safety by being well informed about the procedure (see p. 167).
The timing of immunotherapy
There are various different approaches to the timing of immurotherapy. The basic method (which has a

good safety record in the United States where it is very commonly used) starts with injections once a

week. After the maintenance dose has been reached, maintenance injections are given once every 2-4

weeks. The frequency of these may be increased during the pollen season, for people with pollen

allergies.
It is the regularity of the injection schedule that gradually creates, and then sustains, immune

tolerance, so the treatment is only of value to patients who can reliably keep their appointments.
When immunotherapy is successful, it can eventually be discontinued without any reappearance of the

allergic reaction. It usually takes 4-5 years of regular therapy, from the time of the first injection,

to get to this point. The benefits then persist for many years, perhaps indefinitely in some people,

even without any further injections.
Rush immunotherapy
Trying to speed up the process of immunotherapy greatly increases the risk of a severe reaction

(anaphylaxis). However, there are some situations where fast results are needed, and in such cases rush

immunotherapy, also called accelerated immunotherapy, may be used.
During the build-up stage of rush immunotherapy, injections are given every day, or even several times

a day. All the usual safety procedures (see below) are observed with particular care, to reduce the

chance of a severe reaction.
In semi-rush immunotherapy, the build-up injections are given twice a week, and the risks are lower

than with daily injections, but still higher than with weekly injections.
Minimising the risks
If you are lucky enough to be offered immunotherapy treatment under the National Health Service, you

should not feel concerned about accepting the offer. There is very little risk of a bad reaction

because safety procedures are now so stringent.
To minimise the risk of suffering a severe reaction, the doctor will ask you, at each visit, about any

reactions that occurred after your previous injection. Reactions might include redness, itching or

swelling around the injection site, or (more seriously) symptoms elsewhere on the body, such as nettle

rash (urticaria), itchy skin, sneezing, a runny nose, red or itchy eyes, tightness in the throat or

chest, coughing or wheezing. Always make a note of such symptoms, so that you don’t forget to mention

them at the next visit. This is crucially important, as such reactions can indicate that the immune

system is being hurried along too fast.
The doctor will also ask if you have an infection of any kind, as this can alter your reaction. You

should also tell the doctor about any new medicines being taken, as some, such as betablockers (see box

on p. 150), can make a bad reaction to the injection more likely to occur.
Asthmatics can expect the doctor to ask about current asthma symptoms, and to check their peak flow

both before and after an injection. If there are any symptoms, or if the peak flow is less than 70% of

the best-ever value, the injection won’t be given.
Severe reactions can sometimes begin several hours after the injection, so stay within reach of a phone

for about 24 hours. Among United States allergists (who don’t require their patients to wait after the

injection for more than 20-30 minutes) there are some who believe that everyone undergoing

immunotherapy should carry an adrenaline (epinephrine) auto-injector (see p. 150) on the day an

injection has been given, for use in the event of a severe reaction. Anyone who has suffered

anaphylaxis in response to an insect sting will probably have an adrenaline auto-injector anyway, and

this can certainly be used to treat anaphylaxis following immunotherapy. Note, however, that using the

adrenaline is just the first step in treating anaphylaxis (see p. 98) and you must then go back to your

allergist, or to the nearest hospital emergency department, without any delay.
It is sensible to avoid exercise for two hours after an injection. Be extra-cautious during the pollen

season if you are receiving immunotherapy for pollen allergies.
Immunotherapy for insect-sting allergy
`Our daughter has had two really bad reactions from being stung by a wasp. After the second one, the

doctor at the accident and emergency department told us that she nearly died. We got so anxious about

it that we worried every time we left the house in the summer, and it was even worse if she went out

without us. My wife got so upset about it that she wasn’t sleeping well. It was affecting the whole

family badly.
‘Then we heard about desensitisation treatment, and asked our GP, but he said he couldn’t do it.

According to him, they might be able to do it at the hospital, but it might not work, and it was risky

too. We accepted that at first, but then I started doing some research on the Internet, and discovered

that in America and Germany this treatment is absolutely standard – someone like our daughter would

automatically be given it. We felt very angry when we found this out, and went back to the doctor.

Eventually Ann was referred to the allergy department at a hospital, and now she is getting this

desensitisation treatment. I’m pleased about that, obviously, but I still think it shouldn’t have been

such a fight to get it.’
Immunotherapy provides highly effective protection for those with insect-sting allergy, and should be

given to anyone who has had a severe systemic reaction (see p. 60). Some United States allergists also

recommend it for adults who have had a cutaneous systemic reaction (see p. 60), on the basis that they

may well progress to a severe systemic reaction with the next sting.
Studies of people who have suffered severe systemic reactions, and are then treated with immunotherapy,

show that 97% have no systemic reaction to future insect stings. For the 3% who are not fully

protected, the severity of the reaction is much reduced and far less likely to be life-threatening. In

other words, this is an excellent treatment which can save lives.
Targeting the treatment
Choosing the right venom for immunotherapy can sometimes be difficult. Not everyone with insect-sting

allergy sees the insect that caused the reaction. Skin tests may not give the answer either, because

there are often positive reactions to several different venoms. Some of these may be false positives

(see box on p. 91) and it is impossible for the allergist to say which one(s) are actually relevant.

Most allergists will recommend immunotherapy for all of them, using a mixture of venom extracts.
Where the guilty insect was seen and identified, but other venoms also give positive skin tests, a more

difficult decision has to be made. Many allergists carry out immunotherapy for all the venoms that gave

a positive skin test, on a ‘better safe than sorry’ basis. Since there are cross-reactions between

venoms (see box on p. 113), there is some sense in this. Other allergists just give immunotherapy for

the insect that did the deed.
Will immunotherapy against one insect protect against a related insect? With two closely related

insects such as wasps and hornets, which have many allergens in common, it might do – but there is no

guarantee. The problem is that, as well as the shared allergens, each venom also has its own unique

ingredients. It’s impossible to say, with the kind of tests available at present, if an allergic

reaction was to shared allergens or unique ones. So immunotherapy against wasp venom may give

protection against hornet venom, but it will not necessarily do so – and vice versa.
In the case of bumblebee allergy (seen almost exclusively in those, such as horticulturalists, whose

work involves handling bumblebees) a more definite answer can be given – honeybee immunotherapy does

not work. Immunotherapy with bumblebee venom does work, fortunately. The bumblebee extract has to be

obtained from specialist sources.
Injections are given weekly during the build-up phase, unless protection is needed urgently, as with

work-related sting allergy, in which case rush immunotherapy may be used. Once the maximum dose has

been reached, a maintenance injection is needed every four weeks. After a year, this maintenance dose

can be given every 6-8 weeks.
After 3-5 years of immunotherapy, skin tests with insect venoms are usually tried again. If the results

are negative, the immunotherapy will stop. Research now shows that, even if skin tests are still

positive when immunotherapy ends, there’s an 8090% chance that no systemic reaction will occur to

future stings. Some people are not reassured by this, and prefer to continue with immunotherapy for

their own peace of mind. Indeed, research shows that a near-fatal systemic reaction has a long-lasting

psychological impact, and that many people continue to feel anxious despite completing immunotherapy

and reacting negatively to skin tests.
At one time, challenge stings with live insects were given to check whether immunotherapy had actually

worked. Few doctors do this now, but your allergist may be prepared to do a challenge test if you ask.

Adrenaline and resuscitation equipment would be available if a challenge test were used, so any severe

reaction could be dealt with promptly and effectively. The fact that the psychological consequences of

insect-sting allergy are so persistent suggests that challenge tests with live insects may have a

particular value, in demonstrating that immunotherapy has worked. Challenge tests are also helpful for

those who work with stinging insects, such as honeybees and bumblebees, and who need to be sure that

they can go back to work safely.
Immunotherapy for food allergy?
Attempts to use standard immunotherapy for food allergy have been made repeatedly, but without success.

The process of giving the injections is nerve-racking because of the constant risk of a severe

reaction. The risks prevent the dose of allergen being increased very much, so the beneficial effects

are small. While there may be some reduction insensitivity, it is not enough – or not reliable enough –

to be of any practical value.
What doctors are aiming for here, incidentally, is simply to protect against the effects of

accidentally eating a tiny amount of the food – no one is expecting that someone with peanut allergy

will be able to eat peanut butter sandwiches as a result.
Some of the new developments in immunotherapy may be useful for food allergy, as described in the next

section.
The future of immunotherapy
Many different research teams are working on ways of improving immunotherapy – making it more

effective, safer to give, and less time-consuming.
One approach involves altering the allergen, so that it only interacts with those parts of the immune

system whose job is to control allergic reactions (and therefore bring about tolerance). The changes

made to the allergen are designed to make it ‘invisible’ to the parts of the immune system that

actually attack the allergen. The idea is to inject something that can’t cause a bad reaction, and is

therefore 100% safe.
The modified allergens are called allergoids. Another term often used is peptide immunotherapy – this

describes a technique in which the allergens are chopped up into small pieces to make them safe

(allergens are proteins, and a fragment of a protein is called a peptide).
Already, researchers in Germany have made an allergoid from birch pollen that can reduce hayfever

symptoms with a series of just seven injections given before the pollen season.
Meanwhile, a research team in London is working on peptides made from cat allergen, with encouraging

results so far. In a group of asthmatics who were allergic to cats, a series of 4-10 injections, over a

period of 2-8 weeks, produced benefits in about half those treated. The researchers believe that they

can improve on this and help the majority of people with cat allergy, at least enough to survive

temporary exposure to cat allergen (when visiting cat-owning friends, for example). They hope to refine

the treatment sufficiently to enable some cat-allergic people to keep their pet, rather than finding it

a new home. This is a relatively safe treatment that might be given by a GP, rather than only by

specialists. The research team hopes the treatment will be available by about 2009.
Could this kind of technique work for food allergy? Doctors believe that it can, and a great deal of

research work is being done, in both Britain and the United States. A major focus of this effort is

peanut allergy, since this puts so many young lives at risk. Even if the research is successful, It

will be several years before such treatments become available.
Researchers are also working hard to produce standardised allergen extracts – in other words, allergen

extracts that always contain a standard amount of the allergen. The aim is not only to reduce the

number of treatment failures (which can occur if the extract does not contain enough allergen) but also

to avoid mishaps when a new vial of allergen extract is used (differences in strength, between one vial

and another, are sometimes a cause of anaphylactic reactions).
Standardisation is difficult, because the starting materials –skin particles from horses, for example,

or dust-mite droppings –are natural materials and therefore variable. Some samples contain far more of

a particular allergenic ingredient than others.
One way around this problem is to develop accurate methods of measuring the amount of allergen in the

extract. Another approach is to abandon the whole business of making extracts, and produce allergens

artificially, in a laboratory. This is done by inserting the gene for the allergen – the gene for the

Der p1 allergen of house-dust mite, for example – into bacteria. These bacteria then act as production

units, manufacturing large amounts of the allergen every day. With this high-tech approach, the exact

content of the allergen preparations can be controlled.
These high-tech allergen preparations are extremely pure, and therefore very effective – as long as the

person receiving immunotherapy really is sensitised to the particular allergen that is included.

Unfortunately, most natural allergenic materials contain two, three or even more separate allergens. In

house-dust mite droppings, for example, while Der p1 is the allergen that affects most people, there is

also an allergen called Der p2, and a few people are more sensitive to this than to Der pl.
Artificially produced allergen preparations usually include the main allergen only. For the minority of

people who are more severely allergic to one of the other allergens, this extract will not work.

Eventually this problem will no doubt be circumvented by means of more precise skin testing before

immunotherapy begins – skin tests with individual allergens, rather than with allergen extract

containing a mix of allergens.
A third approach is to change from injections to oral immunotherapy – giving the allergen extracts by

mouth. The best results are obtained when the allergen is held under the tongue for a while and then

swallowed. This is known as Sub-lingual immunotherapy or SLIT, and has become very popular in Italy and

France, where it is a common treatment for hayfever. A recent pilot trial among GPs in Britain suggests

that it may be useful, but is not a miracle cure. Overall, the group treated with SLIT had fewer

symptoms during the pollen season, but antihistamines were still needed. There is some evidence from

Italy that SLIT might reduce the likelihood of children with hayfever going on to develop asthma, and

reduce the chance of new sensitivities.
Side effects are unusual with this treatment, and those that do occur are mostly mild – itching in the

mouth, for example. The treatment is safe enough for routine use in children.
Might oral immunotherapy work for food allergy? Other Italian studies suggest that it could. The

objective of these studies is to reduce the risk to children with cow’s-milk allergy from accidental

encounters with ‘hidden milk’ in prepared food or drink. The immunotherapy treatment begins with

miniscule amounts of milk – the doctors start with a single drop diluted in water, each day for a week

– and increase the dose extremely slowly. Antihistamines are given to minimise the risk of a reaction.
The whole process requires enormous patience, but after seven months, the majority of the children

involved can tolerate some milk – between three tablespoonfuls and a small cupful each day.
This is a very encouraging study that should be repeated by doctors in Britain. Because of the risks of

anaphylaxis – which can, of course, be fatal – it does require full medical supervision, and you should

not attempt it at home. Whether this method would work for allergens other than milk is something that

nobody has yet investigated.
A great many other approaches to immunotherapy are currently being tried for food allergy. Many of the

new techniques are highly experimental, and some show great promise, but it will be many years before

they are in use.
One innovation that is closer to being in general use in the United States involves giving the anti-IgE

drug omalizumab (see p. 149) alongside immunotherapy injections. The drug maximises the benefits from

the immunotherapy, and may make the build-up stage (see p. 165) safer, by lowering the risk of

anaphylaxis. For British allergy sufferers, who cannot yet get omalizumab, and whose chances of getting

immunotherapy are vanishingly small, it may seem unkind even to mention such treatments, but we can

only hope that things will improve here in the near future. You might take some comfort from the

thought that, by the time immunotherapy is available again in Britain, there will be a whole host of

highly effective new techniques available for doctors to try.
All the methods described above are forms of specific immunotherapy – they treat an allergy to dust

mites or to grass pollen or some other specific allergen.
A far more radical and ambitious approach to immunotherapy is now the aim of some medical researchers:

blocking the tendency to allergies as a whole.The underlying idea here is to reverse the basic shift in

the immune response, from Th1 cells to Th2 cells. It is this shift to Th2 cells which produces the

allergic tendency (see pp. 11 –13).
Some interesting findings have already been made in this area, including the surprising discovery that

the balance of Th1 cells and Th2 cells can be adjusted even in people with longstanding allergies.

Inspired by discoveries about hygiene and allergy (see p. 21), British researchers have made a vaccine

containing inactivated cells of a harmless bacterium found in the soil, Mycobacterium vaccae. This is

given as a single injection just under the surface of the skin. It has been used for adult patients

with asthma, and for children with severe atopic eczema, with some improvement in both groups. If the

treatment proves as useful as the preliminary studies suggest, this could be a common treatment in a

few years’ time.

Atopic eczema
A Greek word meaning ‘to boil over’ or ‘to erupt’ is the source of the medical term ‘eczema’. It refers, of course, to the way in which the skin erupts into a rash, but it could equally well describe the eruption of controversy around this disease. No other allergic disease is quite such a cauldron of dissent - indeed, even the question of whether it is an allergic disease remains unresolved. These controversies directly affect the treatment of atopic eczema, so it is useful to understand them if you or your child have eczema.
The disagreement begins with the question of what causes atopic eczema.
Let’s start with the one point that everyone agrees on: dry skin plays a fundamental role. Those with atopic eczema have dry skin, not just in the eczematous areas, but in other parts as well, sometimes all over the body. The skin cells are less efficient than normal skin cells at retaining water.
Everyone would also agree that there is inflammation of the skin – a reaction that is produced by the immune system. But when it comes to the question of what starts off the inflammation there are huge differences of opinion among specialists treating atopic eczema – these specialists include dermatologists, allergists and paediatricians.
Since people with atopic eczema are atopic (allergy-prone), and most have
huge amounts of the allergy antibody, IgE, going round in their blood, it might
seem plausible that an allergic reaction to some external item kicks off the
inflammation. And when skin-prick tests (see p. 91) to common allergens such
as house-dust mite are tried, there are usually a large number of positive results.
But many of these turn out to be false positives – when tested more directly,
the allergen concerned does not actually play a part in causing the skin symptoms.
This has led some specialists working with eczema, mainly dermatologists, to
What the words mean
Eczema is not a disease in itself. The word refers to a certain type of reddish rash — a rash which can be caused in a variety of ways. The type of eczema that affects people of an allergic disposition (atopics), is called either atopic eczema or atopic dermatitis.
The word dermatitis just means inflammation of the skin. Most doctors consider it to be synonymous with eczema, but some give it a slightly broader meaning.
believe that allergic reactions play little part in either initiating or perpetuating atopic eczema. In their view, the basic cause of atopic eczema is dry skin and a generally overwrought immune system, not specific allergic reactions.
To some of these doctors, positive skin-prick tests are all false positives in atopic eczema – that is, irrelevant to the disease process. A positive skin-test result, in their opinion, simply indicates that the skin of atopic eczema sufferers is in a highly sensitive state, not that the allergen concerned plays any causative role.
Allergists tend to take a different view of this, as you might expect. And recent research shows that they are correct – allergens often do play a significant part in provoking atopic eczema.
Research using direct challenge tests (see p. 90) has identified some of the things that could provoke such sensitivity reactions:
• house-dust mites, pollen or moulds
• cats, dogs, rabbits and other furry pets
• cow’s milk or other food – a prime suspect in babies and young children (see p. 68). The response to food is usually delayed, occurring some hours after the item is consumed.
With mite, pollen and pet allergens, the eczema symptoms can be provoked either by allergens falling on the skin, or by direct contact (e.g. mite allergens in the bed, skin contact with pets, or lying on grass for those with grass-pollen allergy).
The rash tends to occur on skin not covered by clothes, as you would expect. But it can sometimes occur only on particular exposed areas – usually the most sensitive areas of skin. For example, there are people who react to house-dust mite but have eczema on the eyelids only.
Additionally, experiments show that even when an airborne allergen is only inhaled it can sometimes provoke eczema symptoms. The allergen probably reaches the skin in the bloodstream. (Alternatively, it might provoke an immune reaction in the airways which generates chemical messages of the kind that promote inflammation – these then reach the skin in the blood.) This means that the skin reaction could occur anywhere on the body, not just on exposed skin.
In the case of food, the molecules of food that cause the trouble are probably being absorbed from the stomach without being completely broken down. They then reach the skin via the blood to provoke a reaction there. (Or, again, it could be an inflammatory messenger chemical travelling from the gut to the skin in the blood.)
When food gets directly onto the skin – which it frequently does with small children, of course – it can provoke a reaction that way too. This may be a slow eczema-causing reaction, or a much faster reaction known as contact urticaria (see pp. 50-51). Reacting to food with contact urticaria is quite common in children with atopic eczema – but the same food doesn’t necessarily provoke atopic eczema when it is eaten. (However, eating these foods can sometimes trigger anaphylaxis – see pp. 58-9. They should therefore be treated with great caution.)
At the same time as all this research – which shows for sure that allergens play a part in atopic eczema – others have been asking what actually happens when skin reacts to an allergen. Their studies have turned the accepted understanding of allergies upside-down. They show that when something like egg or pollen provokes atopic eczema, what is occurring isn’t necessarily an allergic reaction of the usual sort, with IgE and mast cells (see
box on p.12). Instead, other immune cells are causing the trouble. Sometimes IgE is involved, but without mast cells. Sometimes neither is involved. These revolutionary discoveries are described in more detail on pp. 18-19. One interesting realisation from this research is that in different eczema sufferers, different immune reactions may be producing the rash – even if they are reacting to the same allergen! This helps to explain why the results of skin tests are so inconsistent and puzzling.
The wandering rash
For a baby with atopic eczema, the face, and especially the cheeks, are commonly affected, but there may be a rash all over the legs, the backs of the arms, and the back. As the months go by, the rash settles on the lower legs, and spreads to the fold of the elbow, and then the fold at the back of the knees — by about three years of age, this flexure eczema is the main problem for most children.
In adults, eczema is often found in quite restricted areas, such as the hands, scalp, lips, eyelids or chest. It may be located around the nipples — a sensitive spot where rubbing by clothing is enough to initiate a rash.
Atopic eczema is always in a process of change, and different parts of the body may display different stages of the rash:
• The rash is red and usually dry at first, and there may be not a great deal to see. In this early stage the visible signs may be minimal, while the itchiness can be colossal. Sometimes there is oozing of clear fluid.
• Occasionally the first phase is more marked, with dense patches of small red bumps or tiny blisters. On the hands, these may merge to form larger blisters.
• Infections tend to change the appearance of the rash (see p. 44).
• With time the skin becomes thicker, paler and scaly. It may form leathery patches (called lichenification), especially if there is habitual scratching or rubbing. This is chronic eczema.
• When the eczema clears, there may be an area of skin that is lighter in colour, or darker, than the surrounding skin.
The next step
Whatever causes atopic eczema, it provokes the most horrendous itching, as every eczema sufferer knows. The itch cries out to be scratched, and scratching is the major cause of the visible rash. If left untouched, the skin does not erupt into eczema, although it may well turn red, and there are still distinct changes in the skin that can be seen with a microscope.
Once eczema has erupted, the skin is no longer an intact protective layer that neatly separates ‘in-here’ from ‘out-there’. The skin becomes more permeable and loses its own natural moisture far more readily, so the dryness gets worse. At the same time allergens and irritants penetrate far more easily, causing yet more inflammation.
Something else compounds the damage: once atopic eczema is established, the immune system starts making IgE antibodies to the body’s own proteins, especially those found in skin cells. This helps explain why atopic eczema can become so severe and so entrenched.
Infections — another vicious circle
When eczema erupts and the skin barrier is breached, infections often become a problem. A regular source of trouble is the bacterium Staphylococcus aureus, a cause of the infection impetigo. This microbe invades eczematous skin far more readily than healthy skin, causing a prolific ooze with golden-yellow crusting.
Staphylococcus aureus produces a toxin known as a ’super-antigen’ which revs up the immune system to even more furious effort. This effort does not, unfortunately, oust the bacteria, but it does make the skin inflammation even worse. To add to their woes, many who are afflicted with atopic eczema start making IgE antibodies against Staphylococcus aureus toxins.
Infection with fungi (yeasts and moulds) is also a problem in atopic eczema (see p. 49), and there may be sensitivity reactions to these fungi.
The herpes virus, responsible for causing cold sores, can also invade eczematous skin, though this is much rarer. It worsens the eczema and produces fever and general weakness. There may also be flocks of small red bumps, each with a tiny dimple or blister at the centre. Any symptoms of this kind indicate that the patient needs urgent treatment.
Irritants and stress
People with atopic eczema are far more susceptible to everyday irritants such as wool and rough synthetic fabrics, soap, and traces of detergent left behind in clothes. Chlorinated water, either in swimming pools or from the tap, can also aggravate the skin, and even ‘hard’ water (found in areas with chalk or limestone bedrock) may be a factor.
Some air pollutants may play a part in atopic eczema. Researchers in Germany have found that children living close to busy trunk roads, or in homes with a gas cooker and no extraction hood (see pp. 128-9), were more likely to develop eczema. Formaldehyde fumes, often found in modern houses (see p. 129), are sometimes a factor when eczema affects the face and hands.

Hayfever in Allergy

Foxtall grasses release their pollen - a potential source of hayfever symptoms.
`I gradually recognised that it was not an ordinary cold and that the symptoms were much worse on the

golf course or even during a nice day rowing on Loch Lomond.’ Dr John Morrison Smith, then a medical

student, began suffering from hayfever in the late 1930s. ‘At first I did not know what I had, and

neither did any other doctor I encountered in the next two or three years…’
All the classical allergic diseases (see box on p. 11) seem to be increasing, but none has exploded

quite so dramatically as hayfever. The physicians of Ancient Greece described asthma and food allergy,

and the Romans recorded allergy to horses, but there were no reports of hayfever. The only account –

and it is a doubtful one – comes from Persia in AD 925. Two hundred years ago, hayfever was unknown –

and careful research by medical historians has shown that this was not a case of it simply being

ignored, or misinterpreted as a cold.
The first case was reported in 1819, but even in the 1930s it was so rare that a succession of Scottish

doctors and medical students were baffled by Dr Morrison Smith’s symptoms. Today everyone knows what

hayfever is, since huge numbers of people sneeze and snuffle their way through the pollen season. There

are no certain explanations for this meteoric rise, but greater hygiene (21) may be an important

factor.
Symptoms of hayfever
The common symptoms of hayfever are well known:
• itchiness of the nose, mouth, throat and eyes – often the first sign
• a streaming and/or blocked nose
• frequent sneezing
• red, watery eyes (very rarely, hayfever affects the eyes only, with no symptoms in the nose).
Less commonly, there may be:
• dryness of the throat if the nasal blockage results in constant breathing through the mouth
• no sense of smell due to a blocked nose (but nasal polyps can also cause this – 30)
• a feverish sweaty feeling (but the body temperature is usually normal)
• swelling and inflammation of the eyelids, sometimes leading to blistering and ulceration: there

is a risk of blindness if this is not treated promptly
• recurrent sinusitis (30)
• earache, itching or a stuffy feeling in the ears, or ‘glue ear’ (29)
Some sufferers also experience:
• Oral Allergy Syndrome (an itchy tingling mouth) from certain fruits, nuts and vegetables (see

box on p. 63)
• a skin rash from pollen falling on the skin, direct contact with the leaves of the offending

plants, or with droplets of moisture from them – as when mowing a lawn or using a strimmer. If the skin

is cut or grazed, anaphylaxis can (rarely) result from direct contact with the plant (see pp. 58-9).
Even more rarely there can be:
• stomach upsets or even colitis (inflammation of the bowel) possibly due to pollen swallowed

with food or in the saliva
• irritation in the vagina
• migraine
• kidney inflammation (nephritis), leading to puffiness of the face and hands, and possibly other

symptoms
• joint pains.
The last two are probably caused by pollen allergens bound to their antibodies and carried in the blood

(13).
Diagnosis
The standard diagnostic tool here is the skin-prick test (see lo, 91). In diagnosing hayfever there are

three separate questions:
1 Is it actually hayfever?
2 Which pollen or pollens are responsible?
3 Are allergens other than pollen also involved?
Don’t be surprised if none of these questions is asked. In most countries, if you have hayfever-like

symptoms during the pollen season (i.e. when most hayfever sufferers have symptoms), the doctor will

conclude that you have hayfever - and that will be the end of that.
If hayfever seems plausible to you, and you respond to drug treatment, or manage well on pollen

avoidance (126), then -here is probably no reason to go further. Should you want a more thorough

investigation, you will need to be persistent. These are good reasons for requesting a full diagnosis:
• Your symptoms are worse in the pollen season, but they never really go away, suggesting that

you may be allergic to year-round allergens, such as house-dust mite or moulds, as well. It is worth

knowing which ones, so that you can avoid them. If you live in an area that is always warm (such as

California or Southern Australia) it may be that your culprit pollen is in the air all year round -

even so, knowing which pollen it is can help with avoidance. Around the Mediterranean, the pollen from

cypresses can keep hayfever going through the winter (or cause symptoms in winter only).
• Your symptoms are sometimes worse when they should be better, and vice versa. If you are

consistently worse indoors with the windows closed this could indicate that a seasonal indoor allergen

is the culprit - mould spores or cockroach perhaps (cockroach is often seasonal in regions with cold

winters - 118).
• Your symptoms begin before the pollen season begins, or go on long afterwards. Or the severity

of your symptoms does not match the daily pollen count for your suspect pollen. In Britain, the mould

Cladosporium herbarum produces spores in June, roughly coinciding with the grass-pollen season. Allergy

to this mould can easily be mistaken for grass-pollen allergy. You would need skin-prick tests for both

Cladosporium and grasses.
• You are much worse near home than elsewhere. It could just be a garden plant or tree. As one

California resident observed, ‘The worst offender was an olive tree on our front lawn. It’s been

removed.’
• You want to plan holidays free from the culprit pollen.
Moving house - especially to a region with different vegetation
- can be a spur to finding out exactly what your allergens are. If you are going for a full diagnosis

make sure it is done correctly. Don’t accept testing with ‘mixed tree and shrub pollens’ for example,

or ‘weed pollens’. The result tells you very little. Ask for tests with specific pollens.
Treatment
Too many people allow hayfever to spoil the summer months because they are anxious about taking drugs,

or feel that it is nobler to suffer. This book is not in any way complacent about the dangers from

drugs (see Chapter 5), but when it comes to hayfever there really is very little cause for concern. The

risks with drugs used for hayfever are absolutely minimal, and it is such a waste to miss out on the

best time of year.
Most hayfever responds very well to treatment with antihistamines (138). If they make you sleepy,

persist for a while, because this side effect often wears off - or ask for one of the new non-sedating

forms. The sleepiness is annoying, but it is only a minor side effect, and not an indication of the

drug causing any serious harm.
Cromoglycate drops (for the eyes or nose) do not work for everyone, but if they work for you, go for

them. These are absolutely the safest of the anti-allergy drugs. Steroid drops for the nose (144) are

also recommended. The dose of steroid involved is small, and very little gets into the bloodstream, so

there is no risk of serious side effects. If you suffer stinging, burning or dryness, it might be due

to preservatives in the drops, not the drug itself (see box on p. 33). Steroid drops for the eyes

should be used cautiously (144). Don’t use over-the-counter decongestant drops for more than three days

(29).
Immunotherapy is standard treatment for hayfever in many countries, but in Britain you will have a

struggle to get it (see pp. 164-8). Some hayfever sufferers feel they do well with homeopathy (215) or

acupuncture (214).
Pollen asthma
Some people with hayfever also have pollen asthma. Their asthma is worse in the pollen season but it

usually persists all year round (either because there are other allergens or irritants involved, or

just because the inflammation of the airways is self-perpetuating) whereas hayfever itself clears up.

Treating the hayfever fully with antihistamines helps considerably with the asthma symptoms.

 

In medical terms, this article covers a lot of ground.
First there are the classical allergic diseases
 such as hayfever and immediate food allergy, which are caused by the allergy

antibody, IgE .
Then there is non-IgE immune sensitivity, a category which includes a number of quite different

diseases, caused in a great variety of ways. They also vary in severity - there are serious lifelong

problems such as coeliac disease and minor short-lived problems such as contact dermatitis from garden

plants.
Finally the chapter looks at diseases where the immune system seems not to be involved, or

plays only a minor role: the intolerance reactions to food and synthetic chemicals. These are diverse

and rather mysterious in origin. They would not be described as ‘allergies’ by most doctors, though

they often are by complementary therapists (6).
These categories are not nearly as neat and tidy as they might sound. Some problems refuse to fit

anywhere, such as atopic eczema caused by food. A percentage of children with this problem have IgE to

the food concerned, while others do not - so where does it belong?
If you were expecting an answer to that question, you will be disappointed. Nor, quite often, are there

any certain and honest answers to questions such as ‘Has my baby really got asthma?’ or ‘Can you be

sure it’s irritable bowel syndrome?’ There are no answers to
such questions because most diseases do not exist in neat compartments, and the words we use to

describe them really denote rather abstract concepts.
This does not mean that the terms used to describe diseases are invalid - doctors and medical

researchers invent them to try to make sense of a complex, confusing and largely foggy reality. They

also argue over them, split them, unite them and redefine them. There is a constant desire to get the

medical picture of that foggy reality more precise and accurate (although medical politics gets

involved too - 7 -which is unfortunate).
Over time, thanks to huge amounts of research effort, things gradually get clearer. You’ll no longer

hear a doctor talk about ‘rheumatism’ or ‘arthritis’, because it was long since realised that these

categories were useless - they included a number of diverse diseases. And while doctors might say ‘food

poisoning’ or ‘heart attack’ or ’skin cancer’ to a patient, they use much narrower and more precise

terms when talking among themselves, and when ordering tests or prescribing treatment. Each of these

categories has been split into several well-defined sub-categories.
Ideally, this process of splitting continues until each disease category has a set of well-defined

symptoms (this set is known as a syndrome), plus a few simple and definitive diagnostic tests. This

will probably depend on the cause of the disease (the mechanism in medical jargon) being clearly

understood. Once the mechanism is clear, then a disease category is a truly satisfactory tool for

diagnosis and treatment.
Of the disease categories mentioned in this book only a few, such as coeliac disease and hayfever, have

reached that happy state. The majority are still somewhat arbitrary and debatable.
Some disease terms describe a set of symptoms with no clear underlying cause, for example, ‘irritable

bowel syndrome’. Others describe a well-defined response by the body, that can be caused in many

different ways - an endpoint that can be reached by various routes. This is true of ‘asthma’ or

‘urticaria’.
A third type describes a much less well-defined cluster of symptoms. Idiopathic food intolerance,

chemical intolerance and yeast overgrowth all come into this category. A few doctors don’t even see

some of these clusters as real diseases because the symptoms involved are so vague and so widely

encountered. Some of the arguments used to dismiss idiopathic food intolerance are dissected on pp.

74-7. A key point made against these diseases is that the symptoms they produce are non-specific -

common symptoms such as headache, fatigue and diarrhoea, which can arise in a great variety of ways.

Ever since Pasteur and the germ theory, medicine has been based on the idea of each disease having

specific symptoms and specific causes, and it has roared ahead on the basis of this assumption. This is

the prevailing paradigm of modern medicine, and like all
paradigms it blinds people to facts that don’t fit. Evidence is accumulating that there are diseases

which have multiple, non-specific and variable symptoms. Chronic Fatigue Syndrome (CFS - see box on p.

85) is one of these, and its recent transformation from a doubtful diagnosis to a reputable disease

recognised by conventional medicine suggests that the paradigm might be starting to crack.
To sum up, the business of identifying and naming diseases is a complex and uncertain process, in which

the concept of most diseases is only ever that - a concept, subject to change and refinement. This does

not make it worthless - quite the opposite. These concepts are the best we can do at the present time,

and accurate diagnosis is the key to getting the best treatment available now.
As regards both diagnosis and treatment, this book covers a very wide spectrum of medical opinion, from

the entirely orthodox to the frankly whacky. I have tried to give an objective view of these different

opinions and approaches, using the evidence currently available, in the hope that it will help readers

to improve their health while wasting as little as possible of their time or money. In using this

information, you should always try to work closely with your doctor (96), respecting the depth and

breadth of knowledge that conventional medicine has to offer.

 

If you have a child with allergies, sooner or later some friend or relative will tell you not to worry

because your child ‘will probably grow out of it’. Your doctor may well say the same thing. But what

does this mean? Do all children shake off their allergic symptoms as they get older? If the symptoms

go, is the underlying disease completely cured? And why treat allergies if they disappear of their own

accord? The truth is that the relationship between allergy and age is incredibly complex, and doctors

only understand a tiny part of it. The best anyone can offer is a broad overview of how allergies

change with age, with few explanations of the underlying mechanisms, and absolutely no predictions of

what the future holds for any particular allergy sufferer.
It is certainly true that the classical allergic diseases, such as atopic eczema, hayfever and

childhood asthma (see box on p. 11), frequently disappear as children grow up. Babies tend to shrug off

food allergy and eczema by the time they are toddling, and a fair number of asthmatic children lose

their symptoms before they are ten years old, while others do so in their teens or early twenties.
Unfortunately, the disappearance of symptoms does not mean that the underlying disease has necessarily

disappeared, particularly in the case of asthma. Quite a few young adults find themselves wheezy and

breathless again in their late twenties or thirties, especially if they take up smoking. One study of

children who wheezed before the age of seven found that:
• 25% lost their asthma for a time – anything between two years and 25 years – only to get it

back again by their early thirties. Some recovered and relapsed more than once.
• Over 70% shook off asthma and were still symptom-free by their early thirties when the study

ended.
• Only 2% remained asthmatic throughout. Realistically, anyone who has ever been asthmatic should

regard themselves as ‘at risk’ indefinitely and never be careless with their health – don’t smoke, keep

away from smoky bars and clubs, eat a good diet with plenty of fruit and vegetables (206) and avoid

activities that involve an asthma risk, such as strenuous exercise in cold air.
Workplaces with high exposure to allergens, such as saw mills, bakeries or laboratories using animals

(see pp. 133-4) are not recommended for those with a history of allergy. Anyone who has ever had eczema

should also take care with cosmetics and soaps, choosing the gentlest brands. They should also protect

their hands (57) and avoid hairdressing or bricklaying as an occupation, or anything else where skin

irritation is likely.
Moving on
Growing out of classical allergies seems to be a consequence of the child’s immune system changing and

maturing as it grows. This same process, unfortunately, can also substitute one allergic disease for

another.
`When Alex developed eczema as a baby I hoped that she’d grow out of it in time. Well she did,

gradually, and by the time she was five it seemed to have cleared up, but then she started having a

snuffly nose that never really went away. A year or so later, she began wheezing whenever she got a

cold, and this has now developed into asthma.’ The pattern described by Alex’s mother Jenny will be

familiar to many parents, who watch their children slowly work their way through all the allergies in

the medical textbooks. Doctors call it the atopic march or allergic march.
Fortunately, even this type of allergic pattern can have a positive outcome eventually. Many such

children become allergy-free in time, and develop into healthy adults.
In the meantime, there are several itchy, wheezy or sneezy years to get through, and since childhood is

a time to be enjoyed, not endured, treatments that alleviate the symptoms of allergies are generally

welcomed. Being energetic, healthy, ‘normal’ and able to join in with sports and other activities is

particularly important for a child’s social development and self-confidence.
Treating the symptoms also prevents any long-term and irreversible damage, such as the thickening and

loss of elasticity that occurs in the airways of children with untreated asthma.
At the same time as treating the symptoms, it makes sense to maximise the chance of the child growing

out of the allergy. Parents can tip the odds in the right direction by providing an environment that

reduces the chance of new allergies developing. A detailed action programme is described on pp. 248-9.
Allergies that begin in adult life
What about those people who develop classical allergic diseases for the first time as adults - or even

in old age? Will they too ‘grow out of it’ with the passing years?
Only a minority of people develop such allergies for the first time as adults, although the numbers

seem to be increasing. The older you are when your allergies begin, the less likely you are ever to

throw them off. On the positive side, they are unlikely to get a great deal worse than they are at the

outset, especially if you take care of yourself and keep the air at home as unpolluted and

allergen-free as possible (see pp. 114-31).
In the case of asthma that develops in adulthood, there may not be an allergic reaction involved.

Whereas allergies play a part in asthma for 80-90% of children, the figure is thought to be lower for

adults. Nevertheless, it is well worth investigating the possible role of allergens, because avoiding

them is one of the most effective treatments.
The outlook for food intolerance
Food intolerance causes a wide variety of symptoms, from baby colic to migraine. A full list is given

on p. 76. Although far less is understood about food intolerance than about true allergies, there is

much more certainty about the future for affected individuals. With rare exceptions, people find that

the problem clears up as long as they totally avoid their problem food for a year or two. After this

period of strict avoidance, they can eat the food again in moderation but should never forget that the

problem can return. Eating the culprit food very regularly will turn the clock back and all the

original symptoms will return. This change for the worse may be irreversible for people with severe

reactions such as rheumatoid arthritis.
Safety first
Anyone who suffers the life-threatening allergic reaction known as anaphylactic shock (58) is probably

going
to have this for the rest of their days. Some children do become tolerant of food allergens in time

(allergies to milk, eggs or soya may well disappear, whereas fish or peanut allergy is probably going

to be permanent) but before concluding that there is no longer any risk, some extremely careful and

cautious testing should take place. Talk to your doctor about how to proceed. Skin-prick tests may be

helpful, but there must be resuscitation equipment close to hand as anaphylaxis can occur. Never give

the child any of the food to eat, until you (or, preferably, the doctor) have first tested it in other,

less risky, ways. For example, you can smear a little on the face to see if there is any reaction. If

there is none within 24 hours, put a tiny amount on the outer lip and watch again.
If both these tests produce absolutely no reaction then a very small amount of the food can be eaten as

a test: this should be done under medical supervision. The amount can be slowly increased with

successive tests, until it seems certain that no reaction will occur even with a normal portion.

`When I first arrived in Charlottesville in 1982, the senior allergist said “I’ve got to warn you that here in Virginia we have patients who have very severe fungal infection of their feet, and they also have urticaria. If you treat their feet, their urticaria gets better.”‘ Professor Tom Platts-Mills of the University of Virginia in Charlottesville is recalling how his innovative studies of fungal infections and allergy began. That surprising observation about athlete’s foot (a fungal infection) and urticaria (nettle rash) was made by his predecessor, Professor John Guerrant,
‘I followed his advice,’ Platts-Mills continues, ‘and found he was right. Then I started noticing asthmatics in our allergy clinic who also had fungal infections of their feet. They were mostly men with severe adult-onset asthma. We gave them skin-prick tests with the fungus Trichophyton and these were positive – showing they had an allergic reaction to it. So we tried treating them with anti-fungal drugs and the asthma got much better.’
This discovery is not an isolated instance. Research over the last decade or so has revealed that allergic reactions to long-standing infections (chronic infection is the medical term) are far more common than anyone expected. Infections by fungi are frequent offenders.
An infection becomes chronic because, although the immune system tries to rout the infectious agent, it never succeeds. Making IgE may be part of that futile defensive effort. Once the immune system starts making IgE against the allergens produced by the infectious microbe, new symptoms may begin, or existing allergic symptoms may get much worse. The link between the infection and the allergy is far from obvious, however. Both the allergens and the IgE can be carried in the
Fungal infections
‘Fungus’ means everything from an edible mushroom or a huge bracket fungus to the specks of mould on stale bread or a shower curtain. Fungal infections are caused, not by mushroom-like fungi, but by inconspicuous mould-like forms, or by yeasts (which are single-celled fungi).
Once they are flourishing, some fungal infections may be seen as whitish or creamy-coloured patches. But at an earlier stage, the fungi are so small that they cannot be seen without a microscope. They spread as invisibly as bacteria or viruses.
Some infectious fungi can exist in two different forms – a mycelial form (long thin strands, as in a mould) or a yeast form (single cells).
bloodstream, so the symptoms may be somewhere else in the body, far away from the site of infection.
If the symptoms of the infection itself are relatively mild, they may not receive medical attention. Infection-plus-allergy often explains severe long-term allergic problems for which no cause could previously be found. This is the kind of case that gets labelled as ‘intrinsic’ or ‘endogenous’, because all the allergy tests have proved negative. Most patients in this category have had years of simply being treated with steroids (often at high doses) to suppress the symptoms.
Sometimes the infection-plus-allergy is part of a larger picture, with other allergens or irritants also contributing to the symptoms, but with no stunning improvements when they are avoided because the allergic stimulus from the infection remains.
The links between allergy and fungal infections – all those that have been discovered so far – are described below. In such cases, anti-fungal drugs, taken by mouth, usually in capsule form, could be of value. However, they must be taken for an adequate length of time, normally several months.
Bear in mind that, with the possible exception of chronic sinusitis, an allergic reaction to fungal infection is a relatively uncommon cause of symptoms. It is important that, with the help of your doctor, you start with the more likely suspects such as airborne or contact allergens. These are described in detail, for each allergic disease, in the relevant sections of Chapter 2.
Asthma
the common causes and usual treatment of asthma.
Trichophyton – the fungus that causes athlete’s foot – can provoke allergic reactions that contribute to asthma, as already described. This fungus may also infect other parts of the body. Trichophyton diseases have names that begin with tinea (athlete’s foot, for example, is tinea pedis). Other terms you may come across are intertrigo (an itchy rash which develops in skin folds) and onychomycosis (also called `ringworm of the nails’ or tinea unguinum). The research on the link with asthma was published in a respected medical journal, The Lancet, but has been widely ignored, so if you think you have this problem, you may have to be quite persistent with your doctor. Very thorough treatment with anti-fungal drugs (swallowed in capsule form) is required.
Chronic urticaria
many possible causes of chronic urticaria.
Trichophyton infections in any part of the body (see above) can provoke allergies, producing chronic urticarla. A great variety of other infections, including fungal, viral and chronic bacterial
infections, can be the root of the problem in chronic urticaria . However, this may not be an allergic reaction. It could be a direct effect of the infection, provoking the immune system in such a way that it triggers mast cells by itself, without IgE.
Chronic sinusitis
 the causes and treatment of chronic sinusitis.
Long-standing (chronic) sinusitis may be due to a fungal infection with a subsequent allergy. This is now called allergic fungal sinusitis. Some doctors believe that a sensitivity reaction to fungal infection (not necessarily an allergic reaction) could account for 96% of chronic sinusitis. However this is widely disputed .
Atopic eczema (atopic dermatitis)
the causes and treatment of atopic eczema.
The Trichophyton fungus can infect eczematous skin, though this is far less common than infection by Staphylococcus aureus (see below). Among patients infected by it, there can be an allergic reaction to Trichophyton which then makes the eczema worse.
There can also be an IgE reaction to a yeast, Pityrosporum ovale (also called Malassezia ovalis), in atopic eczema. This yeast is a commensal – i.e. a natural, and normally harmless, inhabitant of healthy skin. The inflammation of eczema makes the immune system far more tetchy so that it reacts allergically to this yeast, an innocent bystander which it normally disregards.
Candida  can also provoke an allergic reaction in eczematous skin. This is a more complex story, because while Candida is a commensal in the gut, it does not normally live on the skin. However, it may flourish in the disturbed skin of eczema patients.
Those with atopic eczema may also develop an allergic reaction to toxins from Staphylococcus aureus, a bacterium that often infects skin which is inflamed by eczema and damaged by scratching. Antibiotics are needed to treat the infection .
Seborrheic dermatitis
Not so long ago, this disease – which causes a red, scaly rash on the forehead, nose and cheeks, and sometimes on the chest –was labelled ’cause unknown’. Now most doctors believe that the yeast Pityrosporum ovale could well have a role in causing it. This yeast is part of the normal skin flora (see above), but it is found in greater numbers on the skin of seborrheic dermatitis patients. As well as overgrowth of the yeast, there is an immune reaction against it, usually involving the antibody known as IgG, rather than Fungi in the lungs
One form of infection-plus-allergy has been well recognised for many years - allergic bronchopulmonary aspergillosis, often shortened to aspergillosis.
The problem starts with the fungus Aspergillus fumigates, a ubiquitous mould that is found in special abundance in damp straw, compost heaps, bird cages and any decomposing material. Its spores are everywhere, and most immune systems quickly defeat them, but in some people, especially those with asthma, the spores begin to grow in the lungs. The fungus is found in the lung mucus, but does not actually invade the lungs. However, an allergic reation then occurs to the fungus.
This disease often goes together with asthma, or can be mistaken for asthma. There are three clues that point to aspergillosis:
• rubbery plugs of phlegm, either golden-
brown or green in colour
• fever whenever the asthma is severe
• worsening symptoms despite treatment.
Allergic bronchopulmonary aspergillosis is treated with steroids to control the allergic reaction, and physiotherapy to clear the mucus from the lungs.
Anti-fungal drugs have not proved very effective in the past. There are some newer anti-fungal drugs that may well be more useful, such as itraconazole and terbinafine. These are not widely used for aspergillosis at present, except in patients who also have cystic fibrosis or an immune deficiency. Because there has been no large-scale trial of these drugs, they are not usually given to people who simply have aspergillosis. However, they are sometimes prescribed for people who are unable to take steroids, or are not responding to steroid treatment. Anti-fungal drugs may become more widely used in the next few years, so it is worth discussing the possibility of this treatment with your doctor.
the allergy antibody IgE. Only about 12% of people who suffer from seborrheic dermatitis make IgE against the yeast.
One problem with seborrheic dermatitis is that, while it may improve with anti-fungal treatment, it usually comes back when the treatment stops. Doctors have therefore been looking for ways of keeping seborrheic dermatitis at bay after a successful course of anti-fungal treatment. One method that seems to work is to use a good anti-dandruff shampoo, in place of soap, to wash your skin once a week.
A medical earthquake
The recent discoveries about infection-plus-allergy have not posed any serious challenge to conventional thinking about allergy, because a disease of just this kind - aspergillosis (see box at left) - was already well known. A far more fundamental shake-up of traditional ideas about allergy and sensitivity has been necessitated by new research into atopic eczema. It is little short of an earthquake in the basic concepts of allergy and sensitivity.
To understand the extent of this earthquake, you need to know about the time-honoured system for classifying hypersensitivity reactions, which recognises four distinct types:
• Type I hypersensitivity — the IgE-mediated allergies  such as hayfever.
• Type II hypersensitivity - irrelevant to allergy, these antibody reactions mainly occur after transplant surgery, if the transplanted organ is rejected.
• Type III hypersensitivity - caused by a massive overload of antibodies and antigen in the blood. It is a feature of certain infections and autoimmune diseases, and can also occur in allergic reactions, though this is rare (13).
• Type IV hypersensitivity - the odd man out, because antibodies are not involved, or are not of central importance. Immune cells that can launch a direct attack are the movers and shakers here. These attacking-cells are sensitised for a particular antigen, such as dust mite or lanolin. Type IV hypersensitivity is a very slow reaction. Generally speaking, 48 hours pass, after an encounter with the offending substance, before the symptoms appear. The most common form of Type IV hypersensitivity is contact dermatitis (54).
Mystery has always surrounded atopic eczema. Although it crops up in the same atopic families that suffer from hayfever and asthma, and high levels of IgE in the bloodstream are typical of the disease, the actual role played by allergies in causing the symptoms is far from obvious.
The results of skin-prick tests - the standard test for an IgEmediated reaction - are puzzling. Patients tend to give a lot of positive results, many of which don’t mean much - the substances concerned do not provoke actual symptoms. On the other hand, skin-prick tests are often negative for substances that clearly do cause symptoms in challenge tests. Many children who regularly get eczema when they drink cow’s milk, for example, give a negative skin-prick test to milk. This conundrum has puzzled allergists for decades.
New discoveries about eczema do not entirely solve the puzzle, but they do go some way towards an answer, by revealing an immune response that cuts across the traditional categories. The most surprising fact is that even where skin-prick tests are positive and milk-specific IgE is involved in milk-induced eczema, this is not necessarily a standard IgE-mediated allergy.
While IgE antibodies may be involved, they are not necessarily teamed up with mast cells, their usual partners in crime (see box on p. 12). Instead, the IgE molecules are attached to special skin cells called Langerhans cells and dendritic cells. These have the role of picking up the antigen and showing or ‘presenting’ it to attacking-cells in the skin (a task called antigen presentation which is the ‘go’ signal that starts off all immune reactions).
The involvement of these attacking-cells, which are sensitised for a particular antigen, was a big surprise when first discovered. It makes this resemble a Type IV hypersensitivity reaction rather than a Type I.
IgE is not essential here, it seems — some patients do not have IgE for the substance that triggers their atopic eczema — but when Langerhans cells and dendritic cells are associated with IgE they do become far more zealous. This excitement is communicated to the attacking-cells, which mount a more powerful attack.
It looks as if what really matters in atopic eczema is the presence of antigen-specific attacking-cells in the skin, plus the heightened activity of the Langerhans cells and dendritic cells. If the individual has IgE for the antigen, it can play a part, but it is not essential.
In other words, this reaction cuts across two different categories of immune response — Type I and Type IV. (However, the kind of antigens that provoke the reaction are typical of IgEmediated allergy, rather than the kind of antigens that provoke contact dermatitis.) This has been exploited in a new and more sensitive set of diagnostic tests for food-induced atopic eczema (69).
Why atopic eczema is a feature of atopic families is the crucial question that remains unanswered. One factor may be that high levels of IgE in the bloodstream (not IgE for a particular allergen, but total IgE) make the whole immune system more excitable and prone to over-react. The next few years will no doubt solve this part of the puzzle too.
Peace-keepers or aggressors?
`It is bad enough having a child on an ultra-strict diet — Tim can’t have even a trace of cow’s milk or else he becomes violently ill. What makes it worse is when people — teachers, for example —ask what’s wrong. I take a deep breath and say “eosinophilic oesophagitis” then watch their eyes roll in disbelief.’
Tim’s disease is caused by a particular type of immune cell called an eosinophil. In the right circumstances, eosinophils can be valuable — like IgE and mast cells, they are geared to destroying parasitic worms . They produce some very toxic substances to kill these invaders, and it is the toxins that cause serious symptoms for Tim and others like him.
Any disease with ‘eosinophilic’ in the name involves vast numbers of eosinophils converging on some unfortunate part of the body. The stimulus that attracts them often remains unknown but once there, the toxins they generate cause inflammation (140) of a particularly violent kind.
It is only in recent years that doctors have begun to distinguish between patients such as Tim and children with classical food allergy, and to understand the cause of Tim’s symptoms. Several different forms of eosinophilic food sensitivity are now recognised (72). The exact relationship with IgE-mediated allergy remains a puzzle, because some sufferers make IgE to the culprit food but others do not.
That is not all — the eosinophil is finally coming out of the shadows and being recognised as an important agent in classical allergic diseases as well.
The fact that eosinophils appeared during the aftermath of an allergic reaction had long been known, but their role was misunderstood. What confused researchers was that eosinophils can break down histamine, the substance that kick-starts allergic symptoms. This ability gave eosinophils the appearance of peacekeeping troops, coming in at the close of battle to restore order. In fact, eosinophils are major aggressors — they do a whole lot of other things besides breaking down histamine, most of them pro-inflammatory. They can release toxins, just as they do in eosinophilic diseases, and they attract other inflammatory cells into the area. In short, eosinophils play a big part in keeping allergic reactions going once the initial burst of activity is over. This `Late Phase Reaction’ is enormously important .