Posts Tagged ‘immune cells’

Chemical Intolerance
`To start with, I just used to get this irritation in my throat when I was reading a magazine. Over the years it got much worse, and there was a dreadful burning feeling, not

just in my throat now, but also in my eyes and nose. Sometimes I could scarcely breathe. My doctor said it couldn’t be magazines and diagnosed asthma. Twenty years on, I can’t

look at a magazine, even for a few minutes, and other things affect me now too. If I go in a room with a photocopier running I start to choke and can’t breathe. Whenever I

describe this problem to anyone — apart from the doctor, that is — they almost always say they know someone else who has a similar problem. But the doctors still say that what

happens to me can’t happen.’
Mary has chemical intolerance, which is also known as chemical sensitivity, environmental Illness or idiopathic environmental intolerances. It is a condition that arouses more

passionate controversy than any other described in this book. Many believe that it simply does not exist, or rather that people who claim to have chemical intolerance are

actually victims of psychological problems, which express themselves as physical symptoms. Careful studies show that, while some people with supposed chemical intolerance do

fall into this category, others do not – they have no psychiatric problems, but they do appear to have valid symptoms when exposed to certain synthetic chemicals.
`People with MCS are desperate. They will go to great lengths and do almost anything to find a doctor, anyone, who believes them.’ So speaks one sufferer from MCS (Multiple

Chemical Sensitivity), the most extreme form of chemical intolerance. It is often severely disabling, with symptoms such as exceptional fatigue, nausea, headaches, poor memory

and concentration, dizziness. muscle aches, joint pain, chest pain and digestive problems. Those with MCS react to a very wide range of chemicals, and very often to foods and

food additives as well.
These severely affected patients are a small minority, however, and many more people are like Mary, with sensitivity to just one or two types of chemical exposure. Surveys in

the United States suggest that about 30% of the population are affected in this way. The authors of one such survey note that ‘the widespread idea that chemical sensitivity is a

condition of educated, urban housewives was not supported by our study. The region surveyed was rural… and individuals who reported chemical sensitivity were found in all age,

gender, income, race and employment groups.’
The chemical exposures that are identified as triggering symptoms include:
• perfumes
• pesticides
• cigarette smoke
• paint fumes
• petrol
• exhaust fumes
• cleaning products
• newspaper ink
• plastics, especially those with a strong smell
• glossy paper (e.g. In magazines).
Typical symptoms, in those with sensitivity to just one or two chemical products, are:
• a blocked or runny nose
• sore throat
• irritation of the eyes
• sinus pain and congestion
• headache
• breathlessness and wheezing
• nausea
• skin rashes
• extreme fatigue
• dizziness.
How does chemical intolerance begin?
For some of those with MCS, the problems began with a sudden over-exposure to a toxic chemical, such as a chemical spill, or pesticides from a crop-spraying plane. Others are

first affected by regular doses of pesticide at lower levels, such as spray drift from nearby fields or from a neighbour’s garden. It seems as if, for these people, their inborn

ability to detoxify both natural and manmade toxins is overwhelmed by an unusually heavy exposure, and never fully recovers. Although there have been no systematic studies of

this – it is difficult to imagine how they could be done –the wealth of well-documented cases is convincing. And studies of those exposed to high levels of pesticides in

accidents at work support the idea that this can cause lifelong sensitivity to very small doses of some synthetic chemicals. Sensitivity to alcohol and caffeine usually

increases enormously too.
In some cases, classical allergies also feature in the range of symptoms for those with MCS. If they had an allergic tendency before the accidental exposure to pesticides, this

is especially likely: after the accident, along with chemical intolerance, they have far more pronounced allergic reactions to common allergens.
The loss of tolerance to everyday chemicals may be related to some kind of damage to the enzymes in the liver that carry out the important task of detoxifying toxins that enter

the bloodstream. This detoxification system evolved to deal with natural toxins, such as those in plant foods, and those produced by bacteria living naturally in the gut. These

enzymes can also detoxify the widely used synthetic chemicals, when these are encountered in relatively small amounts, but the enzymes are overwhelmed by large doses.
Chronic Fatigue Syndrome (CFS)
This is a disease that probably has multiple causes rather than a single cause. The main symptom is fatigue that is not relieved by rest. Many people with CFS also have a

slightly raised temperature, problems with concentration and memory, headaches, sore throat and swollen lymph nodes (’swollen glands’). The lymph nodes are part of the immune

system, so this symptom suggests some disturbance of immune function. Other findings, related to immune cells in the blood, also support this idea. However, there are often

minor abnormalities in the brain as well, with some loss of the insulating material around the nerves (myelin).
For many patients, the disease develops in the wake of a viral infection, but for others the origin may be unclear. Whatever the origin of the disease, avoiding synthetic

chemicals is very helpful in many cases. Some sufferers also find an elimination diet helpful (see pp. 194-7). Doctors working in this area say that there is no sharp

demarcation between patients with Chronic
Fatigue Syndrome (CFS) and those with MCS.
Autism
In the search for a cause of autism, many possibilities are being investigated. The consensus now is that there is a genetic predisposition which, when combined with certain

trigger factors, leads to autism.
What are those trigger factors? Some researchers suggest that autistic children have poorly performing detoxification enzymes and are therefore sensitive to synthetic chemicals,

both in food and the environment. The suspicion is that these chemicals affect the developing nervous system.
Other researchers pinpoint food as the culprit. They believe that children who develop autism are affected by exorphins (see p. 76) produced from the proteins in wheat and/or

milk, and that these damage the child’s developing nervous system. There are claims that a dairy-free and gluten-free diet can help, but that it must be ultra-strict to work,

and may need to continue for at least six months before any improvement occurs. You must have your doctor’s approval for this.
Before starting them on such a diet, some doctors also give a course of anti-fungal drugs to those autistic children who have been treated repeatedly with antibiotics. This

combined treatment is reported to have very good effects for some children.
Treatment
Assuming that you really do have chemical intolerance rather than some deep-rooted psychological problem – and you have to be honest with yourself here, because otherwise you

will never get better – then careful avoidance of the offending synthetic chemicals is the only effective treatment. If you have eliminated everything that obviously affects you

and are not much improved, then try tackling common indoor pollutants (see pp. 128-30) as well.
Such measures are of value to some with chemical intolerance but may not be adequate for those most severely affected. If you need to take more radical steps, you may benefit

from the bedding, paints and other household items manufactured for those with chemical sensitivity. Once you reduce the level of synthetic chemicals in your everyday

environment, you may find that you can tolerate occasional exposures much more.
Some doctors recommend taking supplements of vitamins and minerals to speed your recovery. These (especially antioxidants – see p. 206) may be helpful for some people, but be

sure to get nutritional advice from someone with good medical qualifications, rather than a self-styled ‘nutrition therapist’.
Neutralisation therapy (see p. 211) seems to be effective for some people with chemical intolerance, but you will still need to avoid the offending substances. Hyperventilation

(see p. 236) can make chemical intolerance much worse.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Immune reactions to food
`When I finally found someone who could say what was wrong with me, it was such a relief. I can’t tell you how much ill-health and pain and misery I’d had up to that point. I’m immensely grateful to the doctor who sorted the problem out for me. My life has been transformed.’
Richard has eosinophilic gastroenteritis, one of the rarer immune reactions to food. Like all rare diseases, it can escape diagnosis for a long time. IgE (the allergy antibody – see box on p. 12) is sometimes involved in eosinophilic gastroenteritis, but it is not an essential part of the reaction. Those who, like Richard, do not make IgE antibodies to the problem food will not give positive skin-prick tests. For them, the possibility of food being responsible for their symptoms may well be overlooked*.
Another difficulty for patients such as Richard is that most of the non-IgE immune reactions to food affect babies and children exclusively. A few of them can also occur in adults, but this is very rare, so it’s not something that automatically springs to mind when the doctor is searching for a diagnosis.
Eosinophilic diseases
The key event in these diseases is the arrival of large numbers of immune cells called eosinophils (see p. 19) in the walls of the digestive system. If the eosinophils converge on the tube leading down to the stomach (the oesophagus) the disease is called eosinophilic oesophagitis, and the symptoms include reflux (regurgitation) of food, occasional vomiting, refusing food (in babies), stomach pain and disturbed sleep.
If the stomach is the focus for the eosinophils, this is eosinophilic gastritis, and there is vomiting, pain, poor appetite and therefore poor growth. There can also be obstruction of the stomach outlet which may, in a few babies, produce pyloric stenosis (the main symptom is projectile vomiting).
When eosinophils flock to the intestines as well as to the stomach, the disease is called eosinophilic gastroenteritis. In
terms of symptoms, the picture is not much different from the previous condition, but there can be diarrhoea as an additional symptom, and babies may be irritable and puffy in appearance.
These conditions are most common in babies, but sometimes they continue through childhood. Very occasionally they occur in adults too.
Heiner’s Syndrome
This disease affects babies only, and is very rare. It is a severe form of cow’s milk sensitivity leading to wheezing and haemosiderosis (bleeding into the lungs). The child usually seems sickly, growth is slow, and there may be recurrent bouts of pneumonia. A full diagnosis requires blood tests to check for anaemia, examination of sputum under the microscope, and a biopsy or lavage (see p. 92) from the lung. The only effective treatment is to remove cow’s milk from the diet completely. Needless to say, this must be done under full medical supervision.
Other reactions to food
The cause of these diseases is not fully understood, but the immune system is clearly involved.
Dietary protein entero-colitis syndrome
In babies, the symptoms begin with general irritability and vomiting between one and three hours after a feed. Unless the offending food – usually cow’s milk – is withdrawn promptly, there will be bloating, diarrhoea (usually containing blood), anaemia, and poor growth. Older children have similar symptoms, while adults suffer terrible nausea, plus stomach pains and vomiting.
Nickel in food
Nickel and other metals in food may cause immune reactions for those with sensitivity to such metals (see pp. 55-6). The symptoms are usually in the skin, but there can be a few digestive symptoms too.
Dietary protein enteropathy
The main symptom here is diarrhoea, usually very severe. Often babies vomit their feed as well. Most have little appetite, and if the offending food is not withdrawn they suffer from poor growth, anaemia and other signs of malnutrition. This is because damage to the lining of the gut prevents nutrients from being absorbed properly. Older children show similar symptoms.
Dietary protein proctitis
This is a far less severe problem. The babies with this disorder look healthy, but there is inflammation in the bowel and small amounts of blood are passed with the faeces.
Diagnosis
There are two aspects to diagnosis:
• what kind of disease is it?
• what food or foods are causing the reaction?
Your doctor will probably try to answer the first question by looking inside the digestive tract with special equipment (endoscopy) and by taking a small sample – a biopsy (see p. 92).
A blood sample may also be taken to look for raised levels of immune cells and antibodies. Skin-prick tests or RAST tests (see pp. 91-2) will be tried to rule out the possibility of true food allergy – and because IgE may play a small part in these other forms of food sensitivity (in the eosinophilic diseases, for example).
Often the tests yield no very clear answers, especially in babies, and an exact diagnosis is not possible. But failure to answer the first question does not mean that the second question should be ignored. Pinpointing the culprit food or foods is vital.
Identifying the food is easier the younger the child, simply because the range of foods eaten is so much smaller. Cow’s milk is the most common offender when the disease affects young children – particularly bottle-fed babies, since standard infant formula is made with cow’s milk. Your doctor will prescribe an alternative formula (see box on p. 66) for you to try. For older children and adults, an elimination diet will probably be required to identify the food concerned. Among young children, likely offenders include soya, egg, wheat, rice, chicken or fish. A simple elimination diet, similar to that used for atopic eczema (see p. 198) may be adequate. You must have full medical supervision for this.
In the case of eosinophilic reactions, skin-prick tests may help identify the foods concerned, but are usually of limited value, so an elimination diet is again necessary. Where adults are affected by eosinophilic diseases, sensitivity to several different foods is likely, so identifying the offending foods usually requires the most exacting form of elimination diet, using an elemental diet for the exclusion phase (see box on p. 196). The symptoms are very slow to disappear: it can take up to eight weeks of avoiding the foods before your ailing digestive tract recovers. Don’t give up too soon.
Treatment
Avoidance is the only way here. Special infant formula (see box on p. 66) is required for cow’s milk sensitivity in babies.
In the case of eosinophilic reactions, some doctors may use steroid tablets as an additional treatment, just for a few weeks, to get the inflammation under control. Some new studies show that the anti-leukotriene drugs (see p. 149) are very effective for eosinophilic gastroenteritis.
Controversial topics
According to some doctors, a reaction to food may, on rare occasions, produce vasculitis (inflammation of the blood vessels).
Vasculitis itself is a well-recognised condition. The blood vessels are damaged by inflammation, and become more leaky. Symptoms often begin with a general swelling (angioedema), and an outbreak of small red blotches deep in the skin — especially on the legs — where small amounts of blood have escaped. These blotches later turn purplish, then yellow, before fading. This type of rash is known as purpura. Sometimes there are larger emissions of blood, resulting in spontaneous bruising.
Many different conditions can cause vasculitis, but only a few doctors would agree that food sensitivity is one of them. The inflammation could be caused by circulating immune complexes containing food antigens bound to antibodies (see p. 13). There is evidence, in some patients, of a direct effect on the cells called platelets that cause blood to clot.
Equally controversial is the suggestion that food sensitivity can be the cause of trouble for some children with kidney disorders. Some research groups have found that a few children with certain kinds of kidney disease recover on an elemental diet (see box on p. 196). All those affected have a classical allergic disease such as asthma or atopic eczema as well, and they tend to be sensitive to several different foods, plus pollen or other airborne allergens. Circulating immune complexes might be involved here, but no one is sure.
Some cases of food-related rheumatoid arthritis and palindromic rheumatism (see p. 76) could be due to immune complexes involving food molecules becoming deposited in the joints, but it is not the mechanism in all, or even most, of those affected.

Sinus cavities are something that most people just don’t know they have. It’s only when they start to

hurt that you find out where they are. ‘There is this terrible throbbing pain above and around my eyes,

and in my cheeks. It’s the most unpleasant feeling, but it’s hard to describe to anyone who hasn’t felt

it,’ says Gina, who suffers from chronic sinusitis (long-term inflammation of the sinus cavities).

There are no figures, but chronic sinusitis seems to be increasingly common.
A sinus cavity has no function, it is just empty space without which our skulls would be much heavier.

In other words, these airy spaces seem to have evolved simply to help us feel more ‘light-headed’. If

you have sinusitis, unfortunately, you feel just the opposite. ‘I had sinusitis for years,’ says Dr

Wellington S. Tichenor, a New York allergist who now specialises in treating chronic sinusitis. ‘I kept

working but felt like I wanted to die.’
Sinus cavities are lined with a membrane which is essentially similar to that lining the nose. It

contains immune cells and can produce mucus when necessary. Most of the time it doesn’t need to produce

much, because relatively few microbes or foreign particles get into the sinus cavities.
Any mucus that is produced should escape from the sinus cavities through narrow drainage channels,

called Ostia, leading to the nose. Unfortunately, the Ostia are very narrow – the diameter of a

pin-head – and U-shaped, making them prone to blockage. And that is not the only problem. These

drainage channels are situated at the top rather than the bottom of the main sinus cavities – this

arrangement was fine for our ancestors who walked on all fours, and therefore did not have to fight

gravity when clearing their sinuses. Sadly for
us, natural selection has not got around to reorganising things yet. It would be a completely hopeless

arrangement if not for the tiny hairs known as cilia, which lie like a carpet across the membranes

lining the sinus cavities. The cilia beat rhythmically. 18 times a second, to waft the mucus upwards to

the top of the sinus cavity.
This is a far-from-perfect system, and it is hardly surprising that it sometimes goes wrong. Chronic

sinusitis can begin in at least three different ways:
• The sinus membranes become inflamed due to an allergic reaction – 28 for likely airborne

allergens.
• The drainage channels from the sinus cavities become blocked due to events in the nose

(infection or allergy) or due to the growth of polyps (non-cancerous jelly-like lumps that can block

the drainage channels). When mucus cannot drain away, it stagnates in the sinus cavities encouraging

infection by bacteria or fungi. These infections cause inflammation.
• A bout of acute sinusitis (see box on p. 31), due to bacterial infection, never really goes

away and the persistent infection causes longterm inflammation. Note that this is unlikely: it is rare

for acute sinusitis not to clear up.
Whether the problem begins through allergy or blockage or infection, once it has begun a vicious circle

can be set up all too easily. Mucus output increases when there is inflammation, blocking the drainage

channels even more, so the sinus cavities become clogged up and increasingly uncomfortable. More mucus

pooling in the sinus cavities perpetuates any existing infections and fosters new ones.
All this infection results in more severe inflammation, causing the membranes which line the sinus

cavities to swell up. Inflammation also makes polyp growth more likely. The cilia may be lost or

severely depleted, and the mucus gets thicker. All this means yet more blockage. To cap it all, there

can be allergic reactions to some of the microbes involved (see right), fuelling the inflammation

further.
The body’s own attempts to clear the sinuses are defeated, and the problem is also very resistant to

medical treatment. This may make depressing reading, if you have chronic sinusitis, but don’t despair.

Understanding the complexities of the problem is a large part of the battle. Chronic sinusitis is not

invincible, if you have a good doctor to help you - that means a doctor who also understands these

complexities.
The symptoms of sinusitis are:
• pain and a sense of swelling or unpleasant fullness around the cheeks, or over and between the

eyes
• earache or headache; pain around the teeth
• reduction in the senses of smell and taste
• sore throat
• coughing, particularly at night
• post-nasal drip (mucus from the back of the nose running into the throat and airways)
• bad-smelling breath
• feverishness
• for some people, severe fatigue, poor concentration and even (but very rarely) psychiatric

symptoms
• irritability, especially in children.
Note that any of these symptoms can be caused in other ways, and even if you have several of them, you

may not necessarily have sinusitis. On the other hand, sinusitis can go unrecognised - to some people

it may seem like nothing more than a lingering cold.
Acute or chronic?
In medical terms, ‘acute’ means short-lived, while ‘chronic’ means long-lasting.
Acute sinusitis — a short, sharp dose of it, lasting less than 3-4 weeks - usually follows on from a

cold. Colds are caused by viruses, but a bacterial infection can follow, and it is the bacteria that

move into the sinus cavities and cause trouble. Some people are far more susceptible than others and

have an attack of sinusitis after every cold.
Chronic sinusitis means symptoms lasting more than three months, according to some authorities, but the

time point is a little arbitrary. This article deals with chronic sinusitis.
If your sinusitis has been going on for between four weeks and three months you will obviously be

asking ‘Is this acute or chronic?’ At this point, no one can say, but you would certainly be wise to

seek some expert medical treatment now, on the basis that it could be the start of chronic sinusitis.

Tackling chronic sinusitis before the problem becomes
entrenched and complex is a good plan.
Allergy and chronic sinusitis
Chronic sinusitis is not necessarily an allergic disease, but it can be connected with allergies (or

other forms of immune sensitivity) in various ways:
• Allergic reactions can occur in the sinuses, usually in conjunction with allergic reactions in

the nose.
• Even if the allergic reaction does not affect the sinuses directly, allergic reactions in the

nose can block the drainage channels from the sinuses, causing an accumulation of mucus there. This may

lead to sinus infections.
• Once sinusitis has begun, infectious fungi (moulds) in the sinuses may provoke allergic

reactions, or other forms of immune sensitivity. This allergy to ‘the enemy within’ fuels more

inflammation and more mucus production. Right now, allergic fungal sinusitis (as it is known) is a

source of heated debate - 32. Allergic reactions to some of the bacteria that are present may also

occur.
• Chronic sinusitis - however caused - can contribute to asthma. Research on children with both

sinusitis and asthma found that 80% no longer needed asthma drugs once their sinusitis had been

treated, and 85% no longer wheezed. The link may be due to post-nasal drip, increased mouth-breathing,

or to a nerve-connection between the sinuses and the airways (the sinobronchial reflex) which can

stimulate airway inflammation. Alternatively, the sinusitis may simply fire up the immune system with

messenger chemicals in the bloodstream, resulting in more powerful responses throughout the body.
• Chronic sinusitis can also be the root cause of long-standing nettle rash (chronic urticaria),

and treating the sinusitis can result in a prompt and remarkable clearance of the skin symptoms.
• Some people who have chronic sinusitis are sensitive to aspirin (see box on p. 28) - a

sensitivity which is also linked with asthma, nasal polyps, rhinitis and chronic urticaria. Avoiding

aspirin and all other aspirin-like drugs (151) may substantially improve the sinusitis.
Diagnosis
Because so many different factors can play a part in chronic sinusitis, diagnosis should, ideally,

consider the problem from several different angles:
• The sinuses are viewed using X-rays and CT scans (computed tomographic scans - they use X-rays

but give a much more precise picture). These reveal how badly swollen the sinus membranes are, which

sinus cavities are blocked, and how much mucus has collected in the sinuses.
• Endoscopy (92) may be used to look inside the sinus cavities. Polyps are best located by this

method.
• Where allergies seem to be part of the picture, the doctor may employ skin-prick tests (91) to

identify allergies to airborne allergens (from house-dust mites, moulds, pets, pollen, cockroaches,

etc.)
• Laboratory tests on samples taken from your sinus cavities will be used to show which bacteria

and/or fungi have set up home there. There may also be a hunt for the immune cells known as eosinophils

(19) or the typical debris which they generate. The presence of large numbers of eosinophils is one

indication of allergic fungal sinusitis (see below).
• Skin testing with fungi (moulds) found growing in the sinus cavities may also be tried if

allergic fungal sinusitis is suspected.
• In severe cases, there may be tests of immune function, to see whether this is depressed in any

way.
• Children may be tested for an inherited disorder affecting the cilia, or for cystic fibrosis -

mild forms may escape detection, and can produce both chronic sinusitis and wheezing.
The enemy within
The biggest controversy in sinusitis research at the moment concerns allergic fungal sinusitis. The

orthodox view of this condition is that:
• It affects a small minority of chronic sinusitis patients -fewer than 10%.
• There is a true IgE-mediated allergic reaction to the fungus (mould) growing in the sinus

cavities. This allergic reaction is detectable with a skin-prick test (91). Immune cells known as

eosinophils (19) are also key players in the inflammatory reaction to the fungus, but it is an

IgE-response to the fungus that draws the eosinophils into the sinuses.
• There is clear evidence of fungal infection in the mem- banes of the sinus cavities.
• There may also be ‘fungus balls’ - a solid mass of fungus inside the sinus cavity. Or there may

be ‘allergic mucin’, a dark sticky mucus containing fragments of the fungus.
A rare complication
In rare cases, the fungi involved in allergic fungal sinusitis can be invasive, spreading from the

sinuses to the surrounding bone. This problem needs prompt and thorough treatment with anti-fungal

drugs.
In 1996, researchers at the Mayo Clinic in Rochester, Minnesota, USA, caused a rumpus by claiming to

have identified a different form of allergic fungal sinusitis which is overlooked by standard

diagnostic techniques, and which affects 96% of patients with chronic sinusitis.
This is a staggering figure - 96% means, in effect, that they are claiming to have found the

fundamental cause of virtually all chronic sinusitis. ‘Up to now, the cause of chronic sinusitis has

not been known. Our studies indicate that, in fact, fungus is the likely cause of nearly all of these

problems,’ states Dr David Sherris, one of the researchers.
According to the Mayo Clinic team:
• The fungi (moulds) are growing in the mucus of the sinus cavities, not generally in the

membrane itself. They are not detected by normal diagnostic methods which tend to ignore the mucus. A

special method of collecting the mucus is required to detect the fungi.
• The immune reaction to the fungi is not usually an IgEmediated reaction, so skin-prick tests

are often negative.
• Finding evidence of unusual numbers of eosinophils is adequate for diagnosis of allergic fungal

sinusitis because the eosinophils are the prime movers in this sensitivity reaction to the fungi, as in

several other diseases (19).
‘We can now begin to treat the cause of the problem instead of the symptoms,’ says Dr Eugene Kern, head

of the research team. There is a lot of scepticism about these claims among other sinusitis

specialists, and so far no new treatment for chronic sinusitis has emerged.
The Mayo Clinic researchers say that they are in the process of developing a drug treatment, but that

it will take several more years before it is generally available. Existing anti-fungal drugs (taken in

capsule form) could not work on this particular form of allergic fungal sinusitis (if it exists)

because the drug does not get into the mucus. Any new treatment would probably involve inserting an

anti-fungal drug directly into the sinus cavities, which is far from easy.
All we can do for now is wait and see what emerges from the ongoing research. The current treatment for

allergic fungal sinusitis involves all the usual methods (see right) with special emphasis on steroids

to calm the inflammation, plus anti-fungal drugs where fungal infection is detectable in the membrane.

In some countries, immunotherapy is also used to reduce the immune reaction to the fungus, but this is

difficult to obtain in Britain (164).
Clearing moulds from your home may help (34). So may reducing the humidity in the house (119), as humid

conditions seem to be linked with allergic fungal sinusitis.
Treatment
Sinusitis can be very hard to treat, particularly if it has been going on for a long time. You need a

really committed attitude if treatment is to be successful.
All these treatments should be given at the same time:
1 Antibiotics for 2-3 weeks minimum (it takes this long because the antibiotic has such trouble getting

into the sinus cavities – if you are offered a shorter course, this suggests that the doctor does not

have enough expertise with chronic sinusitis, so you might be better off with someone else). It must be

the right antibiotic – commonly used ones such as penicillin, tetracycline and erythromycin are

unlikely to work because the bacteria are usually resistant to them.
2 Steroid drops in the nose to combat the inflammation. It is important to put these in correctly, so

that they have maximum effect (144) especially if you have polyps.
3 Irrigating the nose and sinus cavities daily with sterile salt water (saline). Your doctor will show

you how to do this.
4 Tablets that reduce the congestion in the nose.
5 Nose drops that reduce congestion, but for three days only (29).
6 Steam inhalations to loosen the mucus. There are special steam vaporisers on sale (ask at a

pharmacy), but you can just inhale steam from a bowl of boiling water, with a towel over your head to

keep the steam in. Adding eucalyptus oil to the water may help. For a quick-and-easy version, warm up a

damp flannel in the microwave and place it over your nose. Some doctors recommend having a steam

vaporiser beside the bed at night, when nasal blockage is most likely to occur, but if you have

allergies to house-dust mite or moulds this is not a good idea in the long term, as a damp bedroom will

favour both (and could encourage allergic fungal sinusitis).
7 A drug called guaifenesin which thins the mucus is used in some countries but rarely in Britain.

Alpha-methyl-cysteine is another drug that breaks up mucus. It is mainly used in chronic bronchitis but

some doctors also find it valuable in chronic sinusitis. If steam inhalations didn’t work – suggesting
that the mucus is too solid to be shifted – these drugs may be worth trying.
8 Anti-fungal drugs (taken by mouth) if allergic fungal sinusfis is suspected. Sometimes these have a

dramatic effect on chronic sinusitis that has previously resisted treatment.
You may also be given other drugs, such as steroid tablets. The new anti-leukotriene drugs (149) are

also being tried, with some success. As well as being taken by mouth, they can be applied directly to

the nose in an irrigation fluid, and may be helpful for those with nasal polyps.
Problems with nose drops
Nasal drops and washes contain preservatives and other non-drug ingredients. Some of these may act as

irritants – or the pH (acidity or alkalinity) of the preparation might cause problems. If you

experience burning or irritation after inserting drops or irrigating the sinuses, ask your doctor or

pharmacist about trying a different preparation.
Antibiotic resistance
Bacteria are becoming resistant to the effects of antibiotics: it is probably the biggest headache

facing modern medicine.
This is emerging as a particular problem in chronic sinusitis because many patients have been dosed

very regularly with antibiotics. Although most of the bacteria have been killed each time, the fact

that the sinus cavity is so clogged up with mucus, and so badly accessed by the bloodstream anyway,

means there is always some nook or cranny where a few bacteria survive because they have not been

exposed to the full lethal dose of the antibiotic. As you might expect, these survivors tend to be the

‘tough ones’ – those bacteria that are not just well hidden but also the least sensitive to the

antibiotic.
Repeat this process many times, with frequent courses of antibiotics (separated by intervals during

which the hard-to-kill bacteria multiply in numbers) and what happens? Eventually you breed a race of

bacteria that are completely resistant to one or more of the antibiotics taken.
If you ever get to this point with your sinusitis, treatment is going to be extremely difficult. That’s

why it is so important to treat infections really thoroughly, and get rid of them completely. Expert

medical help is essential for this treatment campaign.
Too many people with chronic sinusitis are careless about taking their antibiotics regularly, or feel

ambivalent about them and stop the course before it’s complete, or don’t see the doctor again when the

tablets are used up. This is courting disaster.
Don’t start antibiotic treatment for chronic sinusitis until you are sure you can see it through. If

you have doubts about taking antibiotics, try all the other treatments and self-help measures first.

They may be sufficient, especially if you find you have an allergy underlying the chronic sinusitis and

can tackle this successfully.
Should there be no improvement, you could then go on to the antibiotic programme: delaying this

treatment for a few months will do no harm. What is hazardous is starting the antibiotic programme and

then stopping, or not taking the drugs consistently.
Antihistamines may be prescribed to treat any allergic reactions, but some specialists feel that they

can also aggravate the problems. In their experience, antihistamines dry out the mucus so that it

sticks to the walls of the sinus cavities, rather than being ushered out by the cilia. Drying out the

mucus may make you feel better initially, by reducing the pressure inside the sinus cavities, but it

makes matters worse in the long run.
Anti-chollnergic drugs (156) are sometimes prescribed for chronic sinusitis, but they too can dry up

the mucus and should be used cautiously.
After three weeks, if the sinusitis has not improved substantially, a different antibiotic is given. If

there are any bacteria resistant to the first antibiotic infesting your sinus cavities, the new

antibiotic is intended to kill them off.
Should you still have sinusitis after another three weeks, you will be given yet another antibiotic.

Changing the antibiotic, and taking prolonged courses, is the best way of exterminating the bacteria

completely, which prevents the development of antibiotic-resistant bacteria (see box at left).
It is crucial that you always see the doctor promptly at the end of each course, so that there is no

gap between the courses – do not give the bacteria any opportunity to build up their numbers again. The

last antibiotic treatment should continue for at least a week after symptoms clear up.
Dealing with allergic reactions is also important:
• If you cannot get allergy tests, try to work out for yourself if an allergen is playing a part.

Ask yourself if there were any changes in your life before the sinusitis began, such as getting a new

pet, moving house, increased exposure to moulds or house-dust mite, or starting a new job with exposure

to allergens. When thinking about this, remember that allergies to newly encountered allergens do not

develop immediately – it may take up to two years. Try avoiding the allergen concerned and seeing if

you improve.
• Should you discover that an allergen is at the root of the problem, but have difficulty

reducing your exposure to the offending item, try to obtain immunotherapy (164) or another form of

desensitisation treatment (210).
• If you suspect allergic fungal sinusitis (32), it is well worth eliminating any mould growth in

your home (120). One research study showed that the moulds growing in a patient’s sinus cavities were

often the same as those growing in the patient’s house. It is possible that, by inhaling the mould

spores from moulds in their houses, sinusitis sufferers are continually reinfecting their sinuses.
Various other self-help measures can be valuable during this medical treatment:
• Reduce your exposure to cigarette smoke (including other people’s) to an absolute minimum.

Cigarette smoke acts as an irritant to the nose and sinuses, but, more importantly, it paralyses the

cilia, preventing them from shifting mucus out of the sinus cavities.
• Avoid breathing other irritants, especially ozone (130). Think about the chemicals you use both

at work and at home – could any of these be irritants that are aggravating your sinusitis?
• Don’t drink too much alcohol – it dries out the sinus membranes and makes matters worse.
• Drink plenty of water, to keep your mucus from becoming too dry and therefore hard to shift.
• Try to breathe through your nose as much as possible. The amount of oxygen in your sinus

cavities drops drastically if you breathe through your mouth, and the low oxygen level probably fosters

the growth of certain bacteria. Devices, such as nose clips, that help keep the nose open at night may

be worth trying.
• Spicy food can help to clear nasal and sinus congestion, so try eating chilli or hot curry

regularly.
• Some people find that garlic helps – either eaten or sniffed.
• If you suspect that your sinusitis might be related to food sensitivity (68) consider trying an

elimination diet to identify the culprit food.
• Observe your reactions immediately after eating – some foods, such as yeast and red wine, can

cause an immediate swelling of the nasal membranes in certain people. So can sulphite food additives.

Avoid such items if you are affected.
• Treating gastro-oesophageal reflux (acid regurgitation from the stomach after meals) can

improve sinusitis.
• See an osteopath. By gently manipulating parts of your face, a good osteopath may be able to

improve the drainage from the sinus cavities.
• Some patients experience good effects from acupuncture although there are no observable changes

on CT scans. Other alternative therapies, such as homeopathy or Chinese herbal medicines, have not been

investigated scientifically, but some patients report good results.
Prolonged courses of antibiotics destroy many of the beneficial bacteria in the intestine, and may

cause long-term bowel problems. It makes sense to take a bacterial replacer (205).
Surgery for sinusitis
Chronic sinusitis sufferers may be offered surgery to remove polyps, or to correct anatomical problems

such as a deviated septum (the central division of the nose).
These operations can be very useful, but if you have asthma try all other options first, because

surgery to the nose can sometimes make asthma much worse.
Surgery on the sinus cavities themselves is also a possibility, when sinusitis does not respond to

medical treatment. The operation enlarges the natural drainage channels, so that mucus drains away more

easily. This rarely cures chronic sinusitis completely, but it usually makes it much easier to manage.

Once the drainage channels are larger, antibiotics can be put directly into the sinus cavities, for

example, avoiding the need for antibiotic tablets.
Don’t agree to surgery unless other forms of treatment, such as allergen avoidance or immunotherapy,

have been tried to the full. Patients for whom surgery seemed to be the only answer have sometimes

found they did not need an operation once their allergies were treated.
If you decide on having an operation, make sure your surgeon has a proven track-record with this type

of surgery. Don’t be afraid to ask searching questions about how many operations of this kind the

surgeon has done, how many he or she carries out per year, and the complication rates (how often things

go wrong). It’s a delicate job, and you want a real expert.