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ECZEMA
Eczema is one of those old-fashioned words, like apoplexy, that sounds as though it should have become obsolete doxycycline buy online . Unfortunately, the condition it describes is still very much in evidence, now perhaps more than ever buy paroxetine on sale . Dermatologists estimate that the red itchy rash of chronic eczema may affect as inuch as 20 percent of the population in Scandinavia, Australia, and England maoi inhibitors and requip .274 The United States has similar figures, compared to only about 2 percent of the population in places like Iran and China sulfamethoxazole prostitis .
Scientists don’t know why the rate of eczema varies so widely from one place to another tetracyclines cipro . A lot of other things are still pretty mysterious about eczema, too motilium and gerd . The researchers who study it have not come up with a single unified measure of eczema severity, so it is sometimes difficult to compare studies nbc candace downing zoloft . In fact, when dermatologists discuss eczema, they frequently use the term atopic dermatitis instead amoxicillin abdominal cramps . It means the same
• Apply moisturizer immediately after washing skin ***
•Take probiQtic supplements such as viable Lactobacillus GG
• Try hemp seed oil capsules **
• Season your food with salsa **
• Sip oolong tea ***
•Take vitamin E capsules daily ***
• Smear Noxzema (original) on itchy skin ****
• Try nonprescription hydrocortisone cream * ***
• Apply CamoCare Soothing Cream to itchy areas ***
• Follow doctor’s instructions for using prescription steroid creams
• Consider prescription Atopiclair ***
• Ask the doctor about Protopic or Elidel as a second-line prescription treatment
glyburide liver damage due to lipitor . Byetta reduces the bump in blood sugar after meals and can help diabetics lose weight does advil contain asprin .
The most common side effect is nausea, but the most serious is hypoglycemia soma vs salsa . Adding Byetta to a medicine like glyburide increases the risk of a dangerous drop in blood glucose level d150 lithium ion . Patients using Byetta must learn what to do if blood sugar drops too low macrobid uti . Other side effects include vomiting, diarrhea, dizziness, jitters, headache, and indigestion lupus testosterone treatment . Byetta should not be given to people with kidney problems or serious digestive disease metformin and sinus inflamation . 273
Conclusions
By now, we hope you appreciate the importance of controlling blood sugar diabetics taking aleve . Diabetes is common (some diabetologists believe it will soon affect nearly half the population), and its complications are devastating how much does nexium cost . We have tried to give you a variety of strategies to prevent or control this disease naproxen acne . Remember, though, that whatever tactics you adopt, you must work in close collaboration with your health-care providers replace lithium with alkaline .
Below you will find an overview of our recommendations in this chapter generic atorvastatin online .
• Preventing diabetes is possible zoloft fedex . Keep your weight under control, emphasize nonstarchy vegetables over pasta or bread, and avoid soft drinks, fruit juice, and processed meats 1 5mg propecia .
• Get plenty of exercise, preferably including some time outdoors so you have 10 to 15 minutes of sunshine on your face and hands several days a week augmentin tablet . If you don’t get outside, take 800 to 1,200 IU of vitamin D3 daily apo sildenafil .
• If you are diagnosed with diabetes, learn to monitor your blood sugar prescription viagra from canada without prescription . Keep track of how exercise and food affect it celexa success . Consider cinnamon or vinegar to help smooth out blood sugar in reaction to a carbohydrate meal naltrexone and behavior .
• If you’re considering using herbs or dietary supplements such as chromium, bitter melon, fenugreek, Gymnema sylvestre, or nopal, check with your health-care providers before taking them using loratadine in cats . Monitor your blood sugar carefully ranitidine used to stop itching .
• If medication becomes necessary, make sure that you and your physician find the safest and most effective option for you caffeine remedies . You shouldn’t have to suffer with dreadful side effects to keep your blood sugar under control caffeine coke coffee .
thing: a nasty, itchy rash, especially in places where the skin creases (like inside the elbows and on the backs of the knees) kamagra barata . It may be associated with dry skin, redness, and irritation on the cheeks or forehead, as well as asthma or hay fever vigorex or viagra .
Very young kids with eczema may have family members with asthma or hay fever can accutane make your periods shorter . Atopic dermatitis is pretty common in children and may start early, at as young as 2 or 3 months of age managing levothyroxine dosing . 275 If it is severe, the itching can drive the sufferer crazy and even keep him or her awake at night pseudoephedrine and hypertension . It is no wonder patients and their parents are anxious to get relief hypothyroidism and glucophage .
Skin Care Basics
There is a huge overlap between eczema and dry skin, so it makes sense that the very first things to try for eczema are recognized as elementary care for dry skin 12.5 cr mg paxil .
Especially in adults, eczema frequently affects the hands light period after taking clomid . Avoid soaking your hands in water side effects of drug lamisil . If they are dirty, by all means wash them college pharmacy pre tramadol . But if you need to do the dishes or wipe off the counters, wear waterproof gloves generic equivalent to zoloft . Likewise, if you are working out in the yard, wear garden gloves properities of caffeine . Apply a moisturizer you like as soon as you finish washing your hands nizoral shampoo helps acne . (We’re fond of Udder Cream atavan and prozac .) You might even consider applying a heavy-duty ointment-type moisturizer at night and wearing cotton gloves to bed, so the sheets are protected and the ointment really gets a chance to sink in duration of celexa withdrawal symptoms .
CeraVe Cleanser and Moisturizer
These skin products contain no fragrances, soap, or detergent atorvastatin joint pain . The cleanser is an emulsified formulation that contains cetearyl alcohol, one of the primary ingredients in Cetaphil cleanser will zelnorm ever come back . But both the moisturizer and the cleanser also contain ceramides when does zyrtec’s patent expire . fSo does Dove Facial Lotion hereditary allergies cipro .) Skin with eczema is depleted of ceramides, 276 and the CeraVe products are supposed to restore these natural skin fats and keep skin from drying out dangers of prozac and peptic ulcers .
Downside: No real downside, but other products may be less expensive bp-2l5 lithium battery .
Cost: A 12-ounce bottle runs about $12 and should last several months detector bandwidth characteristics lithium tantalite .
What about rashes that affect other parts of the body? Basically, follow the same principles testosterone prices . Bathing or showering are okay, but shouldn’t be prolonged free testosterone level normal older . Don’t use soap or detergent, if you can avoid it; instead, use a gentle, nonsoap cleanser such as CeraVe or Cetaphil simvastatin niacin . Gently pat your skin dry and apply moisturizer as soon as you step out of the tub or shower stall weight gain while on synthroid .”‘
Moisturizers don’t actually make eczema better by themselves clomid pcos story success woman .”‘ What they do is improve the symptoms of dry skin, so the skin looks better and itches less accutane weight lose . In addition, a topical medication may work better on skin that is properly moisturized canada cr123a lithium . So, there are reasons to start with a moisturizer, although it’s unlikely to be enough of a treatment on its own doxazosin medications .
Dietary Approaches
The connection between eczema and other allergies has inspired people to search for the source of the allergies and try to avoid them ganciclovir acyclovir . Avoiding one of the most common allergens, dust mites, is very difficult nolvadex or clomid for testosterone boost . Dust mites live in bedding, furniture, carpets, and even stuffed animals lamisil dosage . As it happens, though, even extreme measures such as encasing the mattress in plastic don’t reduce eczema in adults reds lithium .”‘ We don’t have good research on whether this would help in babies or young children discount pharmacy zyrtec .
Dietary recommendations are aimed at reducing a child’s exposure to foods that could be triggering eczema co diovan . One trap that parents sometimes fall into is restricting the diet too much, so that the child isn’t getting enough nutrients doxycycline for std . Scientists say that most of the time, dietary restriction isn’t very helpful for improving eczema zyprexa and high blood sugar . If a child reacts to eggs, though, avoiding them is likely to help clear up the skin caffeine efffects .211 Switching a baby from cows’-milk formula to soy-based formula is often advised and occasionally helpful tadalafil fails .
Luckily, kids often “outgrow” their food allergies as they get older viagra bloody nose . The big exception is peanuts prozac gain weight . Children who are allergic to peanuts need to avoid them scrupulously, and will probably need to do so indefinitely non asprin pain relievers .
I’ve had eczema since childhood, and it had been getting worse, despite applying steroids three times daily sildenafil rdt . I had read advice about cutting back on trans fats and adding omega-3 fats but I had no success until I tried completely eliminating trans fats imitrex withdrawals . Since getting hydrogenated oils out of my diet, my eczema has nearly dis-appeared and I have discontinued the steroids for the first time in 3 years cymbalta teeth clenching . The trans fats that apparently caused this problem were coming from one or two servings of packaged cookies per day what is fluoxetine for .
Probiotics
Most Americans are familiar with the idea of using antibiotics to kill germs when there is an infection itching all over from doxycycline . But probiotics are not nearly as popular in the United States as they are elsewhere in the world, especially in Europe diovan great . Probiotics are beneficial bacteria that are used in an attempt to colonize the gut with “good guys” and crowd out dangerous bacteria regular use of ibuprofen .
There is evidence that babies with eczema may benefit from treatment with probiotics, particularly if they have evidence of allergic-type immune-system activation soma spa ottawa . Doctors determine this by measuring the amount of an immune globulin, IgE, in the blood nnt zocor . It is usually elevated in people who are experiencing an allergic reaction amoxicillin clavulanic acid in ruminants . Adding probiotics such as Lactobacillus fermentum or Lactobacillus GG to formula helped ease the condition in very young children with severe eczema ranitidine expiration date . 281,282,283
We don’t know why probiotics can make eczema better, but some researchers speculate that they may cause a low level of inflammation that stimulates the immune system in a different direction from allergy prilosec nexium compare . 21 More research is needed before that hypothesis can be confirmed—or tossed out does levaquin contain sulfa . For adults, many probiotics are considered relatively safe ‘285 although there are some theoretical risks whenever living microbes are
Probiotics
Beneficial bacteria such as Lactobacillus GG, Lactobacillus reuteri, or Lactobacillus fermentum seem to reduce the severity and extent of eczema in young children neurontin for back pain . This approach is reasonably safe286 and might be worth a try trazodone wikipedia .
Downside: Probiotic products are sold as dietary supplements, so the quality is not regulated charger rechargeable lithium cr123a 3.7v battery . Check www konica rechargeable lithium ion battery pack .consumerlab avelox prescription assistance .com for quality evaluation and price information zithromax dosage 23 pounds . It is important that the supplement contain viable organisms spironolactone for ascites and hyperkalemia .287 Cost: Approximately $10 to $30 per month introduced into the bod y lipitor gross income .288 For very young children, it would be sensible to follow the pediatrician’s recommendation information about levora .
Oil Supplements
We already mentioned that the connection between eczema and diet has led to research investigating various dietary restrictions symptoms of testosterone use . For the most part, a really restricted diet just makes life more difficult without any payoff for the skin augmentin generic . (One big exception is in the case of celiac disease anxiety bupropion . This intolerance of gluten can cause a distinctive skin reaction—herpetiform dermatitis—along with a wide range of other symptoms glimepiride dosage indication . For a person with celiac disease, avoiding gluten completely not only clears up the skin, but also has many additional health benefits lithium ion battery pack 7.2v .)
We have heard from many eczema sufferers who have found that various supplements have helped to clear up their rash, at least for a while naproxen and garlic . Borage oil and black currant seed oil are among the most popular supplements digoxin medicine . They supply fatty acids, especially gamma-linolenic acid, that may be underrepresented in the typical American diet ketorolac surgery .
I have been plagued with persistent eczema carisoprodol mg . The skin on my hands was always red, itchy, cracked, and often bleeding anxiety meds similar to zoloft . My hands were always covered with bandages estrace dosage .
Dermatologists prescribed cortisone creams of increasing strength, but none was helpful over the long-term reduction of prednisone side affects . An allergist I saw for an unrelated problem was concerned that the open wounds on my hands put me at risk of infection what is nifedipine er . He suggested borage oil zyrtec ambien interaction .
I tried it (one capsule after breakfast and one before bed), and
Hemp Seed Oil
Hemp seed offers a balance of omega-6 and omega-3 fatty acids lexapro definition . One study demonstrated that it reduces eczema symptoms significantly more than olive oil does hectoral coumadin .
Downside imipramine histamine h2 ., A single study is not enough for a full evaluation of the supplement’s benefit diovan black box warnings . Another, larger study might not show a significant effect evista fossamax .
Cost: Approximately $5 to $16 per month
within a few months the eczema on my hands disappeared completely cymbalta long term use . While I still have some outbreaks behind my ears, the condition is now only a minor annoyance generic metoprolol succinate 100mg . What a difference!
Although some individuals have found gamma-linolenic sources such as borage oil, evening primrose imrose oil, and black currant seed oil helpful, scientifically controlled studies of these supplements are disappointing acyclovir cream buy . 219 They do seem to be safe, but overall they don’t reduce the rash or itching any more than placebo capsules do zithromax 1 gram . 290
One well possible exception is hemp seed oil overview of rx diltiazem cd . It contains omega- 3 as as omega-6 fatty acids, including gamma-linolenic acid amlodipine besylate norvasc . One placebo-controlled study found that hemp seed oil capsules reduced itchiness and dryness in skin viagra online store . (The placebo capsules contained olive oil caffeine body slimmer .) Patients on the active supplement used less topical medicine for their dermatitis during the 5 months the trial lasted norvasc a drug .291 We hope other dermatologists will continue to study this treatment to see if it stands up to further investigation diprivan interactions with zoloft .
Low-Carb Diet
One of the most unusual testimonials we have received about controlling eczema with diet was from a woman who adopted a low-glycemic-index diet for other reasons ms cymbalta . She found that it helped clear up her itchy rash reis urso and ewald rutland vermont . Cutting sugar, white bread, and pasta out of the diet may well have other health benefits estriol estradiol cream . Most dietary experts agree that these foods are not very nutrient-dense trimox for erectile dysfunction . Your body won’t miss them, even if your taste buds do luvox tablets .
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Q buying generic cialis . I used to get urinary tract infections or yeast infections every other month ptsd using prazosin hcl 1 mg . Then I changed my diet and cut out sugar, white flour, and starches like potatoes or rice methadone xanax diphenhydramine fluoxetine . Since then I have had only one urinary tract infection clomid while breastfeeding .
I’ve lost 20 pounds and my eczema is 99 percent better what is synthroid made from . I have a flare-up only when I eat cake or milk chocolate cipro diarrhea .
I was surprised that diet could have such an effect on my system valacyclovir c gsk dartford . Other people with eczema or seborrheic dermatitis might benefit the way I did synthroid iodine .
A site about tramadol climate . There is next to no research linking a high-carbohydrate diet to urinary tract infections or eczema ultram and ejaculation . On the other hand, reducing the amount of sugar, starch, and refined carbohydrates seems like a simple enough experiment wellbutrin and prices . If it works for some people with such hardto-treat conditions, it might be worth the trouble soma boulder . Thanks for sharing your interesting story sertraline therapy canine .
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This approach has not been well studied, to say the least omnicef price . German researchers have investigated a sugar-free diet in 29 patients free testosterone blood level in women . 292 After 1 week of a strict sugar-free diet, they were given a food that contained either sugar or an artificial sweetener voltarol side effects on stomach . There was no discernable difference between the reaction to sugar and the reaction to an artificial sweetener merck co propecia .
You may feel that this study was small and perhaps didn’t give the diet enough of a chance online prozac online . If so, go ahead and conduct your own personal study proscar and psa . It won’t have scientific significance for anyone else, but if it helps your skin, that’s all you really need to know levothyroxine cytomel together .
Hot Salsa
Believe it or not, some people have done their own experiments on one dietary staple trazodone chemical components . After one person reported that his increased consumption of salsa had been correlated with a decrease in the severity of his lifelong psoriasis, other people decided to try salsa or hot chili peppers for eczema penicillin vk 250mg . At least a few of them have found capsaicin consumption helpful caffeine free low sugar cocoa . (Capsaicin is the compound in chili peppers that makes them hot description of omeprazole . We have no idea if eating it has any role in making eczema better can synthroid affect anti-tpo test .)
I read your column about eating salsa fora skin condition benzapril hydrochlorothiazide . I tried it and it worked forme side effects prednisolone withdrawal . For over a year I’ve been free of the eczema I had for 8 years before that ramipril interactions . I ate salsa daily for about a month amoxicillin color description .
Capsaicin is an ingredient in some topical liniments or rubs designed to alleviate arthritis pain diflucan over the counter . Usually, there is a warning for such products not to apply them to broken skin finasteride prostate treatment . For one thing, capsaicin on a cut or sore would hurt horribly depakote er and bipolar . There is also no evidence that capsaicin cream would be effective for The People’s Pharmacy has received a number of testimonials claiming that eating salsa eased eczema atenolol myl . No clinical trials have been conducted as far as we know vardenafil raw material .
Side effect: Sore mouth
Downside: Not everyone likes salsa anavar or testosterone . Cost: $6 to $10 a month
eczema blach cohosh celexa . A review of the evidence in veterinary medicine concluded that more studies are needed to see if topical capsaicin works for dogs with itchy spots citalopram and bruises . 293 If more data are needed for dogs, you can well imagine how much more evidence is needed for humans!
Oolong Tea
If you think that salsa is on the strange side, you might be nonplussed by oolong tea generic vs brand name wellbutrin . It has one major advantage over salsa, though: A study of people with atopic dermatitis showed that it helped to reduce their symptoms itraconazole for cats .” People with severe eczema that had not responded well to standard treatments were given tea bags and told to make and drink a liter (about a quart) of oolong tea daily aldosterone norvasc . Their symptoms were recorded neonatal thyroxine . Although there wasn’t any placebo tea, researchers and almost two-thirds of the patients noticed an improvement within a couple of weeks paxil antidepressant . The improvement, which lasted for the entire 6 months of the study, might have been due to the anti-allergy activity of the polyphenol compounds in oolong tea winston churchill and penicillin .
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G klonopin prozac interaction . Thank you for your advice to try oolong tea for eczema phenylephrine hci and loratadine . It’s been like a miracle flomax tamsulosin virginia .
I’ve had eczema on my scalp for most of my life naproxen review . I would have terrible itching and scaling on my scalp that would usually bleed and scab over damage prozac overdose . It’s worse around the hairline and is embarrassing as well as painful withdrawal recovery effexor .
I had tried everything my doctor prescribed: Nizoral, Elidel, topical steroids in oils and shampoos, and even an injection abilify hoarding . Nothing worked until the tea no caffeine . I’ve been Oolong Tea
Oolong tea is a popular beverage in China and Japan can prilosec otc raise blood sugar . More than half of the patients in the only study that has been done had good improvement that tasted 6 months tacrolimus ointment .
Side effect: Oolong tea, like other tea, contains some caffeine and could be stimulating artane heat .
Downside: American taste buds need to get used to the flavor alternatives to mesalamine .
Cost: $3 to $5 a month
drinking it for about 2 weeks now and I’d say there’s been at least an 85 percent improvement caffeine culture tour .
A sr wellbutrin xl . You aren’t the only reader to find oolong tea helpful cod shipped tramadol . One person with hard-to-treat eczema reported: “The last time I had an outbreak, I tried oolong tea and the results were amazing wellbutrin and buspirone . Within 24 hours, the itching and inflammation were gone zantac use . It took a couple of days, but the lesions disappeared and didn’t leave scars active ingredients in aleve .”
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Oolong tea is available in many grocery stores, although black tea and green tea are better known in the United States levothyroxine if you miss dose . All three teas are made from the same plant, but the leaves are processed differently gout not sensitive to allopurinol . Green tea leaves are processed very little; black tea leaves are “fermented” and oxidized; and oolong tea leaves are partially oxidized diltiazem and side effects . It’s an acquired taste, but it could be a taste worth acquiring c e s conjugated estrogens

No single factor lies behind the allergy epidemic — the causes are many and various (see p. 20). What this means for parents interested in allergy prevention is that there is no

single measure which will ensure that your children do not develop allergies. Instead there are a great many different things that can be done, each of which reduces the risk to

some extent. The more of these you do, the lower the risk becomes.
Avoiding allergens
Starting before the birth is best, if you want to reduce allergen exposure for your child (see p. 240). But if you have missed the boat with that one, don’t despair – there is

still a lot to be gained by reducing allergen exposure at a later stage.
If you are ridding your home of allergens after the child’s birth, bear in mind that things will get worse before they get better– there will be a temporary surge in airborne

allergen as a result of the clean-up operation, and you will need to protect the child from this. The best strategy is for the child to be away for a few days while the work is

done, especially if you are taking out carpets, furniture or mattresses. Remember to protect yourself as well, if you are allergy-prone (see p. 109).
One of the most important steps you can take to reduce allergen levels is improve the natural ventilation of your home. This lowers the humidity (assuming you don’t live in an

extremely humid climate), which helps combat both moulds and dust mites. Ventilation also flushes out allergens in the air, especially cat, dog and mould allergens. Half the

problem with modern houses is that the airtight seals around doors and windows, introduced to conserve heat and save energy, turn the indoor air into a rich stew of allergens

and irritants.
House-dust mite
Avoiding high levels of house-dust mite in the home is one of the most valuable things you can do to reduce the risk of allergies in your child. Not only is house-dust mite a

powerful allergen in its own right, it may also act as an agent provocateur as far as the immune system is concerned (see p. 12), and may help to initiate allergic reactions to

other potential allergens – such as those from pets or indoor moulds.
Even if you do nothing else to protect your new baby from mite allergen, at least buy a new mattress and pillow for the cot, with ready-fitted allergen-proof covers. Do the same

for the portable crib, if you have one. Choose anti-mite products that are designed for babies and are guaranteed safe – there is a risk of suffocation with some loose covers

sold for older children and adults (see p. 245).
You may want to eliminate house-dust mite from your own bed as well as the baby’s, because there will probably be times when you take the baby into bed with you for a feed or a

cuddle – and times when, as a toddler, he or she just barges in! It is good to know that your child is still breathing air free from dust-mite allergen in these circumstances.
Deal with your own bed as soon as you can. Some doctors believe that lowering your exposure to dust mite during pregnancy may reduce the risk of sensitising your baby before

birth (see p. 241).
When taking anti-mite measures with your own bed, make sure that there is no risk of suffocation to the baby from the allergen-proof materials used. Microporous membranes based

on plastic could, if sucked onto the baby’s face during sleep, cause suffocation. Loose covers on duvets are worrying in this respect. Buy a new duvet with a built-in

allergen-proof cover, for preference, or a duvet that can be laundered at 60°C or above.
All the other measures for combating dust mites, described on pp. 114-17, will help to protect your child. Buy a good anti-allergen vacuum cleaner if you possibly can, and keep

your baby out of the room while vacuuming if you can’t (open the windows too). Make sure the baby only has new soft toys, preferably washable ones (see p. 116).
It is also an excellent idea to reduce dust-mite levels in the carpets and soft furnishings (see p. 117), because children tend to have very close contact with these in their

early years. A crawling baby, motoring enthusiastically around the sitting room floor, is stirring up the stockpile of dust-mite allergen that is found in any carpet, and

inhaling it in full measure. An adult walking around the same room has a far lower exposure, because dust-mite allergen, being relatively heavy, stays near the ground.
The best option is to go for non-carpet flooring, which doesn’t encourage dust mites. Parents tend to worry about the hardness of this, for a baby or toddler. In fact babies are

far more robust than we generally believe, and a hard floor is no problem for a small child who has never known the luxury of carpeting.
If you really hate the idea of your baby having anything other than carpet to play on, the next best option is to get new carpet, so that you start with zero dust mites. You

must then prevent dust-mite numbers from building up too much, by means of good ventilation, or with the use of a powerful dehumidifier (see p. 117).
Although the first year is the most vulnerable time for your baby, you mustn’t let your guard drop too much as time passes. The moment when a toddler moves from a cot to a ‘big

bed’ is sometimes the beginning of allergy symptoms because, after carefully protecting their child from dust mites in infancy, parents then put him or her into a bed with a

used mattress. This sudden exposure to a high dose of
dust-mite allergen can be the start of asthma. Get a new mattress if you can, and put allergen-proof covers on it. Alternatively, put allergen-proof covers on the existing

mattress.
Moulds
Mould spores are another potent allergen, and you should avoid bringing up a vulnerable child in a damp house if you can, because moulds will be growing there in abundance. Some

new research suggests that heavy exposure to mould allergens in childhood makes allergies in general much more likely. Even in a house that is not obviously damp, it is a good

plan to reduce indoor humidity (see p. 119). Carpets and furnishings that are full of mould spores (see p. 122) should be replaced.
Pets
What about pet allergens – should you find another home for your cat or dog when you are expecting a baby? This is a difficult question because the latest research shows that

pets are a double-edged sword as far as allergies are concerned.
A baby with allergic tendencies who is born into a house with a resident cat or dog is more likely to show allergic reactions to cats or dogs some years later. On the other

hand, there is research showing that having a pet in the house reduces the risk of allergies overall, especially for a child with no brothers or sisters. This is probably

because the pet boosts household levels of endotoxin (see p. 21), and generally makes the environment less hygienic for the child, fulfilling the same anti-allergy role as

brothers and sisters would in the early life of a child (see p. 246).
If you are planning to give your child the kind of grubby childhood that seems to protect against allergy (see p. 246), the additional protection provided by a pet is probably

unnecessary. Or, you could view your pet as having both pros and cons, and decide to keep it, while implementing all the other anti-allergy measures described here. If you do

this, ensure that the house is well ventilated (so pet allergens don’t build up to very high levels) and keep the pet out of the child’s bedroom so that he or she is not

breathing huge amounts of pet allergen while asleep. You could also wash the pet regularly (see p. 125) to reduce allergen levels.
If your child begins to show any signs of allergy to the pet, you must then find it another home.
Avoiding irritants
As well as increasing ventilation and eliminating cigarette smoke from the home completely, it may be worth evicting certain specific items that produce irritant gases.
The main ones are:
•    gas cookers (if you can’t afford to switch to an electric cooker, at least improve the ventilation in your kitchen as much as possible)
•    easy-clean plastic wall coverings and flooring
•    materials such as chipboard and MDF, which give off formaldehyde.
The evidence regarding the possible role of these in increasing the risk of allergies and asthma is described on pp. 128-9. In addition, although there is no evidence on this

point, common sense would suggest getting rid of any plastic or lacquered items that have a powerful smell.
Generally speaking, although traffic pollution can act as an irritant, it seems to play a lesser role in causing allergies and asthma than most people imagine. However, it may

sometimes play a part, especially if there are high levels of diesel fumes in the air (see p. 131).
Infections - friend or foe?
A large group of Italian military cadets were recently studied by doctors interested in the causes of allergy. By taking blood samples and testing them for antibodies to common

infections, the doctors could see what diseases the men had been exposed to early in life. At the same time, the young conscripts were assessed for allergies.
Allergies were least frequent among the young men with antibodies against three common infections that are dispersed via food and faeces – Hepatitis A, Toxoplasma gondii and

Helicobacter pylori. Only one in twelve of the cadets in this group had allergies.
Among the men with no antibodies against any of these infections, the rate of allergy was nearly three times as high – one in five of these cadets had allergies.
The doctors who carried out this experiment believe that these three infections are not necessarily important in themselves, but that they identify individuals who were ‘reared

in an environment that provides a higher exposure to many other orofecal or foodborne microbes’. In other words, they grew up in the kind of household where washing your hands

before meals wasn’t considered too important.
This study adds to the growing body of evidence (see p. 21) which shows that an over-clean environment during childhood encourages the development of an allergic disposition.
Those with lower rates of allergy include:
•    children raised on farms with livestock. The more exposure the children have to farm animals, the less the likelihood of them developing allergies.
•    children from homes with high levels of bacterial endotoxin in the household dust (see p. 21)
•    children who have fewer baths, and wash their hands less often (see p. 21)
•    children with brothers and sisters, especially those with older siblings. Some of the protection here may be due to the impact of the mother’s hormones and immune system

on the foetus in the womb: these effects change with successive pregnancies. But close contact with older siblings, and thus exposure to more microbes, probably plays a part.
•    children who go into kindergarten, nursery school or day care with other children at an early age – this is only valuable for children without brothers and sisters
•    children with pets at home – the benefits are much more pronounced for children without brothers and sisters.
The Italian study is especially important because, for the first time, it gives detailed information about the kinds of infections that make a difference in allergy prevention.

The military cadets were also checked for antibodies to measles, mumps, rubella, chickenpox and herpes. None of these infections gives protection against allergies – only

infections carried in food and faeces do.
Exactly what practical use you make of these discoveries is up to you. For most of us, the importance of hygiene was so firmly instilled during our own childhood that it is

quite hard to suddenly become more relaxed about it. But do let your children play in the garden, if you have one, and don’t worry so much about how dirty they get. Encourage

them to do some gardening – medical researchers believe that harmless bacteria in the soil may be particularly important in educating the immune system away from allergies (see

p. 21). Let them play with pets, as long as the animals are not carrying harmful parasitic worms (talk to your vet about whether pets should be treated for parasites). Ease up

or, hand-washing and, if this is your first baby, make sure he or she plays with other children as early in life as possible.
A few chest infections do seem to increase the risk of asthma, notably Respiratory Syncytial Virus (RSV). If this Infects babies, it provokes an IgE-reaction (see box on p. 12)

which may encourage the development of allergies. Unfortunately, there is very little you can do to protect your child from this common virus, but it makes sense not to take the

baby to a hospital for unnecessary trips (visiting relatives, for example) because RSV infections are often picked up in hospital.
Taking care with antibiotics
The possible role of antibiotics in making allergies more likely to develop is an exceedingly controversial topic. Before making any practical decisions in this respect, you

must consult your doctor. Never go against your doctor’s advice, if he or she thinks that antibiotics are necessary.
Several different studies have now produced evidence of a link between antibiotic use before the age of one or two, and the later development of allergies, asthma or both. The

best of these studies was carried out by doctors in Oxford, who followed 1900 children up to the age of sixteen. Among children at risk of allergy (because their mothers had

allergies) taking antibiotics before the age of two was linked with an increase in the rate of allergy from 32% to 54%. The more courses of antibiotics a child received, the

greater the risk.
The type of infection for which the drugs were prescribed was not important, as far as the risk of allergy was concerned, but the type of antibiotic did make a difference.

Broad-spectrum antibiotics, which kill a wide range of bacteria, were more risky –suggesting that the depletion of friendly bacteria in the gut (see p. 204) could be responsible

for increasing the allergy risk. Penicillins seemed less likely to promote allergies than erythromycin or cephalosporins.
This research is not widely known, as yet. And because there is a widespread assumption that giving an antibiotic can do no harm, even if it is unnecessary, antibiotics are

sometimes prescribed when they serve no purpose. In particular, antibiotics are often given for virus infections, especially in childhood, despite the fact that antibiotics are

of no value whatever against viruses. Research shows that doctors are sometimes responding to pressure from anxious parents when they prescribe antibiotics – it is difficult for

some parents to accept that a virus infection cannot easily be treated and just has to ‘run its course’. (Although there are drugs that combat viruses, these are expensive and

produce unpleasant side effects – they are reserved for very serious virus infections such as hepatitis.)
Obviously. when a child needs antibiotics to deal with a serious infection there can be no question about giving them. This is why you should always follow your doctor’s advice.

But it is also worth asking the doctor the following questions before giving antibiotics to your child:
•    are you sure that this is a bacterial infection, and not a virus infection?
•    would it be possible to do tests and check that it is a bacterial infection, before prescribing antibiotics?
•    what is the chance of the child overcoming the infection without antibiotics?
•    would it be dangerous to wait and see if the infection clears up naturally?
Vaccination
The same Oxford research team that investigated antibiotics (see left) also looked at the question of vaccination and allergy. They found a link between vaccination for

pertussis (whooping cough) and increases in asthma, eczema and hayfever. However the increases were not large, and a study from Sweden found that whooping cough vaccination did

not have any effect on rates of allergy and asthma. And researchers in Ethiopia have found that whooping cough vaccination actually reduces the risk of allergy in their country.
This is clearly a complex issue. The contradictory results from different parts of the world suggest that the ‘big picture’ is what counts here – the overall combination of

childhood infections, antibiotic treatment and exposure to harmless bacteria such as those in the soil or from animals. Depending on this big picture, vaccination against

whooping cough may push the allergy risk one way or the other.
There are many other arguments both for and against vaccination and, given our current state of ignorance about the possible effect on allergy, these other considerations are

probably more relevant. Discuss the matter in detail with your doctor before making a decision.

Doctors in Japan recently tried a very simple experiment in allergy prevention. They chose babies suffering from atopic eczema who were allergic to foods, but not allergic to

house-dust mite. Dividing the babies into two groups, the doctors put special allergen-proof covers, designed to protect against house-dust mite (see p. 115), on the mattresses

of all the babies in the first group. Babies in the second group were given ordinary cotton covers.
When the babies were one year old, they were tested again for allergy to house-dust mite. Two out of three children in the second group now gave a positive skin test to

house-dust mite.
By comparison, only one in three of the children from the first group gave a positive skin test. In other words, using the anti-allergy covers for these high-risk children had

cut by half the number who developed an allergic reaction to dust mite.
As this experiment shows, even if a child has already developed allergies, it is not too late to bring protective measures into play. Indeed, an allergy problem in infancy, such

as atopic eczema, can be seen as a warning sign to parents, telling them that they should reduce the child’s exposure to allergens as much as possible.
As well as reducing dust-mite levels, you should minimise your child’s exposure to moulds at home by limiting indoor humidity (see p. 119) and cleaning up any existing mould

growth (see pp. 122-3). This will lessen the chance of mould allergy developing.
Try to avoid staying, even temporarily, in any house that is damp or has old carpets and mattresses. When you are moving house, or carrying out any kind of renovation work,

remember that this will stir up a lot of dust-mite and mould allergens. Protect your child by arranging for a stay away from home.
This pro-active approach should not just apply to airborne
allergens, but also to food, in the opinion of some experts. They
suggest that any child with a true allergy to cow’s milk or egg
should not be given peanuts, tree nuts, fish or shellfish until three
years of age, to avoid sensitisation to these potent food allergens.
Pets are a more difficult issue, with both pros and cons as
regards allergy-prone children (see p. 245). If you decide to keep
your cat or dog, always ventilate the house well, and wash the animal regularly if you can (see p. 125). Be alert for your child developing an allergic reaction to your pet –

don’t turn a blind eye to the symptoms, as parents sometimes do because they are reluctant to accept that the child has become allergic to the family’s much-loved pet. If your

child does develop an allergy to the pet, the best option is to find the animal another home as quickly as possible (see p. 124).
Breast-fed babies with atopic eczema
Although breast-feeding is a good way of protecting children against atopic eczema, it is no guarantee. Sometimes babies become sensitised to food, in spite of being breast-fed,

and then they may react to traces of that same food, eaten by the mother and coming through in her breast milk.
Skin-prick tests (see p. 91) may help to identify the foods responsible for the eczema. Otherwise, a simple elimination diet by the mother, as used for colic (see p. 203), may

pinpoint the offending food. Keeping that food out of the mother’s diet will often clear the baby’s eczema.
Sometimes a breast-fed child’s eczema remains severe, despite the elimination of suspect foods from the mother’s diet. In this case, what should be done? New research from Or

Erika Isolauri – a staunch advocate of breast-feeding – suggests that the best option at this point is to stop breast-feeding promptly. Her research team found that breast-fed

children with persistent eczema had a slower growth rate. If these babies are switched to hypoallergenic formula – either an extensively hydrolysed formula or an artificial

amino-acid formula (see box on p.66) – their eczema symptoms usually subside, and their growth picks up.
Is vaccination safe for those with allergies?
The influenza vaccine and a few others (e.g. yellow fever) are grown in eggs and are not usually given to people with egg allergy. Measles vaccine is grown in cells taken from

eggs and may contain a minute trace of egg allergen, but only those who are extremely sensitive will react: there should be resuscitation equipment available for children who

have had anaphylactic reactions to egg and for those with severe asthma as well as egg allergy. Some vaccines come in vials with latex seals that are designed to be pierced by

the needle of the syringe. A different method should be used for latex-allergic patients. Smallpox vaccine (for bio-terrorism threats) is dangerous for children with atopic

eczema.
Never too late?
The role of modern ultra-clean lifestyles in promoting allergies is now well established (see p. 21). If your child already has allergies, it may seem as if these discoveries

have come too late to help —but that is not the case. Some research suggests that the battle for supremacy between Th1 and Th2 cells (see p. 11) — the unseen power struggle

which decides whether a child will be allergy-prone — is not really settled until some time between the ages of five and seven years. So there is still some potential for

intervening right up to this age. Some studies have suggested that the immune system can be pushed away from an allergic disposition at an even later age, right into adulthood,

by exposure to endotoxin, a bacterial product found around livestock and in `lived-in’ homes.
Several research groups are working on vaccination strategies (for example, using extracts of soil bacteria) that might also be able to achieve this. The initial results are

promising and they suggest that these vaccines can even help adults with allergies. Unfortunately, such treatments will not be available for many years. In the meantime, you can

probably reduce your child’s chance of developing new allergies, and perhaps make the existing ones less severe, by easing up on hygiene (see p. 246).
Fresh air and exercise
With the boom in watching TV and videos, and playing on computer games, some modern children hardly go outdoors at all. As far as allergies and asthma are concerned, there are

two big disadvantages to being a juvenile couch potato. For a start, the couch is also home to dust mites in their millions, and secondly the child is not running about and

using his or her lungs to the full. Airways that are never stretched (because the child never gets out of breath) lose their youthful flexibility in time. Once this has

happened, the airways can never be stretched to their full capacity. Some doctors believe that this may make asthma more likely to develop, or help to make it more severe once

it has developed. Inactivity also encourages obesity, which increases the risk of asthma developing.
Getting outside and running around, or engaging in other vigorous exercise, should be encouraged for any child with allergies. Obviously, you should balance this against the

need to protect the child from pollution peaks and (if your child has hayfever) pollen peaks. Children with exercise-induced asthma should use their reliever inhalers to allow

them to take exercise (see p. 41).
Keep the air at home free from irritants such as nitrogen dioxide (see p. 128), formaldehyde, air fresheners, paint, polish and strong-smelling cleaning fluids. These may

encourage new allergies to develop, and can make existing asthma worse.
Medical treatments
Antihistamines may have a preventive role in very young children with allergies. A study of one- to two-year-olds with atopic eczema found that the antihistamine cetirizine,

taken daily for 18 months, halved the chances of the children developing asthma later.
The children who benefited in this study were those with several risk factors for becoming asthmatic. They had moderate to severe atopic eczema, at least one close relative with

allergies, and allergic sensitisation to pollen or house-dust mite, as shown by skin-prick tests (see p. 91).
The cetirizine was taken at fairly low doses and had no bad effects on the children in this study. What is more, it seemed to benefit their skin as well as reducing the risk of

asthma: those taking the drug had less need of high-strength steroid creams. There is some controversy about the validity of these results, so few children with atopic eczema

are receiving antihistamines at present.
No one yet knows if other antihistamines might have the same effect as claimed for cetirizine. Ketotifen, which is an atypical antihistamine (see p. 159), may do so.
Immunotherapy may also have a protective effect. One study, involving children suffering from nasal allergies, found that those given immunotherapy were less likely to develop

asthma (see p. 165). Another study shows that immunotherapy for children with mite allergy halves the risk of their developing new allergic reactions to other allergens.

Skin-prick tests
This is an indirect method of detecting true allergic reactions. It is one of a family of skin tests that use a similar approach. The three different tests in this family are known as: skin-prick tests or prick tests, puncture tests, and scratch tests.
For the skin-prick test - the technique used in Britain - a small drop of liquid containing an allergen, such as grass pollen, is placed on the arm. The doctor makes a small prick in the skin, under the drop of liquid, allowing a minuscule amount of the allergen to get into the skin. A positive reaction is recorded if a red bump develops soon afterwards. For accuracy, the bump must be compared to positive and negative controls (see below).
The puncture method is very similar to the skin-prick test but uses a slightly different technique for breaking the skin. The term prick-puncture test covers both techniques.
With the scratch method, the skin is scratched lightly, and the allergen solution is then applied over the scratch. This method gives less consistent results than prick-puncture testing.
It is important to include a negative control in the test - a skin-prick test with plain salt water (saline). This should not produce much of a bump - if it does, the skin is clearly over-reactive and the tests more difficult to assess. The doctor should also include a positive control - a skin-prick test with histamine, the substance that plays a central role in allergic reactions. This should always produce a bump. If it does not, the skin is decidedly under-reactive, and the tests are invalid.
Taking antihistamines will make the skin under-reactive, and you should stop taking them before the testing, for a period ranging from a day to several weeks - it varies depending on the particular antihistamine. Ask your doctor for specific instructions about stopping these and other drugs before testing.
Skin tends to be over-reactive to testing in people with dermatographism (see p. 52). Blood tests for specific IgE,
such as RASTs (see p. 92), are needed for anyone who has this condition. Eczema sufferers with a rash over large areas of the body may also require blood tests, if there is too little clear skin for testing.
Skin-prick tests can produce both false positives and false negatives (see box below). Some allergic diseases will give a lot of false negatives and relatively few false positives, while for others the reverse is true. The allergen itself influences the rates of misleading reactions: for example, tests for soya allergy are notoriously unreliable, whereas those for peanut are far more accurate. The age of the person being tested also makes a difference. With all these influences at work, interpreting the test responses is a real art, and the doctor’s experience counts for a lot.
All sorts of people offer skin-prick tests, including alternative practitioners. Get them done by a qualified doctor, preferably by an allergist, who will know how to make sense of the reactions.
Note that the purpose of these tests, and of blood tests for specific IgE, is to identify the allergens that are bringing on your symptoms, not to predict how strongly you will react to those allergens. The tests may give some indication of the intensity of your reaction, but they cannot be regarded as a good guide to how you will respond to the allergen in the future.
The safety record of skin-prick tests is very good. Occasionally a systemic reaction (anaphylaxis) occurs with these tests, but there are no records of any deaths. Nevertheless, if you suffer from severe asthma or have experienced anaphylactic shock in the past, it is advisable for the doctor to have adrenaline and resuscitation equipment available. Those with strong allergic reactions to latex may also react badly if they are tested with an allergen that cross-reacts with latex (e.g. cypress pollen), not just when tested with latex itself. Taking beta-Mockers (see box on p. 150) increases the risk of a life-threatening reaction for anyone in these higher-risk categories.
False positives and false negatives
Apart from challenge tests, none of the tests used for allergy works with 100% accuracy. Most give both false positives and false negatives.
A false positive means that there is a positive test but no actual reaction when the allergen is encountered (e.g. eaten or inhaled). A false negative means that there is a negative test result despite a genuine reaction (as shown by a challenge test, for example).
A test that gives relatively few false positives has good positive predictive value - in other words, if it suggests you are allergic to something, you probably are.
A test that gives relatively few false negatives has good negative predictive value. If it comes up negative, you are probably not allergic to that allergen.
Some tests for allergic reactions show good positive predictive value but poor negative predictive value, while for other tests the reverse is true.
Fresh is best
The fruit and vegetable allergens that provoke Oral Allergy Syndrome (see p. 63) are chemically unstable, so commercially produced extracts for skin-prick testing quickly lose their potency and give false-negative results. Most allergists now favour using a drop of fresh juice from the fruit or vegetable concerned.
Intradermal tests
These tests (also called ‘intracutaneous tests’) put allergen more deeply into the skin than prick-puncture tests. The skin tends to react more when penetrated to this depth, so there are more false positives. There is also a greater risk of a serious reaction which may require emergency resuscitation. Don’t undergo these tests if you are taking beta-Mockers (see box on p. 150).
Blood tests for IgE
There are blood tests that look at the total amount of IgE (the allergy antibody), which is sometimes useful in diagnosis. But more important are blood tests for specific IgE – against egg or grass pollen or latex, for example. There are different ways of measuring the IgE in the blood, the most commonly used being a radio-allergosorbent test or RAST.
Research shows that RASTs are no more accurate than skin-prick tests in confirming real-life allergic reactions. However, they are useful for patients who can’t discontinue their antihistamines without developing severe symptoms, and for those with dermatographism or very severe eczema (see p. 91).
Patch tests
These tests, used primarily for contact dermatitis, are similar to straightforward challenge tests, because the suspect substances are applied directly to the skin.
The test substances are placed on the skin – usually on your back – in small chambers. They are held in place with sticky tape, and left there for several days. Ideally, the reaction of the skin should be checked three times: after two days, again the next day, and again the day after that. It really is worth going back for all these separate visits, because the accuracy of the test increases greatly with repeated checking.
The substances chosen for testing are a standard set of antigens that most commonly cause contact dermatitis. This standard set will pick up 60-80% of all sensitivity reactions in contact dermatitis. If you have substances that you suspect may be causing symptoms, such as cosmetics, the doctor can usually test for these too.
You should not be tested while you still have a rash, as the testing will probably make the existing rash flare up, even though the test patches are applied well away from the rash.
Use of steroid creams and any light treatments (including exposure of the test area to ordinary sunlight) must stop at least a week before testing starts, or the results will not be accurate.
Interpreting patch tests requires a huge amount of skill, plus extensive knowledge of the finicky details of the different test substances. You need a dermatologist with considerable experience in this area.
False positives (see box on p. 91) can occur, especially if you react very strongly to one of the substances tested – some people develop what dermatologists call an ‘angry back’, and this generates false positives to various other substances being tested at the same time. Should you be told that you are sensitive to a great many different things, you may want to query this reading of the test. Ernest N. Charlesworth, an allergist and dermatologist at the University of Texas, describes patients who ‘develop into environmental cripples’ after being told that they are definitely sensitive to multiple antigens, on the basis of misinterpreted false-positive patch tests.
False negatives (see box on p. 91) are also possible, even with very careful testing. Should this occur, a type of challenge test known as a ROAT (Repeat Open Application Test) is possible. The suspect substance is applied to the inner fold of the elbow twice a day for a week. Get your doctor’s agreement before trying this test.
Endoscopy and biopsy
Miniaturised cameras and sophisticated fibre-optics have allowed modern doctors to do something that their predecessors could never have imagined possible – look right inside the human body. This procedure is called endoscopy, and it has a useful role in a few sensitivity reactions.
Looking inside the sinus cavities can assist in understanding exactly what is going wrong in chronic sinusitis. Inspecting the digestive tract can be valuable in several of the non-IgE immune reactions to food, such as coeliac disease (see p. 70) and eosinophilic gastroenteritis (see p. 72).
A biopsy is often carried out at the same time as endoscopy.
s involves taking a small sample from the affected area, such as
I ning of the gut, and studying it in detail under a microscope.
One purpose of a gut biopsy is to look for characteristic :goes of damage to the lining of the gut – such as the distinctive charges produced by untreated coeliac disease. A biopsy can also reveal what kind of immune cells are present. Abnormal numbers of certain immune cells, for example, eosinophils (see p 19), may suggest a particular diagnosis.
Another way of looking at what kind of immune reactions are going on, used for lung diseases, is a bronchoalveolar lavage – iterally a ‘washing out’ of the airways and lungs, allowing immune cells to be collected and studied. This diagnostic technique is lased for Heiner’s Syndrome (see p. 72).
Tests for food intolerance
The only really effective way of testing for food intolerance is an el ruination diet (see pp. 194-7). This is the gold standard. However, it is neither easy nor quick – which has led to a constant search for alternative tests.
The proposed alternatives are all indirect tests, that is to say, non-dietary. The results of the tests are used as a basis for an avoidance diet. In other words, the foods that give a positive test result are avoided.
Some of these tests use samples of hair or blood, others use pulse testing, pendulums, or muscle strength tests (’applied kinesiology’). A few of these tests do show some promise. Pulse tests, and a blood test called the ‘lymphocyte transformation test’. for example, can give a general indication of sensitivity reactions – sometimes. However, even in the most expert hands, these do not give a result that is accurate enough to be useful.
Of the other tests that are available, most have not been evaluated at all objectively.
Many of them are advertised directly to the public, and one of the problems with this approach is that the testing company starts by assuming that food is the problem. The same is usually true of ‘dietary therapists’ and others in the alternative health field offering tests of this kind.
Almost everyone who undertakes such tests is given a fairly long list of foods which have come up positive in the tests. This does not fit with the evidence from medical trials in which a group of people with irritable bowel or migraine (typical food intolerance symptoms) undertake an elimination diet. A significant proportion of them always find that they do not have food intolerance. Of the rest. many find that they react to one or two foods only. The long lists of foods produced by the commercial tests are, to put it mildly, implausible.
With tests that require a sample of blood, sending off two blood samples from the same person, under different names, is a simple way of assessing the tests’ validity. This exercise has been tried several times with different testing companies, and every time two completely different lists of foods have been sent back.
Covert studies of this kind have also shown that the tests overlook genuine reactions. In one alarming case, a woman with a true allergy to peanuts was assured by a ‘dietary therapist’ that she really could eat peanuts safely.
Many people with food intolerance will tell you that they did well after following a diet based on such tests – and they may well have done. Given that common foods such as wheat and milk are regular offenders in food intolerance, and that these foods very frequently feature on the lists of positive test results generated by commercial testing companies, quite a few people should do well. The problem is that these people may also be avoiding many other foods quite unnecessarily.
Furthermore, if people have sensitivities to some other foods that are not on the list, they will be missing out. They could enjoy a far better level of health if all the foods causing symptoms were Identified and removed from their diet.
In the end, an elimination diet is both cheaper and far more likely to give the right answers.
Testing for IgG antibodies
In diagnosing food intolerance, a few doctors offer tests for a type of antibody called IgG. This antibody is formed to any food molecules that get Into the bloodstream after a meal – and some do, even in entirely healthy people. So finding IgG antibodies to food molecules is not indicative of any disease at all. It occurs in everyone and is perfectly normal.
Nevertheless, some doctors feel that by measuring the level of IgG antibodies to foods, they can get a general idea of the permeability of the gut wall (which might possibly be true) and of particular foods that could be causing intolerance reactions (very doubtful – the tests just tell you what you eat most, and you know that already).
This test does measure something real, unlike some of the alternative tests for food intolerance. But the relevance of what it measures to the health of the individual concerned is partial and indefinite. A recent study of IgG testing for irritable bowel syndrome has confirmed this view.
In short, blood tests for IgG antibodies to food molecules seem like very poor value for money, and potentially misleading, whereas an elimination diet is a far more precise way of pinpointing food intolerances.

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

FOOD SENSITIVITY IN ASTHMA, ECZEMA AND OTHER ALLERGIC DISEASES
In 1995, medical researchers in North Carolina, USA, asked over a hundred dermatologists how they treated atopic eczema. All used standard treatments such as moisturisers and steroid creams, but only 14% mentioned the possible role of food to the parents of children with eczema.
Between them, the dermatologists in this study treated about 17,000 children with atopic eczema per year. Using the most widely accepted estimates for food sensitivity in atopic eczema –38% of eczematous children are sensitive to food – one can calculate that there were over 5000 children in this study area who might perhaps have benefited from avoiding a problem food, but whose parents were never told about this treatment option.
North Carolina is by no means unique. The situation is much the same in other parts of the world, which adds up to millions of children and parents not even being told about a treatment that is frequently effective.
Other allergic diseases (see right) can also be triggered by food, although the percentage of patients affected is much lower than for atopic eczema. Here too, many doctors are unaware of (or sceptical about) the possible role of food.
These reactions are best described as ‘food sensitivity’. They cannot be called food allergy (see p. 62) if there are no symptoms in the mouth or gut and if skin-prick tests are negative – as is often the case. Negative skin tests suggest that the reaction is not IgEmediated (see box on p. 12).
However, in some children with atopic eczema. the skin-prick tests to culprit foods are positive. When these foods are eaten after a period of avoidance, such children sometimes suffer an
immediate reaction, with symptoms typical of true food allergy. For these individuals, their atopic eczema seems to be a symptom of IgE-mediated food allergy.
How can an atopic eczema reaction in response to food be IgE-mediated in one individual and not in another? Research is finally beginning to answer this question (see pp. 18-19).
The allergic conditions that may sometimes be induced, or simply aggravated, by a non-immediate reaction to food are:
• atopic eczema (atopic dermatitis)
• asthma
• perennial allergic rhinitis (constantly blocked or runny nose)
• chronic sinusitis
• secretory otitis media (’glue ear’).
In all of these conditions, many other causes exist. Except in the case of eczema, the other causes are far more likely than sensitivity to food. This fact will weigh heavily with your doctor, whose instinct, quite sensibly, is to look for likely causes first.
Taking asthma as an example, food sensitivity is relatively unusual as a primary cause, whereas allergy to airborne items. such as pollen or house-dust mite, is very common. Food probably affects only 8-10% of asthmatics overall, but is much more important for those with brittle asthma (the most severe and unstable form), affecting as many as 60% in a recent study.
The pollen connection
People who suffer from both birch-pollen allergy and atopic eczema may have worsening eczema when they eat certain fruits and vegetables, e.g. apples and carrots. These same foods cause Oral Allergy Syndrome (see box on p. 63) in some with birch-pollen hayfever, but they can aggravate eczema without causing Oral Allergy Syndrome.
Diagnosis
Consider other likely allergens first. Look at p. 28 for the airborne allergens that could play a part in perennial allergic rhinitis, chronic sinusitis, secretory otitis media (’glue ear’), and asthma. Only in the case of children with atopic eczema is food a prime suspect (between 38% and 69% of children with atopic eczema are affected by food), but even here there are a lot of other factors to consider (see pp. 43-4).
If you do decide to investigate the role of food, don’t abandon basic treatments in the meantime. By neglecting these. you could make the whole problem a great deal worse.
There are various clues that food is at fault:
• If you have other symptoms that suggest food intolerance (see p. 76). These problems often seem to go together with food-induced asthma or rhinitis.
• If you have noticed that a particular food makes your symptoms worse. Where there is intolerance to one food, there could well be intolerance to another, which you have not noticed.
• If you have exercise-induced asthma (see p. 41) and sometimes respond severely to exercise but sometimes have little or no reaction. Sensitivity to a food or foods may be instrumental in changing the response to exercise.
• If you have brittle asthma – but you must get your doctor’s consent for an elimination diet. Foods must be tested under medical supervision as severe life- threatening asthmatic reactions can occur on testing.
• If there are also digestive problems such as diarrhoea, vomiting or belching. This is a strong clue in the case of children with atopic eczema. Symptoms such as diarrhoea frequently precede atopic eczema, and it seems likely that a reaction to food in the gut increases the leakiness of the gut wall, allowing more food molecules through to the blood.
• If there is pronounced eczema around the mouth in children (but this can also be due to constant licking),
• For adults with atopic eczema, if there is a persistent rash on the hands, or the lips. Where there is a blistering rash on the hands that erupts at regular intervals, food is often the problem – or it may be metal contaminants of food such as nickel (see pp. 55-6). In general, food sensitivity is rarer among adults with atopic eczema than it is among children.
Skin-prick tests (see p. 91) for commonly eaten foods are worth
trying in all the diseases – if they give a positive result, they should
be noted, but if they give a negative one, they should be disre-
garded. The many alternative tests being marketed (see p. 93) are
highly inaccurate and unlikely to help.
Research from Tampere University Hospital in Finland suggests that babies are much more likely to give false-negative skin-prick tests for food than older children and adults with atopic eczema. The Finnish researchers found that 52% of babies with atopic eczema give a negative skin-prick test despite having a genuine reaction when tested by food challenge. In an attempt to tackle this problem, they have devised a patch test, similar to those used for contact dermatitis. The patch test, in which food is applied to intact skin and left there for two days, gives false negatives in only 39% of babies.
The best way to detect food-sensitive eczema, according to Dr Erika Isolauri. who heads the Finnish research team, is to use both tests, and take note of a positive reaction to either. This detects 80-90% of eczema-causing food reactions in infants.
Few other doctors are currently using patch tests for atopic eczema; because so much controversy surrounds this topic, and no standardised method has yet been devised. You may be lucky and find a specialist who does these tests.
To confirm the role of particular foods in atopic eczema, a food challenge test is essential, having first avoided the food carefully for two weeks. Great care is needed in testing (see p. 198).
If you cannot get suitable tests done. a simple elimination diet will be needed (see p. 198).
Treatment
There is a choice here, between avoiding the offending food, or eating normally and controlling the symptoms with drugs.
The difficulty comes when parents have to make this decision on behalf of their children. Unfortunately, there is insufficient evidence as regards the consequences of this decision. Treating food sensitivity can reduce the eczema symptoms substantially in the short term, but it does not necessarily improve the long-term prospects for the child. Orthodox doctors tend to think that eating a normal diet is much better for a child nutritionally and socially, and they have a point.
Doctors with a special interest in food sensitivity generally believe that treating the problem at source, rather than just suppressing the symptoms with drugs, must take the pressure off the child’s immune system, and give the child a better chance of growing out of sensitivity reactions in the long run.
The decision is yours – but it is vital that the diet is not more of an encumbrance than the disease itself, and that the child’s interests come first (see pp. 170-71). Whatever you do, don’t allow a child to become malnourished (see p. 198).