Written on September 16, 2016 at 9:34 am, by Neil Gershman, MD
Summer means fun – school vacation and long lazy days filled with outdoor family outings, cookouts and adventure. Here in South Florida it likely includes days of sunny sandy beaches, sunscreens, pollens and insects. If you have allergies, take these simple precautions and make them part of your summer routine. Remember, an ounce of prevention is worth a pound of cure.
Flying and Crawling Critters: For most people insect stings are just a nuisance as most people are not allergic. Red and black Imported Fire Ants are common in Florida particularly during the summer months and are members of the same family as bees and wasps. Allergic reactions to these insects can be severe with immediate onset of dizziness, weakness, unconsciousness, throat tightness, difficulty breathing, wheezing or hives. People with severe allergy should carry an epinephrine auto injector (EpiPen) to be used immediately, also, the emergency medical team should be called to the scene to continue medical surveillance as soon as possible because a severe reaction may be fatal.
Insect stings can also cause local reactions that may involve a large, painful, swollen area around the sting site. Local reactions are not a major concern as they do not pose a significant risk of life-threatening reactions. Also, remember that a normal or non-allergic reaction to Fire Ants includes redness and a postule at the sting site. Fire Ants build mounds in the fields and insect repellent does not work against them, therefore, be vigilant, avoid mounds, do not wear sandals or walk barefoot in the grass.
If you have experienced a severe reaction to an insect sting, talk to your doctor for a consultation with an allergist. Your allergist will likely perform skin tests or blood tests to confirm the allergy to the specific insect and recommend a preventative program of desensitization using venom immunotherapy or allergy injection which is close to 100% effective in preventing a subsequent reaction to stings of that insect. Your allergist will prescribe an EpiPen and advise you to carry it with you at all times.
Itchy Skin Rash: Sunscreens are a common cause of both contact dermatitis and photo contact dermatitis. Sunscreens are products applied to the skin that absorb or reflect ultraviolet (UV) radiation. One can develop an allergic reaction to the active ingredient or to the fragrances and preservatives present in the sunscreen. If you experience an allergic reaction to a sunscreen, remove the sunscreen, wash the skin with soap and water and apply a cortisone cream. Follow up with your doctor for possible referral to an allergist or dermatologist to determine a safe UV protection alternative sunscreen. It is important to identify the chemical responsible for the allergic reaction so you can avoid using a skin product containing such a chemical in the future. Contact allergy tends to persist indefinitely and avoidance is the only preventive treatment available at this time.
Achoo: Large amounts of pollen are released into the air by some plants for the purpose of fertilization. These pollen when inhaled by an allergic person trigger an inflammatory reaction in the mucosa of their nose, bronchial tree and conjunctiva which in turn causes sneezing, runny nose, itchy eyes, cough, wheezing and even asthma.
People with seasonal allergies experience symptoms during a specific season. Here in Florida people allergic to grass pollen experience more severe symptoms during the summer months when our grasses are pollinating. Those allergic to tree pollen are affected during the spring and those allergic to weed pollen are affected during the fall.
Most pollens are released into the air during early morning hours, so avoid being outdoors during the early mornings. Wear sunglasses to protect your eyes, avoid gardening and yard work specially during the morning hours, and change clothing, wash your hands and hair when you come home. Monitor the daily pollen and mold counts at allergyweb.com
Immunotherapy or allergy injection is a safe and effective preventive treatment that can significantly reduce allergy symptoms. Your allergist will perform skin or blood testing to accurately identify your specific sensitivities to aero-allergens such as pollen, house dust mites and mold spores. Once your specific allergies are identified, your allergist may recommend immunotherapy or allergy shot which is a treatment program to desensitize you to your specific allergies. Immunotherapy should enable you to inhale the allergens in their natural environment with greatly reduced inflammation of the respiratory tract and therefore significant reduction of symptoms.
One man’s food is another man’s poison: Food Allergy is relatively rare, it affects approximately 1% of the adult population and up to 6 to 8 % of children under 3 years. For reasons not well understood, the incidence of food allergy is increasing and peanut allergy is particularly increasing in some countries such as the United States. Any food can cause an allergic reaction but the foods implicated in the great majority of reactions are cow’s milk, egg peanut, tree nuts, wheat, fish and shellfish.
The allergic reaction is an immunologic reaction to a protein in the food. The reaction occurs shortly, usually within 4 hours but sometimes immediately after the ingestion of the food and can cause itchy hives in skin, swelling, lump in the throat, difficulty breathing , wheezing, tight chest, dizziness, loss of consciousness and even death. People with food allergy, like people with insect allergies, should always carry an epinephrine auto injector or EpiPen to be used immediately after a reaction to an accidental food ingestion. Also, Fire Rescue should be called to the scene to continue medical management as the duration of effects of EpiPen is only about 15 min.
If you have a food allergy ask your doctor to refer you to an allergist. Your allergist will confirm the allergy to the suspected food by performing skin test or blood tests. You should strictly avoid the culprit food, read all food labels and be vigilant of hidden sources of the food in restaurants and friend’s homes. Always carry the EpiPen and familiarize yourself with its proper use. Tell your friends that you are allergic and to which specific food. Make sure to inform teachers, camp supervisors, babysitters and anyone responsible for the care of your child that your child is allergic to a specific food or family of foods. Some people are allergic to peanut and all tree nuts or to all fish or all shellfish. Also, teachers and caregivers should have an EpiPen and be taught when and how to use it.
Prepare and make a check list to not forget necessary medications, sprays and inhalers. If allergic to insects or foods, be vigilant of flying insects, Fire Ant mounds and inform everyone that you have a food allergy. And always, always bring your EpiPen. Have a wonderful and safe summer!
by Dr. Ubals
Written on September 16, 2016 at 9:28 am, by Neil Gershman, MD
An allergy is a peculiar reaction to a substance than is not harmful to normal, non-allergic people. “Allergy,” however, is an often misunderstood term. Most people believe that an allergy refers to any uncomfortable reaction to a substance that is inhaled, eaten, or that touches the skin. Symptoms that are attributed to allergy include sneezing, wheezing, nasal irritation, cough, runny and/or stuffy nose, heartburn, bloating, diarrhea, and a variety of skin rashes.
The main confusion is that some substances can cause these symptoms in a non-allergic way. Examples of non-allergic reactions would be inhaling perfume (causing sneezing because of simple irritation) and ingesting milk (causing bloating because of a deficiency of an enzyme that helps digest sugars in the milk). Further complicating the issue is that a substance like milk can also cause true allergic reactions including hives and wheezing.
In fact, “allergy” implies that the body’s immune system is responding to a substance, or allergen, in such a way that it leads to some of the symptoms mentioned above. This occurs when the immune system sends white blood cells (as well as other cells and chemical mediators) to the site of the body where it encounters an allergen. These cells and chemicals cause the changes in the tissues that lead to allergic-type symptoms. Examples of allergens include tree pollen, cat dander, dust mites, and several foods.
A requirement of such an allergic immune response is that the immune system be able to recognize a substance as being foreign – not normally present in the body. Put simply, the substance must contain molecules with certain characteristics (having a protein or large carbohydrate structure, for example) to enable it to be recognized by the immune system and give rise to an allergic response. This explains why the runny nose caused by cold air in some is not a true allergic phenomenon. People with allergic inflammation in their noses, however, are often more troubled by irritants such as smoke. A useful analogy is the following: Salt poured on intact, healthy skin causes no discomfort, but if you pour salt on an open wound it is quite painful.
Why allergy occurs in the first place is still a mystery. Some believe that allergy is simply a mistake of the immune system. That is, the immune system may “believe” that an allergen is an infectious organism such as a bacteria or virus. Consequently, the immune system sends those white blood cells (such as lymphocytes) and chemicals to the tissues to ward off this false infection. Nasal congestion, for instance, might represent the immune system’s attempt to restrict the allergen (thinking it’s a virus or bacteria) from gaining deeper entry into the body.
Researchers have noted that there is an increase in the proportion of people suffering from allergies. Some believe that air pollution and heavier exposure to indoor allergens (spending more time inside tightly insulated homes) is to blame. Another interesting theory is that allergies are our society’s trade off for being so sanitary. That is, our immune system is not as busy fighting off genuine infections as much as before, with the consequence being more frequent mistaken allergic immune responses. This theory is interesting in light of the lower incidence of allergy seen in poorer parts of the world with more exposure to parasitic infections.
Another very interesting development of the past few years has been the rise in food allergy. It turns out that the medical establishment apparently got this one wrong. They figured that by having infants avoid allergy causing foods until they were older would lead to a decrease in food allergy. So, several years ago, there were recommendations that suggested that children avoid peanuts, for instance, until they were one or two years of age. The result of these recommendations likely lead to the increase in peanut allergy. Recent studies from Israel and England have shown that exposing children to peanuts very early in life led to a decrease in the incidence of peanut allergy.
Finally, the question is what to do about treating allergic symptoms? First, it is important to determine what a person may be allergic to. The diagnosis can sometimes be made by the patient’s history alone, but allergy skin tests are needed to confirm the diagnosis. The next step is to avoid exposure to the allergens. For food allergies this is the only scientifically proven treatment. But for airborne allergens, medications can be very helpful since it may be impossible to totally avoid exposure. In addition to medications, immunotherapy (allergen injections) can be an effective remedy.
Written on July 6, 2015 at 11:52 pm, by Neil Gershman, MD
I was going to write a blog entry about this exciting new asthma drug that should be available for use very soon. But then, Dr. Alan Khadavi, an Allergy/Immunology Specialist from Los Angeles beat me to it. So, as I always say, “Don’t reinvent the wheel.” The drug appears to be very safe and effective, and will be in the form of an injection and probably given in a doctor’s office once a month. It will be for adults with asthma who are still having troublesome symptoms despite the proper use of daily maintenance inhalers such as Advair, Symbicort, Dulera, Flovent, and Qvar.
I read several of the articles on Dr. Khadavi’s blog, and they are all excellent – so check them out at:
Neil Gershman, MD
The US FDA has recently unanimously recommended Nucala (Mepolizumab) for add on maintenance treatment in patients 18 years older with severe eosinophilic asthma. The panel recommended against Nucala (mepolizumab) for children aged 12 to 17 years old. Severe eosinophilic asthma is defined as a blood eosinophil count greater than 150 cells/microliters at the start of treatment or greater than 300 anytime the past 12 months.
There are currently no approved treatments for patients with severe asthma with predefined eosinophil levels.
Nucala or Mepolizumab is a humanized monoclonal antibody to human interleukin 5 (IL-5). IL-5 is primarily involved in the regulation of blood and tissue eosinophils. Eosinophils are responsible for airway inflammation in asthma. Thereby by using Nucala (Mepolizumab) which blocks IL-5, this would reduce expression of eosinophils in the blood and tissue.
Nucala (Mepolizumab) is proposed to be administered subcutaneously every 4 weeks. Clinical studies showed a significant reduction in asthma exacerbations in treatment groups receiving Nucala (mepolizumab). The rate of hospitalizations or ER visits was lower in the treatment groups of Nucala (mepolizumab) than the placebo groups.
Side effects seen were local injection site reactions and possibly hypersensitivity reactions with Nucala (mepolizumab). Long term side effects remain to be seen as this drug still hasn’t come out on the market yet.
This would be the second monoclonal antibody drug to come out in the market for severe asthma. Xolair (omalizumab) has been on the market for years and it is used to treat severe persistent asthma. It blocks IgE receptors in the blood and it also has an indication for chronic idiopathic urticaria. It works well in patients who have allergic asthma, but it is very cost prohibitive, in some cases it can be thousands of dollars a month. There is currently no price yet on Nucala (mepolizumab), but most likely it won’t be inexpensive.
But for the patients who have severe persistent eosionophilic asthma, who do not respond to conventional asthma medications, Nucala (mepolizumab) may be a good treatment option in the future. You should speak with your allergist or allergy doctor to see if Nucala (mepolizumab) is right for you.
Extreme Reversal – Research Now Suggests Early introduction of Peanuts to Infants May Prevent Food Allergy
Written on February 24, 2015 at 11:52 pm, by Neil Gershman, MD
This story reminds me of the movie, “Sleeper.” The Woody Allen movie from the 70s focuses on a man who was put into a cryogenic freeze when he died after a simple operation in a New York hospital. He woke up 200 years later and found that the world was very different. He was surprised that everyone was smoking cigarettes. This future scientists told him that research had determined that tobacco was extremely healthy for the lungs.
Of course this is silly, but one thing rings true. As science moves forward, some old dogma turns out to be very wrong. This is the case with the thought of restricting allergenic foods until later in life. Pediatricians have been taught to tell parents that they shouldn’t give their children such foods as milk, egg, peanuts, and shellfish until the child is much older. That advice is likely the opposite of good advice.
The idea about peanut introduction early in life came from an observation that children in Israel were less likely to develop peanut allergy than children in other parts of the world. Israeli children are fed, at a very early age, treats that contain fairly large amounts of peanuts, whereas children in England, for instance, aren’t supposed to eat peanuts until much later.
So British researchers started a study looking at the very early introduction of peanuts into the diet of infants. They found that there was a dramatic decrease (80% less peanut allergy) in the incidence of peanut allergy as a children grew up. I imagine that, in the very near future, the recommendations for when to introduce allergenic foods will be drastically different than in the past.
Written on January 22, 2014 at 10:23 am, by Neil Gershman, MD
Subcutaneous allergen immunotherapy (SCIT), or “allergy shot therapy,” has been around since the early 1900s. It is considered a well-accepted therapy for allergic rhinitis and asthma. Sublingual immunotherapy (SLIT) has garnered a great deal of attention lately since two sublingual tablet formulations to treat grass allergy were reviewed by an FDA advisory committee. The advisory committee recommended approval of Oralair™ and Grastek™ tablets, which are meant to treat grass pollen allergy symptoms. Although the FDA is not bound by the committee’s guidance, typically approval of the products follows soon afterwards.
While we at the Asthma & Allergy Associates of Florida are always excited about new therapies for allergic disease, we are concerned about what is starting to unfold in the medical community. It is clear that these pharmaceutical company manufactured sublingual tablets are effective, but it is not at all certain that compounded sublingual or under-the-tongue “allergy drops” (liquid treatments made up from allergen extracts that are only approved for injection therapy) will benefit patients. We fear that these drops will gain popularity in that they will be offered as treatment for a larger variety of allergens versus conventional injection therapy. Patients may ask, “Why should I only get treated for grass allergy, when I am allergic to so many things such as dust mite, animal dander, and mold?” There are two main issues regarding sublingual therapy. First, the “devil is in the dosing.” Secondly, there is no good data supporting sublingual therapy for more than one allergen at a time. Thirdly, the delivery system, a tablet versus a liquid, can make a big difference in effectiveness.
Subcutaneous immunotherapy (SCIT), or injection therapy, has been shown in several studies to be a very cost-effective option for treating allergic rhinitis and asthma. It may be a different story for sublingual therapy(SLIT).
As far as the dosing, the most conservative estimates are that the dose needed for effective SLIT is 30 times more than that needed for injection therapy. This can lead to a very high cost to treat a patient effectively. While the raw extract cost for injection therapy may only be a few dollars a month (the majority of the cost being due to the need for administrative staff, nurses, and supervision by the physician), the extract costs for sublingual therapy will end up being extremely high when more one or two allergens is being treated. A ballpark estimate, based on controlled studies of sublingual therapy, would be that the cost of extract alone in treating year-round allergens such as dust mite, cat and dog allergy would be $50-$100 for each allergen. Treating pollens would be slightly less per allergen. The consequence is that the extract costs would be prohibitive for most American patients who are usually allergic to multiple allergens. To this point, in Europe, where sublingual therapy is most popular, patients are typically treated for one allergen. Another hint as to the potential the high cost of this therapy is that the estimate for the cost upcoming grass tablets will be approximately $150 per month, and this is only to treat one allergen.
As far as the second point, there is really no good data to support treating more than one allergen at a time with sublingual therapy, as very few studies have been done. Lastly, as was mentioned above, there may be differences in effectiveness when the allergen is given in different formats (tablet vs liquid). The products on the horizon to be approved in the United States are mostly tablets.
Also concerning to us are claims that sublingual therapy is more effective than injection therapy for allergies. There is absolutely no basis in fact for this. There are some studies showing similar benefit, but the majority of the evidence suggests a greater benefit with injection therapy.
There is no question that the idea of sublingual therapy allergy is an attractive one. Because of the lower incidence of allergic reactions with sublingual therapy, patients would be able to treat themselves at home as opposed to getting therapy in a doctor’s office. Also, because of the lower chance of reactions, very young children can be treated. Plus, no needles are involved.
In summary, the question is not whether sublingual allergen immunotherapy works (it apparently does), it is whether physicians are going to use adequate doses in the proper format. For unclear reasons, allergic individuals in the US tend to be allergic to multiple allergens. This results in sublingual therapy being an expensive proposition.
We foresee that SLIT will have a place in certain situations (small children, patients allergic to one or two allergens, moderate to severe asthmatics). Asthma and Allergy Associates of Florida is in the process of deciding the best situations in which to use this type of therapy. We strongly suggest to the public that the be very aware of the limitations of sublingual therapy. For example, we would advise any patient being offered this therapy to specifically ask their physician whether they will be receiving an adequate dose of each allergen.
There is an detailed and referenced review of this topic at the following address:http://www.asthmacenter.com/index.php/News/details/sublingual_immunotherapy/
Written on December 10, 2013 at 5:48 pm, by Neil Gershman, MD
Here’s an article about food allergies from the Palm Beach Post – with a couple of quotes from me.
New laws aim to save schoolchildren from deadly allergic reactions
By Stacey Singer – Palm Beach Post Staff Writer
Waffles. That’s what sent 8-year-old Emma Serle to the emergency room.
Allergic to five different foods, Emma eats only wheat-free, egg-free waffles.
On a busy weekday morning, her dad, David Serle, accidentally mixed up her waffle with her sisters’ regular ones, and soon, Emma’s stomach hurt. Her throat swelled. Hives appeared. Her mother whisked her to Boca Raton Regional Hospital where she was treated with steroids.
“I was scared,” the little girl acknowledged.
Luckily, she responded quickly to the drugs and was sent home. But food allergies in children can have serious, life-threatening consequences, leading to 90,000 emergency room visits and an estimated 1,500 deaths nationwide each year. Every time there’s news of a child’s death from allergic exposure, David Serle’s mind races.
This fall, 14-year-old Giovanni Cipriano of New York’s Long Island died after eating trail mix he didn’t realize contained peanuts. His parents had given him Benadryl rather than injecting him with his EpiPen, a device that injects epinephrine. He had a heart attack on the way to the hospital.
Katelyn Carlson, 13, of Carmichael, Calif., died after eating a Rice Krispies summer camp treat that she didn’t know contained peanuts. She was administered epinephrine, but too late.
Before them, Ammaria Johnson, 7, had a heart attack in the school nurse’s office in Chesterfield County, Va., while awaiting an ambulance. The school had no epinephrine.
In response to these incidents, new federal and state laws are in place to try to coax school districts to keep lifesaving emergency epinephrine on hand, and ensure that school staff are trained and allowed to use it on children without a doctor’s prescription and without fear of a lawsuit.
That’s because studies show one in four life-threatening allergic reactions happens to a child who had no previous food allergies. Plus, allergic reactions are so unpredictable, and sometimes so sudden and severe, that calling 911 isn’t fast enough.
In Florida, a new state law protects both public and private schools from liability and gives them permission to keep epinephrine pens on hand without a specific student’s name on the drug, said Boca Raton allergist Dr. Neil Gershman, who heads the Florida chapter of the American Academy of Allergy, Asthma & Immunology.
It’s an important step forward, he said, but too few schools are aware of the law.
Palm Beach County School District’s policy hasn’t been updated since 2010.
“In another state, a kid died because an EpiPen didn’t have a name on it, and the nurse was afraid to give it,” Gershman said. “This kind of covers the backside of the nurses and school people to give epinephrine that doesn’t have a name on it to somebody.”
The Palm Beach County Health Department issued a standing order in 2008 giving school nurses the right to administer epinephrine in case of emergency, department spokesman Tim O’Connor said. The agency gives school nurses a vial of epinephrine, syringes and a full protocol for what to do and what dose to give when the tell-tale signs appear: skin warmth, itching, tingling and hives; abdominal pain, vomiting and diarrhea; sneezing; swelling of the face, mouth and tongue; a lump or tightness in the throat; hoarseness, difficulty inhaling, shortness of breath, wheezing; headache, low blood pressure, light-headedness, loss of consciousness, slow heart rate; and feelings of apprehension, anxiety, or “impending doom.”
But the school district’s policy, and state law, requires the drug to be kept under lock and key. The exception is students who have explicit permission from their parent and doctor to keep their epinephrine with them. Epinephrine, also known as adrenaline, is a hormone that can cause the heart to race.
Both the Centers for Disease Control and Prevention and advocacy groups recommend keeping epinephrine in a secure, but unlocked, location, if state and local laws allow it, said Nancy Gregory, a spokeswoman for Food Allergy Research & Education in Washington.
“As the first-line treatment for anaphylaxis (a serious allergic reaction), which can occur suddenly and progress rapidly, epinephrine should be readily available in schools,” she said.
For private and charter schools that don’t have school nurses and may not be able to afford the $250 to $400 cost for a self-injectable epinephrine device, there’s another option.
Mylan Pharmaceuticals, which makes the EpiPen, offers every school — public and private — four free EpiPens a year. The application form is available at www.EpiPen4Schools.com/. A company spokeswoman said more than 30,000 schools nationwide have taken advantage of the program, including 578 in Florida
The issue is hot now because President Barack Obama signed into law the School Access to Emergency Epinephrine Act in November, noting that his daughter, Malia, is allergic to peanuts.
The law gives preference for federal asthma education grants to states that require schools to stock emergency epinephrine and educate school personnel on their use. Only four states have this requirement, according to FARE. Florida isn’t one of them.
Emma Serle’s parents own two brands of self-injectable epinephrine, the Auvi-Q and the EpiPen. Her schoolteacher has one. Her grandparents have another. They keep one at home and one goes with them when they’re out and about, too.
“Emma has severe food allergies to wheat, eggs, tree nuts, peanuts, sesame and shellfish. It’s a lot,” David Serle said.
After the waffle accident, he decided he needed to better understand what his daughter’s life was like. So he put himself on the Emma diet, and challenged others to do so as well. He created a Facebook website, www.facebook.com/eatlikeemma. It was tough, he said. At restaurants, waiters would roll their eyes when he asked detailed questions about ingredients. Chefs would shrug off his concerns. It was a real education, he said.
“You can’t just grab a snack,” he said. “You literally have to plan your meals, which I never did.”
Two months later, Emma is back to gymnastics, enjoying school and planning a family vacation, eating sweet potatoes and chicken for dinner. Is she still mad at her dad for mixing up the waffles? She shrugs.
“I forgive him,” she said.
Food allergy deaths in the news:
Oct. 1: Giovanni Cipriano, 14, of New York’s Long Island, died after eating trail mix he didn’t realize contained peanuts. He had a heart attack on the way to the hospital.
July 26: Natalie Giorgi, 13, of Carmichal, Calif., died after eating a Rice Krispies summer camp treat that she didn’t know contained peanuts.
Jan. 4, 2012: Ammaria Johnson, 7, died after eating a peanut during recess in Chesterfield County, Va. She had a heart attack in the school nurse’s office.
Dec. 17, 2010: Katelyn Carlson, 13, died in a Chicago school after eating Chinese food apparently prepared with peanut products.
Written on August 21, 2013 at 12:07 am, by Neil Gershman, MD
Here is some unexpected news… fresh fruits and vegetables are good for you. It turns out that babies who ate more fruits and vegetables , and less processed foods, seemed to have less problems with food allergy.
Written on July 25, 2013 at 1:42 am, by Neil Gershman, MD
Dr. Gershman and Dr. Ramirez on the set for the “Ask the Allergist” segments.
Dr. Neil Gershman has been elected to be the President of the Florida Allergy, Asthma & Immunology Society!
Written on July 20, 2013 at 3:54 pm, by Neil Gershman, MD
Dr. Neil Gershman is a graduate of the University of Miami School of Medicine. He did his Internal Medicine training at Montefiore Medical Center of the Albert Einstein College of Medicine and his Allergy/Immunology fellowship at the University of California, San Francisco.
Learn more about Dr. Neil Gershman!
Written on December 14, 2012 at 1:22 am, by Neil Gershman, MD
Even though I am no videographer, I think you will get a lot out of watching this video. Just a couple of disclaimers: 1. Watching this video should not take the place of the care and advice of your physician or pharmacist 2. This is some disagreement on the “proper” use of inhalers. The video does not depict the perfect techniques. It demonstrates what I believe are adequate techniques that the majority of people are able and willing to perform.