- 1 Introduction
- 2 What are the types of allergic illnesses?
- 3 Why treat?
- 4 How to treat?
- 4.1 Natural allergy therapy, Singapore
- 4.2 Medications
- 5 Doctor, is there a PERMANENT cure for my allergies?
- 6 Treating the root cause of allergies
- 7 Step 1: Finding out exactly what is causing your allergies
- 8 Step 2: Make the body stop reacting to the exact cause of your allergy
- 9 Sublingual Immunotherapy
- 10 I’m interested!
- 11 References
There is a worldwide increase in prevalence of allergy . In our practice in Punggol, Singapore, there are a lot of patients who doctor hop with undiagnosed allergies. The prevalence of allergy in Singapore is high compared to our surrounding neighbours due to our “urban environment”.
What is so allergic about our environment?
In the study done by , only about 20% of recent chinese migrants from China are sensitive to house dust mites (compared to 70-80% in Singaporean chinese). After 0–3 years stay in Singapore, this number increases to 30%, then to 50% after 3–8 years and then to 60% in the long-term residents (>8 years). So clearly, something is in our air. Unfortunately, we still don’t know why.
What happens if my/my child’s allergy is not diagnosed?
There are a lot of direct and indirect costs, like doctor hopping, trying alternative medications, spend more time, spend more money going around, get side effects from medications and in the end still suffering with no relief, worse of all, the disease will slowly progress through the “allergic march” (read below). I.e. If your child’s allergy is not diagnosed and treated, there is a chance his allergy will go from skin allergy (eczema) to food allergy (many manifestations) to nasal allergy (sensitive nose) to mild lung allergy (bronchial hyper reactivity) and then to severe lung allergy (asthma).
What’s the big deal about allergy problems?
Even the simple sensitive nose (allergic rhinitis) can cause multiple problems and symptoms, see below.
|Physical||% of patients||Mental||% of patients|
|Stuffed-up nose||78||Feel tired||80|
|Runny nose||62||Feels miserable||65|
|Postnasal drip||61||Feels irritable||64|
|Red itching eyes||53||Depression||36|
*Allergies in America Survey, Florham Park, NJ: Altana Pharma US, Inc., 2006
According to half of adult patients and up to 88% of children with sensitive nose have sleep problems, leading to daytime fatigue and somnolence, and decreased cognitive functioning (aka stupider). These are accompanied by disorders of learning performance, behavior and attention in children .
Why are family physicians like Zenith Doctors so interested in this?
There are just so many allergic people out there.
In a survey done in France by on patients with sensitive nose, patients waited
suffered two and a half weeks before seeing a doctor. A lot of them suffered enough to take an MC due to it and most of them had issues with the mood, sleep, nose discomfort and many others. In Singapore, a survey done by for school going children reported a 44% had running nose.
What are the types of allergic illnesses?
Allergic Rhinitis (Sensitive Nose)
You have sensitive nose when 2 or more symptoms below persist for ≥1 hour on most days. (based on ARIA guidelines)
- runny nose
- nasal obstruction
- nasal itch
In this situation, disease severity should be classified below and a confirmatory diagnosis should be established by the skin prick test.
The disease can be further classified as intermittent/persistent/mild/moderate as detailed below:
Intermittent: symptoms are present
- <4 days a week
- Or for <4 consecutive weeks.
Persistent: symptoms are present
- >4 days a week
- And for >4 consecutive weeks.
Moderate/severe if one or more of the following items are present and mild if none of the following items are present.
- Sleep disturbance
- Impairment of daily activities, leisure, and/or sport
- Impairment of school or work
- Troublesome symptoms.
Asthma (Sensitive Lungs)
The following diagnostic criteria are taken from the Global Initiative for Asthma .
You have asthma if you have the following 2 features.
- A history of different lung symptoms
- Typical symptoms are wheezing, shortness of breath, chest tightness, cough
- there are generally more than one of these symptoms
- can occur variably over time and vary in intensity
- often occur or are worse at night or on waking
- triggered by exercise, laughter, allergens or cold air
- worsen with viral infections
- Typical symptoms are wheezing, shortness of breath, chest tightness, cough
- Evidence of variable expiratory airflow limitation
- this is detected on spirometry (a.k.a lung function test), which is available at our clinic.
- other tests include bronchial challenge test (give you something to try to trigger your asthma)
There are people with cough as the only symptom, spirometry in this case is even more important for the diagnosis. However, a normal spirometry test does not mean you have no asthma.
Allergic conjunctivitis (Sensitive Eyes)
Diagnosis is purely based on the doctor’s assessment as described by .
It is based on itching, redness, and swelling of the conjunctiva (white part of the eyes).
- compared to other eye diseases:
- Conjunctival redness tends to be milder
- Conjunctival swelling, or chemosis, tends to be somewhat more prominent than one would expect for a mild amount of redness
- Itching is a fairly consistent symptom
- Corneal (black part of the eye) involvement is rare
Atopic dermatitis (Sensitive Skin)
In order to be diagnosed with sensitive skin, according to the UK Working Party diagnostic criteria , you must have a history of itchy skin plus at least 3 of the following:
- History of a flexural involvement (skin folds in front of elbow or back of knees, front of ankles, wrists, or neck) <will make a diagram>
- Visible flexural dermatitis
- Personal history of asthma or allergic rhinitis (or history of allergic disease in parents or siblings if the patient is younger than 4 years of age)
- History of a generally dry skin in the last year
- Onset under the age of 2.
Other types of allergies
Hypersensitivity to Drugs and Biological Agents
Why spend few hundred dollars to treat allergies over a few years?
Early treatment of allergies can potentially prevent the “allergic march”.
<picture of allergic march>
We are suggesting that if we treat allergies early enough, we can save you (or your child) from developing allergic rhinitis, frequent bronchitis and asthma in the future.
And this is worth a lot of $$$ in terms of time and money in the future.
So is the money spent treating allergies well spent?
suggests that for patients with nasal allergies or nasal allergies and asthma it is probably cost effective. How do you quantify your quality of life anyway? Is there a price tag you can place on seeing your doctor less, breathing better, using less medications, getting better sleep or feeling more energetic generally?
How to treat?
Natural allergy therapy, Singapore
Ventilated homes with low humidity improved the lung functions of patients with asthma. So please no humidifier. Perhaps consider a dehumidifying aircon instead.
The study from suggested the following ways to build tolerance to allergies:
- Living on a farm
- Spending time in nature, outdoor physical activities
- Adherence to natural lifestyle
- Use of probiotics
- Use of other bacteria-containing (fermented) products
- Consumption of fresh fruit and vegetables
- Consumption of farm milk
- Consumption of kefir (fermented milk)
- Consumption of healthy diet (Mediterranean, Baltic)
These are oral medications used to provide temporary relief for runny nose, watery eyes, itching and sneezing. It is also the treatment of choice for urticaria (hives).
Currently there are 2 generations of antihistamines. The 2nd generation is less sedating.
Examples: zyrtec, cetirizine, piriton, chlorphenamine, dimenhydrinate, diphenhydramine, fexofenadine, loratidine, hydroxyzine.
The trouble with using these drugs is the “tachyphylaxis” effect: meaning that higher and higher doses of the medication is needed to give the same effect. In fact, after a while, no amount of antihistamines will work for patients with chronic allergies.
These are used in treatment of allergic rhinitis. They are effective in reducing nasal obstruction but does not improve sneezing, itching and runny nose. They come in the form of tablets and topical (“in-the-nose” or intranasal) forms.
We usually recommend nasal decongestants for children due to it being rather safe for children use. Use it right before drinking milk and sleeping. Sometimes, it can be rather challenging to give it to children as they might not like the feeling of the medicine going into the nose. In these cases, the spray is easier to give, and some other brands could be easier to use than others. Intranasal decongestant should not be used for more than 5 days as there can be interesting side effects. Long term causes a sensation of long term nose block, swelling and other side effects. Otherwise, they are very safe and effective medications when used in the short term.
Side effects with oral decongestants can include irritability, dizziness, headache, nightmares, tremor, poor sleep, as well as fast heart rate and high blood pressure.
Example: Iliadin (oxymetazoline) nose drops, fedac, all the antihistamines containing “D” such as zyrtec-D, telfast-D and fenfedrine.
Saline nasal medications
There are a lot of over the counter saline (aka: salt) containing products over the counter. Some patients even make them at home themselves. (I’ve yet to obtain the formula from them).
They come in the follow forms:
They tend to come in big empty bottles and sachets of medications. The patient will put distilled or boiled water into them and then put the sachets inside. Then half a bottle is used on one nose. This is especially effective to clear the sinusitis infections: where the phelgm is thick yellow and green. Children generally will find it hard to use these.
Nasal Saline Sprays
There are a few brands out in the market, most of them will not work for adults with real sinusitis, try the nasal douche (above) instead. For children however, these works pretty well. They are safe for long term use and more tolerable for children. Do take note that some brands are more tolerable than others for children, try to look for those brands which has a less “strong” spray.
I put this one here as I’ve seen it being use on my children patients in Punggol quite frequently. I would say they work pretty well for those really small kids, but will be really hard to use on older kids. I mean which 1 year old would sit still there and let you try to suck their nose?
This is a new drug that is introduced in the last 15 years. It is as effective as antihistamine but less effective than steroids. It is used in both asthma and allergic rhinitis to improve nasal and bronchial symptoms. This drug is safe and well tolerated, especially in children. Some minor side effects are sleep issues, hyperactivity and rarely overdose (it tastes nice!).
Example: Singulair, Montelukast
Intranasal steroids are very effective for allergic rhinitis, sinusitis, allergic conjunctivitis and polyposis. Due to the way steroid works, maximum effect is only achieved after 2 weeks of continuous usage. Intranasal steroids are well tolerated and adverse effects are few in number.
Examples: Nasonex, Avamys, Flixonase, Nasacort
In asthma, inhaled corticosteroids are used for moderate to severe asthma. Inhaled corticosteroids have shown efficacy in reducing symptoms, improving quality of life, improving lung function, decreasing airway hyperresponsiveness, controlling airway inflammation, reducing frequency and severity of exacerbation, and reducing asthma mortality. At the recommended dose of inhaled corticosteroids, they have no long term effect on growth in children.
Examples: Symbicort, Beclo-asma, Relvar Ellipta, Flixotide, Seretide
Short-term oral steroids are use for bad asthma attacks. Long-term oral steroids may be used for severely uncontrolled asthma, particularly so in low income countries. Oral steroid use is limited by its risk of significant side effects.
Examples: Prednisolone, hydrocortisone, betamethasone
For eczema, topical steroids are very effective in the short term but they may reduce repair of the skin and interfere with recovery in the long term.
Examples: Desowen, hydrocortisone, betamethasone, clobetasol
Adrenaline injections are reserved for severe anaphylaxis. They are usually given deep in the muscle or skin by the doctor to allow quick release of the medication as anaphylaxis is life-threatening. If you have repeated episodes of anaphylaxis or if the trigger is difficult to avoid, an auto-injector can be purchased and kept with you all the time to be elf administered.
There are 2 types of bronchodilators, the short-acting and long-acting B2-agonists.
Other medications for asthma
Doctor, is there a PERMANENT cure for my allergies?
Yes, you are quite right there. All the above medications only give temporary response. After stopping all these medications, after a while, the symptoms do come back. Even the longest lasting inhaled or intranasal steroids only gives few months of relief, and the symptoms sometimes come back after a few months. So is there a magic bullet for my allergies? Well, read on…
Treating the root cause of allergies
Well it turns out the technology to treat and make you/your child not allergic anymore to the *whatever-that-is-giving-you-allergies* (technical term: allergen) has been out there for the past 10 years.
Hold on doc? What did you just say?
Yes that’s right, we can treat the root cause of allergy and potentially cure you/your child of allergies in the air. (Sorry, food allergies are not established for treatment yet) We are hoping to stop allergies there and then and stop the progression of the allergies to something worse. (read above on the allergic march)
Step 1: Finding out exactly what is causing your allergies
Performing the skin prick test
Skin prick test is an essential and reliable tool in the field of allergy . We can confirm the exact cause of your allergic symptoms. Only when the exact cause of your allergy is found then the exact treatment can be prescribed.
The process involves putting rows of fine metal needle through drops of common allergen extracts after wiping the skin with alcohol with little pressure. (Don’t worry, you probably can’t feel it, just a little itchy) The skin will produce wheals (aka:bumps) in response to the allergens. After 15 mins, the diameter of the skin wheals is measured. The larger the wheal the stronger is the allergy.
Below is a picture of such a procedure.
OMG, you are going to *prick* my (or my child’s) skin???
The skin prick test is slightly
painful itchy. It is totally harmless and safe with no reported fatalities in a 5-year USA study by .
The test is done on the skin only but I have nose or lung problem???
The test is meant to diagnose especially inhalant allergies such as allergic rhinitis and asthma. The chemicals used in the test are actually found in the air and not on the skin anyway. It has been shown to correlate highly with the things that you are allergic to in the air <quote req>.
Medications to avoid before coming for a skin prick test
(running nose medications)
|Zyrtec, cetirizine, loratidine, xyzal, piriton, chlorpheniramine, promethazine|
|Skin steroids (up to 7 days)||Hydrocortisone, betametasone, elomet, momethasone|
|Systemic long term steroids||Prednisolone, dexamethasone|
|Systemic UV light treatment||PUVA|
|Phenothiazines||Stemetil, prochlorperazine, chlorpromazine, trifluoperazine|
Montelukast/Singulair is ok to continue.
Can it be run on small children?
Yes. Skin prick test can be done on any age group. A study by in France managed to safely conduct skin prick test on 78 children between 4 days to 24 months old. What’s even more amazing is that allergies to mites, cat, egg and milk was diagnosed even in such young children.
Zenith’s allergy panel
- House dust mites: Dermatophagoides Pteronyssinus, Dermatophagoides Farinae, Blomia Tropicallis
- Cat Fur
- Dog Fur
- German Cockroach
- Bermuda Grass
- Positive control and negative control (to ensure validity of test)
Step 2: Make the body stop reacting to the exact cause of your allergy
How does it work?
Yes, make sure you have completed step 1 first. Then we will try to figure out which allergens we want to treat. Then we will find you a mix of allergens that you/your child will put under your tongue every day of your life for 1 minute each time for 4 years straight.
Gosh, doc did you just say FOUR years???
Yes, suggests that 4 years is the optimal treatment duration. But of course, you are the patient, ultimately you can decide, but I would still recommend 4 years to see the best effects.
Do you mean it will take 4 years to work?
No, actually within 6 months you should start seeing a difference.
Safety and side effects
Sublingual immunotherapy is very very safe. From the review done by , there was no serious life-threatening reactions reported from the 1.18 million doses administered to 4378 patients from 66 different studies. Just like any other medical treatment, sublingual immunotherapy has some possible side effects. However, only 14 adverse events were reported out of the 1 million doses given, which includes asthmatic reactions, abdominal pain and vomiting.
Other milder and commoner side effect is itching over the area where the medication is applied or transient worsening of existing allergic symptoms. The good news is that those milder side effects all resolve with continuation of therapy.
You bet there is. I won’t ask you to waste hard earned $$$ on something which doesn’t work.
There is a huge body of evidence to support this therapy but yet it is almost unheard of in Singapore due to logistical constraints. Below are the multiple organizations which endorse this treatment.
Singapore’s MOH advocates sublingual immunotherapy as treatment for sensitive nose when children are not keen to use medications or when all other treatment has failed . In simple words, if you/your child hate using medications your whole life, sublingual immunotherapy is the way to go!
MOH guidelines are recommendations given by experts and immunotherapy is given Grade A, Level 1++, meaning that the level of scientific support behind it is very very strong. The below is an excerpt from the guidelines:
Grade A evidence, level 1++: Sublingual immunotherapy (SLIT) should be considered in children above 5 years who have poor symptomatic control of allergic rhinitis despite maximal therapy or who cannot or will not take medication (pg 57).
Sublingual immunotherapy is also concluded by the World Allergy Organization to be effective in treating rhinoconjunctivitis and asthma. Besides controlling the symptoms, sublingual immunotherapy has the potential to completely cure such allergies for good or even prevent them from developing at all.
These are extracts from the main article released by World Allergy Organization in 2013.
… Several large ‘definitive’ trials have now confirmed the efficacy and safety for seasonal rhinitis in both children and adults. Long-term benefits of SLIT for at least 1 or 2 years following discontinuation of treatment have been demonstrated in 2 large independent trials of immunotherapy with grass pollen allergen tablets in adults. These studies provide evidence for long-term disease remission and disease…
More extracts from this guideline:
The literature suggests that, overall, SLIT is clinically effective in rhinoconjunctivitis and asthma, although differences exist among allergens.
Sublingual immunotherapy for children significantly reduced nasal symptoms.
In children with running nose without asthma, children who were treated with sublingual immunotherapy was 3.8 times less likely to develop asthma . Another study also demonstrated reduction in frequent bronchitis symptoms and overall reduction in asthma .
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