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MEDICAL CONDITIONS

• What is hay fever?
• Why does an allergic reaction occur?
• What causes allergic rhinitis?
• When and where does allergic rhinitis occur?
• How are allergies identified?
• How are allergies treated?
• Hay Fever At A Glance

Hay fever affects one in every five Americans. Over one billion dollars are spent each year in this country to treat this disorder. Millions of school and work days each year are lost suffering from hay fever symptoms. These figures are probably an underestimate because many sufferers attribute their discomfort to a chronic cold. Although childhood hay fever tends to be more common, this condition can occur at any age and usually occurs after years of repeated exposure to allergic substances.

What is hay fever?

"Hay fever" is a misnomer. Hay is not a usual cause of this problem and it does not cause fever. Early descriptions of sneezing, nasal congestion, and eye irritation while harvesting field hay promoted this popular term. Many substances cause the allergic symptoms noted in hay fever and hay represents only a small percentage. "Allergic rhinitis" is the correct term used to describe this allergic reaction. Rhinitis means "irritation of the nose" and is a derivative of "Rhino," meaning nose. Allergic rhinitis which occurs during a specific season is called "seasonal allergic rhinitis". When it occurs throughout the year, it is called "perennial allergic rhinitis."

Symptoms of allergic rhinitis, or hay fever, frequently include nasal congestion, a clear runny nose, sneezing, nose and eye itching , and tearing eyes. Post nasal dripping of clear mucus frequently causes a cough. Loss of smell is common and loss of taste occurs occasionally. Nose bleeding may occur if the condition is severe. Observers of the person experiencing allergic rhinitis will commonly notice frequent rubbing of the nose using the index finger. This is the so called "allergic salute." Eye itching, redness, and tearing frequently accompany the nasal symptoms. The eye symptoms are referred to as "allergic conjunctivitis" (inflammation of the whites of the eyes). These allergic symptoms often interfere with one's quality of life and total health. Allergic rhinitis can lead to other diseases such as sinusitis and asthma . Many allergic people have difficulty with social and physical activities. For example, concentration is often difficult while experiencing allergic rhinitis.

Why does an allergic reaction occur?

An allergic reaction occurs when the immune system attacks a usually harmless substance called an "allergen" that gains access to the body. To more simply describe this complex immune process, we will make an analogy to a war within the body. The immune system calls upon a protective substance called "immunoglobulin E" or "IgE" antibodies (for erythema or redness) to fight these invading allergic substances or allergens. Even though everyone has some IgE, an allergic person has an unusually large army of these IgE defenders - in fact, too many for his/her own good. This army of IgE antibodies attacks and engages the invading army of allergic substances of allergens.

As is often the case in war, innocent bystanders are affected by this battle. These innocent bystanders are special cells called "Mast" cells. These cells are frequently injured during the warring of the IgE antibodies and the allergic substances. When a mast cell is injured, it releases a variety of strong chemicals into the tissues and blood. These chemicals frequently cause allergic reactions. One of the chemicals released by the mast cells is histamine. These chemicals are very irritating and cause itching, swelling, and fluid leaking from cells. Through various mechanisms, these allergic chemicals can cause muscle spasm and can lead to lung and throat tightening as is found in asthma and loss of voice.

What causes allergic rhinitis?

Any substance can cause an allergy if exposed to a person in the right way. But for all practical purposes and with few exceptions, allergic rhinitis is caused by proteins. Commonly, allergic rhinitis is a result of an allergic person coming in contact several times with protein from plants. Many trees, grasses, and weeds produce extremely small, light, dry protein particles called pollen. This pollen is spread by the wind. These pollen particles are usually the male sex cells of the plant and are smaller than the tip of a pin or less than 40 microns in diameter. Even though pollen is usually invisible in the air, pollen is a potent stimulator of allergy. Pollen lodges in the nasal lining tissues (mucus membranes) and other parts of the respiratory tract where it does harm to an allergic person. Approximately 5-10 percent of Americans at times suffer from allergic rhinitis. A person is programmed to be allergic by his/her genetic makeup and is destined to be allergic from birth.

When and where does allergic rhinitis occur?

Since allergic rhinitis is frequently caused by pollen, symptoms occur when pollen is in the air. Trees primarily pollinate in the spring, while grasses pollinate in the spring and summer. Weeds usually pollinate in the late summer and fall. Of all allergy sufferers in the United States, 75% are allergic to ragweed, 50% are allergic to grasses and 10% to trees. Of course, many people are allergic to other substances such as mold spores, animal protein, and mites to name a few. Food is an uncommon cause of allergic rhinitis. More about non pollen allergy later! If you wish to know the pollen count in your area, this information can often be found in the newspaper in the weather section or you can call the National Allergy Bureau's Hotline at 1-800-9-POLLEN.

How are allergies identified?

The ideal way to manage an allergy is to avoid the substances that cause allergic symptoms. It is, therefore, very important to first identify the substances (allergens) causing the allergic reactions. Many allergens can be suspected by a patient's particular history. For example, if symptoms usually worsen with exposure to cats, then cat protein is a probable allergen causing the symptoms. If cutting grass is associated with the onset of symptoms, then grass allergy is probable. A patient's history of reactions is very important in determining his/her unique allergies.

Because the identification of allergens is important and often difficult to pinpoint, skin testing is often needed to identify exactly the specific substance causing the allergy. Skin testing is now done with minimal discomfort and is performed as follows:

• A small amount of the suspected allergy substance is placed on the skin.
• The skin is then gently scratched through the small drop with a special sterile needle.
• If the skin reddens and, more importantly, swells, then allergy to that substance is probable.
• The skin testing described is tolerated by the youngest of patients and should be the standard of testing.
• Allergy detection by other methods is usually less reliable and more costly.

More expensive and less reliable blood tests are available. These blood tests are usually only used in people who cannot be skin tested for unusual reasons (e.g. severe eczema). These blood tests look for IgE antibodies in the blood and by inference suggest allergy in the tissues. If the allergy testing agrees with the history given by the patient, then a diagnosis of allergic rhinitis is likely.

How are allergies treated?

Avoidance of identified allergens is the most helpful factor in controlling allergy symptoms. Attempts to control the environment and avoidance measures often significantly aid in resolving symptoms. Allergy avoidance is often not easy. A thorough discussion with your physician is needed and control measures are required daily.

If avoidance is not possible or does not relieve symptoms, additional treatment is needed. Many patients respond to antihistamines. Antihistamines combat the histamine that has been released during an allergic reaction by blocking the action of the histamine on the tissue. Antihistamines do not stop the formation of histamine nor do they stop the conflict between the IgE and antigen. Therefore, antihistamines do not stop the allergy "war" but protect tissues from the fallout of the "war." Antihistamines frequently cause mouth dryness and sleepiness. Newer so-called "non sedating" antihistamines are now available. In general, this group of antihistamines is more expensive, has a slower onset of action, is longer acting, and induces less sleepiness.Discuss with your physician other antihistamine side effects that very occasionally occur (e.g. urine retention in males, fast heart rate, and others). You should always discuss the potential side effects of any medication with your physician and/or pharmacist. A thorough review of specific antihistamines can be found under the Medications Center and read the Nasal Allergy Medications article.

Decongestants help control allergy symptoms, but not the causes. Decongestants shrink the swollen membranes in the nose and make it easier to breath. Decongestants can be taken orally or by nasal spray. Decongestant nasal spray should not be used for more than five days without the doctors advice, and if so, usually only when accompanied by a nasal steroid. Decongestant nasal sprays often cause a rebound effect if taken too long. A rebound effect is the worsening of symptoms when a drug is discontinued. This is a result of a tissue dependence on the medication.

Some allergic people need specialized prescription medication such as corticosteroid (cortisone like), cromolyn , and ipratropium (Atropine like) nasal sprays. These nasal sprays do not cause the rebound effect noticed from decongestant nasal sprays. Cortisone nasal sprays are very effective in reducing the inflammation which causes swelling, sneezing and running nose. Cortisone can also stop the allergy "war" by halting the formation of the many allergy chemicals described above. Many cortisone nasal sprays are on the market through prescription only. Cromolyn is also an anti-inflammatory medication. Although cromolyn is not as potent as cortisone, it has a very safe profile. Cromolyn must be used well in advance of anticipated allergy symptoms to be useful. Ipratropium nasal spray is available for drying a wet runny nose. It will not prevent allergic reactions. This is an atropine derivative and although usually very safe, a person sensitive to atropine should be cautious. A note about the proper use of nasal sprays is useful. Repeated spraying of the nose occasionally causes trauma and sometimes bleeding. This effect can be minimized by directing the tip of the spray applicator directly backward thus avoiding the sensitive middle and outside wall of the inner nose.

If antihistamines and nasal sprays are not effective or not tolerated by the patient, other modalities of therapy are available. Allergy desensitization or immunotherapy may be needed. Allergy immunotherapy stimulates the immune system with gradually increasing doses of the substances to which a person is allergic. Since the patient is being exposed to the allergy-inducing substance, an allergic reaction can occur. Caution and experience in this process is very important. An allergy specialist is advised at this point. Although the exact way allergy desensitization works is not completely known, allergy injections appear to modify or stop the allergy "war" by reducing the strength of the IgE and its effect on the mast cells. This form of treatment is very effective for allergies to pollen, mites, cats, and especially stinging insects (i.e. bees). Allergy immunotherapy usually takes six months to one year to become effective. Allergy injections are usually required for three to five years and necessitate frequent office visits. Self administration is not advised by this author. The success rate of an allergy desensitization program in significantly reducing symptoms can be up to about 80%. The effect of allergy immunotherapy should last many years, if not a lifetime. As stated, allergy injections can be dangerous and should be managed by an experienced physician in this field. Although rare (1 in 2-5 million injections given), serious allergy reactions can occur while receiving allergy injections. We cannot predict who will have a severe reaction. Even after years of receiving allergy shots a patient can experience a reaction.

Hay Fever At A Glance

• Hay fever (Allergic rhinitis) is common.
• Allergy symptoms mimic chronic colds.
• Allergic rhinitis can lead to other diseases.
• The best way to treat an allergy is to identify the allergic substance and avoid it.
• Effective treatment is available in many forms.

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