With the arrival of winter, there are several things to consider if you have allergies.  First, if you haven’t done it already, now is a good time to change the filter on your furnace.  Dust has likely accumulated in your furnace for 6 months and old filters, burdened with a large dust load, do not filter as well as new, clean ones. 

Outdoor allergies resolve in the winter but indoor allergies usually worsen.  The most common indoor allergies are cat, dog and other furry animals.  Dust mite allergy also tends to worsen in the winter.

Humidity is something that tends to confuse most people.  I often see patients who use a steamer or humidifier thinking it will decrease their “allergies.”  But if cat and dog are the main indoor allergens, how will a humidifier improve pet allergies?  The answer is they won’t.  Do they help dust mite allergy?  No, just the opposite.  One of the ways to control dust mite population is to keep the humidity low, not high.  Two things that are helped by using a humidifier in the winter are dry nasal passages and dry skin.  Many patients with allergies also have eczema.  Dry skin usually results in a flare of eczema.  So, using a humidifier in the winter can help eczema.  It can also help a dry nose.  Using a water based lubricant for the nasal passages is another way to improve dry nostrils in the winter.  A good rule of thumb is to keep the humidity below 50%, whether it is summer or winter.

During the holiday season, many people get live Christmas trees.  Unfortunately, these trees tend to have a lot of mold on them.  Since Christmas trees do not pollinate in the winter, and definitely do not pollinate in your living room, the increase in symptoms that occur once the Christmas tree is put up and decorated is usually caused by the mold.  If you have significant mold allergies, it would be best to use an artificial Christmas tree.

Michael Park, MD

There are many different types of inhaled medications these days, ranging from the old style inhalers in a pressured canister, to powders, to mists. The following instructions pertain to old style metered dose inhalers (MDI), the traditional asthma inhaler used for the past 50 years. Before you begin, a brand new MDI should be primed by puffing 4 doses into the air, as the first several doses do not contain proper amounts of the medication. This does not have to be done before each use, just when it is new.

Image by Bob Williams from Pixabay

First, shake the inhaler and exhale fully.

Second, close your lips around the mouthpiece making sure your teeth do not block the way.

Third, puff the inhaler and start your inhalation at the SAME time. The inhalation should be SLOW, not fast, and should last 5 SECONDS.

Fourth, hold your breath for 10 seconds.

That’s it. You may run across minor variations to these instruction, but I have found these guidelines to be the easiest, most reliable way to teach patients how to properly use an MDI. The most common error is inhaling too quickly. A slow inhalation delivers more medication to the lungs compared to a fast one. Further, holding your breath for 10 seconds at the end is important, as this is when the medication spreads to the periphery of the lungs.

Michael Park, MD

Ragweed season starts in mid-August and ends at the end of September.

Often, people in the Midwestern United States who suffer from seasonal allergies complain of symptoms in the spring and “in the fall.” However, when asked to specify what part of the fall, they usually mean late August and all of September, not late October when the leaves are on the ground. So, it is more accurate to say “late summer” or “early fall,” when describing this second allergy season of the year. The main allergen responsible for symptoms this time of the year is ragweed. Ragweed is a common weed that grows in many parts of the North America and Central America. Although native to this continent, it has spread to Europe, probably starting in the 1900s during WWI. Unfortunately, for those of us with allergies, it is also a potent allergen.

In Southwest Michigan, ragweed starts to pollinate in mid-August, peaks around Labor Day weekend, and continues till the end of September. There is no detectable ragweed by October 1. As a potent allergen, it is responsible for most of the itchy eyes, running nose, nasal stuffiness and sneezing this time of year. Ragweed pollen levels tend to peak midday and can literally fly for hundreds of miles. So, it doesn’t matter that your yard is a perfectly manicured model of Midwestern grass. You can’t escape ragweed pollen.

Treatment for ragweed is basically the same as for most environmental allergies. The triad of avoidance, medications, and immunotherapy are the hallmark of treatment. Avoidance involves staying indoors, keeping the windows closed, and bathing every night before going to bed (you need to wash that ragweed out of your hair…). I am often asked if there is someplace one could move to avoid ragweed. The short answer is no – unless you’d like to move to Antarctica. However, spending ragweed season on an ocean or large lake (eg. Lake Michigan) shoreline can be helpful. Medications involve allergy eye drops, oral antihistamines, and allergy nasal sprays. Please refer to the previous posts detailing use of OTC allergy medications. Finally, immunotherapy, either via allergy injections or allergy oral drops, probably offers the most effective treatment available.

Michael Park, MD

Honey bee collecting nectar and pollen

Eating local honey has been considered a natural way to treat one’s seasonal allergies for many years. The rationale is since local honey is made with the local pollens from the area, eating the honey on a regular basis will naturally desensitize you to those pollens. Sounds nice, but does this really work?

The short answer is no. First of all, honey bees do not use the pollen to make honey. It is the nectar they collect from flowers that is transformed to honey. Honey bees do collect pollen but they consume both the pollen and honey for food. The bottom line is there is virtually no pollen or plant antigen in honey.

Further, the pollen from flowers do not significantly cross react with the various trees, grass, and weeds that cause seasonal allergies. So even if honey contained pollen, it wouldn’t do much good. Even allergy injections with flower extracts will not help those with tree or ragweed allergies.

Honey

Honey is a delicious, natural sweetener, but nothing more. When it comes to treating your allergies, best to leave the bees out of it.

Some people notice a flare in their seasonal allergies in early July, peaking around the 4th of July Holiday. In the mid-west, the most likely reason for this flare is an allergy to grass. In this part of the country, grass season tends to have two peaks: one in early June and another one in early July.

What can be done about grass allergy? Here are a few tips.

Avoid grassy areas as much as possible, especially during mowing or right after mowing.

Wear a good quality mask during mowing.

Take a shower after exposure to grass.

Saline sinus irrigation after exposure to grass.

Use allergy medications (detailed in previous posts).

Allergy immunotherapy for grass in the form of allergy injections or allergy oral drops.

In late May to early June, we often start to see the cottonwood trees shed their seeds. White, fluffy, cotton-like material can be seen floating all over the place. Some people get itchy and sneeze right around this same time of the year. Naturally, they blame the cotton. Their symptoms must be due to cottonwood tree allergies, right? Wrong.

Cottonwood trees (also known as poplar trees) actually pollenate in April. Their large fluffy seeds that we see in late May and early June are NOT the allergen people react to. So, if it’s not the cottonwood, then what is it? It turns out that Hickory trees, Walnut trees, Sheep Sorrel weed, and mid-western grass all start to pollenate at the same time that the cotton-like seeds are released. In all likelihood, the allergy symptoms are caused by one or more of those 4 culprits. So, don’t blame the cotton!

Brett Molina, USA Today, 2019

Photo by Radu Marcusu

Oral treatment for peanut allergies dramatically increase allergic reactions compared to avoiding the treatment altogether, a study published Thursday revealed.

The study published in The Lancet pulled together results from 12 randomized, controlled trials, including more than 1,000 patients, to compare how participants fared using oral immunotherapy, a treatment where a person with an allergy is fed the allergen in small doses to help build up a tolerance.

The average age of participants was 9, researchers said. They were followed for about a year, measuring adverse reactions, the need to use epinephrine, and reports of anaphylaxis, a life-threatening allergic reaction.

Results showed participants using oral treatment for a peanut allergy were three times more likely to report anaphylaxis than those who didn’t use the immunotherapy. Their risk of using epinephrine or suffering an adverse reaction was twice as high, said the study.

Meanwhile, the study also showed the quality of life for participants on the immunotherapy was no different than those who didn’t use the treatments.

“Our results do not denounce current research in oral immunotherapy, but the method needs to be more carefully considered, improvements in safety made, and measures of success need to be aligned with patients’ wishes,” said Dr. Derek Chu, lead author of the study and fellow in the Department of Medicine at McMaster University in Ontario, Canada, in a statement.

Last December, a study was released saying an experimental drug used to help build a tolerance over time to peanuts is ready for review by the Food and Drug Administration.

In an interview with USA TODAY, Chu said the trials administered immunotherapy in different ways, such as a powder to pour over food, a capsule, or through peanut butter or foods containing peanuts given in controlled doses. However, Chu said while on the immunotherapy, certain activities such as exercise or even a hot shower could trigger someone to have a severe reaction.

“This type of therapy is still investigational. It’s experimental,” Chu said. “Patients need to know the facts exactly where the field is at.”

There are currently no approved treatments for peanut allergies. In 2017, the National Institute of Allergy and Infectious Disease updated guidelines on peanut allergies, saying they could be curbed by introducing items containing the food as soon as early infancy. 

Nasal decongestants come in two basic forms.  One is oral pseudoephedrine, better known as Sudafed.  This drug causes vasoconstriction of the blood vessels.  Since nasal stuffiness is caused by vasodilation of the nasal blood vessels, you can see how it can be an effective treatment.  Since antihistamines alone are not good at treating nasal stuffiness, drug companies quickly came out with combination products like Claritin D, Allegra D, and Zyrtec D.  The D stands for decongestant.  And the decongestant is pseudoephedrine.  The problem with this drug is its potential side effects which include increased blood pressure, racing heart, jitteriness, insomnia, and … it can make men pee in their pants.  Regular use of pseudoephedrine will often result in one or more of these side effects.  The other OTC nasal decongestant is oxymetazoline and comes in a nasal spray.  The most well known version is called Afrin, but I have seen “Meijer Nasal Spray With Saline” which is basically the same thing with different packaging.  This drug is a powerful, topical decongestant.  It improves nasal stuffiness effectively and quickly.  The problem, once again, lies with side effects.  People develop tolerance to this drug quickly, meaning it becomes less and less effective with continued use.  This is the spray that people can “get hooked on.”  Such patients often end up using this spray 6-12 times a day just to keep their nasal passages open a crack.  You should never use oxymetazoline more than 3 days in a row.  Most package inserts contain this warning.  And of course everyone reads package inserts, right?

Overall, I do not recommend either of these products on a regular basis.  As long as you are aware of its potential side effects, brief use may be helpful.  For patients with chronic nasal stuffiness, the best OTC treatment is the allergy nasal spray, discussed in Part 2 of this series.

Michael Park, MD

The next topic will be treatment for allergy eyes.  Unfortunately, allergy eye symptoms are among the most difficult to treat.  If you are a contact lens wearer, it is even worse because pollen just sticks to those lenses like glue.  There are two basic types of medications used in allergy eye drops.  One is a vasoconstricting drug which makes the blood vessels smaller.  This is how it “gets the red out.”  Unfortunately, people usually develop tolerance to this type of medication, meaning “you get used to it,” and it has a weaker and weaker effect the more you use it.  This type of medication is not healthy for the eye with daily use.  The other type of medication is an antihistamine in solution.  So, it works just like oral antihistamines work – they block histamine, the major substance involved in allergic symptoms.  Antihistamine eye drops are the preferred treatment for allergy eyes.  I usually recommend ketotifen.  This medication is available by a variety of different brands including Zaditor and Alaway.  I have also seen Meijer and Walgreens versions of ketotifen eye drops.  Other helpful tips for allergy eyes include NOT wearing contact lenses, and using lubricating drops to gently flush the pollen out of the eyes.  It also helps to keep the bedroom windows closed, wash your hair before you go to bed, and change your pillow case often.

In Part 1, I discussed oral antihistamines.  In this post, I will review OTC allergy nasal sprays.  The main OTC options are Nasacort (triamcinolone), Flonase (fluticasone propionate), Rhinocort (budesonide), and Flonase Sensimist (fluticasone furoate).  These allergy nasal sprays are far more effective compared to oral antihistamines when it comes to treating classic allergy symptoms.  So, if you have tried oral antihistamines but still suffer from allergy symptoms, you should try an allergy nasal spray.  Further, they are effective for nasal stuffiness, whereas oral antihistamines are not.  All of the 4 products above are topical steroid sprays.  They work best if used on a daily basis.  They are not as effective if used intermittently.  Further, they usually become more effective after 3-4 days of use.  Even though they are steroids, they are safe and most are FDA approved down to the age of 2 (Rhinocort is approved down to the age of 6).

In general, I usually recommend Nasacort as I feel it offers the best combination of effectiveness and tolerability.  Nasacort is odorless and gentle on the mucous membranes.  Flonase is effective but not as well tolerated as Nasacort.  It has an odor (artificial flowers) and seems to cause more irritation compared to Nasacort.  Rhinocort is effective, has a mild odor, and is fairly well tolerated.  Flonase Sensimist is the best tolerated of the four, as it is odorless and has the smallest volume compared to the rest.  However, that small volume comes with a price – less medication.  Flonase Sensimist only contains 27.5 mcg of medication per spray compared to 50 mcg for Flonase and 55mcg for Nasacort.

So, if your allergy pill is not doing the job, give an allergy nasal spray a try.

Michael Park, MD