• Allergy Testing

  • Allergy Testing using approximately 250 Prick test allergens. The skin prick test is the most recommended for allergy testing and has stood the test of time as compare to recently introduce RAST test. Computerised reporting and allergen selection for vaccine. Report print outs in English, Gujarati, Hindi, Marathi, Bengali.

    What is Allergy?

    What is Allergy?

    Allergy is the extreme sensitivity of an individual to certain substances in the air or to foods, which are ­harmless to most other individuals. For example, when a room is dusted an allergic individual may get an asthmatic attack or bouts of sneezing. When an allergic person takes a particular food or medicine, he may break out with a skin rash. Nothing may happen to a person who does not have an allergic tendency.

    Man and other living beings have to depend on the environment to survive – to receive oxygen for tissue oxygenation and for food for tissue nourishment. However, in addition to the air we breathe, a number of unwanted items enter – dusts, pollens, fungi, mites, etc. Similarly, foods have to enter from the external world, since man cannot manufacture his own food like plants. Many foods may not agree with some individuals – “One man’s food may be another man’s poison”. Also substances in contact with the skin and injected into the skin like insect stings and injected drugs can cause allergic reactions.

    Man in his environment

    When the body is repeatedly exposed to these foreign substances (called allergens or antigens) the body develops specific fighting bodies (antibodies). Every time a foreign substance enters the body, the antibodies fight it by a reaction known as antigen antibody reaction. Basically, this is a protective reaction. In case of bacterial and viral infections it stimulates the body to form antibodies, which develop immunity to disease e.g. mumps, measles, etc.

    In some individuals however, the antigen antibody reaction takes a violent and exaggerated form. This is an allergic reaction and is harmful to the individual. Certain violent allergy reactions can be fatal, like injections of Penicillin, stings of bees, wasps, scorpions. Repeatedly occuring allergen antibody reactions can cause increasing, irreversible, permanent tissue changes in the target organs-the organs most commonly affected by allergy – the lungs, the nose and the skin.

    Allergic reactions in the body manifest as allergic disease. This is explained later.

    Allergic diseases

    The term allergy encompasses the clinical characteristics of type 1 hypersensitivity reaction, which includes asthma, allergic rhinitis (hay fever) and urticaria and other diseases which can have an allergic background e.g. – Food allergy, migraine etc..

    Various organs in the body (known as the target organs) can be affected by allergy and give rise to specific symptoms and diseases. The lungs, nose and skin are the main target organs where the allergic reaction usually occurs.

    Lung allergy is characterized by sudden cough, sputum accumulation in the chest, wheezing and difficulty in breathing – allergic bronchitis or asthma.

    Nasal allergy is characterized by sudden bouts of sneezing and watery nasal discharge often with itching and blocking of the nose – allergic rhinitis. Long-standing nasal allergy can lead to formation of nasal polyps with severe nasal obstruction. Bronchial asthma develops in 15% of patients suffering from allergic rhinitis.       .

    Skin allergy is characterized by skin rashes with itching.

    Other organs of the body may be similarly affected. In allergy there is fluid logging in the tissues.

    When this occurs in the brain and nerves, mental dullness, tiredness and migraine headaches can occur. In the gastro intestinal tract, abdominal pain, loose stools may occur. When the eyes are affected, itching and swelling can occur. When the inner ear is affected, attacks of vertigo or a sense of imbalance is often present.

    Factors that make an Allergy worse: :

    These are known as “Trigger Factors” since they activate the trigger of the allergen-loaded gun to “fire”.

    Respiratory infections,

    Exercise Emotional stress,

    Change in humidity Weather change,

    Cigarette smoke,

    Exposure to street dust,

    Perfumes,

    Incense smoke,

    Mosquito coils,

    Insecticide  sprays,

    Fresh-up sprays,

    Smoke from factories,

    Automobile exhaust  etc.

    Mechanism of Allergy

    The allergic tendency (tendency to over react to a foreign substance) is often inherited from parents. Such individuals when subject to allergens e.g. house dust, pollen, certain foods etc., which they may be sensitive to give the “allergic reaction.”

    The “March” concept – The allergic march / Atopic march describes the progression of one clinical manifestation of allergy to the next, throughout a person’s life time. Allergic responses of the body take place mainly in the large target organs – Nose, Chest and Skin. It has been found that while the affection starts with one organ, it can “march” ahead to involve other target organs. For instance, 15% of patients with Allergic rhinitis eventually go on to develop asthma. After some months or years later, a skin allergy or food allergy may develop.

    The “Total allergic load” concept.  Allergy is usually caused by a number of allergens in differing proportions. Allergic symptoms like sneezing, wheezing, urticaria are precipitated when the patient is exposed to a large dose of a single allergen, or more commonly, to small doses of a number of allergens. The moment the effects of several allergens build up to a certain upper limit, (threshold level), allergic symptoms are precipitated – the symptoms being that of the target organ affected in a particular individual – Lung, Nose or Skin. Physical factors like change in climate or humidity may increase the chance of allergic attacks by acting as triggering factors.

    The allergy response is basically an inflammatory response and makes the target organ excessively responsive and sensitive – resulting in chronic mucus secretion, tissue damage etc. Repeated exposure to an allergen induces a chronic inflammation and ultimately progressive irreversible changes in the target organ – Lung, Nose or Skin.

    Who should have an allergy test performed?

    Individuals suffering from classical allergic disease like asthma, allergic rhinitis and dermatoses, should most certainly have an allergy test performed.

    It is common experience that after taking certain foods, we feel unwell and tired. Headaches, gaseous distension in the abdomen, abdominal cramps, a feeling of fullness and bloating of the abdomen after meals, diarrhoea follow ingestion of certain foods.

    An always tired and weak feeling, mental dullness, feeling sleepy all the time even after a complete night’s sleep, low grade fever, muscle and joint pains, body aches, sore throat, swollen glands, unexplained headaches and, sensitivity to extremes of temperature has been blamed on allergy to some substance in the environment “that does not agree” with the individual.

    Again vague abdominal pains, recurrent colds and nagging cough not responding to routine treatment, constant fatigue, tension, swelling of eyelids and face, blocking of the nose, diminished sense of smell, mild transient giddiness – in fact many symptoms labeled as ‘vague complaints’ by doctors can eventually be traced to a food or dust allergy. When the body’s immunity is compromised, the body’s resistance to infection is lowered and we are vulnerable to virus infection. Even viral infections occurring in childhood and lying dormant for several years are reactivated, when excess work and tension of modern existence sap up body resources. We fall victim to what is known as CFIDS (Chronic Fatigue Immune Dysfunction Syndrome).

    Clinical approach to diagnosis of allergy

    The Nose and Throat are the portal of entry of most allergens, both inhalants and foods.

    A thorough Nose and Throat examination is therefore mandatory to exclude the conditions which aggravate the allergy. It is essential to exclude sinus infection, infected tonsils and abnormalities of air entry through the nose due to deviated nasal septum, adenoids, nasal polyps etc. The following page gives details on these conditions.  Not paying attention to these would render the treatment of allergy incomplete.

    Common disease conditions affecting the Nose and Sinuses


    Special investigations often required :

    1). C.T. Scans of nose and the paranasal of sinuses.

    2). A chest examination and chest specialist consultation may also be required.

    Chest X-rays to exclude diseases like tuberculosis.

    Lung function tests.

    Sputum examination to exclude diseases like tuberculosis.

    3). Blood examination to exclude eosinophilia

    Stool examination to exclude worms and parasites;

    Nasal discharge examination to note the  presence of eosinophils may be required.

    Allergy test performance

    There are two main ways to test for allergy triggers. Skin prick test test and laboratory RAST blood test.

    The diagnosis of an allergic disease is complete only when the triggers of the allergen-antibody reaction are identified. Here lies the importance of first identifying the causative allergens by a skin prick test.

    Avoidance of exposure to those allergens both foods and components of dusts (like house dust, dust mite, fungus, pollens, animal hair, dead insect parts etc) is the first necessity of treatment of allergy.

    Medication and if necessary oral vaccine therapy follow later.

    The Skin Prick test has extreme sensitivity and specificity for the presence of allergen -specific IgE which is bound to the mast cells which are present in large numbers (70 %) – only in  the nose, lungs and skin – which are the target organs attacked in an allergic patient causing the major allergies in human beings – Nose rhinitis, Chest – bronchitis and asthma and Skin – types of allergic dermatoses.

    The skin prick test much  more sensitive than RAST testing which tests only the minute amounts of allergen -specific IgE circulating in the blood. (30%)  The data obtained is also totally incomplete

    Advantages of Skin Prick tests

    It has stood the test of time and has been in use with minor modifications over the last 130 years.

    Takes only 20 to 40 minutes to get results. It is less expensive, simple to perform, more sensitive than blood testing and causes hardly any discomfort. Measures 70% IgE instead of 30 % of IgE in circulating blood.

    Can be used on any patient above the age of 7 years who all willingly volunteer for the gentle pricks.

    The patient has the satisfaction of seeing the positive reactions coming up.- usually a red itchy area or bump it is taken as a positive to the presence of IgE of an allergic disease. The diameter of these reactions are measured with an allergy test gauge and fed into a computer. The computer separates the reactions of the foods we take and the various dusts that we inhale. These are sub-classified into mild, moderate and severe. Food allergies are printed in English and either Hindi, Gujarati, Marathi, Bengali.

    Nowadays an oral vaccine which can be taken at home by the patient is possible only after the skin prick data is available. It is never available after RAST testing.

    The RAST blood test is an automated test performed on blood samples by a pathology laboratory. It detects only the free antigen specific IgE circulating in blood which is only 30% as opposed to antigen specific IgE bound to mast cells in the skin and other target organs of allergic disease like the nose, skin and lungs which is 70 %. It measures only the minute amounts of IgE circulating in the blood.

    It is therefore never complete and leads to failures and inconsistencies.

    Being a laboratory test which measures extremely tiny molecules of Ige it depends on strict quality control and standardization which all laboratories do not have.

    Methodology and result quality are variable, no standardization or formal quality control of allergens at the current time are available.

    Every time the same patient is tested the results are  variable. It is for this reason that oral vaccine therapy is never recommended after the results of the RAST blood test.

    Any lay man, doctor or nurse can order the test. However correct interpretation of the test results can be done only by a specialist with knowledge of allergy and experience in allergy testing, knowledge of the biology of the various allergens and the exposures of the patient, and the nature and timing of the symptoms to come to a diagnosis and construct an appropriate management plan for the patient suffering from allergy.

    It is therefore mandatory that an allergy problem should be handled by a doctor experienced in allergy diagnosis and treatment. in an allergy specialist’s clinic by the Skin Prick Test method.

                                                    Royal College of Physicians, London   Report 2003, Allergy, Chapter 9, Diagnostic Tests, page 73

     

    Performance of Allergy Prick Test

    Around 250 extracts (dusts and foods) are tested at the Centre which covers almost all possible allergens one can be exposed to. In cases of certain important allergens e.g. House dust, House dust mite etc, the same allergen made by different firms are used for confirmation. This confirms true positive reactions and eliminates from the test results, false positive reactions.

    Skin prick method of Allergy testing

    The commonest and time-tested method of allergy testing is by a ‘skin prick test’. Allergy is tested by noting the responses on the skin to extracts of substances we are exposed to in day to day life.

    The skin of the forearm is the best area for performance of a skin prick test.  The skin is cleaned by alcohol.. Markings are made on the skin by a rubber stamp, corresponding to the box of allergy solutions.

    A tiny drop of allergy extract is placed on the skin of the forearm in the areas marked out.

    A gentle prick through the drop of extractis performed with a small nib-like instrument.  This is washed in distilled water between pricks.

    Being painless, a large number of allergens can be tested at a time   (unlike the intradermal tests where each allergen has to be injected under the skin).   The tests are even acceptable to children above the age of 4 years. The greater the number of allergens tested, the more accurate  and complete the coverage of the allergens man is exposed to in the environment. At the Alecure allergy centre, around 350 allergens from different firms are used – to keep a control  and confirm positive reactions and exclude false positive reactions

    Reactions to individual allergens the patient is allergic to, appear in 15 to 30 minutes

    An elevated area (weal) and a red flush (flare) representing a small antigen-antibody reaction on the skin, shows up for each allergen. The diameter of these is measured in millimeters by a transparent acrilic skin reaction gauge. The reactions are noted in millimeters and entered into a computer

    The computer separates the allergy test reactions into inhalant allergens (dusts) and ingestant allergens (foods). It also classifies the reactions into mild, moderate and marked.

    The computer also guides in accurate selection of specific inhalant allergens for desensitization oral vaccine (immunotherapy)..

    For inhalant and food allergens, advice is given at the Centre following the allergy test.

    Reporting of results of the Allergy test

    Example

    Patient’s Name – Mr. K.M.                                                                                                              Date –    16/May/2008
    Control Reactions:   Negative control (Glycerinated buffer saline)    Positive control (Histamine Dihydrochloride 0.1%)

    INHALANTS – House Dust Mite (Dermatophagoides Pteronyssinus & Farinae)

    H. D. Mite (D. Ptero.) 10mm H. D.  Mite  (D. Pteronysinnus) 9 mm H. D.  Mite  (D. Farinae) (A) 8mm
    H. D.  Mite  (D. Farinae) 10mm H. D.  Mite  (D. Farinae) (HS) 10mm H. D.  Mite  (D. Farinae) 10mm

    INHALANTS – Dusts

    Cotton Mill Dust (A) 7 mm Cotton flock (B) 7 mm Cotton Mill Dust 3 mm Cotton linters (HS) 2 mm
    Cotton Dust (Cr) 2 mm Cotton fabric (B) 3 mm Kapok cotton (A) 2 mm Kapok (B) 3 mm
    Kapok (HS) 3 mm House dust (A) 6 mm House dust (B) 9 mm House dust (Cu) 2 mm
    House dust Mix 8 mm House dust (Cr) 10mm Hay dust (A) 3 mm Hay dust (B) 3 mm
    Hay dust (Cr) 2 mm Orris root (B) 2 mm Orris root (HS) 6 mm Paper dust (A) 2 mm
    Paper dust (Cu) 2 mm Paper dust (Cr) 3 mm Straw dust (B) 2 mm Grain dust mix (HS) 3 mm
    Mx thrsh dust 14mm Threshing dust (B) 2 mm Wheat grain dust 2 mm Wheat grain dust 2 mm
    Wheat thresh dust 3 mm Wheat thresh dust 3 mm Wheat thresh dust 3 mm Wheat thresh dust 2 mm
    Rice grain dust (A) 2 mm Glue fish (HS) 2 mm Pyrethrum (HS) 2 mm Tobacco mix (HS) 2 mm

    INHALANTS – Epithelials (Dander, hair, feathers)

    A1 Mixed inhalants 7 mm A2 Mixed inhalants 3 mm Buffalo dander (A) 2 mm Buffalo dander (Cu) 3 mm
    Cattle hair (HS) 6 mm Cow hair (B) 3 mm Cow dander (A) 2 mm Cow dander (Cu) 3 mm
    Cat fur (B) 6 mm Cat hair (HS) 2 mm Dog hair (3205) (B) 3 mm Dog dander (Cu) 3 mm
    Dog hair (HS) 2 mm Dog hair (Cr) 7 mm Goat hair (B) 2 mm Horse hair (A) 3 mm
    Horse hair (B) 7 mm Horse Dander (Cu) 3 mm Horse Dander (HS) 2 mm Human hair 2 mm
    Rabbit fur (B) 3 mm Rabbiit hair (HS) 3 mm Sheep wool (B) 2 mm Sheep wool (HS) 3 mm
    Sheep wool (Cr) 2 mm White wool (B) 2 mm Wool mixed (A) 3 mm Mix feathers 6 mm
    Mixed feathers (HS) 6 mm Chicken feathers 3 mm Pigeon feathers (B) 2 mm Pigeon feathers 3 mm
    Negative control (Glycerinated buffer saline)

    Scheme of treatment for Allergic disease

    Treatment of Alergic disease

    Allergy treatment has to be planned from 5 main fronts:

    To avoid the allergens causing allergy, the first thing is to know what one allergic is to. This is the main aim of an Allergy Test. An allergy test is the only way that a person’s allergies can be pin pointed. Allergy is a disease caused by multiple allergens. Once the causative allergens are identified, the aim is to keep down to a minimum, the exposure to these items (foods, inhalant dusts) and minimize the “total allergic load”, beyond which the symptoms get precipitated.

    Inhalant allergies are commonly due to inhalation of dust in the home. Even the “cleanest room” anywhere in the world will have “house dust and house dust mite” as important constituents. House dust is inhaled by an individual for 6 to 8 hours during sleep. A room may look clean but may not necessarily be “dust free”. Suggestions on making a room dust free should be followed.

    Other inhalant allergens include  human hair, fungi, disintegrated insect parts, pollens coming in from the environment outside including animal hair etc.

    Food allergies are treated by avoidance of the foods found allergic to, taken in reduced quantity or rotated. It is initially recommended to avoid the foods found allergic to on skin prick testing for one month. Later on the food items are added in a particular sequence.

    Avoid sprays, perfumes, deodorants, insect sprays, odours from paints etc. They are irritants and not necessarily allergenic.

    Avoiding triggers helps cut down on the “total allergic load” and helps keep the total level of allergen exposure to below the threshold level at which the allergic symptoms get precipitated.

    Deworming treatment and vitamin C and calcium tablets may be taken after the initial month of food avoidance and dust control.  Later anti inflammatory and anti allergic treatment may be prescribed as and when necessary. Many people with mild allergies are content to continue with the above as an initial measure and take the help of an occasional anti allergic tablet.

    Reserved for certain cases of nasal polyposis by functional endoscopic sinus surgery (FESS), correction of a deviated nasal septum, drainage of pus locked in the sinuses treatment may be performed as and when necessary. Drainage of sinus discharges to open up drainage paths.

    Oral Vaccine Therapy (OVT) for developing immunity to the offending allergens completes the spectrum of treatment modalities available for complete control of allergic disease. OVT is available only after the Skin Prick Test result  and banned after the RAST Test. World Health Organization – (WHO) and World Allergy Organization (WAO).

    Immuno-modulation is the only way of changing the immune system of a particular person to prevent the antigen antibody reaction in any organ by building up specific IgE antibodies against specific allergens that cause allergy in that person, as identified by an allergy test. Oral vaccines are safe and easy to take in a home environment.

    The final aim of relief from allergy symptoms is to achieve allergy control with allergen avoidance and immunotherapy, with, if necessary, minimal medical therapy. Adhering to the above scheme should improve quality of life, prevent progress of inflammation to irreversible pathological changes, relieve physical distress and prevent the detrimental effects on psychological & social aspects of an allergic individual’s life.

    Oral vaccine treatment for Allergic disease

    Treatment of Allergy  by Oral Vaccine

    (Oral Allergen Mixture for Sublingual Immunotherapy (SLIT))

     

    These are mixtures of glycerinated aqueous allergen extracts for specific de sensitisation of allergic diseases.

    The raw material is extracted with glycerinated buffer saline. Sub lingual Immunotherapy is used for treatment of a wide variety of common allergic conditions – respiratory tract allergies such as asthma, rhinitis, skin allergies, migraine, food allergies etc.

    The oral allergens stimulate the body to develop antibodies against the specific allergens such as pollen, animal hair, fungal spores, mites, dusts and foods.

    Each course of the Allergen mixture therapy is specially dispensed for an individual patient in accordance with the information obtained from the patient’s allergy skin test reactions.

    They are dispensed from standard bulk extracts from Creative Drug Industries, New Mumbai, and have undergone stringent quality control tests such as determination of pH, glycerol limit test, phenol limit test and sodium chloride test. They have also undergone toxicity and sterility tests as per I.P. At no stage is human or animal serum used.

    Side effects from immunotherapy with Oral Allergens are practically unknown. They are safe, effective and acceptable even to pediatric patients.  However, it should be avoided during pregnancy.

    Administration

    It is taken orally, half an hour before or two hours after any meal, according to the recommended dosage scheme. The extract is kept under the tongue for 1 to 2 minutes. It is then swallowed. (SLIT – Sub Lingual Immuno Therapy)

    Dosage: Each course consists of an Initial treatment course of 3 multi dose Vials of allergen extracts in graded concentrations and a Maintenance course of multi dose vials in strength 3.

    Initial treatment course Commenced with the No. 1 Vial, proceeding next to the No. 2 Vial and finally the No. 3 Vial as indicated in the dosage scheme enclosed along with.

    Maintenance course should immediately follow the Initial course without interruption. If for any reason, there is any interruption of treatment of more than 4 weeks maintenance treatment should NOT be attempted, but the Initial course of Vials No. 1, 2 and 3 should be taken again.

    To prevent lapse in continuity, Fresh No. 3 Vials should be obtained well in advance, much before the No. 3 Vial in use is about to finish.

    ALLERGEN MIXTURE DOSAGE GUIDE

    Oral mixture of allergens (Creative Drug Industries)

    For ORAL use only     (Not to be injected)

    Patient’s Name :

    Date -

    Dose No.
    Day
    Date, Month, Year No. of drops Progress relating to severity& frequency of symptoms
    VialNo.1(1+9999)(0.01% w/v) 1 Monday 1
    2 Wednesday 2
    3 Friday 3
    4 Monday 4
    5 Wednesday 5
    6 Friday 6
    7 Monday 7
    8 Wednesday 8
    9 Friday 9
    10 Sunday 10
    VialNo.2(1+999)(0.1% w/v) 11 Monday 1
    12 Wednesday 2
    13 Friday 3
    14 Monday 4
    15 Wednesday 5
    16 Friday 6
    17 Monday 7
    18 Wednesday 8
    19 Friday 9
    20 Sunday 10
    VialNo.3(1+99)(1% w/v) 21 Monday 1
    22 Wednesday 2
    23 Friday 3 Inform for further No. 3 Vial
    24 Monday 4
    25 Wednesday 5
    26 Friday 6
    27 Monday 7
    28 Wednesday 8
    29 Friday 9
    30 Sunday 10

    ALLERGEN MIXTURE DOSAGE GUIDE

    Oral mixture of allergens (Creative Drug Industries)

    For ORAL use only     (Not to be injected)

    Patient’s Name :

    Date -

    Dose No.
    Day
    Date, Month, Year No. of drops Progress relating to severity& frequency of symptoms
    VialNo.3(1+99)(1% w/v) Twice in a week 31 Monday 10
    32 Thursday 10
    33 Monday 10
    34 Thursday 10
    Twice in a week 35 Monday 10
    36 Thursday 10
    37 Monday 10 Inform for further No. 3 Vial
    38 Thursday 10
    39 Monday 10
    40 Thursday 10
    VialNo.3(1+99)(1% w/v) Once in a week 41 Monday 10
    42 Monday 10
    43 Monday 10
    44 Monday 10
    45 Monday 10
    46 Monday 10
    47 Monday 10 Inform for further No. 3 Vial
    48 Monday 10
    49 Monday 10
    50 Monday 10

    Note –

    The final dose of 10 drops once a week should be continued without interruption for 2 to 3 years for lasting benefit.
    There should be no interruption in taking the allergen mixture. Care should be taken to order fresh No. 3 vials well in  advance to avoid break in continuity of administration of the mixture.
    Since extra solution has been added to each vial, some amount may remain in the vials. The extra solution in vials No 1 and No. 2 should not be used, but preserved till expiry in the refrigerator. Vial No. 3 is the main vial and  its contents should be utilised till the bottle is empty.
    If there is an interruption in the continuity of administration of over 2 months, it is advisable to start all over again from Vial No. 1, No. 2 and then No. 3 for maximum therapeutic benefit.
    Contents of Vial Nos 1, 2, and 3 (Initial course) should last approximately 9 weeks. The next Vial No 3 should last approximately 12 weeks (3 months). The subsequent No. 3 vials should last  approximately 16  weeks each ( 4 months).

    Sublingual Immunotherapy  (SLIT)

    Allergen specific immunotherapy, together with drugs and allergen avoidance, is the corner stone of management of res­piratory and other allergies. Allergen-specific immunotherapy is the practice of administering to subjects with aller­gy, increasing amounts of allergens to achieve a hypo sensitization and to reduce the symptoms occurring during the natural exposure to the allergen. Immunotherapy is an allergen-oriented immuno mod­ulator that modifies the body’s immune response to allergens.  The action is seen to develop slowly, but surely, over  many months.

    In SLIT, on an empty stomach, the extract is kept under the tongue for 1 to 2 minutes. It is then swallowed. Contact of the allergen with the oral mucosa leads the allergen into the regional cervical lymph nodes. Also, once swallowed, the allergen enters the abundant gastrointestinal tract mucosal – immune – sys­tem, the so-called gut-associated lymphoid tissue [GALT]. Therefore an effective antigen presentation is achieved. Objectively, increase in allergen-specific IgE and IgG4 have been noted,  which confirm that SLIT has a significant potential to induce immunologic changes.

    SLIT modifies the natur­al history of the disease (i.e, the onset of asthma in patients with rhinitis) and it prevents the onset of new sensitizations. Moreover it has a long-lasting effect after discontinuation. This reduces the days with clin­ical symptoms, the intake of medication and intake of systemic and local steroids and improves the patient’s quality of life. SLIT also significantly reduces non specific (as well as specific) bronchial hyper responsiveness preventing the development of asthma in patients with allergic rhinitis.

    Preventive effect and long-lasting efficacy

    A  SLIT course involves a buildup phase (extract adminis­tered at increasing doses) and a maintenance phase (extract adminis­tered at a final optimum dose), in which the maximum dose is administered 2 or 3 times a week usually for 3 years -long~term immunomodulation. SLIT can be given preseason­ally or pre-coseasonally, (for pollen allergies) or continuously for perennial allergens.

    Efficacy

    Conventional SLIT confers positive clinical benefit in patients whose allergic rhinitis and bronchitis are resistant to conventional drug treatment. Symptom benefits last for at least 4 to 5 years thereafter. Young pediatric patients are started early in AR to prevent asthma. Accelerated build up schedules (“Rush Therapy”) by high dose SLIT are possible due to its good safety pro­file, tolerability and effectiveness.

    SLIT has a similar efficacy as compared with the conventional SCIT (SubCutaneous ImmunoTherapy). Both treatments are  significantly more effective than pharmacologic treatment alone. As with SCIT, SLIT is not an alternative to drugs for controlling symptoms, but it must be used in combination with them.

    Safety

    An ideal allergy de sensitization scheme should offer safe and effective therapy for those with allergic disease even without the presence of an allergist, which can be taken by the patient on his own in community settings. Safety would also ensure  better patient compliance.

     

    Side effects

    Side effects are extremely rare. Occasionally noted are oral/sublingual itching or lip swelling after taking the dose. Rarely headache, rhinorrhea, conjunctivitis, gastrointestinal upset and urticaria. Not a single severe systemic adverse reaction has been reported in the literature in 15 years.  In none of the patients was the discontin­uation of treatment required. Side effects are ususally mild and self-resolv­ing, not requiring any treatment and controlled by a temporary dose adjustment.

    CONCLUSIONS

    The clinical efficacy of SLIT in both asthma and rhinitis is now supported by a large number of controlled trials, and it appears particularly suit­able also in pediatric allergies.

    In 1998 the World Health Organ­ization, and the ARIA (Allergic Rhinitis and its Impact on Asthma) document on the basis of an extensive review of the litera­ture, concluded that sublingual (SLIT) immunotherapy is a viable & valid alternative to injection immunotherapy SCIT) and that its use in clinical practice in adults and children is safe, effective and justified. Cur­rently, SLIT is used in many European countries. Oral immunotherapy has been successfully used since over 15 years now.

    Environmental Control Procedures for Common Allergens

    An important way to reduce the severity and frequency of your allergy attacks is to avoid allergens and irritants that make them worse. Many of them exist in the home and here are a few suggestions to reduce your exposure to them.

    HOUSE DUST

    House dust has been recognized since many centuries as one of the major causes of allergic asthma and allergic rhinitis. It is unique among airborne allergens in that it is prevalent in the atmosphere throughout the world and present even in the cleanest room. House dust is a mixture of materials both living and non-living. It consists of human scales, dried disintegrated parts of domestic insects likes flies, mosquitoes and cockroaches. It also contains particles of wool, cotton, bed clothes, cracked paint, fibers from furnishings, bird feathers, flakes and fur of animals. It is now well known that the most important allergenic component of house dust is the house dust mite. Patients with house dust and house dust mite allergy usually have bouts of sneezing an watery nasal discharge and / or asthmatic attacks when bedroom dust is disturbed by shaking the bedding or switching on the fan which churns up the dust. Attacks usually occur early in the morning or just awaking from sleep. The patient is much better when he is outdoors where house dust exposure is less.

     HOUSE DUST MITE

    House dust is composed of small particles of paint and animal material in the home. While this mix is not appealing to us, microscopic creatures called house dust mites thrive in it. The droppings of these mites are the most common trigger of perennial (round the year)allergy and asthma symptoms. Dust mites are found throughout the house, but they especially thrive in high humidity and in areas where human dander (dead skin flakes) is located. It measures approximately 0.1 mm in size and is invisible to the naked eye. It thrives in the human environment and is therefore found wherever human beings live and especially where they sleep. It feeds on remnants of house hold food and especially on the skin scales shed by human beings. Every minute, 40,000 dead skin cells fall from our body. 70% of the dust in our home consists of shed human skin.

    Each of us sheds approximately 5 grams of skin scales and hair every week. 1 gram of this accumulates in the bed and bed clothes – an amount that can support upto 10,000 mites. In the bedding, upto 400 mites may be found in 1 gram of dust. Not only mites but their excreta and dead mites are allergenic.

    Symptoms of dust mite allergy can include a. congested or runny nose with sneezing (particularly in the morning), itchy, watery eyes, coughing and wheezing. .

    To reduce dust mites, it is important to control humidity to below 50 % throughout the home by using a dehumidifier or central or window or air conditioning.

    Wall-to wall carpeting should be removed as much as possible, especially that which is laid over concrete floors. Hardwood, tile or linoleum is better for those with allergies. Washable throw rugs may also be used if they are regularly washed in hot water.

    Because people spend more time in the bedroom than in any other room, it is essential to reduce mite levels there.

    Cover mattresses box springs and pillow in airtight zippered plastic or special allergen-proof fabric covers. Bedding should also be washed weekly in hot water ( 130 degrees F ) and dried in bright sun light. Mattresses should be aired regularly at least once a week. Pillow and razias ( comforter) made of natural materials such as down feathers or cotton should be replaced with items made from synthetic fibers or covered with allergy-proof encasings.

    It is also best to have smooth, uncluttered surfaces with dust collecting objects placed in drawers or closed cabinets. Avoid using the room where you sleep as a library or study. .

    Weekly vacuuming can help to further remove dust mites. Those with allergies should use a vacuum with a HEPA ( high efficiency particulate) filter or a double bag, since using standard or water filtered vacuum cleaner stirs dust up into the air. Allergic individuals should also wear a dust mask while house cleaning.

    House dust mites live in textile items preferably in deeper zones of the mattresses, carpets, upholstery and clothing. They live where people live even in excellent hygienic or unhygienic conditions and are not seasonally restricted. Allergenic character of mites shows cross reactivity with crustaceans ( shellfish) and insects. They are implicated as triggering factor in as many as 70 % of allergic asthma cases. Cross reactivity between mites and grass pollens has been observed. Remove carpets from bed rooms, dry clean all other carpets in the house, clean heavy drapes and dust regularly. Expose mattresses to sunlight, use mite proof sheets/pillow covers.

    Oral vaccines against House Dust Mite allergy are now available.

    MOLD CONTROL

    Mold is commonly found in outdoor air. However, any house can develop a mold problem given the right conditions. You might not see it growing on walls, but it may still be present in your home. Molds require two factors to grow indoors.

    1.) Free moisture that can occur in the form of relative humidity above 5.0%.

    2.) Something to grown on like food, fabrics, in bathrooms behind the sink, toilets, tubs, washing machines, leaking roofs, poorly sealed basement, refrigerator drip  pans, air conditioner reservoirs.

    These areas should be cleaned regularly and repaired. House plants, stuffed toys, wool carpets should be removed as far as possible. Mold colonies grown on the side of the house, windows next to outdoor plants debris or out side walls that are covered by or adjacent to growing plants. Hence as far as possible keep this area clean. Seal clothing, mattresses and pillows in plastic bags. Use synthetic furnishings. Indoor humidity can also be controlled by good ventilation, bright lights and air conditioning.

    Unlike pollen, mold do not have a specific season, but are affected by weather conditions such as wind, rain or temperature. Outdoor mold spores begin to appear and reach their peak in July in warm states and October in cold. Common airborne molds include Alternaria, . Cladosporium and Aspergillus.

    People allergic to mold should avoid fermented foods, beer, mushrooms, etc. Use of cleaning solutions containing 5% bleach and small amount of detergent is recommended.

    FUNGUS/MOLDS

    Alternaria This is a second most common fungal spore found in the atmosphere on dry days commonly seen on ripening cereal and during harvest time. It is associated with bakers asthma and atopic dermatitis ( skin allergy).

    Aspergillus Fungus commonly found in humid tropical areas and associated       with atopic dermatitis, asthma and alveolitis. Cross reactive with Candida.

    Penicillum This fungus is associated with climatically cold conditions e.g. in humidifiers and air conditioners. It is commonly implicated in atopic dermatitis and find a good nutrient source in the form of paint, wool, cotton, and food scraps.

    Cladosporium It is the most widely found universally present airborne fungal spore limited largely to cool dry seasons.

    Candida There is a wide cross reactivity between various fungi and food mainly wine, cheese, beer and other fermented foods. It is commonly found on mucosal surfaces and cross reacts with Aspergillus

     

    Botrytis Fungus associated with dry dusty areas. Cross reacts with Aspergillus fumigatus

    Mucour Mold seen in bakeries, on floor, wood, dust and dried fruit.

    In general for those allergic to fungi ( molds) like Alternaria, Aspergillus, Penicillum, Candida, Cladosporium, Botyritis etc. should follow these restrictions.

    1.       Remove all damp area on wall by white washing

    2.       Eat fresh food/ not left over food especially bread and roti

    3.       Avoid using wet towels/ shoes/ socks and dry well before use.

    4.       Dust the house regularly.

    TREES GRASSES AND POLLENS

    Pollens are the tiny, egg-shaped male cells of flowering plants. These microscopic .powdery granules are necessary for plant fertilization. The average pollen particle is less than the width of an average human hair. Pollens from plants with bright flowers such as roses, usually do not trigger allergies. These large, waxy pollens are carried from plant to plant by bees and other insects.

    On the other hand, many trees, grasses and low growing weeds have small light, dry pollens that are well suited for dissemination by wind currents. e.g. Parthenium (congress grass), Lawsonia (mehndi), Bermuda grass (dhoob grass ).These are the pollens that trigger allergy symptoms. Each plant has a period of pollination that does not vary greatly from year to year. However, weather conditions can affect the amount of pollen in the air at any give time.

    Generally the pollen season lasts from February or March through October.

    Tress pollinate earliest, from February through May. Although this may fluctuate in different location starting in April in colder northern regions or as early as January in the south. Grasses follow next in the cycle beginning pollination in May and continuing until mid July. Weeds usually pollinate in late summer and early autumn.

    COMMONLY FOUND POLLEN  ALLERGENS AND WHERE THEY ARE FOUND

     

     

    POLLEN ALLERGEN               SITE / CROSS REACTANTS

     

     

    Eucalyptus People allergic to pollen trees should avoid spices belonging to family anise, caraway, coriander (dhania), cumin, (jeera) parsley.

    Parthenium Cross reacts with ragweed.

    Pine Tree / Acacia The trees share common n-glycans, liquid transfer proteins Profilins (panallergens) with other nuts, e.g. cashew nuts, hazelnut, coconut, and recently reported cotton.

    Mugwort /Artemesia This is a widely distributed weed in parks & gardens. It cross reacts with various fruits, e.g. melons, lychees, and vegetables like cucumbers, carrots.

    Grass Smut / (Dhoob Grass) Bermuda Grass is seen in sub tropical areas. Pollination seasons from April to end August. It cross reacts with rye, tomatoes, carrots, wheat, raw potatoes, soybean, peas and peanuts. Individuals allergic to grass should avoid cereals during the harvest season.

    MISCELLANEOUS

    Latex

    It is an active compound in rubber items e.g. gloves, chappals, condoms, elastic etc. It cross reacts with various fruits and vegetables e.g. papaya, bananas, avocados, kiwi fruit and berries, plums, tomatoes, potatoes, chestnut ( singhara).

    Exercise

    This acts as a cofactor in precipitating asthma attacks if allergenic food is ingested prior to an exercise program.

    PREVENTING FOOD ALLERGIES

    Food allergies can cause severe allergic reactions, ranging from rashes to complete systemic failure ( called anaphylaxis ).

    The major strategy for preventing food allergies is to completely avoid or delay exposure to potentially allergenic foods and liquids for a month. This can be followed by gradual reintroduction done one at a time to see which particular food they are sensitized to. Please bear in mind foods are rarely taken in isolation and there may be many hidden additives in and various combinations in the food that we eat.

    The only way to tell for sure whether you have intolerance is to eliminate suspect foods from your diet for five to ten days. Then reintroduce them one by one to see if they spark symptoms, which you should notice within a couple of hours and may last from a few hours to a day or so.

    Keeping a food dairy will help identify culprits. Leave five days between reintroducing foods. .

    Once you’ve identified troublesome foods, cut them out of your diet for three to six ” months. You may then be able to tolerate small quantities without provoking a reaction.

    CONTROLLING HOUSE DUST MITES

    House dust is composed of small particles of paint and animal material in the home. While this mix is not appealing to us, microscopic creatures called house dust mites thrive in it. The droppings of these mites are the most common trigger of perennial (round the year)allergy and asthma symptoms. Dust mites are found throughout the house, but they especially thrive in high humidity and in areas where human dander (dead skin flakes) is located.

    Symptoms of dust mite allergy can include a. congested or runny nose with sneezing (particularly in the morning), itchy, watery eyes, coughing and wheezing. .

    To reduce dust mites, it is important to control humidity to below 50 % throughout the home by using a dehumidifier or central or window or air conditioning.

    Wall-to wall carpeting should be removed as much as possible, especially that which is laid over concrete floors. Hardwood, tile or linoleum is better for those with allergies. Washable throw rugs may also be used if they are regularly washed in hot water.

    Because people spend more time in the bedroom than in any other room, it is essential to reduce mite levels there.

    Cover mattresses box springs and pillow in airtight zippered plastic or special allergen-proof fabric covers. Bedding should also be washed weekly in hot water ( 130 degrees F ) and dried in bright sun light. Mattresses should be aired regularly at least once a week. Pillow and razias ( comforter) made of natural materials such as down feathers or cotton should be replaced with items made from synthetic fibers or covered with allergy-proof encasings.

    It is also best to have smooth, uncluttered surfaces with dust collecting objects placed in drawers or closed cabinets. Avoid using the room where you sleep as a library or study.         .

    Weekly vacuuming can help to further remove dust mites. Those with allergies should use a vacuum with a HEPA ( high efficiency particulate) filter or a double bag, since using standard or water filtered vacuum cleaner stirs dust up into the air. Allergic individuals should also wear a dust mask while house cleaning.

    House dust mites live in textile items preferably in deeper zones of the mattresses, carpets, upholstery and clothing. They live where people live even in excellent hygienic or unhygienic conditions and are not seasonally restricted. Allergenic character of mites shows cross reactivity with crustaceans ( shellfish) and insects. They are implicated as triggering factor in as many as 70 % of allergic asthma cases. Cross reactivity between mites and grass pollens has been observed. Remove carpets from bed rooms, dry clean all other carpets in the house, clean heavy drapes and dust regularly. Expose mattresses to sunlight, use mite proof sheets/pillow covers.