Allergy Information

Seasonal allergy, or hay fever, is a common disorder afflicting between five and ten percent of the population. The Allergy Group is keenly interested in this group.

At its mild stage, seasonal allergy can be easily controllable by avoiding common pollen sources, such as grass mowing and conventional antihistamines. On the other hand, moderate to severe seasonal allergies can be miserable, interfering with normally enjoyable outdoor activities and interrupting proper sleep patterns. This can lead to fatigue and poor concentration with a falloff in school and work performance.

In contrast to other forms of “allergy” such as idiopathic urticaria (hives) or intrinsic non-allergic asthma, seasonal allergic rhinitis is due to the area’s seasonal pollen patterns. This can be accurately determined 90 percent of the time with direct skin testing or a specific blood test termed RAST (radioallergosorbent test).

Before focusing on allergic rhinitis, it is advisable to understand the mechanism of allergy. An allergy is an abnormal antibody response to an external protein termed an allergen. The IgE antibody is fixed to the surface of mast cells in tissue such as the respiratory tract or basophiles which circulate in the blood stream. When a specific allergen is absorbed through the respiratory membrane, the allergen combines with two surface antibodies. This triggers the release of chemical mediators such as histamine that react on the nerves and blood vessels to produce tissue swelling and irritation. The allergy sufferer then experiences nasal congestion, profuse watery drainage, sneezing and eye inflammation—in other words, hay fever. The allergens, which are inhaled, are numerous, greatly magnifying a patient’s symptoms.

To treat the hay fever patient, the general physician diagnoses the problem as allergy versus nasal or sinus infection and prescribes appropriate medication. The medication includes antihistamines (Allegra, Astelin, Clarinex, or Zyrtec), decongestant, pseudoephedrine, topical corticosteroids (Flonase, Nasacort, Nasalide, Nasonex, Rhinocort), or, in severe cases, an injection of cortisone for short-term relief.

Unfortunately, in spite of these fairly recent treatments made available over the last 10-15 years, many seasonal rhinitis patients do not respond and require a specialty evaluation by a trained allergist*. The allergist’s office nurse performs direct skin testing to reproduce the allergic reactions topically to the suspected seasonal pollens and perhaps mold spores. The testing results, which take an hour to perform, are then correlated with the patient’s symptoms. An allergy extract of the reacting pollens is formulated by the allergist to eliminate the allergy and the troubling symptoms. This treatment is termed immunotherapy.**

It is essential that the allergist be familiar with allergic pollinating plants in his area of practice. Southwest Idaho is located in the northern aspect of the Great Basin of North America. The Great Basin is an arid region consisting of grasslands and sagebrush, with trees such as cottonwood and willows in the river corridors and conifers in the mountains. With agriculture with extensive irrigation, the flora of this region has changed drastically over the last 100 years, introducing new trees, weeds, and crops that have significant allergic potential.

Through pollen sampling during the spring (April 1st) to fall (October 31st), the pollen of this region’s allergic plants can be identified. Important allergic plants produce wind-dispersed pollen that adheres to ova resulting in plant seeds and reproduction. A compact sphere of protein and some carbohydrate, this pollen ranges in size from 20-150 microns. These microscopic pollen grains are normally invisible to the human eye.

Our office counts pollen on a daily basis using an electronic device termed a rotorod. The rotorod spins one of every six minutes over a 24-hour period and collects the pollen on a greased rod’s surface.

Once collected, the rods are stained and the pollen counted by Brianne Ayers, PA-C. The results are published in the Idaho Statesman as a public service. Online pollen counts are now available on this website. The pollen data is vital to the understanding of the area allergens. Without such information, formulating an allergy extract for the allergy patient is guesswork. Each season the pollen pattern changes, as it is weather dependent. The spring tree pollen time is especially variable. The heavy rain in May suppressed the pollen count. Ideal pollen conditions consist of hot, dry, windy weather. The wind disperses high volumes of pollen, resulting in flares of allergy symptoms. These conditions occurred during the final week of May, producing high counts of grass pollen.

Southwest Idaho has a long growing season. The worst allergic pollens are grass in late May and especially the first two weeks of June to the Fourth of July. Plus, high mountain pastures of Timothy can bloom in July. The sagebrush pollen is comparable to grass as a cause of allergy, causing late summer and fall symptoms. Sagebrush pollen peaks from September 15 to October 15 in Boise. The weed season (Russian thistle, ragweed, etc.) is of moderate importance allergenically in August and early September. As in most areas of medicine or science, allergic information is not static. Even though I have been sampling pollen since 1971 in Southwest Idaho, a new location at Mercy Medical Center North revealed new spring pollens that have significant allergic potential, namely mulberry, an ornamental tree, and rumex, an introduced weed.

In closing, I should emphasize the importance of integrating a seasonal allergy patient’s symptoms with direct skin testing and a daily area pollen count. This approach, in conjunction with immunotherapy, offers the best prospect of relief for moderate to severe seasonal allergy symptoms.

*An allergist is a physician trained in the general field of internal medicine or pediatrics with a further two years of training in the specialty of allergy. Allergists are also board certified in their general field, as well as the specialty of allergy.

The summer season, despite being while warm to hot, is normally low in pollen production. There are some weeds, such as Chenopod or tumbleweed, and Plantain which are moderate allergy offenders but tend to be of low volume. There may still be some late-blooming high mountain grass fields, especially in view of the wet spring, so don’t forget your usual allergy medications when camping. Be sure not to camp in blooming grass fields, especially Timothy grass. Stick with the woods to set up your camp and tent. The Allergy Group wishes you symptom-free camping until the next major pollen season starts in mid-August.

As the tree pollen season fades away in May, grass pollen begins. Grass pollen allergy, like sage, is a major source of allergy, lasting for six or more weeks. The grass pollen begins to show up in mid-May through the Fourth of July holiday. Fairly low counts of 30 or above on the 24-hour sampler can produce moderate to severe allergy symptoms as allergy patients are quite sensitive to grass pollens. Counts of grass pollen can reach levels of over 100 and are highest the first two weeks of June. Grass pollen may persist into July due to a late spring season in the mountains, which it did this past year because of the wet spring.

Spring allergy begins with ground thawing in February, allowing trees with allergic potential to bloom in late March. Boise is blessed with a variety of introduced trees, some with significant allergic potential. Elm, oak, and maple pollen herald the spring allergy pollen season, at times appearing on pollen samplers the first week or two of March. Relatively low counts of 25 to 30 tree pollen per 24-hour sampling can initiate mild to moderate allergy symptoms.

The tree pollen cycles rather rapidly from a few days to ten to fourteen days. Fortunately, allergic tree pollens are frequently washed away in the usual rainy springtime. Cottonwood and juniper reach high counts during April, at times causing severe symptoms in dry springs. Sycamore, ash, locust, walnut, and mulberry can also reach high levels, 30 to 50 or more pollens seen on a 24-hour sampler, causing their share of allergy. Linden, Russian olive, and willow cause mainly localized concentrations of pollens and might bother people who have these trees present in their yard.

The mid-August through September period has persistent hot temperatures and an upsurge in allergic pollen. This can be classed as a moderate pollen season. Typically Chenopod or tumbleweed pollen increases in mid-August, lasting two to three weeks. Chenopod, namely Lamb’s Quarters, releases small numbers of pollen May through August. The increase in August pollen is due mainly to Kochia, Russian Thistle, Pigweed, Western Waterhemp, and other related weeds. For about a week, Ragweed appears during the Labor Day holiday. This pollen season can be aggravated by dust from grain or alfalfa harvest. At times, smoke from range or forest fires will produce an irritant factor which can further increase hay fever or asthmatic symptoms. Chenopod counts at peak levels range from 30 to 60 per 24-hour sampling period.

Sagebrush is a major source of allergic pollen, equal to grass pollen in symptomatology, and blooms and releases heavy amounts of pollen during mid-September to mid-October causing about a month or more of allergy symptoms. Depending on the weather, sagebrush can bloom a week earlier or one to two weeks later than mid-September. If September rains arrive, sagebrush pollen concentrations can be minimal. Sagebrush counts can reach levels totaling 400 to 500 counts per 24-hour sample in ideal conditions. Sage counts over 100 are not well tolerated, causing moderate to severe allergy symptoms. Sagebrush may bloom two to four weeks early in the mountain plateaus with low sagebrush counts seen on our Boise valley pollen counts. This early mountain blooming of sagebrush can result in significant allergy in susceptible mountain hikers and campers.

When the sagebrush pollen is finished by the end of October, the pollen allergy ceases until next spring. The changeable fall weather, along with viral and other respiratory infections, combined with valley inversions can cause acute and chronic sinusitis, bronchitis, and asthma. Sinus infections are generally triggered by viral pharyngitis, causing a sore throat, persistent nasal congestion, coughing, headaches, and fatigue that lasts beyond the usual three to five days of common cold symptoms. The coughing can progress to asthma adding to this common cause of winter respiratory distress. At times the winter sinus season can be due to household allergens such as house dust, animal danders, or mold spores, but infection is the likeliest trigger. Infectious sinusitis is mainly prevalent in the cold winter season but can occur on a year-round basis.

Temporary treatment of severe nasal allergy symptoms can be accomplished with a corticosteroid injection. It can also be effective in the treatment of asthma exacerbations. This treatment is reserved for those patients who have failed conventional therapy or who are unable to follow conventional treatment. If successful, the injections typically relieve symptoms for two-to-four weeks. If a patient continues to be exposed to allergens after that time, symptoms may recur. The Allergy Clinic requires patients interested in corticosteroid injections to be fully evaluated by one of our clinicians before treatment. Due to the potential for side effects, we limit this treatment to one or two injections each year.

Before you consider this corticosteroid injection, you should be aware of the following:

• A corticosteroid injection is NOT an allergy shot. It is the injection of medicine which will result in the temporary relief of allergy symptoms.
• You may NOT receive the shot if you are diabetic, hypertensive, have a history of peptic ulcers or have an active infection.
• Corticosteroid injections will not be given to children.
• The injection will be given in the muscle of your hip. An uncommon side effect is subcutaneous atrophy. This atrophy manifests as a breakdown of the skin and underlying tissues, which may result in a permanent dimple. In some cases there may be muscle atrophy, a breakdown of muscle, which may result in an even larger indentation at the site of injection. This adverse effect is not serious, but may be significant from a cosmetic standpoint.
• Corticosteroids have systemic effects, the most important of which is decreased bone density (osteoporosis). The injection may also decrease the body’s ability to fight infections. It is unlikely that just one corticosteroid injection per year will place a person at risk, but this is a possibility. For more information about adverse effects, please see the complete list below.
• A corticosteroid injection may temporarily block your body’s ability to produce its own corticosteroids in response to stress such as a serious illness, accident or surgery. Prior to the injection, please let us know if you have a serious illness, have had an accident or anticipate surgery within the next month after you receive your injection.
• You should inform any healthcare provider you see that you have received a corticosteroid injection.

Adverse effects anaphylactoid reactions, aggravation or masking of infections.

General:

Cardiovascular: hypertension, syncope, congestive heart failure, arrhythmias, necrotizing angiitis, thromboembolism, thrombophlebitis.

Fluid and Electrolyte Disturbances: sodium retention, fluid retention associated with hypertension or congestive heart failure, potassium loss which may lead to cardiac arrhythmias or ECG changes, hypokalemic alkalosis.

Musculoskeletal: muscle weakness, fatigue, myopathy, loss of muscle mass, osteoporosis, vertebral compression fractures, delayed healing of fractures, pathologic fractures of long bones, spontaneous fractures.

Gastrointestinal: peptic ulcer with possible subsequent perforation and hemorrhage, pancreatitis, abdominal distention, ulcerative esophagitis.

Dermatologic: impaired wound healing, thin fragile skin, petechiae and ecchymoses, facial erythema, increased sweating, purpura, striae, hirsutism, acneiform eruptions, lupus erythematosus-like lesions, hives, rash, suppressed reactions to skin tests.

Neuropsychiatric: convulsions, increased intracranial pressure with papilledema (pseudotumor cerebri) usually after treatment, vertigo, headache, insomnia, neuritis, parasthesias, aggravation of pre-existing psychiatric conditions, depression (sometimes severe), euphoria, mood swings, psychotic symptoms and personality changes.

Endocrine: menstrual irregularities, development of the cushingoid state, suppression of growth in children, secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress (e.g., trauma, surgery, or illness), decreased carbohydrate tolerance, manifestations of latent diabetes mellitus, and increased requirements for insulin or oral hypoglycemic agents in diabetics.

Ophthalmic: posterior subcapsular cataracts, increased intra-ocular pressure, glaucoma, and exophthalmos.

Hematologic: lymphopenia, neutropenia.

Immunogical: diminished IgE levels, loss of delayed-type hypersensitivity, potential for increased risk of opportunistic infection/severe varicella infection.

An allergy is an abnormal reaction to an ordinarily harmless substance called an allergen. When an allergen, such as pollen, is absorbed into the body of an allergic person, that person’s immune system views the allergen as an invader and a chain reaction is initiated. White blood cells of the immune system produce IgE antibodies. These antibodies attach themselves to special cells called mast cells, causing a release of potent chemicals such as histamine. These chemicals cause symptoms such as a runny nose, watery eyes, itching and sneezing.

People can be allergic to one or several allergens. The most common include pollens, molds, dust mites, animal dander (dead skin flakes from animals with fur); foods; medications; cockroach droppings and insect stings.

An allergist/clinical immunologist is a Pediatrician or Internist who has undergone 2-3 years of special training in the diagnosis and treatment of allergic and immunologic diseases. To understand what you are allergic to, an allergist will take a personalized patient history, including a thorough record of the illness, family history, and home and work (school) environments; perform allergy testing, and possibly perform other laboratory tests. An allergist can create a management plan with you for better control of your environment. Your plan may also include proper medication and perhaps immunotherapy.

Immunotherapy, or "allergy shots", is recommended for patients with moderate to severe allergy symptoms throughout most of the year, who do not respond adequately to medications, and whose symptoms are triggered by an allergen that is not easily avoided, such as pollens or house dust mites. Immunotherapy involves the injection of allergenic extracts (tiny amounts of allergens) that are given over a period of 3-5 years. By gradually increasing the amount of extract, tolerance to the offending allergen will increase, and the patient’s symptoms will be relieved.

People with allergies have an inherited, genetic tendency to produce IgE, the allergic antibody, to many different substances such as seasonal allergens, (trees, grasses, weeds) or year-round allergens (dust mites, pet dander). When a person with allergies moves to another location, exposure to different allergens in the new location will likely result in a new set of allergy triggers, thereby trading one set of symptoms for another. In some cases, the benefits of a change in location may outweigh the negative aspects.

The tendency to have allergies is genetically inherited. Thus, instead of a cure, patients should work with their allergist to keep their allergies under control. Successful treatment of allergies includes early detection, proper usage of medications and simple allergen avoidance techniques.

In some cases, it is dangerous to ignore allergy symptoms. Severe and untreated hay fever may lead to asthma, sinusitis, and other serious conditions. Allergic dermatitis or eczema can spread to secondary infections if they are not treated properly, and untreated asthma can lead to chronic symptoms. Early detection and treatment of all allergic diseases is important.

Immunotherapy for food allergies is not recommended because of the chance of a severe allergic reaction to the injection. Currently, immunotherapy is used to treat patients who are sensitive to inhaled allergens—pollens, molds, dander and house dust. Studies have also found immunotherapy to be extremely effective in many cases of stinging insect allergy as well.