By Bobbie Fisher
After a winter that saw more snow than most years, Hampton Roads seemed more than ready to welcome spring – even that yellow pollen that collects on cars, sidewalks, creekbeds and of course, lungs. So like clockwork, rather than the cold, people are now grumbling about the allergies that accompany spring. It’s a common complaint: “Hampton Roads is the worst place in the world if you have allergies!”
That’s actually not true, although there is some basis for the misconception. At one point in time, about 20 years ago, Tidewater (as the area was then known) was the No. 2 area in the United States for allergy issues, although today, according to the Allergy and Asthma Foundation of America, Hampton Roads doesn’t even rank in the Top Ten. The closest city in that group is Richmond, which occupies the No. 8 spot. The first appearance by a Hampton Roads city is Virginia Beach, at No. 29.
Even at that, says Himanshu D. Desai, MD, a pulmonologist with Bayview Physicians Group, he is seeing 25 percent more patients with asthma in Hampton Roads than he did in Buffalo, where he trained.
That’s small comfort to those who suffer the sneezing, runny nose, watery eyes and other symptoms of the seasonal allergies that beset them every spring? And why does Hampton Roads get such a bad rap?
“It’s our climate,” says Gary B. Moss, MD, of Allergy & Asthma Specialists, Ltd., who is Board certified in internal medicine as well as allergy and immunology, “we live in a mild, temperate climate. The ocean has a warming effect that keeps us above freezing most of the year, so allergens don’t die off. We’re wet and warm and moist, so these allergens just abound. Up north, people get a break from allergies when there’s so much snow on the ground for so long.”
Despite our heavier than usual snowfall in this past winter, there was tree pollen present in Hampton Roads in February. In fact, when the first snow of 2015 fell, there was already a tree pollen rating of 2.3, on a scale of one to 12.
There’s still another aspect to the warm, wet climate in Hampton Roads that affects and even causes allergies, says Ann P. Zilliox, MD, of Allergy & Asthma of Oyster Point in Newport News, a Board certified allergist/immunologist. “It’s mold,” she says, “something people don’t understand particularly well. Mold will grow any place there’s organic material and water. Everything that isn’t stone or metal can develop mold. Patients can have problems with mold that run the gamut from severe allergic reactions to no symptoms at all.”
So while Hampton Roads might not be the worst place for allergy sufferers, there are a great many tree pollens and grasses – and of course, mold – that send sufferers to their physicians for relief from their symptoms.
Making the diagnosis.
It starts with a comprehensive history and physical exam. If patients present with a green/yellow discharge, that indicates an infection. It’s difficult because patients might have both an allergy and an infection that’s exacerbated by that allergy. In those cases, physicians treat the infection aggressively, and if they feel better quickly, allergy is unlikely. Or if patients feel better, but symptoms recur right away, then physicians will look for an underlying allergy issue that might be triggering the infectious problems. Unlike infections, allergies are not caused by bacteria or virus.
Sometime the history and physical is all it takes to make a diagnosis. “If a patient comes in and says, ‘every time a cat walks into the room, my nose gets stuffy and runny and my eyes itch,’ that’s kind of obvious,” Dr. Moss says. And there are lots and lots of cat allergies. In fact, there are more people seriously allergic to cats than to dogs. “Cat allergen is very light, aerodynamically stable in the air,” Dr. Zilliox explains. “That’s why when an allergic person walks into a house where there’s a cat, they don’t need to see the cat to know one’s around. These people don’t get beyond the foyer before they start blinking.” Even when a cat leaves the house, there is measurable cat allergen hanging around in the air for an average of six months.
Of course, it’s rarely that obvious, Dr. Moss says, so after taking an exhaustive history, if he believes skin testing is necessary, he’ll perform those by pricking the skin with several different allergens to see what patients react to. But, he notes, “We only pick certain patients for testing, when the results can help define a treatment regimen.”
Most physicians are doing fewer skin tests today, a departure from the huge numbers done several years ago. Dr. Zilliox explains, “Ultimately, when you test patients, the results of the tests have to correlate with the history; it’s the only way to make the tests valid. A patient might test positive for horses, but never be around horses. And if they have symptoms all year round, but their tests only show positive to grass and pollen, that doesn’t explain enough. History, symptoms and test results have to jibe.”
Skin tests remain the preferred method of testing, although in certain cases – including patients on certain medications, having unstable hearts or poorly controlled asthma, or severe skin conditions – physicians use blood tests to determine antibodies in the system.
What’s not understood is the mechanism that makes someone produce such antibodies.
What we do know, says Dr. Angela Hogan, an allergist/immunologist at Children’s Hospital of the King’s Daughters, is that we’re born with all the hardware we need to become allergic in early infancy: “The allergy cell is called the MAST cell, or mastocyte, and there is plenty of histamine in them that could be released should we have an allergic reaction.” Dr. Hogan has patients as young as six weeks who are diagnosed with an allergy; although, she points out, “it’s usually a milk allergy, or something infants have more immediate exposure to. Environmental allergies tend to be more delayed” – but the process for allergic reaction is in place and viable.
There is a genetic component, Dr. Hogan says. “We know that allergies run in families. And we know that if one parent has allergies, there’s a 50 percent chance the child will have them as well. If both parents have allergies, the child has an 80 percent chance.”
But it is the child who determines the specific allergy, and a parent’s allergy is no predictor of the child’s, Dr. Hogan adds. Additionally, allergies are affected by birth order. The firstborn child, who tends to be kept at home a lot, is more likely to develop allergies than a child later in the birth order. The firstborn brings home infections to younger sibling(s), who gets sick – but those very illnesses might be protecting the younger child(ren) from the development of allergies.
“We still don’t really understand it,” Dr. Zilliox says. “I just returned from the annual American Academy of Allergy, Asthma and Immunology conference in Houston. And that’s still what the conferences are dealing with: identifying what causes a person to make an allergic antibody. We’re still working to answer that.”
In Hampton Roads, as in the developed world, allergies and asthma are on the rise.
“There are many theories as to why that is,” Dr. Zilliox says. “One is the so-called ‘hygiene theory,’ which essentially says that the less sick we are, and the less dirty we are, the more allergic we are.” Dr. Moss agrees: “It’s our clean, hygienic environment and access to medical care that keep us free of a lot of diseases that might actually predispose us to becoming allergic.”
In places like South America, Southeast Asia or Africa, where people still have parasites and still have lives dealing with dirt and agriculture – which North Americans increasingly don’t – there’s virtually no childhood asthma, virtually no hay fever, and very few of the allergic diseases that Americans suffer.
Treating allergies and asthma.
There are three basic treatment options: “The first is avoidance,” Dr. Moss says, “but that’s not always possible. The second is medication, and there are many good medications on the market that work for a lot of people, both controller meds and rescue medications.”
The mainstay of treatment for asthma is inhaled corticosteroids. “Patients with uncontrolled allergic asthma might benefit from omalizumab, which is an antibody to immunoglobulin E,” Dr. Desai says. “New drugs are in Phase III clinical trials,” he adds, including interleukins, which are showing great promise.” He cautions patients and caregivers that asthma is a leading cause of death, but it is preventable, so long as medications are used regularly and appropriately.
When medications fail, the third strategy is allergy shots.
The past year has the introduction of sublingual immunotherapy. Rather than the standard subcutaneous immunotherapy, the allergen is placed under the tongue. “We’ve been able to do that for a number of years as an off-label treatment,” Dr. Moss says, “but it hasn’t been FDA-approved so insurance doesn’t cover it. Two products were introduced this last year – one for grass allergies and one for ragweed.”
In every case of allergy and asthma, these doctors agree, it’s critical to follow medication regimens exactly. “Too often, when people start to feel better, they stop taking their medicines,” Dr. Desai says. “But the allergy isn’t going to go away. People need to use these medications regularly, so when they’re exposed to triggers, they don’t react.”
