The Allergy and Asthma Clinic
Andrew C. Engler, M.D.
Medical Director
(650)343-4597
290 Baldwin Avenue
San Mateo, California 94401

The Allergy and Asthma Clinic Monthly Newsletters

February Newsletter 2012

Happy Valentines Day!

If kissing leaves you tingly, is it love or allergies?

“Kissing” allergies are most commonly found in people who have food or medication allergies. Symptoms can include swelling of the lips or throat, rash, hives, itching and wheezing. Food allergies affect about 2-3% of adults and 5-7% of children in the US population accounting for more than 7 million people, according to the ACAAI .

Even brushing your teeth or waiting hours after eating may not prevent some partners of people with food and medicine allergies from triggering an allergic reaction through a kiss, according to experts at the American College of Allergy, Asthma and Immunology (ACAAI), of which both Dr. Engler and Dr. Zhang are members.

According to allergist Sami Bahna, MD, past President of the ACAAI, if you have food allergies, having an allergic reaction immediately after kissing someone who has eaten the food or taken oral medication that you are allergic to isn’t highly unusual. Some patients even react after their partner has brushed their teeth or several hours after eating. It has been found that their partners’ saliva is excreting the allergen hours after the food or medicine has been absorbed by their body.

During one of Dr. Bahna’s presentations, an example of a 30 year old male with a peanut allergy who had recurrent anaphylaxis - which is a life-threatening allergic reaction - was discussed. This patient developed lip swelling and itching in his mouth when his girlfriend kissed him. It was discovered later that she had eaten peanuts two hours earlier and even though she brushed her teeth, rinsed her mouth and chewed gum prior to seeing him, it still wasn’t enough to protect him.

So what are lovebirds to do? It is recommended that the non-allergic partner brush their teeth, rinse their mouth and avoid the offending food for 16-24 hours before smooching with a person who is highly allergic to that food. But even these steps may not help in some cases.

According to the ACAAI, there may be more who are suffering from this than it is known because people may be embarrassed to bring it up. But we can help determine what’s causing the allergy and find the right treatment so no one has to needlessly suffer.

Interestingly, it’s not always the “obvious” food which is causing the problem. We’ve had quite a number of cases where the testing to the suspected food was negative, despite a very high level of suspicion. So often, it’s almost as important to know what you’re not allergic to as it is to know what you are. After all, why give up that delicious piece of mouth watering dark chocolate if it turns out it’s the almonds in the chocolate that are causing the problem and not the chocolate itself?

If you or someone you love is experiencing these or other symptoms you think could be related to an allergy, please feel free to contact our office and speak to us. We can help you identify the allergy, discuss therapy options such as appropriate lifestyle changes, preventative medications (for some cases) as well as many other options, including determining whether you are a candidate for desensitization to help you become less allergic.

Patching up your skin with Patch Testing!

Allergic Contact Dermatitis is a skin condition that occurs when your immune systems reacts to a chemical that is found in a product with which you come in contact. The contact can occur anywhere, including at home or work. Allergic Contact Dermatitis (ACD) symptoms include itchiness, redness, cracking or flaking of the skin, or fluid-filled blisters. It can occur anywhere on the body, and it is different than Atopic Dermatitis (eczema), although it is possible to have both skin conditions simultaneously. ACD is frequently caused by a chemical found in products or objects that you regularly use such as soap, lotion, sunscreen, cosmetics, perfume, sports equipment, shoes, or even clothing. You may have used a product for years without any problem, but at some point along the way, your immune system develops a sensitivity to this product. Once you develop an allergy to a particular chemical your immune system will usually react to that substance for a very long time, often the rest of your life. You may try to switch products on your own; however, many products contain similar chemicals so even if you switch to a different lotion or shampoo your skin stills reacts to the new product because it still contains that allergy causing chemical. In order to best treat your rash it is important to identify which chemical or substance is causing the problem so that you can avoid products that contain this substance in the future.

Our office is able to perform Patch Testing which can help to identify which chemical(s) may be causing your skin symptoms. At your first Patch Testing appointment, we will put a series of panels on your back, which you will then wear at home for 48 hours. There are several substances in these panels that are commonly known to cause allergic contact dermatitis such as nickel sulfate, Parabens, fragrances and wool alcohols. In addition, we can usually prepare additional testing panels to check for specific substances about which you or we have a high level of suspicion. You will be asked to return for 2 additional office visits during a 1 week period, at which time we will evaluate your test results and discuss them with you. We will also discuss how to identify which products contain the substances you are allergic to and talk about some medication options to help improve your rash more quickly. Patch testing is usually very well tolerated and side effects are minimal, but can include some itchiness at the test site. You may take oral antihistamines during the Patch Test to help with any itchiness you may experience.

In the last few months, we have diagnosed quite a number of cases of contact dermatitis, ranging from makeups used by television personnel which prevented them from going on the air, suture materials used during surgery that prevented wound healing, various soaps and cleansers used on a daily basis which suddenly started causing problems and various articles of clothing that suddenly started causing mysterious rashes. If you, or someone you know, has a persistent rash and you suspect that it could be Allergic Contact Dermatitis, please get in touch with our office for an evaluation. The test is simple and it can make a world of difference in your skin!

In observance of President’s Day the office will be closed

Monday, February 20th.

January Newsletter 2012

Want a pet and think a hypoallergenic dog is the answer?
Research studies are saying “think again”!

If you are thinking about adopting a dog and someone in your household suffers from pet allergies, you may have been told that certain breeds, including the Portuguese water dog famously adopted by the Obamas, are less likely to cause symptoms. But this may be just a myth, a new study suggests. According to a study recently published in the American Journal of Rhinology and Allergy, owners of poodles, schnauzers, and even Portuguese water dogs, widely promoted as hypoallergenic, have the same amount of a dog allergen known as “Can f 1” (canis familiaris allergen 1) in their homes as owners of dogs not typically billed as hyporallergenic. Researchers collected dust samples from 173 homes. The study included 60 breeds, 11 of which are frequently promoted as hypoallergenic. The researchers found that 94.2% of homes showed detectable levels of the allergen, and there were no significant differences between breeds.

According to Rohit Katial, MD Program Director of Allergy and Immunology at the National Jewish Medical and Research Center in Denver, the new study proves what he and others have been saying for a long time: “There is really no statistical difference in “hypoallergenic” dogs and others as far as allergen levels in the home. The allergen comes out of a dog’s saliva and their pelt and the hair is just a carrier as dogs lick themselves.”

However, the new findings don’t mean people with allergies can’t or shouldn’t adopt dogs. If someone with a pet allergy wants a dog or has a dog, there are many preventative steps that can be taken to help control allergies such as:

-Wash the dog regularly to remove allergy causing animal dander from its coat.

-Keep the dog out of the bedroom at all times, even when the allergic patient is not in that room.

-Use a high-efficiency particulate air (HEPA) filter. This can remove much of the animal dander in the air. Some HEPA filters can be attached to the furnace and may be efficient enough to clean the air in the entire house. However, a free standing unit which runs in the allergic patient’s bedroom should also be used and preferably should run 24/7.

-Visit a breeder or someone you know with the type of dog you are considering to make sure it is the right fit. Keep in mind the more active the dog, the more time you will spend outdoors with your pet.

-Work with your allergist to determine what level of allergy to the dog is present and how this level of allergy compares to the other allergies the patient may have.

- Consider immunotherapy to treat the underlying animal allergy. Immunotherapy, delivered as allergy shots or drops, can be remarkably effective in decreasing or even eliminating the actual cause of the symptoms. While we do not recommend that patients with allergies get a pet, we understand that it frequently happens and we have successfully helped thousands of patients become much less allergic, thereby decreasing both their symptoms and their need for medication.

Keep in mind no dog is 100% hypoallergenic, but there are steps you can take to ensure you can continue to love and enjoy your pet! Please contact us if you would like more information of this subject.

eNO and Spirometry, important tests to help keep you breathing well

In our November 2011 newsletter, we described the importance of monitoring exhaled nitric oxide levels in patients with respiratory allergies. Equally important, especially when done in conjunction with eNO, is spirometry. Spirometry is a simple test to measure how much (volume) and how fast (flow) you can move air into and out of your lungs. Utilizing spirometry is crucial in the management of any respiratory condition but especially in those already diagnosed with or at risk for developing bronchial asthma. (Remember patients with upper respiratory allergies such as hayfever and sinus problems have a 20 times higher risk of developing asthma than those without allergy.)

When outlining a treatment plan for asthma, it is important to take into consideration several points, including frequency of symptoms, how often a rescue inhaler is used, frequency of nighttime and early morning symptoms and how the respiratory condition affects daily activities, including sleep. While it is very important that these questions be answered, it is also imperative that we utilize diagnostic tools, such as spirometry, which will also provide us with objective data. Spirometry allows us to detect even subtle changes, often before the patient even experiences symptoms. With spirometry, many abnormalities can be detected in the early stages, when treatment is usually most effective. Spirometry can also help us assess airway function, as well as evaluate the patient’s response to a change in therapy, including changes in the type of or dose of medication.

INSURANCE CHECKUP

Now’s the time to complete a thorough review of your health insurance coverage and benefits. You will need to make informed decisions about your benefits as 2012 begins. Make certain that your plan allows you access to our Clinic and that we have accurate updated information. Your plan may require a referral. And remember, most insurance plans have a time limit for filing after which they may not cover your medical expenses. So make sure we have your new insurance information if you have any changes taking place in 2012. Ongoing access to the allergy and asthma care you require should be a critical factor in selecting your health plan for the New Year. If you have any questions with regard to your insurance coverage, our insurance specialists are ready to assist you in getting the full benefit out of your 2012 health plan to which you are entitled. Give us a call today! We’re here to help. We all wish you and your loved ones a Healthy and Happy 2012!

December Newsletter 2011

Is the winter holiday season triggering your allergies instead of your holiday spirit?

During the holiday season many people experience an increase in their allergy or asthma symptoms and the number of people visiting doctor’s offices are increasing every year during the holiday season according the American Academy of Allergy, Asthma and Immunology.

Winter and holiday allergies can be equal, if not worse, than other seasonal allergies. During the winter season air circulation tends to be stagnant because doors and windows are closed to prevent the cold air from entering. Un-circulated air causes allergens to build up providing a breeding ground for allergy attacks. In some homes raising the thermostat, using furnaces or stoves to keep warm, can trigger allergies for many people. In the winter season people spend more time indoors, exposed frequently to mold, dust mites, Christmas trees, as well your pets may tend to stay in more to stay warm.

There are a variety of things during the winter and holiday months that can cause allergy symptoms such as real Christmas trees, wreaths, holiday greenery, artificial decorations, potpourri and candles. The trick to making the holidays more enjoyable is keeping symptoms to a minimum. Here are some helpful holiday hints that should help you avoid a trip to the doctor’s office:
Live Christmas Trees and garland gives off a fresh woodsy odor to which many people are allergic. Commercially sold trees may also have been sprayed to help them stay green but a spray that may cause respiratory symptoms. Hosing down a live tree with water before bringing it in can help reduce allergens.

Artificial Trees and Decorations – because these are stored for a long period of time, these are often dusty and therefore a source of dust mites. These should be dusted outside before decorating. Use a hand held hand dryer
set on cool.

After decorating your tree – in the vicinity of your tree, place an air filter in the room using a HEPA filter. Alternatively, dust mite control sprays can often be used on trees while they are on display.

Storing Decorations – never use paper or newspaper when wrapping your decorations. This may harbor paper mites causing allergy triggers next year when the decorations are unpacked. Store your decorations in plastic.

Winter heating systems – Before turning on the heat for the season, change your furnace filters. Also, forced air heat and wood stoves can create low humidity causing many people to develop respiratory problems. Replace moisture in the air with humidifiers but make sure these are maintained to prevent mold and bacterial growth and make sure you keep the humidity below 40% to slow down mold growth; or you may want to just consider putting an inch of water in the sink and bathtubs or simply place a pot of water on the stove. Drink more water to prevent dry skin and to keep your nose, sinuses and lungs from becoming dry.

Potpourri and Candles – Many people are sensitive to the floral odors and allergic to mold spores that may come from dried vegetation in potpourri. Consider making your own potpourri blend of cinnamon, cloves, vanilla or peppermint. Avoid scented candles as these can also trigger allergy symptoms and even an asthma attack.

Fallen leaves – If you must rake leaves, wear a mask. People whose eyes itch when raking leaves may want to wear a pair of swimmers goggles to protect their eyes from allergy causing mold spores.

Cozy fires in the fireplace – Make sure there is adequate draft for the stove or fireplace. The person with allergies should not be in the room when a fire is being built. Wood bark can accumulate mold, put wood directly into the fire and do not stack wood in the house. Persons allergic to tree pollen may also be allergic to the wood when it is burned. The wood people are least likely to react to is oak.

A pet from Santa – Children who grow up with pets do appear to be happier and healthier as long as they are not allergic to the pet. If there is a family tendency towards allergy to pet dander and fur bearing pets, before considering getting a new puppy, kitty, rabbit or guinea pig for Christmas, you may consider allergy testing to make sure the person isn’t allergic. How sad it is for a child to get a new pet only to find they are allergic to it. But symptoms can decrease if the animal is kept in a specific area of the home and preferably where there is no carpet and not allowed on furniture and in bedrooms. Additionally regularly bathing cats and dogs, as well as their bedding, can reduce symptoms.

Stuffed Toys – Avoid stuffed animals with real fur. Also, stuffed animals may be filled with dusty or moldy foam strips. It is best if the stuffed animal is polyester filled and washable. Check the label for filling and washing instructions. Another alternative to decrease dust mites is placing the stuffed toy in a plastic bag and putting it in the freezer overnight or place the toy in a clothes dryer set on high for 30 minutes.

Holiday Stress – The immune system is powerfully affected by stress. Holiday stress from celebrations, over eating, alcohol consumption, and interruption of normal sleep patterns can worsen allergy and asthma symptoms. Getting regular rest and slowing down the pace of the holiday celebration promotes good health to help us enjoy the holiday season.

Immunotherapy – During the busy holiday season, it is important to continue to make the time to stay on track with your immunotherapy treatments. Just because spring isn’t in the air, doesn’t mean allergens aren’t. Continuing your immunotherapy treatments will help keep you feeling healthy allowing your holiday spirit to shine through.

We wish you all a wonderful and healthy holiday season filled with family and friends!!

November Newsletter 2011

Immunotherapy: Is it best to muster the cluster?

Allergy Immunotherapy is the medical term for a very effective treatment to help you become less allergic. The most common form of allergy immunotherapy is injection immunotherapy or allergy shots. This is a process where immunotherapy is gradually given in a steady process to "teach" your immune system a better way to work and is the closest we have to a cure.

While no allergy treatment is 100% effective for all patients, most patients dramatically improve and immunotherapy usually provides a better life style than the alternative, which is the ongoing use of pills or sprays to relieve allergy symptoms. These medicines only give you temporary relief and when you stop taking medications the benefit goes away; on the other hand, immunotherapy retrains your body's response and helps you become less allergic for long term relief.

Immunotherapy is a very effective treatment but is a long term commitment for patients and sometimes can be inconvenient. For some patients who have time constraints, there is an alternative immunotherapy choice called "Cluster Immunotherapy" which we are now providing in our office. Patients who are considering immunotherapy treatment may want to explore this as another option. Cluster Immunotherapy usually allows the patient to reach their maintenance dose more rapidly, which will allow the patient to begin experiencing the benefits of allergy immunotherapy sooner. Another benefit is your time commitment may be decreased because Cluster Immunotherapy typically requires fewer visits to reach the target or maintenance dose. Additionally, patients usually receive fewer injections than they would receive with conventional immunotherapy. Most of the time, during the buildup phase, the patient is able to receive the equivalent of a month’s worth of treatment in one visit to the office. This benefit occurs as a series of injections are given over a 2 hour period, hence the name: Cluster Immunotherapy. Although the risk of reactions is slightly higher, we can usually control this by pre-medicating the patient with antihistamines before their cluster visit. In a number of cases, Cluster Immunotherapy may be more convenient for the patient and can reduce their costs.

If this is something you wish to consider for yourself or a loved one, please discuss it with one of our health care providers to see if you would be a candidate for this treatment option.

The use of Exhaled Nitric Oxide (eNO) is now considered the gold standard in clinical practice.

Although we have recognized the benefit of eNO testing for many years, it is finally an Official Clinical Practice Guideline as announced by the American Thoracic Society in September. The American Thoracic Society now strongly recommends the use of eNO as an important tool in the routine management of asthma and has published clinical guidelines which will standardize the approach by which healthcare providers use this test to manage patients with airway disease.

Patients with respiratory allergies such as hay fever or sinus problems can have 20 times the risk of developing asthma as those who do not have allergies. Therefore, it was good news when, in 2008, the FDA approved the clinical use of eNO monitoring, to measure bronchial airway inflammation, thus enabling the health care provider to evaluate their patient's respiratory status more effectively. The eNO system is designed to quantitatively measure exhaled nitric oxide in human breath as a marker of inflammation in persons with allergies, asthma and other respiratory conditions. This objective biomarker also helps healthcare providers evaluate the patient's response to anti-inflammatory therapy and, if indicated, allows reduction of medication dosage without diminishing treatment outcomes.

Dr. Engler was among the first physicians in the community to begin using eNO evaluation in the management of patients with allergies and other respiratory problems. With this tool, we have improved our ability to diagnose and treat many of our patients and we are happy that we have been able to provide you with this valuable procedure for many years. We are even happier now that many insurance companies are including this as a covered benefit for our patients, saving them out of pocket costs for a treatment that has proven very beneficial!

It's that time of the year again, it's flu season!

Seasonal influenza (the flu) results in higher morbidity and mortality rates among patients with certain chronic medical conditions such as allergies and asthma. This is a reminder to all our patients that we recommend an influenza vaccination annually. If you want more details regarding the safety of receiving the influenza vaccine or if you or a loved one have an egg allergy and have been told you should not receive a flu shot, please visit our website www.theallergyclinic.com and go to our Newsletter archives section and click on November 2010. There you can read more about scientific studies showing that most patients allergic to eggs, (long thought to be a contraindication for receiving the flu shot), can now safely receive this vaccination.

Thanksgiving Office Schedule
Wed, Nov 23 - Open 9am-5pm
Thurs, Nov 24 - Closed
Friday, Nov 25 -Closed
Sat, Nov 26 - Open 9am-12pm

October Newsletter 2011

Take the tricks out of treats and keep your little pumpkin safe!

Halloween can be a tricky time for the growing number of children who have food allergies. The scary parts of Halloween are supposed to involve ghosts and witches, not the treats!

According to the Kids with Food Allergies Foundation, today one in 17 children are affected by allergies to foods such as milk, peanuts and tree nuts, ingredients commonly found in candy. Peanut allergy, among the most common life threatening allergies, has doubled in frequency within the last five years. As the number of food-allergic children continues to rise, more and more parents are challenged with keeping their own kids and their neighbors’ children safe this Halloween.

We would like to offer some Halloween tips to keep all of our gremlins, ghosts, and ghouls safe to enjoy another Halloween celebration next year. Here are some Halloween suggestions for parents with food allergic children:

Purchase a variety of candy, including some that does not include any milk, soy, or peanuts. Read labels carefully as some ingredients may be hidden. Check all ingredients and remember that treat-sized candy may have different ingredients or be manufactured on different machinery than their full-sized counterparts.
Consider having non-food item treats on hand such as stickers, fun pencils, small toys or even coins for the child's piggybank.
Plan an alternate activity such as going to the movies, a slumber party or have a safe treat scavenger hunt.
When trick-or-treating, carry your child's emergency medicine, bring sani-wipes with you and carry safe snacks for your child to enjoy during this time.
Give neighbors safe Halloween treats in advance to hand to your food allergic child.
Prepare a container filled with safe treats in advance, and then swap it for the treats collected.
Try a variation of the "Tooth Fairy" and leave the unsafe candy for the "Candy Fairy" who exchanges it for a small gift, toy or money.
If your child is older, have him or her trade unsafe treats for safe ones with their friends.
If possible, donate leftover candy to children who may not be able to go out and trick or treat.
For school parties, you may want to speak to your child's teacher in advance and make some suggestions or provide safe snacks. You also may want consider attending the classroom party so you can monitor the situation, but remember your child's emotional needs and be careful about drawing unnecessary attention to his or her food allergies.

Food allergies can be life altering, but not always life long.

Food allergy symptoms can range from mild to life-threatening. The most common symptoms of a food-allergic reaction include hives, itchy rash, swelling, itching, tingling, swelling of the lips, tongue, or mouth, vomiting, abdominal cramps, or diarrhea. Other symptoms may include coughing, trouble breathing, wheezing, drop in blood pressure, or loss of consciousness. Though most symptoms occur within minutes of eating the allergy causing food, reactions can present up to two to four hours later. The specific type of symptoms that occur during a food-allergic reaction can be hard to predict. In addition, what may initially appear to be a mild reaction may quickly turn more severe and dangerous.

Having a child with food allergies means constant anxiety, vigilance, planning, and limitations on family activities. Additionally, it gives a child the feeling of being "different" which can cause social stresses throughout their school years and into their adulthood and sometimes lead them to feel stigmatized. The unfortunate reality is that there is presently no proven cure, other than avoidance of these food allergens. However, many investigational studies are showing that oral and sublingual desensitization, similar to the very effective technique used for airborne allergens such as pollen and dust, will eventually be an excellent treatment for many patients with food allergy.

Placing restrictions on your diet throughout your lifetime can be difficult and can give you a sense of anxiety about eating outside of your own environment as well as an uneasiness about trying new foods. Statistics show that 80% of children outgrow some food allergies such as eggs, milk, soy and wheat. Peanut allergies, however, have a lower chance of being outgrown, at 20%.

Food allergies have increased substantially over the past decade, leading many parents to institute dietary restrictions for their children. However, it should be noted that serious food allergies are often over diagnosed. In addition to over diagnoses, many children outgrow their food allergy and their parents are not being made aware of it.

Our new associate physician, Dr. June Zhang, has a special interest in this area and brings to our group her expertise in assessing whether our patients must continue to restrict their diets. A procedure called “Oral Food Challenge" is currently being offered at our clinic. The goal for this procedure is to determine whether the patient needs to avoid the food in question or if they have outgrown their allergy to a particular food(s). Knowing that you have outgrown a particular food allergy can provide a better quality of life, give you the ability to open up your diet without restrictions and relieve any stigma you may feel. Being made aware that you no longer have an allergy to a particular food can be a life long relief and provide the pleasure of knowing that you or your child can live more freely and enjoy foods you have missed throughout the years.

When properly conducted, Oral Food Challenges are safe. Dr. Zhang has her patients go through a series of simple screenings first to determine whether she is confident the patient will safely pass the food challenge testing level.

If you or a loved one have experienced a reaction to certain foods in the past and/or have been told that there is a food allergy concern and you would like to know if you have outgrown your allergy to these foods, please contact our office and set up an appointment to meet with Dr. Zhang and discuss it with her. Dr. June Zhang's credentials include board certifications in both Pediatrics and Allergy and Immunology and she is here to help you. Wouldn't it be a relief to know that you no longer have to avoid certain foods for the remainder of your life?

September 1, 2011

It’s back to school time.

Be prepared to get a good start for this academic year!

Heading back to school is an exciting time for most students and parents. However, for parents of children with allergies, it can be a time of anxiety and fear.

The school environment exposes students to many allergy and asthma triggers. The challenges of school life frequently add additional stress that can aggravate allergies and asthma. And, for those with food allergies, dining at school or on campus can seem like a minefield.

These may seem like daunting hurdles to overcome. But with a little planning, prevention and preparedness, it can be accomplished successfully. If you have teens, start working with them now so they can successfully transition from high school to college and at the same time take a more active role in managing their health. Studies have shown that young people are more likely than others to take risks with their health. For example, one study found that many young people with food allergies have eaten a food even though they know that it contains an allergen. As responsible parents, it is time to educate your children about their allergies and what measures to take to prevent reactions and to keep them healthy and safe. Inform your teens that taking control of their health and being prepared for emergencies will help them manage their asthma and allergies and give you some peace of mind.

Cooperation is the key. Parents, school officials and teachers should work together to create a safe environment for students with allergies. Depending on your child's allergic condition, you may want to consider the following:
Tour the school to identify potential asthma or allergy triggers.
Talk with your child's teacher(s) and other relevant school personnel (such as sports coaches and school nurses) about your child's condition, food allergies and treatment plan.
If your child is at risk for life-threatening reactions, such as those to food or insect stings, complete an Anaphlyaxis Action Plan and show school staff how to administer autoinjectiable epinephrine and provide them with a doctor's note to allow your child to take emergency medication at school.
Send safe snacks with your child for classroom parties. Or, ask the teacher to limit goodies to stickers, pencils and other non-food treats.
Keep in mind the most common asthma and allergy triggers in the classroom include: dust mites, mold, chalk dust, animal dander.

Recess, gym class and after-school sports may be a favorite time of the school day for many children but for those with allergies or asthma it can be a war zone of potential triggers. You may want to consider signing up for regular pollen count email alerts with the National Allergy Bureau so you can plan accordingly if your child takes medication to control symptoms.

Children with exercise-induced asthma may complain about participating in physical activities. However, it is very important for children to stay active, so work with our staff to develop strategies to keep your child symptom-free while exercising. You may want to consider the following:

Using a short-acting inhaler 15 minutes prior to exercise.
Drinking plenty of water before, during and after exercise.
Choosing sports that are less likely to trigger symptoms.

It is particularly exciting for students to go off to college because it marks the beginning of adulthood and it may be the first time they will be living independently. Here are some additional tips for the college bound:

Keep prescriptions filled and up-to-date. -Always have your medications on hand, including your autoinjectable epinephrine and quick-relief inhaler.
Be aware of signs that you need to seek medical attention.
Consider talking to your friends and roommates about your allergies and asthma. Letting those close to you know about your health and the signs of a medical emergency can help you stay safe.
When you arrive on campus, meet with staff, especially food service personnel and residence hall advisors, to develop a plan to control your allergies and asthma.

Has your family been on vacation and taken a holiday from their allergy treatments?

Now is the time to restart their preventative treatment so your child is prepared for the upcoming school year. If their medications no longer seem to work or they have let their immunotherapy lapse, it is time to talk with us about getting back on track for school. As we noted in earlier newsletters, although allergy shots remain the gold standard, sublingual drops can be a very effective alternative, especially for those patients who can’t or won’t take allergy injections. Allergy drops have proven very successful with many of our patients and are very easy to incorporate into a child or teen’s busy schedule.

We can help you create an effective treatment plan for your child’s allergy problems. Our professional staff will give you the information you need to choose the right treatment that will help your youngster feel better and perform at their best. Give us a call and let us help you get your child off to a great start in the new school year.

August 1, 2011

Please welcome a new physician to our team!

We are very proud to introduce our new associate physician, Dr. June Zhang, who will be starting practice with our group on September 1, 2011.

Dr. Zhang grew up in Seattle and received her MD degree from the Medical College of Wisconsin. She completed her pediatrics residency at Children's Hospital of Oakland in 2006 and her allergy and immunology fellowship at the Children's Hospital of Pittsburgh and University of Pittsburgh Medical Center in Pennsylvania in 2008. She started her career in private practice with Allergy, Asthma & Immunology Associates in Dallas, Texas where she also was a clinical instructor of Allergy/Immunology at the Children's Medical Center of Dallas, University of Texas Southwestern Medical Center. She loves children and has extensive training in asthma, food allergy, eczema and other allergic conditions . Dr. Zhang is Board Certified both in Pediatrics and Allergy & Immunology. She also is a member of American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology.

Dr. Zhang is excited to be a part of our group and to contribute to the health and well-being of our patients. She plans to spend the remainder of her career in the Bay Area working closely with Dr. Engler as well as being nearer to her family and friends.

Dr. Zhang enjoys cooking, painting, traveling and spending time with family and friends. She is also proficient in Chinese (Mandarin). We are currently making appointments for Dr. Zhang; please let us know if you would like an opportunity to meet with her so that she can help you with your allergies and asthma.

With Dr. Zhang's expertise, we are able to expand the scope of our practice and offer new
technology and procedures in our office

Dr. Zhang has a strong interest in asthma and food/drug allergy evaluations. She believes optimal asthma management and the identification of food and drug allergies with subsequent oral challenge and/or desensitization can be life changing for patients.

Food Allergy Challenges

Food allergies can be very hard on not only the patient but the entire family, especially when the patient is a child. Fortunately, 80% of children will eventually outgrow their egg, milk, wheat, and soy allergies and 20% will outgrow their peanut allergy; the question is when. Properly performed oral challenges coupled with skin and blood testing can all assist in identifying these children. Dr. Zhang is very adept at performing food challenges and has helped many patients successfully identify whether their food allergies have clinical significance and whether it remains important to keep these foods out of the diet.

Drug Allergy Testing and Desensitization:

Penicillin Allergy--Like Dr. Engler, Dr. Zhang feels it is crucial to evaluate, test, and desensitize patients with drug allergies, especially those with a history of penicillin sensitivity. More than 97% of patients with a positive history of penicillin allergy have negative skin tests and can safely be treated with penicillin without developing a life-threatening allergic reaction. Often childhood rashes and adverse drug reactions are mistaken for a penicillin allergy which leads to unnecessary avoidance of this family of antibiotics. In addition, the natural history of penicillin allergy is that it often lessens or even resolves over time. Knowing if a patient is truly allergic offers many benefits including allowing the use of what is often the “antibiotic of first choice”; penicillin is frequently less likely to cause side effects and is usually a more cost effective medication.

Aspirin Allergy—Many patients would benefit from taking aspirin but cannot do so because of allergic reactions they have experienced. This is especially troubling for patients with heart disease whose doctor has advised them to take aspirin daily to help prevent cardiovascular disease or patients with arthritis who are unable to get the relief they need. Scripps Institute has developed very successful protocols for both diagnosing and desensitizing aspirin allergy and like many allergy practices in the SF Bay Area, we have sent a number of patients down to San Diego for this medical procedure. Dr. Zhang has extensive experience in diagnosing and treating aspirin allergy and we are very excited to now be able to treat our patients in our office. This procedure can be very beneficial for patients allergic to aspirin who have trouble with nasal polyps and/or asthma. Successful aspirin desensitization also allows patients to take similar medications such as Ibuprofen or Aleve.

Plavix Allergy—Most patients who have cardiac stents need to be on a medication such as Plavix to help prevent a clot from forming. However, studies have shown that 2% of patients who need to take Plavix are allergic to it. Dr. Zhang has helped many patients with this problem overcome their allergy with oral desensitization, thereby allowing them to take this important medication.

Nasal Endoscopy---Dr. Zhang performs nasal endoscopies and laryngoscopies, which are valuable tools to assist in the evaluation and diagnosis of sinusitis, nasal polyps, vocal cord dysfunction, vocal cord nodules and other sinus diseases. It also helps to determine when consultation with an ENT specialist is necessary.

In observance of Labor Day, please be advised that we will be closed on Monday, September 5th

July 1, 2011 - Newsletter

Is Summer becoming the new Allergy Season? Tips on How to “Ease the Sneeze"

We recently came across a news interview in which ABC Medical News Medical Editor Dr. Tim Johnson spoke with Dr. John Costa, Clinical Professor of Medicine at Harvard Medical School. Dr. Costa noted that more and more individuals are suffering itchy, stuffy, sneezy symptoms not only in the spring time but now well into the summer months.

Global climate changes appear to be causing a shift in the typical pollen seasons, making the individual seasons last longer and the amount of pollen produced higher. Historically, pollen counts here in California have followed a fairly standard pattern. Spring is usually the time when tree pollens (such as cypress, eucalyptus, oak and pine) are the most prevalent. As we get into the later months of spring, tree pollen counts usually wane and grass pollen counts begin to dominate. For the last few years, the spring tree pollen season has started earlier and lasted longer. At the same time, grass pollen counts have been elevated the last few months—giving many allergy sufferers a one-two punch, without the chance to catch a break in between. The result? A longer, more pronounced spring pollen season, which is lasting well into the summer months, causing ongoing discomfort for many allergy sufferers without adequate protection.

The frustrating dilemma is that the spring and summer months are when we most want to be outdoors enjoying ourselves but this is also when exposure to pollens is at its highest. Fortunately, there are a number of things you can do to decrease your allergy discomfort.

Here are several simple ideas to help reduce exposure:

Avoid going out early in the morning between 5am and 10am, this is when most pollens are emitted into the air and when pollen counts are at their highest level.
Keep windows closed in your house, especially on windy days when pollen is high.
Roll up car windows and use your air-conditioner when you are driving.
Your hair collects a lot of pollen during the day. To avoid getting it on your pillow, and then into your nose and eyes, wash your hair before you go to bed at night.
Avoid hanging your laundry out to dry.
Keep your house and particularly your basement dry; use dehumidifiers if needed.

Using medications properly can help reduce your allergy symptoms. Remember, most allergy medicines work best when taken before you have exposure, rather than after you are already experiencing allergy symptoms. However, if you suffer from allergies or asthma year after year, if your symptoms seem to last longer and/or seem to be getting worse, or if you don’t want to be needing to take allergy and asthma medications to feel healthy, you should talk to us about whether you are a candidate for immunotherapy to treat your underlying allergies. Immunotherapy is the closest thing we have to a "cure". If you want to speak to us to see if this might be a good option for you, please contact our office. We are here to help you feel better and enjoy our beautiful weather.

Are you planning a summer vacation? Make sure allergies and asthma don’t ruin your fun.

Summer vacation: It conjures up visions of relaxation, sports, sunny days, perhaps sand and water or mountains and woodlands. For individuals and families with asthma and allergies though, it means extra thought and preparation before "the good times roll."

As we head full tilt into summer, here is a list of some useful hints, courtesy of The Allergy and Asthma Foundation of America, to help you enjoy a healthy and fun vacation.

Take with you a detailed list of your medications showing prescription refill number, prescribing physician and dosage. (Each medication's original label should have all the needed information.)
Pack the needed quantities of medications and, if possible, also pack a backup quantity to avoid being caught short. Be sure to pack your medication in your carry-on luggage in case checked luggage is lost.
Be sure to bring an emergency epinephrine injection kit if you or someone in your family has insect sting or food allergies which have caused life threatening allergic reactions.
Include with your medications a topical hydrocortisone cream and oral antihistamine (prescription medication, if available, or an over-the-counter brand previously used with good results).
For those prone to exercise-induced asthma, it may be a good idea to keep prescribed emergency medication with you at all times.
If you or a family member with asthma is using a peak flow meter, be sure to bring it along on your vacation, with the chart that is used to record the results.
If you are using a nebulizer to deliver anti-asthma medication, it should not be left at home when going on vacation. Be sure that, if traveling abroad, you have an electrical current converter for the nebulizer. For campers and others who will be "roughing it", portable nebulizers powered off on an auto cigarette lighter receptacle are available.
To protect against dust mites, it may be wise to pack your own allergy-proof pillow or mattress encasings.
People with serious asthma and allergy conditions should consider wearing a medical alert-type necklace or bracelet at all
times.
Check the limitations of your medical insurance policies before leaving the country or state.
Know your vacation destination's available

medical facilities and specialists. If you take a vacation in a foreign land, you might consider contacting the International Association for Medical Assistance to Travelers at (716)754-4883.

When in hot weather, people with asthma and allergies should drink plenty of fluids.
Avoid exposure to tobacco smoke whenever possible.
Call ahead to order a special meal on the airplane or pack your own "safe" snacks.
If eating out of the country where you don't speak the language, have a warning note drafted in local language that alerts wait staff to your allergy.
Prior to beginning a lengthy auto trip to your vacation spot, take appropriate measures to rid the vehicle's ventilating and air conditioning system of mold and mildew.
Request a hotel room that is nonsmoking and mold free.
If you receive allergy injections, make sure to time your visits so you receive an allergy shot shortly before you go on vacation, to help keep your immune system in tip top shape.

If you have health concerns or questions that pertain to your trip, please do not hesitate to contact our office and discuss these concerns with us. We want to do everything possible to make sure your summer vacation is fun and rewarding!!!

Please be advised that in observance of 4th of July, we will be closed on Monday. We will open during our normal business hours on Saturday, July 2, from 9am-noon and on Tuesday, July 5, from 9am-7 pm.

June 11, 2011

Can "global warming" actually cause more allergies?

According to researchers who are monitoring this trend, it does! Pollen counts were at record levels last year and it was deemed one of the worst allergy seasons we have seen. With the heavy and sustained rain we have had to date, the unfortunate fact is that pollen counts appear to be even worse this year.

Researchers found that increased temperatures are causing the spring allergy season to come earlier in the year and last longer into the summer. Ten sites were monitored between Canada and across the United States from 1995 thru 2009. Daily temperatures were measured and then compared to corresponding pollen counts. The results showed that the higher the temperature, the higher the pollen count became. The explanation was that high temperatures produced more plant growth and more plant growth produced more pollen. Thus, higher temperatures and more rain have caused higher pollen counts which have resulted in an increase in allergies.

Their findings demonstrate a domino effect: The increase in carbon monoxide causes an increase in temperature which causes an increase in pollen which causes an increase in allergies. Even people who have never suffered allergies before are now suffering symptoms for the first time because pollen counts are steadily increasing to record levels. And many patients are finding that treatment that used to work quite well for them is no longer giving them adequate relief because their allergies have gotten worse. We’re also seeing many patients who previously had only upper respiratory allergies who have now developed asthma.

If you or your loved one are experiencing miserable sneezy, stuffy, itchy symptoms that never seem to go away or if you are now getting symptoms you have never experienced before, you just may be starting to develop new or increased allergies to pollens. Fortunately, with proper allergy testing and treatment, we can usually reduce, if not eliminate, many of these symptoms to ensure a better quality of life. One very effective treatment, immunotherapy through shots or drops, makes most patients much less sensitive to the harmful effects of pollen.

If allergies are getting you down, please contact us to discuss what treatment options will best fit into your lifestyle and help you fight back against the rising pollen levels.

We now have Penicillin allergy testing available at our clinic.

It is estimated that penicillin allergy is greatly overstated and a lot more people think they are allergic to penicillin than really are. Approximately 85% of patients who describe themselves as penicillin allergic will have negative skin tests and can safely receive penicillin. PrePen is the only FDA approved skin test for the diagnosis of penicillin allergy and we are excited to offer this service to our patients.

Penicillin allergy testing not only benefits patients, but also physicians and other health care providers, as well as surrounding communities. These benefits include fighting resistant bacteria and offering less expensive treatments for patients. As many of you know, drug-resistant bacteria pose a major public health threat in today’s world. Many patients thought to be allergic to penicillin are treated with very potent antibiotics which are often quite expensive. Continued use of these antibiotics may lead to increased drug-resistant bacteria, limited availability of alternative treatment for more severe infections, and greater side effect profiles.

How does one undergo Penicillin allergy testing?

After obtaining your medical history, you and your healthcare provider will decide if you are a candidate to undergo this evaluation. Penicillin allergy testing is performed via skin tests and if the skin tests are essentially negative, an “oral challenge” to penicillin is performed. Negative test results using PrePen indicate a 97% confidence that the patient can be treated without the fear of a life threatening reaction if they are to take an antibiotic in the penicillin family. It is important to note that penicillin allergy testing may be contraindicated in those patients who have had a systemic reaction to penicillin. However, many patients with a history of penicillin allergy had a rash many years ago or were told when they were younger that they were allergic to penicillin but do not remember the details. Most of the time, these people are good candidates for penicillin allergy testing and will be found not to be allergic to this antibiotic—thus making treatment of future infections much safer and less expensive.

If you or someone you know would like to consider undergoing an allergy evaluation to penicillin, please contact our office and our staff will be happy to assist you.

Does your mouth itch after you eat apples, melon or other fruits and veggies? You may have a common allergic condition known as The Oral Allergy Syndrome.

Many patients have remarked that they when they eat apples, melons or other fruits, within a few minutes they develop intense itching of their tongue, throat and roof of their mouth. It turns out that many patients with seasonal allergies experience itching of the oral cavity after eating certain foods that share common proteins with pollens. This condition is called The Oral Allergy Syndrome and has been found to be quite common in those allergic to birch tree pollen (spring pollen), grass (summer pollen), and ragweed (fall pollen). Patients with tree pollen allergy often have oral itching after eating apples, pears, peaches, kiwi, celery, and parsley. Patients allergic to grass may react to kiwi, peach, celery, melon and tomato. Finally, ragweed-sensitive patients may have these same oral symptoms after eating bananas and watermelon. The allergic reaction to these foods can occur any time of the year when eating them but tends to be worse during the pollen season, especially if your typical allergy symptoms are very troublesome. Importantly, heating most of these foods at high temperature often reduces or eliminates the allergenic proteins, so the patient may be able to tolerate cooked fruits and veggies (although for me, cooked watermelon is not a culinary delight).

Interestingly, many patients who receive immunotherapy for their pollen allergies, with either allergy injections or sublingual drops, find that their oral allergy symptoms also improve. While it’s not recommended that you take allergy shots so you can eat apples without having your mouth itch, this phenomena is a good example of how allergic cross reactions work and of the benefits of getting your underlying allergies under optimum control.

If you’ve noticed adverse symptoms in response to fruits, vegetables or other foods, refrain from eating them and check with us about the safety of eating them in the future.

In addition, If you are concerned about a food allergy or sensitivity, please contact our office so we can arrange appropriate testing to help you sort this out and develop a game plan designed to keep food allergies from causing irritating symptoms, making you sick and/or disrupting your life.

Andrew C. Engler, M.D.