Meeting Updates

Highlights from the 2009 Allergy Meeting

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I recently attended the 2009 annual meeting of the American Academy of Allergy, Asthma, and Immunology(AAAAI) in Washington, DC. There were five days of extraordinary educational activities (March 13-17, 2009). I thought that while I could still read my notes I would share with you a few things I observed, heard, and learned in the ever evolving world of allergy. I plan to adopt many of these changes in my practice.

The meeting’s agenda covered a wide variety of clinical conditions. It would have been impossible to attend every session. I chose sessions on the allergic environment, eczema, immunotherapy, food allergy, re-certification, headaches, and asthma. There are a number of ideas that are evolving and a number of things currently done in allergy/asthma care that need to change. Each and every one of these topics is truly worthy of more extensive review. I would be happy to use this blog to delve into topics in more detail (per request).

Atopic Dermatitis (aka Eczema)

I still need to be convinced regarding what to call this condition. Dr. Jeff Travers (chief of Dermatology at the IU School of Medicine) and I go back and forth on this topic. During the meeting I heard the concept of extrinsic and intrinsic atopic dermatitis. Extrinsic means from the outside and intrinsic from the inside. These terms have also been used for years to describe two presentations of asthma: extrinsic asthma due to allergy, and intrinsic asthma when no allergy is found. The word atopic means 1) the tendency to come from families with allergy, 2) to make the antibody seen with allergy (IgE, which would be elevated) and 3) to have positive allergy tests. Thus, Intrinsic AtopicDermatitis means no allergy demonstrated (intrinsic) in a condition associated with allergic sensitization (atopic). This blending of terms leads to confusion–why not stick with the simpler term of eczema?

I learned about the use of silver impregnated clothing to decrease the amount of bacteria on the skin. Skin bacteria can cause flaring of atopic dermatitis.

A number of  genes associated with atopic dermatitis have been discovered. These discoveries should increase our understanding on how this condition starts and hopefully how we can manage it better.

There was information on allergens that contain enzymes called proteases and how these protease containing allergens aggravate the skin.

Probiotics have been used to treat allergic conditions especially conditions related to food allergy. A review of studies on probiotics have not shown them to be effective in preventing or treating atopic dermatitis.

I listened to debates about being proactive in skin care therapy vs. being reactive. Proactive would be trying to prevent and reactive being treating only when there is a problem. This idea was particularly interesting. Atopic Dermatitis Guidelines and package inserts for a variety of medications used for atopic dermatitis treatment stress short courses of use, the reactive approach. The proactive debater posed the problem of a chronic disease that will have episodic flaring. The abnormality of the skin is there all the time requiring the need for medication to be used perhaps twice a week to avoid flares (those times when the skin is more itchy, more inflamed, and more broken down). Pediatrics deals extensively with disease prevention. My pediatric perspectives are preventative- proactive. All too often we (as patients) tend to be crisis-oriented or reactive to chronic conditions. I am obviously on the proactive side of this argument.

Therapies emphasized moisture and more moisture. Keep these kids wet! This is clearly a major step that is contrary to previous approaches that recommended the avoidance of frequent soaking/bathing. The avoidance of baths is clearly one of those long established principles of atopic skin care that has fallen by the wayside in contemporary skin care.

Foods are an issue in atopic dermatitis. The protease containing allergens such as molds, pets, and mites may have a role in triggering flares.

In Boston a program that has had success includes insuring compliance with the medications (taking them as prescribed), addressing the parents concerns about medication side-effects (helps with compliance), decreasing the itch, and increasing sleep. These are all essential elements to help with control of the condition.

Of note, we need to re-think the role of a specific therapy and make adjustments. Antihistamines are frequently used in atopic dermatitis. In allergic rhinitis and in hives, these products help control itch. However, in atopic dermatitis, the antihistamines have little effect on itch. The role of the anti-histamine is to sedate. Most of the scratching happens at night. A sedating antihistamine used at night works best.

Asthma

There were a number of new ideas regarding asthma. Look for vitamin D to have a possible role in treatment.

Current recommendations from evidenced-based asthma guidelines point out a difference between adults and children and the use of the long-acting bronchodilators in the two populations. These agents are called long-acting broncho-dilators (LABAs). In children, we should increase the dose of the inhaled corticosteroid before adding a LABA. This recommendation appears in two major asthma guidelines with type A evidence used to support the recommendation. This type of evidence (A) means that there are a substantial number of studies that support this statement.

Asthma may be related to bacterial colonization at birth and to the occurrence of the common cold virus later in life. Evidence was also presented regarding the observation from large population studies that the process of airway inflammation starts well before actual symptoms. We heard about diet, viruses, stress, ozone, and endotoxin having a role in the development of asthma. The gene or genes for asthma need to be present. These genes then need to be activated or expressed for the child to show the signs and symptoms of disease. Bacterial colonization and a variety viruses may have a role in activating the genes.

Headaches

This was a great session. The audience heard from an ENT surgeon, an allergist, and a neurologist regarding their approach to headaches. The consensus was that migraine is the biggest player in these situations. The connection of allergy to headache has always been a concern. However, headache is not a manifestation of allergy. There are many studies that have looked at this. People with headaches can have positive allergy tests but does that make the allergen the cause of the headache? Think about other conditions or associations. Could there be an allergic cause for an appendicitis?

I heard of the concept of ‘allergic appendicitis’ during this presentation. It was very odd to hear about this in a headache session, but a valid point was made. This concept of the allergic appendix was compared to allergic headaches. Follow along; data from a national health survey from 1994 indicated that 50% of the population reported that they had allergy. So if someone who had problems with the appendix was allergy tested, the chances are very high that allergy would be found. This however does not make the inflammation of the appendix due to allergy. You can find a significant number of positive allergy tests, be sure of why the tests are being ordered. Think migraine more often as a reason for headache. Allergy is not a major reason for headaches.

Food Allergy

The biggest news from the meeting was the work done by Wes Burks at Duke on peanut allergy. This is exciting and long awaited for those who have peanut allergy and for the families who have someone with peanut allergy. Immunotherapy for peanut trials have allowed the equivalent of about 12 peanuts to be eaten without any problems/reactions. This would certainly take the fear from accidental exposure to peanut especially from tabletops at school cafeterias. I have to check my note again, but I had written down the treatment would be a suppository(?).

There was a very popular abstract (a quick presentation of work in progress prior to it being published in a journal) on food allergy and the over- use of panels for food allergy (pet peeve). A New York Times article a few months ago reported that food allergies were being over diagnosed. Dr. Sears at National Jewish Hospital in Denver, Colorado reported on over one hundred children seen at their center who had food allergy as determined by blood test panels. The average number of food allergies reported were six. After undergoing food challenges the number decreased to only 2 foods. 88% of the foods this group of children were told to avoid based on RA ST panels were added back into the diet. Using a food challenge, no one with meat ‘allergy’ had a positive food challenge (where meat caused a problem), 88% of the grain ‘allergic’ children were negative on challenge, and 83% of the fruit and vegetable group were also negative after a food challenge. Bottom line- the use of these panels is giving falsely positive information and leading to a misdiagnosis of food allergy.

Allergy Testing

I learned that I should no longer use the word RAST. The term is outdated and refers to a technology not used. The blood tests for allergens should no longer have a 0-6 grading scale and should only be reported in what is actually measured kU/l of serum. The test measures a concentration of a specific antibody in the blood. The relationship of that concentration to clinical activity needs to be determined by the clinician. I predict that the interpretation of the blood test results may be a huge issue.

A new in vitro or blood test for specific IgE in the blood is called an ISAC chip. This technology will help with cross-reacting proteins. We see the problem of cross-reactivity with multiple positive allergy tests to legumes (peanut, soy, beans, and peas). I think this will be a very worthwhile test in allergy.

There are three blood tests out there for detecting specific IgE. These are the Immunolite, ImmunoCap, and Hytec. Each of these measure something different. They measure a different population of IgE antibodies and may not be comparable. Caution was advised regarding the blood tests for specific IgE. The physician should know the method used, the validity of the assay, the performance of the laboratory in doing the assay, and realize that no test for allergy is infallible.

Conclusions

Each and every one of these topics could stand alone for more detail and interpretation and I would be most happy to elaborate in more detail. Let me know if you would like more information by adding a comment. If there continues to be an increase in the use of specific IgE panels (as advocated by those who market these tests) we will be doing significantly more food challenges in our office. Usually we are doing food challenges for those who may have outgrown a food allergy. We certainly can offer a food challenge for a child who has been told that food allergy exists based on blood test results. One of my tasks upon my return to the office is to look at our track record of doing food challenges. I hope to report on our successes and failures for our food challenge experience with milk, egg, soy,wheat, and of course peanut.

Respectfully submitted,

Fred Leickly

Practical Pediatrics- Providence, Rhode Island April, 2009

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I had the chance to moderate a course given by the American Academy of Pediatrics (AAP) last weekend. For many years I had the role as a speaker for these programs. These are great opportunities for primary caretakers, pediatricians and nurse practitioners to hear some very practical approaches to common problems in pediatrics.

Providence, Rhode Island was the host city for this Practical Pediatrics offering. In early April Providence does not have a lot going on. The weather was wet and cold. This kept us indoors. The seafood and Italian food were great! I also recommend the IMAX 3-D movie Aliens vs. Monsters. Despite the inclement weather, I did learn a few new things and learned to appreciate many other aspect of care for our children.

Dr. Martin T. Stein, Professor of Pediatrics at the University of California, San Diego shared a few thoughts on pediatrics in general. He presented things that made me stop and wonder about the incredible job that is done by healthcare providers that look after our children. Did you know that for well child care the recommendation is for 31 visits? Back in the day (okay, 1974) only 14 well child care visits were the standard. I am sure this increase is due to the need for guidance, safety, development, and prevention. It makes our pediatricians busier. I also learned that our children benefit from a level of primary care above what is offered in other countries. The United States is the only country where board certified pediatricians provide that essential well child care. I have always held our pediatricians in high esteem. I learned a few things that have increased my respect for them and for what they do.

I learned a few more things about allergy and had a few of my standard issues emphasized by Dr. William T. Boleman, who is the Chief of Allergy at the Keesler Medical Center (USAF) in Biloxi, Mississippi.  I learned that controversies in allergy are not at all unique to Indiana. Mississippi seems to be affected by theories, practices, and therapies done under the name of allergy, but clearly without a shred of evidence that allergy accounts for the problem. Dr. Boleman talked about sugar, wheat, yeast, chemical, electromagnetic radiation, hormones, and voodoo allergy testing including IgG antibodies to foods. One of his messages was to be sure that the story matches a condition in which allergy may be a cause. History taking remains an essential part of any allergy evaluation.

I have always enjoyed listening to the dermatologists. Their lectures are replete with pictures and practical information on a wide variety of things that can affect our skin. Dr. Miriam Weinstein from Toronto Sick Children’s hospital shared her opinion on a condition that is often seen by both the allergist and the dermatologist. That condition is atopic dermatitis, a form of eczema that has associations with allergy. I was surprised and concerned after the talk on evidence-based therapy of atopic dermatitis. She had pulled references from the dermatology literature. The evidence-based review is a critical summary of good and bad studies. One of my courses in the public health program actually taught us how to critique one of these reviews. It is quite an art to go over a vast literature looking for answers to specific questions and making sure that the methods used to get that answer were without any flaws.

The things that I learned and what I thought would be very helpful for the children I see with atopic dermatitis in my allergy practice include the emphasis that it is not just one thing such as a food that will trigger a flare of itchy, dry, flaky skin. There are many different reasons for the condition to flare and sometimes it just happens. When we discover something like a food that could trigger that is great because there is one less thing to worry about.

We also need to keep the skin as moist as possible. Moisturizing the skin can be considered front or first line therapy. These children need to be so slicked-up that they just slide through your fingers.

Using the topical steroid ointments once a day may be just as effective as using them twice a day and using them a few times during the week even when the skin is clear may help keep the skin from flaring.

I now emphasize that the use of the anti-histamines is not so much for the itch component of the skin, but for sedation. A significant amount of scratching of the skin occurs during the night. Helping with sleep by taking advantage of the sedative aspects of antihistamines makes a difference. Choices here would be agents like Benadryl or preferably Atarax (Hydroxyzine).

Skin infection needs to be controlled. The scratching and breakdown of the skin leads to infection. The infected skin then causes further scratching and misery.

Also, contrary to what an allergist would like to believe, being allergic to house dust mites and consequent house dust avoidance techniques may not make any difference in controlling flares.

Food allergy may not be the cause of many of the flares. Unfortunately these children have many positive skin tests and the track record is that the positive predictive value of the food test is about 50%. So when the allergy test for food is positive, there is a 50/50 chance that it is relevant and that exposure to that food causes a flare of the skin. Of all the foods that have been associated with flaring, egg is the most common.

It is important to keep learning new things, new perspectives, and be open to changes that may be of benefit to our patients. Hopefully a few of these tidbits may help.

Fred Leickly