Pearls and Hot Topics in Atopic Diseases

Wisdom from a 35 year Career

James P. Rosen, MD

Topics to be discussed

  1. Seasonal Allergic Conjunctivitis
  2. Allergic Rhinitis
  3. Asthma
  4. Atopic Dermatitis
  5. Epinephrine auto injectors
  6. Recurrent Otitis Media, Sinusitis and Purulent Rhinitis
  7. Acute Urticaria and Angioedema

Seasonal Allergic Conjunctivitis- Diagnostic Pearls

  1. Rarely if ever very painful
  2. Very itchy and almost always bilateral
  3. Almost never is beefy red, more boggy
  4. If really red, think secondary bacterial/viral infection
  5. No Photophobia unless cornea is scratched from rubbing…use fluorescein
  6. Clear watery discharge, never yellow or green, again unless if secondarily infected
  7. Worse in morning, better as the day goes on

SAC-Treatment

  1. Antihistamines by themselves are not very effective
  2. Preventative eye drops
  1. Alaway $58/oz.
  2. Zaditor $150/oz.
  3. Patanol $785/oz.
  4. Pataday $1520/oz.
  1. From my experience no difference in efficacy, only price

SAC-Treatment-To refrigerate or not, that is the question

  1. When symptomatic, use cold wash cloth on eyes x 5 minutes then cold eye drops- COLD SUPRESSES ITCH
  2. Rescue Eye Drops: the “A”s, Opcon, Albalon, Naphcon –KEEP IN REFRIGERATOR
  3. Sport Glasses before going outside, wrap-around sun glasses for adolescents

SAC-Treatment

  1. Antihistamines & oral decongestants {+/- results} together for a few days then d/c dc
  2. Nasal Steroids help in AC: reduce inflammation of tear duct and Trigeminal ganglion
  3. LT receptor antagonists (LTRA) can be a helpful as add on as AC pathology is rich in mast cells and eosinophils- both release large amounts of Leukotrienes
  4. Loteprednol (Alrex): not active in the anterior chamber thus very safe for long term use (weeks): really good and very safe…fluorescence eyes first
  5. Can alternate Loteprednol and Alaway, each qod- very effective strategy
  6. For severe AC, oral steroids and LTRA are a great combo then onto Alrex and then onto non-steroidal…continue oral and nasal meds

Allergic Rhinitis

  1. Mouth Breathing can lead to facial issues, high arch palate and type 2 dental malocclusion BRACES!!!
  2. Observing nose breathing is a good way to tell you that nose is healthy
  3. Mouth breathing for years can be habitual even if medical issues corrected
  4. Mouth breathing and “nasal congestion” with healthy appearing nasal turbinates….always think enlarged adenoids
  5. Check for adenoids…with healthy turbinates, pinching nostrils and saying the alphabet…no change in phonation=enlarged adenoids

AR-Treatment-Antihistamines and Other

  1. Dosing Antihistamines- does time make a difference?
  2. Allergic symptoms usually worse in am, high pollen counts in AM and dust mites
  3. Cortisol levels are physiologically lowest in the morning
  4. Best time to give antihistamines is at bed time so AM levels are high
  5. Using decongestant nose sprays just before nasal steroids for 3-4 days till meds have effect is completely safe
  6. Nasal saline is more valuable than you think…use just before dc spray and nasal steroids

AR-Treatment- Nasal Steroids

  1. Are all nasal steroids alike… for the most part yes except
  2. Fluticasone and mometasone are very lipid soluble and thus as nasal steroids have almost no bioavailability...these are the only ones
  3. When patients are on lungs steroids for asthma, best to use the two above to decrease steroid load to the body
  4. If patients are on ILCS, EXHALE THE LUNG STEROID THRU THE NOSE to help treat allergic rhinitis and enlarged adenoids
  5. To reduce the effect on growth hormone secretion and growth velocity, all nasal steroids should be given early in the morning with exception of fluticasone and mometasone, which can be given at night
  6. Budesonide nasal spray has 44% less volume per spray than others...good for small children

AR-Treatment- Nasal Steroids

  1. Efficacy of nasal steroids can be seen in as little as 12 hours
  2. Nasal steroids ARE effective when used PRN
  3. There is a dose responsive curve with nasal steroids, 2 sprays/nostril can be better than 1 and 3/nostril can be better than 2 but the curve flattens out for the vast majority of patients at 4 sprays/nostril

AR-Treatment- How to Prevent Adverse Side Effects from Nasal Steroids

  1. Turbinate enlargement comes from lateral aspect of nasal vault
  2. Septal mucosa does not become edematous
  3. Septal mucosa is susceptible to damage from any nasal spray, not just steroids
  4. To avoid necrosis & possibly perforation of septum, aim nasal spray “up and out”

AR/AC Treatment Non-Pharmacological

  1. Shower before bed or wipe face and hair before going to bed-pollen gets on pillow
  2. Keep bedroom windows closed at night or if use fan, blow it out
  3. Turn off attic fan…brings large amounts of pollen into house
  4. Do not hang clothes or sheets out to dry in spring…pollen sticks to them
  5. Plant crocuses for spring hayfever for timing to begin meds
  6. Again, keep rescue eye drops in refrigerator really important

Asthma: Inhaled Steroids- Is There a Better Time to Give Them?

  1. All Inhaled steroids are bioavailable to the body, some more than others
  2. Fluticasone is an outlier in that it has a long half-life (~12-14hrs) and very lipophilic, thus large volume of distribution
  3. Greatest side effects are seen with Fluticasone
  4. Have seen patients with severe adrenal crisis while on large doses of Fluticasone
  5. There are much safer steroids in kids than Fluticasone and I do not recommend it
  6. Budesonide nebulized at sleep to deliver dose…giving during crying and waving in front of face does not deliver a good therapeutic dose

Asthma: Inhaled Steroids #2

1. Inhaled steroids are absorbed and can cause adrenal and growth suppression

  1. Inhaled steroids have the greatest effect on growth and growth hormone when given in the evening because inhaled steroids increase serum cortisol level which decreases growth hormone and subsequent growth
  2. Can and do effect growth velocity (~3-5% of kids on ILCS) but dramatically reduced almost to zero when given in the morning…reduction ~1/4-1/2 inch, small price to pay for breathing
  3. The vast majority of patients with growth velocity reduction get catch-up growth within two years
  4. Uncontrollable asthma however can cause irreversible growth stunting and severe morbidity and mortality
  5. Lung steroids can control asthma very well when given in the morning…safer giving 400ug in the am than 200ug bid
  6. Do not hesitate to give severe asthmatics epinephrine auto injectors at home in case of a severe asthma attack..certainly can administer two or three 10-15 minutes apart if needed

Exercise Induced Intolerance

  1. All SOB with activity is not always asthma
  2. Causes of EII:
  3. Asthma
  4. Anemia
  5. Allergic rhinitis in season
  6. Arrhythmia
  7. Hyperventilation syndrome
  8. Super ventricular tachycardia

EII #2

  1. Deconditioning
  2. Inappropriate expectations
  3. Exercise induced anaphylaxis
  4. Gerd
  5. Elite athlete syndrome
  6. Vocal cord dysfunction
  1. LTRA and albuterol are good therapeutic interventions, especially when albuterol by itself is not helpful…use LTRA in day camp or in school when not feasible to take albuterol before gym
  2. Two important questions to ask; how soon does your EII occur and how long does it take for you to recover

Asthma- LTRA

  1. Eosinophils and Mast Cells are rich in leukotrienes
  2. Pulmonary Leukotrienes cause pathology as seen in asthma like migration of eosinophils, edema, bronchospasm and mucus secretion
  3. Inhaled and oral steroids do not affect the production or effects of leukotrienes in the majority of patients
  4. In asthma patients, especially allergic ones who are not well controlled on just ILCS, add LTRA

Chronic Cough in YoungKids…Asthma or TWI

  1. Dry or wet…wet always coming from the chest, dry could be from chest but not always…sinusitis never gives a wet cough
  2. Worse with exercise, crying, laughing, very important to ask…supports asthma, not TWI
  3. Family history of asthma…supports asthma
  4. Presence of Atopic Dermatitis…supports asthma
  5. Positive ImmunoCap or Skin tests…supports asthma

CCK continued

  1. Worse at night and with lying down
  2. Response to albuterol and steroids
  3. Sinus x-rays, barium swallow, for sinusitis, gerd, esophageal or vascular issues
  4. Methacholine challenge…use nebulizer and listen for cough or wheeze...really can be very helpful
  5. TWI only occurs with colds… but can be chronic in young kids in day care
  6. TWI…do not treat with controller meds

Atopic Dermatitis- An Itch that Rashes

  1. Remember lessons from allergic conjunctivitis…cold suppresses itch
  2. Cold washcloths or cool baths to suppress itch
  3. Never use hot baths or showers as this will degranulate mast cells and increase itch
  4. Keep kids covered in cotton and avoid sweating-Atmokinesis- air causing pruritus

AD- Staph Aureus and AD, A Frequently Overlooked Complication

  1. 90% of patients with AD have Staph A. on their skin vs 5 % of those without AD
  2. Staph presence is due to many factors: impaired skin barrier, increase fibronectin,and impaired local skin immunity {impaired WBC chemotaxis, phagocytosis and killing, and reduced skin Antimicrobial Peptides which kill viruses, bacteria and fungi}
  3. Importance of Staph supported by dramatic clinical response to antibiotics
  4. Staph produces enterotoxins which are extremely inflammatory
  5. Vast vast majority of flares are caused by Staph A
  6. Treat with Keflex for 7-10 days…think of MRSA if not responding, but not as frequent as once thought

AD – Staph issues further treatment

  1. After oral antibiotics, bleach baths are needed to prevent recurrence of staph
  2. Use 8oz. of house hold bleach in 32 gallons of water or 2 tsp/gallon
  3. Soak in bath for 15 minutes then shower off bleach immediately and apply topical therapy (TIM or moisturizers) within three minutes of exiting the bath
  4. Nasal bactraban (spray or ointment) may be needed for recurrence of Staph… 7 days out of 30 per month to whole family..don’t forget the dog
  5. Protopic and Elidel are not adversely affected by Staph whereas topical steroids are, Staph Enterotoxins induce the production of IsoformBeta receptors on inflammatory cells which arean inactive receptor andcompetewith the Alpha receptor (active receptor) for the topical corticosteroids (TCS) thus rendering TCS less effective; Protopic or Elidel do not bind to these receptors

AD –Skin Barrier Issues: A Place for Baths

  1. Skin of patients with AD is very dry with impaired skin barrier due to a defect in the Filaggrin gene and certain cytokines which causes a reduction of ceramide and other skin sphingolipids, which not only hold water, but prevent water loss
  2. Frequent daily baths for 15 minutes 1-3x/day helps repair skin- frequency depends on severity of AD, usually 5x/week
  3. Use Dove soap, a SynDet (Synthetic Detergent) with a lower Ph, high Ph soaps are bad for the skin
  4. Place moisturizers on skin within 3 minutes of exiting the bath
  5. Place something on skin 14x per week
  6. Do not put oils in bath as they might reduce water penetration into the skin
  7. Vanicream and Vaniply I find to be the best moisturizers

ADand Vitamin-D

  1. Vit-D very important in AMP (Antimicrobial Peptide) production
  2. Patients with AD have reduced AMPs due to many factors…cytokines, Vit-D deficiency;
  3. Low Vit-D secondary to; increase sedentary life style with decrease sun exposure
  4. North–South gradient for AD; North lower Vit-D levels & higher frequency of bad AD
  5. Vit-D supplementation in AD patients augments AMP production with improvement of AD secondary to reduced Staph on skin
  6. 1000 Units of Vit-D 3/day (USP) increases Vit-D level in adults about 10ng/ml, with surprisingly similar results in children…check levels 4-6 weeks after starting…best to check in summer to obtain peak level

AD – Viral infections of the skin MC

  1. MC very common in AD; impaired skin immunity
  2. Check Vit-D level
  3. Use Apple Cider Vinegar
  4. Use topical steroids with ACV to reduce inflammation

AD- Viral infections of the skin Herpes

  1. Not itchy, unless present in active AD
  2. Associated with bad AD
  3. Lesions are painful and present in three phases…macules, vesicles and punched out divots…all usually present at same time
  4. Treatment…herpes can be very serious, Valtrex and close follow up, small infants in hospital if extensive

AD- Food Allergy

  1. Patients usually under a year of age, is extensive and usually hard to treat
  2. Positive IgE or Skin Test with significant AD…DO NOT STOP A FOOD THAT THE PATIENT IS EATING EVEN IF IgE IS PRESENT AND YOU ARE SUSPICIOUS OFA FOOD, JUST REDUCE IT. STOPPING THE FOOD CAN CAUSE ANAPHYLAXIS UPON SUBSEQUENT INGESTION
  3. Positive IgE or skin test with mild AD…if child is eating a food with positive CR or ImmunoCap and is fine, with minimal AD, keep eating food as is, do not stop it or reduce it..major error with physicians…can then cause anaphylaxis with repeat ingestion

Food Allergy- When to introduce foods

  1. Start foods early, especially peanut and nut butters to prevent sensitization and possibly allergy…6 months is not too early…Bamba
  2. Prevalence of Peanut Allergy in Israel in young children~ 6yo is .17% and in England 1.8%
  3. Difference due to timing of ingestion, Israel early @ ~ 6 months, using Bamba, in England, usually over three years of age per recommendation

Epinephrine Auto Injectors

  1. Epi Auto injectors should be used quickly…best outcomes
  2. Shelf life longer than printed on device
  3. Can use beyond expiration date if liquid is clear and not yellow
  4. Concentration of Epi will decrease with time but some is better than none
  5. Can use two 0.30 mg injectors in heavy adolescents or adults if reaction is severe and accompanied by co-morbid conditions such as asthma
  6. Can be used for severe asthma attack
  7. I recommend self-administration to adolescents as an exercise...I’ve done this to ~280 patients since 2003..empowers them to administer their own Epi

Recurrent Otitis Media, Sinusitis and Purulent Rhinitis

  1. Atopic patients have increase prevalence of URI
  2. Nasal tissue in AR has reduced local immunity
  3. Reduced immunity due to many factors…edema, decrease migration, phagocytosis, and killing in WBC, {due to cytokines} increase mucus…ripe milieu for increase infection
  4. Increased morbidity and job loss
  5. Treatment…nasal saline and nasal antibiotics…5 grams of bactraban ointment in 45 mls of saline, shake vigorously and use 1-2sp/nostril bid….discard after 30 days and check for thrush…will only treat bacterial infections but may decrease morbidity

Urticaria

  1. Acute urticaria very common 35% in kids
  2. Most common cause…immune complex mediated urticaria…degranulates mast cells
  3. 4 Ps and other…causes of concern…point to vasculitis
  4. Hives leave Pigmentation when gone
  5. Hives Persist beyond 36 hours in one location
  6. Hives are Painful
  7. Hives once gone are Palpable
  8. Other…fever, joint pain, cough, sinus pain, weight loss, not feeling well

Urticaria

  1. Lab tests are for most part not contributory
  2. Dermatagraphism and cold, are most common physical urticarias in children
  3. Epi should be available for severe cold urticaria if patient is a swimmer

Urticaria-Treatment

  1. Antihistamines … push dose…fexofenadine’sadvantage
  2. Use Decongestants with AH when symptomatic; constricts blood vessels in skin
  3. Cool showers/baths when unbearable…cold suppresses itch
  4. Oral steroids for short period (5-10 days)
  5. Add LTRA for chronic urticaria… 30% autoimmune …IgG antibody to IgE receptor on mast cell or to IgE itself (rarer) complement mediated
  6. Continue AH and LTRA (use LTRA in chronic) for 10-14 days after better…general rule

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