Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance.
Usually, allergies cause sneezing, watery and itchy eyes, a runny nose, itchy skin, and rash.
Some allergic reactions, called anaphylactic reactions, are life threatening.
Symptoms suggest the diagnosis, and skin testing can help identify the substance that triggers the allergy but does not predict the severity of a future reaction.
Avoiding the trigger is best, but if it is impossible, allergy shots, when given long before the exposure occurs, can sometimes desensitize the person.
Severe reactions require emergency treatment in an emergency care facility.
Normally, the immune system—which includes antibodies, white blood cells, mast cells, complement proteins, and other substances—defends the body against foreign substances (called antigens). However, in susceptible people, the immune system can overreact when exposed to certain substances (allergens) in the environment, foods, or drugs, which are harmless in most people. The result is an allergic reaction. (Allergens are molecules that the immune system can identify and that can stimulate a response by the immune system.) Some people are allergic to only one substance. Others are allergic to many. About one third of the people in the United States have an allergy.
Allergens may cause an allergic reaction when they land on the skin or in the eye or are inhaled, eaten, or injected. An allergic reaction can occur in several ways:
Triggered by substances present only during certain seasons, such as tree, grass, or ragweed pollens (seasonal allergy, including hay fever)
Triggered by taking a drug (drug allergy)
Triggered by eating certain foods (food allergy)
Triggered by breathing in dust, animal dander, or molds (year-round allergy)
Triggered by touching certain substances (such as latex)
Triggered by insect bites or stings (as occurs in anaphylactic reactions and angioedema)
In many allergic reactions, the immune system, when first exposed to an allergen, produces a type of antibody called immunoglobulin E (IgE). IgE binds to a type of white blood cell called basophils in the bloodstream and to a similar type of cell called mast cells in the tissues. The first exposure may make people sensitive to the allergen (called sensitization) but does not cause symptoms. When sensitized people subsequently encounter the allergen, the basophils and mast cells with IgE on their surface release substances (such as histamine, prostaglandins, and leukotrienes) that cause swelling or inflammation in the surrounding tissues. Such substances begin a cascade of reactions that continue to irritate and harm tissues. These reactions range from mild to severe.
Some people have an inherited tendency to produce a lot of IgE (a condition called atopy) and may overreact to some antigens that cause hay fever, asthma, skin problems, or a food allergy.
Latex sensitivity
Latex is a fluid that comes from the rubber tree. It is used to make rubber products, including some rubber gloves, condoms, and medical equipment such as catheters, breathing tubes, enema tips, and dental dams.
Latex can cause the immune system to produce antibodies to IgE, which can lead to allergic reactions, including hives, rashes, and even severe and potentially life-threatening allergic reactions called anaphylactic reactions. However, the dry, irritated skin that many people develop after wearing latex gloves is usually the result of irritation and not an allergic reaction to latex.
In the 1980s, health care workers were encouraged to use latex gloves whenever touching patients to prevent the spread of infections. Since then, latex sensitivity has become more and more common among health care workers.
Also, people may be at risk of becoming sensitive to latex if they
Have had several surgical procedures
Must use a catheter to help with urination
Work in plants that manufacture or distribute latex products
For unknown reasons, people who are sensitive to latex are often allergic to bananas and sometimes other foods such as kiwi, papaya, avocados, chestnuts, potatoes, tomatoes, and apricots.
Doctors may suspect latex sensitivity based on symptoms and the person's description of when symptoms occur, especially if the person is a health care worker. Blood or skin tests are sometimes done to confirm the diagnosis.
People who are sensitive to latex should avoid it. For example, health care workers can use gloves and other products that are latex-free. Most health care institutions provide them.
Causes of Allergic Reactions
Genetic and environmental factors work together to contribute to the development of allergies.
Genes are thought to be involved because specific mutations are common among people with allergies and because allergies tend to run in families.
Environmental factors also increase the risk of developing allergies. These factors include the following:
Repeated exposure to foreign substances (allergens)
Diet
Pollutants (such as tobacco smoke and exhaust fumes)
On the other hand, exposure to various antigens, such as bacteria and viruses and foods (including peanuts), during childhood may strengthen the immune system. Such exposure may help the immune system learn how to respond to allergens in a way that is not harmful and thus help prevent allergies from developing. An environment that limits a child's exposure to bacteria and viruses—commonly thought of as a good thing—may make allergies more likely to develop. Exposure to microorganisms is limited in families with fewer children and cleaner indoor environments and by the early use of antibiotics.
Microorganisms live in the digestive tract, in the respiratory tract, and on the skin, but which microorganisms are present varies from person to person. Which ones are present appears to affect whether and which allergies develop.
Allergens that most commonly trigger allergic reactions include
House dust mite droppings
Animal dander
Pollens (of trees, grasses, and weeds)
Molds
Insect venom
Latex
Household chemicals, such as cleaning products and fragrances
House dust mites live in the dust that builds up in carpets, bedding, soft furnishings, and soft toys.
Symptoms of Allergic Reactions
Most allergic reactions are mild, consisting of watery and itchy eyes, a runny nose, itchy skin, and some sneezing. Rashes (including hives) are common and often itch.
Hives, also called urticaria, are small, red, slightly elevated areas of swelling (wheals) that often have a pale center. Swelling may occur in larger areas under the skin (called angioedema). Swelling is caused by fluids leaking from blood vessels. Depending on which areas of the body are affected, angioedema may be serious, particularly when it occurs in the throat or airways.
Allergies may trigger attacks of asthma.
Certain allergic reactions, called anaphylactic reactions, can be life threatening. The airways can narrow (constrict), causing wheezing, and the lining of the throat and airways may swell, interfering with breathing. Blood vessels can widen (dilate), causing a dangerous fall in blood pressure.
Photo provided by Thomas Habif, MD.
Diagnosis of Allergic Reactions
A doctor's evaluation
Sometimes blood tests
Often skin tests and the allergen-specific serum IgE test
Doctors first determine whether a reaction is allergic. They may ask
Whether the person has close relatives with allergies because a reaction is more likely to be allergic in such cases
How often reactions occur and how long they last
How old the person was when the reactions started
Whether anything (such as exercise or exposure to pollen, animals, or dust) triggers the reaction
Whether any treatments have been tried and, if so, how the person responded
To help determine whether a reaction is allergic, doctors sometimes do blood tests to detect a type of white blood cell called eosinophils. Eosinophils, although present in everyone, are usually produced in greater numbers when an allergic reaction occurs. However, the usefulness of this test is limited because other eosinophilic disorders can cause the number of eosinophils to increase, and a normal number does not exclude the presence of an allergy.
If it seems likely that a person's symptoms are caused by an allergy, the main goal is to identify the specific allergen. Often, the person and doctor can identify the allergen, or at least the type of allergen, based on when the allergy started and when and how often the reaction occurs (for example, during certain seasons or after eating certain foods).
Skin tests and a blood test called the allergen-specific serum IgE test can also help doctors detect the specific allergen. However, these tests may not detect all allergies, and they sometimes indicate that people are allergic to an allergen when they are not (called a false-positive result).
Skin testing
Skin tests are the most useful way to identify specific allergens. An allergen applied to or injected into the skin should cause a skin reaction in people who are allergic to it. There are two types of skin tests:
Skin prick test
Intradermal test
To help ensure that the results of these skin test are reliable, doctors give two control solutions in addition to the test solution (which contains the suspected allergen). The control substances are
A drop of a histamine solution, which should trigger an allergic reaction in anyone, is given. If there is no skin reaction, it may be because the immune system is not working normally or because people have allergy drugs in their system. People who do not react to histamine probably will not react to the test solution that contains the allergen. Thus, people may appear to have no allergy to the allergen when they do (a false-negative result).
A drop of diluting solution that contains no allergens and thus should not trigger an allergic reaction is given. If people react to the diluting solution, they probably have sensitive skin, and probably will also react to the test solution that contains the allergen, even if they are not allergic to it (a false-positive result).
Usually, doctors give several test solutions. These are dilute solutions, each with one specific antigen. Commonly used antigens include pollens (of trees, grasses, or weeds), molds, dust mites, animal dander, insect venom, foods, or some antibiotics. Doctors choose the antigens for this test based on which substances they suspect to be the cause.
Usually, a skin prick test is done first. A drop of each of the control and test solutions is placed on the person’s skin, which is then pricked with a needle through the drop. The skin prick test can identify most allergens.
If no allergen is identified, an intradermal test may be done. For this test, a tiny amount of each of the control and test solutions is injected into the person’s skin through a needle. This type of skin test is more sensitive and more likely to detect a reaction to an allergen.
If the person is allergic to one or more of the allergens in the test solution, the person has a wheal and flare reaction, indicated by the following:
A pale, slightly elevated swelling—the wheal—appears at the pinprick site within 15 to 20 minutes.
The resulting wheal is about 1/8 to 2/10 inch (about 0.3 to 0.5 centimeters) larger in diameter than the wheal caused by the diluting solution.
The wheal is surrounded by a well-defined red area—the flare.
Before skin tests are done, people are asked to stop taking drugs that may suppress a reaction in a person who actually has an allergy to allergens in the test solution. These drugs include
Antihistamines
Some doctors also do not test people who are taking beta-blockers because if such people have an allergic reaction in response to the test, the consequences are more likely to be serious. In addition, beta-blockers may interfere with the drugs used to treat serious allergic reactions.
Allergen-specific serum IgE tests
The allergen-specific serum IgE test, a blood test, is used when skin tests cannot be used—for example, when a rash is widespread. This test determines whether IgE in the person's blood binds to the specific allergen used for the test. If binding occurs, the person has an allergy to that allergen.
Provocative testing
For provocative testing people are directly exposed to a small amount of the suspected allergen. This test is usually done when people must document their allergic reaction—for example, for a disability claim. It is sometimes used to diagnose a food allergy. If doctors suspect an exercise-induced allergy, they may ask the person to exercise. If doctors suspect an allergy triggered by cold, they may place an ice cube on the person's skin to see if a rash develops.
Prevention of Allergic Reactions
Environmental measures
Avoiding or removing an allergen, if possible, is the best approach. Avoiding an allergen may involve the following:
Stopping a drug
Keeping pets out of the house or limiting them to certain rooms
Using high-efficiency particulate air (HEPA) vacuums and filters
Not eating a particular food
For people with severe seasonal allergies, possibly moving to an area that does not have the allergen
Removing or replacing items that collect dust, such as upholstered furniture, carpets, and knickknacks
Covering mattresses and pillows with finely woven fabrics that cannot be penetrated by dust mites and allergen particles
Using synthetic-fiber pillows
Frequently washing bed sheets, pillowcases, and blankets in hot water
Frequently cleaning the house, including dusting, vacuuming, and wet-mopping
Using air conditioners and dehumidifiers in basements and other damp rooms
Treating homes with heat-steam
Exterminating cockroaches
People with allergies should avoid or minimize exposure to certain other irritants that can make allergic symptoms worse or cause breathing problems. These irritants include the following:
Cigarette smoke
Strong odors
Irritating fumes
Air pollution
Cold temperatures
High humidity
Allergen immunotherapy (desensitization)
Allergen immunotherapy, usually allergy shots (injections), can be given to desensitize people to the allergen when some allergens, especially airborne allergens, cannot be avoided and the drugs used to treat allergic reactions are ineffective.
With allergen immunotherapy, allergic reactions can be prevented or reduced in number and/or severity. However, allergen immunotherapy is not always effective. Some people and some allergies tend to respond better than others.
Immunotherapy is used most often for allergies to
Pollens
House dust mites
Molds
Venom of stinging insects
When people are allergic to unavoidable allergens, such as insect venom, immunotherapy helps prevent anaphylactic reactions. Sometimes it is used for allergies to animal dander, but such treatment is unlikely to be useful. Immunotherapy for peanut allergy is available, and immunotherapy for other food allergies is being studied.
Immunotherapy is not used when the allergen, such as penicillin and other drugs, can be avoided. However, if people need to take a drug that they are allergic to, immunotherapy, closely monitored by a doctor, can be done to desensitize them.
In immunotherapy, tiny amounts of the allergen are either injected under the skin or given by mouth, depending on the specific allergen. The first dose is so small that even an allergic person does not react to it. However, the small dose starts to get the person's immune system used to the allergen. Then the dose is gradually increased. Each increase is so small that the immune system still does not react. The dose is increased until the person is not reacting to the same amount of allergen that once caused symptoms. This dose is their maintenance dose. A gradual increase is necessary because exposure to too much allergen too soon can cause an allergic reaction. Injections are usually given once or twice a week until the maintenance dose is reached. Then injections are usually given every 2 to 4 weeks. The procedure is most effective when maintenance injections are continued throughout the year, even for seasonal allergies.
Alternatively, doses of the allergen may be placed under the tongue (sublingual) and held there for a few minutes, then swallowed. The dose is gradually increased, as for injections. The sublingual technique is relatively new, and how often the dose should be given has not been established. It ranges from every day to 3 times a week. Extracts for grass pollen, ragweed, or house dust mite, placed under the tongue, can be used to help prevent allergic rhinitis.
Immunotherapy for peanut allergy may also be given by mouth. The person receives the first several doses of the allergen over the course of a single day while in a doctor's office or clinic. The person then takes the allergen at home. Each time the dose is increased, the first dose of the higher dosage is given under a doctor's supervision.
Allergen immunotherapy may take 3 years to complete. People who develop allergies again may need another longer course (sometimes 5 years or more) of immunotherapy.
Treatment of Allergic Reactions
Avoidance of the allergen
Antihistamines
Mast cell stabilizers
Corticosteroids
Avoiding the allergen is the best way to treat as well as prevent allergies.
If mild symptoms occur, antihistamines are often all that is needed. If they are ineffective, other drugs, such as mast cell stabilizers and corticosteroids may help. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not useful, except in eye drops used to treat allergic conjunctivitis.
Severe symptoms, such as those involving the airways (including anaphylactic reactions), require emergency treatment.
Antihistamines
The drugs most commonly used to relieve the symptoms of allergies are antihistamines. Antihistamines block the effects of histamine (which triggers symptoms). They do not stop the body from producing histamine.
Antihistamines are available as
Tablets, capsules, or liquid solutions to be taken by mouth
Nasal sprays
Eye drops
Lotions or creams
Which is used depends on the type of allergic reaction. Some antihistamines are available without a prescription (over-the-counter, or OTC), and some require a prescription. Some that used to require a prescription are now available OTC.
Side effects of antihistamines include anticholinergic effects, such as drowsiness, dry mouth, blurred vision, constipation, difficulty with urination, confusion, and light-headedness (particularly after a person stands up), as well as drowsiness. Often, prescription antihistamines have fewer of these effects.
Some antihistamines are more likely to cause drowsiness (sedation) than others. Antihistamines that cause drowsiness are widely available OTC. People should not take these antihistamines if they are going to drive, operate heavy equipment, or do other activities that require alertness. Antihistamines that cause drowsiness should not be given to children under 2 years old because they may have serious or life-threatening side effects. These antihistamines are also a particular problem for older people and for people with glaucoma, benign prostatic hyperplasia, constipation, or dementia because of the drugs’ anticholinergic effects. In general, doctors use antihistamines cautiously in people with cardiovascular disease.
Mast cell stabilizers
Mast cell stabilizers block mast cells from releasing histamines and other substances that cause swelling and inflammation.
Mast cell stabilizers are taken when antihistamines and other drugs are not effective or have bothersome side effects. These drugs may help control allergic symptoms.
Cromolyn is available by prescription as follows:
For use with an inhaler or nebulizer (which delivers the drug in aerosol form to the lungs)
As eye drops
As a liquid to be taken by mouth
Cromolyn is available without a prescription as a nasal spray to treat allergic rhinitis. Cromolyn usually affects only the areas where it is applied, such as the back of the throat, lungs, eyes, or nose. When taken by mouth, cromolyn can relieve the digestive symptoms of mastocytosis, but it is not readily absorbed into the bloodstream and thus has little effect on other bodywide allergic symptoms.
Corticosteroids
When antihistamines and mast cell stabilizers cannot control allergic symptoms, a corticosteroid may help.
Corticosteroids can be taken as a nasal spray to treat nasal symptoms or through an inhaler, usually to treat asthma.
corticosteroids can have many, sometimes serious side effects. Therefore, corticosteroids taken by mouth are used for as short a time as possible.
Other drugs
Emergency treatment
Severe allergic reactions, such as an anaphylactic reaction, require prompt emergency treatment.
If an anaphylactic reaction occurs, the airways can become swollen and narrowed, making breathing difficult. The doctor may have to insert a tube through the nose or mouth into the windpipe (trachea) to help with breathing. Sometimes the trachea becomes too swollen and narrowed for the tube to pass through into the trachea. In such cases, the doctor may have to insert a tube directly into the trachea through an incision in the front of the neck (tracheostomy) to make breathing possible.
Treatment of allergies during pregnancy and breastfeeding
Whenever possible, pregnant women with allergies should control their symptoms by avoiding allergens. If symptoms are severe, pregnant women should use an antihistamine nasal spray. They should take antihistamines by mouth (oral antihistamines) only if antihistamine nasal sprays do not provide adequate relief.
Women who are breastfeeding should also try to avoid antihistamines. But if antihistamines are necessary, doctors prefer to use antihistamines that are less likely to cause drowsiness, and they prefer antihistamine nasal sprays to oral antihistamines. If oral antihistamines are essential for controlling symptoms, they should be taken immediately after feeding the baby.
