Episode transcript
Time stamps
0:00 - Introduction
0:46 - Summer allergies overview
2:08 - Class 1 vs Class 2 allergies explained
4:08 - Pollen food allergy syndrome in summer
6:38 - Summer camp allergy considerations
10:18 - Importance of medication adherence in summer
13:24 - Insect allergies in summer
17:12 - Air conditioners and dust mite exposure
19:55 - Non-allergic triggers in summer
23:26 - Summer allergy management tips
27:52 - Conclusion
Announcer (00:00):
ImmunoCAST is brought to you by Thermo Fisher Scientific creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
Gary Falsano (00:13):
I'm Gary Falsano, a licensed and board certified PA with over 12 years experience in allergy and Immunology.
Luke Lemons (00:18):
And I'm Luke Lemons with over six years experience writing for healthcare providers and educating on allergies. You're listening to cast your source for medically and scientifically backed allergy insights. When we think of a season, we often think of spring allergies, but the allergies don't stop when that spring tree pollen dies down. There's a lot of other allergies that may be affecting patients, especially during these sunnier summer months. Exactly.
Gary Falsano (00:47):
We're thinking about things like grass, pollen, weed, pollens, and then there's a whole slew of other allergens that are more prevalent in the
Luke Lemons (00:54):
Summertime from air conditioners, which we'll talk about to summer camps and insects like mosquitoes, bees and wasps. There's also a bunch of non-allergic triggers that are more common in the summer. So as we come out of spring months and patients are coming in for summer physicals or maybe any other sort of allergy related issues, we might still have tree pollen on the mind, but really we need to be focusing and shifting our perspective to grass and ragweed pollen when we think about respiratory allergies outside.
Gary Falsano (01:27):
Yeah, 100%. We've got the classic symptoms of respiratory allergy, which I think everybody are aware of, but there's also the pollen food allergy syndrome, right, the oral allergy syndrome that is just as prevalent in the summer, late summer and even into the fall as it is in the springtime.
Luke Lemons (01:45):
Yeah, and we've talked about pollen food allergy syndrome before in episode 30, which is from pollen to plate. And just as a quick reminder, pollen food allergy syndrome is when a patient may experience some itching of the mouth or the throat when they eat specific vegetables or fruit. And this is actually a cross reaction with their potential pollen allergy. Look,
Gary Falsano (02:08):
We haven't talked about these classes before, but I think that this would be a really good episode to introduce another way of thinking about primary food allergy versus cross reactivity from pollens. And these are termed class one versus class two allergies.
Luke Lemons (02:27):
Class one. If a patient has a class one allergy specifically, let's look at food. So a class one would be that they are allergic to that food and it really has nothing to do with the pollen. So for example, a patient who has a peanut allergy and they eat the peanut and they have a reaction, potentially anaphylaxis, that is a class one allergy.
Gary Falsano (02:50):
And typically these class one allergies are instigated by sensitization through the GI tract. I guess they can also be, because we talked about this with the epithelial barrier hypothesis, they can also be sensitized through the skin, but these aren't respiratory allergies that cause a cross reactivity. They're primary food allergies.
Luke Lemons (03:10):
Different from that is the class two allergy, which is an allergy to let's say pollen that causes overlapping symptoms. So for example, when we are thinking about grass and ragweed pollen, this time of year, a patient may eat cantaloupe, honey dew, watermelon, all those really refreshing foods during the summer and experience an itchy throat or an itchy mouth. That is a class two allergy. There is some cross reactivity there with the proteins found within those fruits to also the proteins found within grass and ragweed pollen,
Gary Falsano (03:46):
100%. So those listeners that have heard our previous episodes, especially on the pollen to plate episode, these proteins are very similar in structure, right? Their amino acid sequences are very similar to each other, which is why a pollen allergy can cause symptoms, especially in the oropharynx when you eat a food that contains a similar protein. And
Luke Lemons (04:09):
Because this episode we're really talking about summer allergies, you may see patients coming in who just had a barbecue and there was a big plate of watermelon or some refreshing mango, and they may say and think that they are allergic to these fruits because their mouth started to itch or their throat felt a bit uncomfortable. And with those patients, of course, it's important to evaluate whether they have a class one allergy to those foods, but also consider that it may be class two, that they may actually have a ragweed pollen or a grass pollen allergy. So it's important to really differentiate between those classes when patients come in.
Gary Falsano (04:48):
Yeah, 100%. And we also know that there's even some things like tree nuts and peanuts that also can be caused by these class two type allergic reactions, these allergies to pollens. We saw the PR 10 proteins with cross-reactivity to birch pollen with the tree pollens. But there's even other, there's prophy lens, there's CCDs that are found in grasses and ragweeds that can also cause reactions in that quest two arena of those food pollen syndrome.
Luke Lemons (05:17):
And especially for children, as we still think about summer allergies, it takes, what is it, Gary? It's about two years since we need a sensitization year of exposure to pollen. And then usually the next year is when we start seeing symptoms. So young children who maybe are enjoying the summer, they're maybe two or three years old and they're experiencing this pollen food allergy syndrome because they're now sensitized and exposed to ragley pollen or grass.
Gary Falsano (05:47):
Exactly. Because it takes several pollen seasons to become sensitized and exhibit allergic symptoms. So yeah, absolutely. We tend to see that in that two to three year age group. And it keeps increasing as we get older. As you go through more and more pollen seasons, the more chances are that you're going to be not only exposed but become allergic to the pollens in the environment. And that translates to then that oral allergy or pollen food allergy syndrome.
Luke Lemons (06:15):
And speaking of children, summer camps are a big hotspot for potential exposure to allergic triggers. And I'm sure that many of the clinicians who are listening right now have patients coming in for their summer camp physicals or met with patients before talking about summer camp and how to prepare those patients for their long or short stay. Exactly. I don't
Gary Falsano (06:39):
Think I realized there's like 26 million children and adults. So at the summer camp experience is a big part of a lot of people's lives. We've got over 26 million people attending these summer camps, both day camps and overnight camps. Look, there's like 15,000 camps in the us. I had no idea.
Luke Lemons (07:00):
And we think about that and all those 15,000 camps may be, again, hotspots for potential exposures. It's
Gary Falsano (07:08):
A scary time sometimes. This is one of the first times children have been away from home for a prolonged period of time other than school. This may be the first time they're away, especially overnight. So it can be scary for children, it can be scary for their parents and caregivers, and especially scary for those food allergic patients or those patients with asthma.
Luke Lemons (07:31):
So 8% of children are food allergic, so that's about 6 million in America. And so when we think about this in relation to summer camps, the average summer camp has about 250 kids during a session. So that 8% means that 20 children per camp has a food allergy or potentially has a food allergy as any pediatrician knows, when these summer physicals come in and maybe kids are starting to head to these camps, evaluating and preparing patients for food allergies is extremely important.
Gary Falsano (08:07):
And that's where preparing and sending an allergy action plan for patients with food allergy is so important and making sure they're prepared. The camps are prepared to handle any potential emergencies, making sure they have their, I was going to say epinephrine autoinjectors, but we also have inhaled epinephrine now. So making sure they have their emergency epinephrine in whatever form that they're using available and with them is so important.
Luke Lemons (08:36):
Actually, a really scary fact about that Gary one study found of those food allergic children who are going to these camps less than half actually brought their epinephrine autoinjector, 39%, only 39% brought their epinephrine autoinjector.
Gary Falsano (08:51):
So less than half brought their epinephrine autoinjector or now that whatever emergency epinephrine to camp, I don't think the laws in each state, I mean they vary from state to state whether schools can even have epinephrine available for general use that isn't specific to a student. I think the laws around summer camps are even more varied, right?
Luke Lemons (09:16):
The study doesn't really go into why they didn't have their epinephrine autoinjector camp. But I think what this number tells us is that patients need to have some advice and need to have some counseling on best ways to be sure that they're safe. During the camp time season, there was another stat that was that 44% of those children with food allergies also had concurrent asthma.
Gary Falsano (09:42):
So we know that patients with concurrent asthma and food allergies are at the highest level of risk for a more severe phenotype of food allergy and also a more severe phenotype of asthma exacerbations. These campers are at the highest risk, and we know that some of them may not even be bringing their epinephrine autoinjectors. So it's incumbent upon anyone who is preparing children for summer camp to make sure they have their prescriptions and they're bringing them to summer camp and they have that asthma or allergy action plan.
Luke Lemons (10:14):
It seems to really be a gap that we see. There was a study that found that patients will not fill their prescription more often in the summer months, so like June and July compared to let's say September when asthma and asthma peak weeks start happening. That's when it comes to filling asthma medication. We see an uptick, but during the summer we don't see it as often. And if you think about it, these children are out there running around. They may be exposed to outdoor pollens or other allergens, which we'll talk about in a minute, and they need to have that controller med. They need to have their inhaled corticosteroids. They need to be sure that they're staying safe. And so as patients come in for these summer physicals and maybe they say that they have trouble breathing, you're suspecting maybe allergies, it's important to evaluate, to rule in or rule out whether it is an allergy that's affecting them, and then also counsel them on how to stay safe. And you had mentioned earlier, Gary, an asthma action plan is a great way, but then also a food allergy action plan,
Gary Falsano (11:22):
Going back to kind of preparing patients. We know that with children, 90% of children with asthma have allergic triggers up to 90% have allergic triggers that can drive their symptoms. So knowing what those allergic triggers are can really help to empower patients to take control of their disease and mitigate them. And especially when you're going to now a foreign environment, if you identify a patient with say, allergic sensitization of dust mites, they need to take some specific steps when they get to summer camp. My daughter has been a counselor in her summer camp for multiple years now, and the bedding there is pretty disgusting, right? We know that's full of dust mites. It's full of probably mold because it's been sitting unused all winter long. These are things that patients can do and providers should counsel on to maybe bring their own bedding, maybe bring their own dust mite, impermeable coverings to make sure that they don't have an exacerbation while they're away at camp.
Luke Lemons (12:23):
I love that suggestion of bringing their own covers and pillows. And it actually reminded me, Gary, because you had spoken on a video with Dr. Rubin, with our friends over at Ask the Insider, and we'll link that on this episode specific page with the link in the description. One thing that Dr. Rubin had suggested was taking stuffed animals, if a patient does have dust mites and putting it in the freezer to kill off those adult dust bites that may be on that stuffed animal. So that's just a great little tidbit. If you have patients who love their stuffed animal and want to have some company and some friend while they're far away from home, maybe advise the parents to put that stuffed animal in the deep freezer for a little bit so that they're prepared.
Gary Falsano (13:07):
Yeah, I was going to say, put it in the deep freeze. If you can wash it in hot water and dry it, that's the best. But if you can't, it's not really good to do that, then absolutely freezing. It helps kill those dust mites, especially.
Luke Lemons (13:19):
Another allergic trigger that we see as being common in the summer is insects stinging insects. So let's start there with mosquitoes. Gary, what can you tell us about mosquitoes? When it comes to allergies?
Gary Falsano (13:35):
We don't typically think of mosquitoes, right? We think of bees and wasps, and there's certainly more prevalent in the summertime. So we definitely see more stings and we'll talk about that in a minute. But I think anybody who's spent any time outside, I know you and I both have recently, and we're both kind of sitting here itching our mosquito welts that we've gotten, but those are local reactions, and those are typically those itchy kind of singular hives with a little bit of erythema. Those are typically from the anticoagulant in the mosquito bite, other than if you itch it or scratch it too much, you may get a cellulitis, right? Those typically aren't harmful at all, but people do have allergic reaction to mosquitoes.
Luke Lemons (14:18):
Yes. So when we think of a mosquito allergic reaction, we see symptoms that are very similar to systemic reactions. So that's hives, respiratory symptoms, circulatory symptoms. It's similar to when a patient may get stung by a bee, right, Gary? When it comes to these symptoms of the mosquito bites,
Gary Falsano (14:39):
Yeah, I mean, if they have a type one hypersensitivity reaction to mosquitoes, it's going to be no different than a beer or wasp sting. It's not super common. It is something that happens, and we can test for that as well. There is specific IgE testing to test for sensitization to mosquitoes.
Luke Lemons (14:58):
We've also found that there's some cross reactivity with mosquitoes with other arthro pods. So that's like wasp, venom bees, dust mites, cockroaches and shrimp. We're getting
Gary Falsano (15:09):
Now into that tropo mycin again, aren't we?
Luke Lemons (15:12):
Yeah. Yeah. So we see that there's some cross reactivity there. If you haven't listened to the episode related to dust mites and shrimp, definitely recommend checking that out. It's episode 33. We talk about why there's some overlap between foods like shrimp and some of these bugs. It's a very interesting and maybe a little disgusting conversation, but patients who do have hypersensitivity, a type one hypersensitivity to mosquitoes may cross react with again, bees, wasps, cockroaches, dust mites.
Gary Falsano (15:42):
And speaking of the bees and the wasps, I don't know that we realize as providers close to 3% or 10 million people in the US have actually experienced a systemic reaction to a B wasp, not a local reaction that pretty much anyone has when they're stung, but a systemic reaction. So it's so important because when we talk with Dr. Golden in some of our previous episodes, he's really kind of relayed that a lot of patients, number one, won't tell their providers that they've had a systemic reaction or a more severe reaction. And the second thing that Dr. Golden has told us is that a lot of primary care providers are unaware of just how effective venom immunotherapy is. So those two things are just key to keep in mind, especially during the summer, have a high level of awareness. Ask your patients during a history if you've ever had a systemic reaction and if they had, get them tested and get them to an allergist for potential venom immunotherapy.
Luke Lemons (16:45):
And speaking of pests, and the summertime when we turn our gaze inside indoors, we also may see that patients are exposed to dust mites, not through the common bedsheet or pillow, even though that is a possibility, but the air conditioner. So Gary, why don't you explain a little more about the air conditioner.
Gary Falsano (17:08):
So Luke, we've mentioned dust mites and how to control dust mites in multiple previous episodes. There's such a big driver of respiratory symptoms, whether it be rhinitis, whether it be asthma, and we know putting on those impermeable covers, washing the bedsheets is so important. But in the summer especially, we talk about keeping humidity levels low, and one of the ways that most people do that in the summer is using an air conditioner. And we think, all right, that's a way to combat the dust mites. Well, it is, but we've seen recent data that shows that you can actually detect dust mite concentrations in air conditioner filters.
Luke Lemons (17:46):
So one study found that when they were looking at air conditioners, two of the major allergens associated with dust mites were at elevated levels in the air conditioner. And when they started the air conditioner, it increased significantly.
Gary Falsano (18:01):
So on the startup of the air conditioning cycle, it blew out those allergens from the dust mites into the environment. And what they found was in the air conditioner filters, the dust mites had actually colonized there.
Luke Lemons (18:16):
And so this is just another allergen that in the springtime may be affecting patients. And we've listed a lot of different ones right now, and we've listed a lot of different ones from grass, pollen, ragweed, pollen to mosquitoes to sids and bees, and there's just a lot that may be affecting patients. So when they come in with symptoms, it's important to rule in and rule out allergy, and we say rule in and rule out pretty often when we think about allergies. So when we say rule out Gary, what do we mean necessarily? Because there are other triggers that could be affecting patients that aren't related to allergies.
Gary Falsano (18:55):
Yeah, exactly. So we know that when we talk about testing for allergic triggers, we know especially the whole extracts that we commonly test for environmental triggers. They're really sensitive, and what that means is if they're negative, we can effectively rule out that allergen that we test it for as a cause of symptoms. So they have a high negative predictive value. Once we've ruled out allergic triggers, as we mentioned in the beginning, there's a slew of non-allergic triggers that can potentially cause allergic like symptoms. And even associated with that, some of those non-allergic triggers can make airways more hyperresponsive. That actually makes them more responsive to allergic triggers if someone is sensitized to an allergen. So they can come into play in both ways, both causing symptoms on their own as a non-allergic trigger and making the airways more responsive if someone has an allergy.
Luke Lemons (19:51):
Some of the more common non-allergic triggers that patients might be exposed to during the summer are chlorine from pools, sunscreen, which a reaction may be a type four hypersensitivity. There's poison ivy, which can be a type four hypersensitivity. So during the summer when patients are out lounging by the pool, maybe they've jumped in, they got out, they're eating some fresh watermelon, they're running around, there's a chance that they may if they are allergic or not have difficulties breathing. And it's important to evaluate why that is. Is it the pollen, is it the chlorine? So we've gone over a lot of allergens so far in this episode from dust mites and mold to foods that are reactive in pollen food allergy syndrome to the pollens like grass, pollen and ragweed pollen. But there are also non-allergic triggers that may heighten symptoms of allergies or cause symptoms very similar to allergies.
Gary Falsano (20:50):
Yeah, I mean, we think about chlorine and pools, and I think if our listeners remember back to our allergies and athletes episode, there's a high percentage of patients who are swimmers who experience respiratory issues and have a high incidence of allergy, and we're not quite sure if it's the chlorine making their airways more hyperresponsive to those allergens they're sensitized to, or if it's the chlorine itself causing kind of a bronchospasm on its own. But either way, chlorine can be a trigger certainly for both allergic and non-allergic symptoms outside of chlorine. There are other reactions that people have in the summer, and I think some really common ones are poison vy sunscreen reactions. These are not type one hypersensitivity typically defined allergic reactions, but they are hypersensitivity reactions and anybody that's experienced any of those knows they're really bothersome. So when we think about these type four hypersensitivity reactions, we don't have a blood test for these or a skin prick test.
Gary Falsano (21:58):
These are typically assessed usually by a dermatologist, sometimes by an allergist. Using patch testing type four by its very definition is not an immediate reaction. These are things that happen sometimes 8, 10, 12, 24, 48 hours after the exposure because of that type four type reaction. So in those cases, it's important to identify that and make sure we're giving preventative guidance to patients, to kids going off to summer camp, right on how to prevent that. So if they've had previous sunscreen reactions in the past, again trying to find one that is perhaps hypoallergenic or not, they're not reacting to different sunscreens have different ingredients. It's important to differentiate that on the respiratory side of things, like with chlorine, it's important to get an assessment of patient's respiratory triggers, so we know whether that's a type one reaction or if it's just an irritant from the chlorine itself.
Luke Lemons (22:58):
So we've talked about a lot of different allergies this episode related to summer, and I think that we can have an agreement here. Gary Spring allergy season isn't really always the star of the show when it comes to a bunch of allergens in the air or exposing patients to potential triggers. Summer also has a lot of opportunities for potential exposure as we review.
Gary Falsano (23:25):
What are the most typical or prevalent allergens in the summertime? I think some of the advice that we need to communicate to our patients are, number one, if you have pollen allergies, so you have identified, we've tested and identified sensitization to grasp pollens or as we get into the late summer weed pollens, you need to stay inside when possible during peak pollen periods.
Luke Lemons (23:52):
And also with those patients who have grass pollen allergy or ragweed pollen allergy, it's important to let them know of potential symptoms related to pollen food allergy syndrome, which is the itchiness of the throat and the mouth and letting them know that when they experience that, that's due to their exposure to that pollen.
Gary Falsano (24:12):
Because we talked about the kind of cumulative threshold, so if you're in a peak pollen season, that's going to bring up your level of allergic response because you're allergic to those pollens and then you eat a food that contains a similar looking pollen, and that's going to cause even more severe symptoms than perhaps if you ate that same food in December when you're not being exposed to those pollens.
Luke Lemons (24:34):
Exactly. Also, with the patients who are coming in who are preparing for summer camp, especially those kids who are getting their physicals right now, really taking a moment to counsel the patients that are food allergic and letting them know of potential ways to stay safe at camp. Like Gary, you had suggested when it comes to dust mites, at least bringing dust mite covers and dust mite pillows for the food allergic patients, it's making sure that prescriptions are up to date, making sure that their asthma is also under control if they do have it, and creating a food action allergy plan.
Gary Falsano (25:07):
And if they do have asthma and asthma action plan as well. So they should be prepared. They should be going to summer camp with what they need to keep themselves safe, and those summer camps really need to be advised through those action plans of what they need to do, should their children and even their adult campers and counselors have a reaction, especially in those summer camps that are pretty remote. Right? They need to be prepared to take action
Luke Lemons (25:32):
And we'll have links on this episode specific page to those action plans that you can utilize within your clinic. A couple of other
Gary Falsano (25:39):
Kind of standard management tips for patients who are allergic in the summer during peak pollen periods, make sure you keep your windows and doors closed. Use air conditioners to filter out pollens and other allergies. Keep you humidity low to control the dust mites, but those same air conditioners, we need to make sure we're cleaning the filters, making sure we're replacing the filters so we don't have those dust mite colonies that are living in the air conditioner filters that we're exposed to when the air conditioner turns on.
Luke Lemons (26:07):
Exactly. Also too, a great tip to tell patients who have a pollen allergy is to shower and wash their hair after spending time outdoors in order to remove that pollen. Just rinse off. If they go into their bedroom and they lay down because maybe the heat's getting to them, they're bringing all that pollen into that space where they're going to spend maybe eight hours a night resting, and it's going to affect the way in which they breathe. We've
Gary Falsano (26:33):
Talked about in previous episodes how important it's to protect that sleep space. And if that sleep space happens to be at a summer camp, let's try to protect that as well. It may not have air conditioning, they may not be able to keep their windows closed, but if they have a dust mite sensitization or a mold sensitization, let's make sure they're not putting their head in a pillow full of dust mites.
Luke Lemons (26:54):
And we always say on cast that knowledge is power. And so it's really our call to action here to make sure that everyone out there is being evaluated if they're showing symptoms of a potential allergic reaction, because like we spoke about, it may not be an actual allergic reaction, but a non-allergic reaction. So that's evaluating patients who are coming in and have symptoms and being sure to prepare them enough so that they can be outside and so that they can have fun at summer camp or lounging by the pool, or having a nice crisp bowl of watermelon even though there's some grass and ragweed out there.
Gary Falsano (27:32):
Exactly. Summertime is a great time. It's one of my favorite times of the year. We should prepare our patients to really maximize their enjoyment, maximize the fun that they're having during the summer, but also let's be prepared to stay safe and make sure we
Luke Lemons (27:48):
Make it to the fall. As always, there will be resources related to this episode on this episode's specific page, which you can find a link to in the description of this podcast. Thank you for listening. Yeah, thanks so much
Gary Falsano (28:00):
And we'll see you next time.
Announcer (28:07):
ImmunoCAST is brought to you by Thermo Fisher Scientific creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems. For more information on allergies and specific IgE testing, please visit thermofisher.com/immunocap. Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy clinical history alongside specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
